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pass along informat...

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helped these people m...

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analytics company...


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were advised to stay...

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work to ease uncerta...

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(King, 2008). Resea...

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Computer-mediated C...

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itself – that scho...

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Figure 4. Representa...

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2009). On the t...

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Table 1Tweets Relati...

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Death due to 20...

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about the virus and ...

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however, unlike sch...

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from the first step ...
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
Thesis - A Little Birdie Told Me
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Thesis - A Little Birdie Told Me

  1. 1. 
 Twitter and H1N1 1
Running head: TWITTER AND H1N1 A Little Birdie Told Me: H1N1
Twitter Tonya Oaks Smith University of Arkansas at Little Rock
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 Acknowledgements American writer Cynthia Ozick said “We often take for granted the very things that mostdeserve our gratitude.” I would not have truly engaged in the process that is the AppliedCommunication Studies Program in UALR’s Department of Speech Communication if I did nottake the time to thank the myriad individuals who helped me along the way. Here, I would like tothank many people who were dedicated in their own ways to my success in graduate school. My parents have always been the most supportive imaginable. I especially appreciate mymother’s strong example in earning her master’s degree when she had a family to take care of;she proved anything can be done with hard work and perseverance. Thank you both for believingI could complete this step in my educational journey. My husband and daughter deserve to havetheir names included as authors of this research paper as much as I do. They helped me checkformatting and sources and dealt with my anxiety and sleep deprivation. I am thankful for theirjoining the collective and their sacrifices to get us where we are today. Dr. Avinash Thombre has been a true inspiration in this process. His background issimilar to mine, and we were able to make a great team when it came to interpreting Ev Rogers’Diffusion of Innovation and applying that work to my research. The other professors on mycommittee – Dr. Rob Ulmer and Dr. Julien Mirivel – gave excellent advice to strengthen myarguments. I am indebted to each of these men – as well as the other professors in the SpeechCommunication Department – for their contributions to my education. Through you all, I havelearned what Krishnamurti meant when he said, “There is no end to education. It is not that youread a book, pass an examination, and finish with education. The whole of life, from the momentyou are born to the moment you die, is a process of learning.” I hope to learn from each of theseprofessors’ examples and be a leader in the work for excellence in communication.
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 In the completion of this project, I depended on a number of friends to read sections,respond to questions, and tell me if my reasoning made sense to someone who was not acommunication scholar. I so appreciate your indulgence of my work, and I commit here toreturning the favor when needed. Finally, I’d be remiss if I did not thank the multitude of people who inspire me each daywith their work in the field of computer-mediated communication. With all of us workingtogether, we will establish a generation of ethical communicators who just happen to practicetheir craft on their Internet. I’m incredibly proud to be a part of that group of individuals strivingfor excellence in communication every day.
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 A Little Birdie Told Me: H1N1 Information and Misinformation Exchange on Twitter Today, people expect to share information, not be fed it. They expect to be listened to when they have knowledge and raise questions. They want news that connects with their lives and interests. They want control over their information. And they want connection – they give their trust to those they engage with – people who talk with them, listen and maintain a relationship. – Michael Skoler, 2009, p. 39 Since 1997, computer programmers have worked to develop social networks that make itpossible for users to connect with others who share common interests. The first of thosenetworks,, allowed individuals to establish profiles, list friends, and connectwith others who have similar interests and contacts (boyd & Ellison, 2007). In effect, the adventof social media allowed users to share information, just as Skoler noted. Individuals began tocontrol the data they received (Skoler, 2009). The phenomenon has grown since then to includesites focused on music, job hunting, buying and selling used items, and blogging (boyd &Ellison, 2007). One of the newest introductions into the world of social networks is Twitter, amicroblogging site that restricts user posts to 140 characters or less. According to Twitter’s chiefoperations officer, in June, the service boasted 190 million users who post about 65 millionmessages per day (Schonfeld, 2010). This number is growing almost exponentially each month;in April, 180 million users were recorded (Schonfeld, 2010). Developing connections among individuals with common interests is only one way thatsocial networks are used. The worth of the Internet has increased as individual users haverealized the value of connecting with other people, changing the perception of the Web from “aone-way broadcasting or publishing medium” to a one that allows individuals to create valuedinterpersonal networks (Gordon, 2009, p. 7). Internet-based communication channels can also
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pass along information to consumers and diffuse data to a group of individuals who are in one’sinner circle. Twitter helps users “make better choices and decisions and, … creates a platform for[users] to influence what’s being talked about around the world” (Twitter, 2010). Individualsaround the world use Twitter to learn and then share their knowledge with other users. Therefore,the medium stands as a one of the powerful new ways we use the Internet to diffuse informationwithin networks of individuals who are alike in their beliefs (Rogers, 2003). Ev Rogers’ theory of Diffusion of Innovation focuses on diffusion as a “process by whichan innovation is communicated through certain channels over time among the members of asocial system” (Rogers, 2003, p. 11). Twitter is not only a new innovation itself, it is a primecommunication channel many individuals use to share information about their lives and interests.In particular, users employ Twitter to share news events – either with a small impact like thebirth of a child or large impact like the spread of the H1N1 virus. Social media, includingTwitter, have dramatically changed how individuals share and receive information and news(Ludtke, 2009). With this research project, I analyzed the diffusion of information about H1N1 flu onTwitter. I used the theoretical lens of diffusion of innovation to examine the information-sharingbehaviors of individuals on Twitter. To begin, I briefly explain the new communicationphenomenon known as Twitter and the H1N1 virus as well as its progression throughout theworld. Then, I examine the research that other scholars have completed on computer-mediatedcommunication, diffusion of innovation, and health communication. Next, I outline the researchmethodology followed in order to examine how individuals used Twitter in the midst of aworldwide health crisis. The paper details content themes within the online discussion of H1N1and then I draw parallels between individuals’ use of Twitter and how this use of the medium
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helped these people make a decision on whether or not to vaccinate themselves and theirfamilies. Finally, I offer analysis of what the content analysis and survey data mean as well assuggestions for the future use of Twitter to communicate pertinent information – particularlyhealth information – more effectively as a part of a well-rounded communication plan designedto diffuse innovations and change behaviors.
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 A Twitter Primer Twitter was developed in 2006 after years of work by co-founders Biz Stone and EvanWilliams (Malone, 2009). Twitter allows users “to post short text messages – called ‘tweets’ – ofno more than 140 characters on their personal feed” (Malone, 2009). The innovation iscommonly called microblogging, and an individual’s followers can read posts. Since itsinception, the tool has been used to communicate the mundane – information about what anindividual has eaten for dinner – to the incredibly important – information on the forced landingof American Airlines flight 1549 in the Hudson River (Malone, 2009). Indeed, during the 2009presidential elections in Iran and subsequent citizen revolt, Twitter was the only way residentscould get information to the outside world about the government’s actions (“Twitter links Iran,”2009). Apparently, Iranian officials did not assign much importance to this new innovation, butits power is growing exponentially as the number of adopters grows. Twitter can be used to talk to one individual or a small group, in the same fashion asinterpersonal communication, or to millions, in the same way as mass media are used. In fact, themedium allows individuals to embrace the old-style idea of journalism and interpersonalcommunication, one that delivers news to help readers “connect with neighbors, be activecitizens, and lead richer lives” (Skoler, 2009, p. 38). The innovation has been wholeheartedlyembraced as a result of this change in thinking about communication – the movement from one-way to reflexive (Gordon, 2009). In April 2009, over 7 million unique visitors used the site,proving the application’s reach and influence in the social networking community (McGiboney,2009). Currently, Twitter users share 65 million messages per day (Schonfeld, 2010). Thus,Twitter shows promise for communicating useful information to multitudes of people in realtime, as shown in Figure 1 below, completed with information from, a web
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analytics company that monitors the use of websites with surveys of over 2 million Internet usersin the United States. These users gave the company their permission to analyze their web usageas well as conduct surveys into their habits on the Internet (, 2010). Thiscommunication tool roughly follows the traditional S-shaped curve that Rogers (2003) statesinnovations will adhere to during the innovation-adoption process. Despite the fact that Twitter can – and is – used to share positive information, the tool canalso be used to spread misinformation, as can be seen in the beginning of the H1N1 outbreak inspring 2009. Journalists commented in April 2009 on the microblogging site’s becoming “ahotbed of unnecessary hype and misinformation about the outbreak” (Sutter, 2009). Tweeps, asthose who post on the site have become known, spread information about the false connectionbetween consuming pork and the flu, the possibility of germ warfare, and other assertions aboutthe disease and its spread (Day, 2009; Morozov, 2009). The ease with which misinformation canbe spread, as well as the possibility of information overload, or “the state of an individual or asystem in which excessive communication inputs cannot be processed and utilized, leading tobreakdowns,” are two of the prime problems seen with using Twitter as a communication vehiclefor important information (Rogers, 2003, p. 368-369).
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 29 28 27 Users in Millions 26 25 24 23 22 21 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 DateFigure 1. Graphical representation of the Twitter adoption curve – an S-shaped curve.Data course is
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 H1N1: The Health Crisis When a crisis occurs, individuals instinctively seek information that will help themalleviate their uncertainty. They want to acquire data that will help them process their situationand respond effectively to the danger it presents (Ulmer, Sellnow & Seeger, 2007). The H1N1outbreak, which began in April 2009, is no different than other health crises such as the SevereAcute Respiratory Syndrome (SARS) outbreak of the early 1990s or the HumanImmunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) outbreak inthe 1980s. Many individuals sought to create self-efficacy, the perception of an individual’s“capacity to organize and execute the actions required to manage prospective situations”(Singhal & Rogers, 2003, p. 313-314). However, with the latest health crisis that the H1N1 virusoutbreak presented, a number of new communication media were available that simply did notexist in the late 20th century. Twitter was one of the many ways that individuals employed tocollect information on the virus and how to avoid contracting it. Both the World HealthOrganization and the Centers for Disease Control and Prevention utilized the new medium tocommunicate timely information on the virus to their followers. When the H1N1 virus was first diagnosed as a unique illness in April 2009, the Internetcame alive with stories from around the world of those who were sick with the illness. The firstdocumented death occurred in Oaxaca, Mexico, and health officials there declared the death asan isolated incident, even though individuals who had been in contact with the deceased womanwere suffering mild symptoms of pneumonia (World Health Organization, 2009a). Soon after,there were other deaths from the same illness, which was then feared to be avian flu, and theMexican government reported the illnesses to the World Health Organization (WHO). SomeAmerican travelers returned home from Mexico with symptoms of the mystery illness, and they
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were advised to stay home until a cause could be found (Chen, 2009). Canadian health officialsdetermined – after studying samples sent from Mexico – that the virus was not avian. Instead, itwas found to be the H1N1 “swine flu” virus (WHO, 2009a). Later in April, the first H1N1 caseswere reported in the United States, and the WHO declared a health emergency on April 26. Atthat time, there were a total of 40 cases of the H1N1 virus in the United States (Cable NewsNetwork, 2009). The number of H1N1 cases rose almost exponentially in the following months. In June2009, 74 countries had verified H1N1 infections, and WHO director general Dr. Margaret Chodeclared the virus outbreak a pandemic (WHO, 2010). The virus was different in that it causedhigh rates of infection in the summer, when most viruses are largely dormant. The virus was alsounique from other seasonal flu outbreaks, according to the WHO, because pandemic H1N1 was a new virus when it emerged and most people had no or little immunity to it. In addition, one of the lessons from history is that influenza pandemics can kill millions. Finally, there was no pandemic influenza vaccine at the outset (WHO, 2010).In addition, individuals who were not normally susceptible to flu hospitalization and death –namely young adults – experienced the highest percentage of deaths by age group (See Figure 2). After the initial surprise of discovering that a new H1N1 virus was running rampant inmany countries, both the CDC and the WHO worked to respond to the crisis by sharinginformation with those who might be negatively impacted. They utilized unique approaches tocommunicate information, and through their work, uncertainty was alleviated (Ulmer et al.,2007). Both organizations posted information regularly to their Twitter feeds – and – and held timely press briefings. Their
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work to ease uncertainty positively impacted how individuals dealt with the crisis (Littlejohn &Foss, 2008). 140 120 100 Deaths 80 60 40 20 0 0-4 years5-24 years 25-49 50-64 >65 years Unknown years years Age of DeceasedFigure 2. Bar chart of H1N1 deaths in the United States by age group. Source is theCenters for Disease Control and Prevention.
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 Reviewing the Literature In recent years, much research has been conducted on the formation of opinions throughthe use of computer-mediated communication (CMC) and social networks (Black, 2007; boyd &Ellison, 2007; Lyons & Henderson, 2005). Twitter, however, is such a new phenomenon thatscholarship has not caught up with the technology. The body of work instead focuses on theconstruction of online personas and the use of social media to spread marketing information(Neff, 2009). Since Twitter and other social networks are computer-mediated communication,we will apply the same theories and techniques that other researchers have used in its analysis. In addition to the formation of networks with CMC, communication research touches oncomputer-mediated spread of misinformation, without connecting the construction of collectivetruth and conversion to action through false information (Black, 2007; Eastin, 2001). Healthcommunication literature also focuses on the use of mass media to diffuse innovations andencourage healthy behaviors. However, this section of the literature does not includecommunication mediated by computers. In short, the literature fails to connect the dots betweentraditional mass media and new media and their shared use as cooperative channels in the spreadof health information.Sense Making Authors have examined sense making with computer-mediated communication,specifically Twitter, as well as the overload of data available in this channel (Farhi, 2009). Inaddition, researchers have examined the information overload in the light of news consumers’attempts to become active participants in the process of constructing news (King, 2008). Theprocess of gathering and productively using information in the digital age has changeddramatically, and users must work to determine which information is true and which is false
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(King, 2008). Researchers, however, offer no way to determine the veracity of data passed alongthrough digital channels or discuss the process by which users determine which informationallows them to develop self-efficacy (Botta, 2006). There is, however, a focus on readeracceptance and contribution of information and misinformation to the new-media stream (King,2008). Researchers also attempt to provide a basis for how journalists and other news-gatherers– including other Twitter users – regard the new medium. Companies respond daily tomisinformation spread through Twitter – either intentionally or unintentionally (Neff, 2009).Their responses – and the analysis of these defensive communication acts – helps provide bestpractices for response to misinformation could be used by for-profit organizations or governmentagencies who are responsible for disseminating information about health crises in the digital age(Eastin, 2001; Neff, 2009). Research has, however, contributed to the understanding of how truthis constructed through public discourse, and this theory can be applied to analysis of new mediasuch as Twitter (Black, 2007). Black, specifically, focuses on the formation of public knowledge and truth. Hisargument centers on “how information, both factual and nonfactual, can evolve into truths withinthe realm of public knowledge” (Black, 2007, p. 2). The researcher notes several instances ofhow misinformation has been spread through word of mouth and mass media, entered into thepublic consciousness as truth, and been acted upon. Black (2007) makes use of diffusion ofinnovation theory in his argument, specifically the use of interpersonal communication to spreadideas that then make their way into the public consciousness (Rogers, 2003).
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Computer-mediated Communication The literature also explores the differences between computer-based opinion leaders andopinion leaders from more traditional environments (Lyons & Henderson, 2005). While thecharacteristics for both groups are similar, computer-mediated opinion leaders are moreexploratory in their behaviors (Lyons & Henderson, 2005). Though the research provides basicinformation on opinion leadership in a computer-mediated world, it does not examine theblurring between interpersonal communication and mass media that computers allow those whochoose to use them to communicate. In addition, we have seen a contrast between the negativeand positive aspects of information sharing via CMC (boyd & Ellison, 2007; Eastin, 2001).Media Intervention in Health Behaviors Finally, much research has focused on media intervention in health behaviors,specifically when individuals do not have enough interpersonal communication support to formopinions (Singhal & Rogers, 2003; Botta, 2006). By applying the media dependence theory inconjunction with research on the diffusion of innovation, Botta (2006) discusses the importanceof mass media when individuals have unmet information needs. The added information –delivered by mass media – provides these individuals with messages of self-efficacy (Botta,2006). In this article, the author focuses on behaviors associated with HIV and AIDS prevention,but the theory could be applied to any health crisis. Information’s empowering force – especiallywhen delivered in a trusted forum – allows individuals to make intelligent decisions regardingtheir health during crisis. Each of these studies shows that information and misinformation are easily spreadthrough both mass media and interpersonal communication channels, including new mediachannels. However, Twitter is such a new innovation – it has not yet become completely diffused
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itself – that scholarship has not focused on it in a concrete way. Future researchers need toextend focus beyond traditional mass media and examine new media in the same fashion. Thisresearch project in part attempts to examine Twitter in the same light as researchers have studiedother communication channels.
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 Theoretical Framework As an overarching theoretical tool, this research project uses Everett Rogers’ extensiveconceptualization of how an innovation spreads in a social system among its members. Asdefined earlier, diffusion is the way that a new idea is shared through communication channels.This spread takes place over time and throughout a social system (Rogers, 2003). However,diffusion is more than simply wanting to ensure that a new idea will be shared. Instead, the bestexamples of diffusion of innovation show that an idea has been adopted (Dearing & Meyer,2006). Future scholars noted that education and mass media directly contributed to this idea ofsuccessful innovation through adoption (Melkote, 2006). Whether that idea is planting a newlydeveloped kind of seed corn or using a condom to prevent the spread of AIDS, those who diffusethe innovations want to ensure that the idea is accepted and adopted quickly (Singhal & Rogers,2003). There are several concepts within the theoretical framework that help us understand theuse of Twitter to diffuse information and how its use can help influence future health behaviors.In this section of the research, I will focus first on the innovation-decision process and howindividuals follow this path to adopt or reject innovations. Then, I discuss communicationnetworks and why they are formed and used to diffuse information about innovations. I will alsoutilize the concept of opinion leaders, showing how they are differentiated from change agenciesand agents. Next, I examine the differences between mass media and interpersonal channels,discussing how each of these communication tools is used in different ways to diffuseinnovations. Finally, I will focus on disinformation and misinformation and how their use cancloud the perceptions of message receivers, changing their minds on adopting innovations.
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Innovation-decision Process The process of determining whether or not an innovation should be accepted is knownthroughout Rogers’ work as the innovation-decision process (2003). This five-step program (SeeFigure 3) allows individuals to first work through a knowledge phase, where he or she learns ofan idea or innovation and how it works (Baumann, 2008). During this phase, “potential adoptersdevelop perceptions of the innovation characteristics, which are influenced by peers, changeagents, mass media portrayals, social norms, the kinds of innovation information needed, initialexperiences, and, in some cases, the adoption by others” (Rice, 2009). The individual then movesthrough the persuasion phase, where he or she forms an attitude toward the innovation (Rogers,2003). Then, the prospective adopter actually makes a decision and implements it in the third andfourth stages of the process (Baumann, 2008). Finally, the decision and implementation must bereinforced in the confirmation stage (Rogers, 2003).
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Figure 4. Representation of the five stages in the innovation-decision process. Adaptedfrom Ev Rogersʼ Diffusion of Innovations.Communication Networks According to Rogers, communication is the “process in which participants create andshare information with one another in order to reach a mutual understanding” (Rogers, 2003, p.5). The mutual understanding happens as communication brings together those who are insimilar circles – because of socioeconomic status, learning, or other factors. Thesecommunication circles allow individuals to come to a conclusion about an innovation – namelywhether to adopt and use it or not. Information by itself cannot help an individual come to theconclusion to adopt an innovation. Instead, personality – the very charisma that helps constructan individual’s position as an opinion leader – is also necessary (Dearing & Meyer, 2006).Integral to the idea of effective diffusion of innovation through communication and shared
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agreements is the concept of a communication network, or a group of individuals who areconnected by sharing information on topics in their common interest (Rogers, 2003). The effectiveness of communication networks can frequently be determined by the levelof homophily, or the “degree to which a pair of individuals who communicate are similar,” of theindividuals within those networks (Rogers, 2003, p. 305). While it usually adds to the level ofdiffusion, homophily can sometimes serve as a barrier to innovation because individuals who aresimilar in beliefs and behaviors do not interact with those who would most benefit from theintroduction of innovation (Leonard, 2006). For instance, those of higher status – the ones mostlikely to encounter new innovations – rarely interact with those of lower status. Groups ofindividuals who are too similar are also not as creative as groups of people who are slightlydifferent. These individuals simply don’t have to be creative. Their ideas are the same aseveryone else’s, and there is no reason to venture beyond their comfort zone to find remedies forproblems. Therefore, individuals who are too similar to their peers will lose the ability to serve asopinion leaders and persuaders (Leonard, 2006). Parallel thinking dilutes potential opinionleaders’ power and can bring the diffusion process to a standstill. Contrary to homophily, heterophily is the dissimilarity between communication partners(Rogers, 2003). Differences in opinions can cause cognitive dissonance, but these differencescan inadvertently work to strengthen communication between diverse cliques (Rogers, 2003). Infact, in today’s rapidly changing world, creative friction is often necessary to inspire inventors tocreate new products and processes (Leonard, 2006). However, despite the advantages thatinfrequent communication and differences across social and economic boundaries can have tohelp diffuse innovation, Rogers believed that homophily among interpersonal communicationnetworks is one of the greatest engines for change. Opinion leaders pilot these networks, and
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their effectiveness is gauged on the “degree to which [they] are able to influence otherindividuals’ attitudes or overt behavior informally in a desired way with relative frequency”(Rogers, 2003, p. 27). Because these influential individuals are the ones who largely drive thediffusion process, in the next section, I elaborate on the definition of opinion leaders.Opinion Leaders Change agents are the first individuals charged by a change agency – or an organizationworking toward the adoption of an innovation – but they are frequently unable to directly impactindividual behaviors. Opinion leaders serve as the sergeants in the fight to diffuse innovations ina system. They are closer to the average foot soldiers – and command these individuals’ respect– than those who are at the top of the chain of command, or the change agents and agencies. Inmuch the same way a general’s ability to win a war is dependent on his sergeant’s ability to carryout orders and influence others to carry them out, the success of a change agent is directly and“positively related to the extent that he or she works through opinion leaders” to achieve theagency’s goals (Rogers, 2003, p. 388). Because opinion leaders are closer to the actualprospective adopters, they are able to impact behaviors more quickly and directly than the actualagents of change. As stated above, Rogers believes that opinion leaders can share the innovationthrough homophilious or heterophilious communication through these channels. Homophily,however, is the strongest method of sharing information and converting behaviors. A successfulopinion leader must walk a fine line between being similar to those he works for and those he isworking to persuade. If diffusion is to be successful, opinion leaders must bridge the gapbetween those who have diverse bodies of knowledge (Leonard, 2006). Contrary to many change agents’ beliefs, those who adopt new innovations the quickestdo not often serve as true opinion leaders in a community. Opinion leaders are not innovators,
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nor are they the first individuals to adopt an innovation or make a change (Rogers, 2003). Thesepeople – early adopters – are frequently seen as deviants within a social system and do not garnerthe respect that true opinion leadership commands (Rogers, 2003). Instead, opinion leaders areindividuals who have followers. They are respected in their community, and they are “sought byothers for their opinions and advice” (Lyons & Henderson, 2005; Singhal & Rogers, 2003).When change agents are able to train influential individuals and send them out to spread themessage, then more persuasion is accomplished and innovations are adopted successfully. Opinion leaders can share information in many ways, among them mass media andinterpersonal channels, which are discussed below. But one of the most effective ways for thesepersuaders to share their knowledge is through a demonstration (Rogers, 2003). In fact, whenAIDS ran rampant through the gay community in the 1980s, the most effective ways ofspreading information about the effectiveness of condom use was through demonstrations andinterventions held in gay bars (Singhal & Rogers, 2003). Demonstrations help to increase theobservability of advantages involved in an innovation – one of the requirements for adoptionaccording to Rogers’ theory. Demonstrations are often effective, Rogers said, because they addthe “perceived competence credibility of the change agent with the perceived safety credibility ofthe demonstrator” (Rogers, 2003, p. 390). Demonstrations are even more effective in creatingbehavioral change or achieving adoption if the demonstrator is an opinion leader, or one who istrusted to share authentic information about the innovation and the results of the demonstrationwith those who fall later in the adoption cycle (Rogers, 2003). When the opinion leader isoutfitted with pertinent information and supplies from the change agent, then he or she is alsobetter able to share ideas and persuade individuals to adopt innovations (Adhikarya, 2006).Demonstrations and pertinent information can be counted as two of the ways opinion leaders
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engage in interpersonal communication with their target audiences. In the next section, wediscuss mass media and interpersonal channels, as well as the differences between the two andhow new methods of communication are serving to blur the lines between mass and interpersonalcommunication channels.Mass Media and Interpersonal Channels In addition to utilizing demonstrations, opinion leaders can spread information throughmass media or interpersonal communication. Mass media channels, usually the most efficientway to talk about innovations, are perceived to be the “magic multipliers of developmentbenefits, and as harbingers of modernizing influences” (Melkote, 2006, p.151). Interpersonalchannels, however, “involve a face-to-face exchange between two or more individuals” (Rogers,2003, p. 18). The informal influence that opinion leaders exert often results from “product-related conversation, referred to as ‘word-of-mouth’ communication” (Lyons & Henderson,2005). In his theory, Rogers emphasizes the importance of both mass media and interpersonalcommunication channels in sharing information during the course of a diffusion project. Opinionleaders also have the opportunity to share pertinent information through interactivecommunication via the Internet, and this method of communication has become “more importantfor the diffusion of certain innovations in recent decades” (Rogers, 2003, p. 18). Scholars oftenrefer to this method of communication as “word of mouse,” and much study remains to beconducted if researchers and change agents are to understand the power of computer-mediatedcommunication as either a mass medium or interpersonal channel (Lyons & Henderson, 2005). Each channel has its own strengths and weaknesses, and change agents must determinewhich one will be more effective in ensuring that an innovation will diffuse. In discussing theinnovation-decision process, Rogers asserts that “mass media channels are relatively more
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important at the knowledge stage, and interpersonal channels are relatively more important at thepersuasion stage” (2003, p. 205). Researchers have found recently, however, that mass media cansubstitute for interpersonal channels in certain circumstances, such as when an individual doesnot have access to expert interpersonal communication (Botta, 2006). These two channels, whilevery different, are connected by their focus on sharing message content that is “concerned with anew idea” (Rogers, 2003, p. 18). Differences, especially in the age of more computer-mediatedcommunication and shrinking boundaries between communities, may be disappearing. TheInternet provides opinion leaders with both “an unprecedented repository of information” on anumber of subjects and the ability to share that information with an untold number of individuals(Lyons & Henderson, 2005, p. 321). The innovation that we know as the World Wide Web hasopened up a new idea of opinion leadership and blurred the lines between social classes andfamiliar groups. How the spread of information is accomplished and how that information diffusion leadsto adoption of innovation figures heavily in this research. The discussion of opinion leaders andthe examination of new communication technology bring us to the following research questions: RQ1: How is Twitter used as a communication channel for H1N1 information diffusion? RQ1a: How are opinion leaders determined on Twitter? What constitutes an interpersonal network on Twitter? Interpersonal communication and mass media channels are focused on sharinginformation, or data that can change the level of uncertainty in a given diffusion situation(Rogers, 2003). However, in order to effectively share an innovation, the information that isshared must be accurate. The Internet has no “government or ethical regulations controlling the
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majority of its available content” (Eastin, 2001). Because information is not verified, audiencemembers are forced to distinguish for themselves between accurate information andmisinformation (Eastin, 2001).Misinformation and Disinformation Governments have used misinformation and disinformation for centuries to control thehearts and minds of their citizens and others commonly thought outside the normal sphere ofinfluence (Hachten & Scotton, 2007). Most often used during war efforts, misinformation isemployed to help control messaging, and the media are not immune to the ready flow ofincorrect information. While the aim of spreading incorrect information may be seen to benegative, it has been used to positive ends. Of course, the perception of those ends depends onwhich side of the conflict the audience supports. During Operation Iraqi Freedom, for example,information has been tightly controlled, and some official news “was actually disinformationintended to mislead the enemy, not to inform the public” (Hatchen & Scotton, 2007).Broadcasters, however, acknowledge the need to give accurate information to viewers andlisteners (Clark & Christie, 2005). In fact, later in the Iraqi War, reporters and broadcasterswhose information was passed along in the Middle East recognized the importance of sharingtruthful information and established outlets to do just that (Clark & Christie, 2005). The use of computers to share stories has muddied the water for those who seekinformation from opinion leaders and other authoritative sources. While misinformation anddisinformation have always been available through both mass media and interpersonal networks,the quickness with which individuals can communicate via computers has increased the amountof incorrect information that can be shared with anyone and everyone all over the world (Seidel& Rogers, 2002). Information innovations “have revolutionized the speed of information and
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provided global reach coupled with easy affordability and accessibility for large portions of theworld population” (Mohammed & Thombre, 2003). There are several reasons thatmisinformation and disinformation are so easy to share online. First, the Internet is a cost-effective way to share data, and individuals who would serve as self-appointed opinion leadersare no longer required to be members of news-gathering organizations or to show credentials fortheir presumed expertise (Carmichael, 2003). Second, individuals and organizations working aschange agents or opinion leaders are able to publish “Websites with apparently greater authorityand with a potentially far larger audience than would otherwise be the case” (Carmichael, 2003).While many embrace the effortlessness with which individuals can share information via theInternet, this ease of exchange can negatively impact diffusion of innovation as well ifmisinformation is shared. Social media networks are prized for their focus on authenticity. But just as interpersonalexchanges can share fallacies, the Internet can be a tinderbox for misinformation that causes awildfire in today’s rapid communication environment. If individuals have the capacity todetermine which individuals they will follow through Twitter, then researchers should determinethe answer to another research question: RQ2: How do people on Twitter distinguish its credibility or lack thereof, and how does this credibility influence their behavior? Researchers have long engaged in studying news events for their salience (Seidel &Rogers, 2002). The H1N1 outbreak surprised scientists and health officials with its speed andferocity, and its propensity to attack individuals who were not normally at risk for death from aflu virus (WHO, 2010). In the beginning of the outbreak, the virus was a totally newphenomenon, and there was a great deal of uncertainty for both officials and regular citizens
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about how the virus was spread and how best to prevent that spread. Therefore, this news eventwas highly salient for most individuals around the world. In the same way, Twitter – and research on its adoption and use – has its own salience.New media have recently become the topic of much more research (Tomasello, Youngwon, &Baer, 2009; Kim & Weaver, 2002). Millions of individuals use the microblogging service eachday to send short messages to millions of other individuals. It is one of the newest methods ofcommunication, and people are still learning about its use in everyday life. In addition, Twitterand other social media applications offer the opportunity for interactivity, which allows forstronger relationship development and is considered a “central influence upon the outcomescommunicators take away from the interactions” (Ramirez, 2009, p. 301). The first stages ofTwitter adoption and the H1N1 virus outbreak share roughly the same timeframe. Each of theseinnovations is worthy of study on its own. However, when two such important advances collidein the way that Twitter and H1N1 did in mid-2009, researchers should take notice. In thefollowing section, I explain the methodology for exploring the significance of the diffusion ofinformation on H1N1 via Twitter.
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 Methodology Both prior research and the theoretical framework of diffusion of innovation led to theaforementioned research questions. In order to answer these questions, I defined a researchmethodology that examines both the content that Twitter users choose to share and their self-reported habits in communicating that information. To conduct research on the prevalence ofcorrect information and misinformation on the H1N1 outbreak that was shared via the web-basedcommunication tool known as Twitter, I employed a three-step data collection process. First, Igathered data from Twitter and performed a content analysis. Next, I conducted a survey ofrandom Twitter users on their habits while utilizing the microblogging platform. Finally, Iperformed interviews with a sub-sample of those who answered the initial survey in order tofurther discern their Twitter use and behaviors. In the following section, I will describe each ofthese steps in more detail, explaining the reasoning behind each of the research segments.Step 1 – Content Analysis of Tweets To begin, I collected individual posts from Twitter. This dataset – all Tweets ever postedto the site – was randomly searched for postings that mentioned at least one of three terms:Swine flu, swineflu, and H1N1. The resulting dataset numbered approximately 300,000. In orderto further reduce the number of posts to be examined, I isolated the Tweets sent on three keydates – April 25, Sept. 4, and Oct. 24, 2009. These dates were chosen for their relative importance in the progression of the virusthroughout the world. On the first date, April 25, 2009, the World Health Organization met todiscuss the epidemic and ways to deal with virus treatment and prevent the spread of the disease(, 2009). On Sept. 4, 2009, the second date in question, the number of deathsaround the globe ramped up, and the virus killed 625 people in the week prior (,
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2009). On the third date, Oct. 24, 2009, President Obama declared a national emergency to dealwith the flu outbreak, freeing up significant resources to deal with the issue (,2009). On each of these dates, Twitter traffic concerning the outbreak swelled in comparison toTweets about other topics. This increase in traffic led me to believe that the events occurring onthese three dates were important among Twitter users. By narrowing the dataset to these threedates, I reduced the number of Tweet posts to be examined to 46,000. I determined this numberwas representative of the original 300,000 as well as more manageable than the original dataset,so I began the process of content analysis. To start the content analysis, or the “procedure that helps researchers identify themes andrelevant issues often contained in media messages,” I read one-third of the dataset attempting toavoid bringing preconceived notions about the Twitter posts’ themes (Rubin, Rubin & Piele,2005, p. 223). By viewing the tweets, or “data as representations not of physical events but oftext, images, and expressions that are created to be seen, read, interpreted, and acted on for theirmeanings,” I drew parallels between pieces of information from disparate sources (Krippendorf,2004). From this content emerged common communication themes relating to the reasonsindividuals share information via computer-mediated communication. After reading these 15,000tweets, I was able to determine that Twitter users focused much of their online conversation onfour major topics. Interest in content analysis is tied not only to the topics inherent in the individual postsbut also to the effect that the content has on those who send it and receive it (Rubin et al., 2005).After determining the topics, therefore, I had to categorize those ideas into communication-seeking or -giving posts. This classification is akin to Burgoon’s principle of interactivity, whichholds that “human communication processes and outcomes vary systematically with the degree
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of interactivity that is afforded or experienced” (Ramirez, 2009, p. 302). Posts that notedinteractivity – or a desire for interactivity – were further categorized into one of three majorcommunication themes – health information, uncertainty reduction, or misinformation anddisinformation.Step 2 - Survey Following this content analysis, an online survey was designed to ask Twitter users onhow much H1N1 information they have obtained and the actions they have taken as a result ofthat information was conducted. The survey was self-administered, and no prompting forparticular answers was given (Rubin et al., 2005). In order to encourage individual Twitter usersto participate in the survey, which was based on the online survey tool Survey Monkey, I posteda Tweet requesting participation in a short survey about Twitter attitudes. I also asked forfollowers to retweet the original post – “Help with research on Twitter and communication.Survey here:” – and several assisted me with communicating information about the survey to asmany individuals as possible. After posting the request for participation once a week for amonth, I received 59 responses to participate in the survey. Only 42 of these 59 completed thewhole survey. The survey form (Appendix A) was chosen to allow collection of individuals’ “attitudes,opinions, and reported behaviors or behavioral intentions” (Rubin et al., 2005) about how theyuse Twitter as a communication tool. Among the topics of interest in the survey were closed-ended questions on the number of followers an individual user has – or how potentially large hisor her reach is – and open-ended and closed-ended questions on retweeting – passing along ofpertinent information between related users. In addition, I asked open-ended questions todetermine how long individuals had engaged in Twitter as a social medium, and how their – and
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responses to prior tweets. In addition, I asked if individuals had received a vaccination for H1N1and whether or not information they received via Twitter helped them reach a concrete decisionon vaccination for themselves and their families. This analysis helped determine how individualswho use Twitter are able to serve as opinion leaders, and whether Twitter is being used as achannel for interpersonal communication between related community members or if it is beingused more as a mass media channel with information being pushed out by subject matter experts.Lastly, the survey helped ascertain whether or not Twitter was being used effectively as a tool tocreate successful diffusion of information about H1N1 and the innovation of preventativevaccinations for the pandemic flu virus.Step 3 - Interviews To complete the analysis of individuals’ personal and unique use of Twitter as a healthcommunication and uncertainty-reduction medium, I lastly conducted 10 short telephoneinterviews comprised of two questions only. These interviews allowed qualitative answers to the“why and how come questions” that concerned me when I examined the survey results. In orderto obtain a group of respondents for this section of the research, I again used Twitter to requestparticipation. I sent out an appeal for those who already responded to my survey to contact mevia direct message to further explain their involvement with Twitter. I contacted the first 10individuals who responded and asked them two questions over the telephone: • Did you or your family obtain the H1N1 flu vaccination? • How did reading information on Twitter contribute to your decision to get this vaccination? In these interviews, I was able to obtain more qualitative data about where theserespondents’ information about H1N1 and vaccinations to prevent the spread of the disease came
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from. By asking if individuals had obtained the vaccinations for themselves and their familiesand where their information came from, I could further discern which information source servedas the tipping point for vaccinations and whether that information was supplemented with face-to-face interactions (interpersonal communication) or news reports (mass media).
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 Results – Twitter Themes Rogers’ innovation-decision process provides a framework for the analysis of Twitterposts concerning H1N1 on the three key dates in the spread of the virus mentioned earlier. Theprocess allows an individual to go from being aware or learning about something that is new tomaking a decision to use or not use it. Then, the individual must have his or her decisionconfirmed. Rogers’ definition of this frame of understanding consists of five stages – knowledge,persuasion, decision, implementation, and confirmation (Rogers, 2003). These five stages areoutlined in Figure 5 below.Figure 5. Representation of the five stages in the innovation-decision process. Adaptedfrom Ev Rogersʼ Diffusion of Innovations.
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 During the knowledge stage of the process, individuals must receive and comprehendenough information to be able to begin to make a rational decision on the adoption of aninnovation (Rogers, 2003). Mass media – like Twitter – work to create awareness-knowledge,while interpersonal communication can be used to tie individuals together and begin to helpindividuals enter the persuasion stage of the cycle. Though different, interpersonalcommunication also involves the transfer of knowledge. In fact, all innovation diffusionprocesses begin with the acquisition of knowledge from a vast array of sources (Leonard, 2006). During the information stage, individuals are able to discuss the innovation within theirsocial systems and start to gain support for their change in behavior from inside the system. Massmedia can also share information about innovations. Twitter, however, can serve as both of thesecommunication channels, guiding individuals through the information-gathering step in theprocess (Seidel & Rogers, 2002). After the information stage, individuals will enter thepersuasion stage, where they form a good or bad attitude, or “organization of an individual’sbeliefs about an object that predisposes his or her actions” (Rogers, 2003, p. 174). In hisresearch, Rogers focused on the idea of a preventative innovation as one that would help anunwanted future event from happening, such as birth control to control unwanted pregnancies. Inthis same way, H1N1 vaccinations serve as preventative innovations to help stop the spread ofthe swine flu influenza. Mass media and interpersonal communication continue to influence anindividual’s decision – they persuade a person to accept a preventative innovation like a flu shot.Twitter also serves a purpose in this stage of the innovation-decision process by providingadditional information to help persuade potential users. Next, individuals enter the decision stage of the innovation-decision process. At thispoint, each person has to make a determination to try out the innovation – or not. Each individual
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has a different threshold of information that must be acquired in order to make a decision aboutan innovation (Dearing & Meyer, 2006). An individual will choose to adopt or reject aninnovation, sometimes trying out that new idea or tool on a partial basis (Rogers, 2003). In thisresearch project, the decision stage was represented by a determination whether or not to obtainan H1N1 influenza vaccination. Each step of the research for this project was designed to followan individual Twitter user through the steps of the innovation-decision process and determinewhether or not the new method of communication helped that person reach the decision tovaccinate or not. A content analysis was undertaken to determine the information individuals andorganizations were sharing on Twitter about the H1N1 influenza pandemic in late 2009.Individuals certainly communicated about the virus in great detail during the outbreak, but whattypes of information were they sharing? A content analysis, where the researcher examinestextual information for patterns, was the tool chosen to find out main topics and themes forH1N1 information on Twitter (Krippendorf, 2004). The analysis helped lead me to an answer forthe first research question – How is Twitter used as a communication channel for H1N1information diffusion? To ascertain the pertinent topics and communication themes, I analyzed 46,000 Tweetsthat users posted about the H1N1 pandemic flu virus outbreak for prevalent themes. Through thiscontent analysis, which is the process of drawing similarities between information from differentsources (Krippendorf, 2004), I was able to identify three broad umbrella themes concerning theH1N1 virus on Twitter – health information, uncertainty reduction, and misinformation. Each ofthese three themes further divided into sub-themes – deaths, vaccinations, symptomidentification, and prevention. These three umbrella communication themes were chosen because
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they shed light on the information stage portion of the innovation-decision process. Furtheranalysis, through surveys and interviews, helped determine how Twitter users progressedthrough the next two stages of the process, persuasion and decision. While these Tweets cancommunicate information in multiple ways – among them humor – the three main themes werethe most prevalent when the analysis was completed. In this section, I begin by giving a broad view of the health-information-seekingbehaviors apparent in Tweets that focused on three topics – symptom identification, preventativebehaviors, and vaccination information. Next, I focus on misinformation and disinformation andthe three topics that feed into this theme – deaths, preventative behaviors, and symptoms of thevirus. Finally, I explore the theme of uncertainty reduction, and how information passed viaTwitter on both preventative measures and vaccinations contributed to the information-gatheringcycle individual users engaged in before entering the persuasion phase of the process, which wascharted through the survey phase of this research project.
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 Health-information-seeking Behaviors Health-information themes focus on “the origin, treatment, symptoms, and otherbiological perspectives associated with a disease” (Wang, Smith, & Worawongs, 2010). Byframing the H1N1 outbreak with medical or health information, communicators create aperception of the virus as a health crisis and lead others to understand the virus outbreak in thismanner (Entman, 2007). Medical frames can allow communicators the ability to be more neutralin sharing information, and thus, researchers can conclude that more organizations would posthealth information-themed Tweets than would individuals (Clarke, 1991). According to Entman,medical frames can also “introduce or raise the salience or apparent importance of certain ideas,activating schemas that encourage target audiences to think, feel, and decide in a particular way”(2007, p. 164). In effect, Tweets that deal with health information and are framed in a medicalmanner help users in the first step of the innovation-decision process – the information stage. Inmy research, I discovered that Twitter users posted both information-seeking and -giving poststhat fit into the health information theme. These Tweets point to the first step in the innovation-decision process – the information stage.
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Table 1Tweets Relating to Information on H1N1Categories of Information Example TweetsHealth information Symptom identification Swine flu: symptoms so mild many donʼt recall them Preventative measures There is a lot more to preparing for and preventing Swine Flu than just washing your hands… Vaccination Swine flu ʻshould be included in new seasonal vaccineʼ – AFPMisinformation and disinformation Symptom misidentification Swine flu publicity means uptick in OCD symptoms Preventative measure confusion Human Protein That Can Prevent or CURE H1N1 Swine Flu—Naturally! Vaccination misinformation They are Injecting Mercury into ChildrenUncertainty reduction Deaths Another swine flu death this time from Bahraich Prevention of spread Ordinary disposable surgical masks do not protect health care workers from swine flu Safety and availability of Swine flu jab receives good response vaccinesIn addition, public health entities like the CDC use Twitter as a portion of their public healthinformation network, which was instituted “to make communication easy, to make informationaccessible, and to make secure data exchange as swift and smooth as contemporary technologywill allow” (Peddecord et al., 2008; Baker, Freide & Moulton, 1995). These public entities workto persuade users to embrace behavioral change, the true test of diffusion of an innovation, andthis behavior was evident from some health information Tweets as well (Peddecord et al, 2008).
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Symptom Identification The first sub-theme relating to health information found during the content analysis ofTweets about H1N1 was symptom identification. It was a primary way users found both to seekand share information on the virus. The sharing of health information ranged from users tellingtheir particular symptoms and seeking verification of those symptoms’ validity to complainingabout other people’s symptoms when they appeared in public ill with what appeared to be thepandemic virus. A sample of symptom-related Tweets included: • Feel crap. Reckon its #swineflu. How would ya know? A 2 wk cold that suddenly gets worse with fever and weepy eyes...feel like death • Swine flu: symptoms so mild many don’t recall them: • I am that coughing guy on the tube who you are looking at trying to determine if thats swine flu or just a nasty cold. #innocent #swineflu • 100.4 fever... who wants to bet what time i end up at the ER? #swineflu • the fifth day the 2yrs old had fever hope it will stop tomorrow hate the #swineflu • sudden onset of extreme nausea & fever. #swineflu ?? • Do you know the #symptoms of #H1N1 in #pets? #animals #cats #dogs #swineflu #flu #family • Dude in the office moaning and coughing like he has emphysema. #contagious #swineflu • On the train to london. Desperately trying not to sneeze on people and creating a #swineflu stampede. Still would get carriage to myself.
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 • In times of #swineflu its somehow irritating to see people that handle your food cough or sneeze. Tweets such as “Why would you go in public if you were non-stop coughing?!?” and“looking at people with disgust when they sneeze” summed up what many individuals felt aboutthose who had either the regular flu or a more dangerous variant, yet refused to go to the doctoror stay away from crowds. While these tweets may appear that individuals on Twitter are simplycomplaining about inconsiderate sick people, perhaps their complaints were able to help othersick individuals from entering society and spreading their illness. Individuals not only sought information about symptoms as shown above. Organizationswere able to share pertinent information that would help individuals determine if they needed toseek medical advice because of sickness. Tweets like “What is H1N1 swine influenza & Whatare the symptoms?” followed with a link to a website containing more health information aboutthe flu were able to connect many with concise and precise data about flu symptoms, treatmentsand prevention. Many health organizations were able to use the medium of Twitter not only toshare information about vaccination clinics, as seen above, but also to help guide sick individualsto the proper treatment when necessary. In fact, the World Health Organization, one of therecognized global leaders in the fight against the spread of H1N1 was able to use tweets like“Swine Flu symptoms still widespread globally; statistics update by WHO” to share authoritativeinformation with the approximately 75,000 followers who watch the @whonews Twitter feed tofind out the latest information on H1N1 and other world health crises.Information on Preventative Measures Symptoms were not the only subject that individuals and organizations sought and sharedinformation about. Tweets such as “Morbid Obesity as a Risk Factor for Hospitalization and
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Death due to 2009 H1N1 Virus” led readers to more health information about the spread of thevirus – combining data about the virus with more health information about preventativemeasures. The obesity-focused tweet was particularly popular for retweeting, or the passingalong of information that individuals find to be important or particularly informative, as it waspassed along the Twitter information superhighway another seven times – within the three dayswhen Tweets were analyzed – beyond the initial sharing. The sharing of this pertinentinformation shows particular interest in how different lifestyle choices figured into the possibilityof the virus’ spread. The obesity-centered H1N1 Tweet was but one example of how healthinformation was tied to preventative measures – both for individuals seeking help and thosetrying to give help. The Tweets numbered in the hundreds in the dataset; here are a fewexamples: • RT @fffabulous: simple preventative ways to avoid the swine flu #swineflu (via @LoriGregory) #momspotting • There is alot more to preparing for and preventing Swine Flu than just washing your hands. .. #swineflu • Household Transmission Of H1N1 Influenza During Initial Outbreak Limited By Preventive Behaviors #swineflu • New blog post: : Preventing Common Cold and Flu with an Air Purifier in Your Home #airpurifiers #cold #swineflu • #H1N1 #SwineFlu #News Surgical masks effective in preventing H1N1: • #swineflu Clean Door Handles Prevent Swine Flu | If one of them had swine influenza you might have p...
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 • #swineflu H1N1 Swine Flu Prevention in the Dental Office | jellofarts blog: Personnel providing direct patient ca... • #SwineFlu Schools add Swine Flu Prevention 101 to their curriculum - WMBF • Do You Want To Keep Your Family Safe? Learn How To Prevent Swine Flu #swineflu • #swineflu Alert swine influenza … You can prevent infection and a pandemic ...: When most people think about the p... such as the ones focused on sharing preventative measures within the classroom andthe workplace are particularly strong illustrations of organizations utilizing the medium ofTwitter to share health information with the world in order to help stop the spread of the virus.H1N1 Vaccination Information Sharing Just as the swine flu Twitter stream featured hundreds of Tweets about both symptomsand preventative measures, posts focused – especially well into the outbreak – into sharing andsearching for information on vaccinations. Information on H1N1 vaccination shared via Twitteris wide-ranging, from particulars on where and when flu shots would be offered to the possibleside effects of H1N1 vaccinations. These health-information Tweets are focused on theinformation-sharing side of the equation, but one can also see a number of posts seekinginformation about the safety of vaccinations. One of the most important uses of the medium during the height of the outbreak,however, was the use of Twitter to share information on vaccine clinics. Thousands of tweetssuch as “Free H1N1 vaccine available Sunday at Pensacola locations” allowed residents ofcertain areas the opportunity to find pertinent health information as well as alleviate uncertainty
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about the virus and its prevention. In addition, organizations whose job was to ensure thatvaccines were administered were able to pass their message along in much the same way as theywould use mass media. When individual Twitter users reposted information on clinics throughretweets, the message from health organizations was simply communicated to a larger audiencethrough the mass medium. Indeed, sharing information via Twitter on vaccination clinics becamea new form of mass media, albeit with an interpersonal communication twist, and a valuableweapon for those fighting the spread of the virus. A sample of vaccination-related Tweetsincluded: • Swine flu vaccine producers reach last trial stage in India - ( #swineflu #H1N1 • Commentary on potential CDC pandemic #H1N1 vaccine mismatches #swineflu • #SwineFlu #H1N1 #News Get your children vaccinated against swine flu: • Get your children #vaccinated against #swineflu - This Is : • Contra Costa County Offering New #SwineFlu Clinics - CBS 5 : • #SwineFlu #H1N1 #News Scottish GPs hit swine flu vaccination targets: • RT @intouchwme RT @hniman: Comments on #H1N1 #vaccine failure in #Wyoming & D225G role #swineflu :[ • Majority of at risk Islanders did not bother with the #swineflu jab - Isle of Man Today :
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 • CSL Profit Beats Estimates on Swine Flu Vaccine Sales #swineflu #vaccine • Swine flu should be included in new seasonal vaccine - AFP ( #swineflu #H1N1 Throughout the spread of the virus, individuals and organizations shared data onvaccination clinics as well as how the vaccine was perceived in different areas of the world. Thisinformation sharing was valuable to those who might not obtain information in traditional ways,particularly those who were in a high-risk category but unable to obtain information fromtraditional mass media or interpersonal connections.
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 Misinformation and Disinformation While Twitter certainly allows legitimate organizations and individuals to pass alonginformation related to H1N1, its symptoms, prevention, and vaccinations, the medium alsoallows individuals and groups the opportunity to pass along false information. This data sharingis not always intentionally malignant. However, disinformation can negatively impactindividuals’ ways of dealing with the virus during times of crisis. In addition, misinformation cancause individuals to avoid life-saving measures because there is a vacuum of correct information.In the absence of data that could influence users to embrace the innovation of immunization orpreventative measures, disinformation and misinformation can cause real issues for health-careproviders. In short, the use of misinformation can prevent individuals from reaching the secondstep of the innovation-decision process, persuasion, which Rogers (2003) states is the stage in theprocess where an individual forms a positive or negative opinion of an innovation. In this case,individuals needed to form a positive opinion of the H1N1 vaccination and preventiontechniques in order to practice them. From uncertainty, which will be discussed in the following section, frequently comes aspread of misinformation. A lack of information in a crisis creates a vacuum that communicatorsare driven to fill (Ulmer et al., 2007). For instance, during the October 26, 2009, shooting on theUniversity of Central Arkansas campus, individuals were driven to blogs, Twitter, and otherCMC tools in order to find out more information. The quickest individuals to respond touncertainty with information are frequently not the ones with correct information. The spread ofmisinformation could easily be seen in the beginning of the H1N1 outbreak by the numerousmentions of staying away from pork or avoiding travel to certain areas of the world – bothTweets that were carried around the world but that had no actual basis in fact. In this case,
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however, unlike scholars had earlier noted, misinformation and disinformation were not passedalong because of an ill intent or a desire to persuade (Hatchen & Scotton, 2007). Instead,individuals were trying to fill an overwhelming information vacuum with their Tweets.Symptom (Mis)identification Perhaps the most misinformation on H1N1 that was shared via Twitter concerned theidentification of symptoms related to the spread of the virus. According to the Centers forDisease Control and Prevention (2010a), H1N1 flu symptoms included fever, cough, sore throat,runny or stuffy nose, body aches, headache, chills and fatigue. However, during the height of thevirus discussion, Tweeters attributed everything from hot hands to pale skin to the onset of thevirus. No doubt many individuals were confused if they were unable to verify information aboutsymptoms of the virus with expert sources. Posts that featured misinformation about H1N1symptoms differed from posts that featured health information-seeking and -sharing because theindividuals who broadcast symptom misinformation listed incorrect symptoms. In addition, theseTweets with misinformation focused on missing work or school or taking advantage of one’sapparent symptoms. In the course of the three days targeted for content analysis, the tweet “I look like a#zombie really feel awfull, … maybe i have the #swineflu” appeared over 120 times in theanalyzed tweets. The individual user who originally sent this tweet may have known that H1N1symptoms include fever, aches, and fatigue, but he or she may not have known that a simplecomplaint would spread so rapidly (CDC, 2009a). And while this Twitter user did not spreadcompletely false information, his or her approach certainly raised red flags for those of herfollowers who were concerned about the spread of the disease and their contact with him or her.Individuals also expressed concern when actress Lindsey Lohan tweeted about being achy
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(“Lindsay’s tweet sparks,” 2010). Her offhand remark sent shockwaves through news media aswell as the Twitter universe, with a number of tweets such as “Lohan sparks #swineflu fears with‘achey’ tweet” being sent after her original message. Other Tweets that spread misinformationabout symptoms included: • Swine flu publicity means uptick in OCD symptoms - Gloucester Daily Times: All those swine flu warnin.. #swineflu • Im almost certain that with the amount of coughin sneezing and blowing of the nose going on in this train car somebody has the #swineflu • Speaking at Harvard: - Salon: randomly shouting -Swine Flu- at anyone who coughed.) I experienced my .. #swineflu • Going down hill rapidly I hope this isnt swineflu #swineflu symptoms • #nevertrust a person that says “my allergies actin up” a cough a sneeze or a runny nose lasting more than 3 days = #swineflu • #nevertrust someone thats been coughing/sneezing and wants to give u daps or if its a female give u a hug...#swineflu • #nevertrust a person thats too touchy feely especially if you dont them #swineflu #H1N1 • S/O 2 Me Coughing all over the place acting like I got the #SwineFlu ... Lol can we say day off #WithPAY Hello Brooklyn :-) !!!!Confusion on Preventative Measures Alongside many Tweets about symptoms that contained misinformation anddisinformation, there were a large number of Tweets that featured dubious data on preventativemeasures. Most of the tweets aimed at preventative measures appeared to be designed to sell
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some specific tool or information about the spread of the virus. And for almost every one tweetthat tried to sell something, there was a tweet designed to debunk the misinformation that waspassed around. For instance, for every “Should I wear a flu mask to protect myself from swineflu?” tweet accompanied by a link to a medical supplies warehouse, there was a “Garlic SellersCashing In On Flu Rumors (That Garlic Prevents Swine Flu” to dispel myths. In this way,Twitter became a self-correcting network during the H1N1 outbreak. Individuals were able tofind information – both correct and incorrect – about the virus, and they were able to reactappropriately when choosing preventative measures. A few of the preventative measure Tweetswere: • Preventing Illness- Including the Flu! | #h1n1 #health #swineflu #flu • #SwineFlu Human Protein That Can Prevent or CURE H1N1 Swine Flu--Naturally! - • Aurelie with the bear mask : #mask #swineflu #bear #H1N1 #vaccine #flu #protection #pimp #prevent • Tonight Im trying a humidifier some voo-doo and any other magical snake oil I can find. #bedtimesucks with my cough from the #swineflu! • Epigallocatechin Gallate (EGCg) in Green Tea Confirmed to Prevent ... - Yahoo Finance: Influenza viru.. #swineflu • #SwineFlu Prevention Tip 34: This Christmas dont open any presents and avoid all contact with loved ones to keep from getting sick. Tweets aimed at helping individuals prevent the spread of the swine flu virus ranged fromthe innocuous “Here are 10 swine flu prevention tips” to the inflammatory “Think schools should
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be closed to prevent #SwineFlu outbreaks?” While the first tweet was clearly information-sending and designed to help individuals, the second tweet on prevention was information-seeking and appeared to be designed to spark a discussion on the virus. Especially during theheight of the virus spread, such discussions could quickly go awry, resulting in arguments overthe safety of everything in the brave, new world that contained such horrors as H1N1.Vaccination (Mis)information While organizations and individuals worked to share the correct and official informationconcerning vaccination programs surrounding the H1N1 outbreak, a great deal of what could beperceived as misinformation was also shared about vaccines and their safety. These posts – onesthat shared incorrect information or showed that the user was uninformed about the vaccine –disagreed with public health policy that advocated the vaccination of most individuals (Centersfor Disease Control and Prevention, 2009b). Side effects resulting from a vaccination were themost common types of posts that featured misinformation. These misinformative vaccinationposts were different from other Tweets focused on vaccinations because they listed a host ofnegative symptoms that were different from those listed in CDC materials. The CDC listed themost common vaccination side effects as soreness, redness, and swelling where the shot wasgiven (2009b). However, Twitter users listed a litany of possible negative effects from thevaccination as well as questions about the vaccinations’ efficacy and safety; a sample of thoseTweets included: • My arm hurts and I feel weak and milky today. Poor me. #symptomsfromtheswinefluvaccine #swineflu • If these are swineflu #vaccine symptoms I do not want to have the #swineflu. • #Swineflu jabs may be wasted - The Age :
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 • Live #Radio #Today 3PM EST They Are Injecting #Mercury into Children #H1N1 #Swineflu #novacs @mayereisenstein • #SwineFlu Severity warning over low uptake of swine flu jab - The Standard • Vulnerable patients shunning #swineflu #vaccine GPs warn - : • No soreness in my arm but am feeling the first side-effect of the vaccine: lethargy #swineflu
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 Uncertainty Reduction In addition to communicating via Twitter on H1N1 for health information and findinginformation, misinformation, and disinformation, users of the microblogging service were able touse Twitter to alleviate uncertainty. Frequently, information was shared to dissuade individualsfrom believing the misinformation and disinformation that were passed along through Twitter atthe beginning of the outbreak. When Tweets were examined for content, a large number surfacedthat related to the uncertainty that individuals felt in the context of a worldwide health crisis.Ulmer, Sellnow, and Seeger (2007) define a crisis as an exceptional event, something that resultsin a certain amount of surprise and threat for individuals as well as a situation that requires ashort response time for communication of answers or assistance. In fact, the less individualsknow about a given situation, the more uncertain they are and the more they search outappropriate information to make themselves comfortable with a situation (Littlejohn & Foss,2008). The H1N1 outbreak in 2009 is a pertinent example of a health crisis; a large amount ofuncertainty resulted for individuals who felt they were in danger of contracting the virus. Theunique pattern of deaths that resulted from the virus (Figure 2), with a large number of youngadults dying from the disease, caused even more uncertainty for those who would normallyconsider themselves safe from such an infection. As a result, a large number of Tweets wereposted that showed individuals’ concerns with deaths as well as a number of Tweets that werefocused on finding information about symptoms and vaccination sites. Though these sub-themesrepeat the themes discussed in earlier sections, an analysis helped discern that individual usersand organizations are clearly concerned with alleviating uncertainty through CMC. As asecondary result of the effective use of Twitter to remove uncertainty, organizations were able to
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bring individuals to the tipping point of information, helping them enter the persuasion phase ofthe innovation-decision process (Figure 6).Figure 6. Representation of the tweeting processes Involved in persuasion for decisionmaking in H1N1 vaccination. Adapted from Ev Rogersʼ Diffusion of Innovations.
Information about Deaths On each of the three key analysis dates, a number of Tweets appear detailing death countsin various countries, and these “death Tweets” are directly tied to the uncertainty-reductiontheme. While individuals may not like hearing about the number of deaths throughout the worldbecause of H1N1, it was certainly better for users to know the truth than guess about thepossibilities. Observers were able to watch the spread of the virus throughout the world viaTwitter. In addition to sharing information on numbers and the virus’ spread, these focused
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Tweets allow a view into the effect of the virus on health-care workers. For instance, a tweetstating “Moldova: 15 H1N1 deaths incl doctor infected from patient” reminds observers thatthose who are entrusted with treating patients are also in danger of contracting H1N1. Other“death Tweets” included: • #SwineFlu Another swine flu death this time from Bahraich - Indian Express • CDC Offers Latest Estimates of H1N1 Toll #h1n1 #swineflu (via @Breaking_h1n1) • Medics meet to discuss #swineflu death - Daily Echo : • US #h1n1 #swineflu figures for last year: up to 86m infections 12000 deaths • Swine Flu Death Toll in India goes up to 1415 - BreakingNewsOnline. ( #swineflu #H1N1 • 2 some-more deaths in Oklahoma uncover H1N1-flu risk remains #swineflu #hongkong • Global #swineflu death toll creeps towards 16000: #WHO - Victoria Times Colonist : of H1N1 Prevention Information In addition to sharing H1N1 death tolls or seeking information on them, individuals whoused the social media microblogging service sought and shared information on their symptoms.Organizations also used the medium to share data about how to prevent the spread of the virus.These tweets went much further than the health information recommendations for hand washingand covering the nose and mouth when coughing and sneezing, however. Many groups –
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companies that were probably marketing items designed to play on individual fear about H1N1spread – used the service to tout their wares as the best way to keep from getting swine flu. Byusing Twitter in this way, these companies not only shared health information, they also tookadvantage of individuals’ uncertainty about the H1N1 virus and its spread. Examples of theseTweets designed to relieve uncertainty about prevention of the virus include: • #swineflu Swine Flu- How Can I Optimize My Immune System? | Swine Flu: Swine flu or swine influenza was first • Swine Flu Protection. Flu Masks Surface Disinfectants. Be prepared. Protect yourself today. #swineflu • Ordinary disposable surgical masks do not protect health care workers from swine flu. #swineflu • Study links lack of paid sick days to spread of Swine Flu - Bristol Press ( #swineflu #H1N1 • N95 masks are the only masks that provide protection from the swine flu virus. #swineflu • Swine Flu: Know what to do if a family member gets sick #swinefluSafety and Availability of Vaccines Finally, individuals and groups used the medium of Twitter to communicate informationabout vaccinations – their safety and availability – in order to alleviate uncertainty within thegeneral population. The vaccine talk received much attention in each of the areas covered byH1N1 themes in this content analysis. A sample of the information-seeking and -supplyingTweets that focused on vaccinations are:
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 • #SwineFlu #H1N1 #News Swine flu jab receives good response: • Commentary on potential CDC pandemic #H1N1 vaccine mismatches #swineflu • U.S. may end up discarding unused #swineflu vaccine #tcot #tlot • #H1N1 #SwineFlu #News 500000 people vaccinated against A/H1N1 flu in Mexican capital: • #H1N1 #SwineFlu #News 34300 doses of imported H1N1 vaccine arrive in Mumbai: • #H1N1 #SwineFlu #News Azerbaijani health minister: No complications in A/H1N1 vaccination in Azerbaijan: The concept of using information to promote particular health-related behaviors is not anew one, though scholars have recently become more interested in health information as an areafor study. The use of entertainment media in particular has become more popular in recent years,as scientists and doctors attempt to use friendly methods of sharing health information with theindividuals who are most affected by particular diseases and syndromes (Peddecord et al., 2008;Singhal, Njogu, Bouman, & Elias, 2006). From birth control to preventing HIV and AIDS toencouraging vaccinations, communicators frequently use a variety of mass media andentertainment venues to share information with audiences. The use of Twitter to talk about the H1N1 outbreak is no different. In fact, according to apost from the computer-mediated communication tool, “#swineflu and #H1N1 were two of themost popular hashtags in all of 2009. #whenswineflew.” Twitter can also help individuals move
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from the first step of the innovation-decision process – information acquisition – to the secondstep – persuasion. In the second section of my research, I worked to discern how much individualTwitter users paid attention to their feeds when it came to information on H1N1.