#Asthma #Inhaler: Evaluation of visual social media depictions of inhalers and spacers

#Asthma #Inhaler: Evaluation of visual social media depictions of inhalers and spacers

Clinical Communications #Asthma #Inhaler: Evaluation of visual social media depictions of inhalers and spacers Danielle Rosenzweiga, and Andrew S. Nic...

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Clinical Communications #Asthma #Inhaler: Evaluation of visual social media depictions of inhalers and spacers Danielle Rosenzweiga, and Andrew S. Nickels, MDb,c,d Clinical Implications

 Visual depictions of inhalers on social media infrequently include spacers. An opportunity exists to improve the social media depictions of the optimal inhaler technique.

TO THE EDITOR: Social media is an important part of health care, with patients using this evolving technology for both disease information and advice.1,2 The role of social media and its utility in the management of asthma is being actively researched.3 Inhalers and appropriate techniques are essential for appropriate asthma care. Spacer use is important for drug delivery and can lead to improved outcomes.4 We undertook a study to characterize the visual depiction of inhalers on 3 prominent social media sites. On the basis of author’s (A.S.N.) personal observation using social media and informal discussions with colleagues, we hypothesized that spacer use would be depicted in the minority of photos showing inhalers. We performed observations on 3 social media websites (Facebook, Twitter, and Instagram) daily for 3 days on 2 separate occasions (July 14-16, 2016, and August 8-10, 2016). Two “hashtags” were used to perform the searches: #asthma and #inhaler. Native search engines were used for Facebook and Instagram, and the service TwiPho (twipho.net) was used to search Twitter photos. For each day of collection, 100 consecutive photos were reviewed for inclusion. A total of 3600 photos were screened (1200 per social media site or 1800 per hashtag). Photos with inhalers were included in the analysis. Included photos underwent visual analysis for the following observations: source (Facebook, Twitter, Instagram), hashtag search term use (#asthma, #inhaler), branded (yes, no), device only or with person, device in use (yes, no), age of person (adult, pediatric, not applicable), spacer shown (yes, no), type of spacer (mask, mouthpiece, not applicable), type of depiction (real or abstract), and duplicate photo (yes, no). “Real” depiction was defined as photo realistic representation, and the label of “abstract” was used for nonphoto realistic portrayals (ie, drawings, cartoons, etc). Observations/categorizations were performed visually by a primary investigator (D.R.) with confirmation from a coinvestigator (A.S.N.) if the classification was not clear. Thirty-six photos (4.7%) were flagged for review. The senior author’s (A.S.N.) decision was final. Descriptive analysis and Pearson chi-square testing were used. Statistical significance was set at P < .05. Of the 3600 photos screened, 762 photos contained inhaler depictions and were included in this analysis. Photos with inhalers occurred most frequently on Facebook (25.0% [n ¼ 300

of 1200]) and least on Twitter (18.5% [n ¼ 222 of 1200]) (P < .01). We identified 240 (18.5% of 1200 screened) photos from Instagram. Most depictions (91.7% [n ¼ 699 of 762]) were unbranded. Slightly over half the photos depicted only the device (without a person). Of the photos with people, 67.4% (n ¼ 299 of 340) appeared to be adults. Spacers were shown in only 7.7% (n ¼ 59 of 762) of photos that showed inhalers. Photos that were nonduplicates, “real” depictions, depicted inhalers with patients, and showed pediatric patients were all statistically more likely to show spacers. Table I presents the full descriptive findings as well as the associations that would likely depict spacers. This observational pilot study suggests that depictions of inhalers on social media infrequently include spacers. This finding raises a timely concern regarding the portrayal of disease-specific content our patients may be viewing online. Spacers have been shown to improve inhaled drug delivery to the lung and are recommended by the National Asthma Education and Prevention Program.4,5 If the overwhelming majority of depictions of inhalers are shown without spacer use, this may serve to normalize suboptimal drug administration behavior by our patients who view this content. Depictions of health careerelated topics in popular media may lead to inaccurate vernacular beliefs about important concepts. An example of this phenomenon is a family’s optimistic beliefs regarding cardiopulmonary resuscitation outcomes, with a family citing television as a frequent informational source.6 Cardiopulmonary resuscitation portrayals on major TV medical dramas have been shown to depict high rates of survival and low morbidity following arrests.7 As patients increasingly engage on social media, the more common portrayal of inhalers without spacers may influence the general population’s view on the importance of spacers in asthma care. This study has several limitations. Observations were made over a relatively brief time period. It is unknown if the study period or the number of photos offer generalizable observations. Authors made observations for this study and some categorizations were subjective (ie, adult vs pediatric). The use of visual recognition software could improve this study. Despite these methodologic considerations, we believe that this study provides valuable insight into social media representations of asthma medications. The importance of social media in health care continues to be recognized. Academic medical centers are actively promoting the importance of social media activities among their faculty/staff. Allergy/Immunology providers are championing social media to improve patient care, enhance information found online, and promote their practices.8-10 National allergy and asthma organizations, as well as patient advocacy groups, should be aware of the role of social media with visual representations in the optimal use of common medications such as inhalers with spacers on social media. Further exploration into this area could lead to the formation of best practice guidelines for trusted social media voices (ie, physicians, patient advocacy organizations, etc) regarding how visual media depicting patient behavior ought to be managed. Studies are needed to determine whether exposure





TABLE I. Descriptive findings and associations with spacer depiction in 762 photos showing inhalers identified on 3 commonly used social media sites Observation

n (%*)

Spacer shown, n (%†)

to ideal medication depictions on social media by patients with asthma or other allergic conditions improve medication use, technique, adherence, or clinical outcomes.

Pz a

Social media source Facebook 300 Instagram 240 Twitter 222 #HashTag Asthma 268 Inhaler 494 Spacer shown Yes 59 (7.7) No 703 (92.3) Spacer type (n ¼ 59) Mouthpiece 26 (44.1) Mask 32 (54.3) Both 1 (1.7) Branded inhaler Yes 63 (8.3) No 699 (91.7) Device in use Yes 313 (41.1) No 449 (58.9) Device only or with person Device only 422 (55.4) Device with person 340 (44.6) Age (n ¼ 340) Adult 229 (67.4) Pediatric 111 (32.6) Duplicate Yes 493 (64.7) No 269 (35.3) Real or abstract depiction Real 575 (75.5) Abstract 187 (24.5)

University of Notre Dame, Notre Dame, Ind Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn c Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn d Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tenn Conflicts of interest: The authors declare that they have no relevant conflicts of interest. Received for publication October 29, 2016; revised March 13, 2017; accepted for publication April 17, 2017. Available online -Corresponding author: Andrew S. Nickels, MD, Vanderbilt Asthma, Sinus, and Allergy Program, 2611 West End Ave, Suite 200, Nashville, TN 37203. Email: [email protected] 2213-2198 Ó 2017 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2017.04.029 b

19 (6.3) 20 (8.3) 20 (9.0)


19 (7.1) 40 (8.1)


1 (1.6) 58 (8.3)


31 (9.9) 28 (6.2)


19 (4.3) 40 (11.8)


7 (3.1) 33 (29.7)


29 (5.9) 30 (11.2)


59 (10.3) 0 (0.0)


*Percentage out of 762 photos unless otherwise noted. †Percentage out of total photos present in respective category. zBased on Pearson chi-square test.

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