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?????????All paragraphs must be narrative and cited in the text- each paragraph
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?????????Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph
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5) Identify your answer with the numbers, according to the question. Start your answer on the same line, not the next
Q 1. Nursing is XXXXX
Q 2. Health is XXXX
Please, read the attached article and analyze it based on its merit by answering the following questions:?
1- Has the author formulated an appropriate research question based on the problem/issue? (1 page)
2- Is the research question clearly defined in terms of its scope and relevance? (1 page)
3- What is the author?s orientation towards the research problem/issue? (1 page)
a.Is it critical analysis or interpretation based??
4- How does this article contribute to your understanding of possible research modalities and methods (yes)? (1 page)
a. Explain why?
The student’s current research is: “Evaluation of therapeutic adherence in patients with diabetes type 2 Mellitus”
5- What are the strengths, limitations of the study? (1 page)
6- Which Essentials do you see represented in this article and why? (1 page)
a. ?Scholarship?for Evidence?Based?Practice?
b. ?Information Management and?Application of Patient? Care?Technology??
Translating evidence to practice in the health professions:
a randomized trial of Twitter vs Facebook
Jacqueline Tunnecliff,1 John Weiner,2 James E Gaida,3 Jennifer L Keating,1
Prue Morgan,1 Dragan Ilic,2 Lyn Clearihan,4 David Davies,5 Sivalal Sadasivan,6
and Stephen Maloney
1Department of Physiotherapy, Monash University, Frankston, Australia, 2Department of Epidemiology and Preventive Medicine,
Monash University, Melbourne, Australia, 3Discipline of Physiotherapy and University of Canberra Research Institute for Sport
and Exercise (UCRISE), University of Canberra, Canberra, Australia, 4School of Primary Health, Monash University, Melbourne,
Australia, 5Warwick Medical School, University of Warwick, Coventry, United Kingdom, 6JC School of Medicine & Health Scien-
ces, Monash University Malaysia and 7Swami Vivekanand National Institute of Rehabilitation Training and Research, Odisha,
Correspondence to Associate Professor Stephen Maloney, Department of Physiotherapy, Monash University, PO Box
527, Frankston, 3199, Victoria, Australia; [email?protected]
Received 7 October 2015; Revised 21 April 2016; Accepted 30 April 2016
Objective: Our objective was to compare the change in research informed knowledge of health professionals
and their intended practice following exposure to research information delivered by either Twitter or Facebook.
Methods: This open label comparative design study randomized health professional clinicians to receive
?practice points? on tendinopathy management via Twitter or Facebook. Evaluated outcomes included knowl-
edge change and self-reported changes to clinical practice.
Results: Four hundred and ninety-four participants were randomized to 1 of 2 groups and 317 responders ana-
lyzed. Both groups demonstrated improvements in knowledge and reported changes to clinical practice. There
was no statistical difference between groups for the outcomes of knowledge change (P? .728), changes to clini-
cal practice (P? .11) or the increased use of research information (P? .89). Practice points were shared more by
the Twitter group (P < .001); attrition was lower in the Facebook group (P < .001).
Conclusion: Research information delivered by either Twitter or Facebook can improve clinician knowledge and
promote behavior change. No differences in these outcomes were observed between the Twitter and Facebook
groups. Brief social media posts are as effective as longer posts for improving knowledge and promoting
behavior change. Twitter may be more useful in publicizing information and Facebook for encouraging course
Key words: social media, evidence-based practice, communication, education, professional, computer-assisted instruction
A significant gap remains between research generated healthcare
knowledge and clinical practice.1?3 Social media can rapidly link
researchers and clinicians from diverse geographical regions,
disciplines, and areas of practice; making it an ideal medium for
knowledge exchange and education. Approximately 25% of
health professionals currently use social media for obtaining
Social media has been defined as a ?collection of web-based
technologies that share a user-focused approach to design and func-
tionality, where users can actively participate in content creation
VC The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved.
For Permissions, please email: [email?protected]
Journal of the American Medical Informatics Association, 24(2), 2017, 403?408
Advance Access Publication Date: 29 June 2016
and editing through open collaboration between members of com-
munities of practice.?5 The use of social media in education may
lead to positive learning experiences,5,6 increases in knowledge and
skills,7?10 and changes to the clinical practices of health professio-
nals.10,11 However, there is a need for studies to evaluate the relative
effectiveness of different social media based applications.12
Two of the largest social media applications are Facebook (1.49
billion monthly active users) and Twitter (316 million monthly
active users).13,14 Both sites promote user interaction and allow
posting of text, videos, and weblinks; however, Twitter limits posts
to 140 characters. Neither site charges access costs. The popularity
and features of these sites indicate their potential application in
communicating research information and, therefore, were chosen
for investigation in this study.
The primary objective of this study was to determine if research
information delivered by Twitter or Facebook would result in
greater changes in research informed knowledge and practices of
health professionals. The secondary aim was to compare participant
behavior and engagement with the two mediums.
An open label randomized comparative design was used, with a
mixed methods approach to data collection and analysis. The Mon-
ash University Human Research Ethics committee (CF 14/1372 ?
2014000640) approved the study.
Health professional clinicians of any discipline (e.g., medicine, phys-
iotherapy, podiatry), geographical location, or level of expertise
(including undergraduate students), were eligible to participate.
Recruitment occurred via an email invitation distributed to clinical
affiliates and departments of Monash University, Faculty of Medi-
cine, Nursing and Health Sciences, Australia; Monash University
Malaysia; Swami Vivekanand National Institute of Rehabilitation
Training and Research, India; and the University of Southern Cali-
fornia. Professional associations representing professions registered
with the Australian Health Practitioner Regulation Agency15 were
also invited to distribute the invitation to participate via email or
their own social media sites.
A short course, consisting of the same 8 ?practice points? or key
educational messages of 140 characters or less, on topics related to
tendon management were delivered to each group via posts on Twit-
ter16 and Facebook17 web pages. Each practice point was linked to
supplementary information in the form of peer-reviewed journal
articles or podcasts by clinical experts. The course was designed by
educational, clinical, and research experts, and was identical except
that the Facebook posts contained the practice point plus an addi-
tional 2?6 short written statements (1?2 sentences) that highlighted
key concepts from the supplementary information. The practice
points were delivered evenly over a 2 week period, to both groups at
the same time points. The pages were not restricted access.
Clinicians consented to participate by providing contact details
through an online survey. Those who provided a valid email address
were enrolled. Participants were stratified by role (student, clinician,
or other) and randomized to receive the practice points via Twitter
or Facebook. Participants received video and written instructions on
obtaining a social media account and accessing the practice points
from their allocated site. The instructions also encouraged interac-
tion on the allocated site. Participants were sent three reminder
emails at each data collection point to minimize attrition. The study
was conducted between August and October 2014.
Data was obtained via an anonymous online survey completed 1
week before (baseline assessment) and after (post-intervention
assessment) the short course. A password was used to match pre-
and post-course data. Demographic details, information on tendon
management experience, and current use of social media were
Outcomes were determined based on the Kirkpatrick hierarchi-
cal levels of evaluation 1?3.18 Participation and engagement data
was also collected. A data collection summary can be found in
Kirkpatrick Level 1: Participant Reactions
The Social Media Use and Perception Instrument (SMUPI), a ques-
tionnaire of 10 items with high internal consistency,19 measured
attitudes towards using social media in continuing professional
Kirkpatrick Level 2: Knowledge
Sixteen multiple choice questions assessed knowledge (A?E
responses) (Appendix 2). One question correlated with each
?practice point? and one correlated with information from each
piece of supplementary information. The questions in both assess-
ments were identical, but question and response order were random-
ized to minimize score improvements based on pattern recognition.
Participants were not given assessment answers until the conclusion
of the study. Self-rated measures of tendon management confidence
and knowledge were also obtained.
Kirkpatrick Level 3: Behavior Change
Participants were asked ?has the education you have received via
social media during this trial changed the way you practice, or
intend to practice, with musculoskeletal clients?? and ?has the edu-
cation you have received during this trial increased your use of
research evidence within your clinical practice??
Participation was evaluated via the number of participants who
connected with the social media pages and completed the assess-
ments. Data on interaction was obtained through participant self-
report and from the number of times posts were approved of
(?liked? or ?favorite?), shared or commented on.
Mixed linear models were used to analyze the repeated measure-
ments (pre- and post-exposure to the intervention) on the partici-
pants. The restricted maximum likelihood method (REML), as
implemented in the GenStat statistical package,20 was used to fit the
models, calculate predicted means and test, using F-tests, the main
effects of group (Twitter vs Facebook) and time (pre vs post) as well
404 Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2
as their 2-way interaction. Pairwise least significant difference tests of
the group-by-time means were based on these analyses and conducted
at the 5% significance level. Diagnostic plots of residuals were
checked for assumptions on which these methods are based. Analyses
of the 5-point Likert scale responses also used the restricted maximum
likelihood method as is customary with large datasets.21 The analyses
of binary response outcomes, measured post intervention, were based
on logistic regression models, also fitted using GenStat. Discrete count
data from Twitter and Facebook sites were analyzed using a variance-
stabilizing transformation in an analysis of variance.
Five hundred clinicians consented to participate. Five were excluded
due to an invalid email address, and one participant asked to be
removed. Four hundred and ninety-four participants were randomized.
The attrition rates from randomization to baseline assessment were
48.2% for the Twitter group and 41.7% for the Facebook group; the
difference was not significant [v2 (1, n?494)?2.09, P? .148]. Attri-
tion from baseline assessment to post intervention assessment was
32.8% for the Twitter group and 8.3% for the Facebook group; this
difference was significant [v2 (1, n?494)?17.37, P < .001]. Three
hundred and seventeen responses were analyzed (140 Twitter, 177
Facebook). There were 99 baseline assessments, 45 post intervention
assessments, and 173 matched baseline and post intervention assess-
ments. A consort flow-chart is available in Figure 1.
Demographic data and data on tendon management experience and
social media use was obtained from the baseline assessment and is
presented in Table 1.
Kirkpatrick levels 1, 2 and 3
Following the intervention, (the short course consisting of practice
points) there were statistically significant increases in SMUPI score,
self-rated confidence, self-rated knowledge and multiple choice
assessment score; but no statistically significant differences between
the groups in their changes over time. Participants in both groups
reported a change in practice/intended practice and increased use of
research in practice/intended practice as a result of the intervention
but there was no statistically significant difference between the
groups. This is shown in Table 2.
The Twitter page developed 428 ?followers? and the Facebook
page received 155 ?likes.? An estimated 10.0% (8/80) of the Twitter
group and 7.8% (9/115) of the Facebook group reported interacting
online. The difference between groups was not significant [v2 (1,
n?195)?0.28, P?0.597)]. An estimated 42.6% (20/47) of the Twit-
ter group and 34.8% (24/69) of the Facebook group reported lack of
time as a reason for lack of interaction on the social media sites.
Statistically significant differences were found between groups
for number of times information was shared (mean shares per post
Twitter 10.40, Facebook 0.20, SED 3.030, P < .001) and approved
of (?liked?/?favourite?) (mean Twitter 14.00, Facebook 8.00, SED
1.414, P? .005).
This study has demonstrated that research information delivered by
either Twitter or Facebook can improve clinician knowledge and
Expressed interest in par?cipa?ng (n=500)
n=1 complaint about process
n=5 no email address provided
Allocated to Facebook (n=247)Allocated to Twi?er (n=247)
Comple?on of baseline Assessment
Comple?on of baseline Assessment
Comple?on of post interven?on
Comple?on of post interven?on
Figure 1. Consort flow chart showing attrition of study participants.
Table 1. Participant demographics and participant characteristics
N (%)a N (%)a
Baseline demographic data sets 128 144
Area of practice
Physiotherapy/physical therapy 95 (74.2) 98 (68.1)
Medicine 18 (14.1) 19 (13.2)
Osteopathy 2 (1.6) 3 (2.1)
Podiatry 7 (5.5) 11 (7.6)
Other 4 (3.1) 11 (7.6)
Not stated 2 (1.6) 2 (1.4)
Undergraduate Student 33 (25.8) 36 (25.0)
Postgraduate Clinical Trainee 9 (7.0) 13 (9.0)
Clinician 78 (60.9) 78 (54.2)
Other 8 (6.3) 17 (11.8)
Not stated 0 (0.0) 0 (0.0)
Under 18 0 (0.0) 0 (0.0)
18?24 28 (21.9) 39 (27.1)
25?34 59 (46.1) 64 (44.4)
35?44 31 (24.2) 28 (19.4)
45?54 8 (6.3) 8 (5.6)
55?64 2 (1.6) 4 (2.8)
65? 0 (0.0) 1 (0.7)
Male 79 (61.7) 71 (49.3)
Female 47 (36.7) 71 (49.3)
Not stated 2 (1.6) 2 (1.4)
Australia 48 (37.5) 59 (41.0)
India 14 (10.9) 14 (9.7)
Malaysia 5 (3.9) 6 (4.2)
UK 29 (22.7) 23 (16.0)
USA 12 (9.4) 17 (11.8)
Other 19 (14.8) 24 (16.7)
Not stated 1 (0.8) 1 (0.7)
Tendon management experience
Provide health care to clients with
tendon disorders once a week or more
61 (47.7) 62 (43.1)
Social Media experience
Use Twitter 75 (58.6) 66 (45.8)
Use Facebook 106 (82.8) 130 (90.3)
aPercent of group (Twitter or Facebook) that provided baseline data.
Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2 405
promote behavior change. No statistical differences in these out-
comes were observed between the Facebook and Twitter groups.
This research is consistent with previous literature that indicates
that web based or social media programs are useful as learning
tools,5,7,8,10,11 and can improve clinician knowledge and promote
This study has also found that the provision of extra informa-
tion, beyond a 140 character message, did not impact on knowledge
or behavior change. Short messages may be beneficial to busy
healthcare workers as lack of time is often cited as a barrier to evi-
dence based practice.1 However, trustworthiness of information
gathered via social media is a key concern of clinicians.4 Our data
indicates that brief messages, when obtained from a reputable
source and linked to full sources of information may be acceptable
There were two interesting differences between the groups.
There was greater overall attrition from the Twitter group. Site
familiarity may be a factor, as more health professionals use Face-
book than Twitter.4 In this study, over 80% of clinicians in each
group use Facebook; <60% in each group use Twitter. The prefer-
ence of clinicians to use Facebook over other social media sites for
obtaining research information may also be a factor.4 Therefore, the
use of Facebook may have encouraged online course completion.
The Twitter page developed a far greater following than the
Table 2. Kirkpatrick level 1?3 outcomes
Predicted Mean (n)
Predicted Mean (n)
Difference (SED)b P-value
Kirkpatrick level 1 outcomes
Twitter 40.34 (126) 41.85 (86) 1.51 (0.66) .024
Facebook 39.53 (143) 40.86 (127) 1.33 (0.58) .022
Difference (SED)b ?0.81 (0.82) ?0.99 (0.91)
P-value .326 .277 .841d
Kirkpatrick level 2 outcomes
Self-rated confidence in tendon managementc
Twitter 3.380 (128) 3.784 (86) 0.404 (0.083) <.001
Facebook 3.216 (143) 3.644 (131) 0.428 (0.072) <.001
Difference (SED)b ?0.164 (0.106) ?0.141 (0.116)
P-value .124 .227 .830d
Tendon management self-rated knowledgec
Twitter 3.181 (127) 3.727 (86) 0.546 (0.082) <.001
Facebook 3.027 (143) 3.570 (131) 0.543 (0.071) <.001
Difference (SED)b ?0.154 (0.102) ?0.157 (0.112)
P-value .135 .163 .975d
Multiple choice assessment total score (max score 16)
Twitter 7.649 (123) 10.308 (80) 2.659 (0.381) <.001
Facebook 6.599 (136) 9.435 (118) 2.835 (0.331) <.001
Difference (SED)b ?1.050 (0.469) ?0.874 (0.521)
P-value .026 .095 .728d
Assessment score for questions that addressed the practice points (max score 8)
Twitter 4.155 (123) 5.523 (80) 1.368 (0.233) <.001
Facebook 3.789 (136) 5.431 (118) 1.642 (0.203) <.001
Difference (SED)b ?0.366 (0.259) ?0.093 (0.293)
P-value .159 .752 .378d
Assessment score for questions addressing the supplementary information (max score 8)
Twitter 3.485 (123) 4.819 (80) 1.333 (0.211) <.001
Facebook 2.848 (136) 4.025 (118) 1.177 (0.184) <.001
Difference (SED)b ?0.637 (0.255) ?0.793 (0.211)
P-value .013* .006* .578d
Number reporting change (n) % of group (95% CI) P (between group
Kirkpatrick level 3 outcomes
Reported change in practice due to intervention
Twitter 59 (77) 77 (67-86) .11
Facebook 77 (117) 66 (57-74)
Reported increased use of research in practice
Twitter 55 (78) 71 (60-81) .89
Facebook 80 (115) 70 (61-78)
aTotal of ten items, each measured on a 5 point Likert scale, whereby higher score?more favorable attitude.
bSED?Standard Error of the Difference.
cMeasured on a 5 point Likert scale 1?very poor, 5?very good.
dP-value is for the F-test of a two-way interaction.
*Statistically significant difference between groups.
406 Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2
Facebook page, and more participants in the Twitter group shared
the received information within their own social networks. Twitter
is particularly useful in publicizing information, and it appears this
also applies to research information.
Social media promotes online social interactions, which may
enhance learning22 and promote change through social influence.23
Interaction in this study was encouraged in the course instructions, and
a tendon expert was available to answer questions. However, 10% or
less of the participants in each group reported interacting online. Over
30% of participants in each group cited lack of time as a key barrier to
interacting. Approximately 60% of clinicians are evidence
?pragmatists? ? those to whom validity of evidence is secondary to the
daily demands of practice.2 Therefore, the interaction in this study may
reflect everyday professional use of social media for accessing research
evidence. Concerns about professional image may also influence online
interactions.4 Herein lies the paradox of social media based learning
communities; the openness and diversity which can enrich learning
may also negatively impact upon the socio?emotional aspects of group
formation which may be beneficial for collaborative learning.24
While significant improvements in knowledge occurred, the
improvements were small (an increase in total assessment score of
<3). A lack of time to read or listen to supplementary information
may have influenced this result. The practice points may also have
been lost among the large volumes of information that can appear
on social media accounts, or may have been filtered out by the social
media sites themselves.
There are several limitations to this study. Baseline measures
were collected shortly after randomization had occurred, potentially
resulting in chance bias. However, participant assessments were
anonymous, therefore randomization after completion of baseline
measures was not possible. There was no control group to assess the
impact of a learning effect from the assessment or to see if the course
was equally effective if delivered via email or text message. How-
ever, this study aimed to compare social media modalities and the
benefits and limitations of each. Participants from the Twitter group
had a statistically significant higher baseline assessment score for
knowledge related to the supplementary information. There are a
number of health professional information sharing sites on Twitter,
and participants allocated to Twitter may be more inclined to partic-
ipate if they had previous exposure to these sites. An error resulted
in 5 participants from the Twitter group obtaining the course infor-
mation for both Twitter and Facebook, however due to the small
number of participants affected, this is unlikely to have impacted the
results. Both Facebook and Twitter sites were publically available,
and participants were not asked to keep group allocation or infor-
mation confidential, meaning the groups may not have been mutu-
ally exclusive. However, participants were not informed of the
alternate group, and the diversity of participants limits the potential
impact of this confounding factor. The sites were open access; there-
fore people other than study participants may have interacted on the
sites. The same assessment was used before and after the interven-
tion however, question and answer order were randomized to limit
any potential learning effects. The high attrition rates may have
resulted in attrition bias,25 however, given that online courses often
have dropout rates of ?50%26,27 the attrition level is not abnormal
for this type of education.
Evidence based ?practice points? on tendinopathy management can
increase clinician knowledge and influence changes in practice,
whether delivered by Facebook or Twitter. No differences in these
outcomes were observed between the Twitter and Facebook groups.
Messages of 140 characters or less are as effective as longer posts in
conveying research information.
Future research directions may include investigating social media
interaction and the subsequent impact on learning and behavior
change, and how perceived e-professionalism influences clinicians?
willingness to participate in social media based professional educa-
tion. Social media may provide a low cost method of widespread
distribution of information and an economic analysis of using social
media to distribute research information would complement existing
The authors listed contributed to the research design, data collec-
tion, analysis, write-up, and critical review of the final manuscript.
This work was supported by the Monash University Strategic Project Grant
Scheme 2014, Grant Number: SPG-L 007
The authors of this article have no formal relationship with either Twitter or
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