Social Media and Dialogues: Unpacking The Role Of Social Networking Sites In Individualised Care

Communication theorists discern six types of dialogue that occur between participants in discourse with each other: persuasion, inquiry, deliberation, information-seeking, eristic, and discovery. Although social media use in health care settings has been investigated from diverse perspectives, few studies have analysed social media interactions as dialogues and the implications for individualised care. The objective of this study is to identify the extent to which the six types of dialogue can be discerned from the self-reported social media activities of health care providers and the implications for individualised care. To realise the objectives of this study, transcripts of the interview of health care providers that use social media were thematically analysed using NVivo software. Findings reveal that each of the six types of dialogue is discernible from the social media posts of health care providers, and these dialogues help narrow the communication gap between stakeholders in health care. This suggests the use of social media in health care can be analysed using dialogue theory and paves the way for future research to discover precursors that trigger a dialogue shift from one type to another and a new way to assess the effectiveness of social media.


INTRODUCTION
According to Walton and Krabbe [1], there are six types of dialogues: persuasion, negotiation, inquiry, deliberation, information seeking, eristic, and discovery (not listed in the original 1995 formulation); each type has a different communication goal.The goal implicit in a persuasion dialogue is for one party to persuade the other to accept a proposition.Negotiation dialogues have the goal of distributing limited resources, and dialogic exchanges reflect bargaining and trade-offs.Inquiry dialogues have parties jointly framing problems in search of solutions.Deliberation dialogues involve parties reflectively reasoning towards optimal solutions.Information-seeking dialogues involve one party seeking information from another.The goal of eristic dialogues is to emotionally vent, whereas discovery dialogues frame research questions.
Web sites and social media have not traditionally been seen as dialogues.The first wave of web sites (known as Web 1.0) were largely static pages characterised as one-way communication between health care providers and patients.These were soon discredited because the views expressed on these sites were perceived to be unresponsive to the peculiar health matters of their audience [2].Many health care provider organisations shifted from the static delivery of information with Web 1.0 technologies to more dynamic message exchanges using social media sites in the promise of better outcomes than static web sites [3] [4] [5].According to Thackeray, this represented a paradigm shift in how health care organisations engage in public relations, shifting from one-way communication to an emphasis on dialogue mediated through social media [6].Internet-enabled social media reaches large numbers of people and enables them to have more meaningful health-related conversations [6].In hospital settings, social media platforms have become accepted as effective mediums to communicate with patients outside of the few formal face-to-face contacts [7].Social networking sites are emerging as new mediums for dialogic communication broadly [8], including in health care settings [9] [10] [11] [12].
The generation of productive conversation is critical to health intervention efforts [13] and a lack of adequate opportunities for dialogue, among other things, undermines patients' ability to receive individualised care [7].Many organisations are unable to build mutually beneficial relationships with stakeholders because they fail to understand the full gambit of dialogic strategies that social networking sites offer [14].Ongoing dialogues between doctors and patients to encourage the engagement needed for effective management of chronic conditions have been found to be critical [19,20].Sharma identifies deliberation dialogues amongst participants in multi-disciplinary meetings in cancer care [21] whereas Lindgren advances an approach to support clinicians' search for online information based on inquiry dialogues [22].While some research has been done on the role of communication in health care [13,15,16], and how social networking sites enhance individualised access to health care [17,18], little or no research attention has been paid to understanding how the different types of dialogues on health care social media sites contribute to the delivery of individualised care.
The objective of this study is to identify the extent to which the six types of dialogue can be discerned from the self-reported social media activities of health care providers and the implications for individualised care.Understanding health-related dialogues on social media sites can help design individualised well-being interventions for specific contexts.By investigating the various types of health-related dialogues on social networking sites, this study facilitates a better understanding of the behaviour of evidencebased sources of health information on social networking sites as well as the sharing decisions of users of social networking sites, both of which are relevant for developing an evidence-based approach to addressing medical misinformation on social networking sites [23].The methodology deployed in this study is described in the next section, prior to results, discussion, and suggestions for future research.

METHODOLOGY
This qualitative study was exploratory in nature and followed a broadly interpretivist [24] and inductive approach [25].In line with Federation University Australia's ethics procedure, an ethics review form was submitted, and approval was granted on August 23, 2017.Participants were interviewed between 2017 and 2019.Eleven health care providers in Australia that use social networking sites participated in the study.The authors interviewed participants aged more than 18 years without offering financial incentives.Both purposive and snowball sampling were used to select clinical, administrative, and management staff that had some involvement in social media at their health care organisation.Purposive sampling involved the identification of major stakeholders [26] and ensured that the initial participants were drawn from health care providers that use social networking sites.Five health care providers that use social networking sites were contacted to participate in the study.The remaining participants were recruited through snowball sampling from organisations that varied in size and were located throughout Australia.Four were large organisations, while the rest were either mid-size or small organizations.Four of the participating organisations were in major cities, whereas the rest were located in regional areas outside major Australian cities.The final composition of interviewees was six medical doctors and five social networking sites/communications managers.All the interviewees had at least six years of experience using social networking sites for health-related purposes.
Qualitative data were collected through semi-structured interviews, as recommended by Walsham [27].When developing the interview questions, the broad areas of knowledge considered relevant to answering the research questions were initially outlined.Questions were developed, adjusting the language to suit participants' backgrounds so that clinicians and communications personnel could relate to the questions.In line with the process of conducting semi-structured interviews, an interview guide was used flexibly [28], which ensured free-flowing yet focused conversations.The flexible use of the researcher-developed interview questions enabled the interviewees to be probed further based on their responses [29].
The average duration of the interviews was 50 minutes.All the interviews were audio-recorded and transcribed verbatim by the first author.After each interview transcription, the researchers carefully reviewed the transcripts and recordings to ensure that no relevant information had been missed.The expectation was to conduct between 12 [30] and 15 interviews [31] to reach knowledge saturation.After the seventh interview, the analysis of subsequent interview transcripts yielded little or no new themes.In total, 11 in-depth interviews were conducted.
The interview data were anonymized, and utmost care was taken to preserve the richness of the interview material wherever possible while also protecting the participants' privacy [32].Then, the transcriptions were uploaded to NVivo (lumivero.com/products/nvivo/)for coding until themes emerged that helped elucidate the phenomenon under investigation.The first step was to assign summative or evocative attributes consistent with the six types of dialogue to different portions of the transcribed interviews and thus identified similarities, patterns, and relationships.Several initial codes were applied, with some of them overlapping to a certain extent.A preliminary categorization system was applied to the interview data.Subsequently, codes with similar meanings were clustered, and a corresponding theme was formed.The categories were modified when the data showed additional or new information that required a new category.The resulting defined themes were then differentiated into main categories and subcategories, and relevant original statements in the transcripts were assigned to these categories.The first author coded and analysed the interview transcripts, and the second author checked the codes for alternative explanations.This process helped reduce subjectivity and ensured the consistent interpretation of the codes.Moreover, to ensure the validity of the results, they were compared with explanations from relevant literature in line with triangulation techniques [33].

RESULTS
Thematic analysis of interview transcripts was performed to identify the extent to which the six dialogue types could be discerned from the self-reported social media activities of health care providers and the implications for individualised care.Findings reveal that the participants' social media activities clearly exemplified all six types of dialogue identified by Walton and Krabbe [1].The themes that emerged covered medical doctors (MD) as well as communications personnel (CP).Feedback from participants was organised using Walton and Krabbe's [1] categories of dialogue, namely persuasion, negotiation, inquiry, discovery, deliberation, information seeking, and eristic.The subsequent sub-sections present the findings.

Persuasion
One participant, a doctor, explained they use social networking sites to persuade other health care professionals to believe or do something: "most of my posts are for medical audiences. . ..after interacting with my posts, some will say, yes, okay, I reckon you're right, I'm going to modify that" [Participant MD5] Going further: "There was a campaign in 2014 [on social networking platforms] which a lot of doctors, have come back to me and said it changed their practice.So, for me, the interesting thing [about my posts on social networking sites] is its influence on other health professionals.And I think it influences them greatly.So, I think both medical and nonmedical people are heavily influenced [by my posts] [Participant MD5].
A non-medical, participant alluded to leveraging social networking platforms to persuade people in their community to avail the services offered by their health care organization.Explaining why they do so, the participant stated that: "Even though we are a not-for-profit organization, we still need to attract clients.We have some programs like the family health program that are funded [by the government], and if no one takes that up, we may not get funding again for it" [Participant CP2].
The goal for using persuasion-dialogue in the words of a participant is to have: "Better informed patients who are able to make better informed choices by taking on board some of the advice that we are able to post"

Negotiation
On how they use social networking sites to negotiate with stakeholders, in the words of one respondent: "So I'm either in the forum engaging with people or answering comments on posts that I'd put on the site" [Participant MD3].Another participant stated that: "Before social media, we used to use print media a lot.'Spray and pray', that is sending out a wide message with no way of monitoring impact.At that time, we were just telling the community what to do, but now we are able to engage with them through social media two-way communications.We are also able to reach many people and groups" [Participant CP1] In the words of another participant, a doctor: "Twitter has enabled me to interact with people that I would never have met in real life.Also, the space in which I work, which is the Aboriginal health, makes really good use of social media.So, for me it's a way of hearing from people unfiltered, an indigenous side of health policy not mediated by journalists.I think what it will really be good at is patient opinion, understanding the patient experience, patient feedback.That's where it will be a real benefit for the health system and health practitioners.

It will help in understanding what the patients' perspectives are. There is real potential there" [Participant MD1]
Unlike face-to-face communication, social networking sites enable discreet communication, thus, making it an effective medium for negotiation in health care settings.A participant opined that: "I think with our work, to a point, we can serve people very well with social media.For instance, with Facebook you've got private interaction and public.You can interact in private messages, and you can interact in a public forum as well.So, people can choose if they don't want to have their personal information aired" [Participant CP3] Many participants attested to the effectiveness of social networking sites in facilitating negotiation with stakeholders.In the words of one of the participants: "I think it's made a difference globally to the way we are able to interact with patients".Corroborating this point another stated that: "It's allowed us to engage with our patients more and to connect with them and that is quite crucial in health care.It's such a powerful way to speak directly to a market" [Participant CP5]

Inquiry
In the words of a respondent: "I use twitter to discuss research findings and implementation of that across geographical boundaries with people already working in health or health policy" [Participant MD1] Going further, they stated that: "I use Twitter to discuss with other health care professionals, things about research evidence, implementation of findings, how you do things in clinic, I also get their perspectives.So, I see my role as getting the evidence that's out there, that clever other people have produced, researchers at universities, and then trying to translate that into something useful and meaningful for doctors" [Participant MD1] Another doctor explained that social networking platforms give them an opportunity to collect data for research, which in turn allows them to find and verify evidence, or to prove (or disprove) hypothesis.". ..we got about 2,500 people in a very short space of time who filled in the survey [on social networking sites] and we had detailed information about them very quickly.So, if I wanted to do that in a face-to-face environment, I'm not sure I ever would have got that many people.And the other advantage was we had people from 57 countries.So, because of the reach of [social networking sites], we were able to recruit people from countries we would never be able to recruit people from" [Participant MD3]

Discovery
In the words of a participant, "we may find that there is a lot of negativity about this thing that we have done, we have to find an explanation for that, then we decide what we need to do to address Commenting on how they use social networking sites to dialogue with colleagues, a doctor stated that "we might see a case that has stimulated our thought process in a certain way, we attack the problem with a great degree of differential diagnosis [on social networking sites], and thereby improve patient care" [Participant MD4]

Deliberation
On how they use social networking sites to deliberate, and to coordinate goals and actions, a participant had this to say: "So the first goal [of their social networking activities] was to create a community where people can chat and ask each other questions or ask us questions and interact with each other" [Participant CP3].
Some of the deliberation is between colleagues.In the words of a respondent, "I've got my accounts which I would use just for sharing with professional colleagues" [Participant MD6].
Another respondent stated that: "There is a large private group on Facebook called GPs down under.You are allowed access if you are able to prove that you are currently a registered GP working in Australia.There are thousands of GPs having conversations about being a GP in Australia [on that platform].So that's happening more and more routinely".Going further, they stated that: "there's lots of replies and influx.For instance, often I will post something and there'll be, I don't know, within 24 hours there'll be 70 or 80 comments and all of them by practising Australian or New Zealand GPs.So that sort of thing" [Participant CP5]

Information Seeking
Patients often seek information from health care providers.According to a participant: "in the first instance, an enquiry [received through social networking sites] goes to the social media person at the organisation.If it's a general enquiry, the social media person will post about it and respond to the comments.If it [an enquiry] is something that needs specialist medical knowledge, we'll consult a specialist medical advisor" [Participant MD3].
Health care providers on their part, respond to patient queries and share health information on social networking sites.Responding to a question on how they use social networking sites for information sharing, a health care provider had the following to say: "We now have a platform through which we run a scheme called "ask us".People can ask any question related to the organization and get an answer.We forward the question to the right person within the organization to answer the question.We use that to collect feedback from staff and community" [Participant CP2].
Another participant shared a similar view: "We have leveraged on the reach of our social media to inform people about measles and the vaccinations available" [Participant MD2]."What social media can do is to help in education and directing people towards education resources.

" [Participant CP2]
Health care providers also seek information from patients, as shown in the following comments: "So for me it [Twitter] is a way of hearing from people unfiltered . ..not mediated by journalists.People will listen to me because I am a doctor."It [social networking] allows information to be broadcast quite quickly, as compared to the old newsletter" [Participant MD2].Providing an example, a participant had the following to say: "Twitter, for instance, has got a wide range in global audience, and there's a speed of interaction which allows me to build up a rapport with people to be able to ask questions and disseminate information.I think that it [social networking] has allowed access to new information, to an alternate way of looking at clinical cases" [Participant MD4]

Eristic
Citing an example of this type of health-related dialogue on a social networking site, a doctor stated that: "If you ever read anything in the media about doctors not being sure that My Health Record was a good thing.Most of that came out of a private group on Facebook for GPs called GPs down under originally.So, it was all this whole bunch of doctors coming together and saying, this is just wanting another way of compromising patients' privacy.And doctors from within the group started writing articles and contacting people and from there sprung the whole sort of media, interpretation that even doctors weren't happy with it" [Participant MD5] Another doctor stated that they use social networking platforms to hit out at conditions that compromise public health.In their words: "we use it [social networking sites] to raise awareness of issues usually related to health, inequality and social and environmental causes of ill health, there is an audience out there that are interested in such, and I reach this audience through Twitter [Participant MD1].

DISCUSSION
This study explored the types of health-related dialogue on social networking sites and their implications for individualised care.The findings were organised using the categories put forward by Walton and Krabbe [1]: persuasion, negotiation, inquiry, discovery, deliberation, information seeking, and eristic.The subsequent subsections discuss the various types of health-related dialogue on social networking sites and their implications.

Persuasion
Persuasion is the action or process of influencing someone to believe or do something through conversational and messaging strategies [34].The aim of persuasion is to convince the other party in order to resolve or clarify an issue [1].Going by the findings of this study, some of the health-related dialogues on social networking platforms are aimed at persuading other health care providers or patients to take a health-related action.For instance, health care providers may use the medium of social networking sites to persuade colleagues to review, adjust, and improve aspects of their practice [35] or to persuade patients to take a health action [36,37].Thus, persuasiondialogue on social networking sites between or among patients, doctors, and other users enables individualised care [38].

Negotiation
Feedback from participants indicates that social networking sites are effective channels through which health care organisations negotiate with their audience.Negotiation involves intentional communication between two or more parties, intended to reach an agreement by taking the needs of the other party into account [39].Health care providers leverage the ability of social networking sites to facilitate discrete communication to connect and engage with patients [11].Instead of talking at them, health care providers may use social networking sites to engage patients in two-way communication.This allows them to hear unfiltered patient opinion, patient experience, and patient feedback.Social networking siteenabled negotiations allow them to reach settlements that all parties in the interlocution can live with.
Organisations use social networking sites to create an ongoing dialogic conversation with the communities they serve.Social networking sites provide a free, flexible, and secure environment for negotiation dialogue.Online contacts make patients feel they are partners in dialogue [7], and social networking sites can drive important negotiations towards beneficial outcomes-and savvy practitioners can harness this to their advantage [40].The aim for practitioners should be to create an ongoing dialogue, that is, a back-and-forth interaction that ensures that their key constituents return to the page and return frequently [6].

Inquiry
Participants' feedback shows that many health care professionals use social networking sites to engage in inquiry-dialogue with stakeholders.The aim of inquiry dialogue is to find and verify evidence and/or to prove or disprove hypothesis [1].Many approaches to health care delivery are based on empirical evidence [41,42].Thus, health care providers constantly seek to find, prove, or verify evidence.Health care providers increasingly see social networking sites as mediums for research data collection [8,43], as sources of data for health research [44,45], and as mediums for disseminating results and the discussion of evidence across geographical boundaries [46,47].
Inquiry dialogue leans towards evidence-based practice.Thus, it does not directly contribute to individualised care.Many literatures acknowledge the notion that evidence-based medicine and individualised medicine are mutually exclusive paradigms [48,49].However, skills such as communication techniques, identified through evidence-based inquiry, could facilitate individualised care [48,50].It could therefore be argued that inquiry dialogues on social networking sites may indirectly facilitate individualised care.

Discovery
Some health-related dialogues on social networking sites are aimed at discovery, that is, finding an explanation for facts and/or finding and defending a suitable hypothesis.The results of this study demonstrate that social networking sites are good platforms for health care professionals to brainstorm on a difficult case.For instance, social networking sites are increasingly used for diagnostic brainstorming, thereby hastening the process of determining the possible causes of a problem or relevant solution [51].
Participants feedback shows that health care providers leverage data from social networking sites to identify factors that underpin patients' negativity towards existing or proposed health interventions.For instance, sentiment analysis methods can be employed to automatically detect the positive or negative mood of patients by analysing their posts on social networking sites [52].
As shown in the results of the study, patients' comments on social networking sites indicate their level of awareness, and health care providers use this information to adjust their health communication strategies.Understanding patients opinions about health issues enables relevant organisations to better educate them and improve their services to them [6], and social networking sites yield information that can considerably contribute to understanding health conditions beyond clinical practice, thereby supporting individualised health care [17].

Deliberation
Social networking sites are used for health-related deliberative dialogue.In the event of a dilemma or difficult choice to make, people may use deliberation to coordinate goals and actions in order to decide the best available course of action [1].Deliberation helps health care providers navigate difficult situations [53].This accounts for the growing popularity of online communities on social networking sites, where health-related topics are discussed.The results of the study show that online communities enable stakeholders in health care to share ideas and information, which in turn enables them to navigate difficult situations.
The growth of social networking sites in recent years is changing the interaction among physicians through the provision of online communities that enable physician-to-physician communication and the transfer of ideas, surgical experience, and education [54].Social networking sites advance knowledge exchange, knowledge sharing, and knowledge transfer.Hence, health care providers increasingly acquire existing and new knowledge through social networking sites [35].
In healthcare settings, deliberation dialogue encourages individualised care by emphasising the exploration of a patient's illness experience and the utilisation of the patient's interpretations, feelings, preferences, values, and social context to reach a collective goal of care [55].

Information seeking
This study demonstrates that information seeking is increasingly done on social networking sites.Health care providers and patients increasingly exchange health-related information on social networking sites.Health-information exchanges on social networking sites have been categorised into four major types, namely: health care professional to health care professional, health care professional to patient, patient to patient, and patient to health care professional [56].Health care professional to patient represents a situation in which a health care professional provides information to patients [57], patient to health care professional involves patients sharing information regarding their experience and opinions with health care professionals [58].Health care professional to health care professional represents a situation in which health care professionals exchange information with each other [59], while patient to patient represent interactions and exchange of support among patients [60].Virtual communities on social networking sites are now serving as mediums for seeking health information online, and they have been found to be positive mediators of health as they facilitate communication between physicians and patients, support health promotion and health information, and provide community support networks [61].
Information exchange provides access to detailed knowledge of patients' needs and preferences, which in turn enables the provision of person-centred care [62].Social networking sites are enhancing information exchange between and/or among patients and physicians beyond the walls of clinics, especially in an era where digital technologies have become ubiquitous [63].Dialogues between patients and health care professionals require two prerequisites.First, availability-that is, it must be relatively easy for the patients to access the health care professionals.Secondly, there must be opportunities for exchanging information, which is essential for individualising health care and support [7].Social networking sites enable both prerequisites to be met.Thus, social networking sites can be used to actively engage and empower patients in their health care journey and to tailor care to their individual needs [64].

Eristic
The results of the study show the emergence of eristic dialogue on social networking sites.An eristic dialogue is an adversarial and competitive kind of interlocution where each party attempts to use clever and skilful interlocution to advance their place in an intellectual hierarchy [65].Eristic dialogue involves interlocutors attacking and defeating the other side while appearing to be verbally more skilled [65].Eristic dialogue is often underpinned by personal conflict and may involve verbally hitting out at opponents [1].The medical community has a growing online presence, and they increasingly use their platform to contribute, comment on, question, and provide a "peer review" of health-related information posted on social networking sites [66].Health-care providers are now pushing back against medical misinformation by denouncing opinions not founded on science [67].
As demonstrated by the results of the study, health care providers increasingly confront opinions on social networking sites that may undermine public health.On face value, confrontation with patients appears inconsistent with health improvement, but that is not necessarily the case.Confrontation is informed by doctors' sense of shared responsibility and a strong desire to do what is best for their patients, as per patient-centeredness [68].In this context, confrontation is relevant for patient care and contributes to individualised care [68].

LIMITATIONS
Despite the contributions of this study to the growing body of literature on the role of social networking sites in health care settings, it has some limitations.The results should be interpreted as indicative and not necessarily generalizable, given the somewhat modest sample size and the fact that only medical doctors and communications personnel of hospitals and medical clinics were interviewed.Probably, a larger and more heterogeneous research sample may suggest additional themes.Furthermore, it is important to note the time frame of this study when considering its findings since the usage of and attitude toward social networking sites evolve rapidly.

CONCLUSION
This paper sought to identify the extent to which the six types of dialogue can be discerned from the self-reported social media activities of health care providers and the implications for individualised care.The results show that social networking sites facilitate various types of health-related dialogue, namely persuasion, negotiation, inquiry, deliberation, information seeking, and eristic.This suggests that a dialogue-based analysis of social media use in health care is compelling for future research aimed at discovering how social networking sites influence stakeholders to reach personalised decisions in real-life contexts related to interventions aimed at enhancing their wellbeing.
It is clear that social networking sites offer dialogic opportunities [14].The different types of dialogue impact individualised care differently.However, all types of dialogue involve productive conversations between and/or among health care providers and patients to encourage the engagement needed for the provision of individualised care.The online space contributes to accessibility and exchangeability and adds new possibilities for dialogues from which patients can benefit [7].Given the wide variety of healthrelated dialogue that social networking sites facilitate, health care providers must be prepared to dedicate the appropriate amount of time and resources to keeping these dialogues going on these sites [6].
this and better explain to people.What we do kind of informs the next thing.Patients' comments [on social networking sites] may indicate their level of awareness and might influence what we do in future [Participant CP1].
It's keeping an eye on what people are saying and retweeting some of that and directing people to those voices" [MD1].". ..the [patients'] posts indicate what works and what does not." [Participant CP1] ". ..they [patients' social media posts] might actually inform things that we need to change. .." [Participant MD3] Social networking sites are effective mediums for information exchange because they are neither restricted by geographical boundaries, nor limited by time.The following comments corroborate this assertion: "I use twitter to discuss research findings and the implementation of that across geographical boundaries with the audience" [Participant MD1].