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Intervention A short course, consisting of the same 8 “practice points” or key

educational messages of 140 characters or less, on topics related to

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tendon management were delivered to each group via posts on Twit-

ter16 and Facebook17 web pages. Each practice point was linked to

supplementary information in the form of peer-reviewed journal

articles or podcasts by clinical experts. The course was designed by

educational, clinical, and research experts, and was identical except

that the Facebook posts contained the practice point plus an addi-

tional 2–6 short written statements (1–2 sentences) that highlighted

key concepts from the supplementary information. The practice

points were delivered evenly over a 2 week period, to both groups at

the same time points. The pages were not restricted access.

Procedure Clinicians consented to participate by providing contact details

through an online survey. Those who provided a valid email address

were enrolled. Participants were stratified by role (student, clinician,

or other) and randomized to receive the practice points via Twitter

or Facebook. Participants received video and written instructions on

obtaining a social media account and accessing the practice points

from their allocated site. The instructions also encouraged interac-

tion on the allocated site. Participants were sent three reminder

emails at each data collection point to minimize attrition. The study

was conducted between August and October 2014.

Outcomes Data was obtained via an anonymous online survey completed 1

week before (baseline assessment) and after (post-intervention

assessment) the short course. A password was used to match pre-

and post-course data. Demographic details, information on tendon

management experience, and current use of social media were


Outcomes were determined based on the Kirkpatrick hierarchi-

cal levels of evaluation 1–3.18 Participation and engagement data

was also collected. A data collection summary can be found in

Appendix 1.

Kirkpatrick Level 1: Participant Reactions The Social Media Use and Perception Instrument (SMUPI), a ques-

tionnaire of 10 items with high internal consistency,19 measured

attitudes towards using social media in continuing professional


Kirkpatrick Level 2: Knowledge Sixteen multiple choice questions assessed knowledge (A–E

responses) (Appendix 2). One question correlated with each

“practice point” and one correlated with information from each

piece of supplementary information. The questions in both assess-

ments were identical, but question and response order were random-

ized to minimize score improvements based on pattern recognition.

Participants were not given assessment answers until the conclusion

of the study. Self-rated measures of tendon management confidence

and knowledge were also obtained.

Kirkpatrick Level 3: Behavior Change Participants were asked “has the education you have received via

social media during this trial changed the way you practice, or

intend to practice, with musculoskeletal clients?” and “has the edu-

cation you have received during this trial increased your use of

research evidence within your clinical practice?”

Participation was evaluated via the number of participants who

connected with the social media pages and completed the assess-

ments. Data on interaction was obtained through participant self-

report and from the number of times posts were approved of

(“liked” or “favorite”), shared or commented on.

Analysis Mixed linear models were used to analyze the repeated measure-

ments (pre- and post-exposure to the intervention) on the partici-

pants. The restricted maximum likelihood method (REML), as

implemented in the GenStat statistical package,20 was used to fit the

models, calculate predicted means and test, using F-tests, the main

effects of group (Twitter vs Facebook) and time (pre vs post) as well

404 Journal of the American Medical Informatics Association, 2017, Vol. 24, No. 2



as their 2-way interaction. Pairwise least significant difference tests of

the group-by-time means were based on these analyses and conducted

at the 5% significance level. Diagnostic plots of residuals were

checked for assumptions on which these methods are based. Analyses

of the 5-point Likert scale responses also used the restricted maximum

likelihood method as is customary with large datasets.21 The analyses

of binary response outcomes, measured post intervention, were based

on logistic regression models, also fitted using GenStat. Discrete count

data from Twitter and Facebook sites were analyzed using a variance-

stabilizing transformation in an analysis of variance.


Five hundred clinicians consented to participate. Five were excluded

due to an invalid email address, and one participant asked to be

removed. Four hundred and ninety-four participants were randomized.

The attrition rates from randomization to baseline assessment were

48.2% for the Twitter group and 41.7% for the Facebook group; the

difference was not significant [v2 (1, n¼494)¼2.09, P¼ .148]. Attri- tion from baseline assessment to post intervention assessment was

32.8% for the Twitter group and 8.3% for the Facebook group; this

difference was significant [v2 (1, n¼494)¼17.37, P < .001]. Three hundred and seventeen responses were analyzed (140 Twitter, 177

Facebook). There were 99 baseline assessments, 45 post intervention

assessments, and 173 matched baseline and post intervention assess-

ments. A consort flow-chart is available in Figure 1.

Demographics Demographic data and data on tendon management experience and

social media use was obtained from the baseline assessment and is

presented in Table 1.

Kirkpatrick levels 1, 2 and 3 Following the intervention, (the short course consisting of practice

points) there were statistically significant increases in SMUPI score,

self-rated confidence, self-rated knowledge and multiple choice

assessment score; but no statistically significant differences between

the groups in their changes over time. Participants in both groups

reported a change in practice/intended practice and increased use of

research in practice/intended practice as a result of the intervention

but there was no statistically significant difference between the

groups. This is shown in Table 2.

The Twitter page developed 428 “followers” and the Facebook

page received 155 “likes.” An estimated 10.0% (8/80) of the Twitter

group and 7.8% (9/115) of the Facebook group reported interacting

online. The difference between groups was not significant [v2 (1, n¼195)¼0.28, P¼0.597)]. An estimated 42.6% (20/47) of the Twit- ter group and 34.8% (24/69) of the Facebook group reported lack of

time as a reason for lack of interaction on the social media sites.

Statistically significant differences were found between groups

for number of times information was shared (mean shares per post

Twitter 10.40, Facebook 0.20, SED 3.030, P < .001) and approved

of (“liked”/”favourite”) (mean Twitter 14.00, Facebook 8.00, SED

1.414, P¼ .005).


This study has demonstrated that research information delivered by

either Twitter or Facebook can improve clinician knowledge and

Expressed interest in par�cipa�ng (n=500)

Excluded (n=6) n=1 complaint about process n=5 no email address provided

Randomized (n=494)

Allocated to Facebook (n=247)Allocated to Twi�er (n=247)

Comple�on of baseline Assessment (n=128)

Withdrew (n=1) Reason unknown

Comple�on of baseline Assessment (n=144)

Comple�on of post interven�on assessment (n=86)

Comple�on of post interven�on assessment (n=132)

Figure 1. Consort flow chart showing attrition of study participants.

Table 1. Participant demographics and participant characteristics

Twitter Facebook

N (%)a N (%)a

Baseline demographic data sets 128 144

Area of practice

Physiotherapy/physical therapy 95 (74.2) 98 (68.1)

Medicine 18 (14.1) 19 (13.2)

Osteopathy 2 (1.6) 3 (2.1)

Podiatry 7 (5.5) 11 (7.6)

Other 4 (3.1) 11 (7.6)

Not stated 2 (1.6) 2 (1.4)


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