Social Media-Based Interventions for Health Behavior Change in Low- and Middle-Income Countries: Systematic Review

"The preponderance of evidence characterizing effective behavior change techniques using digital interventions has been collected by focusing on residents of high-income countries."

With a wide reach and worldwide omnipresence, social media platforms - including Instagram, Twitter, Reddit, WeChat, and others - have been of increasing interest in the implementation of behaviour change interventions and public health campaigns. This review identifies and describes the available literature on effective social-media-based behaviour change interventions in low- and middle-income countries (LMICs).

This systematic review was conducted in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The researchers searched PubMed, Embase, Elsevier, CINAHL, PsycInfo, and Global Index Medicus, with the final search conducted on April 6 2021. The review excluded studies published before 2000 and included studies that evaluated interventions conducted at least partly on a social media platform. This search identified 1,832 studies, of which 33 were included in the final analysis.

The key study characteristics are summarised in Tables 1 and 2 of the paper but, in short, the studies most frequently aimed to change HIV testing and knowledge, increase physical activity and weight loss, and foster smoking cessation. Overall, the authors of the reviewed studies concluded that the use of social media in the interventions was effective (22/33, 67%). Studies, especially those with data on outcomes or impacts, frequently paired data on social media use with a measurement of effectiveness captured outside of social media use, such as changes in anthropometric measurements, knowledge of a specific health topic, or smoking status (22/33, 67%). Notably, some studies reported that their social media efforts were effective without clearly reporting quantitative data (e.g., clicks, shares, and views) on social media use.

Other lapses or gaps cited by this review's researchers include, for example:

• Although social media interventions have been conducted in a number of LMICs worldwide, few have been conducted in the economically poorest countries, and few have been done in sub-Saharan Africa.
• There is a lack of formative research evaluating the feasibility, appropriateness, and acceptability of social-media-based health behaviour change projects in LMICs, and yet this type of research helps ensure that a specific intervention is likely to be needed, understood, and taken up by the population of interest.
• Few studies included a description of either a theoretical model (8/33, 24%) or developed a conceptual model (5/33, 15%) that guided researchers' efforts in the design or evaluation stages.
• Although every study focused on an intervention that, by its nature, required access to technology and the internet, relatively few highlighted this as a potential source of selection bias that might lessen an intervention's external validity (11/33, 33%). "This suggests that researchers do not perceive technology access as an obstacle to the effective implementation of such interventions in LMICs."
• Behaviour change can take time, yet the length of observation after the intervention ended for most of the studies was less than 1 year, and half of the studies (17/33, 52%) did not report any follow-up data.
• None of the studies reported on methods used to diminish the possibility of interference or data theft on behalf of the participants, despite the sharing of data with a third-party service being a requisite of participation eligibility. "Ensuring participant security and protection of privacy are among the most critical components of ethical research; explicit explanation of these risks to personal data loss is necessary to incorporate in every public health social media study."

In conclusion: "This systematic review of social media-based behavior change interventions conducted in LMICs highlights the need for diversity and methodological rigor at every step in the planning, implementation, and evaluation stages of programming."