In Latin America, there are more than 23 leading causes of death, some of which are preventable. For example, diabetes or HIV/AIDS can be prevented and, in this case like in others, access to reliable and high-quality health information and proper medical advice can contribute to reducing mortality rates in these countries. In a world where there are numerous content producers with different intentions, there is too much information –sometimes of questionable quality–, and there are different ways to access the information (media, search engines, social media, etc.), governments should be one of the reference sources of information for citizens. This doctoral thesis is framed in the context of access to information and use of social media in public health in Latin America. Based on the study of some characteristics of the websites of the national health authorities, including an analysis of web ranking, and the study of their presence and institutional activity on social media, this study reviews some of the features related to websites and institutional activity on social media. Based on direct and structured observation and a comparative analysis of information retrieval, this thesis aims to analyze the availability of information about the ten leading causes of death by national health authorities in 18 countries in Latin America, both in their websites and their institutional profiles on the major social media platforms. Novillo-Ortiz D. Acceso a información y uso de redes sociales en salud pública: un análisis de las autoridades nacionales de salud y de las causas principales de defunción en Latinoamérica [Tesis doctoral]. Getafe: Universidad Carlos III de Madrid, Facultad de Humanidades, Comunicación y Documentación; 2015 [citado 19 de enero de 2016]. Disponible en: http://e-archivo.uc3m.es/handle/10016/22158.

1. School of Humanities, Communication and Library Science
Department of Library and Information Science
Access to Information and Use of Social Media in Public Health:
an Analysis of National Health Authorities and Leading Causes
of Death in Latin America
DOCTORAL DISSERTATION
Director:
Antonio Hernández Pérez
Author:
David Novillo Ortiz
PhD Program:
Documentation: Archives and Libraries in a Digital Context
www.uc3m.es | Getafe, 8 January 2016
@tonywebsoc @davidnovillo

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Contents
1. Introduction
• Problem description
• Objectives
• Methodology
• Limitations of the study
2. The Use of ICTs in Public Health
• eHealth or Digital Health
• Access to information within the context of eHealth
• The use of social media within the context of eHealth
3. The Role of Health Authorities on the Internet
• Analysis of websites and search engines
• Analysis of social media
4. Final Conclusions
• Conclusions
• Recommendations

3. 1. Introduction
[Doctoral Dissertation] Access to Information and Use of Social Media in Public Health:
an Analysis of National Health Authorities and Leading Causes of Death in Latin America

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Problem Description
1. Introduction
In the Latin American setting:
– 23 leading causes of death (e.g., acute respiratory tract infections,
ischemic heart disease or stroke).
Points to consider:
– Increasing number of people with Internet access
(Internet penetration is 66%)
– Too much health information on the web
(575 million results are returned by Google when searching for
“cancer”; and 250 million when searching for “diabetes”)
– High percentage of social media users (70% of the population with
Internet access use social media)
Role of
National
Health
Authorities?

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Objectives
1. Introduction
Main objective:
– To know how national health authorities release information about the
leading causes of death in Latin America through their institutional
websites (including positioning of their contents in main search engines)
and their profiles in the main social media channels.
Secondary objectives (five dimensions):
– With regards to Internet penetration (ICT penetration)
– With regards to national health authorities’ institutional websites (website
features; availability of access to information through internal search
engines; number of indexed files)

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Objectives
1. Introduction
– With regards to website positioning and competitors, particularly in
reference to Google (website positioning, frequency of content availability;
countries with positioned content; search strategies with results of
institutional websites; types of websites with the highest visibility;
identification of competitors and allies; websites of national health
organizations)
– Also regarding website positioning and competitors, a global and
comparative overview of results returned by Google, Yahoo and Bing
(overlap between top websites, types of websites with the highest visibility;
websites with the highest visibility; websites of national health
organizations)
– Regarding the dimension of the presence of national health authorities in
social media (scientific literature review; presence of national health
authorities; activity of national health authorities on Facebook, Twitter and
YouTube; identification of use standards and policies; development of
recommendations)

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Methodology
1. Introduction
Problem description
Research objectives
Literature review
Research design
Methods for data collection
Direct observation: websites
Design
Data collection
Website features
Website positioning
(keywords: WHO)
Preliminary analysis
Final analysis and recommendations
Conclusions
Comparative analysis
Preliminary analysis
Design
Internal searches on
websites (keywords and
synonyms, PAHO and DeCS)
Internal searches in social
media (keywords and
synonyms, WHO and DeCS)
Direct observation: social media
Design
Data collection
Facebook, Twitter and YouTube
Preliminary analysis

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Limitations of the study
1. Introduction
– Geographical analysis: 18 Latin American countries (Argentina, Bolivia,
Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala,
Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic,
Uruguay and Venezuela)
– Language: Spanish
– Chronological framework: database analysis as from December 2013;
searches on search engines (Apr.-May 2015); searches in internal search
engines (Aug. 2015); social media analysis (Apr.-Sept. 2015)
– Subject matter under study: leading causes of death (Source: WHO)
– Institutions under study: national health authorities (ministries and
secretariats of health )

9. 2. The use of ICTs in public health
[Doctoral Dissertation] Access to Information and Use of Social Media in Public Health:
an Analysis of National Health Authorities and Leading Causes of Death in Latin America

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eHealth or Digital Health
“ the support that the cost-effective and secure use of information and
communication technologies offers to health and health-related fields,
including health-care services, health surveillance, health literature, and
health education, knowledge and research” (WHO, 2015)
2. The Use of ICTs in Public Health
eHealth
Access to information
Use of social media
↘ Between 65 and 72% of Internet users search for health
information
↘ Eight in 10 online health inquiries started at a search engine such
as Google
↘ One in 20 searches on Google are for health-related information
↘ Over 70% of the population with access to the Internet uses
social media
↘ Average time on social media is 8.67 hours
↘ Most visited websites: Facebook (95.6% time spent) and Twitter
(1.4% time spent)
SOME DATA

11. Access to information within the context of eHealth
– Access to reliable health-related information and the exchange of health
knowledge are key elements for health development (Alma-Ata
Declaration, 1978 and Millennium Declaration, 2010).
– Training on access to information improves the capacity of health
professionals to search for scientific literature and facilitates the integration
of evidence for clinical decision making.
– An increased consumption of health-related information through the
Internet is observed among citizens, although this information is never or
rarely discussed with health professionals.
2. The Use of ICTs in Public Health
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12. The use of social media within the context of eHealth
– The use of social media is changing the traditional dynamics of interactions
characterized by personal, face-to-face communication.
– Social media are a source of health information of interest vis-à-vis the
information stored by people relative to their lifestyle, interests, work
environment, etc.
– Potential use of social media in public health:
1. Emergency, disasters and crisis situations
2. Clinical practice
3. Doctor-patient relationship and professional ethics
4. Health professionals’ education
5. Health promotion
2. The Use of ICTs in Public Health
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13. 3. The Role of National Health Authorities on the Internet
[Doctoral Dissertation] Access to Information and Use of Social Media in Public Health:
an Analysis of National Health Authorities and Leading Causes of Death in Latin America

14. Analysis of web sites and search engines
With regards to website positioning on Google and competitors:
– The chance of finding information provided by national health authorities
on the ten leading causes of death in their countries in the top ten results
on Google is 6,66%.
– Twelve countries were able to position their contents among the top 50
results (ARG, BOL, CHI, COL, CUB, ECU, ELS, GUT, HON, PAR, PER and VEN).
– The “National Health Institutions” category is the most visible website,
reaching a 21% (e.g. CDC or NLM).
– Wikipedia is one of the sources of information with greater visibility.
– National health organizations in countries such as ARG, CHI, MEX and
PER are positioned among the most visible search results.
3. The Role of Health Authorities on the Internet
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15. Analysis of web sites and search engines
– Citizens are not able to retrieve information from national health
authorities on 14 out of the 23 leading causes of death (60,9%).
3. The Role of Health Authorities on the Internet
(Availability of information from national health authorities among the top 10 search
results in Google) 15 / 30
Protein-energy malnutrition
Breast cancer
Tuberculosis
Diarrheal diseases
Birth asphyxia and birth trauma
Alzheimer’s disease
Colorrectal cancer
Preterm delivery complications
Prostate cancer
Congenital abnormalities
Lung cancer
Gastric cancer
HIV/AIDS
Kidney disease
Interpersonal violence
Liver cirrhosis
Chronic obstructive pulmonary disease
Hypertensive heart disease
Road traffic injuries
Diabetes
Acute lower respiratory tract infection
Ischemic heart disease
Stroke
Information from national
health aurhotiries available
Information from national
health authorities unavailable
Number of countries

16. Analysis of web sites and search engines
With regards to website positioning and competitors on Google, Yahoo and
Bing:
– Overlapping of results regarding websites with the highest visibility is
27.6%.
– Non-health websites account for 10%.
– Wikipedia and the National Library of Medicine are the sources of
information with the highest visibility.
– National health authorities in countries such as ARG, CHI, CUB, MEX and
PER are positioned among the most visible search results.
3. The Role of Health Authorities on the Internet
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17. Analysis of web sites and search engines
With regards to national health authorities’ institutional web sites :
– National health authorities issue press releases on health within an average
of 1.88 days.
– Four out of 18 websites analyzed – accounting for 22.2% – do not have an
internal search engine (or it does not work properly).
– Fourteen countries – accounting for 77.7% – provide information through
multimedia formats (ARG, BOL, CHI, COL, ECU, ELS, GUT, HON, MEX, NIC,
PAN, PAR, PER and DOR).
– No electronic services are available to improve virtual procedures.
– Average indexed files in Google are 114,000.
3. The Role of Health Authorities on the Internet
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18. Analysis of social media
Regarding the presence of national health authorities in social media:
– 90% of national health authorities have a presence in social media.
3. The Role of Health Authorities on the Internet
(Distribution of national health authorities in social media)
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19. Analysis of social media
– The mean population with Internet access that follows national health
authorities on Facebook is 0.79% and on Twitter is 0.86%.
3. The Role of Health Authorities on the Internet
(Percentage of population with Internet access that follows national health authorities
on Facebook and Twitter) 19 / 30

20. Analysis of social media
– A mean of 3.78 messages/day have been posted on Facebook, with
147.6 interactions/publication (Like, Share and Comment) and an
average activity index of 1.66 interactions/follower.
– A mean of 7.09 twits/day have been posted on Twitter, with 5.91
interactions/publication (Re-twits and Favorites) and an average activity
index of 0.61 interactions/follower.
– The mean number of YouTube channel followers on the Internet accounts
for 0.005%, with a mean of 36 videos posted per profile and 4.500
reproductions/video.
3. The Role of Health Authorities on the Internet
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21. Analysis of social media
– Considering the publications with the highest number of interactions
received, 4 of 17 topics – accounting for 23,52% – have been recurrent on
Facebook, Twitter and YouTube (health alert, organ donation, institutional
information and immunization).
– 114 hashtags have been identified on Facebook and 132 on Twitter.
The three hashtags used by three or more countries have been: #dengue,
#chikungunya and #health.
– National health authorities do not have use policies on social networks
visible and available for citizens.
3. The Role of Health Authorities on the Internet
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22. 4. Final Conclusions
[Doctoral Dissertation] Access to Information and Use of Social Media in Public Health:
an Analysis of National Health Authorities and Leading Causes of Death in Latin America

23. Final conclusions
4. Final conclusions
Regarding the availability of information on the leading causes of death on
websites and social network profiles of national health authorities:
– There is an increased chance of retrieving information through
internal search engines (7.92 in 10) than through Facebook (3.2) or
Twitter (2.93), employing the synonyms used against the keywords used.
– Only 5 out of 18 countries – accounting for 27.77% – offer information
about all their relevant causes of death through their search engines (COL,
COR, CUB, PAR and URU).
– The country with more information available on the subject under study on
Facebook is Paraguay, while on Twitter is El Salvador (both have
information available on 7 out of the 10 leading causes of death).
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24. Conclusions
4. Final conclusions
(Countries with access to information from national
health authorities by group)
Group 1 = Countries that exceed mean
information retrieval on leading
causes of death in the 3 platforms.
Group 2 = Countries that exceed mean
information retrieval on leading
causes of death in 2 of the 3
platforms.
Group 3 = Countries that exceed mean
information retrieval on leading
causes of death in 1 or none of the
platforms.
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25. Conclusions
4. Final conclusions
– The leading cause of death with more available information is “VIH/SIDA
[HIV/AIDS]” on Facebook, and “Enfermedad de Alzheimer [Alzheimer’s
disease]” on Twitter, both with 100% effectiveness in retrieval.
– There are five leading causes of death with low probability of retrieving
information from the different platforms (*):
1. cardiopatía isquémica [ischemic heart disease] (18)
2. cirrosis hepática [liver cirrhosis] (11)
3. violencia interpersonal [interpersonal violence] (11)
4. cáncer de próstata [prostate cancer] (4)
5. Cáncer de colon y recto [colorectal cancer] (3)
(*) The number of countries in which this is the leading cause of death is included in brackets.
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26. Recommendations
4. Final conclusions
Regarding Internet access penetration :
– Perform an analysis of the population connected to the Internet
considering age and gender variables.
Regarding institutional websites of national health authorities:
– Check that institutional content indexing is properly done on search
engines.
– Improve internal search engines.
– Design dissemination strategies trough social media.
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27. Recommendations
4. Final conclusions
Regarding web positioning and competitors:
– Build partnerships with search engines.
– Assess the possibility of including pay per results in search engines.
– Get possible ideas and identify good practices to apply to the
information dissemination strategy of the websites with the highest
visibility.
– Identify and provide collaboration to those institutions with a good
visibility and with which strategies and agreements could be feasible.
– Explore options for collaborating with other types of websites with
good visibility, especially those related with the Web 2.0 such as Wikipedia
or Slideshare.
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28. Recommendations
4. Final conclusions
Regarding the presence of national health authorities on social media:
– Define and explain the institutional policy to use social media.
– Evaluate who should be the team responsible for managing social media.
– Invest in sponsored publicity on Facebook and Twitter to attract citizens.
– Analyze interactions with followers to be able to know what they write
about and what their interests and concerns are.
– Assess the use of Twitter in the case of an emergency or disaster
situation.
– Consider using Facebook to carry out public health campaigns.
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29. Recommendations
4. Final conclusions
– Keep up a high rate of posting (at least 7 messages/day on Facebook ,
and 12 twits/day on Twitter).
– Increase the use of photograph and image social media such as Flickr
or Instagram.
– Strategic use of hashtags.
– Improved virtual coordination at national and international level regarding
World Health Days.
Two overall recommendations:
– Develop periodical analyses based on statistics of use and operation both
in websites and social media profiles.
– Review the vocabulary used when referring to terms concerning public
health.
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30. Thank you
[Tesis doctoral] Acceso a información y uso de redes sociales en salud pública:
un análisis de las autoridades nacionales de salud y de las causas principales de defunción en Latinoamérica
How to cite this work?
Novillo-Ortiz D. Acceso a información y uso de redes sociales en salud pública: un análisis de las autoridades
nacionales de salud y de las causas principales de defunción en Latinoamérica [Tesis doctoral]. Getafe:
Universidad Carlos III de Madrid, Facultad de Humanidades, Comunicación y Documentación; 2015.
Doctoral Dissertation available at: http://e-archivo.uc3m.es/handle/10016/22158
E-mail: dnovilloo@gmail.com | Twitter: @davidnovillo | Web: http://www.davidnovillo.es