Email updates

Keep up to date with the latest news and content from BMC Pediatrics and BioMed Central.

Open Access Highly Accessed Research article

A systematic review of the use and effectiveness of social media in child health

Michele P Hamm13*, Jocelyn Shulhan1, Gillian Williams1, Andrea Milne1, Shannon D Scott2 and Lisa Hartling1

Author Affiliations

1 Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

2 Faculty of Nursing, University of Alberta, Edmonton, Alberta, Country

3 4-488B Edmonton Clinic Health Academy, 11405 – 87 Avenue, Edmonton, Alberta T6G 1C9, Canada

For all author emails, please log on.

BMC Pediatrics 2014, 14:138  doi:10.1186/1471-2431-14-138

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2431/14/138


Received:22 January 2014
Accepted:27 May 2014
Published:2 June 2014

© 2014 Hamm et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Abstract

Background

Social media use is highly prevalent among children, youth, and their caregivers, and its use in healthcare is being explored. The objective of this study was to conduct a systematic review to determine: 1) for what purposes social media is being used in child health and its effectiveness; and 2) the attributes of social media tools that may explain how they are or are not effective.

Methods

We searched Medline, CENTRAL, ERIC, PubMed, CINAHL, Academic Search Complete, Alt Health Watch, Health Source, Communication and Mass Media Complete, Web of Knowledge, and Proquest Dissertation and Theses Database from 2000–2013. We included primary research that evaluated the use of a social media tool, and targeted children, youth, or their families or caregivers. Quality assessment was conducted on all included analytic studies using tools specific to different quantitative designs.

Results

We identified 25 studies relevant to child health. The majority targeted adolescents (64%), evaluated social media for health promotion (52%), and used discussion forums (68%). Most often, social media was included as a component of a complex intervention (64%). Due to heterogeneity in conditions, tools, and outcomes, results were not pooled across studies. Attributes of social media perceived to be effective included its use as a distraction in younger children, and its ability to facilitate communication between peers among adolescents. While most authors presented positive conclusions about the social media tool being studied (80%), there is little high quality evidence of improved outcomes to support this claim.

Conclusions

This comprehensive review demonstrates that social media is being used for a variety of conditions and purposes in child health. The findings provide a foundation from which clinicians and researchers can build in the future by identifying tools that have been developed, describing how they have been used, and isolating components that have been effective.

Keywords:
Social media; Pediatrics; Systematic review

Background

The popularity of social media has changed the way healthcare providers and consumers access and use information, providing new avenues for interaction and care. This advancement of technology has created an environment in which individuals have the opportunity to participate and collaborate in the sharing of information, and may be particularly relevant for children and youth. In a 2013 report on adolescents’ use of social media and mobile technology, researchers from the Pew Internet and American Life Project found that 95% of teens surveyed used the Internet, a figure that has remained constant in the United States since 2006 [1]. Additionally, 73% of teens have a cell phone, of which almost half are smartphones [1]. In 2012, Lenhart et al. [2] reported that when teens possess a smartphone, more than 90% use it to connect with social networking sites. Even without such a highly connected mobile device, 77% of teens still logged into social networking sites, and overall, almost 50% sent daily text messages to their friends [2]. Furthermore, many teens employ multifaceted methods to communicate with their peers, including the Internet, instant messaging, and social networking sites [3].

Considering the extensive degree of connectivity exhibited by today’s youth, it may be worthwhile for healthcare providers to find ways to engage with teens in forums in which they are already comfortable interacting. Some success has been achieved in the use of mobile technology (i.e., instant messaging, text messages) for increasing medication adherence and appointment attendance, and it has been noted that many adolescents are using the Internet to find health information, especially on sensitive topics (e.g., sexual health, drug use) [4]. Given this context, the use of social media tools may be an effective strategy in developing healthcare interventions for children and youth.

There is clear interest in how new technologies can be used to improve patient outcomes, including in children and youth, therefore we conducted a systematic review to answer two key questions: 1) for what purposes are social media being used in the healthcare context for children, youth, and their families, and are they effective for these purposes; and 2) what are the attributes of the social media tools used in this population that may explain how they are or are not effective.

Methods

This systematic review was based on a scoping review that we conducted to determine how social media is being used in healthcare [5]. Child health emerged as an area for further study, therefore the scoping review was used as a foundation, and the search was updated with a focus on children, youth, and their families.

Search strategy

A research librarian searched 11 databases in January 2012: Medline, CENTRAL, ERIC, PubMed, CINAHL, Academic Search Complete, Alt Health Watch, Health Source, Communication and Mass Media Complete, Web of Knowledge, and Proquest Dissertation and Theses Database [5]. Dates were restricted to 2000 or later, corresponding to the advent of Web 2.0. No language or study design restrictions were applied. The search was updated in May 2013. The search strategy for Medline is provided in the Additional file 1.

Additional file 1. Sample Search Strategy (Medline).

Format: DOCX Size: 18KB Download fileOpen Data

Study selection

Two reviewers independently screened titles and abstracts of studies for eligibility. The full text of studies assessed as ‘relevant’ or ‘unclear’ was then independently evaluated by two reviewers using a standard form. Discrepancies were resolved by consensus or adjudication by a third party.

Studies were included if they reported primary research, with analytic quantitative designs used to answer whether social media is effective for use in child health, and descriptive and qualitative designs used to provide context to attributes that may contribute to the effectiveness or lack of effectiveness of the tools being studied. Further, studies were included if they focused on children, youth, or their families or non-professional caregivers, and examined the use of a social media tool. Social media was defined according to Kaplan and Haenlein’s classification scheme [6], including: collaborative projects, blogs or microblogs, content communities, social networking sites, and virtual worlds. We excluded studies that examined mobile health (e.g., tracking or medical reference apps), one-way transmission of content (e.g., podcasts), and real-time exchanges mediated by technology (e.g., Skype, chat rooms) [5]. Studies relevant to pediatric mental health were also excluded as they are being evaluated separately in a systematic review currently underway. Outcomes were not defined a priori as they were to be incorporated into our description of the field.

Data extraction and quality assessment

Data were extracted using standardized forms and entered into Microsoft Excel (Microsoft, Redmond, Washington, USA) by one reviewer and verified for accuracy and completeness by another. Reviewers resolved discrepancies through consensus. Extracted data included study and population characteristics, description of the social media tools used, objective of the tools, outcomes measured and results, and authors’ conclusions [7]. Studies that examined social media as one component of a complex intervention were noted as such.

Two reviewers independently assessed the methodological quality of included analytic studies and resolved disagreements through discussion. We used the Cochrane Risk of Bias tool to assess randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) [8]. We used a tool for before-after studies that was developed based on the Newcastle-Ottawa Scale [9] and used in a previous review [10]. Quality assessment was not conducted on cross-sectional or qualitative studies as they were used to provide additional context to how social media is being used in child health, rather than to provide estimates of effect.

Data synthesis and analysis

We described the results of studies qualitatively and in evidence tables. Descriptive statistics were calculated using StataIC 11 (StataCorp, College Station, Texas, USA). Studies were grouped according to target user and study design. When studies provided sufficient data, we calculated standardized mean differences and 95% CIs for the primary outcomes and reported all results in forest plots created using Review Manager, Version 5.2 (The Cochrane Collaboration, Copenhagen, Denmark). We did not pool the results as the primary outcome varied across studies; however, we displayed the information graphically to examine the magnitude of effect of the social media interventions.

Results

We identified 25 studies in 26 articles that met our inclusion criteria: 16 from the original search [5] and 10 from the update. Figure 1 outlines the flow of studies through the inclusion process and Table 1 provides a description of the included studies. The most common uses for social media were for health promotion (52%) and the tools were largely community-based (64%). Adolescents were more often the target audience (64%) than children (36%) or caregivers or families (44%; 40% targeted multiple groups). Discussion forums were the most commonly used tools (68%). Nearly all authors concluded that the social media tool evaluated showed evidence of utility (80%) and the remainder were neutral (20%); none reported negative conclusions.

thumbnailFigure 1. Flow diagram of study selection.

Table 1. Description of included studies

How social media is being used in child health

While social media interventions were used to target health outcomes in children, youth, and caregivers, adolescents were the most commonly studied population. Two studies were based on acute conditions; 10 on chronic conditions, with clusters in type 1 diabetes (n = 3) and cancer (n = 2); and 13 for health promotion purposes, focusing mainly on healthy diet and exercise (n = 5), sexual health (n = 4), and smoking cessation (n = 2; Tables 2 and 3).

Table 2. Characteristics of included studies

Table 3. Results for primary outcomes and conclusions of included studies

Acute conditions

Two studies evaluated social media as an intervention in an acute context: one in families of patients in the pediatric intensive care unit [11] (PICU) and one to help parents of children experiencing infantile spasms [12]. While both focused on pediatric health conditions, social media use was directed towards knowledge translation efforts, providing a source of information for the caregivers. The authors concluded that the interventions were beneficial to parents in both cases (Table 3).

Chronic conditions

Two studies conducted in populations with chronic health conditions evaluated Zora, a virtual world [16,17], and the remaining eight studies investigated the use of discussion forums (Table 2) [13-15,18-22]. In each of the 10 studies, the primary objective of the social media tool was to provide support to the pediatric patient (n = 3), the parent or family of the patient (n = 3), or both (n = 4). These tools were often in the form of multi-faceted interventions (n = 5), in which the discussion forum was just one component. Discussion forums appeared alongside condition-specific information, interactive features, and links to other online and physical resources such as camps and support groups. Conditions included cancer, juvenile idiopathic arthritis, renal disease, organ transplants, and type 1 diabetes. Adolescents were included in all studies that were intended for the patient; children, ranging from 4 to 12 years old, were also included in five of these studies [13,16,17,19,22]. Outcomes in this group of studies were nearly all related to coping or self-efficacy, or perceptions and usage of the intervention. One study measured the impact of the social media tool on a change in a health outcome [15].

Health promotion

Thirteen studies evaluated the use of social media as a health promotion tool. Health promotion efforts were directed at children and adolescents, but rarely at caregivers. The two studies that were exclusively aimed at children were focused on healthy diet and exercise, made use of discussion forums, and were aimed towards children from 8 to 12 years old [26,27]. The two studies evaluating tools intended for caregivers used online educational strategies incorporating discussion forums [28,35]. The remaining nine studies evaluated social media use in adolescent populations, covering healthy diet and exercise [23-25], sexual health [29-31], smoking cessation [32,34], and parenting issues [36].

The largest proportion of health promotion studies was in the area of healthy diet and exercise [23-27]; three of these five studies have been examined in more detail in another systematic review conducted by our group [37]. Although most of the social media tools evaluated were discussion forums, there was more variety in the health promotion studies in the interventions used than for acute or chronic conditions, including investigations of existing, widely used platforms such as Facebook. Four studies evaluated the use of Facebook as an outreach strategy to engage with adolescents in a school setting or in the general public [23,25,29,31]. The primary goals of the interventions in the health promotion category were to effect change in health outcomes, or to act as educational resources.

Effectiveness of social media in child health

We included 12 studies that evaluated the effectiveness of a social media intervention versus a comparator; their results are described below.

Randomized controlled trials

Data were available from seven RCTs. Six trials evaluated discussion forums and all seven trials included the social media tool as a component of a complex intervention. Only one study [24] compared two social media interventions; two compared the social media intervention to an online tool without the social media component [20,35], two used a non-technological aspect as the comparison group [34,36], and two compared social media to no intervention [25,26]. In all seven RCTs, there was no significant difference in the primary outcome measured between the social media group and the comparator. Two studies [24,36] used composite measures as primary outcomes and significant benefits were found in individual components. The statistical significance of the primary outcomes in these seven RCTs is in contrast to the authors’ conclusions, in which four studies concluded that the social media intervention had a positive effect (Table 3).

Quality assessment of the RCTs was conducted using the Risk of Bias tool (Table 2) [8]. Two trials were at unclear risk of bias [20,35] and the remaining five were at high risk of bias [24-26,34,36]. Sequence generation and allocation concealment were poorly reported. While the nature of the intervention precluded blinding of participants, blinding of outcome assessors was only reported in two studies [24,26]. Attrition was high, leading to high risk of bias in four studies [25,26,34,36]. Selective outcome reporting was not present in any of the studies.

Non-randomized and before-after studies

One NRCT [32] and two before-after studies [18,23] included sufficient data to calculate standardized mean differences. Two studies found no significant difference between groups [23,32], and the other found a significant benefit of social media using one scale but not another [18]. Despite these results, two studies [18,32] claimed that the social media intervention had a positive effect (Table 3).

Using the Risk of Bias tool [8] for the NRCT, and the before-after quality assessment tool, all three studies were poor to moderate quality (Table 2). The before-after studies described the intervention well, but lacked detail on the representativeness of the samples and the reliability of the outcome measures. The non-randomized controlled trial was at high or unclear risk of bias regarding allocation, blinding, and incomplete outcome reporting.

Cross-sectional studies

Two of the included cross-sectional studies evaluated health outcomes following exposure to a social media intervention [27,29]. One further cross-sectional study [12] found that approximately 60% of YouTube videos on infantile spasms screened depicted accurate portrayals and 18.5% of videos were considered to be excellent patient resources.

Attributes of social media associated with effectiveness or lack of effectiveness

While the social media tools and the conditions and outcomes they aim to address vary widely, we used descriptive, qualitative, and mixed methods studies to explore whether there were overlapping characteristics of social media generally that may help to explain their effectiveness or lack thereof.

Cross-sectional studies

Three cross-sectional studies were used to evaluate users’ experiences with social media interventions. Yager et al. [31] investigated the use of a Facebook site as a source of information on sexual health, and found that adolescents appreciated the availability of this resource and the comprehensiveness of the information. Braner et al. [11] and Baum et al. [21] both evaluated tools used to provide support to parents and caregivers and found that user satisfaction was driven by finding the right balance between providing informational and emotional support.

Qualitative and mixed methods studies

All seven of the qualitative and mixed methods studies that met our inclusion criteria evaluated social media tools that were intended to provide support to their users. Two studied a virtual world and five studied discussion forums.

The two evaluations of Zora, a virtual world designed to help young users explore identity issues, highlighted different aspects of what made the tool successful. In children and adolescents with end-stage renal failure undergoing dialysis, Zora provided an opportunity for distraction from their illness, and a means by which to escape their reality [16]. While healthcare providers felt that it would be an ideal tool to teach their patients about their illness, none of the children endorsed this view. Conversely, in adolescents who had undergone an organ transplant, communication with others who had been through the same experience built a sense of community and was a method of coping with their conditions [17].

Mirroring the findings related to the virtual world, the studies evaluating discussion forums found a dichotomy in that some groups preferred to use the social media tools as a distraction from their illness [13,22], while others valued the ability to connect with others [14,15,19]. One distinction between these two groups was that younger children tended to be included in those studies that presented social media as a diversion, while adolescents were more highly represented in studies that found a benefit in building a social network. In one study of fathers of a child with a brain tumor, connections with others helped them cope by limiting isolation and normalizing their experiences [14]. However, other studies found that parents and caregivers were less likely to feel comfortable participating in an online forum [13,15]. Other features identified as being important included maintaining a certain level of activity on the forum in order to attract returning users [19], and minimizing access barriers related to technology, such as the use of passwords [19,22].

Discussion

The use of new technology such as social media in child health is rapidly expanding and evolving. This systematic review provides a comprehensive review of the research that has been conducted in order to serve as a resource to guide future clinical and research efforts in this area.

The majority of studies included in our review investigated the use of a discussion forum and assessed social media as one component of a complex intervention. Discussion forums were often intended to provide support, and were particularly prevalent in studies of chronic conditions. While there were reported benefits in this context, especially from the qualitative investigations, none of the studies that used a discussion forum to effect change in a health outcome reported significant results. Given the focus on health promotion in this group of studies, and the familiarity that children and youth have with current social media platforms, outreach strategies may be more effective if efforts are made up-front to identify the tools that the target audience is already using and tailor the intervention accordingly, rather than expect the group to find and adopt new technologies that have been developed to suit a more limited, condition-specific purpose.

The use of complex interventions limits the ability to tease out any effects specific to the social media component; however, the inclusion of qualitative research helped to provide context to some of the attributes that were perceived to be effective. In general, users were most drawn to the ability of social media to facilitate the development of a support network. This did not apply to all populations, though, and tended to be more relevant to older children, and parents or caregivers. In the study populations including younger children, the reported advantage of the social media intervention tended to lie within its ability to serve as a distraction from their illness.

The use of social media varied according to the type of condition studied. Tools applied to acute conditions targeted the parents, and were intended to be educational resources and promoted information sharing. As described above, provision of support, either to the patient or to the caregiver, was the primary goal in chronic conditions. Health promotion was the category that most directly targeted children and youth, and demonstrated the greatest variety in tools used and outcomes measured, perhaps indicating potential for future development.

The authors’ conclusions tended to be positive with respect to the effectiveness and promise of social media as an intervention or promotional tool for child health. However, this was rarely supported by the statistical significance of the results. While this is a new technology with plenty of advocates and hypothesized benefits, there is no clear evidence that it is effective in improving health outcomes in children and youth. The included studies were of poor to moderate quality and many did not use rigorous study designs. Moving forward, an emphasis on well-conducted experimental designs and qualitative research, rather than on descriptive studies, would help to illuminate whether social media demonstrates effectiveness, and what characteristics contribute to that potential impact. This could include an increased focus on head-to-head comparisons of the effectiveness of specific social media tools, qualitative evaluations of their perceived strengths and limitations, and the use of changes in health outcomes as end-points.

Strengths and limitations

We conducted a comprehensive systematic review of the literature following well-endorsed methods [38,39]. Our results provide a view of how social media is being used in child health, including the target audiences and intended purposes. We included all study designs including qualitative and descriptive research in order to provide information to help understand how these interventions may or may not be effective. These results may help inform the development of future interventions and research. The limitations of this review pertain to the nature of the topic and the methodological quality of the primary research. Specifically, in the majority of studies, social media was used as one component of a complex intervention making it difficult to tease out the specific impact of the social media modalities. Further, the primary research in this area had methodological limitations that should be addressed in future research. For example, in randomized and non-randomized trials, attention should be focused on adequate sequence generation, allocation concealment, and blinding of outcome assessment. Attrition was problematic and may be reflective of the challenge of maintaining engagement with the target audience through the interventions employed. Integrating end-user engagement in the development of the social media tools or strategy may be a step in overcoming this obstacle in future research [40]. Finally, while this review provides a thorough examination of the academic literature, the nature and evolution of social media has left a gap between tools that are currently used and those that have been scientifically evaluated. Other tools may have been developed that were not captured in our search of formal academic investigations. Therefore, the findings of this review may point towards an absence of evidence, rather than evidence of the absence of effectiveness of social media as a strategy for health-related interventions in children and youth.

Conclusions

This systematic review demonstrates that social media is being used extensively in child health for a variety of purposes. The most common uses for social media were for health promotion with a focus on healthy diet and exercise, sexual health, smoking cessation, and parenting issues. Adolescents were the most common target audience, discussion forums were the most commonly used tools, and the tools were largely community-based. Nearly all studies concluded that the social media tool evaluated showed evidence of utility; however, results of the primary outcomes from the majority of comparative studies showed no significant effect. This synthesis offers an important resource for those who are developing and evaluating interventions involving social media.

Abbreviations

NRCT: Non-randomized controlled trial; PICU: Pediatric intensive care unit; RCT: Randomized controlled trial.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MPH, SDS, and LH designed the study. MPH coordinated the project and is the guarantor. AM conducted the literature search and contributed to drafting the manuscript. MPH, JS, GW, and AM screened articles and performed data extraction and quality assessment. MPH and LH interpreted the data. MPH drafted and all authors critically reviewed the manuscript. All authors read and approved the manuscript.

Acknowledgements

The authors thank Annabritt Chisholm, Michelle Foisy, and Baljot Chahal for assistance with study selection, and Ben Vandermeer for his assistance with the statistical analysis. This review was supported by a Knowledge-to-Action Grant from Alberta Innovates – Health Solutions. The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Dr. Scott holds a Canada Research Chair in Knowledge Translation in Child Health and Population Health Investigator Award from Alberta Innovates – Health Solutions. Dr. Hartling holds a New Investigator Salary Award from the Canadian Institutes of Health Research.

References

  1. Madden M, Lenhart A, Duggan M, Cortesi S, Gasser U:

    Teens and Technology 2013.

    [http://www.pewinternet.org/Reports/2013/Teens-and-Tech.aspx webcite]

    OpenURL

  2. Lenhart A:

    Teens, Smartphones & Texting.

    [http://www.pewinternet.org/Reports/2012/Teens-and-smartphones/Summary-of-findings.aspx webcite]

    OpenURL

  3. Lenhart A, Madden M, Smith A, Macgill A:

    Teens and Social Media, Report: Teens, Social Networking, Blogs, Videos, Mobile.

    [http://www.pewinternet.org/Reports/2007/Teens-and-Social-Media.aspx webcite]

    OpenURL

  4. Schurgin O’Keeffe G, Clarke-Pearson K, Council on Communications and Media: The impact of social media on children, adolescents, and family.

    Pediatrics 2011, 127(4):4. PubMed Abstract | Publisher Full Text OpenURL

  5. Hamm MP, Chisholm A, Shulhan J, Milne A, Scott SD, Given LM, Hartling L: Social media use among patients and caregivers: a scoping review.

    BMJ Open 2013., 3(5) OpenURL

  6. Kaplan AM, Haenlein M: Users of the world, unite! The challenges and opportunities of Social Media.

    Bus Horiz 2010, 53:10. OpenURL

  7. Tricco AC, Tetzlaff J, Pham B, Brehaut J, Moher D: Non-Cochrane vs. Cochrane reviews were twice as likely to have positive conclusion statements: cross-sectional study.

    J Clin Epidemiol 2009, 62:8. OpenURL

  8. Higgins JPT, Green S (Eds): Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (Table 8.4a). Cochrane Collaboration; 2011.

    [http://www.cochrane-handbook.org webcite]

    OpenURL

  9. Wells G, Shea B, O'Connell J, Robertson J, Peterson V, Welch V, Losos M, Tugwell P: The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analysis. [http://www.ohri.ca/programs/clinical_epidemiology/oxford.Asp]

  10. Bond K, Ospina M, Blitz S, Friesen C, Innes G, Yoon P, Curry G, Holroyd B, Rowe B: Interventions to reduce overcrowding in emergency departments. Ottawa: Technology Report 67.4; 2006. OpenURL

  11. Braner DA, Lai S, Hodo R, Ibsen LA, Bratton SL, Hollemon D, Goldstein B: Interactive Web sites for families and physicians of pediatric intensive care unit patients: a preliminary report.

    Pediatr Crit Care Med 2004, 5(5):434-439. PubMed Abstract | Publisher Full Text OpenURL

  12. Lim Fat MJ, Doja A, Barrowman N, Sell E: YouTube videos as a teaching tool and patient resource for infantile spasms.

    J Child Neurol 2011, 26(7):804-809. PubMed Abstract | Publisher Full Text OpenURL

  13. Ewing LJ, Long K, Rotondi A, Howe C, Bill L, Marsland AL: Brief report: A pilot study of a web-based resource for families of children with cancer.

    J Pediatr Psychol 2009, 34(5):523-529. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  14. Nicholas DB, Chahauver A, Brownstone D, Hetherington R, McNeill T, Bouffet E: Evaluation of an online peer support network for fathers of a child with a brain tumor.

    Soc Work Health Care 2012, 51(3):232-245. PubMed Abstract | Publisher Full Text OpenURL

  15. Stinson J, McGrath P, Hodnett E, Feldman B, Duffy C, Huber A, Tucker L, Hetherington R, Tse S, Spiegel L, Campillo S, Gill N, White M: Usability testing of an online self-management program for adolescents with juvenile idiopathic arthritis.

    J Med Internet Res 2010, 12(3):e30. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  16. Bers MU, Gonzalez-Heydrich J, Raches D, DeMaso DR: Zora: a pilot virtual community in the pediatric dialysis unit.

    Stud Health Technol Inform 2001, 84(Pt:1):1-4. OpenURL

  17. Bers MU: New media for new organs: A virtual community for pediatric post-transplant patients.

    Convergence 2009, 15(4):462-469. Publisher Full Text OpenURL

  18. Merkel RM, Wright T: Parental self-efficacy and online support among parents of children diagnosed with type 1 diabetes mellitus.

    Pediatr Nurs 2012, 38(6):303-308. PubMed Abstract OpenURL

  19. Nordfeldt S, Hanberger L, Berterö C: Patient and parent views on a Web 2.0 Diabetes Portal–the management tool, the generator, and the gatekeeper: qualitative study.

    J Med Internet Res 2010, 12:9. Publisher Full Text OpenURL

  20. Whittemore R, Grey M, Lindemann E, Ambrosino J, Jaser S: Development of an Internet coping skills training program for teenagers with type 1 diabetes.

    Comput Inform Nurs 2010, 28(2):103-111. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  21. Baum LS: Internet parent support groups for primary caregivers of a child with special health care needs.

    Pediatr Nurs 2004, 30(5):381-401. PubMed Abstract OpenURL

  22. Nicholas DB, Darch J, McNeill T, Brister L, O’Leary K, Berlin D, Koller DF: Perceptions of online support for hospitalized children and adolescents.

    Soc Work Health Care 2007, 44(3):205-223. PubMed Abstract | Publisher Full Text OpenURL

  23. Cordeira KL: Effects of a Health Advocacy Program to Promote Physical Activity and Nutrition Behaviors Among Adolescents: An Evaluation of the Young Leaders for Healthy Change program MPH Thesis . School of Public Health: The University of Texas; 2012. OpenURL

  24. DeBar LL, Dickerson J, Clarke G, Stevens VJ, Ritenbaugh C, Aickin M: Using a website to build community and enhance outcomes in a group, multi-component intervention promoting healthy diet and exercise in adolescents.

    J Pediatr Psychol 2009, 34(5):539-550. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  25. Lao L: Evaluation of a social networking based SNAP-Ed nutrition curriculum on behavior change MS Thesis. Department of Nutrition and Food Sciences: University of Rhode Island; 2011. OpenURL

  26. Rydell SA, French SA, Fulkerson JA, Neumark-Sztainer D, Gerlach AF, Story M, Christopherson KK: Use of a Web-based component of a nutrition and physical activity behavioral intervention with Girl Scouts.

    J Am Diet Assoc 2005, 105(9):1447-1450. PubMed Abstract | Publisher Full Text OpenURL

  27. Savige GS: E-learning: a nutritionally ripe environment.

    Food & Nutrition Bulletin 2005, 26(2:Suppl 2):S230-S234. PubMed Abstract OpenURL

  28. Cox MF, Scharer K, Clark AJ: Development of a Web-based program to improve communication about sex.

    Comput Inform Nurs 2009, 27(1):18-25. PubMed Abstract | Publisher Full Text OpenURL

  29. Jones K, Baldwin KA, Lewis PR: The potential influence of a social media intervention on risky sexual behavior and Chlamydia incidence.

    J Community Health Nurs 2012, 29(2):106-120. PubMed Abstract | Publisher Full Text OpenURL

  30. Lou CH, Zhao Q, Gao ES, Shah IH: Can the Internet be used effectively to provide sex education to young people in China?

    J Adolesc Health 2006, 39(5):720-728. PubMed Abstract | Publisher Full Text OpenURL

  31. Yager AM, O'Keefe C: Adolescent Use of Social Networking to Gain Sexual Health Information.

    J Nurse Pract 2012, 8(4):294-298. Publisher Full Text OpenURL

  32. Chen HH, Yeh ML, Chao YH: Comparing effects of auricular acupressure with and without an internet-assisted program on smoking cessation and self-efficacy of adolescents.

    J Altern Complement Med 2006, 12(2):147-152. PubMed Abstract | Publisher Full Text OpenURL

  33. Chen HH, Yeh ML: Developing and evaluating a smoking cessation program combined with an Internet-assisted instruction program for adolescents with smoking.

    Patient Educ Couns 2006, 61:411-418. PubMed Abstract | Publisher Full Text OpenURL

  34. Patten CA, Croghan IT, Meis TM, Decker PA, Pingree S, Colligan RC, Dornelas EA, Offord KP, Boberg EW, Baumberger RK, Hurt RD, Gustafson DH: Randomized clinical trial of an Internet-based versus brief office intervention for adolescent smoking cessation.

    Patient Educ Couns 2006, 64(1–3):249-258. PubMed Abstract | Publisher Full Text OpenURL

  35. Baggett KM, Davis B, Feil EG, Sheeber LL, Landry SH, Carta JJ, Leve C: Technologies for expanding the reach of evidence-based interventions: preliminary results for promoting social-emotional development in early childhood.

    Top in Early Child Spec Educ 2010, 29(4):226-238. Publisher Full Text OpenURL

  36. Hudson DB, Campbell-Grossman C, Hertzog M: Effects of an internet intervention on Mothers' psychological, parenting, and health care utilization outcomes.

    Issues Compr Pediatr Nurs 2012, 35(3/4):176-193. PubMed Abstract | Publisher Full Text OpenURL

  37. Williams G, Hamm MP, Shulhan J, Vandermeer B, Hartling L: Social media interventions for healthy diet and exercise: a systematic review and meta-analysis of randomized controlled trials.

    BMJ Open 2014, 4(2):e003926. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  38. Chandler J, Churchill R, Higgins J, Lasserson T, Tovey D:

    Methodological Standards for the Conduct of New Cochrane Intervention Reviews. Version 2.2.

    [http://www.editorial-unit.cochrane.org/sites/editorial-unit.cochrane.org/files/uploads/MECIR_conduct_standards%202.2%2017122012_0.pdf webcite]

    OpenURL

  39. Institute of Medicine: Finding what works in health care: Standards for Systematic Review. Washington, DC: The National Academies Press; 2011. OpenURL

  40. Hartling L, Scott S, Pandya R, Johnson D, Bishop T, Klassen TP: Storytelling as a communication tool for health consumers: development of an intervention for parents of children with croup. Stories to communicate health information.

    BMC Pediatr 2010, 10:64. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2431/14/138/prepub