Opportunities and challenges of using social media communication in patient care and counselling in family practice: a scoping review and ethical analysis.

Background Healthcare professionals frequently use social media in interacting with colleagues or patients. The aim of this review is to provide a conceptual analysis of ethical issues related to utilization of social media in patient care and health professional training.Methods Using a scoping review, electronic databases (PubMed, HINARI, Google Scholar and ERIC) were searched for publications on use of social media (especially Facebook and WhatsApp) during patient care. Challenges and opportunities faced by users (patients, educators and healthcare professionals) were analyzed.Results Communication between patients and healthcare professionals using WhatsApp and Facebook can improve patient care through improving patients’ understanding of and coping with their illness in family practice. It may also improve the learning environment, increase learning opportunities, complement the teaching/learning process, and enhance professional networking and performance. This presents potential risks and burdens to all related to the technology, user behaviors and nature of interactions. The ethical challenges affect data quality, security and effectiveness of the media.Conclusion


Background
Social media tools include Facebook, Instagram, WhatsApp, Twitter, LinkedIn, and video-hosting sites like YouTube [1][2][3][4]. Healthcare professionals and medical students frequently make use of social media in communicating, learning or interacting with colleagues or patients [2,5,6]. Since these platforms provide tools where users exchange conversation, comment, deliberate, critique, contribute, share, create, modify and evaluate contents online, their potential uses are enormous [2][3][4][5][6][7]. They present a personal learning environment for students [2,3,8,9], a forum for communication 3 between patients and healthcare professionals [10,11], and a medium for communication between healthcare professionals [12,13]. While offering great potential to improve patient care, the use presents potential risks to patients and health workers that relate to the technology and the users, include distribution of poor-quality information [13][14][15][16][17][18][19]. The aim of this review is to provide a conceptual analysis of ethical issues related to utilization of social media and media applications in improving healthcare patient care.  25], and Jonas' theory of responsibility [21]. The data were grouped into themes and sub-themes following an inductive qualitative approach [20], with the ethics domains constituting the themes and the specific challenges constituting the sub-themes.

Theoretical framework: Jonas' theory of responsibility
Jonas [21] developed a theory of ethics applicable to the technological age. Modern technology has potential to generate new threats which are inseparably linked with the technology [21]. Agents are accountable irrespective of the intentions of the action, and accountability may be at individual or collective level [21], and as an imperative of responsibility, humans as rational agents ought to minimize risks and burdens imposed by technology [21].

Results
Social media (such as WhatsApp and Facebook) presents an effective learning and teaching environment, as they can be adapted to the internet [26][27][28], offering invaluable opportunities for patient education and counselling [2,29] as well as for social, participatory and collaborative learning [31][32][33][34]. While social may create ethical issues related to loss of autonomy, inequitable access, risks such as loss of data security, or unfair distribution of risks and benefits, classifiable into four categories: Beneficence (maximizing benefit and minimizing harms), Autonomy (respect for individuals and communities of users) and justice (treating people equally and fairly. Whats App and Facebook communication have potential to improve patient-physician interactions, enhance patient motivation, improve patient awareness about illness, provide accurate information, issues, facilitate the exchange of ideas, frame and reframe health-related questions, and ultimately improve patient outcomes across health systems. Table 1 shows the analysis of ethical issues during information exchange and interaction.
These are related to integration of two opposed fields: medicine with values of privacy, confidentiality, interpersonal and one-to-one interactions and the field of social media, with a culture of sharing, openness, transparency and informality [35,36]. This raises concerns over regulations of user interaction and file sharing [37,38].

Discussion
Jonas [21] made assumptions that dealings with the non-human world are ethically neutral, the entity (man) and his condition is constant in essence and cannot itself be object of "reshaping techne. Jonas' theory is a reformulation of Kant's categorical imperative, which Myskja [39] presents as: "Act so that the effects of your action are compatible with the permanence of genuine human life", and therefore, agents ought to ensure that the effects of their actions do not destroy the future "genuine human life". Therefore, to ensure "genuine human life", agents ought to protect the future humanity's autonomy, dignity, integrity and risk from vulnerability. Jonas theory [21] highlights three key components of "substantive responsibility", namely, "totality, continuity and the future".

Individual and collective agency
The Social Cognitive Theory (SCT) posits that learnt behavior occurs in a social context, with a dynamic and reciprocal interaction between the individual and their environment to enact a given behavior [24,25]. SCT adopts an agent perspective in which individual efficacy motivates individuals 5 as producers of experiences and shapers of events.

Ethical issues related to use of social media as platforms for information exchange
The information communicated or shared on digital platforms may lead to loss of privacy as it may be visible to others [40], and may include words, photos and videos [2]. The data, however, may include patient-identifying information, such as likeness, reports discussed on ward rounds, or data shared with others in seeking opinions and consultations for patient care-related services [32,41].
Such use markedly improves the patients' understanding of their illnesses and offers opportunity and forum to provide expert opinions and interpretations to broader patient populations [41,42].
Ethical issues may be related to justice. These digital platforms are cheaper compared to other modes of communication such as telephone, making it more possible for users to communicate [32], often with many users in a short time, such as in an emergency [32]. Users who share private or confidential thoughts risk causing harms through revealing confidential patient information, as postings have potential to portray unprofessional behaviors [43]. The potential harms include violation of patient/client privacy or posting of confidential information [43], which may lead to dismissal or censorship [44,45].

Ethical issues related to the technology itself
Facebook and WhatsApp have interconnections that allow individuals to connect with each other digitally and have the freedom to create their identities within this system [46]. On Facebook and WhatsApp, one can have multiple identities. This may influence a user's behaviour, whereby a user can create a false identity and use this to send false messages. Anonymity could enable users to send anonymous messages in case of a problem that needs concealment of identity, for example, when they want to act as whistle-blowers [47][48][49]. Ethical issues may be related to transmission of photos and pictures that could be uploaded and shared with other users of other platforms such as Instagram, Facebook or Twitter [4], where data (photos) may be edited to obscure reality. Inability to always transmit anonymized information raises ethical concerns. There are additional challenges of data storage, data security and data safety, which further adds to risk of loss of privacy and confidentiality. When a message is sent from a device via instant messaging, the data contained is 6 transmitted via commercial servers on the Internet, from where it is retrieved by the message recipient [14]. The unpredictable risk from hackers or other intrusive malware creates concern over security of confidential patient information. Harms may arise out of over-use. While increasing connectedness [50], fuse may disrupt critical activities such as lectures or patient care [51,52].
Addiction manifests as over dependency. Spread of negative information (cyber-bullying) may also occur [53]. Another ethical concern is need for local, institutional and national guidelines on which data may be shared and what media should be used, depending on sensitivity and security concerns related to the data [34]. Misuse of social media potentially damages the reputation of both individuals and the institutions they represent [54].

Conclusion
Communication between patients and health workers using WhatsApp and Facebook can enhance patient care through improving patients' understanding of and coping with their illness. Health workers have for long used social media to benefit patients and enhance professional Networks.

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Competing interests
The author declares that he has no competing interests

Funding
The author did not receive specific funding for the writing of the manuscript