Use of images of patients in social networks : how do speech-language therapists perceive and act ?

Purpose: Investigating the perception and self-reported behavior of speech-language therapist about ethical and legal aspects related to the use of images of patients in social networks, comparing such findings with sociodemographic data. Methods: An online questionnaire with 13 questions was the instrument used to collect data related to the demographic data of the participants and to the perception of speech-language therapists. The questionnaire was available on the Google Forms platform e was answered by 765 participants. Results: Most participants agreed that the Code of Ethics of Speech-Language Pathology gives information about the use of images in social networks (67.98%), that the publication of photos and / or videos of patients in social networks without authorization by written is an ethical infraction (93.33%) and that the image ́s rights is guaranteed by the Brazilian Constitution (89.94%). 18.56% of speech-language pathologists stated that they had never used the Code of Ethics in Speech-Language Pathology. Concerning the exhibition of images in social networks, 5.1% stated that they had shown on their social networks photographs and / or videos without authorization, and 21.18% did so with only verbal authorization. Almost all participants (95.16%) mentioned having seen photographs or videos of patients on virtual social networks posted by speech-language therapist. Conclusion: It was possible to verify the relevance of the results obtained and the impact of the research to encourage reflection on the subject.


INTRODUCTION
Virtual social networks are communication tools that allow people with common interests and practices to interact regularly in an organized way on the internet, using a specific mechanism (1) , regardless of where they are (2).This communication tool has generated great impact in society and daily activities (3).It is estimated that in the world today there are two billion monthly users on Facebook, 1.2 billion on WhatsApp and 328 million on Twitter (4) .
The access to social networks from devices containing a camera has contributed to an increase in the number of photo and / or video publications, including by health professionals (5,6) .Thus, it can be said that the image, as a legal good, becomes easily violable according to the facility and speed with which its capture and transmission can occur (7) .
Is not uncommon for health professionals to record patient's images to be attached to medical records to publishe in scientific journals, to use in classes, lectures and other educational spaces, and to promote their work (8).
Especially at the beginning of the millennium, ethical shocks have been perceived as regards privacy and confidentiality of information (9) , contrary to the precepts of codes of professional ethics, which have recommendations for norms for adequate action, in order to guarantee privacy in different contexts (10) .The Code of Medical Ethics, for example, seals the doctor from […] referring to identifiable clinical cases, displaying patients or their portraits in professional advertisements or in the dissemination of medical matters in general media, even with patient authorization […] (11:44) .
The Code of Ethics of Speech-Language Pathology (12:23) , in turn, establishes as an ethical infraction: Refer to clients or identifiable clinical cases or display client, family, group and community image in professional advertisements, lectures, classes, scientific events or in the dissemination of therapeutic matters in any media, when not authorized by written by them or by their legal representative (s).
However, although professional codes of ethics guide patients exposure and need for confidentiality, a considerable number of undue publications have been noticed in social networks.In Brazil, Martorell et al. (13) , when analyzing 39 images posted on Facebook by doctors or dental surgeons, verified a significant number of positive comments and likes.Martorell et al. (14) analyzed 123 images of dental patients published on Instagram and found that they were predominantly associated with professional profiles (46.4%) and referred to procedures used in the conduct of the case.In the United Kingdom, from 2009 to 2013, the Medical Council received 27 complaints from doctors who used Facebook and Twitter in their activities.Prior to 2009, there were no complaints related to the use of these mass communication tools (15) .Over the past two years, the same board has conducted 28 investigations into allegations of misuse of Facebook, Twitter or WhatsApp by doctors (4) .Therefore, it is necessary to investigate the knowledge, perception and motivation of health professionals to expose images of patients in social networks.Caires et al. (6) evaluated in Brazil the knowledge of 360 health professionals about the capture and reproduction of images of patients in a hospital environment.Although almost all (98.1%) considered it necessary to preserve the image, most of them mentioned ignorance regarding the Brazilian constitution (65%) and professional codes of ethics (53.6%) on the subject.Bal (16) , in India, conducted a brief survey of 32 doctors from a WhatsApp group and found that 75% considered it acceptable to share patient data, as long as unidentifiable, and 12.5% considered it acceptable to share unreservedly, in other words, even if the information could identify the patient.About the reasons of the social media use during the professional exercise, Antheunis et al. (17) conducted a survey of 153 health professionals in the Netherlands and verified how the motivation, the contact with other professionals and self-disclosure.
With regard to the perceptions and behaviors of speech-language therapist about the exposure of patients' images in social networks, it is important to question: What do they know?What is the prevalence of those who expose images on social networks?Do they feel sufficiently informed by the Code of Ethics?Considering that few researches were found on the health are, with this theme, this study was designed with the following objectives: to investigate the perception and self-reported behavior of speech-language therapist about ethical and legal aspects related to the use of images of patients in social networks, comparing such with sociodemographic data.

METHODS
This study was initiated after approval of the Research Ethics Committee with human beings from a hospital in the interior of the State of São Paulo (case No. 1,996,062).All individuals involved in the study agreed to participate in the study from the reading of a Free and Informed Consent Term (FICT).
The sample consisted of 765 speech-language therapists who met the following inclusion criteria: being Brazilian and agreeing to participate voluntarily, regardless of gender, age and training time.It was excluded from the sample questionnaires with incomplete answers and / or with duplication evidence (they presented identical answers to the previously answered questionnaire).
The Table 1 shows the distribution of the participants regarding the age group, the region of the federative entities and the time of formation.
To obtain the data of this research, it was opted for using an online questionnaire in order to reach audiologists from all over the country.This instrument contained 13 questions of obligatory completion, developed by the researchers and was available on the GoogleDrive platform via the link, which was made available to interested speech therapist by email and WhastApp, as well as speech therapist groups via Facebook and Instagram.The questionnaire was available for completion for five months (from April 3 to September 11, 2017).
The instrument was structured in two parts.The first included personal and professional data, such as age, federative unit and year of training.The second investigated the subject of the study, such as the perception of speech therapist about ethical and legal aspects related to the use of patient images on social networks, frequency with which they used the Code of Ethics in Speech-Language Pathology, frequency with which they used social networks, used social networks to publicize work as a speech therapist, the frequency with which they exhibited or saw speech-language therapist displaying patient images on social networks.The perception of speech-language therapist was measured from Likert scales of agreement, ranging from 'totally disagree' to 'strongly agree'.Speech-language therapist' behaviors were measured from frequency scales, varying from 'never' to 'always'.
Previously to the application of the online questionnaire, the content was validated by a group of 10 speech-language therapist judges, servants of a hospital complex in the interior of the State of São Paulo, following Lawshe's guidance (18) .
Concerning the judges, two were men and eight women, with a minimum age of 26 years and a maximum of 53 (average: 33.1 years), a training period of one year to 32 years (average: 12.7 years) born in the State from Sao Paulo.
In this study, the categorical variables were described by frequency and percentage and presented in figures.The associations of interest were analyzed through the Chi-square test with Monte Carlo simulation, considering 2000 replications.The comparisons of the question answers regarding the age and the time of formation were made through the Kruskal-Wallis test.A significance level of 5% was adopted.

RESULTS
About the perception of speech-language therapist concerning the use of images in social networks, particularly regarding the agreement with the affirmations about the Code of Ethics of Speech-Language Pathology and the Brazilian Constitution, the results can be visualized in Figure 1.
About the frequency of behaviors related to the Code of Ethics of Speech-Language Pathology and social networks, participants' answers can be visualized in Figure 2.
As of the Kruskal-Wallis statistical test, it was verified that age and training times were associated with the frequency of access to the Code of Ethics Speech-Language Pathology (p <0.01), the participants that answered 'always access' were the older age and training time.The region of origin of the participants did not determine a change in the distribution of the answers, according to a Chi-square test with Monte Carlo simulation.
About the dissemination of patient images in social networks, according to self-reported information, Figure 3 shows the distribution of the participants in relation to the frequency of responses.
The Kruskal-Wallis statistical test showed that the participants' ages and training times were associated with the frequency of dissemination of photos and videos with written permission in social networks.The ages of those who answered 'always' were statistically greater than the ages of those who answered 'sometimes' (p = 0.02).The same occurred with the comparison of training years in relation to the frequency of responses (p <0.01).It was also possible to notice that the ages and years of training were higher for those who never and 'rarely' saw photographs and / or videos of patients in social networks compared to the other frequencies (p <0.01).The region of origin of the participants did not determine a change in the distribution of these responses, according to the Chi-square test with Monte Carlo simulation.

DICUSSION
Regarding the perception of speech-language therapist about the Code of Ethics of Speech-Language Pathology, particularly on the use of images in social networks, 67.9% of speech-language therapist agreed to some degree that this document clarifies this issue.The percentage of those who did not agree or who did not have an opinion (almost a third of the speech-language therapist interviewed) can be considered elevated and worrying, considering the impact of this disinformation on the professional performance, since it favors the occurrence of ethical infractions related to the use of images on social networks.This lack of knowledge can be justified by the lack of access or non-reading of the version of the Code of Ethics of Speech-Language Pathology, published in 2016 (12) , which clarifies this subject in CHAPTER X, section II, which deals with social networks.
When questioned if the publication of images on social networks without formal written authorization would be ethical infraction, almost all (93.3%) agreed to some degree.Considering that a smaller percentage said to agree that the Code of Ethics of Speech-Language Pathology clarifies on the subject, it is believed that the participants have agreed with the affirmative because this is the subject of the study.
The most part of the participants (89.9%) agreed, to some degree, that the right to the image is guaranteed by the Brazilian Constitution, with 70.7% fully agreeing.This finding is positive, since the high percentage of speech-language therapist knowledgeable about the Brazilian Constitution is a factor that contributes to inhibit the practices of exposing images of patients in virtual social networks.
The right to the image is constitutional, explicitly protected, in the Constitution of the Federative Republic of Brazil (19) , as transcribed after: [...] the intimacy, private life, honor and image of persons shall be inviolable, and shall be entitled to compensation for the material or moral damage resulting from their violation [...] (Article 5, subsection X).
Also in Article 20 of the Civil Code (20) , it is explained: Unless authorized or necessary for the administration of justice or for the maintenance of public order, the disclosure of writs, the transmission of a word, or the publication, exposure or use of a person's image may be prohibited, at his request and without prejudice to any indemnity that may be incurred, if they achieve their honor, good name or respectability, or are destined for commercial purposes.
Another aspect investigated in the study was the use of the Code of Ethics of Speech-Language Pathology in speech-language therapy practice, as well as the use of virtual social networks by these professionals.The majority (52.8%) revealed having resorted to the code of ethics 'never' or 'rarely'.The average ages and training times were associated with the frequency of access to the Code of Ethics, indicating that the speech-language therapists who responded 'always' to access the code were those who were older than the others.This finding can be explained by the greater time of practice, experiences and doubts regarding the ethical issues of care.
An important data for the study is that 88.7% of participants reported using 'always' or 'often' virtual social networks.This high prevalence reinforces the importance of updating and revising professional codes of ethics, since it is during  the use of this communication tool that demands and needs of orientations will arise (21) .
About the use of virtual social networks for the dissemination of professional activity, the majority (76.1%) reported frequency equal to or greater than 'rarely'.This disclosure may be related to self-promotion, which is not contraindicated by the The Code of Ethics of Speech-Language Pathology current.Special care should occur when disclosure of the work involves use of patient images, due to the ethical and legal consequences that this practice may cause.
When asked if they had already released photos and / or videos of patients in virtual social networks without authorization, 5.1% responded positively.The number of those who reported verbal consent increased to 21.2%.It is likely that professionals who are not aware of the revised version of the code in 2016 believe that just the verbal authorization suffices, unaware that the authorization must be in writing by the patient or his or her legal guardian.In any case, undue exposure of patients' image on social networks happens and can be considered a violation of image privacy rights.Thus, it is necessary that health professionals question if the intended publication is legal and / or morally acceptable (22) .A constant discussion about exposing images of people (patients or clients) without authorization is fundamental, although it is used for some interest in the community (5) .It is important to note that the analysis of this response according to age and time of formation revealed a statistical difference between the groups compared.Thus, speech-language therapists, who responded 'always' to disseminate images or videos with written authorization, were those of greater age and time of training than those who mentioned "sometimes." Almost totality (95.2%) has seen photographs and / or videos of patients being posted on social networks by colleagues, which is very worrying.When there is capturing and exposing the image of a patient without authorization, it is fundamental to question the intention of this action, even if it is used for the benefit of the community.It is unacceptable to use images that expose a person in a sensationalist way (5) .Also, another aspect to be considered is that the patient being treated may develop feelings of loss of control over himself, by feeling fragile physically and emotionally.Often, he feels that the professional has "power" over him and, for this reason, does not question some behaviors (23) .
If used correctly, technology is a great allied of health professionals, but for this, care must be taken regarding patients' rights to exposure, which can cause some kind of embarrassment or even prejudice (5) .
Although the current Code of Ethics in Speech-Language Pathology approaches the theme of 'social networks', it is necessary for the Federal and Regional Speech-Language and Regional Councils to broaden the discussion on the subject in order to raise the attention of speech-language therapy grader and the professionals to the likely implications and consequences of patient imaging as well as the real motivations for such behavior.Likewise, it is necessary that health institutions discuss the risks of the digital age and exposure in social networks (22) .One way to reduce undue exposure of patients' images in hospital settings is to outlaw the use of personal cell phones in capturing patient images (16) .
This study presented three main limitations: 1) low dissemination of research in other regions of the country (besides the Southeast region), 2) non-control of duplicate responses, since it was not possible to identify the participants, 3) not to assurance of the veracity of the answers, common in surveys involving questionnaires.
Although these limitations, it was possible to verify the relevance of the results achieved and the impact of the research to encourage reflection on the subject.Due to the importance of the theme and lack of research in the area, new studies should be done in order to contribute to understanding the inadequate behaviors of speech-language therapists in social networks.

CONCLUSION
The most of the speech-language therapists surveyed were aware that the Code of Ethics of Speech-Language Pathology clarifies the use of images in social networks and that the image of the patient has legal protection.It was also possible to verify that the greater the age and the training time, the greater the frequency of access of the code of ethics by the participants.The region of origin did not interfere in the distribution of responses.
The percentage of those who have already reported images of patients without written authorization was 5.1%.This frequency increased to 21.2% when the disclosure was only with verbal authorization.Almost all participants (95.2%) have seen photos or videos of patients on virtual social networks posted by speech-language therapists

Figure 2 .
Figure 2. Distribution of the participants about the frequency of conducts related to the Code of Ethics of Speech-Language Pathology and Social Networks

Figure 3 .
Figure 3. Distribution of participants about the frequency of conduct related to the dissemination of images in social networks

Table 1 .
Distribution of the participants about the age group, the region of the federative entity and the time of formation Figure 1. Participants' agreement regarding statements about the Code of Ethics of Speech-Language Pathology and the Brazilian Constitution