Factors associated with the professional use of social media by speech-language therapists and audiologists working in Brazil: a web-based survey

Purpose: to verify personal and work factors, and specialties of Brazilian speech-language therapists and audiologists who use social media profiles, professionally. Methods: an online questionnaire was used to carry out a population survey with working speech-language therapists and audiologists in Brazil, in 2020. The outcome of “How would you describe your use of social media?” was recategorized into “personal use” and “professional use”. Absolute and relative frequencies were calculated. Multivariate prevalence ratios were adjusted using the Poisson regression model with robust variance and 95% confidence intervals. Results: out of the 442 respondents, 93.7% were females, with a mean age of 38.0 years (± 11.1). The primary outcome, “professional use of social media”, occurred for 64.7% of the participants. In the multivariate analysis, private employment, participants in the 31-45 age range, and >26 years of work history after graduation were significantly associated with the professional use of social media. Conclusion: social media are used by approximately two-thirds of Brazilian speech-language therapists and audiologists. This finding suggests a need for reflection and discussion about the proper use of social media for work purposes.


INTRODUCTION
Social media, also known as online social networks, are internet-based tools that are mediated by information and communication technologies (ICTs) to accommodate the exchange of information and the dissemination and creation of user content 1,2 . These tools offer a wide variety of resources that can be used according to users' interests 3 .
There has been a notable increase in the popularity of these tools. Most human activities involve them, and 3.6 billion people use them worldwide 4,5 . According to the Brazilian geography and statistics institute (IBGE), in 2019 82.7% of the general population had access to the internet and 95.7% used this service to send or receive text messages 6 .
The development of social media has revolutionized and intensified forms of interaction and increased the access to and dissemination of information in all areas, including human health 7 . Online social networks are the best-known example of how digital health has shaped the participatory health paradigm, given its potential to support the provision of health services, as well as the search for and provision of health information 8,9 .
Despite the numerous benefits and potential to promote health care, using social media poses risks, many of them arising from the inappropriate management of these means of communication 10 . Studies have shown that networking with colleagues and connecting with other professionals from the same field are two of the main benefits of participating on social media platforms. Several platforms provide opportunities for professional development such as online discussions about clinical cases as well as exchanges between communities of individuals practicing the same specialty 11 . The lack of clear guidelines regarding privacy on social media can threaten patient autonomy and the trust between professionals and patients 12 .
In some areas of health, such as nursing, medicine and dentistry, there has been an increase in the number of published studies on the behavior and perception of professionals who use social media [12][13][14][15][16][17] . However, in the field of speech-language therapy and audiology, studies on this topic are still scarce 18 .
Although there is a gap in the literature, the rights and responsibilities of speech-language therapists and audiologists (SLTAs) on social networks are already included in their professional codes of ethics. The rights involve publicizing services, creating or participating in discussion groups and giving lectures and interviews on the aspects of speech-language pathology and audiology that fall within their field of expertise. Responsibilities on social media encompass expressing professional, evidence-based opinions with respect, addressing peers in a dignified and considerate manner, obtaining formal written consent and authorization from clients or their legal representatives, and also using caution and references when posting photos, videos, information, or messages 19 . However, there are still no other recommendations or guidelines for online behaviour.
Before issuing formal guidelines or recommendations for their online behavior, it is important to verify how social networks influence the professional lives of SLTAs. To facilitate the development of regulations and public policies regarding the proper use of social media, the first step is to investigate how they use these platforms professionally.
This research aimed to verify the personal and work factors, and specialties of Brazilian speech-language therapists and audiologists who use social media profiles, professionally.

METHODS
This was a cross-sectional study using an online population survey, carried out between November and December of 2020. All working SLTAs in Brazil who had access to social networks, and agreed to participate in the study, were considered eligible. Individuals who did not report any of the variables were excluded from the analysis. This research was approved by the university ethics committee of the Instituto de Psicologia at the Universidade Federal of Rio Grande do Sul, Brazil, under approval no. 4.401.801. All respondents filled out an online free and informed consent form.
Before calculating the sample size, the lack of data regarding the proportion of professionals who used social media in the target population was taken into consideration. An outcome proportion of 50%, a confidence level of 95% and a sampling error of 5% were used. In addition, 10% was included for loss prevention, leading to a total of 410 speech-language therapists. Sampling was performed in multiple stages, beginning with convenience sampling and then simple random subsampling per region of the country. This was done to keep the sample proportional to the number of SLTAs per region reported by the Brazilian federal speechlanguage and audiology council (CFFA) by April 2020, when data collection began 20 . First, SLTAs with profiles on online social networks were selected. Then, participants in groups with other SLTAs on platforms like Facebook®, WhatsApp® and Instagram® were included. From these, more SLTAs were found, using the snowball method.
Data were obtained through an online Google Forms questionnaire that was sent to working SLTAs in Brazil with profiles on social media. As there was no validated questionnaire available, previously published works were used to create a questionnaire (Appendix 1) consisting of 43 questions divided into three sections: (1) professional characteristics (2) social media use and (3) perception of social media use [21][22][23][24] . The questions were tested in a pilot group of seven health professionals before data collection, to ensure the questions were clear and preserve the general acceptability of the research. Minimal corrections were made based on feedback from the pilot group.
The outcome (based on the responses to "How would you describe your use of social media?") was categorized into professional use and personal use. The answers "predominantly professional use", "exclusively professional use" and "personal and professional use" were considered professional use. The answers "exclusively personal use" and "predominantly personal use" were considered personal use.
"Employment sectors" were analyzed after being categorized as "private", "public" and "mixed". In the mixed group, respondents had more than one job or a working relationship with a non-governmental organization. The variable "work history after graduating" was subdivided into 0-10 years, 11-25 years and 26 years or more, "specialty", and "employment setting". The contextual factor was the "region of employment".
Absolute and relative frequency analyses were performed with a 95% confidence interval (CI) stratified by descriptions of use. For an associative analysis of the outcome, multivariate prevalence ratios were (PR) used. A Poisson regression model with robust variance and 95% confidence intervals (95%CI) were used to adjust the analysis for possible confounding. Data were analyzed with SPSS v.21 software (Chicago: SPSS Inc).

RESULTS
In this study, 532 responses were collected and processed through simple random sub-sampling, according to the primary region in which the respondent worked. This left 443 responses. The participants were mostly female, with a mean age of 38.0 years (SD ± 11.1).
The outcome of "professional social media use" was reported by 286 (64.7%) individuals. The personal, work and contextual aspects, stratified by outcome, are presented in Table 1. The age group that most used social media professionally was 31 to 45 years. As for education, the most prevalent type was SLTAs with a lato sensu postgraduate degree. SLTAs who had been practicing for the shortest time since graduating (between 0 and 10 years) were the largest group to professionally use social media.
Among the work aspects, privately employed professionals demonstrated the highest prevalence of professional social media use. Furthermore, SLTAs who   Table 3 shows the crude and adjusted analyses of the association between type of employment, age, work history after graduating, and the outcome. SLTAs from the private sector demonstrated a higher prevalence ratio than SLTAs from the public sector (PR 1.40 95%CI 1.09 -1.79). Respondents who were 46 or older showed a higher prevalence of professional social media use when compared to their younger peers aged 21 -30 years (PR 1.41 95%CI 1.17 -1.74). In addition, those who had practiced speech therapy and audiology for a longer time after graduating presented a higher prevalence of the primary outcome than individuals with shorter work experience (PR 1.41 95%CI 1.19 -1.67).
In the adjusted analysis, privately employed SLTAs between the ages of 31 to 45, who had practiced for more than 26 years after graduating, showed a statistically significant association with professional social media use.

DISCUSSION
In this study, 64.7% of working SLTAs in Brazil used their social media profiles professionally. No previous studies about this topic had been found in the literature from the field of speech-language therapy and audiology. However, in related fields such as dentistry and pharmacy, studies have reported a prevalence of 55% and 61.1% in the professional use of these platforms, respectively 22,25 .
In the North region, where the smallest number of SLTAs practice, there was a lower prevalence of professional social media use (51.9%). This suggests that, in regions with more concentrated work markets, such as the Southeast, more SLTAs use social media professionally. However, as another Brazilian study showed, the difference between the prevalence in this and other regions is relatively small. Furthermore, the researchers found no differences in the perception SLTAs have about social media, regardless of the region 14 .
The most frequently used social media sites and tools for professional purposes were Instagram® (98.6%), WhatsApp® (92.7%) and Facebook® (82.2%), and most SLTAs used social media several times a day (72.8%) for professional activities. Another study involving radiologists presented similar data: the most frequently used social media site was Facebook® (59.6%) and most of the participants used social media sites several times a day (47.4%) 21 . Moreover, our findings suggest that awareness campaigns for SLTAs can be carried out through these tools, especially since 67.5% of SLTAs used social media to keep up with professional developments and 57.3% to follow professional organizations.
Although the greatest portion (45.1%) of SLTAs had two profiles on social media, one for personal use and another for professional use, 39.7% had only one profile for both purposes. It is well known that the online image of health professionals can invite criticism, affect a patient's ability to trust in their health care, and impair their compliance with therapeutic plans 26 . Using one social media account for personal and professional purposes may also violate a professional's privacy. In addition, accounts created to address health-related issues should identify the original author, and great care must be taken to publish appropriate content 27 .
Most SLTAs share other professionals' content (76.1%) and have shared data and photos of their patients on social media sites (35.9%). On the other hand, only 25.1% have received some type of training on social media use and 31.9% said they did not post content based on strict scientific evidence. Although SLTAs have the right to advertise their services online, in order to publish patient data and images the clients or their legal representatives must first provide formal, written consent 19 . Additionally, when sharing online content, the sources of published material should be checked. However, most professionals post content with no scientific basis, and this can lead to the dissemination of erroneous or inappropriate content or information.
By using social media sites for professional purposes, healthcare professionals usually aim to address patient education and career needs or promote themselves 28 . Our data and results reflect this, since most SLTAs reported using social media to connect with their peers, keep abreast of professional developments, connect with patients they already treat, or connect with potential clients/patients. A study involving pharmacists in Alberta, Canada published similar results: the participants reported that the main benefit to using social media professionally was the ability to connect with fellow pharmacists and keep abreast of the literature in their field 22 .
Speech-language therapists and audiologists employed in the private sector and engaged in outpatient work seemed to demonstrate a higher prevalence of professional social media use, due to lower job stability and a need to attract new clients. This hypothesis was proven in a study involving dentists in Ecuador, in which employment in private institutions was associated with social media use to connect with patients (OR 2.17 CI 1.14 -4.16) 15 .
Still, with regard to the area of expertise, there seems to be a greater demand in the specialty of orofacial myology to identify and disseminate relevant information regarding impairment to patients and their families. This may stem from the fact that signs of orofacial myofunctional disorders are not as easily identifiable to non-experts as language disorders (oral or written) or dysphagia, for example. This may justify the higher prevalence of professional social media use by orofacial myologists than SLTAs who specialize in language disorders.
Another study involving health professionals found that younger age groups showed a higher prevalence of social media use and more time spent on these networks 29 . The data from this study also revealed that younger individuals used social media less professionally. This was attributed to their intense personal use of social media, which may have led them to respond that they use social media sites predominantly for personal purposes. Consequently, this type of response was analyzed as "personal use".
Networking through social media allows individuals to connect with others with similar interests, promote collaborations and gain support for personal and professional growth 11 . Considering that professionals with stricto sensu graduate degrees aim for an academic career, their work does not need to be publicized on a large scale. Thus, their professional relationships are usually managed privately by email, while their social media sites are used predominantly for personal purposes. Conversely, respondents with lato sensu postgraduate degrees used social media more frequently for professional purposes, to enhance their work options.
Social media has caused a significant shift in healthcare professions in recent years. Part of this change is related to increasing bodies of knowledge, and quicker and easier access to new information. A recent study of physicians in Saudi Arabia reported that 43.4% with more than 10 years of professional experience recognize the role of social media in improving knowledge and skills 5 . Respondents with a longer history of practicing speech-language therapy and audiology after graduating (>26 years) were associated with a higher use of social media for professional purposes. This may be related to a greater confidence in addressing professional issues in an environment where information disseminates quickly.
This study had some limitations. Using an electronic survey to collect data meant that a portion of the target population would not respond to this format nor use this means of communication. However, considering that, among the population with higher education in Brazil, 98% have access to the internet and 88% use social networks, it is reasonable to conclude that a large portion of the target population was included in this research 30 . Another limitation was not using a probability sampling technique in the first sampling step. This may have affected the generalization of results for the entire population of working SLTAs in Brazil, since individuals from the same groups tend to have similar habits. However, the sample consisted of respondents from all regions of the country and, to mitigate this bias, subgroup analyses were performed for age, employment sector and time after graduating. Lastly, the questionnaire was not validated. However, a pilot study was carried out to assess and correct potential weaknesses in the intrinsic qualities of the instrument regarding its accuracy and intelligibility.

CONCLUSION
In this study, the factors associated with the professional use of social media by SLTAs with a social media profile were private employment, ages between 31 and 45 years, and a work history of more than 26 years after graduation. In addition, the high prevalence of professional social media use by these Brazilian professionals suggests a need for further studies on the subject. Also, as is already the case with other professions in the health sector, SLTAs should reflect on and hold discussions about the proper use of these means of communication for work purposes.