Exploring critical media health literacy (CMHL) in the online classroom.

Journal of Media Literacy Education, 15(1), 58-71, 2023

https://doi.org/10.23860/JMLE-2023-15-1-5

ISSN: 2167-8715

Journal of Media Literacy Education

THE OFFICIAL PUBLICATION OF THE

NATIONAL ASSOCIATION FOR MEDIA LITERACY EDUCATION (NAMLE)

Online at www.jmle.org

Exploring critical media health literacy (CMHL) in the online classroom

OPEN ACCESS

Peer-reviewed article

Citation: Squires, L., Peters, A., &

Rohr, L. (2023). Exploring critical

media health literacy (CMHL) in the

online classroom. Journal of Media

Literacy Education, 15(1), 58-71.

https://doi.org/10.23860/JMLE-2023-

15-1-5

Corresponding Author:

Laura Squires

[email protected]

an open access, peer-reviewed article

published by Bepress and distributed

under the terms of the Creative

Commons Attribution License, which

permits unrestricted use, distribution,

and reproduction in any medium,

provided the original author and

source are credited. JMLE is the

official journal of NAMLE.

Received: May 10, 2021

Accepted: September 13, 2022

Published: April 28, 2023

Data Availability Statement: All

relevant data are within the paper and

its Supporting Information files.

Competing Interests: The Author(s)

declare(s) no conflict of interest.

Editorial Board

Laura Squires

Memorial University of Newfoundland, Canada

Adrienne Peters

Memorial University of Newfoundland, Canada

Linda Rohr

University of Windsor, Canada

ABSTRACT

Critical media health literacy (CMHL) is concerned with identifying health-

related messages in the media, acknowledging the potential effects on health

behaviours, critically analyzing the content of the message, and the subsequent

application of the message to one’s health behaviours (Levin-Zamir &

Bertschi, 2018). This exploratory research examined the CMHL skills of

students (n = 120) in an entry-level, online asynchronous health and wellness

course, by examining their ability to think critically about health-related

themes presented in news media articles online and apply course-based

knowledge during a Twitter event. Employing a content analysis of tweets

from the event, students were found to illustrate CMHL skills when interacting

with peers on Twitter, more than when directly assessing online news media.

The findings suggest that the course curriculum be altered to include CMHL

skills, to better equip students with the ability to identify accurate health

information in the media.

Keywords: critical media health literacy, Twitter, media literacy education,

media health literacy, online learning.

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 59

INTRODUCTION

Technology-mediated sources have become a

dominant means to access health-related information

(Berkman et al., 2010). Related importantly is media

health literacy, which is concerned with the production

and dissemination of health-related information by

media outlets, and most commonly today, internet

sources of media (Levin-Zamir et al., 2011). Past

research indicates that mass media can have a significant

effect on the health-related knowledge and behaviours

of adolescents and young adults, acting as both health-

compromising and/or health-promoting influences

(Levin-Zamir et al., 2011; Squiers et al., 2012). In

consideration of this, and the rapid growth of internet-

based knowledge, critical media health literacy

(CMHL) is valuable to understand and explore (Wharf

Higgins & Begoray, 2012). CMHL involves critically

analyzing the content of health-related messages found

on various media platforms, to determine any potential

effects, negative or positive, on health-related

behaviours, and the subsequent application, or lack

thereof, of these messages to one’s personal health-

related behaviours (Wharf et al., 2012). CMHL allows

users to engage with and analyze health messages that

are found in the media, determine if they are

correct/incorrect, accurate/inaccurate, and how/if the

content of these messages is then implemented to a

person’s life.

Young people, in particular, are often perceived to

be increasingly media and health conscious (Goodyear

et al., 2019; Gustafson, 2017) and research has found

that with the proliferation of social media, (a high

proportion being young people

) users should possess

critical thinking skills to conscientiously and effectively

use these platforms in the acquisition and application of

knowledge (Levin-Zamir & Bertschi, 2018). The

present exploratory study builds on the authors’ past

research (Rohr, Squires & Peters, 2022), and was

particularly interested in understanding postsecondary

undergraduate students’ CMHL through their

application of social and news media as a pedagogical

online course component. Specifically, this research

examined whether entry-level university students taking

a human kinetics and recreation course demonstrated

CMHL, using Twitter to connect course-based

knowledge on themes of health, fitness, and wellness to

A high proportion of social media users are young people –

50 percent of Canadian Twitter users are between 18 and 34

years of age (Gruzd & Mai, 2020).

similar themes presented in news media. In an

increasingly mediated world, CMHL skills are essential

when accessing and understanding the health-related

information presented on social media.

LITERATURE REVIEW

Social media platforms have become an avenue to

access health-related information for users of all ages

(Berkman et al., 2010). The health messages that

circulate on these platforms can include inaccurate

information, even if the source is generally accepted as

trusted and reliable (Alnemer et al., 2015). These health-

related messages on social media are often fraught with

the bi-directionality of the relationship between media

use for social media marketing and social media user’s

perceptions/behaviours, further complicating the intent

of health-related media messages. Although health

professionals tend to perceive social media sites as less

reliable sources of health-related information for their

patients, the patients (i.e., social media users)

themselves frequently rely on social media for health-

related information (Ventola, 2014; Zhou, et al., 2018).

This can be problematic, especially when it comes to

health-related information, because users may not

possess the knowledge/ability to process/understand the

information in their personal context (Ventola, 2014).

High levels of CMHL can lessen these risks and can also

be applied to all media literacy contexts. In an online,

self-directed course that is designed to promote health

and wellness, CMHL is an imperative skill.

Media literacy

Media literacy can be defined as the ability to

identify the hidden messages encoded in different forms

of media, and to understand the importance and

implications of such messages /meanings (Hobbs &

Jensen, 2009; Potter 2010), although, consensus on its

exact definition is evasive (Koltay, 2016; Livingstone et

al., 2012). Media plays a significant role in

disseminating public health information. The integration

of media in our daily lives and routines impacts the

information we receive from these sources. In Canada,

internet users aged 16-24 are the largest accessors of

information via online resources, with 88% of this age

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 60

group reporting accessing the internet at least once per

day (Statistics Canada, 2020).

For students enrolled in online learning, all course

information is mediated through the internet and the

educator is tasked to adapt teaching processes to reflect

the habitus of students in the social, mediated world.

Students must have solid media literacy skills to

properly employ and sift through the onslaught of

information available on the internet.

Health literacy

Health literacy is an individual’s ability to

operationalize the health information they consume

through media messages and determine whether that

information is health-promoting or health-

compromising (Berkman et al., 2010; Liu, Wang, Liu, et

al., 2020). Health literacy empowers individuals to make

their own informed health decisions that favor health-

promoting behaviours, and limit health-compromising

behaviour. Critically, this explanation of health literacy

includes and accounts for the social determinants of

health as literacy levels are impacted by the economic

and social conditions (Berkman et al., 2004). Improving

social determinants of health, such as health literacy,

was highlighted by the Millennium Development Goals

in 2008 as a means to improve the equality and

accessibility of health-promoting behaviours across

social classes and geographic locations.

Berkman and associates (2010) indicate that the

definition and our understanding of health literacy is

continually impacted by technology. It is therefore

important to teach rudimentary health literacy skills to

university-aged students, the largest users and accessors

of health information via technology (Statistics Canada,

2020). Health literacy is directly connected to health

behaviours, in individuals of all ages.

Media health literacy

Health literacy and media literacy are intrinsically

connected: an individual’s level of health literacy can be

impacted by their level of media literacy, as much of the

health information available is communicated through

mediated channels. Media health literacy (MHL) in

particular, is concerned with identifying health-related

messages in the media, acknowledging the potential

effects on health behaviours, critically analyzing the

content of the message, and the subsequent application

of the message to one’s health behaviours (Levin-Zamir

& Bertschi, 2018).

Much like general literacy, an individual’s level of

MHL is influenced by a number of contextual factors

(Levin-Zamir & Bertschi, 2018); for example, age,

socioeconomic status, culture, access to technology and

experience with technology affect a student’s access to

and knowledge of MHL (Rababah, Al-Hammouri,

Drew, & Aldalaykeh, 2019). A student in rural Africa

would typically have lower fluency in MHL than a

student in a large Canadian city because technology is

less widely available and used less commonly. These

contextual factors suggest that students will likely

possess various levels of MHL depending on their

background and combined life experiences. Therefore,

it is necessary to provide equal and accessible

rudimentary MHL education for students.

Mass media messages are often implicitly encoded

with health-related information that can either promote

or compromise health. For example, the ketogenic diet

has been widely praised for its rapid results across social

media platforms, news media and print media. Despite

its widespread popularity and positive media portrayal,

long-term adherence is linked to negative health

consequences (Dafoe & Gyenes, 2020; Dashti et al.,

2006), similar to other fad-type diets. Despite the overall

lack of positive empirical findings, fad-type diets

proliferate the media we consume. MHL is valuable

because it instructs the consumer to consider the explicit

and implicit messages encoded in a media production

(such as promotional marketing), which instructs the

reader/consumer to assess whether or not the

information presented is health-promoting or health-

compromising (Levin-Zamir & Bertschi, 2018; Liu,

Wang & Liu et al., 2020).

It is best to view MHL as a continuum of ability and

skill (Levin-Zamir & Bertschi, 2018); ranging from low

ability to very capable, to identify how media messages

affect our health behaviour and recognizing information

may be laden with hidden meaning, marketing ploys or

outright misinformation. Media influences our

knowledge, behaviours and attitudes, and we are heavily

reliant on sources of media for information, through

acculturation and processes of meaning making. Greater

levels of MHL are correlated with health empowerment,

as MHL provides users with the skills and competencies

needed to make informed health-related decisions

(Johnson & Johnson, 2014; Levin-Zamir & Bertschi,

2018).

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 61

Critical media health literacy

CMHL, proposed by Wharf, Higgins and Begoray

(2012), is more explicitly concerned with the process by

which users engage with MHL and how they apply a

critical lens as a central component in this. Although

some literature uses these terms interchangeably, they

appear to be differentially applied and may actually be

referring to, and thus assessing, varying levels of online

engagement. Drawing on a scoping review, Wharf

Higgins and Begoray (2012) developed a more concise,

yet comprehensive and multidisciplinary concept of

MHL that explicitly comprised an analytical/critical-

thinking component. To identify examples of CMHL,

the researchers outlined three defining characteristics: a

skill set, empowerment, and a competency of engaged

citizenship.

Related to the skill set, beyond possessing

knowledge of material and understanding existing

theory and constructs, postsecondary students are often

asked to examine and evaluate information; it is then

expected that they create new ideas based on course

materials as a means of encouraging engagement. This

requires skills not only attached to literacy, but also

attached to critical thinking (e.g., requiring reflection,

comparison, and interpretation; Wharf Higgins &

Begoray, 2012). Empowerment is connected to ideas of

individual autonomy and choice, rights and freedoms,

and a desire to better society/the world. According to

Wharf Higgins and Begoray (2012), this guides health-

related decision making in seeking appropriate,

informed, and accurate information and even calling for

changes to our health systems. From the combination of

these, a competency of engaged citizenship is formed.

Rohr, Squires and Peters (2022) promote the adoption of

CMHL for work examining these themes, and we will

be applying a similar framework in this paper.

Research on the relationship between media, health,

and literacy

In the past two decades, the connection between

health status, health outcomes, and levels of literacy has

been explored and identified as impactful and

imperative to health behaviour outcomes. While there is

a limited but growing body of research literature

identifying a direct link between CMHL on Twitter and

the health behaviours of younger adults/youth, the level

of CMHL individuals exhibit is relational and dependent

on their past exposure to CMHL education, general

literacy abilities and socioeconomic background

(Lastrucci et al., 2019; Muvuka et al., 2020; Stormacq et

al., 2019; Swisher et al., 2020). Students from low-

income households are more likely to report engaging in

harmful health behaviours (Fleary, Joseph &

Pappagianopoulous, 2018). This can be explained by the

unique situational/environmental factors that each

student experiences. Internet access is affected by class

and income level, which radiates down to the

availability and accessibility of health information.

However, exposure to MHL for lower socio-economic

groups was advantageous for positive health behaviours,

when compared to those who have a higher baseline

knowledge of MHL, reinforcing the influence of the

environment and exposure to health behaviours can be

mitigated with education and exposure to positive health

behaviours (Fleary et al., 2018). A negative relationship

was found to exist between age and accessing health

information online; younger users are more likely to

access the internet for sources of health information,

whereas older adults are less likely to participate in

technology-mediated forms of health information

(Fischer et al., 2014).

Qualitative research explored young/emerging

adults’ (18 to 30 years old) social media use in collecting

information on common health issues (i.e., diabetes,

depression, anxiety, and posttraumatic stress disorder;

Fergie et al., 2016). Based on semi-structured interviews

(N=40), the researchers classified online information-

sharing behaviours under one of three types: 1)

“prosumption,” a combination of conventional

production and consumption activities online (i.e.,

“prosumers”); 2) tacit consumption, online

consumption of health-related content, as well as

support offline, but no production (i.e., “tacit

consumers”), and 3) non-engagement, offline supports

and no engagement with this type of online content (i.e.,

“non-engagers”).

Their results revealed that the presence of external

environmental factors – which in this study comprised

strong offline social supports – mitigated the

relationship/need to seek health-related information or

related engagement and support online. This may impact

postsecondary students, who have varying degrees of

social, educational, and other forms of support or capital

in their lives outside those in the course/classroom

context (Rababah et al., 2019). There may be some

students who are more isolated in comparison to their

classmates, particularly during the pandemic, and this

can impact how they engage with content and users

online. As illustrated, CMHL is impacted by several

factors that are unique to the individual based on their

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 62

experiences and social supports/relationships/

interactions outside the classroom/online platform.

Health messages on Twitter

A study completed in 2018 compiled 1000 of the

most common health-related journal articles and found

that 48% of health-related media messages posted to

Twitter and Facebook discussing these articles

contained disparity in the strength of the language used

and the results reported (Haber, Smith, Moscoe et al.,

2018); the information was presented in a generalized

manner, despite the results not being generalizable

(Haber et al., 2018). Further, media representations of

the information were more likely to use stronger, more

persuasive language than what was used in the original

article, misrepresenting the facts portrayed in that article

(Haber et al., 2018).

When examining the accuracy of health-related

tweets, researchers found that 25.4% of COVID-related

tweets contained inaccurate information (Swetland et

al., 2021). Albalawi and colleagues (2019) found that

31% of health-related tweets in Saudi Arabia were

inaccurate or incorrect by medical doctors (Albalawi et

al., 2019). A second Saudi Arabian study found that

approximately 52% of respondents reported using

Twitter as a source of public health information was a

positive experience, specifically for the ease in

accessing information, and that the majority of

respondents were satisfied to use Twitter as a source of

public health information (Alassiri & Alowfi, 2019). It

is important to note the differences in culture between

Saudi Arabia and North America, and Canada in

particular, where our research was conducted. Despite

the differences in culture, we believe these studies to be

valuable in framing our research, especially when

limited research is available. Saudi Arabia has the 4

highest number of Twitter users in the world, and the

highest proportion of users relative to their population.

Furthermore, the authors of these Saudi Arabian studies

were informed by the same authors cited in this paper.

Twitter is an important resource for health

information and is used to promote health literacy

(Begoray, Banister, Higgins et al., 2014; Zhou et al.,

2018). However, it is problematic that any Twitter user

can generate media/health information, which may not

be accurate, helpful, or based on scientific fact. Tse et

al. (2015) identified Facebook and YouTube as more

efficient media outlets for the promotion of health

literacy compared to Twitter. Despite these findings,

health-related information proliferates the mediated

Twittersphere, and tweets need not be accurate or

correct to elicit engagement.

The current study

In the present study, Twitter was selected as a social

media tooldespite it not being the most commonly

used social media platform among the average

postsecondary student age demographicas it

facilitates social interaction where users can be active in

constructing and presenting their identity as one that is

often closer to their identity offline. The intent of the

present research was to determine if students in an

online, highly digitized environment illustrate CMHL

skills without being taught them. If they don’t, we need

to prioritize incorporating CMHL education into the

course content and design, as we are requiring students

to utilize such capabilities for their Twitter assignments.

There are noticeably few studies concerning the use of

Twitter to examine CMHL skills, therefore, this research

contributes to this gap in the literature.

METHODOLOGY

The purpose of this exploratory research was to

examine students’ CMHL skills in two sections of an

entry-level health and wellness course at a mid-sized

Canadian university, to determine if we need to

incorporate CMHL skills into the curriculum, as we

require these skills of students in the evaluations. This

research is part of a multi-tiered project designed to

improve teaching strategies and pedagogy, to better

serve the needs of students, and prepare them for the

course evaluations. Details about the intentionality of

curriculum design and approaches can be found in Rohr,

Squires and Peters (2022).

The current research collected data from the tweets

of a convenience sample of university students enrolled

in an entry-level, online asynchronous fitness and

wellness course (HKR 1000) at a Canadian university in

the spring semester of 2019, before the COVID-19

pandemic took hold.

HKR 1000 is frequently taken as an elective course

and there are no prerequisites for enrollment. Students

aged 17 years or older who typically are not pursuing

health-related careers may be enrolled in this course,

meaning they likely have varying levels of health

knowledge and operationalization (i.e., CMHL). The

course instructor and teaching assistants utilized

Twitter-based evaluations for multiple semesters prior

to and following the semester when this data was

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 63

gathered. The main objective of this evaluation was to

develop an understanding of students’ CMHL skills,

through how they interact with media on Twitter, and to

incorporate the results into our teaching strategies,

modifying the course and teaching/delivery styles to

better serve the needs and wants of the students. HKR

1000 was offered online, so any and all information and

data were mediated through the online space (i.e.,

Brightspace Learning Management System).

Specifically, the focus of this work involved a

preliminary assessment of students’ existing CMHL

abilities through their proficiency to think critically

about health information presented in the media.

Participants

The sample was composed of university students

enrolled in two sections of an introduction to human

kinetics and recreation course, HKR 1000-Fitness and

Wellness, comprising 155 students. The data from this

study was initially collected from the course

assessments and course evaluation questionnaires

available for all students to complete at the end of the

semester. After consultation with the university ethics

board, it was determined that the data aligns with the

secondary use of information not initially intended for

research, therefore, ethics clearance was not required.

Approximately 120 students participated in posting

tweets, giving a 77% completion rate. As the data was

initially collected for course evaluation purposes,

information regarding age, gender, race/ethnicity were

not collected.

Twitter activities/events

Twitter was used for three assessments throughout

the semester (scheduled in weeks 6, 10 & 12) and

students were required to post a total of six tweets, i.e.,

two tweets per each of the three activities; this was a

deliberate course design that can foster communication

and interaction in an online classroom (Rohr, Squires, &

Peters, 2022). The data reported here were from the

week 10 assignment, which instructed students to

“locate a recent news story (from the past year), from a

recognized, credible news source that exemplified one

or more of the health and wellness topics discussed in

the course. Share the link for this news story on Twitter,

commenting in your tweet on the relevance/importance

of the story to individual health and wellness. Consider

the words and language used, the images portrayed, the

people interviewed, and/or the ultimate perspective

taken” (Brightspace, 2019). This assignment was

purposefully scheduled later in the semester to provide

students sufficient opportunity to gather a basic

understanding of the course expectations and also

manifest health-related information contained in the

news article. We examined students’ ability to

understand the latent content of the news article, or the

underlying meaning of the health-related information

they were viewing. We specifically prompted students

to think critically about the information presented and

how it related to health. We were cognizant, however,

that students may not have developed baseline CMHL

skills, (i.e., operationalization of health knowledge),

despite learning health-related knowledge in this course.

Students were expected to use their own discretion with

regards to decide what “reputable” news sources may

be; this was done purposely to ascertain what students

generally deemed to be reputable news sources. No

explicit examples of expectations were provided. This

again was purposeful; we were measuring

existing/baseline CMHL and did not want to direct or

sway students with examples. Students were required to

include the hashtag in each and every Tweet they made

in order for Brightspace, the learning management

system, to capture and record their responses.

Much of the existing research can be divided into

that which independently examined media literacy only

or health literacy only; however, we were interested in

measuring CMHL, given the opportune course themes

and online activities/evaluations. The requirement of

having to locate a reputable online news source through

an online course platform leans toward examining media

literacy, while asking students to exemplify course

concepts, which are all health/wellness related, leans

more towards health literacy. We believe such an

assignment to be a good measure of CMHL; requiring

students to search for an article that epitomizes a course

concept shows their ability to apply/put to

use/operationalize the information presented.

Students were required to make a total of six tweets

throughout the semester. Of the students for who we

have data for, approximately 31.6% did not meet the

assignment’s minimum requirements. Approximately

28.4% of our sample posted exactly six tweets; however,

a larger proportion (44%) posted more than required.

We were unable to gather this information from 13% of

students who either deleted their profiles as soon as the

course finished, or who had changed their profile

viewing settings to private. From the data available,

68% of students met or exceeded the tweet requirements

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 64

while 32%, nearly one-third, of the students did not

complete the required number of tweets.

Coding protocol/procedures

Content analyses are commonly used to reveal

messages and meaning behind textual data, by

determining themes or concepts, which are then

quantified and analyzed for meaning and patterns

(Erlingsson & Brysiewicz, 2016; Kleinheksel et al.,

2020). A content analysis was conducted, and coding

protocol was inductively developed while examining the

data for patterns in the tweets posted (Fereday & Muir-

Cochrane, 2006; Thomas 2003). Themes were then

identified from these patterns and quantified to illustrate

the frequency of their occurrence. The coding categories

were loosely based on the course grading scheme, where

the better-quality tweets were indicative of a higher

mark, and lower-quality received lower marks. After

coding individually, inter-coder agreement was reached

between 3 researchers, and the coding categories were

decided.

These categories of quality were then placed on the

continuum of health literacy (ability to think critically

and operationalize the information presented in the

article; Levin-Zamir & Bertschi, 2018) to coincide with

the categories below (1 on the left, 5 on the right) (see

Figure 1). Students who make critical thinking or

critical thinking + personalization tweets are more

capable of illustrating how they operationalize the

health-related information relayed to them via the

media, and therefore, fall towards the right on the

CMHL continuum, when compared to those students

who make summary/general statements or personal

statements only, who are less capable of illustrating how

they operationalize the health-related information

relayed to them via the media.

Figure 1. As critical thinking skills increase, so do CMHL abilities

Tweets were coded separately by three researchers

and then compared for consistency (O’Connor & Joffe,

2020). Coding was based on the five developed critical

thinking categories, mirroring the continuum of health

literacy: 1) summary/general statements, 2) personal

statements, 3) summary + explicit mention of course

concepts, 4) critical thinking, and 5) critical thinking +

personalization. The categories were developed

organically and inductively, following a general review

of the tweets to determine what categories were present.

Coding for critical thinking would indicate that students

have a higher level of health literacy than those who just

summarize the information found in the article.

Summarizing equates to a lesser indication of health

literacy, or thinking critically about the content,

reliability, or validity of the information presented in the

news article.

Personal statements comprised of “I” statements; for

example, “I agree with your tweet! Personally, with

siting at a desk all hours of the day my body feels it. We

need to make stretching a priority in our lives” (Student

36). Statements were coded as personal statements if

they spoke only of a personal experience and omitted

any reference to course material. Summary/general

statements were directly related to summarizing the

news article students chose for their assignment. For

example, “This article shows how to build mental

health. This gives a larger over all wellness. It’s

interesting all the ways you can work in your mental

health and how each person may have different needs”

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 65

(Student 17). Summary + explicit mention of course

concepts was the third category, in which a student must

have summarized the article and provided a direct and

specific reference to the course content. For example,

“As we have discussed in the course, people often

overlook the dangers of mental illness and the

importance of emotional wellness. Schools in Oregon

are trying to end the stigma by having mental health days

as well as sick days” (Student 111), was coded as

summary + explicit mention of course concepts.

The fourth category, critical thinking, exemplified

critical media literacy. Here students were required to

illustrate how they operationalize health-promoting or

health-compromising information (i.e., can they

transition that knowledge to behaviours/beliefs). For

example, the following tweet was coded as critical

thinking “As obesity decreases physical wellness, we

can expect other areas of physical wellness to be

affected as well - in this case, asthma. By teaching our

children proper eating habits, we can help them increase

their physical wellness and lower their risk of health

issues” (Student 18). Lastly, the fifth category, critical

thinking + personalization captured tweets that were

both illustrating CMHL and included personal

examples. All tweets in this category could have been

classified as critical thinking only, however, student’s

inclination to include their personal examples was

noteworthy, so this category identified these exceptional

tweets. For example, “This topic is very relevant to

today's ongoing health/wellness challenges! I have

experienced this during my BN program. When caring

for patients with mental health issues, many of them

unfortunately used unhealthy coping mechanisms, such

as smoking or unhealthy eating #HKR1000” was coded

as a critical thinking + personalization.

Data was analyzed using SPSS. Percentage and

frequency data are reported. The results reported are not

generalizable, and if repeated with different populations,

are likely to elicit different results, based on the

literature and the fact that CMHL is dependent on

several factors external to education.

RESULTS

The results from this exploration of students’ CMHL

are divided into four main sections, based on the

type/item of analysis and include information on the

sample of students and their Twitter use for the course,

and more specifically, the depth of engagement

exhibited in the tweet (referred to as the “quality” of the

tweet).

Study sample and Twitter course use

In total, 155 undergraduate students were required to

complete the course assignment. Seventy-seven percent

of students in the class completed the Twitter event from

which our data is pulled, indicating slightly less than

one-quarter of the class (23%) did not participate or post

any tweets. This data was collected prior to the COVID-

19 pandemic and work-/learn-from-home/public health

measures, eliminating that as a factor impacting

completion rates. A secondary goal of this assignment

was to promote engagement and interaction between

students in an online course, further explaining why the

hashtag was a requirement (Rohr, Squires & Peters,

2022).

Tweets were received from 58 and 62 students in the

two course sections, representing a total of 120 students.

Of the tweets, 52% were original tweet posts and 47%

were response tweets. Overall, the vast majority of

students (98%) did not directly reference/cite course

readings or resources in their tweet(s). This omission

could be for a variety of reasons, including that the

assignment instructions did not explicitly state/require

citing course readings, the 280-character limit per

tweet/imposed by Twitter, as well as individual

reluctance/omission.

In order for a student’s tweet to be included in the

analysis the hashtag #HKR1000 was required. Slightly

under one-third (32%) of students failed to include the

hashtag in their post ultimately impacting 13% of the

responses.

Quality of tweet

As demonstrated in Figure 2, approximately 48% of

students’ tweets could be classified as the

summary/general statement category, meaning the tweet

either summarized the article they posted or the tweet

included what would be considered generalized health

statement (for example, exercising helps our physical

wellness); 10% of students posted tweets classified as

personal statements only, where their tweet contained

only information that was personal/related to their

personal health/wellness; 5% of students summarized

the news article and then explicitly mentioned course

concepts in their tweet, 24% of students posed tweets

considered to be critical thinking (i.e. health literacy);

and approximately 13% of tweets were classified as

critical thinking and personalization.

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 66

Original tweets and quality

For analysis of the original tweets, approximately

78% were classified as summary/general statement

tweets; this was by far the most common classification

(see Figure 2). This illustrates students were

overwhelmingly inclined to summarize the information

in their chosen article. The remaining original tweets

were coded as critical thinking (10%), summary +

explicit mention of course concepts (7%), critical

thinking + personalization (3%) and personal

statements only (1%). Only 13% of all original tweets

were classified as incorporating critical thinking, or

CMHL.

Response tweets & quality

Results for the response tweets (Figure 2) illustrate a

dramatic difference in the quality of the information

contained in the tweet. Here, the majority of tweets,

approximately 39% were classified as critical thinking,

23% as critical thinking + personalization, 20% as

personal statements only, 15% summary/general

statements and 2 percent summary + explicit mention of

course concepts.

Figure 2. The quality of the tweet varies based on the category, or type of tweet posted

Of the categories that incorporate critical thinking,

63% of response tweets were classified as either critical

thinking or critical thinking + personalization. This is

significantly higher and by far surpasses the 13% of

original tweets that were classified as critical thinking or

critical thinking + personalization. Students were more

likely to utilize/illustrate critical thinking (i.e., CMHL)

in response tweets compared to original tweets.

DISCUSSION

The purpose of this research was to determine if

students in an online, entry-level health and wellness

course exhibit CMHL skills, through their critical

analysis of news media articles using Twitter. We

identified the need to add CMHL training to our course.

From all the tweets, approximately half (49%) were

summary/general statement tweets; 24% were critical

thinking (i.e., demonstrating health literacy); 13% were

critical thinking and personalization; 10% were

personal statements only; and 5% summarized the news

article and then explicitly mentioned course concepts.

When combining the critical thinking and critical

thinking and personalization categories, 37% of all

tweets incorporated critical thinking. The majority of

tweets, nearly 50%, summarized the article posted

without incorporating any critical thinking,

personalization, criticism, or reflection; all skills that are

essential in CMHL.

In original tweets, students were overwhelmingly

inclined to summarize the information in their chosen

article (77%). This is significantly larger than any of the

other categories. The critical thinking categories for

original tweets only amount to 13% of posts. Students

were found to be less able to operationalize the health-

related information presented to them in the news article

and were more likely to summarize the information

presented instead of synthesizing and applying it. Given

the limitations of the data collected, we are not able to

determine why this occurred. It is anticipated however

that these findings are attributed at least in part to

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 67

students’ inexperience applying information/knowledge

and critical thinking skills.

When considering reply/response tweets, 40% were

classified as critical thinking, the most common of the

response tweets; 23% of tweets were critical thinking +

personalization, 20% as personal statements only, 15%

summary/general statements and 2% summary +

explicit mention of course concepts. In total, the critical

thinking categories comprise 63% of all response

tweets. The response tweets illustrate a significantly

higher percentage of CMHL and by far surpasses the

13% of original tweets that comprised the critical

thinking categories. Students were more likely to

utilize/illustrate critical thinking (i.e., CMHL) in

response tweets than original tweets. One possible

explanation is that by the response tweets, students had

read other students’ initial tweets/other responses

demonstrating a higher level of application and analysis,

thereby providing a model for students who had not

demonstrated this initially. Students may have also felt

more comfortable sharing more, once they saw the

support provided by others in the course (Fergie et al.,

2016).

Overall, students were less likely to critically engage

with the information presented to them on media

platforms; they were more likely to summarize the

article, which, while valuable was not the purpose of the

assignment. A large proportion of students who

completed the Twitter events would benefit from

additional guidance/practice in CMHL analysis and

applying course content to guide them in identifying,

assessing, and using information presented online.

Engaging with the course material illustrates critical

thinking processes, which we believe represents CMHL

and the ability of students to comprehend and question

the information presented in such media articles.

As presented in the above results, ninety-eight

percent of students did not directly cite course readings

or resources. This may be attributed to the character

limit Twitter places on tweets (i.e., 280

characters/tweet); however, an alternative explanation is

that the instructions did not explicitly require students to

reference course material; rather students were directed

to find a “credible news source that exemplifies one or

more of the health and wellness topics discussed in the

course” (Brightspace, 2019). Altering the assignment

instructions to more clearly direct students to

incorporate course content and/or the textbook would

clarify the expectations and may result in better

outcomes.

Thirty-two percent of students omitted or forgot to

include the designated course hashtag. This omission

may have been due to a multitude of factors including,

students simply forgot, they did not correctly

read/understand the instructions, or they misspelled the

course hashtag. This was imperative for evaluation, as

students and the instructor/teaching assistants could

view only those tweets with the specified hashtag. There

were more original tweets than reply tweets posted in the

event. This may be explained by the fact that students

sometimes posted more than one original tweet to fully

explain/expand on their initial tweet. This strategy

circumvented Twitter’s character limit and was within

the assignment guidelines. Students may not have

read/understood that they were required to reply to a

classmate’s post, but we do not have further data on

these findings. Failure to include the course hashtag and

only completing one tweet may not be directly related to

CMHL per se but is noteworthy as it may indicate

student’s general media literacy abilities and their

ability/inability to navigate online courses. Further

research is needed to determine the reasons for such. As

our intent of this work is to apply our findings to

improve the course, we may adjust the

syntax/presentation of directions in future course

offerings to make the hashtag requirement more explicit.

As social media users become more confident online

and engage more as “prosumers” (Fergie et al., 2016),

particularly during the current pandemic/virtual world,

it is important to recognize the strong relationship

between user’s identity and their content production and

consumption. Among social media users, these impact

one another in multiple ways, and it is further

compounded by external factors outside the

university/classroom setting. As a result of the varying

levels of offline/online support and image management,

CMHL is a complicated skill to develop and/or goal to

attain using social media activities in the classroom

alone. To address some of these differences and effort to

make credible content accessible and understood by a

greater number of students/young adults, all students

would likely benefit from additional pre-Twitter/pre-

course lessons and experience in critically examining

knowledge production and consumption on social and in

news media sources.

CMHL’s defining attributes – a skill set,

empowerment, and a competency of engaged citizenship

(Wharf Higgins & Begoray, 2012) – are highly valuable

and often help individuals thrive in

educational/professional settings. In addition to

exposing students to opportunities to practice these

Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023 68

skills, it is crucial for instructors to first ensure students

possess the foundational tools attached to these skills

and engaging in these activities. There would be great

benefit in focusing on the development and then refining

of these skills, so as to prepare students for future roles

that will require proficiency in analytical/critical

thinking, building effective “prosumers” of information

(Fergie et al., 2016). The importance of critical thinking

for health education has been amplified during the

pandemic and with the current news and social media

climates and continued growth in these areas, the

absence of critical media literacy more generally will

present challenges for individuals entering these spaces.

Education in and “IRL” practice of these skillsets can

have extensive impacts on individuals’ knowledge. To

establish students’ baseline CMHL,

instructors/educators can integrate lectures and/or

classroom-based activities and informal assessments

that ask students to identify or demonstrate examples of

critical thinking. These can be distinct activities or

modeled after the planned course activities/evaluations.

It is also important that instructors provide students with

clear evaluation guidelines and expectations as early as

possible and avoid any assumptions about students’

previous critical thinking experience or CMHL. Based

on our findings and the research demonstrating that clear

communication of expectations has been found to

improve the quality of student work, especially in lower-

level university courses (Rapanta et al., 2020), the health

and wellness course examined here will be amended to

reflect this.

Limitations

Some limitations of the presented research include

the sample size, the nature of the data collected and the

exploratory basis of the study. Our sample was limited

to two mid-sized course sections and the data collected

was conducive only to univariate analyses. As the

findings are not generalizable outside the present

context, should the study be replicated, results may vary

based on the nature of CMHL and CMHL’s contingency

on demographic factors. The Twitter API does not

collect users’ demographic information, so analyzing

and differentiating for age, race, gender, or

socioeconomic status was not possible, despite the

suggested correlation between MHL and gender

(Swisher et al., 2020), race (Muvuka et al., 2020) and

socioeconomic status/class (Lastrucci et al., 2019;

Stormacq et al., 2019). This information may be

valuable in future work, but here, it was not the intent to

collect such detailed information; rather we aimed to

examine tweets to determine if CMHL skills were

evident in an entry-level online health and wellness

course. Furthermore, the exploratory nature of the study

and lack of prior research specifically concerning

CMHL via Twitter elicited some complications with

regards to the methodology and analysis. This research,

therefore, uniquely contributes to this gap identified in

the literature, examining CMHL and social media use

together.

CONCLUSION

The increased use and pervasiveness of social media

platforms has created new communication networks

which have subsequently altered our behaviours to

reflect the instantaneous, 24/7 nature of social media

platforms and in turn, social media has become a pivotal

part of our daily life. Social media platforms are

frequently accessed as sources of public health

information; they offer instantaneous answers to health-

related queries at little to no cost and can be consulted

more readily than a medical doctor (Hesse et al., 2010).

The plethora of health information available online

provides the general population with the opportunity to

become self-informed about health and wellness, which

may lead to improving and increasing public knowledge

and competencies surrounding decision making when it

comes to health-promoting or health compromising

behaviours (Tonsaker et al., 2014).

We were able to determine that students in our

sample were more likely to summarize health-related

information they viewed online than operationalize and

exhibit the critical thinking skills that comprise CMHL.

Students were found to illustrate CMHL skills, critically

thinking and engaging with the information presented,

when interacting with peers on Twitter (response

tweets), more so than when interacting directly with

online news media (original tweets). These results

illustrate that improvements and adjustments are needed

to better fit the needs of our students, which includes

educating students about CMHL. Educating students to

be more critical of the information consumed online,

especially when it is health-related can impact overall

wellness and health-compromising or health-promoting

behaviours.

REFERENCES

Alassari, S. A., & Alowfi, A. S. (2019). Public’s attitude

toward health information on Twitter: A cross-

 
 
Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023  69
   
sectional  survey  based  on  the  Saudi  population. 
Cureus, 11(10). https://doi.org/10.7759/cureus.5863 
Albalawi,  Y.,  Nikolov,  N.  S.,  Buckley,  J.  (2019). 
Trustworthy health-related tweets on social media in 
Saudi Arabia: Tweet metadata analysis. Journal of 
Medical  Internet  Research,  21(10). 
https://doi.org/10.2196/14731 
Alharbi, A., & Al-Sowayan, N. S. (2020). The effect of 
ketogenic-diet on health. Food & Nutrition Sciences, 
11(4). https://doi.org/10.4236/fns.2020.114022  
Alnemer,  K.  A.,  Alhuzaim,  W.  M.,  Alnemer,  A.  A., 
Alharbi, B. B., Bawazir, A. S., Barayyan, O. R., & 
Balaraj,  F.  K.  (2015).  Are  health-related  tweets 
evidence  based?  Review  and  analysis  of  health-
related  tweets  on  Twitter.  Journal  of  Medical 
Internet Research, 17(10).   
https://doi.org/10.2196/jmir.4898  
Begoray, D., Banister, E., Higgins, J.W., & Wilmot, R. 
(2014).  Online,  tuned  in,  turned  on:  Multimedia 
approaches to fostering critical media health literacy 
for  adolescents.  (2014).  Asia-Pacific  Journal  of 
Health, Sport & Physical Education, 5(3), 267-280. 
https://doi.org/10.1080/18377122.2014.940812 
Berkman, N. D., Davis, T. C., & McCormack, L. (2010). 
Health  literacy:  What  is  it?  Journal  of  Health 
Communication, 15(2), 9-19.   
https://doi.org/10.1080/10810730.2010.499985 
Berkman,  N.  D.,  DeWalt,  D.  A.,  Pignone,  M.  P., 
Sheridan, S. L., Lohr, K. N., Lux, L., Sutton, S. F., 
Swinson, T., & Bonito, A. J. (2004). Literacy and 
health  outcomes:  Evidence  report/technology 
assessment No. 87. Silver Spring, MD: Agency for 
Healthcare Quality and Research.   
http://hdl.handle.net/10822/993646 
Dashti,  H.  M.,  Al-Zaid,  N.  S.,  Mathew,  T.  C.,  Al-
Mousawi, M., Talib, H., Asfar, S. K., & Behbahani, 
A. I. (2006). Long term effects of ketogenic diet in 
obese  subjects  with  high  cholesterol  level. 
Molecular  &  Cellular  Biology,  286(1). 
https://doi.org/10.1007/s11010-005-9001-x 
Dewalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. 
N.,  &  Pignone,  M.  P. (2004). Literacy and health 
outcomes;  A  systematic  review  of  the  literature. 
Journal of General Internal Medicine, 19(12), 1228-
1239.   https://doi.org/10.1111/j.1525-
1497.2004.40153.x 
Diviani, N., van den Putte, B., Giani, S., & van Weert., 
J. C. M. (2015). Low health literacy and evaluation 
of online health information: A systematic review of 
the literature. Journal of Medical Internet Research, 
17(5), e112. https://doi.org/10.2196/jmir.4018 
Escoffery, C., Miner, K. R., Adame, D. D., Butler, S., 
McCormick, L., & Mendell, E. (2005). Internet use 
for  health  information  among  college  students. 
Journal  of  American  College  Health,  53(4),  183-
188. https://doi.org/10.3200/JACH.53.4.183-188 
Erlingsson,  C.,  &  Brysiewicz,  P.  (2017).  A hands-on 
guide to doing content analysis. African Journal of 
Emergency Medicine, 7(3), 93-99.   
https://doi.org/10.1016/j.afjem.2017.08.001 
Fereday, J. & Muir-Cochrane, E. (2006). Demonstrating 
rigor during thematic analysis: A hybrid approach of 
inductive  and  deductive  coding  and  theme 
development.  International  Journal  of  Qualitative 
Methods, 5(1), 80-92.   
https://journals.sagepub.com/doi/pdf/10.1177/1609
40690600500107 
Fergie, G., Hunt, K., & Hilton, S. (2016). Social media 
as a space for support: Young adults' perspectives on 
producing  and  consuming  user-generated  content 
about diabetes and mental health. Social Science & 
Medicine, 170, 46-54. 
Fischer, S. H., David, D., Crotty, B. H., Dierks, M. P. 
H.,  &  Safran,  C.  (2014).  Acceptance  and  use  of 
health  information  technology  by  community-
dwelling  elders.  International  Journal  of  Medical 
Information, 83(9), 624-635.   
https://dx.doi.org/10.1016%2Fj.ijmedinf.2014.06.0
05 
Fleary,  S.  A.,  Joseph,  P.,  &  Pappagianopoulos,  J.  E. 
(2018).  Adolescent  health  literacy  and  health 
behaviours:  A  systematic  review.  Journal  of 
Adolescence 62, 116-127.   
https://doi.org/10.1016/j.adolescence.2017.11.010 
Goodyear, V. A., Armour, K. M., & Wood, H. (2019). 
Young  people  and  their  engagement  with  health-
related  social  media:  New  perspectives.  Sport, 
Education and Society, 24, 673-688.   
https://doi.org/10.1080/13573322.2017.1423464 
Gustafson, T. (2017, January 23). Younger consumers 
are more health conscious than previous generations. 
The Huffington Post Canada.   
https://www.huffingtonpost.ca/timi-
gustafson/younger-consumers-are-
morb14290774.html 
Gruzd, A., & Mai, P. (2020). The state of social media 
in Canada.   
https://papers.ssrn.com/sol3/papers.cfm?abstractid=
3651206 
Haber, N., Smith, E.R., Moscoe, E., Andrews, K., Audy, 
R., Bell, W., Brennan, A.t., Breskin, A., Kane, J.C., 
Karra,  M.,  McClure,  E.S.,  &  Suarez,  E.A.  (2018) 

 
 
Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023  70
   
Causal  language  and  strength  of  inference  in 
academic and media articles shared in social media 
(CLAIMS): A systematic review. PLoS ONE, 13(5), 
e0196346. 
https://doi.org/10.1371/journal.pone.0196346  
Hayes, M., Ross, I. E., Gasher, M., Gutstein, D., Dunn, 
J. R., & Hackett, R. A. (2007). Telling stories: News 
media, health literacy and public policy in Canada. 
Social  Science  and  Medicine,  64,  1842-1852. 
https://doi.org/10.1016/j.socscimed.2007.01.015 
Hesse,  B.  W.,  Moser,  R.  P.,  &  Rutten,  L.  J.  (2010). 
Surveys  of  physicians  and  electronic  health 
information. The New England Journal of Medicine, 
362(9), 859-860.   
https://doi.org/10.1056/NEJMc0909595 
Hobbs, R., & Jensen, A. (2009). The past, present and 
future of media literacy education. Journal of Media 
Literacy Education, 1(1), 1-11.  
https://digitalcommons.uri.edu/jmle/vol1/iss1/1 
Johnson, D. W., Johnson, R. T., & Smith, K. A. (2014) 
Cooperative  learning:  Improving  university 
instruction by basing practice on validated theory. 
Journal on Excellence in College Teaching, 25(3-4), 
85-118. 
Kleinheksel, A. J., Rockich-Winston, N., Tawfik, H., & 
Wyatt,  T.  R.  (2020).  Demystifying  Content 
Analysis.  American  Journal  of  Pharmaceutical 
Education, 84(1), 7113.   
https://doi.org/10.5688/ajpe7113 
Koltay, T. (2016). The media and the literacies: Media 
literacy, information literacy, digital literacy. Media 
& Society, 33(2), 211-221.   
https://doi.org/10.1177/0163443710393382  
Kutner,  M.,  Greenberg,  E.,  Jin,  Y.,  &  Paulsen,  C. 
(2006).  The  health  literacy  of  America’s  adults: 
Results from the 2003 National Assessment of Adult 
Literacy  (NCES  2006–483).  Washington,  DC: 
National  Center  for  Education  Statistics. 
https://nces.ed.gov/pubs2006/2006483.pdf 
Lastrucci, V., Lorini, C., Caini, S.,  & Bonaccorsi, G. 
(2019).  Health  literacy  as  a  mediator  of  the 
relationship  between  socioeconomic  status  and 
health: A cross-sectional study in a population-based 
sample in Florence. PLOS ONE, 14(12), e0227007. 
https://doi.org/10.1371/journal.pone.0227007 
Levin-Zamir,  D.,  Lemish,  D.,  &  Gofin,  R.  (2011). 
Media  health  literacy  (MHL):  Development  and 
measurement  of  the  concept  among  adolescents. 
Health  Education  Research,  26(2),  323-335. 
https://doi.org/10.1093/her/cyr007 
Levin-Zamir, D., & Bertschi,  I. (2018). Media health 
literacy, eHealth literacy and the role of the social 
environments  in  context.  International  Journal  of 
Environmental  Research  and  Public  Health,  15, 
1643-1655. https://doi.org/10.3390/ijerph15081643 
Liu, C., Wang., Liu, C., Jiang, J., Wang, X., Chen, H., 
Ju, X. & Zhang, X. (2020). What is the meaning of 
health literacy? A systematic review and qualitative 
synthesis.  Family  Medicine  &  Community  Health, 
8(2),  e000351.  https://doi.org/10.1136/fmch-2020-
000351 
Livingstone,  S.,  Papaioannaou,  T.,  del  Mar  Grandio 
Perez, M., Wijnen, C. (2012). Editors’ note: Critical 
insights  in  European  media  literacy  research  and 
policy.  Media  Studies,  3(6),  2–12. 
https://hrcak.srce.hr/ojs/index.php/medijske-
studije/article/view/6063 
Muvuka, B., Combs, R. M., Ayangeakaa, S. D., Ali, N. 
M.,  Wendel,  M.  L.,  Jackson,  T.  (2019).  Health 
literacy in African-American communities: Barriers 
& strategies. Health Literacy Research and Practice, 
4(3),  138-143.  https://doi.org/10.3928/24748307-
20200617-01 
Mwalimu, E. C., Mulauzi, F., & Mwiinga, T. M. (2017, 
August  23-25).  Use  of  social  media  among 
university  of  Zambia  lecturers  in  teaching  and 
learning  [Conference  Presentation].  International 
Multi-Disciplinary  Conference,  Lusaka,  Zambia. 
http://dspace.unza.zm/bitstream/handle/123456789/
5517/MWALIMU%20-
%20Social%20Media%20PaperFinal.pdf?sequence
=1&isAllowed=y  
O‘Connor, C., & Joffe, H. (2020). Intercoder reliability 
in  qualitative  research:  Debates  and  practical 
guidelines.  International  Journal  of  Qualitative 
Methods, 19, 1-13.   
https://doi.org/10.1177/1609406919899220  
O’Neill,  B.,  &  Raggi,  P.  (2020).  The  ketogenic  diet: 
Pros  and  cons.  Atherosclerosis,  292,  119-126. 
https://doi.org/10.1016/j.atherosclerosis.2019.11.02
1  
Potter, W. J. (2010). The state of media literacy. Journal 
of Broadcasting and Electronic Media, 54(4), 675-
696. https://doi.org/10.1080/08838151.2011.521462 
Rapanta, C., Botturi, L., Goodyear, P., Guardia, L., & 
Koole, M. (2020). Online university teaching during 
and  after  thr  Covid-19  crisis:  Refocusing  teacher 
presence  and  learning  activity.  Postdigit  Science 
Education, 2, 923-945.  
https://doi.org/10.1007/s42438-020-00155-y 

 
 
Squires, Peters & Rohr ǀ Journal of Media Literacy Education, 15(1), 58-71, 2023  71
   
Rohr, L., Squires, L., & Peters, A. (2022). Examining 
the Use of Twitter in Online Classes: Can Twitter 
Improve  Interaction  and  Engagement?.  The 
Canadian Journal for the Scholarship of Teaching 
and Learning, 13(1).   
https://doi.org/10.5206/cjsotlrcacea.2022.1.10892 
Song, H.,  Omori,  K.,  Kim, J.,  Tenzek,  K.  E.,  Morey 
Hawkins, J., Lin, W. Y., Kim, Y. C., & Jung, J. Y. 
(2016). Trusting social media as a source of health 
information: Online surveys  comparing the United 
States, Korea, and Hong Kong. Journal of Medical 
Internet Research, 18(3), 1-25.  
https://doi.org/10.2196/jmir.4193 
Squiers, L., Peinado, S., Berkman, N., Boudewyns, V., 
& McCormack, L. (2012). The health literacy skills 
framework.  Journal  of  Health  Communication, 
17(3), 30-54.   
https://doi.org/10.1080/10810730.2012.713442 
Statistics Canada (2020). Table 27-10-0018-01 Internet 
use  by  frequency  of  use,  age  group  and  sex. 
https://doi.org/10.25318/2710001801-eng 
Stormacq,  C.,  van  den  Broucke,  S.,  &  Wosinski,  J. 
(2018). Does health literacy mediate the relationship 
between  socioeconomic  status  and  health 
disparities?  Integrative  review.  Health  Promotion 
International, 34(5), 1-17.   
https://doi.org/10.1093/heapro/day062  
Swetland, S.B., Rothrock, A.N., Andris, H., Davis, B., 
Nguyen,  L.,  Davis,  P.,  Rothrock,  S.G.  (2021). 
Accuracy  of  health-related  information  regarding 
COVID-19  on  Twitter  during  a  global  pandemic. 
World  Medical  &  Health  Policy,  13(3),  5-3-517. 
https://doi.org/10.1002/wmh3.468 
Swisher, J., Blitz, J., & Sweitzer, B. J. (2020). Special 
considerations  related  to  race,  sex,  gender  and 
socioeconomic  status  in  the  preoperative 
evaluations: Part 2: Sex considerations & homeless 
patients.  Anesthesiology  Clinic,  38,  263-278. 
https://doi.org/10.1016/j.anclin.2020.02.001 
Thomas, D. R. (2003). A general inductive approach for 
qualitative data analysis.   
https://citeseerx.ist.psu.edu/viewdoc/download?doi
=10.1.1.462.5445&rep=rep1&type=pdf 
Tonsaker, T., Bartlett. G., & Trpkov, C. (2014). Health 
information of the internet: Gold mine or mine field. 
Canadian  Family  Physician,  60,  407-408. 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC402
0634 
Tse,  C.  K.  W.,  Bridges,  S.  M.,  Srinivasan,  D.  P.,  & 
Cheng, B. S. S. (2015). Social media in adolescent 
health  literacy  education:  A  pilot  study.  JMIR 
Research Protocols, 4(1).   
https://doi.org/10.2196/resprot.3285 
Ventola,  C.  L.  (2014).  Social  media  and  health  care 
professionals;  Benefits,  risks  and  best  practices. 
Pharmacy & Therapeutics, 39(7), 491-499.  
West, B., Moore, H., & Barry, B. (2015). Beyond the 
tweet:  Using  Twitter  to  enhance  engagement, 
learning  and  success  among  first-year  students. 
Journal  of  Marketing  Education,  37(3),  160-170. 
https://doi.org/10.1177/0273475315586061  
Wharf Higgins, J., & Begoray, D. (2012). Exploring the 
borderlands  between  media  and  health: 
Conceptualizing  ‘critical  media  health  literacy.’ 
Journal of Media Literacy Education, 4, 136-148.  
 Xie,  B.  (2011).  Effects  of  an  eHealth  literacy 
intervention  for  older  adults.  Journal  of  Medical 
Internet Research, 13(4), 90-108.   
https://doi.org/10.2196/jmir.1880  
Zhou, J.,  Liu,  F.,  &  Zhou,  H.  (2018).  Understanding 
health food messages on Twitter for health literacy 
promotion.  Perspectives  in  Public  Health,  138(3), 
173-179. 
https://doi.org/10.1177/1757913918760359 
Zhou, L., Zhang, D., Yang, C.,  & Wang, Y., (2017). 
Harnessing  social  media  for  health  information 
management.  Electronic  Commerce  Research  & 
Applications, 27, 139-151.   
https://doi.org/10.1016/j.elerap.2017.12.003 
 