Examining the Role and Strategies of Advocacy Coalitions in California's Statewide Sugar-Sweetened Beverage Tax Debate (2001-2018).

PURPOSE: California's failed attempts to enact a statewide sugary beverage tax presents an opportunity to advance understanding of advocacy coalition behavior. We investigate the participation of advocacy coalitions in California's statewide sugar-sweetened beverage (SSB) tax policy debate. DESIGN: Document analysis of legislative bills and newspaper articles collected in 2019. SETTING: California. METHOD: A total of 11 SSB tax-related bills were introduced in California's legislature between 2001-2018 according to the state's legislative website. Data sources include legislative bill documents (n = 94) and newspaper articles (n = 138). Guided by the Advocacy Coalition Framework (ACF), we identify advocacy coalitions involved in California's SSB tax debate and explore strategies and arguments used to advance each coalitions' position. RESULTS: Two coalitions (public health, food/beverage industry) were involved in California's statewide SSB tax policy debate. The public health coalition had higher member participation and referred to scientific research evidence while the industry coalition used preemption and financial resources as primary advocacy strategies. The public health coalition frequently presented messaging on the health consequences and financial benefits of SSB taxes. The industry coalition responded by focusing on the potential negative economic impact of a tax. CONCLUSION: Multiple attempts to enact a statewide SSB tax in California have failed. Our findings add insight into the challenges of enacting an SSB tax considering industry interference. Results can inform future efforts to pass evidence-based nutrition policies.

A text message intervention to support latino dementia family caregivers (CuidaTEXT): feasibility study.

OBJECTIVES: To test the feasibility, acceptability, and preliminary efficacy of CuidaTEXT: a bidirectional text message intervention to support Latino dementia family caregivers. METHODS: CuidaTEXT is a six-month, bilingual intervention tailored to caregiver needs (e.g., education, problem-solving, resources). We used convenience sampling and reached 31 potential participants via clinics, registries, community promotion, and online advertising. We enrolled 24 Latino caregivers in a one-arm trial and assessed feasibility, acceptability, and preliminary efficacy within six months. RESULTS: None of the participants unsubscribed from CuidaTEXT and 83.3% completed the follow up survey. Most participants (85.7%) reported reading most text messages thoroughly. All participants reported being very or extremely satisfied with the intervention. Participants reported that CuidaTEXT helped a lot (vs not at all, a little, or somehow) in caring for their care recipient (71.4%; n = 15), for themselves (66.7%; n = 14), and understanding more about dementia (85.7%; n = 18). Compared to baseline, at six months caregiver behavioral symptom distress (0-60) decreased from 19.8 to 12.0 and depression (0-30) from 8.8 to 5.4 (p < .05). CONCLUSIONS: CuidaTEXT demonstrated high levels of feasibility, acceptability, and preliminary efficacy among Latino caregivers. CLINICAL IMPLICATIONS: CuidaTEXT's feasibility and potential for widespread implementation holds promise in supporting Latino caregivers of people with dementia.

The Communication of Scientific Information to Scientists, Clinicians, and the Public: Recommendations for Achieving Health Equity.

Optimizing health care decisions relies critically on the availability of health-related information appropriate to the specific needs and circumstances of the individual. Abundant research has demonstrated that information relevant to health care decision-making reflects disparities along multiple axes of sex, race, socioeconomic status, geography, sexual orientation, and other factors. Compounding the problem is that mechanisms of access to information themselves, increasingly recognized as part of the social determinants of health, can perpetuate and even exacerbate these disparities. Critical to achieving neurologic health equity is the application of evidence-based strategies to inform the effective and efficient communication of information that can influence patients' behaviors, enhance community trust in the scientific enterprise, and shape health systems and policies. In 2020, as part of a strategic planning initiative, the National Institute of Neurological Disorders and Stroke (NINDS) charged its Advisory Council to form a working group of experts to provide recommendations for reducing health disparities. Here, we report our subgroup's findings, which focused on the role of communication in addressing neurologic disparities and inequities to achieve health equity. We find a need for incentivizing and supporting the application of communication science across the spectrum of neurologic health research. We present recommendations for NINDS and individual investigators to support communication activities that advance neurologic health equity.

Testing the effectiveness of narrative messages using critical health communication.

BACKGROUND: Latinos suffer from health disparities associated with excessive consumption of sugar-sweetened beverages. This study aimed to test the effectiveness of messaging using critical health communication approaches and delivered by two narrative modalities (video and comic book) with similar content that aims to empower Latinos to advocate for social change and to make individual behavior change related to sugary beverage consumption. METHODS: Participants (N = 129 Mexican American women between 18 and 29 years) completed an online survey before and after exposure to an embedded stimulus. Participants were randomly assigned to a stimulus, a narrative message in video or comic book format, both developed using critical health communication approaches that focused on individual harms and social causes of sugary beverage consumption. RESULTS: Paired sample t-test results showed that both narrative messages increased intentions to reduce sugary beverage consumption (Video: P < 0.01; d = 0.43; Comic: P = 0.03; d = 0.28). Both groups also demonstrated significant improvements in sugary beverage-related media literacy (Video: P = 0.01, d = 0.34; Comic: P = 0.05, d = 0.25), public health literacy (Video: P = 0.05, d = 0.24; Comic: P = 0.01, d = 0.32), and empowerment to engage in sugary beverage-related community movements (Video: P = 0.003, d = 0.38; Comic: P = 0.034, d = 0.27). CONCLUSIONS: This study provides initial evidence indicating the effectiveness of narrative messages in two modalities using critical health communication for promoting individual behavioral intention and social activation in reducing sugary beverage consumption.

Communicating about the social determinants of health: development of a local brand.

BACKGROUND: Successful comprehensive population-based approaches to chronic disease prevention leverage mass media to amplify messages and support a culture of health. We report on a community-engaged formative evaluation to segment audiences and identify major themes to guide campaign message development for a transformative health communication campaign. METHODS: Four key phases of campaign development: (I) Formative evaluation to identify priorities, guiding themes, and audience segments (interviews/focus groups with residents, N = 85; representatives of community-based partner organizations, N = 10); (II) Brand development (focus groups and closed-ended surveys; N = 56); (III) Message testing approaches to verbal and visual appeals (N = 50 resident intercept interviews); (IV) Workshop (N = 26 participants representing 15 organizations). RESULTS: Residents were engaged throughout campaign development and the resulting campaign materials, including the campaign name and visual aesthetic (logo, color schemes, overall look and feel) reflect the diversity of the community and were accepted and valued by diverse groups in the community. Campaign materials featuring photos of county residents were created in English, Spanish, and Hmong. Plain language messages on social determinants of health resonate with residents. The county was described as a sort of idyllic environment burdened by inequality and structural challenges. Residents demonstrated enthusiasm for the campaign and provided specific suggestions for content (education about disease risks, prevention, management; information about accessing resources; testimonials from similar people) and tone. CONCLUSIONS: Communication to support a policy, systems, and environmental change approach to chronic disease prevention must carefully match messages with appropriate audiences. We discuss challenges in such messaging and effectiveness across multiple, diverse audiences.

Perceptions of and Experiences With Cigarette and E-Cigarette Use Among a Diverse Population of US Latino Adolescents and Young Adults.

PURPOSE: To determine potential unique factors influencing cigarette and e-cigarette use in US Latino youth. APPROACH: We conducted a qualitative study assessing cigarette and e-cigarette perceptions and experiences, including experiences with/perceptions of the products, cultural influences and influences of friends and family. SETTING: Four online discussion boards, conducted in October 2020. PARTICIPANTS: 92 Latino youth aged 15-21 years living in the US. METHOD: Data from the discussion groups were coded and analyzed by three trained coders using a thematic analysis approach. RESULTS: Stress relief emerged as the dominant theme connected with both cigarettes and e-cigarettes. Apart from stress, perceptions of and experiences with the products differed. E-cigarettes were commonly viewed as trendy and cool and participants often reported using them due to curiosity and popularity. Participants commonly compared e-cigarettes to cigarettes, noting benefits of e-cigarettes. Participants also noted more negative short and long-term health effects of cigarette use, and discussed generational differences between the two products. CONCLUSION: Findings from this study help address a dearth of research examining tobacco use among diverse groups of Latino youth. Findings indicate that despite differences in country of heritage, Latino youth are united by similar opinions about cigarettes and e-cigarettes. Additionally, they share cultural values and experiences which could be leveraged for tobacco control communications that cut across populations of Latino youth.

Health Information Seeking From an Intelligent Web-Based Symptom Checker: Cross-sectional Questionnaire Study.

BACKGROUND: The ever-growing amount of health information available on the web is increasing the demand for tools providing personalized and actionable health information. Such tools include symptom checkers that provide users with a potential diagnosis after responding to a set of probes about their symptoms. Although the potential for their utility is great, little is known about such tools' actual use and effects. OBJECTIVE: We aimed to understand who uses a web-based artificial intelligence-powered symptom checker and its purposes, how they evaluate the experience of the web-based interview and quality of the information, what they intend to do with the recommendation, and predictors of future use. METHODS: Cross-sectional survey of web-based health information seekers following the completion of a symptom checker visit (N=2437). Measures of comprehensibility, confidence, usefulness, health-related anxiety, empowerment, and intention to use in the future were assessed. ANOVAs and the Wilcoxon rank sum test examined mean outcome differences in racial, ethnic, and sex groups. The relationship between perceptions of the symptom checker and intention to follow recommended actions was assessed using multilevel logistic regression. RESULTS: Buoy users were well-educated (1384/1704, 81.22% college or higher), primarily White (1227/1693, 72.47%), and female (2069/2437, 84.89%). Most had insurance (1449/1630, 88.89%), a regular health care provider (1307/1709, 76.48%), and reported good health (1000/1703, 58.72%). Three types of symptoms-pain (855/2437, 35.08%), gynecological issues (293/2437, 12.02%), and masses or lumps (204/2437, 8.37%)-accounted for almost half (1352/2437, 55.48%) of site visits. Buoy's top three primary recommendations split across less-serious triage categories: primary care physician in 2 weeks (754/2141, 35.22%), self-treatment (452/2141, 21.11%), and primary care in 1 to 2 days (373/2141, 17.42%). Common diagnoses were musculoskeletal (303/2437, 12.43%), gynecological (304/2437, 12.47%) and skin conditions (297/2437, 12.19%), and infectious diseases (300/2437, 12.31%). Users generally reported high confidence in Buoy, found it useful and easy to understand, and said that Buoy made them feel less anxious and more empowered to seek medical help. Users for whom Buoy recommended "Waiting/Watching" or "Self-Treatment" had strongest intentions to comply, whereas those advised to seek primary care had weaker intentions. Compared with White users, Latino and Black users had significantly more confidence in Buoy (P<.05), and the former also found it significantly more useful (P<.05). Latino (odds ratio 1.96, 95% CI 1.22-3.25) and Black (odds ratio 2.37, 95% CI 1.57-3.66) users also had stronger intentions to discuss recommendations with a provider than White users. CONCLUSIONS: Results demonstrate the potential utility of a web-based health information tool to empower people to seek care and reduce health-related anxiety. However, despite encouraging results suggesting the tool may fulfill unmet health information needs among women and Black and Latino adults, analyses of the user base illustrate persistent second-level digital divide effects.

Toward a Recipe for Deep versus Surface Level Tailoring: Mixed-Methods Validation of Message Features to Reduce Sugary Beverage Consumption.

Targeted marketing contributes to the overconsumption of sugary beverages, which contributes to obesity and diabetes disparities among African American and Latino populations in the U.S. Health communicators can similarly use culturally tailored messages to decrease sugary beverage consumption among these groups, yet the specific strategies to operationalize cultural tailoring-the message components essential for such tailoring-are ill-described. We sought to identify and validate authentically created, culturally tailored messages using a multiple step mixed-methods approach. First, we used a snowball approach to identify nutrition education messages targeting ethnic minorities about reducing sugary beverage consumption (N = 85). Via content analysis, we assessed message features (character gender and race/ethnicity), level of change of the appeal (individual or social), and level of cultural tailoring (surface level tailoring in the form of matching character gender and race/ethnicity with target audience versus deep structural tailoring in the form of appealing to values is an effective message strategy). The highest-rated videos were then validated by a sample of the target audience using a quantitative survey and qualitative comments (N = 76). The results inform theorizing on message tailoring and provide a validated pool of culturally relevant messages intended both to reduce intentions to consume sugary beverages and to engage in social change actions.

News coverage of Mexico's front-of-package food label policy.

OBJECTIVES: To examine news coverage of Mexico's front-of-package food labelling policy. METHODS: We used Lexis Nexis to identify newspaper articles that mention the proposed law in four Mexican newspapers representing politically centre-left and centre-right perspectives. We coded for type and valence of arguments, sources and research evidence cited. RESULTS: We identified N=361 relevant articles. Coverage of the front-of-package food label policy was primarily news (vs editorial/opinion). While most were neutral in tone, left-leaning newspapers had slightly more positive overall coverage compared with right-leaning newspapers, indicated by publishing more stories in favour of the policy, fewer in opposition, more propolicy arguments and more frequent inclusion of perspectives by government officials and public health advocates. Despite some evidence of bias, there was a general lack of credible opposition to the policy and mention of opponents across newspapers. CONCLUSIONS AND POLICY IMPLICATIONS: The relative absence of food and beverage industry stakeholders in news coverage of the food label policy is unexpected given their documented involvement in prior food policy debates. We discuss possible reasons for their conspicuous absence and lessons for public health advocates around the globe.

A Text Messaging Intervention to Support Latinx Family Caregivers of Individuals With Dementia (CuidaTEXT): Development and Usability Study.

BACKGROUND: Latinx family caregivers of individuals with dementia face many barriers to caregiver support access. Interventions to alleviate these barriers are urgently needed. OBJECTIVE: This study aimed to describe the development of CuidaTEXT, a tailored SMS text messaging intervention to support Latinx family caregivers of individuals with dementia. METHODS: CuidaTEXT is informed by the stress process framework and social cognitive theory. We developed and refined CuidaTEXT using a mixed methods approach that included thematic analysis and descriptive statistics. We followed 6 user-centered design stages, namely, the selection of design principles, software vendor collaboration, evidence-based foundation, caregiver and research and clinical advisory board guidance, sketching and prototyping, and usability testing of the prototype of CuidaTEXT among 5 Latinx caregivers. RESULTS: CuidaTEXT is a bilingual 6-month-long SMS text messaging-based intervention tailored to caregiver needs that includes 1-3 daily automatic messages (n=244) about logistics, dementia education, self-care, social support, end of life, care of the person with dementia, behavioral symptoms, and problem-solving strategies; 783 keyword-driven text messages for further help with the aforementioned topics; live chat interaction with a coach for further help; and a 19-page reference booklet summarizing the purpose and functions of the intervention. The 5 Latinx caregivers who used the prototype of CuidaTEXT scored an average of 97 out of 100 on the System Usability Scale. CONCLUSIONS: CuidaTEXT's prototype demonstrated high usability among Latinx caregivers. CuidaTEXT's feasibility is ready to be tested.

The Racialized Marketing of Unhealthy Foods and Beverages: Perspectives and Potential Remedies.

We propose that marketing of unhealthy foods and beverages to Black and Latino consumers results from the intersection of a business model in which profits come primarily from marketing an unhealthy mix of products, standard targeted marketing strategies, and societal forces of structural racism, and contributes to health disparities.

Protocol: Effectiveness of message content and format on individual and collective efficacy in reducing the intention to consume sugar-sweetened beverages.

The strategic use of media is a common approach to promote health. A large body of evidence identifies specific features that increase message efficacy, including tailoring messages to the target audience and using a storytelling format. Yet most message testing research has focused on individual-level outcomes, ignoring the social and environmental determinants of health behaviors, which require collective action and political will to change. Grounded in an ecological approach to communication, we will carry out two double-blinded randomized experiments to test the relative effectiveness of message tailoring (culturally-tailored vs. standard) and format (narrative vs. didactic) to increase the intention to reduce individual sugar-sweetened beverage consumption, the understanding of social and commercial determinants of health, and the sense of empowerment among young adult Latinas. Based on power analyses (80% power at alpha = 0.05), we will randomize 438 participants to two groups (traditional standard infographic and culturally-tailored infographic) in the first study, and 662 participants to two groups (culturally-tailored infographic and culturally-tailored comic book) in the second study. All participants will be measured by a pre-treatment test and an immediate post-treatment test. We hypothesize that culturally-tailored comic book will be most effective, and traditional standard infographic will be least effective, on all levels of outcomes. This study will provide empirical evidence in communication strategies to help young Latinos or other racial/ethnic minority young people to pursue positive dietary behaviors that both benefit themselves and contribute to change of social norms.

Perceptions of Arguments in Support of Policies to Reduce Sugary Drink Consumption Among Low-Income White, Black and Latinx Parents of Young Children.

PURPOSE: To test for racial/ethnic differences in perceived argument strength in favor of structural interventions to curb childhood obesity among lower-income parents of young children. DESIGN: Cross-sectional, self-report. SETTING: Online research panel, national sample of 1485 US adults in Fall 2019. PARTICIPANTS: Parents of children (age 0-5 years) with an annual income <$40,000, stratified by White, Black and/or Latinx race/ethnicity. MEASURES: SSB consumption, policy support, and strength of arguments in favor of marketing restrictions and a penny-per-ounce tax. ANALYSIS: Descriptive statistics, multivariable OLS models. RESULTS: Race/ethnicity was not a significant predictor of the perceived strength of a composite of marketing arguments (pBlack = 0.07; pLatinx = 0.10), however it was a significant predictor of the perceived strength of tax arguments (pBlack = 0.01; pLatinx = 0.01). Perceptions of strength of 12 of 35 discrete SSB tax arguments differed by race/ethnicity (p < .05). Arguments regarding industry targeting of Black children (marketing: pBlack < .001; pLatinx = .001; tax: pBlack < .001; pLatinx = .001), were particularly demonstrative of this difference. In contrast, arguments that these policies would provide support for parents (marketing: pBlack = 0.20; pLatinx = 0.84) and communities (tax: pBlack = 0.24; pLatinx = 0.58) were seen as strong arguments across groups. CONCLUSIONS: Black and Hispanic/Latinx parents may be more prepared to move toward SSB policy support than white parents. Emphasizing community benefits of policy may be effective in moving constituents toward policy support across groups.

Segmented assimilation as a mechanism to explain the dietary acculturation paradox.

Latinos have disproportionately high rates of diet-related diseases which are associated with acculturation to the U.S. This negative shift in dietary quality is paradoxical in light of gains in income and education that would be expected to lead to better diet. We examined the extent to which the dietary acculturation paradox among Mexican Americans can be explained by segmented assimilation, a theory that considers how immigrants' and their descendants' trajectories of integration are influenced by a complex interplay of individual, social, and structural factors. First, we performed confirmatory cluster analysis to identify three assimilation segments (classic, underclass, and selective) based on education, income, and an acculturation proxy derived from language, nativity, and time in the U.S. among Mexican-origin participants (N = 4475) of the 2007-2016 National Health and Nutrition Examination Survey (NHANES). These segments were then used as independent variables in linear regression models to estimate the relationship between cluster and dietary quality (assessed by the Health Eating Index (HEI)) and the interaction between cluster and gender, controlling for marital status. There were strong effects of cluster on dietary quality, consistent with hypotheses per segmented assimilation theory. The classic assimilation segment had the poorest diet, despite having higher income and education than the underclass segment. The selective segment had higher or similar dietary quality to the underclass segment. Consistent with expectations, this difference was driven by the relatively higher consumption of greens and beans and whole grains of those in the selective and underclass segments. Overall, women had better diets than men; however, the strongest gender contrast was in the underclass segment. This study advances understanding of dietary acculturation and potential disparities in diet-related health outcomes.

Coverage and Framing of Immigration Policy in US Newspapers.

Policy Points Although immigration policy is recognized as a social determinant of health, less is known about how mechanisms, such as news coverage of policy, influence intermediary and proximal health processes like seeking health care. The extent of news coverage of federal, state, and local exclusionary or integration immigration policies can influence public agendas regarding immigrant inclusion and exclusion. Exclusionary federal immigrant policies have dominated the news across the United States over the past ten years, despite active immigrant integration policymaking at national, state, and local levels. CONTEXT: Immigration policymaking at federal, state, and local levels in the United States has proliferated in the past decade. While evidence demonstrates that immigration policy is a determinant of health, there has been limited examination of the mechanisms by which policy influences proximal health processes. News coverage has served as a central platform for debates over restrictive and inclusive immigration policies and may constitute an important health mechanism by shaping public agendas, influencing support for immigrant exclusion or inclusion, and framing policy issues, thereby influencing immigrants' social climates. This study sought to examine the extent of news coverage of exclusionary and inclusive immigration policy at federal and state levels and variations in messages about immigrants during two periods of extensive policymaking. METHODS: We conducted a quantitative content analysis of newspapers' coverage of immigration policy between 2010 and 2013 and between 2017 and 2019. We conducted a systematic NewsBank search of articles covering legislation, lawsuits, and other policies related to immigration (n = 931). Articles were coded for policy type and level, positive or negative framing of immigrants, and other characteristics. Our analysis then compared the patterns of the two periods. RESULTS: In both periods, the majority of coverage focused on exclusionary policies at the federal level, despite a significant increase in integration policies between 2017 and 2019. We found significant shifts in both the negative and positive framing of immigrants, from the dominant negative messages of immigrants as an economic drain to immigrants as criminals and the dominant positive messages of immigrants' economic contributions to immigrants as families. CONCLUSIONS: Since 2010, coverage of exclusionary federal policy has consistently dominated the news, as messages have increasingly described immigrants as either criminals or part of families. We discuss the health implications and future research directions of news coverages' role in influencing the immigration policy and social contexts that have been linked to health outcomes.

Framing Food Access: Do Community Gardens Inadvertently Reproduce Inequality?

BACKGROUND: Alternative food programs have been proposed as solutions to food insecurity and diet-related health issues. However, some of the most popular programs-farmers markets and community-supported agriculture-overwhelmingly serve White and upper-middle-class individuals, exacerbating food security and health disparities. One explanation for the mismatch is the way in which alternative food programs are framed: Language used to encourage participation may reflect priorities of upper-middle-class and White populations who create and run these programs while lacking resonance with food-insecure populations. This literature, however, lacks consideration of how lower-cost, more participatory programs-community gardens-are framed. We therefore explore the framing of community gardens through a quantitative content analysis of the descriptions, missions, and goals provided by community garden managers across Minnesota (N = 411). RESULTS: Six frames were consistently present in the community garden statements: greater good, community orientation, healthy food access, food donation, self-empowerment, and symbolic food labels. Greater good and community orientation were significantly more likely to be used than any other frames. CONCLUSIONS: Taken together, our findings suggest that community gardens may be welcoming toward a diversity of participants but still have room to improve the inclusivity of their frames. The common use of a community orientation suggests the unique ability of community gardens among alternative food programs to benefit Black, Latino, and working-class populations. However, the most common frame observed was "greater good," suggesting one mechanism through which community gardens, like other types of alternative food programs, may be reproducing inequality through alienation of food-insecure populations.

Media Reporting on Air Pollution: Health Risk and Precautionary Measures in National and Regional Newspapers.

Exposure to air pollution is one of the primary global health risk factors, yet individuals lack the knowledge to engage in individual risk mitigation and the skills to mobilize for the change necessary to reduce such risks. News media is an important tool for influencing individual actions and support for public policies to reduce environmental threats; thus, a lack of news coverage of such issues may exacerbate knowledge deficits. This study examines the reporting of health risks and precautionary measures regarding air pollution in national and regional print news. We conducted a content analysis of two national and two local newspapers covering the USA's most polluted region during a 5-year period. Coders identified information on threat, self-efficacy, protective measures and information sources. Nearly 40% of air pollution news articles mentioned human health risks. Fewer than 10% of news stories about air pollution provided information on the precautionary measures necessary for individuals to take action to mitigate their risk. Local newspapers did not report more threat (Χ2 = 1.931, p = 0.165) and efficacy (Χ2 = 1.118, p = 0.209) information. Although air pollution levels are high and continue to rise at alarming rates, our findings suggest that news media reporting is not conducive to raising environmental health literacy.

From "Infodemics" to Health Promotion: A Novel Framework for the Role of Social Media in Public Health.

Despite the ubiquity of health-related communications via social media, no consensus has emerged on whether this medium, on balance, jeopardizes or promotes public health. During the COVID-19 pandemic, social media has been described as the source of a toxic "infodemic" or a valuable tool for public health. No conceptual model exists for examining the roles that social media can play with respect to population health.We present a novel framework to guide the investigation and assessment of the effects of social media on public health: the SPHERE (Social media and Public Health Epidemic and REsponse) continuum. This model illustrates the functions of social media across the epidemic-response continuum, ranging across contagion, vector, surveillance, inoculant, disease control, and treatment.We also describe attributes of the communications, diseases and pathogens, and hosts that influence whether certain functions dominate over others. Finally, we describe a comprehensive set of outcomes relevant to the evaluation of the effects of social media on the public's health.