Using social media in health literacy research: A promising example involving Facebook with young Aboriginal and Torres Strait Islander males from the Top End of the Northern Territory

ISSUE ADDRESSED
The term 'health literacy' is used in various ways in health promotion contexts. An increased global interest in health literacy has resulted in diverse methods to measure health literacy at individual, population and organisational levels. In this brief report we begin to discuss how social media platforms can be a useful source of information - when used in conjunction with other methods - to ascertain broader understandings of health literacy among marginalised populations. We use empirical research with young Aboriginal and Torres Strait Islander males in the Top End of the Northern Territory (NT), Australia to demonstrate the utility of social media, specifically Facebook, in this regard.


METHOD
We used content from Facebook posts of young Aboriginal and Torres Strait Islander males living in the Top End of the NT to gauge their understanding of health and wellbeing. Facebook posts were only accessed and used with individual consent in accordance with ethics approval provided by the Charles Darwin University Human Research Ethics Committee.


RESULTS
We found triangulating social media content with transcripts from nine yarning sessions was a useful way to explore the synergies and differences in the way our participants convey understandings of their health and wellbeing. Paying attention to the content of Facebook posts was a particularly useful and non-invasive way to assess their health literacy from a qualitative perspective.


CONCLUSION
This approach provided an alternative strengths-based narrative about the health and wellbeing of young Aboriginal and Torres Strait Islander males that differs markedly to more regular negative, and arguably health-damaging, public and popular media portrayals of this population. SO WHAT?: We argue that innovative methodological approaches that are non-invasive and reflect the use of Facebook, and potentially other social media platforms, should be better utilised in qualitative health literacy research aiming to engage marginalised populations.

Qualitative research approaches, when applied to health literacy research, can assist the health promotion community to better tailor programs and policy responses that aim to reduce health inequities among marginalised populations. 5,[19][20] For example, yarning has been increasingly used to understand the health and well-being needs of Aboriginal and Torres Strait Islander people at individual, family and community levels. 18,[20][21] Yarning typically involves a fluid and interactive discussion with participants in a culturally safe environment. Interviews and focus groups have also been used repeatedly in health literacy research with youth, migrant, and low socioeconomic status populations. [22][23][24] Visual methods, such as Photovoice, have also been increasingly used in health literacy research -primarily with youth, men and people with mental health conditions. [25][26][27] Photovoice is a community-based research method that involves capturing a participants' ideas and reality on a given topic through photographs, and then discussing these through group interviews or individual interviews. [28][29] These types of visual methods are perceived to be a powerful means for minority populations to express their understandings of health and well-being. 29 It can support critical thinking, self-reflection, discovering strengths and social support. 28 However, there are also important ethical implications that need careful consideration when using visual research methods in health promotion practice and research contexts. These relate to a broad range of recruitment, consent, engagement, use and research translation issues. 30-32

| Approach
In this brief report, we offer new methodological and ethical insights about the way popular and emerging social media platforms can be used in equity-focused health literacy research. More specifically, we reflect on our experiences of using Facebook to gain a deeper understanding of the health literacy needs of young Aboriginal and Torres Strait Islander males in the Top End of the Northern Territory, Australia. 18 This project received ethics approval from the Charles Darwin University Human Research Ethics Committee (H18043). The intent of this paper is not to present empirical findings. Rather, we aim to discuss the methodological and ethical benefits of using social media platforms -such as Facebook, Snapchat, Instagram and Tik Tok -to undertake content analyses in health literacy research. We present three lessons learned when using Facebook in this way, but consider the concepts could be extended to other social media platforms, particularly those use by marginalised or vulnerable populations. We envisage these insights will make a valuable contribution to professional dialogue and debate on this topic.

| Social media can provide an authentic window into the lives of 'hard-to-reach' populations
A significant research base suggests that vulnerable populations experiencing health inequities can be difficult to engage through health promotion research and practice. [33][34][35] Evidence points toward strategies that involve meeting these 'hard-to-reach' populations on their terms in settings and environments of relevance to them. [33][34][35] In our case, we were interested in the lived-experiences of young Aboriginal and Torres Strait Islander males. Current scholarship suggests that both youth and men are considered to be hard-to-reach populations in health research contexts. [36][37] Emerging evidence also indicates that youth are actively using social media to communicate with their social networks, with some scholars arguing that social media has become their virtual world. 38 During yarning sessions with young males, we observed that participants were readily accessing and using a range of social media platforms, including Facebook. After discussing this with the Chair of our Human Research Ethics Committee, we successfully sought an ethics amendment to approach the yarning session participants to seek their informed consent to access their Facebook posts and related conversation threads. We limited this to retrospective posts and threads from the last two years -that is, information that had been posted prior to the date of consent. Our original intent was to gauge the extent to which participants discussed health and well-being issues through social media. Our early analysis revealed there was significant content being posted that related to their health and well-being, and that of their friends and family. Importantly, these posts reflected a pre-existing and authentic expression of their day-to-day lives. This contrasts many other qualitative research approaches where information is sought, and thus generated, for the purpose of further analysis.
We recognise that Facebook posts may not be a true and accurate reflection of an individual's health behaviours -that is, there may be a gap between expressed health perceptions and attitudes, and subsequent health behaviours. Indeed, some researchers have suggested that social media evokes unique styles of public performance that can differ markedly from non-virtual behaviours. 39  These qualitative perspectives are unique, and paying attention to these Facebook discussions can offer the health promotion community important insights about the health literacy of hard-to-reach populations, with potential to inform needs assessment, planning and evaluation practices that are concordant with core health promotion competencies.

| Careful consideration of ethical implications is important
Two critical ethical implications that we were required to navigate in our study related to that of informed consent; and researcher burden.
In our research with young Aboriginal and Torres Strait Islander males, the staging of different research phases meant that seeking informed consent was a relatively easy process. That is, when participants were involved in a Yarning Session, we sought either written or oral informed consent at that point in time to enable access to their personal Facebook page, and to make use of the retrospective content they had shared. This included the ability to access and use their commentary, photos and memes. We ex-

| Analysing social media content can be a useful way to triangulate data
Data or methodological triangulation is an important approach used in qualitative health research internationally. 47 This involves comparing and contrasting one source of data to another to increase the validity of assumptions made. [47][48] In this sense, data triangulation is a way to strengthen the legitimacy and rigour of research findings. In

| CON CLUS ION
In this brief report we have discussed how one social media platform, Facebook, can be a useful source of information -particularly when used in conjunction with other methods -to ascertain broader understandings of health literacy among a marginalised population in Australia. We have described how Facebook provides an authentic perspective into the lives of hard-to-reach populations; requires considered and pragmatic thought about ethical considerations such a secondary consent and participant research burden; and can be used strategically as a data triangulation tool in qualitative health research.
We recognise this paper only provides a snapshot into the utility of Facebook in health literacy research with vulnerable populations.
It is important to reiterate that while we observed that participants were readily accessing and using a range of social media platforms, the subsequent interaction has provided a valuable contribution toward ongoing professional dialogue associated with engaging young