“Be sweet to babies”: Use of Facebook as a method of knowledge dissemination and data collection in the reduction of neonatal pain

Abstract The Be Sweet to Babies video demonstrates the analgesic effects of breastfeeding, skin‐to‐skin care, and sweet‐tasting solutions as interventions to reduce pain during blood sampling in newborns. Although effective and safe, these strategies are implemented inconsistently in clinical settings. Given the increasing popularity of social media, there is a potential to disseminate and promote health information through it. The study aim was to evaluate the use of Facebook as a means of disseminating the Be Sweet to Babies video in Portuguese, and to evaluate respondents’ prior knowledge, previous use of the three pain management strategies and intent to use the strategies in the future. We conducted a cross‐sectional study, using the “virtual snowball” sampling method. A Facebook webpage was created, in which the video was posted along with a brief survey. Data analyzed included number of views and visits to the page, number of views of the video, likes, dislikes, and survey responses. One year after posting, the page had 70 753 views and 2199 accesses; there were 1553 “likes”, no dislikes, and 43 positive comments. The survey was completed by 930 respondents (42% response rate based on the page access). Over two thirds of the respondents had previous knowledge about breastfeeding, skin‐to‐skin care, and sweet solutions for pain relief. After watching the video, 87% of the respondents intended to use breastfeeding or skin‐to‐skin care in the future, and 71% intended to use sweet solutions. Almost all viewers rated the video as very useful (n = 917, 99%), easy to understand (n = 926, 99%), and easy to apply in real‐life situations (n = 903, 97%). Using Facebook to deliver and evaluate an intervention is feasible, rapid in obtaining responses, low cost, and it is promising for data collection and knowledge dissemination. Further studies are warranted to evaluate the actual impact of the use of social media in practice change.


| INTRODUC TI ON
All healthy newborns undergo at least one blood sampling for newborn screening, and preterm and sick infants undergo many more blood sampling procedures during hospitalization. 1 Blood sampling is painful, and there is growing evidence of adverse effects of poorly treated repeated procedural pain in preterm infants. 2 High quality synthesized evidence demonstrates analgesic effects of breastfeeding, 3 skin-to-skin care, 4 and sweet-tasting solutions. 5 These strategies are described as effective, safe, low cost, and feasible to implement. However, there is inconsistent use of these strategies in practice. [6][7][8] To increase awareness and facilitate the implementation of evidence-based strategies on newborn pain management, the Be Sweet to Babies team, which includes parents, clinicians, and researchers, co-produced a 5-minute video targeted at parents.
The video demonstrates three newborns undergoing blood collection while being breastfed, held skin-to-skin and given sucrose (https://youtu.be/L43y0 H6XEH4), and is endorsed by Baby Friendly Initiative, Ontario. The video presents user-friendly language and is available in multiple languages.
In order to reduce gaps between what is known and what is done, researchers are increasingly using social media to promote quality information about health and to evaluate the impact of using social media as a strategy for translating knowledge into practice. [9][10][11][12][13][14] These resources are mainly targeted at families, especially parents, healthcare professionals, and the public in general. Previous studies by this team have used YouTube to disseminate the parent-targeted and mediated Be Sweet to Babies video 12 as well as the team's infant vaccination reduction videos. 11 The findings of these video evaluation studies were that there were very high view rates of the videos, showing that YouTube is a useful way of sharing information to large numbers of people around the world. However, response rates to the linked viewer surveys, aimed at ascertaining previous knowledge about the pain management strategies, as well as intent to either use, or advocate for use of the pain management strategies in subsequent painful procedures, have been extremely low, only 0.24% and 1.7%. 12 Such a low response rate was also reported by Campbell-Yeo et al, 14 in their study of the evaluation of a parent-targeted video to disseminate maternal-led comfort measures for newborns. However, a 3-month pilot evaluation of the posting   of the Portuguese language version of the Be Sweet to Babies newborn pain video, using the Facebook platform, resulted in a higher   response rate based on viewers to the Facebook page. There were   1531 viewers to the page, and 709 viewers completed a linked on-line survey-a response rate of 46%. 13 The Facebook platform is considered the most popular and widely used social media platform in the world when compared to platforms such as YouTube, Instagram, Twitter, and LinkedIn. [15][16][17] Due to the number of connections established among those who use Facebook, there is a high possibility of reaching large numbers of people globally; in addition, it is low-cost and a feasible method of dissemination. 15 Based on our promising response rate after a 3-months trial evaluation period, 13 this current study aimed to use and evaluate the Facebook platform as a means of disseminating and evaluating the Portuguese language version of the Be Sweet to Babies video after a 12-month period of being posted onto Facebook.
The specific aims of this study were to (a) evaluate the use of Facebook as a platform to share and evaluate the Be Sweet to Babies video; (b) evaluate viewers' prior knowledge, viewers' previous use of the three pain management strategies, and viewers' intention to use the strategies in the future, and (c) evaluate acceptability, usefulness of the video.

| ME THODS
This was a cross-sectional study using Facebook to host the video and the survey.
Firstly, an open-access page on Facebook was created, supported by experts in advertising, who advised on choice of colors and layout, all inspired by the "Be Sweet to Babies" logo (https://www.faceb ook.com/sejad oceco mosbebes). The Portuguese version of the Be Sweet to Babies (Seja Doce com os Bebês) video was produced and initially uploaded to YouTube in 2014, then revised and re-uploaded F I G U R E 1 Screenshot of Portuguese be sweet to babies video in January 2016. The Portuguese Be Sweet to Babies video was produced in the audiovisual department of the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada (https://www.youtu be.com/watch ?v=nk2w-CAVVG0). Figure 1 shows a screenshot of the Portuguese Be Sweet to Babies video.
A brief survey, developed initially in English 11,18,19 and then translated to Portuguese, 19,20 was linked to the video on the Facebook page (Appendix 1). The survey included demographic questions about the respondents (parents, health professionals, researchers, and others); prior viewing of the video; prior knowledge of analgesic effects of breastfeeding, skin-to-skin care, and sweet solutions; intent to use or encourage the use of the pain management strategies for future newborn painful procedures; and if they would recommend the video to others (Appendix 1). Finally, respondents were asked about acceptability of the usefulness and duration of the video, and whether it was easy to understand and if the strategies were easy to apply. Participants were promoted to complete the survey immediately after watching the video by clicking on a link.
Before the page was launched, a pilot test was conducted.
Twenty-five individuals (parents of infants, researchers, and clinical professionals with expertise in the field), whose first language was Portuguese, evaluated the Facebook page in terms of functionality and clarity of the survey questions. The data collection process was also evaluated at this point. No changes were suggested or required; therefore, no modifications were made to the page or data collection processes.
Once the page was launched on September 26, 2016, invitations to access the page, to watch the video, and to complete the brief survey were distributed by e-mail to colleagues and researchers from various states in Brazil. In addition, invitations were made through the Facebook page using "the snowball method". 20 Snowball sampling is an extension of convenience sampling, and results from an initial group of recruited people further recommending potential participants for the study. Those participants then recommended additional participants, and so on, thus building up like a snowball rolling down a hill. To improve awareness on the study, a summary of the results from the pilot study 13 was published in the first author's city newspaper and in the official webpage of the affiliated University of the first author. The first author engaged with local, regional, and national press and shared the study information and the link to the Facebook page on Twitter. Finally, Facebook messages were distributed to groups of parents on Facebook, such as the Brazilian Association of Parents of Premature Babies (Prematuridade.com), seeking their social network support to collaborate and disseminate the page and the study. No paid advertisements or paid monitoring strategies were implemented.

| Statistical analysis
Descriptive statistics were used to analyze Facebook analytics and survey data. The responses regarding users' knowledge before and after watching the video were made using McNemar's test, with the significance level set at .05.  The majority of the respondents rated the video as very useful (n = 917, 99%), easy to understand (n = 926, 99%), and easy to apply in real-life situations (n = 903, 97%). After watching the video, 928 respondents (99.8%) intended to use or advocate for the use of all three pain management strategies and only two respondents answered they would not recommend the video to others. After watching the video, respondents stated they wished to use breastfeeding or skin-to-skin contact (n = 807, 87%, and n = 808, 87%, respectively), while 659 (71%) intended to use sucrose. Table 2  Recommendations. Key comments which best illustrate the three codes were translated by the first author and second author and summarized in Table 3.

| RE SULTS
There were no dislikes or negative comments posted into the Facebook page.   These large numbers of views highlight the great potential for using social media platforms to share information.

| D ISCUSS I ON
Although these results are promising in terms of the extremely wide reach of the information posted onto social media, using these platforms to collect participants' data in order to evaluate acceptability and effectiveness of the information shared has been less successful to date. For the three studies discussed above, 11,12,14 viewer surveys were linked from YouTube to collect information on previous knowledge of the evidence; previous use of the rec- Overall, although these studies indicate the video as a persuasive tool, further research is still required to ascertain whether the strategies are actually implemented in clinical practice.
Information shared on social media may create awareness of best practices and may provide motivation to change but it is not yet known whether the information directly changes behaviors.
Although this process represents an opportunity to share common interest or engage parents, it is a challenge to present information and build credibility. 23 In addition to that, further challenges include identifying how patients and families perceive the use of social media in research, how they prefer to be involved, and whether different tools or approaches are more effective for different questions, in

Usefulness General praise Recommendations
The study brought me simple practices with scientific foundations that really work! We can greatly help reduce the discomfort of our babies Relieving pain in "usually" painful procedures is a challenge for us health professionals, especially for babies Congratulations. Simple methods that make the difference I'm a mother for the second time, and I posted on my Facebook that I was devastated because of the first dose of the vaccines on my baby's thighs…Hence a friend, who is a nurse told me about the study of breastfeeding while my baby received doses of vaccine…And incredible, it worked! My baby did not feel any more pain in the applications of the vaccines, much less reactions I learnt about the work by Dr Vieira today at CBCENF in Rio de Janeiro and I simply loved it Relieving pain in "usually" painful procedures is a challenge for us health professionals, especially for babies Beautiful project, congratulations… Very good! Exemplary work and the most beautiful of all is to see the care and care that each one has with the babies Congratulations and nice to see that there are still people like this A wonderful study.
My rating is Excellent! I will share with my colleagues and put into my professional practice…Very good Super recommend breastfeeding while the baby takes the vaccine… loved it! Relieving pain in "usually" painful procedure is a challenge for us health professionals, even more so when it comes to babies. A necessary initiative for the physical and mental health of infants.
order to establish guidance/a model or standard on using social media in different health contexts. 23 In another study, a video demonstrating pain management strategies recommended during infant vaccination, which included breastfeeding, sucrose, and topical anesthetics, was shown at prenatal classes. 24 Of the 88 mothers included in the video group, only one third used one of the three strategies during their infant's 2-month vaccination, and another 16% attempted to breastfeed, but were unsuccessful in actually carrying this out. The reasons given were that the clinicians did not approve or allow this to occur. 24 This is despite the high quality synthesized evidence of effectiveness of breastfeeding during infant vaccination 25 and the World Health Organization recommendations to breastfeed during vaccinations. 26 Understanding and addressing such clinician related factors will be important in future studies aiming to ascertain effectiveness of interventions aimed to improve practices. Nurses' and other HCPs' ongoing use of social media platforms to widely disseminate best evidence and to engage the public has been recommended. 27 Since the popularity of the use of social media has changed the way of obtaining information, HCPs and researchers need to update themselves and understand how to use them in order to provide quality information. 28 As researchers and HCPs, it is recognized that there is an obligation to widely share research findings, especially with end users such as families. 27

| CON CLUS IONS
The brief parent-targeted Portuguese language Be Sweet to Babies video demonstrating use of breastfeeding, skin-to-skin care, and sweet-