Pandemics in the Age of Twitter: A Content Analysis of the 2009 H1N1 Outbreak by Cynthia Mei Chew A thesis submitted in conformity with the requirements for the degree of Master of Science Department of Health Policy, Management and Evaluation University of Toronto © Copyright by Cynthia Mei Chew 2010 Pandemics in the Age of Twitter: A Content Analysis of the 2009 H1N1 Outbreak Cynthia Mei Chew Master of Science Department of Health Policy, Management and Evaluation University of Toronto 2010 Abstract This thesis reports on the use of Twitter during the 2009 H1N1 pandemic to explore its use as an “infoveillance” approach complementary to traditional surveys and content analysis. This study aimed to: 1) report on the use of “H1N1” versus “swine flu”, 2) conduct a qualitative analysis of tweet content, and 3) assess the feasibility of Twitter as a real-time content, sentiment, and public attention trend tracking tool. A manual content analysis of tweets revealed that H1N1 resources were the most commonly shared. Few tweets provided inaccurate information. News websites were the most popular resources while official agencies were rarely referenced directly. Our automated analysis correlated well with manual results and showed that Twitter activity was influenced by external events. This study describes the character and quality of Twitter communications during the H1N1 pandemic, and illustrates the potential of using social media to conduct real-time “infodemiology” studies for public health. ii ACKNOWLEDGEMENTS I would like to thank my thesis supervisor, Dr. Gunther Eysenbach for his invaluable guidance, insight, and expertise. I greatly appreciate Dr. Jennifer Keelan for helpful discussions while serving on my thesis committee. I am grateful to the Canadian Institutes for Health Research for their financial support. I thank Claudia Lai for her assistance with coding. I thank my parents, Sam and Shirley, my sisters, Catherine and Carolyn, and my wonderful friends for their love and support. And lastly, I thank my husband, Charles, for his encouragement, prayers, and unconditional love. iii TABLE OF CONTENTS ABSTRACT..................................................................................................................................... ii ACKNOWLEDGEMENTS........ ...................................................................................................... iii TABLE OF CONTENTS.................................................................................................................. iv LIST OF TABLES............................................................................................................................ viii LIST OF FIGURES.......................................................................................................................... ix LIST OF APPENDICIES................................................................................................................. x CHAPTER 1: INTRODUCTION.................................................................................................... 1 CHAPTER 2: LITERATURE REVIEW.......................................................................................... 4 2.1 Web 2.0 and Social Media.................................................................................................. 4 2.1.1 Web 2.0 and Apomediation..................................................................................... 4 2.1.2 Social Media............................................................................................................ 5 2.1.2.1 Social Media Applications......................................................................... 6 2.1.3 Internet & Social Media Usage................................................................................ 7 2.1.4 Social Media Analytics............................................................................................ 10 2.1.5 Summary.................................................................................................................. 11 2.2 Public Health Emergencies................................................................................................. 12 2.2.1 Crisis Risk Communication & the Social Amplification of Risk............................ 12 2.2.2 The Social Amplification of Risk & Social Media................................................. 14 2.2.3 Public Health 2.0...................................................................................................... 15 2.2.3.1 Centers for Disease Control and Prevention (CDC).................................. 16 2.2.3.2 Federal Emergency Management Agency (FEMA)................................... 18 2.2.3.3 Public Health Agency of Canada (PHAC)................................................. 19 2.2.3.4 The Red Cross............................................................................................ 19 2.2.4 The Public‟s use of Social Media & Web 2.0 in Emergencies................................ 20 2.2.4.1 2003 SARS Epidemic................................................................................. 20 2.2.4.2 December 26, 2004 Indian Ocean Earthquake & Tsunami........................ 21 iv 2.2.4.3 August 29, 2005 Hurricane Katrina............................................................ 22 2.2.4.4 April 16, 2007 Virginia Tech Shootings.................................................... 23 2.2.4.5 October 2007 California Wildfires............................................................. 25 2.2.4.6 May 12, 2008 China Sichuan Earthquake.................................................. 26 2.2.4.7 2008 Hurricane Gustav & Ike..................................................................... 28 2.2.4.8 2009 Red River Flooding........................................................................... 29 2.2.4.9 January 13, 2010 Haiti Earthquake............................................................ 30 2.2.5 Summary.................................................................................................................. 32 2.3 Traditional Methodologies & Infodemiology.................................................................... 33 2.3.1 Traditional Methods of Public Polling & Content Analysis................................. 33 2.3.2 Infodemiology & Infoveillance............................................................................... 34 2.3.2.1 Infodemiology Applications in Research................................................... 35 2.3.2.2 Infodemiology Applications in Public Health............................................ 37 2.3.2.3 Advantages & Disadvantages of Infodemiology Approaches................. 40 2.3.3 Summary.................................................................................................................. 41 2.4 The 2009 H1N1 Pandemic Influenza................................................................................. 42 2.4.1 A Brief Timeline of H1N1....................................................................................... 42 2.4.2 Public Perceptions & Attitudes towards H1N1..................................................... 42 2.4.2.1 Risk Perception of H1N1............................................................................ 43 2.4.2.2 Knowledge & Misconceptions of H1N1.................................................... 44 2.4.2.3 Behavioural Responses to H1N1................................................................ 45 2.4.2.4 Emotional Responses to H1N1................................................................... 49 2.4.2.5 H1N1 Vaccination Attitudes & Intentions................................................. 49 2.4.2.6 Perceptions of Authorities.......................................................................... 51 2.4.2.7 Information Needs & Sources.................................................................. 51 2.4.3 Summary.................................................................................................................. 52 CHAPTER 3: RESEARCH DESIGN............................................................................................... 54 3.1 Research Design Overview................................................................................................ 54 v 3.2 Data Collection & Database............................................................................................ 55 3.3 Knowledge Translation: H1N1 versus Swine Flu Terminology........................................ 56 3.4 Manual Content and Sentiment Analysis........................................................................... 56 3.4.1 Codebook................................................................................................................. 57 3.4.2 Content Analysis...................................................................................................... 58 3.4.3 Statistical Analysis................................................................................................... 58 3.5 Automated Content & Sentiment Analysis........................................................................ 59 3.5.1 Query Development................................................................................................. 59 3.5.2 Validation Analysis.................................................................................................. 60 3.6 Public Attention & Sentiment on Twitter........................................................................... 60 3.7 Audit of Retweets..............................................................................................................