Global Handwashing Day 2012: a qualitative content analysis of Chinese social media reaction to a health promotion event

BACKGROUND
Global Handwashing Day (GHD) is a handwashing promotion campaign organized by the Global Public-Private Partnership of Handwashing with Soap. In China, it has been promoted by the Chinese public health authorities, international organizations and multinational corporations through various channels including social media such as Sina Weibo, the leading Chinese microblogging site similar to Twitter. The objective of this study is to qualitatively assess Chinese social media users' reactions to a health promotion campaign using Global Handwashing Day (GHD) 2012 as an example.


METHODS
We conducted a qualitative content analysis of 552 Weibo posts generated on GHD 2012 by Weibo users with 1000 or more followers with the Chinese keyword for "handwashing." We categorized the Weibo posts into groups by keywords that frequently appeared in the data set. These groups were either exact reposts of an original post, or they conveyed similar information.


RESULTS
We observed the interconnections between traditional media and social media in handwashing promotion. Social media were found to serve as amplifiers of contents provided by traditional media. We observed the contextualization of global hygiene messages in a unique national social media market in China.


DISCUSSION
Our study showed that social media and traditional media are two interconnected arms of the GHD campaign in China. Our analysis demonstrated that public health campaigns in China can be evaluated using social media data. The themes and topics identified in this study will help public health practitioners evaluate future social media handwashing promotion campaigns.


Authors Authors
Isaac Chun-Hai Fung, Jingxian Cai, Yi Hao, Yuchen Ying, Benedict Shing Bun Chan Chan, Zion Tsz Ho Tse, and King-Wa Fu This journal article is available at HKBU Institutional Repository: https://repository.hkbu.edu.hk/ hkbu_staff_publication/7082 Discussion: Our study showed that social media and traditional media are two interconnected arms of the GHD campaign in China. Our analysis demonstrated that public health campaigns in China can be evaluated using social media data. The themes and topics identified in this study will help public health practitioners evaluate future social media handwashing promotion campaigns.
H andwashing with soap has been shown to reduce the risk of diarrhoeal diseases and respiratory diseases. 1-4 However, handwashing compliance at critical times (for example, before eating and after defecation) in many parts of the world is far from ideal. Gaps between knowledge and practice of handwashing persist. 5 The Global Public-Private Partnership of Handwashing with Soap (PPPHW) was founded in 2001 to promote handwashing with soap across the globe. 6 It is a "coalition of international stakeholders", including the United Nations Children's Fund (UNICEF), Global Handwashing Day 2012: a qualitative content analysis of Chinese social media reaction to a health promotion event government agencies, universities, nongovernmental organizations and representatives of the private sector. 6 One of the key events that PPPHW organizes annually is Global Handwashing Day (GHD). The first GHD was organized on 15 October 2008 when more than 120 million children in 73 countries across five continents were mobilized to wash their hands with soap. 6 Since then, 15 October has been designated as GHD, and handwashing promotion activities are organized globally on that day each year.
Social media have been used by community-based organizations 7 and government agencies 8, 9 to promote hypotheses about social media health promotion. It will serve as a starting point for future studies that can test these hypotheses.

Data acquisition and sampling
Weibo data were collected through the Weiboscope project, as reported elsewhere. 14,18, 19 Through a systematic search of the Sina Weibo user database via the Sina Weibo Application Programming Interface (API), we generated a list of about 350 000 indexed microbloggers who had 1000 or more followers when the project began data collection in 2011. We retrieved their Weibo posts regularly via API over the year of 2012. We selected a high-follower-count sample for two reasons. First, Weibo users with a high number of followers are more influential than those with a low follower count, and they frequently attract disproportionately large attention from the public. 13 Second, spam Weibo accounts are very common in China, 20 and our sampling methods minimize their influence (Figure 1). Our data set covered the year of 2012, and it is publicly available online. 21 For the purpose of this study, we only performed qualitative analysis on the data from 15 October 2012 containing the Chinese keyword for "handwashing." The raw Weibo data were acquired in Comma-Separated Values (CSV) format. 14 The content of the Weibo posts as well as their metadata (e.g. their date of creation and the user IDs) were then available for secondary analysis. De-identification of the user IDs was performed through a process known as "hashing" (conversion into a different string of characters). The properties of each file were recorded in the first line, health. Examples of social media include Facebook, the world's leading social networking site, 10 and Twitter, an online platform that allows users to post and repost 140-character-long messages online to the public. However, social media use in health promotion in many circumstances has remained uni-directional so that information flows only from public health professionals to the audience, 7 as observed in a recent study of Twitter use in Breast Cancer Awareness Month. 11 Raising health awareness and promoting healthy behaviours via social media remains a practical challenge for many organizations.
Weibo is the Chinese name for online platforms that provide microblogging services similar to Twitter. Weibo allows users to post publicly accessible messages of a maximum length of 140 Chinese characters via computers, tablets and smartphones. As Twitter is not accessible in mainland China, Weibo is popular as an alternative. Sina Weibo, the largest provider of Weibo services in China, claimed to have more than 500 million registered users as of December 2012. 12 Meanwhile, 98% of Weibo users were from mainland China, according to a random sampling study. 13 Weibo has been instrumental in online discussion of political and social events in China, 14 responses to natural disasters 15 and suicide prevention. 16 Conversations about various aspects of health are common on Weibo. 17 Weibo has also been a useful indicator of Chinese citizens' reaction to infectious disease outbreaks. 18 Given its unique characteristics, Weibo facilitates study of the online reaction to a health promotion campaign in a well-defined population.
The purpose of this study is to provide a qualitative content analysis of Weibo posts that helps generate  Our data set included original Weibo posts and reposts, i.e. forwarded messages posted by someone else, or retweets in Twitter parlance. (Please note one important difference between Weibo re-posts and Twitter re-tweets. A re-tweet on Twitter must be limited to 140 letters, including the content of the original tweet. In contrast, Sina Weibo allows users to re-post a Weibo post and add another 140 Chinese characters.)

Qualitative content analysis
We performed a qualitative content analysis of the Weibo posts mentioning handwashing. First, preliminary analysis was performed by identifying certain keywords that frequently appeared in the data set and noting their frequency of appearance. Next, the Weibo posts were categorized into groups. These groups were either exact reposts of an original post or they conveyed similar information. Topics of interest that might help generate hypotheses for future studies were then identified. We also visited the Weibo home pages of the key stakeholders of GHD 2012 in China, including the Chinese public followed by the Weibo post content. 18 This protocol of data processing and anonymization was approved by the Human Research Ethics Committee for Non-Clinical Faculties, The University of Hong Kong (EA440512) and by the Institutional Review Board, Georgia Southern University (H14167).

Keyword detection
A string-searching algorithm was used in our keyword detection. We searched the Chinese keyword for handwashing in the data set through a Python-based platform described in a previous study. 18 "The stringsearching algorithm in Python was implemented in C programming language. Python's multiprocessing library was used to process multiple files in parallel to accelerate the search." 18 Every Weibo post in the data set was searched, and we recorded if the keyword occurred in the data file (Figure 1). The daily count of Weibo posts mentioning handwashing is presented in Figure 2. We note that the Chinese keyword for handwashing may be combined with other Chinese characters to form other terms such as toilet/restroom or hand soap bottle which will reduce the positive predictive value (or precision) of our keyword. (For the original Chinese

Basic information about GHD
There were 13 Weibo posts (13/552, 2.4%) that mentioned PPPHW by either its Chinese name or its English acronym ( Table 1). These posts provided correct information about the origin of GHD. There were another seven Weibo posts in our data set that suggested that the GHD was established by the World Health Organization on 13 October 2005 (Table S2 in Online Supplementary Materials).

GHD promotional events, videos and commercial advertisements
We identified 56 Weibo posts (56/552, 10.1%) that were related to the official GHD promotional event organized by the Chinese Government. The guests of honour were an Olympic gold medallist and his mother. UNICEF also used Weibo to promote their GHD videos on the Chinese equivalent of YouTube (Youku) that featured a movie star.

Description of peaks of handwashing Weibo posts
In 2012, there were four major peaks in our Weibo data set with the keyword for handwashing (Figure 2). The peak on 19 February 2012 was generated by reposts of news about the extravagant cost of accessories on certain Chinese high-speed trains, including an expensive hand soap bottle. The peak on 30 August 2012 was generated by news about an E. coli concentration in ice-cream of a certain brand exceeding established standards. Because the news proposed that "incomplete handwashing" by production personnel was a potential source of secondary contamination, a surge in Weibo posts mentioning "handwashing" was observed. 22 The peak on World Toilet Day (19 November 2012) was unrelated to that campaign but related to a news report on that day about the suicide of a university student who dropped to her death out of a restroom window in a university building. 23

Content analysis
In total, 552 Weibo posts on GHD by keyword search were identified. Of these 552 posts, 82 (15%) were

Six steps of handwashing
The "Six Steps of Handwashing," first originated in an experiment by Ayliffe et al, 24 are now being promoted globally as a standard handwashing method. We identified 29 Weibo posts (29/552, 5.2%) that mentioned six steps of handwashing (Examples 1 and 2 in Table 3). Interestingly, this method, though it originated in the United Kingdom, gained a new nickname in China. We identified posts that described the six steps of handwashing as the "Buddha's Palm", literally "Tathāgata Palm" (10 posts) or "Tathāgata Divine Palm" (4 posts) (Examples 2 and 3 in Table 3). This was originally a fictional martial arts move that appeared in movies. The People's Daily released a poster on their official Weibo with the title "Practice 'Buddha's Palm' diligently. Wash hands and keep healthy" and described the six steps of handwashing in a poem 25 (Table S6 in Online Supplementary Materials). This is an example of how a hygiene practice adopted by the global medical community can be adapted and contextualized in a health promotion campaign in a particular culture.

Importance and benefits of handwashing
Weibo posts described the importance and benefits of handwashing. Examples include the "very important effect on raising people's hygiene awareness and preventing diseases" ( Table 1, Example 2), the reduction of "the incidence of diarrhoeal diseases by over 40% and the incidence of respiratory diseases by nearly 25%" ( Table 2), and that "correct handwashing is more costeffective than vaccines or any other health interventions" (

A report on a survey of handwashing behaviour
We identified 50 Weibo posts (50/552, 9.1%) in our data set that quoted a report from the official national paper of the Chinese government (People's Daily) on a survey that found that only 7% of the respondents washed hands in all seven circumstances specified in the survey (after defecation, before meals, after changing nappies, after meals, after touching pets, after touching money and after sneezing). We identified another 19

Four criteria of correct handwashing
Several Weibo posts mentioned a so-called "World Health Organization's (WHO) four criteria on correct handwashing" (the WHO guidelines have six steps): (1) handwashing before meals, after defecation and touching coins, etc.; (2) using running water; (3) using soap or other cleansing products; and (4) handwashing for no less than 20 seconds. For example, we identified 52 posts (52/552, 9.4%) that mentioned "20 seconds". Forty-one posts mentioned all four criteria, five mentioned three criteria and six posts mentioned just one criterion (handwashing for no less than 20 seconds) ( Table 1, Example 1). handwashing method and the importance and benefits of handwashing. We also identified some comments created by individual Weibo users.
As a global health promotion initiative, GHD 2012 was chosen as a case study because this health promotion campaign was promoted by the Chinese Government and its partners through a few clearly identified activities and multimedia materials within a well-defined time frame. 26 It was advertised via social media as well as other traditional mass media. Moreover, PPPHW had developed social media guidelines for its partners to use in GHD promotion.
We found that Weibo was used as a means to disseminate information by various stakeholders of GHD in China, including the Chinese public health authorities, UNICEF and a few corporations that produced hand hygiene products. Weibo posts formed part of the overall health communication strategy to raise GHD awareness together with other promotional events, TV shows, guest celebrities, videos and songs. Posting events in real time in Weibo, and posts having links to instructional videos or songs about handwashing helped the promotion.
Social media can serve as amplifiers of contents provided in traditional mass media such as radio, television and print. 11, 27 As illustrated by the Weibo

IndividualsÊ comments
Apart from public health agencies, commercial firms and mass media outlets, some Weibo users also generated their own comments in reaction to GHD. To illustrate the diversity of contents, we chose five posts as examples (see Table S8 in Online Supplementary Materials): (1) an example of someone's personal experience after attending four sessions of hand hygiene training; (2) a creative Weibo post promoting GHD; (3) a sarcastic comment on GHD; (4) a Weibo post that freely associated GHD with a scene in a popular novel; and (5) a Weibo post that took the opportunity to persuade fugitives and potential criminals to stop committing crimes. These examples highlight how a successful public health campaign may draw attention from a variety of people, who may or may not interpret it in the way the organizers of the campaign initially envisioned.

DISCUSSION
We performed a qualitative content analysis of 552 Weibo posts generated on GHD 2012 by Weibo users who had 1000 or more followers. We identified various GHD-related themes and topics, including basic information about GHD; promotional events, multimedia and commercial advertisements; and health information such as prevalence of handwashing behaviour, the correct (2) rub palm to back of the hand with fi ngers interlaced, and then repeat after changing hand positions; (3) rub palm to palm with fi ngers interlaced; (4) bend fi ngers, rub the fi nger joints in the palm of the other hand; (5) clasp the thumb of the left hand with the right hand and rub in a rotational movement; (6) rub the fi nger tips in a closed position in the opposite palm in a circular motion. Literally "Tathāgata Palm". "Buddha's Palm" is a fictional martial arts move that appears in popular kungfu (martial arts) movies and wuxia (martial hero) novels.
adapted messages. They were then disseminated from the capital to the rest of China via China-based social media. The re-invention of the six steps of handwashing as the "Buddha's Palm", as found in the Weibo posts, is a good illustration. Further analyses on the contextualization of these promotional messages will inform public health professionals on how they can better contextualize health communication in today's digital age. 31 As the data were originally collected for a different study, 14 we did not define our operational sampling parameters to optimize collection of data pertaining to any specific health-related keywords. Our data set only comprised 350 000 Weibo users who had 1000 or more followers. Among these users, around 5000 were Chinese dissident writers, journalists and scholars; another 38 000 were users with an authenticated status having more than 10 000 followers. 14, 19 The study sample constituted less than 1% of all registered users of Sina Weibo. 13 Nonetheless, the study samples represent the most influential Weibo users who contributed the most content in Weibo. According to a random sampling study, 5% of Weibo accounts generate 80% of the original posts, and over 50% of Weibo accounts never post anything. 13 The Chinese keyword for handwashing may be combined with other Chinese characters to form other terms as demonstrated in two of the four peaks discussed in the Results section. Eighty-two (15%) of the 552 posts belonged to this category in which the Chinese characters for handwashing were part of a longer term; those posts were irrelevant to GHD. The positive predictive value was found to be about 85% for handwashing in this study.
A certain level of subjectivity cannot be avoided in our qualitative analysis. Nonetheless, our goal is to identify topics and themes that will facilitate future research in digital health communications and, in particular, handwashing promotion. Categories created in this paper can be adapted to code Weibo posts and Twitter tweets in future studies.
While handwashing Weibo posts might lead to increased awareness and practice of handwashing among its users, our analysis did not provide any direct evidence to support that. Obtaining such evidence requires surveys of knowledge, attitudes and perceptions of hand hygiene, 32,33 structured observation studies 34,35 posts about the survey on the prevalence of handwashing behaviour among Chinese urban residents, newspapers used Weibo to disseminate headlines and provide links to their newspaper articles (Table S6 in Online Supplementary Materials). Traditional media may report on contents that are originated on social media. 28 While our analysis suggested that social media were used by organizations as a means for health promotion, it did not provide evidence that social media had replaced traditional media in health communications.
Social media facilitate evaluation of health communications campaigns. In the past, health communications via mass media could be evaluated through surveys such as TV ratings. The dissemination process of Twitter or Weibo messages can also be documented and analysed now. The availability of social media data allows public health professionals to evaluate their health communication campaigns in a timely manner through both quantitative and qualitative analyses. By identifying the themes and topics of social media contents, health communication professionals may be able to focus their efforts on creating and disseminating contents that attract more attention. In the future, researchers can also investigate how photo and video links in Weibo posts may attract more attention and determine the characteristics of Weibo users who are more likely to repost health communication messages.
Social media in mainland China form a distinctive national market as there is only limited access to certain global social media (e.g. Facebook, Twitter and Youtube, etc.). China-based, Chinese-language social media such as Sina Weibo and Youku have attained phenomenal success in this unique environment. 29 However, their role in health communications in China has not yet attracted much scholarly attention. Future research that compares Weibo with Twitter, or Youku with Youtube, will further reveal the similarities and differences between these platforms and how health information disseminates and evolves in a distinctive national Internet user community. 28 Social media are lenses through which contextualization of global public health messages can be observed and documented. GHD as a global initiative relies on national and local partners to promote handwashing. Handwashing promotional messages that originated from international organizations were contextualized by the Chinese stakeholders into culturally and/or video surveillance 36 of handwashing behaviours in community settings. Furthermore, as with other social media, Weibo users are, in general, younger and more urban. 37 Reaching the rural poor, especially the elderly in China, as in any middle or low-income country, will require other creative means.
We performed a qualitative analysis of the content of Weibo posts about GHD 2012 to identify topics and themes of handwashing promotion in China. Our study showed that social media and traditional media are two interconnected arms of the GHD campaign in China. We documented the contextualization of global handwashing messages and their dissemination to audiences in a national social media market that is protected from international competition. Our analysis demonstrated that public health campaigns in China can be evaluated using social media data. 11 Our analysis serves as one step towards future comparative social media studies of global health promotion campaigns.

Conflicts of interest
None declared.

Funding
None.