Saudi Diabetic Patients’ Beliefs and Experiences with Health Related Information from Social Media

Introduction: Social media and acceptance of the information related to health is becoming acceptable to an extent for the public. The use of social media is rapidly growing and it is being used both by healthcare professionals and patients. The aim of this study was to evaluate the use of social networking applications for experience and behaviour towards health information among diabetic patients. 
Materials and Methods: The present study was a cross sectional study, conducted in spring of 2020 (April to May). The distribution of the survey questionnaire was done online through various social media platforms with a convenience sample of people with diabetes (n=569), Eligibility criteria were aged 18 and above, Saudis with diagnosis of diabetes and willing to give consent were included in the study. Exclusion criteria were less than 18 years old and non-Saudis and non-diabetic. 
Results: Analysis of online survey data indicated that WhatsApp (89.1%) was the most commonly used social network followed by Snapchat (66.3%), Instagram (40.6%), Twitter (35%), Telegram (19.5%), Tiktok (12.5%) and Facebook (10%). About 25 (4.4%) participants strongly agreed that health information from social media impact life positively. More than half 290(51%) participants agreed to apply information only from the trusted websites. Near about half 275(48.3%) disagreed that social media could invent treatment for diabetes more than believing in health institution and medicinal industries. Nearly one-fourth 141(24.8%) of participants agreed that all health information from social media is right. Almost 264 (46.4%) said that they sometimes face health information in social media. Nearly 265(46.6%) patients mentioned that they never applied themselves any information claiming treating diabetes. 
Conclusion: This study shows the effect of social media on diabetic patients and various responses of diabetic patients in regard of their beliefs and experience towards health information from social media. Most of the respondents agreed that they apply information obtained from social network and the same could lead to some deleterious effects on health.


INTRODUCTION
Diabetes mellitus is one of the most common chronic diseases in the whole world, especially in the Middle East [1]. According to International Diabetes Federation (IDF), Saudi Arabia ranks fourth in the prevalence of diabetes in the Middle East and North Africa (MENA) [2].
Diabetes can be classified into the following general categories: Type 1 diabetes (due to βcell destruction in pancreas, usually leading to absolute insulin deficiency) and Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) [3].
Many factors can cause diabetes mellitus like: Family history, Physical inactivity, High blood pressure, most of the causal factors are related to behavioural change, for example eating habits and exercise namely [4].
Approximately 463 million adults (20-79 years) will be diabetics by 2045 and this will rise to 700 million. In 2019, approximately 54.8 million adults aged 20-79years, or 12.8% of the MENA population (Middle East and North Africa) in this age group, have diabetes. Diabetes and its complications were mainly responsible for an estimated 418,900 deaths among adults aged -years audi rabia as cases in 2019. Diabetes caused at least USD 760 billion dollars in health expenditure in 2019 which is 10% of total spending on adults [4].
In 2019, diabetes-related health expenditure in the MENA Region totalled USD 24.9 billion and expected to increase by 30.3% to USD 32.5 billion by 2030. It is estimated that more than 1.1 million children and adolescents are living with type 1 diabetes. Also more than 20 million live births (1 in 6 births) are affected by diabetes during pregnancy and around 374 million people are at increased risk of developing type 2 diabetes [4].
The use of social media such as YouTube, Twitter and Facebook are rapidly growing.
Facebook alone has over 800 million active users [5]. People are using online resources for health purposes for example seeking advice, connecting with individuals with the same experiences, sharing questions and concerns about treatment options, or understanding professional diagnoses.
With the wide spread use of the Internet and its relatively inexpensive bandwidth, social media, and specifically social net-working sites, are beginning to be more utilized by both healthcare professionals and patients [6].
Social networking can be useful in many areas and play an important role in sharing information and knowledge. It can be used in managing chronic diseases like diabetes when there is an immediate need to raise awareness of various behavioural aspects of healthy diet, physical exercise and knowledge of self-management [6]. People can be educated and their awareness levels can be increased through information sharing and discussions via mobile social media applications, which are very convenient and easy to use. This can rapidly decrease healthcare expenditures in managing such chronic diseases and help people to self-manage their disease effectively [7].
Since the data regarding the same in paucity in Saudi Arabia Region which could explore the potential benefits and harms of the social networking platforms, hence the aim of this study was to evaluate the use of social networking applications for the experiences, behaviour of Saudi diabetic patients toward health information from social media; overuse of social media and wide spread of health information including fake or misleading material.

MATERIALS AND METHODS
Information regarding diabetes mellitus was collected through online survey. As part of the survey, participants were asked to answer questions broadly classified as: demographic information; educational level; the social media platforms used; to what extent diabetes is controlled; they believe in the importance of social media; How many times did you apply it on yourself the information claiming treating diabetes; Participation was anonymous and inclusion criteria required patients to be at least 18 years old and to be Saudis and diabetics. An exclusion criterion is less than 18 years old, non-Saudis and non-diabetics. No compensation was offered for participation. The study was approved by the Institutional Review Boards of the participating institutions. Firstly, we did a pilot study on 10 patients, then after validation the link of survey was distributed in Arabic language through the various social media platforms: Tiktok, Instagram, Snapchat, Telegram, WhatsApp, Twitter, Facebook among Saudi participants. We also asked about clarity of the questionnaire and nobody reported any problem in the language and the content. Secondly, participants had to agree that they are Saudis, diabetics and willingly agree to fill the survey then redirected to the survey, if answer were No the survey will closed automatically.

Statistical Analysis
All the responses were coded and entered into the statistical package for social sciences SPSS (IBM-SPSS version 25, Armonk, NY) and analysis was performed. A descriptive statistics of frequency distribution and percentages were calculated for the characteristics of the study participants. Chi-Square test was applied to know relationship between use of social media application and demographic factors and diabetic type. A p value below (p<0.05) was considered significant for all the statistical purposes.

RESULTS
A total of 569 diabetic patients responded to the questionnaire items. More than one fourth of the patients were aged 45-54 years. More than half 326 (57.3%) of the participants were females while 243 (42.7%) males responded to the questionnaires. High percentage 188 (33%) of the participants had university level of education. Majority of the participants were having type 2 diabetes 344 (60.5%), followed by type 1 diabetes 207(36.4%) and gestational diabetes 18(3.2%). Most of the patients fairly 380 (66.8%) controlled their diabetic condition, as shown in (Table 1).

Fig. 2. Belief of study participants in importance of social media in health information
Use of diabetic information among the study participants is displayed in ( About 34.3% of the participants believed that the social media is very important in day to day life, while 31.8% believed that the social medial is very important in sharing health information (Fig.  2).
Nearly one-fourth 141(24.8%) of the participants agreed that all Health information from social media is right. Only 16 (2.8%) strongly agreed to believe in any information claiming treating diabetes. Only 14(2.5%) patients strongly agreed to information claiming treating diabetes was religious. About 25 (4.4%) participants strongly agreed that health information from social media impact life positively. More than half 290(51%) participants agreed to apply information only from the trusted websites. Near about half 275(48.3%) disagreed that social media could come up with treating for diabetes more than believing in health institution and medicine companies. Almost 66 (11.6%) strongly agreed to travel to other country claiming treatment for diabetes. The attitude towards health information and diabetic treatment are displayed in (Table 3) 1%), primary (7.3%) and no formal educational (6.9%) categories, and the difference was statistically significant (p<0.001). On the contrary, diabetic type did not show any significant differences in use of Twitter (p=0.592).
When enquired about the use of Facebook between male and female diabetic patients, significantly higher male (15.6%) patients tend to use Facebook compared to the female patients (5.8%) (p<0.001). While type 1 diabetic (6.8%), type 2 diabetic (12.5%) and none of the gestational diabetic used the Facebook. The use of Facebook across different diabetic types showed statistically significant difference (p=0.034). However, age groups (p=0.101) and educational categories (p=0.118) of the study subjects did not show any significant difference in use of Facebook. Relation between social media and demographic factor is displayed in (Table 4).

DISCUSSION
Health information importance from social media is significant in Saudi community as the study depicts. The overall participants believed in importance of the social media and specifically here health information from social media which assure that social platforms are highly effective in delivering health messages and also indeed carrying a risk of misleading or fake information. Overall 65.3% of participants have either secondary or university education level which reflects that education level is impacting patients in positive way when using social media and is same according to the study reported by Alanzi, T et al. [8]. When participants asked about their beliefs in any information claiming to be treating diabetes, a small number of them agreed to believe any information in this regard but oppositely when they asked about travelling to particular country based on the claiming information the percentage of agreed on that and is significantly higher and the results were in concordance according the study done by Shaw R.J et al. [9]. Because of the religious background of Saudi society, they were asked about extent of belief in claiming information for treating if the introducer of it was a religious person, so approximately half of the patients either strongly agreed or agreed or neutral which gives a hint that using religion for delivering health information impacts patients in a way cannot be ignored, the results shown by AlQarni was in favour of the present study [10]. 72% of participants either rarely or never used social media to communicate with their health providers although they overall agree on the importance of the health information from social media, which raises a question of origin of this gap between patients and health care providers, the study was in accordance to the study done by Alanzi, T et al. [11]. Moreover it was also seen that, based on the available information the finding could be because of defects in methods of health care providers to reach and contact their patients on social media, the study done Nelakurthi A.R et al showed different results and were not in agreement with the present study [12]. More than 1 quarter of participants either always or often or sometimes apply on themselves that kind of information claiming treating DM which might predicts reason of occurring some complication DM patients especially if they were asked to stop their medication as advised by the alleged information, again the study results were not in concordance with the study and review done by Abedin, T et al and Chhabra KG et al. [13,14].
In the present research, the authors agreed with Mohammadi, H et al. [15] in using WhatsApp as an effective tool to improve diabetes knowledge and self-efficacy moreover because its heist usage among other social platforms.
Moreover, our finding matches the point mentioned in Fergie, G et al. [16] that higher number of posters targeting diabetic patients was between 40-60 years of age. In the present study, we recommend organized channels through social media between health care providers and patients. In a systematic review done by Abdelaziz Elnagga et al shown that use of internet was promising among diabetic patients [17].
Authors have reported that, raising the awareness toward alleged information in treating DM and Advise them to get the health information from health organization like ministry of health and official accounts for example such that found on twitter and find out reason of the gap between health care provider and patients in addition in social media. Another area for future research is on patients, and especially applying the alleged information claiming treating diabetes mellitus and specific its impact on complication on their health.

CONCLUSION
From the present it can be concluded that using health information through social media is very important as the study mentioned. Most of the participants received information from the social media about diabetes but not many applied to relieve the symptoms of the same. WhatsApp was the most common social media platform utilized by the participants to get the information. Most educated class in any age group uses more of sanpchat and Twitter. Males used more of facebook as compared to females. The risk of getting complication from believing information claiming treating DM was very much high. There is a clear gap in communication between patients and health care provider through social media.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard respondents' written consent as been collected and preserved by the author(s).

ETHICAL APPROVAL
It is not applicable.

All Health information from social media is right?
Strongly agree Agree Neither agrees nor disagrees Disagree Strongly disagree

Do you believe in any information claiming treating diabetes?
Strongly approve Approve Neutral Disapprove Strongly disapprove 12. How many times did you apply on yourself that information claiming treating diabetes?

Always
Often Sometimes Rarely Never

How many times you forward to others any information claiming treating diabetes?
Always Often Sometimes Rarely Never

Do you feel more convinced if the introducer of that information claiming treating diabetes was religious?
Strongly approve Approve Neutral Disapprove Strongly disapprove