Health Promotion Practice

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Harnessing Social Media for Health Promotion and Behavior Change

Holly Korda and Zena Itani
Health Promot Pract 2013 14: 15 originally published online 10 May 2011
DOI: 10.1177/1524839911405850

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405850 HPPXXX10.11
77/1524839911405850Korda, Itani / HARNESSING SOCIAL MEDIAHEALTH PROMO-
TION PRACTICE / Month XXXX

Articles

Harnessing Social Media for Health

Promotion and Behavior Change
Holly Korda, PhD, MA1
Zena Itani, MPH, CHES1

Rapid and innovative advances in participative Internet collaborative content sharing, referred to as “Web 2.0
communications, referred to as “social media,” offer social media,” include Internet-based social network-
opportunities for modifying health behavior. Social media ing services such as Facebook and MySpace, Twitter,
let users choose to be either anonymous or identified. wikis for collaborative content development, blogs, and
People of all demographics are adopting these tech- two-way mobile messaging platforms that connect peo-
nologies whether on their computers or through mobile ple through cell phones and personal digital assistants.
devices, and they are increasingly using these social Health promotion professionals have been quick to
media for health-related issues. Although social media recognize the potential of social media for reaching
have considerable potential as tools for health promo- broad audiences in social marketing campaigns and
tion and education, these media, like traditional health enabling and empowering consumers in their health
promotion media, require careful application and may and health care–related interactions (Thackeray, Neiger,
not always achieve their desired outcomes. This article Hanson, & McKenzie, 2008).
summarizes current evidence and understanding of using The widespread public engagement with social media
social media for health promotion. More important, it creates a ready platform for its application in the health
discusses the need for evaluating the effectiveness of field. At the end of 2008, 74% of U.S. adults went
various forms of social media and incorporating outcomes online, including men and women in nearly equal per-
research and theory in the design of health promotion centages; more than half of Whites, African Americans,
programs for social media. Hispanics, and individuals aged 65 years and older;
and individuals across the income spectrum (Fox &
Keywords: social media; behavior change; consumer Jones, 2009). A vast majority of those online adults are
health; health promotion; evaluation meth- searching for health information—80% in 2010, accord-
ods; program planning and evaluation; social ing to the Pew Internet and American Life Project (Fox,
marketing; mass media; health communica- 2011). Deloitte’s 2010 Survey of Health Care Consumers
tion; Internet; electronic interventions; tech- confirms this trend: More than half of consumers said
nology; behavior change theory; theory they looked online for health information, including
53% of seniors, 57% of Generation X (born between
approximately 1961 and 1981), and 56% of Generation
Y (born between 1982 and 2001). In fact, searching for

S
ocial media, known as the “participative Internet” health information is the most popular online activ-
(Jones & Fox, 2009), encompass a broad set of ity for adults after e-mail and using search engines
Internet-based communications, tools, and aids. (Fox, 2011).
These online communications offer easy, cost-effective
access to large numbers of people across geographic 1
Altarum Institute, Portland, ME, USA
distances. Technologies that expand interactivity and 2
Altarum Institute, Washington, DC, USA

Health Promotion Practice

January 2013 Vol. 14, No. 1  15­–23 Authors’ Note: The authors would like to thank the reviewers
DOI: 10.1177/1524839911405850 for their comments and suggestions and Mary Joscelyn, Altarum
© 2013 Society for Public Health Education Institute, for her assistance in preparing this article.

15

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 Studies of social media as a channel for health pro-
motion have been limited; however, evidence is growing
>>
Background
as interest in and experience with new media increase. Social media include a broad spectrum of online
Research now shows that some online communications communications tools and work through several mecha-
are effective at improving knowledge and understand- nisms. Social media can provide a channel for social
ing of specific health topics and that certain conceptual support and facilitate a sense of connectedness among
models and features are more likely than others to pro- individuals. These online tools let users share informa-
duce desired results (Bennett & Glasgow, 2009; Evers et al., tion that is consumer-centric and consumer controlled,
2003; Portnoy, Lori, Sheldon, Johnson, & Carey, 2008). enabling anonymity or personal connection as preferred,
Studies have also found that social media can success- and can be an inexpensive way to reach large audiences
fully encourage health improvement and behavior change over great distances. Perhaps most important, social
(Webb, Joseph, Yardley, & Michie, 2010). Some approaches media have become firmly established across sociode-
appear to be more effective than others in addressing mographic groups. All of these features make social
short- or long-term goals. media well suited and popular tools for health promo-
This article offers a synthesis of what works and tion. Table 1 describes different online tools and gives
what does not and how these emerging communication examples of their use in health promotion.
methods can be most effectively used for health promo- Web 2.0 is a term used to distinguish the current
tion and behavior change. We address the following: iteration of the Internet that is shaped by interactive,
user-generated, and user-controlled content and appli-
cations, from the original, more static Internet. Reports
• What types of social media are currently employed on Web 2.0 trends show widespread use of social media
for health promotion and education? tools and applications throughout the general popula-
• Who uses social media, and what types of social tion. Although online content sharing has been largely
media do they prefer for health information? an activity of younger users, adults are picking up the
• Which features of social media affect health knowl- pace: 30% of adult online users reported sharing con-
edge, behaviors, and outcomes? tent in 2009, compared with 38% of teens (Lenhart,
• What types of social media applications show most Purcell, Smith, & Zickuhr, 2010). Social networking
promise for health promotion and education, and sites are one of the most popular forms of social media,
how can we measure their effect and optimize their used by 35% of adult (18 years and older) Internet users
use? in the United States (Lenhart, 2009), including general
social networking sites, such as Facebook and MySpace,
>>
Method and health-specific sites that focus on health conditions
We conducted a broad environmental scan and and services. These direct-to-consumer sites encourage
reviews of evidence that included a search and review people to use online networks to discuss and ask about
of academic, peer-reviewed studies, systematic reviews, health and to find others with the same conditions at
and meta-analyses; white papers and reports from foun- the same stage of treatment.
dations, federal and state public health agencies, and
organizations involved with social media and health >>
What do we know
issues; and websites and online and print media from about what works?
public, private, and nonprofit organizations. Evidence
was drawn from several disciplines, reflecting social Social media are becoming preferred methods of
media’s increasing application in multiple fields. Studies health promotion as evidence builds showing their
of social media and Internet-based approaches to health effectiveness in reaching public audiences. But how
promotion and behavior change were identified in the effective are these approaches as tools for health pro-
fields of psychology and behavioral sciences, library and motion and public health education? What do we know
information sciences, health communications, and about what works and how best to use social media for
health education and promotion. Incon­sistent and inter- health promotion?
changeable use of terms and definitions for social media,
social networking, participative Internet, and web-based
Social Media Audiences and
interventions was common. In this review, we have
Health Information Preferences
attempted to define, describe, and reconcile these differ-
ences. The scan and research reviews also build on More than half of U.S. adults across all age and ethnic/
related work and experience of the study team. racial groups use the Internet to search for health

16 HEALTH PROMOTION PRACTICE / January 2013

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 TABLE 1
Social Media Tools for Health Promotion and Education

Tool Definition/Use Examples

Weblogs (blogs) Online journals where the author can write www2.mdanderson.org/cancerwise/
about any topic of interest, receive
comments, and share posts across
multiple platforms
Content syndication/ RSS feeds enable users to subscribe to and Health.com, mayoclinic.com, cancer.org
RSS feeds receive online text, video, and other
media updates
e-Games Interactive games played through the CDC.gov, healthgamesresearch.org (Robert
Internet, a video game console, or a Wood Johnson Foundation), and others
mobile phone have developed a variety of e-games
Message boards Synchronous and asynchronous platforms Everydayhealth.com, Healthboards.com
where users can post messages and (hosts more than 150 message boards)
questions and receive responses from
other users
Microblogs Length-restricted blogs Twitter and Twitter-specific applications,
Tumblr
Short message service Also known as texting, SMS can be sent and Text4baby
(SMS)/texting received by anyone with a mobile phone
Social networking sites: Vehicle for people to create online Facebook, MySpace, LinkedIn
general communities and allow users to add
friends, send messages and share content
Social networking sites: Health- and condition-specific sites allow dLife.com, stickK.com
health specific users to share information and
experiences with others online
Video file sharing Users create and upload video files for Youtube.com, health-related channels
sharing and commenting include youtube.com/
plannedparenthood.org
Widgets Widgets are web applications that display Cdc.gov, widgetbox.com
featured content from one site directly to
a user’s web page or another website
Wikis Allow multiple users to create and post Wikihealth.com, wikiph.org
content as a community

information (Fox, 2011). Social media were used to boomers, Generation X-ers, and those with chronic
obtain information about health and wellness by 34% conditions were more likely to participate in online
of online health information seekers in one study, wellness programs than younger, Generation Y con-
whereas Wikipedia and online forums and message sumers. Chou, Hunt, Beckjord, Moser, and Hesse (2009)
boards were reported as the most important individual reported generational differences in their study of
tools for adults (Elkin, 2008). General social network- online information preferences, which found that
ing services are secondary to these sources for adults younger groups were more likely to participate in
but are important information vehicles for the more social networking and blogging sites, regardless of
than 70% of adolescents and young adults online who health status.
use them, according to one Pew study (Lenhart, Purcell,
Smith, & Zickhur, 2010). Generational differences in social media use. Internet
Deloitte’s 2010 Survey of Health Care Consumers users’ information preferences and use of online tools
reports that older consumers including seniors, baby also differ by gender, race/ethnicity, education, and income

Korda, Itani / HARNESSING SOCIAL MEDIA 17

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 TABLE 2
Social Media Use by Audience Segment

Audience Social Media Use

Generation Y 14% of web users 18-29 years old downloaded podcasts in 2006 (Centers for Disease
(˜18-29 years) Control and Prevention [CDC], 2007)
  76% watch online video in 2007 (CDC, 2007)
  23% are interested in using a mobile device for accessing their personal health records
(Deloitte, 2010)
  56% say they look up treatment information online (Deloitte, 2010)
  As of 2010, 90% of this age-group own a cell phone, using them to send text messages, take
and send pictures, and access the Internet (Smith, 2010)
Generation X 57% watched online video in 2007 (CDC, 2007)
(˜30-49 years)  37% of cell phone users 30-49 years old sent text messages in 2006 (CDC, 2007)
  28.9% of 35- to 54-year-olds downloaded mobile applications in 2009 (Smith, 2010)
 
44% of 18- to 49-year-olds played computer or video games in 2006 (CDC, 2007)
 
22% are interested in using a mobile device for accessing their personal health records
 
online (Deloitte, 2010)
57% say they are interested in using the Internet to find treatment information (Deloitte,
2010)
Baby boomers 46% watched online video in 2007 (CDC, 2007)
(50-65 years)  13% of cell phone users 50-64 years old sent text messages in 2006 (CDC, 2007)
  12.1% of Internet users 55-69 years old downloaded apps in 2009 (CDC, 2007)
  25% of users >50 years played computer or video games in 2006 (CDC, 2007)
 
15% are interested in using a mobile device to access their personal health records online
 
(Deloitte, 2010)
55% say they use the Internet to find treatment information (Deloitte, 2010)
Seniors (>65 years) 39% watched online video in 2007 (CDC, 2007)
  8% of cell phone users >65 years sent text messages in 2006 (CDC, 2007)
  4.3% of seniors >70 years downloaded mobile applications in 2009 (Zogby, 2009)
  17% are interested in using a mobile device to access their personal health records
(Deloitte, 2010)
  53% say they use the Internet to find treatment information (Deloitte, 2010)

characteristics. For example, women are reportedly more Whites, noting that these differences are likely explained
likely than men to search for information about symp- by age.
toms, treatments, diseases and conditions, and medica-
tions; men are more likely than women to conduct topical
Using Social Media to Influence
searches about vitamins and supplements, health insur-
Health Knowledge, Behavior, and Outcomes
ance providers, and physicians; both m[[en and women
were equally likely to search for wellness-related topics; Evidence about social media’s impact on health
and men were more likely than women to use social knowledge, behavior, and outcomes shows these tools
media (Elkin, 2008). can be effective in meeting individual and population
Chou et al. (2009) found that people of any ethnic- health needs. Most research addresses specific inter-
ity, regardless of education level, used social net- ventions and approaches, which vary widely in focus,
working sites at a higher rate than all non-Hispanic target population, theoretical foundations, mode of

18 HEALTH PROMOTION PRACTICE / January 2013

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delivery, functionality, and usability. This variation patients may experience empowerment in decision
makes it difficult to find out what works and how, and making about their health through online learning, find-
it complicates efforts to compare approaches. ing they have increased confidence in asking questions
Studies of Internet-based interventions for weight of providers and information to help them manage their
loss, tobacco cessation, and physical activity were among conditions (Fleisher et al., 2002, as cited in Jacobson,
the first to identify positive effects and provide some 2007; Fox, Ward, & O’Rourke, 2005, as cited in Jacobson,
quantitative evidence of impact (Portnoy et al., 2008). 2007). However, this does not always translate to their
Meta-analyses have examined Internet-based interven- feeling empowered in the clinical encounter, for fear of
tions and tools and have found positive impacts of web- challenging the physician’s authority (Lupton, 1997, as
based interventions, although these studies have been cited in Jacobson, 2007).
limited in the populations and intervention types they
have studied. A meta-analysis by Murray, Burns, See Tai, Delivering the message. Social media can be custom-
Lai, and Nazareth (2005) of interactive health communi- ized and tailored to the needs and preferences of different
cation applications showed that they improved users’ audiences. Several themes about what works to optimize
knowledge, social supports, health behaviors and clinical messaging are beginning to emerge from early studies.
outcomes. Wantland, Portillo, Holzemer, and Slaughter’s Using tailored messaging, repurposing and applying
(2004) study of web-based and non-web-based interven- multiple complementary delivery modes to reinforce key
tions also showed positive impacts of online applica- themes, and encouraging users to engage with web-based
tions, although these were typically small improvements applications as well as with other users are among the
over non-web-based approaches. Further research is most promising. Webb et al. (2010) found that tailored
needed in these areas. text messages are highly effective to promote interaction
with the intervention, to send motivational messages
Use of behavioral change theory and techniques. (e.g., reminders of the benefits of exercise), to challenge
Behavioral change theories have proven important in dysfunctional beliefs, or to provide a cue to action. Use of
developing successful online health promotion activi- communicative functions, especially access to an advisor
ties. One of the most comprehensive investigations we to request advice, also tends to be effective, and personal
identified is a recent meta-analysis of 85 studies by contact via e-mail, online, or text message helps support
Webb et al. (2010) that found interventions that were behavior change. Similarly, Fry and Neff (2009) found
strongly based in theory had greater impact than those positive results from tailoring prompts through regular
that were not, and interventions that incorporated more contact with a counselor, especially when compared
behavior change techniques tended to have larger with groups not receiving personal contact.
effects than interventions that incorporated fewer tech- Repurposing content through cross-platform commu-
niques. These findings underscore the importance of nications strategies expands messaging opportunities at
using a validated theoretical framework as a road map the same time reinforcing messages through multiple
for program design and development. Still, many health channels. This long-established advertising approach
behavior change websites are not theory driven and fail has readily translated to social media as blogging,
to incorporate proven, evidence-based approaches. A “tweeting,” and posting on social networking sites such
study by Evers et al. (2003) found that of 37 public as LinkedIn.com and Facebook.com. Effectiveness stud-
health behavior change sites, few were theory driven or ies in this area are few, although anecdotal reports are
used evidence-based approaches. encouraging. As the number of sites and messaging
Feeling empowered in decision making about one’s channels expand, finding ways to engage users to visit,
health can play an important role supporting individu- participate in, and return to social media sites becomes
als as they seek positive health behavior and lifestyle more challenging. Sites that succeed tend to be highly
change. Several studies have shown that web-based dynamic and flexible and change content and approach
interventions had a significant positive effect on empow- often in order to stay entertaining and engaging. Developing
erment, although results are small. A recent review to active user communities is one way to keep content fresh
evaluate the effectiveness of web-based interventions in and interaction alive.
increasing patient empowerment compared with usual
care or face-to-face interventions found significant positive
Evaluating the Effects of Social Media
effects on empowerment as measured on self-efficacy
scales and mastery scales (Samoocha, Bruinvels, Elbers, Health promotion evaluations typically seek to
Anema, & van der Beek, 2010). Other studies show that understand who receives the intervention, what impact

Korda, Itani / HARNESSING SOCIAL MEDIA 19

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the messaging has (by audience subgroup), and what system and self-reports to collect information about
changes in health behavior and health outcomes can be website visits as an overall measure of use and page-
attributed to the intervention. Many health promotion specific hits to obtain information about content-specific
professionals are questioning the cost and comparative use. Measurements were recorded within each of six
effectiveness of social media approaches. This informa- 4-month follow-up intervals. Geocoding software let
tion is crucial when assessing tradeoffs of one social the researchers determine distance from the main inter-
media tool versus another. vention site, hypothesized to be related to participants’
choice of in-person or online sessions, using partici-
Evaluation framework and metrics. Analytic frame-
pants’ reported zip codes. The study used clinical health
works for evaluation of online health promotion are in
measures, in-person interviews, and focus groups to
their early stages. Many researchers adapt established,
validate data across sources.
proven approaches used in traditional health promotion
efforts (Glasgow, 2007; O’Grady et al., 2009). Kaiser Evaluation design and methods. The design and meth-
Permanente researcher Russell Glasgow (2007) recom- ods used to evaluate health promotion interventions are
mends the 1999 RE-AIM framework for evaluating similar for programs delivered through social media
population-based impacts of online health promotion and those delivered through more conventional media
interventions and behavior change programs. The and outreach. The main differences lie with study design
framework addresses Reach (participation rate and rep- and execution using Web 2.0 technologies rather than
resentativeness of participants), Effectiveness (on primary conventional paper and pencil and in-person tools and
outcomes and quality-of-life/negative consequences), with difficulties in designing and maintaining study rigor.
Adoption (participation rate and representativeness These issues emerge as evaluators consider design issues
among settings and staff-implementing program), Imple­ such as whether an experimental or quasi-experimental
mentation (consistency of program delivery), and Mainte­ design will be used, how study participants will be recruited
nance (sustainability at patient and setting levels). This or randomized, how survey design can yield best response
framework has been used “to translate research into prac- rates, and how to control for the influence of other inter-
tice and to help plan programs and improve their chances ventions and confounding factors that might affect study
of working in ‘real-world’ settings” and incorporates results. Attrition, when participants stop usage or are
the formative, summative, and outcome components of lost to follow-up, has also been identified as a funda-
traditional evaluation frameworks (RE-AIM, 1999). mental issue for evaluation of online interventions
Selecting and applying appropriate metrics present (Eysenbach, 2005).
additional hurdles for evaluating health promotion Experimental and quasi-experimental designs can be
interventions that use social media. Most forms of social difficult to implement because randomization to the
media—blogging, social networking sites, and others— intervention—critical to avoid selection bias—and even
are not designed with evaluation or assessment in mind, recruitment of participants, is extremely difficult. Dansky,
challenging evaluators to use basic analytics generated Thompson, and Sanner (2006) note that mailings to pro-
by the sites themselves. Google Analytics and other viders, community organizations, and other gatekeepers
free-to-the-public sites are widely used to provide infor- or radio or other traditional media are often used to meet
mation on items including number of hits, time spent recruitment goals. However, because by design many social
on a page, audience location, and more, although these media tools allow consumers anonymous access and use,
approaches are not always appropriate evaluation tools. follow-up and linkage are often not viable.
To address these limitations O’Grady et al. (2009) pro- Identification of effects of specific interventions also
pose a novel evaluation framework for evaluating inter- presents problems because social media is often used
active media that ties together five dimensions: people, as one of several health promotion tools. For example,
content, technology, computer-mediated interaction, consumers often use health information websites as an
and health systems integration. This framework incor- adjunct to visits with their provider, sharing informa-
porates criteria such as interactivity, platforms/portability, tion with friends and family or using other social or
users’ e-health literacy, and use of open-source technol- traditional media outlets, making it difficult to deter-
ogy to capture the social, interactive nature of collabora- mine the relative influence of each.
tive, adaptive, and interactive technology.
Putting evaluation frameworks into action requires
objective measures, for both qualitative and quantita-
>>
Discussion
tive assessment. DeBar et al.’s (2009) study of website Much of what works using social media for health
use and behavioral outcomes used an automated tracking promotion can be found in the theories and approaches

20 HEALTH PROMOTION PRACTICE / January 2013

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used for traditional health promotion program design, incentives such as web badges for bloggers to post
implementation, and evaluation. Understanding target online and encouraging viewers to post photos of
audiences and their information preferences, develop- themselves wearing a red ribbon on their social net-
ing tailored messaging for different audience segments, work profiles and blogs improved participation
basing program design and evaluation on theories of and increased user-generated content (Anderson &
social-behavioral change, and defining process and out- Gomez, 2009).
come measures to assess intervention impacts, interme- Multipronged strategies: Repurposing and using several
diate outcomes, and health status outcomes are priorities tools as complementary approaches can reinforce
for all health promotion initiatives. and increase the impact of messages. The World
AIDS Day campaign found that an integrated Web
Health promotion interventions delivered online
2.0 approach using social network services, blogs,
and through traditional field-based approaches are
Twitter, and free content was effective in expanding
challenged to understand the most effective strategies
audience “reach,” as did continuing the outreach
for changing behaviors. Recent meta-analyses help iden- beyond World AIDS Day (Anderson & Gomez, 2009).
tify features common to successful strategies. Developing Theory-based interventions: Although there is consid-
and adapting frameworks for program design and met- erable variation in the efficacy of individual inter-
rics to guide health promotion using social media also ventions, evidence shows that those developed and
challenge practitioners to consider how to meld novel guided by theories of social and behavioral change
Web 2.0 approaches and health promotion goals and are more effective at promoting desired change than
objectives effectively. efforts that are not theory based (Webb et al., 2010).
Several key themes and implications for using social Theoretical models of behavior change, such as the
media for health promotion emerge from this review. widely used health belief model, the transtheoretical
model, social cognitive theory, or others, help advance
intervention efficacy for both social media and tradi-
Audiences, messaging, and approaches: Experience tional health promotion approaches.
with Web 2.0 suggests that audience targeting must Evaluation to frame and measure change: Evaluation is
consider demographic profiles of users together with important for monitoring, tracking, and providing
their preferences for type of content and preferred formative input for Web 2.0 interventions. The
technologies or tools. Message development should health promotion field offers a rich base of proven
account for user characteristics, information prefer- frameworks to guide evaluation of field-based inter-
ences, and mode or type of social media. Several ventions, and these frameworks can often be adapted
sources of information are available to guide these to evaluate online activities (Glasgow, 2007). New
decisions, including the periodic surveys conducted models that directly address the applications and
by the Pew Internet & American Life Project. Custom­ technologies of Internet-based interventions are
izing messages through iterative processes as indi- refining their approaches to incorporate assessment
vidual users interact with the social media tools and of specific Web 2.0 features (O’Grady et al., 2009).
interventions helps to sustain participation. Stages Metrics: Online health promotion applications generate
of change proposed by the transtheoretical model many of their own metrics as users approach and
may also prove helpful in targeting messaging to interact with the intervention. These metrics docu-
audience needs. ment website visitors, impressions and page views,
Trends, transactions, and tools: Staying on top of the time spent on specific activities, and more and can
trends that shape and target social media is essential provide valuable information about reach and usabil-
to effective use of these tools and technologies. New ity. Social media applications that build in activities
technologies and tools are introduced and adopted that can track and be tracked are most successful at
at a rapid pace as older approaches shift popularity measuring intervention effects, such as recent public
with users. Blogging, for example, was popular among education interventions seeking to improve knowl-
teens as recently as 5 years ago, but current partici- edge and willingness to register as an organ donor.
pation rates have dropped whereas older users are Scaling for broader impact: Much of the research about
increasing their use (Lenhart et al., 2010). the efficacy of social media applications for health
User-generated content: Health promotion activities promotion reviewed here is based on studies applied
that use social media can encourage users to gener- to participants in wellness promotion and disease
ate and share content. This engagement is key to management programs in health plans and work
successful social media outreach. Monitoring con- sites. Some larger scale interventions at the commu-
tent posted during its Facing AIDS Campaign for nity and national levels have also been imple-
World AIDS Day 2008, AIDS.gov found that providing mented. Evaluation of these interventions shows

Korda, Itani / HARNESSING SOCIAL MEDIA 21

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 mixed results, but specific applications have dem- messaging. Social media has proven potential for
onstrated great promise and effect (Webb et al., 2010). health promotion and behavior change. Now we need
Little is known about whether and to what extent to know: more of what, for whom, how much, and at
these applications can be transferred and replicated what price.
to truly leverage the power of social media.

References
>>
Conclusion: Leveraging Social
Anderson, J., & Gomez, M. (2009, August). From Flickr to a blog-
Media to Advance Public Health ging call to action: User generated content lessons learned from
AIDS.gov. Presentation at the CDC National Conference on Health
This review summarizes current evidence and
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