Journal of Social Marketing

Applying the dialogic theory to social networking sites: Examining how university health
centers convey health messages on Facebook
Richard D. Waters Rachel R. Canfield Jenny M. Foster Eva E. Hardy
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Richard D. Waters Rachel R. Canfield Jenny M. Foster Eva E. Hardy, (2011),"Applying the dialogic theory
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University health
Applying the dialogic theory centers on
to social networking sites Facebook
Examining how university health centers
convey health messages on Facebook 211
Richard D. Waters
School of Business and Professional Studies, University of San Francisco,
San Francisco, California, USA, and
Rachel R. Canfield, Jenny M. Foster and Eva E. Hardy
Downloaded by University of Queensland At 07:48 26 April 2016 (PT)

Department of Communication, College of Humanities and Social Sciences,

North Carolina State University, Raleigh, North Carolina, USA

Abstract
Purpose – The purpose of this paper is to examine how US universities’ health centers are using
dialogue and engagement on social networking sites to educate students and their followers about
health issues.
Design/methodology/approach – Through a content analysis of health centers’ Facebook profiles,
the research team examines the use of Kent and Taylor’s dialogic principles of communication.
Findings – Results indicate that when a health center attracts a large number of followers online,
their usage of the outlet as a dialogic tool increases significantly.
Practical implications – The study found that university health centers have a presence on
Facebook, but they really are not using the site strategically to gain followers and educate them about
health issues that they have pledged to address on their campuses.
Originality/value – The dialogic principles of communication have been examined significantly on
web sites and blogs, but this is one of the first studies to test them in the social networking site
environment.
Keywords United States of America, Social networking sites, Community health centres, Universities,
Internet, Dialogic theory, Health communication, Facebook
Paper type Research paper

Introduction
The rise of web technologies has dramatically impacted a number of fields, and health
communication is no exception. Research over the past several years has demonstrated
the prevalence of online health information-seeking behaviours (Fox, 2005; Suggs and
McIntyre, 2009) among the general population. In addition, researchers have detailed
the even more far-reaching use of online communication for health information,
specifically those age 18-24 (Chou et al., 2009). As a result, universities have been
increasingly turning to online channels to communicate to an array of publics. While
much of the scholarly research on universities’ use of online communication has been
focused on the recruitment of prospective students, valuable insights can be gathered Journal of Social Marketing
Vol. 1 No. 3, 2011
from examining how universities communicate with their current students. pp. 211-227
One important, yet often undervalued, aspect of the university community is q Emerald Group Publishing Limited
2042-6763
the health centre. From healthy living strategies to pandemics to alcohol abuse, DOI 10.1108/20426761111170713
 JSOCM university health centres have a number of public health messages they must
1,3 communicate to students to ensure the health and well-being of the entire campus. Given
the significant amount of time students spend using social media (Lenhart et al., 2007),
various university departments have started using these channels to communicate with
students. This study investigates how university health centres use a popular social
networking site, Facebook, in communicating with their publics using Kent and
212 Taylor’s (1998) dialogic principles as its theoretical framework.

Literature review
Online health communication
In recent years, health communication has become a major focus in the discipline of
communication. Understanding how consumers perceive and discuss health matters
greatly enhances how for-profit, nonprofit, and government entities can educate and
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treat the citizenry. While Springston and Lariscy (2003) note that profit can be an
underlying motive for the creation of strong health communication campaigns,
nonprofits and government agencies are more likely to use health messages as a means
of reducing widespread illness and education (Relman, 2009). As an extension of the
university, it is important that university health centres find effective methods of
connecting with their publics.
Increasingly, the internet is proving to be an outlet that individuals from a wide
range of ages turn to for health information. In a nationwide, randomly sampled survey
of 4,300 individuals found that nearly 75 per cent of the public used the internet to
research health topics and nearly one-third of those surveyed made health decisions
based on information learned online (Baker et al., 2003). A significant number of
individuals, however, remain sceptical about internet-based health messages. Research
has shown that individuals often question the accuracy of the information shared
online and the credibility of those discussing healthcare topics since they often are not
the individual’s healthcare provider (Bernhardt et al., 2002; Eastin, 2001).
Cline and Haynes (2001) found that the principal concern for consumers was the
amount of misinformation on frequently visited healthcare web sites. They concluded
that respected medical organizations must take a more proactive step into virtual
communication to establish trusted online resources for health information. Specific
strategies that were offered as possibilities to reduce consumer concern included e-mail
exchanges between a doctor and patient, question-and-answer blogs, and online
messaging through message-relay programs. These suggestions bring together the
ability to reach large numbers with a mass-mediated approach and interpersonal
communication strategies to have more meaningful conversations on health topics.
A growing body of research focuses on online methods of communicating health
information to publics (Fox, 2005; Suggs and McIntyre, 2009). Robinson et al. (1998)
support the use of interactive online approaches to health communication citing their
great potential benefits, including providing more tailored messages to target
populations and increasing anonymity and access to support from others facing
similar health issues.
Overwhelmingly, consumers favoured sources that offer elements of interactivity
(Cassell et al., 1998). Whether an individual is seeking to educate themselves on a
specific topic to make a health decision or to receive social support or whether an
organization is seeking to promote healthy behaviours or discuss the delivery
 of health services, interactivity has been one of the principal methods of keeping University health
individuals’ attention (Suggs, 2006). Virtual brochure web sites that used one-way centers on
communication to present health topics were more likely to be discredited by
consumers because they did not perceive the organizations sponsoring the web sites to Facebook
be responsive to individual health matters (Freeman and Spyridakis, 2004).
As message delivery has shifted from the static delivery of information with Web 1.0
technologies to more dynamic message exchanges with Web 2.0 technologies, 213
organizations are finding that using existing social networks can reap better outcomes
rather than dedicating significant organizational resources to revamping their own web
sites (Thackery et al., 2008). By using social media, nonprofit organizations and
government agencies have seen increased participation in specific campaigns because
they were able to tap into social networks that their target audiences were already using
(Maibach et al., 2007). Eysenbach (2008) suggested that more physicians, community
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clinics, and agencies explore social media outlets for their awareness and education
campaigns because of the ease with which information is shared in the social media
realm and because consumers and patients are often more open in asking health-related
questions with a level of anonymity before going to their personal physicians.
Video-sharing sites, such as YouTube, are the most often used social media sites for
health communication campaigns; however, Abroms et al. (2008) caution that the
dominance of this tactic was due to the one-way broadcasting of public service
announcements and entertaining healthcare commercials. When looking at the truly
interactive forms of social media (e.g. blogging, Twitter, and social networking sites),
most organizations had created specific accounts on social networking sites to get their
messages out to their publics. Specifically, Facebook was preferred over MySpace
(Abroms et al., 2008). Scholars and practitioners have suggested using social networking
sites, specifically Facebook, because of its ability to attract large number of internet
users, particularly college-aged users (Chou et al., 2009). This recognition of the
importance of social networking sites underscores its potential as an important outlet
for university health centres.
Facebook (2010) is home to more than 400 million active users and is the second
most-trafficked PHP site in the world. With the average user spending 55 minutes a
day on the site, social networking sites like Facebook have become an area of interest
for communication scholars.
Early research on social networking sites focuses on user motivation and uses and
gratifications. Urista et al. (2008) found students were most likely to use social
networking sites because they provide efficient and convenient communication,
are curious about others, seek popularity, and for relationship maintenance and
reinforcement. Additionally, students have been shown to invest time and energy into
building these relationships around shared interests and communities (Maloney, 2007).
Madge et al. (2009) found that Facebook was used most frequently to keep track of
community events, most notably even those that were not social in nature but focused
on the university community.
As Facebook was developed to help students communicate with one another and
emerged as an electronic competitor to the printed college yearbook, it has been found
to be a useful tool for getting information to students (Selwyn, 2008). In one study,
84 per cent of respondents reported that Facebook was part of their everyday routine
(Madge et al., 2009). Greenhow and Reifman (2009) suggest that social media are more
 JSOCM adept at generating conversations among college-age students than other forms of
1,3 online communities. Selwyn (2008) concluded that organizations must learn to use
social networking sites as part of their communication campaigns because “traditional
methods of communication are not always contiguous with student modes of
communication and information gathering” (Selwyn, 2008, p. 163).
As a result, universities must recognize the potential of engaging students on social
214 networking sites. Xia (2009) found that Facebook served as an effective platform to market
university services to students. A similar study indicated creating events and engaging
Facebook groups were specific strategies to stay connected to students (Breeding, 2007).
While some preliminary research has been done on university engagement on
Facebook, most of the work has been done by the library science discipline. Research needs
to be done in other domains, such as university health centres and colleges/departments,
to strengthen the understanding of how colleges and universities use Facebook to connect
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with their publics. Kent and Taylor’s (1998) dialogic theory provides a solid basis for
examining an organization’s interactive nature in the social media realm.

Dialogic theory
Over the past decade, the field of public relations has seen a theoretical shift, from a
one-way approach of managing communication to an emphasis on relationship
building through dialogue. As the dialogic approach to public relations has gained
traction in the field, so has the use of the internet as a means of communicating with
publics. From web sites to social networking pages, organizations have a range of
opportunities to connect with publics.
Kent and Taylor (1998) established a framework of five principles to examine
organizational use of dialogue on web sites. This framework has since been applied to a
variety of organizational web sites, including both universities (Gordon and Berhow, 2009)
and community colleges (McAllister-Spooner, 2008). To achieve dialogue with publics
online, Kent and Taylor (1998) provide five principles that can guide organizations.
Creation of dialogic loop. Organizations should create a dialogic loop as a means of
feedback for publics. Interaction is a necessity in the loop, allowing publics to ask
questions and the organization to respond. To effectively employ this principle, a trained
organizational member needs to be available to close the loop. The ability to create a
dialogic loop has been met with some difficulty, as evidenced in both Taylor et al. (2001)
study on activist web sites and Taylor and Kent’s (2004) study on congressional
web sites.
Usefulness of information. Organizations should provide useful information,
including necessary general information that will appeal to all publics. In providing this
information, the issues of hierarchy and structure should be considered. Community
colleges have proved successful in presenting their publics with useful information on
their web sites (McAllister-Greve, 2005).
Generation of return visits. Organizations should generate return visitors by
providing a visually appealing and dynamic web site. This may prove to be the most
difficult principle to effectively implement on web sites, blogs or social networking
sites, as a number of studies have demonstrated low scores on this principle
(McAllister-Greve, 2005; Seltzer and Mitrook, 2007).
Ease and intuitiveness of use/interface. Organizations should ensure ease and
intuitiveness of interface. Publics need to be able to navigate the site easily, without
 slow graphic features or disorganized information. A variety of organizations have University health
been able to implement this dialogic principle across online, including community centers on
colleges on their web sites (McAllister-Greve, 2005) and activist and watchdog blogs
(Seltzer and Mitrook, 2007). Facebook
Conservation of visitors. Organizations should conserve visitors by limiting
unnecessary links outside of the site and providing clear paths back. While some
organizations met this challenge with ease, like activist and watchdog groups (Seltzer 215
and Mitrook, 2007), others, such as community colleges failed to fulfil this principle,
despite scoring high on other dialogic principles (McAllister-Greve, 2005). In a recent
study, Rybalko and Seltzer (2010) found that conservation of visitors was one of the chief
dialogic principles that organizations used on Twitter. Practitioners realized that by
referring Twitter users to other information provided by the organization rather than
linking to external information provided more time for a relationship to develop with the
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organization.
In the context of student recruitment in higher education, similar findings have been
revealed. Although universities excelled in providing accessible information, they
generally failed to create a dynamic, interactive web environment (Gordon and Berhow,
2009; McAllister-Spooner, 2008). These studies found that smaller liberal arts colleges
were more likely to feature dialogic web features and that there was a statistically
significant correlation between the incorporation of dialogic principles and offline
behaviour, such as student retention and alumni giving (Gordon and Berhow, 2009).
McAllister-Spooner (2008) found that students had neither a positive nor negative
reaction to most college web sites; however, they had increased negative reactions when
the sites lacked dialogic loop elements. In a ten-year review of dialogic internet
principles, McAllister-Spooner (2009) concluded that organizations, regardless of type,
do not effectively utilize all five dialogic principles on their web sites. Additionally,
global research has shown that most web sites do not fully employ dialogic features,
regardless of their region (Kim et al., 2010).
On social networking sites specifically, the dialogic communication potential has
also been supported (Sweetser and Lariscy, 2008; Bortree and Seltzer, 2009). However,
like previous studies on web sites and blogs, the usage of the dialogic principles still
falls short. Bortree and Seltzer (2009) found that advocacy organizations thought that
simply creating social networking profiles was enough engagement in dialogic
communication. Hickerson and Thompson (2009) have applied the dialogic principles
to health wikis and found that users were more likely to be committed to future
participation when wikis used dialogic content.
Based on this past research and the continuous development of interactive online
technologies, there is a need for ongoing research on the use of dialogic internet
strategies. This study will investigate the extent to which university health centres utilize
the dialogic principles on Facebook profiles by exploring the following research question:
RQ1. To what extent do university health centres employ the dialogic principles on
their Facebook pages?
Despite the overall finding that nonprofit advocacy organizations were not engaging in
dialogue on their Facebook pages, Bortree and Seltzer (2009) found a strong
relationship was found between use of dialogic strategy and positive dialogic
outcomes, such as network activity and growth. For this reason, a second research
 JSOCM question was created to examine potential differences in terms of adoption of the
1,3 dialogic principles based on size differences in the organization’s Facebook network:
RQ2. How does the use of the dialogic principles on university health centres’
Facebook pages differ based on their number of friends, fans or members?
Finally, a RQ3 was created to address the types of messages that were communicated
216 by the university health centres. For 2010, the American College Health Association
established 11 priorities to guide university health centres in their efforts. These
priorities include, social and emotional health, coping with stress, psychological
relationship with food, sexual health, nutrition, health service costs, insurance
availability, tobacco usage, substance abuse, immunization, and general health and
hygiene. As Facebook becomes a more primary method of communication between
university health centres and their publics, the final research question explores the
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content presented on Facebook profiles, specifically regarding the ACHA’s priorities:

RQ3. To what extent are university health centres discussing the American College
Health Association’s 2010 health priorities on their Facebook pages?

Method
To determine how university health centres were incorporating dialogic principles on
Facebook, a content analysis of university health centre profiles was conducted. To select
the sample, a census had to be conducted to determine which universities had health
centres with Facebook profiles. The universities that were examined were those listed on
the Carnegie Foundation for the Advancement of Teaching’s list of doctoral/research
universities (University of Washington, 2007). To determine whether the 157 universities
on the Carnegie Foundation’s list of doctoral universities had a health centre with a
Facebook presence, the research team examined the university’s health centre web site
for an official link to its Facebook page. After this check, the researchers searched within
Facebook for official health centre pages that were not linked to the university health
centre’s web site. Combining the scrutiny of their web sites and the Facebook search
revealed that 51 per cent of the nation’s 157 doctoral-granting institutions had health
centres that maintained a presence on Facebook.
The coding scheme used was adapted from Bortree and Seltzer’s (2009) study on
environmental advocacy groups’ use of social networking sites. Five dialogic content
categories were included based on Kent and Taylor’s (1998) principles: creation of a
dialogic loop, usefulness of information, generation of return visits, ease and
intuitiveness of use/interface, and conservation of visitors. The individual items that
comprise these principles are shown in Table I. For this study, they were measured
using a dichotomous scale (e.g. being present or not).
Additional items to gather descriptive data about the university health centre
included textual description of the profile; tallies for the total number of “friends,”
“fans,” or “members;” information provided on contacts and hours of operation; type of
profile picture; and overall presentation of health information (idealistically versus
pragmatically). Topic areas were based on the American College Health Association’s
2010 health priorities and included social and emotional health, coping with stress,
psychological relationship with food, sexual health, nutrition, health service costs,
insurance availability, tobacco usage, substance abuse, immunization, and general
 Profiles with a Profiles with a Profiles with a
University health
high fan/ moderate fan/ low fan/ centers on
Scale items Total (n ¼ 80)
friend base
(n ¼ 26)
friend base
(n ¼ 27)
friend base
(n ¼ 27)
Facebook
Ease of interface (mean/SD) 39.74 (24.98) 18.00 (18.43) 39.81 (19.92) 60.57 (16.08)
Tab 22 1 5 16
Picture 63 13 24 26
217
Video 39 4 14 21
Special search 0 0 0 0
Usefulness (mean/SD) 42.79 (20.30) 37.98 (20.15) 38.81 (20.52) 51.00 (18.37)
Link to news 38 9 11 18
Nonprofits 24 5 8 11
Government agencies 20 7 7 6
Organizational material 37 6 14 17
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Calendar 50 13 18 19
Identifies audience 36 16 11 9
Mission statement 40 15 11 14
Describe programs 23 8 6 9
Dialogic loop (mean/SD) 32.03 (20.37) 18.67 (13.88) 29.01 (17.66) 48.67 (17.29)
E-mail address 24 8 11 5
Social media 35 7 8 20
Vote in polls 12 1 2 9
Reply to comments 42 4 15 23
RSS feeds 4 0 0 4
Request information 36 10 11 15
Conservation of visitors
(mean/SD) 47.95 (21.22) 39.23 (19.98) 48.15 (21.67) 56.80 (18.87)
Link to the university’s site 77 25 26 26
On topic comments 45 11 15 19
News catchy titles 3 0 0 3
Cartoons 50 11 19 20
Mascot 14 3 6 5
Return visits (mean/SD) 21.75 (17.84) 13.00 (14.65) 20.37 (13.93) 32.00 (19.79)
Explicit appeal to return 8 0 1 7
Frequently asked questions 1 0 0 1
Become friend statement 8 3 1 4
Updated in 30 days 50 10 20 20 Table I.
Occurrence of dialogic
Note: As in the Kent et al. (2003) study, composite data for each dialogic principle index is provided, features on university
followed by data for individual items expressed as a percentage of web sites with those items coded as health centers’
“present” Facebook profiles

health/hygiene. Services covered included events, small group workshops, speeches,

medical checkups, condom distribution, pharmacy sales, counselling, and other.
Both topic areas and services were coded as present or absent.
Two researchers content analyzed the sample of 80 university health centre Facebook
profiles using a 61-item questionnaire. After a 90-minute training session, the researchers
coded 15 Facebook profiles of university admission offices to determine intercoder
reliability. These profiles were chosen because they were similar to the population that
would ultimately be studied so that any questions that arose during the coding could be
discussed before the official coding began. When the practice coding was completed,
 JSOCM PRAM was used to calculate intercoder reliability using a variety of measures. The
1,3 simple percentage agreement was more than 93 per cent for all variables; however, using
the more conservative Cronbach’s a, the researchers were still found to be in agreement
on all coding items as reliability ranged from a low of a ¼ 0.82 to a high of a ¼ 0.94.
Given that the research team had achieved intercoder reliability, the three coders
were able to proceed to coding the university’s health centre profiles. Because of the
218 changing nature of social media, the researchers used the Teleport Pro computer
software program to download all of the Facebook profiles so that a comparison could
be made of the profiles all from one point in time. After the URL addresses of the
Facebook profiles were entered into the software, they were instantly downloaded and
archived to a shared computer directory. Then, coding was conducted over a
one-month period in mid-2010.
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Results
The sample of university health centres that had a Facebook presence consisted of
58 of the 107 public universities (52 per cent) and 22 of the 50 private universities
(44 per cent) that were listed on the Carnegie Foundation for the Advancement of
Teaching’s list of doctoral/research universities in the USA. Of these 80 health centres,
65 (81.2 per cent) of them maintained an actual profile on Facebook while
15 (18.8 per cent) managed a group page. Although these types of profiles are different
in terms of having multiple administrators who can make changes to the account,
they both are able to be analyzed in terms of the dialogic principles.
University health centre profiles have on average 158 fans or friends (SD ¼ 182.1),
though this number ranges from a low of 2 to a maximum of 714. In the description box
on their Facebook profile, the health centres are more likely to share their organization’s
web site (96 per cent) and physical location/address (79 per cent) than their phone
number (73 per cent) and operating hours (56 per cent). The health centres represent
themselves visually by sharing a graphic of the health centre logo (46 per cent), a picture
of the building (34 per cent), a picture of people using their services (10 per cent), pictures
of university-specific signage (10 per cent), and a graphic with the university’s mascot
(4 per cent). Overall, the profiles share an average of 1.54 favourite Facebook pages
(SD ¼ 3.4), 9.7 links to non-Facebook pages (SD ¼ 17.37), and 6.4 events (SD ¼ 22.5).
The RQ1 sought to determine how university health centres employ these five
dialogic principles on their Facebook pages. As shown in Table I, the university health
centres only modestly incorporated the dialogic principles into their Facebook profiles.
In regard to the ease of interface principle, over half of the profiles (77.5 per cent)
featured pictures as a method of relaying information to visitors and nearly half
(48.75 per cent) used videos to provide additional information. None of the profiles used
in this study provided a specialized search engine for their Facebook page.
As a built-in function of Facebook, all of the profiles use a “wall” and “information”
tab to relay information to users. However, the health centres on average used 5.51 tabs
(SD ¼ 1.89) to categorize information they shared. From a design perspective,
Facebook only displays six categories or tabs. More than one-quarter (29 per cent) had
more than six tabs; this is important to note from an ease of navigation perspective
because having so many tabs requires that users click a specific link on the profile to
reveal all of the tabs. In addition to the two required tabs previously mentioned, the
most commonly used tabs included photos (89 per cent), discussions (71 per cent),
 events (50 per cent), notes (36 per cent), videos (24 per cent), and links (21 per cent). University health
Many other tabs existed; however, they were often organization-specific focusing on centers on
the university’s Facebook policy or specific campus health initiatives.
To address the dialogic principle involving useful information, the researchers found Facebook
that nearly half (45 per cent) of university health centre profiles directly identified a
target audience, and 52.5 per cent health centres provided a mission statement from the
organization directly on their profile. Less frequent (27.5 per cent) was the presence 219
of a description of the programs and services provided by the organization.
Most organizations (62.5 per cent) provided a calendar or listing of events for visitors.
Nearly half (48.8 per cent) of the profiles provided links to news reports on health
issues that were not organizational reports, including material from health nonprofit
organizations (28.8 per cent) and health information from government agencies
(25 per cent). Again, nearly half of the profiles (46.3 per cent) linked to health
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information produced by the organization. These messages were relayed in a variety of

formats, including news releases (21 per cent), flyers (14 per cent), text from
organizational speeches and presentations (14 per cent), downloadable brochures
(11 per cent), reports (10 per cent), newsletters (4 per cent), and podcasts (3 per cent).
One of the lowest scores received by the health centres concerns the creation of the
dialogic loop. Only 30 per cent of the profiles provided an e-mail address for a health
centre contact even though the option is made available as a default option by Facebook.
Few profiles (15 per cent) encouraged visitors to vote on issues or participate in polls,
and only a small number (5 per cent) encouraged visitors to sign up for RSS updates.
More favourable results were found for encouraging visitors to request additional
information from the university health centre via the Facebook profile (45 per cent) and
having discussions using the comment feature for item shared (53 per cent). However,
further analysis revealed that health centres are not getting many people to respond to
their posts. Facebook allows users to see items that were posted specifically by the
organization as well as posts made specifically by their fans. Administrators of the health
centre accounts posted on average 51.8 items (SD ¼ 119.65) for public discussion;
however, these items generated only 5.9 replies (SD ¼ 22.07) from their fans. One reason
for the lack of active discussion may be that at the time of data collection, the health centres
on average had not shared new information in the past 52.1 days (SD ¼ 112.1 days).
One additional measure of the dialogic loop included the provision of additional
social media outlets through which the user could connect to the health centre.
Nearly 44 per cent of the organizations linked to their other social media accounts with
Twitter (35.29 per cent), YouTube (33.33 per cent), and blogs (31.37 per cent) being the
sites that were most often referenced.
To conserve visitors and keep them using the health centre’s information, the most
commonly used strategy was to connect back to the university health centre’s web site
from the Facebook profile (97.5 per cent) and to share information visually through
pictures (97.5 per cent). The profiles shared 41.7 pictures (SD ¼ 70.6) in 2.5 organized
photo albums (SD ¼ 3.8). The administrators of the profiles also attempted to keep the
health centres’ stakeholders connected through discussions (85 per cent) and notes
(61 per cent). The profiles averaged 1.13 discussions (SD ¼ 2.1) and 5.67 notes
(SD ¼ 25.3). Regardless of where the conversation was being held, researchers found
that nearly 43 per cent of the conversations being held on the health centres’ Facebook
profiles were not related to the topics that were being shared.
 JSOCM Other methods of keeping a visitor engaged and interested in the material conveyed
1,3 through the Facebook profile were used with less frequency included the use of cartoons
to draw an visitor’s attention to information (62.5 per cent), highlighting the connection
to the university by incorporating the school’s mascot into the material (17.5 per cent),
and by using attention-grabbing headlines for items shared (3.8 per cent).
University health centres received their lowest score on the final dialogic principle,
220 the generation of return visits by Facebook users to the profile. Only a small number
(10 per cent) of profiles made an explicit appeal to users to come back and visit the
profile in the future. Likewise, only 9 profiles (11.25 per cent) were found to have an
explicit statement encouraging people to become fans/friends of the organization. Only
1 profile (1.25 per cent) provided a FAQ or Q&A section for visitors.
Even in new information was not shared by the health centres, a majority of profiles
(63.75 per cent) had been updated their profiles in the past 30 days. Wall posts made in
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the past 7 days (M ¼ 1.77, SD ¼ 3.24) and the past 24 hours (M ¼ 0.33, SD ¼ 0.76)
were also present.
This RQ2 sought to determine if there was a significant difference in the number of
friends, fans and members and the health centres’ use of each dialogic principle on their
Facebook pages. A one-way ANOVA was calculated to compare whether high,
moderate, and low levels of social networking (as evidenced by the number of friends)
was related to how well the Facebook profiles used the dialogic principles.
Table I shows that the three groups do incorporate the five dialogic principles in
different proportions. One-way ANOVA tests revealed that these differences were
statistically significant for each of the dialogic principles. The strongest statistical
difference was observed for the creation of dialogic loop (F(2, 78) ¼ 21.62, p , 0.001), ease
of interface (F(2, 78) ¼ 34.74, p , 0.001), and generation of return visits (F(2, 78) ¼ 8.67,
p , 0.001). The differences for usefulness of information (F(2, 78) ¼ 3.24, p , 0.05) and
conservation of visitors (F(2, 75) ¼ 4.80, p , 0.05) were also found to be statistically
significant. Bonferroni tests revealed that in all instances, Facebook pages with high
levels of friends, fans, or members were statistically different than those Facebook pages
with the lowest number of social connections. Additionally, the university health centre
pages with the most social connections to friends, fans, or members also were statistically
separated from the mid-range group for ease of navigation, generation of return visitors,
and creating a dialogic loop.
The final research question sought to determine whether the university health
centres were discussing the 2010 health objectives that were laid out for them by the
American College Health Association. Frequency statistics run on these indicators
revealed only four topic areas receiving coverage by the majority of the sample.
General health and hygiene was covered by 75 per cent (n ¼ 60), responsible sexual
behaviour 60 per cent (n ¼ 48) and immunization 56.3 per cent (n ¼ 45). Among the
least covered topics were environmental quality (16.3 per cent, n ¼ 13) and overweight
and obesity (22.5 per cent, n ¼ 18).

Discussion
The fundamental principle of using social media well for an organization is to create an
ongoing dialogue, a conversation with the publics that your organization serves. These
results indicate that while university health centres are taking some steps to create this
dialogue and initiate online conversations that address health topics of importance
 to college students, these organizations are not using Facebook to its fullest potential. University health
This study supports previous findings that organizations are not effectively centers on
implementing all five dialogic principles online (Bortree and Seltzer, 2009;
McAllister-Spooner, 2009; Seltzer and Mitrook, 2007; Taylor et al., 2001). Facebook
This study indicates that university health centres vary widely in their ability to
utilize these dialogic principles in order to create that ongoing conversation with the
campus community. Mirroring the conclusions of McAllister-Spooner’s (2009), work all 221
of the health centre Facebook profiles are taking some steps to build online relationships
through continuing dialogue, but none appear to be overly effective at doing so using all
of the five dialogic principles. In general, they have shown to be strongest in the areas of
providing useful information and conserving visitors. The area of greatest weakness
among the health centres is in generating return visits. These results connect nicely with
the numerous studies indicating that generation of return visits is the most difficult of
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the five dialogic principles to implement effectively (Bortree and Seltzer, 2009;
McAllister-Greve, 2005; Seltzer and Mitrook, 2007; Taylor and Kent, 2004).
For years, campus health centres have worked to provide information online
through their web sites. The results of this work indicate that many are using
Facebook pages as an extension of the web site, linking to health-related information
both internal to the organization and to external news reports or materials. About half
identified a target audience, provided the mission statement, or posted relevant health
information. Even more are using a calendar to publicize upcoming events. These
strategies effectively present one-way information, though they do little to encourage
interaction with the target audience.
To better utilize Facebook, health centres should not assume that visitors have been
to their web site or know the basic information they have presented through other
channels. Providing a description of the health centre’s services would help to support
the presence of the mission statement, showing how they go about meeting that
mission. Providing outside links to timely information (e.g. articles about stress
management just before exams or resources on personal hygiene before the start of flu
season) can show that the organization is in touch with the needs of the college student
population. That audience awareness helps to build a relationship with the campus
that supports an ongoing dialogue.
Because ongoing dialogue requires a back-and-forth interaction, successful creation
of a dialogic loop is critical in using social media effectively. Most health centres began
discussions with students, but they are not using the various Facebook discussion
forums too regularly to continue existing conversations and begin new ones.
More importantly, only 59 per cent of the health centres responded to comments.
Simple responses, such as “great point!” or “thanks for your feedback” help to present
the organization as responsive and attentive to the needs of its audience and would go
a long way to generating goodwill for the organization.
Once an organization has proven they can manage the basic interactions effectively,
they might consider other ways to extend the dialogic loop by creating polls for
friends/fans/members to vote on issues or linking to other social media. While some are
linking to Twitter, YouTube, and blogs, they must ensure that those other social media
sites are also being frequently maintained and updated to ensure ongoing dialogue.
Future dialogue with the organization will not happen if the organization cannot
keep visitors coming back to its profile. With only 10 per cent of profiles explicitly
 JSOCM requesting visitors to return and only 11 per cent explicitly asking visitors to become
1,3 fans/friends, health centres have not focused on relationship building on social media
sites. To create an ongoing dialogue, organizations must find ways to get their key
constituents to return to the page and to return frequently. Appeals encouraging
visitors to return are one way to start an ongoing dialogue, but are generally
insufficient to continue building a relationship online.
222 The five dialogic principles established by Kent and Taylor (1998) for measuring a
web site’s ability to create ongoing dialogue are closely interconnected and
interdependent. Moreover, a single strategy could potentially fall into multiple
categories. Responding to the comments of visitors creates a dialogic loop as well as
generates return visits. Frequent posting of appropriate, timely resources on the page
wall provides useful information as well as conserves visitors on the page (as opposed
to sending them away to other resources to seek outside information). Use of images
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improves the ease of navigating the interface as well as conserves visitors by capturing
the viewer’s attention. So, university organizations such as health centres must see
these five principles as pieces of an overall puzzle and seek out strategies to maximize
all ways to begin and maintain dialogue with their publics.

ACHA 2010 health indicators

One component of this study sought to explore what types of information are being
presented to students via Facebook and whether that content follows the guidelines set
forth by the American College Health Association (ACHA). This question speaks to the
usefulness of the information presented, as the health indicators are all issues
important to universities from a public health perspective. Results indicate that only a
few of the objectives (general health/hygiene, responsible sexual behaviour,
and immunization) received significant coverage and discussion.
One important consideration is that the fall semester of 2009 saw widespread
national discussion of vaccination for H1N1 influenza. Because this research was
conducted in the months immediately following the H1N1 pandemic and subsequent
shortage of H1N1 vaccine, much of the information on immunization was directly
related to this particular issue. In addition, widespread emphasis on general hygiene
to prevent transmission of the flu likely increased online discussion of that particular
topic. Owing to the prevalence of H1N1 influenza information in contemporary public
health discussion, it seems likely that these two areas of focus were overrepresented as
compared to other health issues. Further research would be required to determine if
other health priorities enter the stream of discussion when H1N1 is not making
national headlines.

Conclusion
This study results indicate that university health centres are not using Facebook to its
fullest potential as a way to reach student populations. While the entrance of university
health centres into the realm of social media indicates that these organizations want to
reach out to students, they are not creating the dialogue and ongoing interaction that
have become hallmarks of social media. The “If you build it, they will come,” approach
that these organizations have taken does not encourage visitors to develop an ongoing
relationship with the organization online. Better use of Kent and Taylor’s (1998) five
 dialogic strategies could allow these health centres to provide the public health University health
information, which is so critical to the health of the college campus. centers on
Implications for web site management
Facebook
Ultimately, there are several implications for university health centres or any
organization that choose to actively participate in Facebook or any social media
platform that need to be discussed. First, organizations must be prepared to dedicate 223
the appropriate amount of time and organizational resources to maintaining the site.
Most organizations will not need a staff member who solely focuses on social media
efforts; however, someone should monitor the sites each day to ensure appropriate
responses are made to others’ inquiries and comments. Additionally, staff need to be
prepared not only to remove any posts that are made to their profile, site, or blog
that are inflammatory, but also to deal with any potential follow-up posts made by
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those seeking to challenge the removal of the initial post. Ultimately, staff must be
prepared to defend their virtual turf and should not be fearful of confronting social
media bullies.
It is important for organizations dabbling in social media to realize that it takes time
to build a social media community. Creating a Facebook profile or a blog will not result
in an immediate following overnight. It takes time to build an audience; however, the
inclusion of the dialogic principles can aid in organic growth of the organization’s
social media community. Strategic communicators certainly want to create the dialogic
loop by not only providing opportunities for the site visitors to send messages to
the organization and each other, but they also want to make sure they respond to these
messages appropriately. As these conversations unfold and those managing the
account learn about the users’ needs and wants, it is important to provide information
relevant to them and make sure that they have an abundance of information to ensure
they do not lose the audience to competitors. One way of building the community is to
make frequent updates to keep people coming back to check out the site.
Once individuals feel as if they are truly in a community, they are more likely to
provide their own content for the site (e.g. videos, pictures, notes, links to helpful
information).
Public relations and marketing practitioners may be tempted to fall into their
traditional one-way communication patterns and delete messages that were not
provided by the organization. However, the lack of institutional control ultimately can
lead to a more dynamic and successful social media community. Certainly off-topic
and inflammatory messages should be deleted, but as found in this study, the most
successful Facebook profiles have an active community where fans/friends of the
university health centre not only post messages but are also encouraged to post
videos and pictures, share links, and ultimately contribute to everyone’s Facebook
experience.

Limitations and future research

This study leaves a number of questions unanswered and a number of avenues for
future research. Profiles were evaluated using a “snapshot” approach, analyzing the
information at one particular moment in time. This work did not take into
consideration the length of time since creation of the Facebook page, and newer
pages have had less time to generate a fan base or to create a conversation with
 JSOCM their audience. Whether these new pages are able to successfully create a stronger
1,3 dialogue with their publics remains to be seen.
This study did not track whether health centres used fan pages, friend pages, or
member pages to showcase their organizations. Different universities are using
Facebook in different ways to reach the students, faculty and staff that make up the
campus community. There are advantages and disadvantages to each choice, and it is
224 worth investigating whether one type of page is more conducive to ongoing
conversation with friends/fans/members.
There are also methodological implications that need to be addressed. First, Gordon
and Berhow (2009) found that smaller institutions were more likely to use dialogic
principles than larger institutions. The size of the university was not taken into account
for this project; certainly differences in student enrolment exist between the large public
universities on the Carnegie list of doctoral-granting institutions and smaller private
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universities. Additionally, variations are likely to be found by comparing doctoral,

master’s, baccalaureate, and associate-granting institutions. A comprehensive study
comparing these four institution types would provide greater insights into the role
the dialogic principles play in university health centre’s virtual communication.
Additionally, the measurement instrument used by this study was a simple dichotomous
scale, measuring whether the specific elements demonstrated in Table I were present or
not. Although this study used the measurement schema used by other dialogic principles
studies on Facebook, this simplistic measurement approach may be overlooking
subtleties that could provide significant revelations about the incorporation of the
principles. For example, rather than solely using a scale of yes or no to determine whether
the creators of the profile provide an e-mail address to contact them, it may be better to
revise the scale to provide additional categories that allow the research to reveal whether
the e-mail address was provided on the main page, whether it was hidden internally on
the profile, or whether it was omitted. Expanding the scale could reap benefits in making
academic studies more meaningful to both the scholarly and practitioner communities.
It is important to note that the scope and focus of a particular page varied
depending on whether the university health centre was simply a campus clinic or a
major teaching hospital. Many universities that include a medical school do not
provide a separate clinic for healthcare but instead provide medical services for their
students at the larger teaching hospital. These hospitals obviously serve a much more
far-reaching audience in the surrounding community and their Facebook pages likely
reflect that in a reduced emphasis on the ACHA priorities for student health.
A comparison of the Facebook pages of campus clinics and university teaching
hospitals might provide insight into the success of each group at generating dialogue
with its intended audience.
Because universities have only begun using Facebook to connect with current
students in recent years, there are few studies available on which to build a foundation
for comparison. Do these trends carry over to other departments or units within the
overall campus? Would an academic unit, such as a College of Journalism, or a different
student service department, such as the Office of Financial Aid, see similar challenges
in creating dialogue with campus constituents? Additional research is required to
determine the generalizability of these results and the applicability of the dialogic
principles to other types of health organizations or to other units within a university
setting.
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About the authors

Richard D. Waters is an Assistant Professor in the School of Management at the University of
San Francisco. He teaches courses on Strategic Communications, Fundraising, and Social
Marketing. He has published more than 45 journal articles in a variety of outlets, including
Journal of Public Relations Research, Public Relations Review, Nonprofit & Voluntary Sector
Quarterly, and Journal of Nonprofit and Public Sector Marketing. Prior to earning his doctorate,
Waters was a Vice President of Development and Communications at a statewide healthcare
nonprofit in California, and he continues to remain active in consulting with Philanthropy
400 and Fortune 500 organizations. Richard D. Waters is the corresponding author and can be
contacted at: rdwaters@usfca.edu
Rachel R. Canfield received her Bachelor’s degree in Communication Studies and Media Arts
and Design from James Madison University in 2008 and her Master’s degree in Communication
from North Carolina State University in 2011. Before receiving her Master’s degree, she worked
in marketing and business development for a global public relations firm and has also served
in a communications capacity for a federal government agency.
Jenny M. Foster is a Graduate Student in the Department of Communication at North Carolina
State University. She completed her undergraduate degree in Communication at NC State in
2000. Her research interests focus on communication within the higher education setting,
including college students’ use of social media and financial literacy programs for students.
In her professional role, she is an Assistant Director in the Office of Scholarships and Financial
Aid at NC State.
Eva E. Hardy received her BA in Communication Studies from the University of
North Carolina Wilmington in 2008. She recently completed her MS in Communication at
North Carolina State University where she concentrated her research in public relations.
She served as a Social Media Specialist for a national nonprofit organization in Raleigh, NC,
while completing her degree and has also interned for the North Carolina State Port Authority in
Wilmington and Stolen Horse International in Shelby, NC. She plans to continue in the public
relations field in the nonprofit sector.

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