The effect of Covid-19 in digital media use of Finnish physicians – Four wave longitudinal panel survey

Background Covid-19 pandemic has boosted digitalization in healthcare, as mobility restrictions and social distancing rules have made healthcare providers to adopt digital tools to replace or complement face-to-face interactions. Purpose We discuss the effects of Covid-19 pandemic on physicians’ use of digital media. We examine whether Covid-19 conditions have changed how physicians use internet resources for information search, how they engage in social media, and their attitude towards online events. Basic procedures The study was done as a longitudinal panel survey in four waves. The sample was a panel including active physicians in Finland. The panel was updated annually. Identical surveys were administered in 2018, 2019, 2020 and 2021. Spring 2020 was the time when Finland executed mobility restrictions and re-organization of healthcare because of pandemic. Comparing results of the survey before and after Covid-19 restrictions gives us a unique opportunity to do comparative analysis of Covid-19 effects. Main findings Our results show that the use of digital media for information search stayed relatively stable without statistically significant change during the four-year period covered in the study. The use of social media rose steadily from 2018 to 2021 with no significant difference in the trend. However, there was a significant change in the attitude of Finnish physicians on online events. Year 2021, the attitude remained in this more positive level. Principal conclusions As use of digital media including social media was already high prior Covid-19 in Finland, our results do not show significant change because of special circumstances introduced in 2020. However, our results show that the attitudes towards online events turned more positive during Covid-19 related restrictions. This could indicate that Covid-19 era has triggered a change that might continue also when pandemic related restrictions will be removed.


Introduction
Digitalization of healthcare has been expected to transform healthcare, and Covid-19 has been proposed to boost this process [1,2]. Due to mobility restrictions and social distancing, many healthcare practices based on face-to-face interactions become difficult, if not impossible. Preparing to sudden increase in patients with new, severe symptoms has caused re-prioritization of healthcare, leading to postponing non-urgent care and re-organization of work.
In this paper, we investigate if Covid-19 has had an impact of physicians' use of digital media. We performed a survey study among physicians in Finland. The survey was administered in an identical manner in four waves annually from 2018 to 2021. By comparing the survey results of these four years, we are answering a research question: "Has Covid-19 had an effect on how Finnish physicians use digital media?" Digital resources have become important in fulfilling everyday information needs of medical professionals. They use digital resources to seek information at the point of care, to update their professional knowhow, and to communicate with colleagues [3]. They obtain new information or confirm diagnostic or therapeutic decision [4] through internet. Recent evidence shows that use of online resources in information search in European physicians is prevailing method to fulfil information needs, while offline resources are used more seldomly [5].
Whereas using internet to fulfil information needs is already widespread, use of social media by medical professionals for professional purposes is not as common [4 6]. There is indication that social media has an influence especially in the patients' decision making [7,8] and in providing patients emotional support [9], suggesting that the use of social media in healthcare might be actually driven by patients, not healthcare professionals. There is some evidence that Covid-19 has increased the use of social media to disseminate health-related information in both health media and in healthcare professionals [10].
Social distancing and mobility restrictions hinder healthcare ecosystem to organize events that allow person-to-person communication and information sharing. Academic detailing is one of the practices that benefits from in-person peer education visits to improve patient outcomes, and is suffering from Covid-19 related restrictions [11]. Life sciences companies have responded to this challenge by developing their digital service offering; more than 60% of life sciences companies have been reported they have increased virtual meetings with healthcare professionals [12]. However, this increase is only partially offsetting the decline of communication between pharma and healthcare professionals, which has been reported by McKinsey to fall an average of 65% because of Covid-19 [13]. Medical congresses facilitating learning and networking of the community have been postponed or cancelled [14], or organized as virtual or hybrid events with the help of digital technologies [15]. On the other hand, medical congresses experimenting with web-based delivery methods to tackle Covid-19 challenges have reported even higher number of participants and more diverse global audience compared to pre-pandemic face-to-face congress arrangements [16].
However, high numbers of internet use among medical professionals are not valid in all parts of the world [17]. Also, as the possibilities of digital media are getting more advanced, healthcare professionals have been found to express needs related to increasing their digital health literacy skills to be able to integrate new digital information to care practice [18]. Finland is generally seen as a forerunner in regards digitalization of healthcare and use of internet for healthcare related information search [19]. For example, use of electronic health records (EHRs) is reaching 100% [20] and the percentage of population using eHealth services is the highest in the European Union [21]. The broadband network has been available in all populated areas of the country, and digital health literacy has been high already at least for a decade [22], allowing individuals to adopt digital tools in their everyday lives. The national electronic patient record system has been widely adopted, as well as the electronic prescription system [23].
The global pandemic resulted in mobility restrictions and social distancing in most parts of the world. These drastic changes caused by Covid-19 have impacted people's online behaviors in general. A study in Germany found out that over 70% of respondents representing adult population reported increased use of digital media [24]. Female respondents had higher increase in social networks, information search and video streaming, whereas male respondents reported increased consumption of gaming and erotic content. Whereas there was surge of digital media use in the early phases of pandemic, surveys done in the USA and the UK indicate that the social media use has stayed relatively stable over the past years [25,26]. There is evidence [27] that social media causes information overload, stress and decrease of mental wellbeing by increasing fear and the perception of risk, which may lead to information avoidance leading to decreased use during crisis situations like Covid-19.

Survey instrument
The survey instrument has been developed to monitor how different communication channels reach healthcare professionals in Finland. The results have been disseminated to healthcare ecosystem stakeholders, such as pharma companies, health technology providers and policy makers through dissemination events, social media channels and targeted communication with stakeholders. The summaries of the yearly surveys are published at the web site of the organization administering the survey (http://successclinic.fi). The questions have been refined through a collaborative process of healthcare ecosystem stakeholders and the company administering the survey (later referred as SC in this paper). For the purpose of this paper, we picked survey questions relevant to our research question. The survey has been repeated yearly for over 10 years. The questions selected for this study have been identical for the four years period analyzed.
The questions selected for the purpose of this study were the following (translated from Finnish by the authors): 1. How are the media you use at work distributed among the following options?
• Print media • Internet (service includes ads) • Internet (service does not include ads after login) 2. How often do you use the following social media services?
• WhatsApp, YouTube, Facebook, Instagram, Twitter, LinkedIn (the survey had more options, we selected these to this paper based on the significance) • Daily, Weekly, Monthly, Once in three months, Couple of times a year, More seldom, Never 3. Currently, what is the role of social media in your work?
• The survey was administered online. The survey instrument was implemented with Webpropol. Invites were sent by email.

Data collection and analysis
The participants were recruited through SC panel of Finnish healthcare professionals. The panel has been constructed in an iterative process with the Finnish healthcare professionals. The panel is a representative sample of Finnish physicians. It includes majority of registered physicians in Finland, 27,254 physicians in year 2018.
The data was stored in SC data server located in Finland. SC is a registered registry operator. It follows GPDR regulations in data storage and management. For the purpose of this study, all data analytics were done by SC personnel using SC servers and computing resources.
The data covers years 2018, 2019, 2020 and 2021. The survey instrument has evolved slightly during the years, but the questions examined in this paper have remained identical. The process of administering the survey has followed the same protocol every year. Cherries table [28] is provided in appendix for describing the details of the survey design and protocol.
For the purpose of this study, we selected only respondents who had registered themselves in the SC panel as "physicians". Demographics are described in appendix tables. As only the questions related to demographics were mandatory, the number of responses varied between questions. The highest number of individual respondents for the question receiving highest number of responses was 933 in year 2018, 904 in year 2019, 659 in year 2020 and 354 in year 2021. There are variations in response rates between years. However, representativeness of respondents has been yearly checked in regards of specialty, geographical area, and representation of both private and public sector. Microsoft® Excel® for Microsoft 365 MSO 64-bit -program was used in all analyses. Data analysis includes creation of summative graphic representations of distribution of answers, and χ 2 -test (Chi-squared test) for identifying statistical significance of differences between years.

Results
We group our findings here into three broad categories according to the type of media as follows: 1. Media services. This category includes external media services based on broadcasting model, where media content is created and/or curated primarily by the service provider, for example, professional magazines and national databased used to communicate standard care information.
2 Social media. This category includes social media platforms, where the content is both produced and consumed by the users, such as Twitter, Facebook and LinkedIn.
3. Attitudes towards online training. Online trainings were described in the survey to mean marketing services used by pharmaceutical companies or other product or service providers to train physicians on their offerings.
The demographics of respondents were similar in each year, representing the demographics of the Finnish physicians. This allows statistical comparisons across years. In year 2018, 39% of the respondents were male and 61% female.

Use of media services
The physicians reported that their use of print and internet-based media services had remained relatively stable (Fig. 1). Digital media is clearly more common (70% of respondents) way to access professional information compared to print media (30% respondents), and this has remained the same for the past four years.

Social media
The most frequently used social media was WhatsApp, which was used daily by 91% of the respondents, with the annual growth of 3% during the analysis period. YouTube and Facebook use has stayed rather stable. Both are used weekly or more often by more than 50% of Finnish physicians. Instagram, Twitter and LinkedIn have lower usage numbers. Fig. 2 summarizes the results, and shows the numbers used for calculating statistical significance of differences between years. χ 2 -test shows no statistical significance between years in any of the usage frequencies (X2(15) = 21,74, df = 15, p = 0,115). Majority of the respondents report that social media plays a moderate role in their work (see Fig. 3). There was a significant relationship between yearly periods and yearly evaluation of the role of social media in the working context (Х2(9) = 34,70, df = 9, p < 0,001). The number of respondents who answer that social media has no role in their work has dropped from 29% in 2018 to 20 % in 2020, and it remained on that level also in 2021. The number of users who report that social media has a moderate role in their work increased from 15% in year 2019 to 25% in year 2020, and then dropped to 22% in 2021.
More than half of the respondents reported that they are members in one or more private groups in social media to discuss work related topics (see Fig. 4). 38% of respondents were members of closed social media groups in 2021, whereas the number had been 25% in 2018. At the same time, number of respondents who show no interest towards joining social media private groups has decreased from 39% in 2018 to 31% in 2021. There was a significant relationship between yearly periods and the attitude towards private groups in social media in years 2018-2021 (X2(12) = 35,47, df = 12, p < 0,001). However, the growth seems to be rather stable over the analysis period.

Discussion
Covid-19 pandemic has been expected to boost digitalization of healthcare. Our findings show that there is no increase of use of online resources in information search of physicians in Finland. The use of digital media continues to be high, and print media seems to be maintaining its role among Finnish physicians. Our results highlight that the use of social media is growing and increasing its importance among Finnish physicians, but this growth has started already before Covid-19, and our results do not show significantly increased growth in 2020 and 2021. However, our results show change in attitudes towards online training into more positive.

Principal findings
Our findings show that the use of web sites in information search is already at a high level among Finnish physicians. The numbers were at a high level already before year 2020, and the use of web resources in information search remained in high level also in 2020. Interestingly, also print media stayed at the level of previous years, indicating that Covid-19 has not had an impact on Finnish physicianś information Fig. 1. The use of media services. Answers to question "How are the media you use at work distributed among the following options? " searching practices. In Finland, the digital platforms providing access to latest care guidelines and databases of medical products seem to have a relatively established role in the everyday work of care professionals. Close to 90% of professionals report frequent use of digital media portals for accessing work related information, and Covid-19 does not seem to have a major effect in that.
Social media tools, such as instant messaging, private work-related group communication, and peer-created content, also have reached a high level of frequent use in the work-related communication and information sharing. Our results show that the use of social media has been on a steady rise already before 2020. There is an increase both in numbers of users and the frequency of use. However, this rise seems to be stable over years, with no significant difference in the rise in year 2020. This is well aligned with surveys for general public, which show that the use of social media has been rather stable during last five years [26]. Interestingly, the numbers of Finnish physicians who report using Twitter for work purposes was found to be rather low in our study, whereas it has been seen to be popular among healthcare professionals in some other contexts [29,30].
Our findings show that the biggest changes are in increase of positive attitude towards online training. This can be seen as an indication experiences of participating had been positive. As pandemic is forcing event organizers to adopt digital practices, it is likely that this creates opportunities to learn and develop practices that embrace the possibilities of virtual events in ways that can serve the medical community also after pandemic [14]. As there is a positive change in attitude, we predict

Strengths and limitations of the study
As the survey used in this study has been repeated in a same form before and during pandemic, it provides a unique dataset for analysis of changes in media consumption of physicians. Also, the response rates and demographic distribution of the survey each year are high enough to be representative of the Finnish population of the physicians. However, limiting the scope to the Finnish physicians limits the generalizability of the results. As Finland has high level of digitalization also in healthcare, the results may not be directly applicable in areas with lower level of adoption of digital media in general population and in healthcare particularly. For example, in other areas the physicians may be in a different phase of an adoption curve of social media or national digital health web resources. The quantitative nature of the survey limits the insights we have to interpret reasons behind changes and getting explanations of different usage patterns.

Future work
Our survey has explanatory power to show trends and changes in the use of digital media, but only in regards how much digital media is used, and how many physicians use digital media in their work. However, our survey does not allow us to increase understanding on how the use of digital media has evolved as they have become more common communication tools. Future work on the role of digital media and its impact on work practice would be needed. Summary

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. CHERRIES description of survey [28]
Category

Checklist item Explanation
Design Describe survey design Survey was targeted for physicians in Finland. The sample was gathered from Success Clinic's physician register. Institutional review board approval and informed consent process IRB approval The research follows the ethical guidelines of ethics committee of Human Sciences at University of Oulu (Eudaimonia) Informed consent The participants were informed the length of the survey within invitation letter. The consent to analyse data was given when responding the survey. The data were stored in data secure database, which requires passwords from users. The investigator was Success Clinic. The purpose of the study was to gather opinions from physicians.

Data protection
No personal information was collected. The aggregated results were stored in company's data secure database, and access to data is not possible without passwords.
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