**1. Introduction**

Nowadays, health communication plays an important role for citizens [1] and, therefore, contributes to social sustainability. Society is increasingly using the Internet in a bid to obtain health information, share experiences related to pathologic processes or find people with similar physical or psychological conditions [1,2]. Since information and communication technologies are being used in the field of health, terms such as e-patient or e-health are widely used, which is evidence of the increasing role citizens play in making decisions about their well-being [3,4].

Terrón [5] o ffers his perception from an anthropological point of view. In his opinion, the interest in health communication in a country like Spain has increased significantly due to the growing need for lifestyles that entail greater social well-being. This idea is reinforced in the feedback required by the supply and demand of information. Thus, interest in what is communicated grows as more information is o ffered [5,6].

The Internet has become the most important "loudspeaker" for patients' expectations and demands. This fosters the emergence of associations that support patients' rights to make their voices heard [5]. As a result, this makes patients feel stronger as they are members of a collectively supported platform on which they can express their needs and the needs of their environment.

Social media play a relevant role in this sense, with a progressive increase observed in terms of their use in the health field [3,7]. Factors such as the accessibility, immediacy or their potential to communicate bidirectionally with di fferent audiences allow active communication [8]. Health centers are aware of the potential of social media and use them to promote interaction and collaboration between patients, relatives and professionals [9].

However, the democratization of information through social media [10] in the field of health means that social networks, blogs or mobile social media have developed peer communication with an increasingly participative audience, but above all, it has also made it more credible. Therefore, it confers greater communicational power to citizens and professionals in the sector when their messages reach a greater number of people [11,12].

These channels have become the preferred communication instruments for health corporations, by facilitating participation and collaboration with their stakeholders and allowing, thanks to a two-way communication, the control of the quality and e fficiency of the institution [6,13], but also for the education of citizens with new healthy lifestyle habits [14,15]. It is also a key tool for communicating health alerts, the creation of networks of groups of patients with the same pathologies, or professionals for research purposes [12,16].

These real-time interactive information platforms provide a free online resource [17]. Therefore, another advantage of social media for the health sector is its low cost [7,18,19]. They are, therefore, a very e ffective two-way communicative tool for communication with stakeholders, such as sector professionals and patients [20].

The most popular health-related social media are those specifically intended for patients [1,21]. Nevertheless, other sectors of the population could also play a central role and benefit from the knowledge circulating on these networks if they became stakeholders of such information channels. Swan [1] suggests that agents in the health field who are meant to take care of patients, researchers and other agents involved in this area could take part more actively [21]. In the patient's view, social media are the best instrument for real-time interaction, enabling the exchange of information and participation not only simply as patients or users, but also as groups or associations [22]. In the case of professionals, social media are used primarily for the dissemination of results, research, networking or teaching, among others [23].

However, this issue has disadvantages, the democratization of communication via social media entails, in some cases, a lack of veracity and information control [19]. Anyone may stir-up anxiety within society with their opinions or unconfirmed facts [6], as well as harmful criticisms or falsehoods directed at health professionals or health institutions [24]. It would not be ignored both the legal problems and lack of privacy, such as damage to professional image, violation of patient privacy, etc. [7,19,23]. In order to solve this problem, health institutions and professional organizations, such as O fficial Medical Colleges (OMC), have developed prevention guidelines and guides to good practices [7] aimed at protecting institutions in this area on a legal, clinical and organizational level [25–28]. OMC, together with health institutions, play a crucial role in developing recommendations for the use of social media. For this reason, the work of professionals with an expert profile in information and health is essential.

The choice of the o fficial medical associations for this research is determined by the obligation that doctors must be registered to be able to practice the medical profession representing all the doctors in the country.

In detail, this work attempts to answer the following research questions:

RQ1: Are the o fficial medical colleges in Spain valid interlocutors with their stakeholders?

RQ2: Do the communication professionals of the Spanish o fficial medical colleges mainly use social media for their work as a source of information and verification?

RQ3: Do social media have any involvement in the agenda setting of the o fficial medical colleges?

This study is structured as follows. It begins with a review of the existing literature focused on the importance of communication professionals and the use of social media in the health sector. Next, an analysis of the o fficial medical colleges is carried out within the health field in Spain and analyzing the stakeholders with which it is related. Second, the methodology used is presented. This research work is carried out with a qualitative technique through semi-structured interviews with the communication experts of o fficial medical colleges with the support of the Atlas.ti. Third, the most important research results are shown. The main contribution is a framework with strategic communication keys and the use of social media as an essential element of information. Finally, conclusion, managerial implications in health sector and limitations of the study are discussed.

### **2. Theoretical Background**

#### *2.1. Communication in Health and Social Media*

Scientific literature regarding health communication highlights the necessity of the professionals practicing it to adapt to the changes brought about by the rapid invasion and evolution of social media.

With social media, access to information has changed, currently people do not rely exclusively on traditional or governmen<sup>t</sup> media but trust the social media for essential information from the health sector [29]. Nowadays, social media such as blogs, websites or social networks such as Twitter, Facebook, Instagram, etc. are increasingly used by the population to acquire health knowledge [30].

It is necessary to design new strategies and challenges to cope with the apparition of a new style of network communication in real time [31]. Health professionals can make use of the new communication scenarios and their position as authoritative and credible sources in order to promote and defend health [32].

The professional practice of those who develop informative content for the media has been recognized for over a decade. As Arkin points out [33], in a study focusing on the American population, social media, as a leading source of health information, could potentially save lives in the event of a health crisis [29]. Nevertheless, those who develop informative content can also be alarmist and spread false information in the news or the coverage they o ffer.

Therefore, while the media selects the version of reality that it transmits and o ffers its own views on matters, it has the power to give this information the importance it considers appropriate [5]. It could be added that citizens search for increasing health communication, not only in what could be considered reliable sources, such as health professionals, but also in the media, so it seems necessary for the media to proceed responsibly [6]. Due to this fact, the media must o ffer true, transparent and coherent information [34].

Social media provide such health communication specialists with valuable information about patients' experiences with which they can monitor public reaction to health problems. They also highlight the potential of such information for the development of health policies [35]. An example are medical blogs, which are frequently visited by the most important media outlets [36].

However, Leask, Hooker and King [32] also highlight how the role of specialists in charge of communication is losing relevance. This incurs a disappearance of the basic technical knowledge that is necessary to transmit health communication correctly. One of the new challenges is developing tools to verify contents, given the risk of spreading inaccurate or false information generated by the ever-increasing speed with which information emerges [31].

Rumors, conflicting news and speculation are characteristics of the messages circulating within social media. According to Hermida [37], it is the responsibility of media professionals to select, contextualize and verify the enormous amount of information. In this sense, it is not conceivable that the health communicator is dependent on sources, funders, or other informants with certain interests to reliably inform society and not be detrimental to the well-being or the quality of life of society [38]. Therefore, ethics and responsibility at work, as well as a commitment to society, are key elements of the

communicator. This is how better care is o ffered to the population [39]. This work is reflected when organizational interests are transferred in order to reinforce the welfare or quality of life of citizens.

However, the veracity of the information lies with the communication professional, the determination of correct information now becomes complicated due to, among other aspects, the vast amount of information generated by social media. Knowing how to use them for professional purposes is no easy task and a new type of reasoning is required. In spite of this, the authors both defend this new scenario, saying that the communicative potential of social media is "far from being negligible" [40] (p. 67).

As well as verification and credibility of the information spread through social media, other aspects of social media that the studies under analysis expose are the e ffects that these produce in professional practice [41]; the use that professionals make of them [42] and their importance for communicators or the weight they bear regarding information [43].

Since McCombs and Shaw proposed the theory of agenda-setting in 1972 [44,45] to explain how the media influence the shaping of public opinion, its application to research has been intense and fruitful. In the process of establishing the news that attracts the attention of the audience, each media has tried to play a di fferentiated role [46]

The change of the hierarchical structures regarding the organization of the information by the spaces of conversation, connectivity and the creation of a community that have provoked social media is one of the changes highlighted by Hermida, Lewis and Zamith [41] in the exercise of communication professionals who work on social media. There is no longer a single paradigm for the structure of news as proposed by Almaguer [46], but there are many di fferent ways of developing content. Even if corporations seem particularly interested in social media as a vehicle to market news content, increase tra ffic to their websites, and strengthen relations with the customers, communication professionals, on the other hand, mainly use social media to talk about what they are working on or share opinions or ideas. This implies that the content provided by corporations does not enrich the media agenda. On the contrary, according to these authors, news that refers to social media as the source of information is rare or infrequent [42].

Lariscy et al. [43] not only put the emphasis on the attention that corporations should expend in terms of the content that is disseminated through social media, in addition, they point out that the task of communication or public relations professionals are to closely monitor the information issued from the entities for which they work and possibly involve those who are the originators of the content [47], considering that social media contribute to the construction of the agenda setting [48–50].

Di fferent studies highlight the potential of hospital social media and how society can profit from them. In this way, Shepherd et al. [51] place these in a favorable and expanding environment, which favors personal relationships. De la Peña and Quintanilla [52] (p. 495), describe the role they play for citizens as "a virtual community where they can find stimulation, ge<sup>t</sup> answers to specific questions related to health and a place to share success stories" and Koteyko et al. [53] add that this tool has grea<sup>t</sup> potential to promote initiatives.

To the field of hospital information, the content producers would be health professionals and managemen<sup>t</sup> and service professionals, together with users of the health system, patients and family members, among others.

Influencing the importance of information supervision, social media is considered as an effective instrument to promote communication between public administrations and di fferent stakeholders [48,54]. Specifically, in the sector in charge of communication through social media within the field of specialized health care, scientific publications that focus on the practice of communication professionals specialized in health are scarce [49,50,55].

However, as well as these publications that underline the benefits of health communication by means of social media, there are others that focus on their harmful e ffects or potential dangers. Among these dangers are the loss of privacy or security regarding shared information [50,56] and the lack of specialized training, both in health and in the managemen<sup>t</sup> of social media among communication professionals [57,58].

#### *2.2. O*ffi*cial Medical Colleges (OMC) in Spain*

In many countries, registration in the medical association is legally mandatory for all doctors who practice medicine temporarily or permanently. Thus, in Europe, as examples, there are the *Conseils de l'Ordre des Médecins* in France, the *Fédération des Médecins Suisses*, the general medical council in the United Kingdom, the *Ordre des Médecins* in Belgium or the *Colegio Oficial de Médicos* in the case of Spain. The first regulations in Spain of the o fficial medical colleges date from April 12, 1898, but it is not until the Royal Decree of May 28, 1917 where the compulsory registration in the college to practice the medical profession is definitively approved.

Professional colleges play an essential role. This relevance of professional services lies in the protection of the rights and interests of citizens who receive them.

Throughout diverse regulations on professional associations in Spain, the sector has undergone di fferent transformations, but maintains the same structure that it originally had. The law defines professional associations as legal public corporations, protected by the law and recognized by the State, with their own legal personality and full capacity for the fulfilment of their purposes, which empowers them as entities that represent and defend the profession that each college has and points out the obligatory registration for the professional exercise which is regulated by law.

In the present case, the Spanish o fficial medical college promotes the scientific work of doctors and connects this collective with patients and society. Most importantly, its ethical code committees ensure that health institutions adhere to the norms.

There are currently 52 o fficial medical colleges in Spain with a territorial structure. The number of doctors registered at the o fficial medical colleges have been increasing year-by-year to reach a total of 267,995 in 2019, as represented by Table 1.


**Table 1.** Number of doctors registered at the Spanish o fficial medical colleges. Series 2015–2019.

> Source: Instituto Nacional de Estadística. 2019 [59].

The number of registered medical professionals per 1000 inhabitants is 5.66 on average. By autonomous communities, the representation is as follows (Figure 1).

**Figure 1.** Registered medical professionals in 2019. Quota per 1000 habitants. Source: Instituto Nacional de Estadística. 2019 [59].

O fficial Medical Colleges and the Relationships with Stakeholders

The situational theory of Grunig's audiences [60] identifies stakeholders as groups formed by people who unite them with a problem or end of a similar nature and of which they are aware and so they group together to adopt a proactive attitude focused on action, in its attempt of resolution.

The professional managemen<sup>t</sup> of communication according to Grunig and Hunt [61] identifies three weaknesses and three strengths. The weaknesses are: (a) the saturation of the communicative channels due to the lack of well-documented and orderly information that ends up becoming irrelevant to the public, (b) frequently this information overshadows the true relevant facts of interest and (c) it ends up generating distrust in interest groups because of the sense of deception. The strengths are: (a) it approaches and sensitizes the entities with their stakeholders, by establishing a more dynamic and bidirectional communication, (b) it acts as a clear and concise spokesperson for issues of public interest and (c) it promotes the knowledge of the various stakeholders through information in formal and informal communication media.

For Ruiz de Azua [62], health communication managemen<sup>t</sup> requires an open and empathetic communication style that generates public trust. It is most e ffective when health professionals try to stimulate the population to take positive action or abstain from a harmful act. However, trust is essential, public mistrust of other stakeholders such as health experts and representatives of health institutions can increase for a variety of reasons, one of the priorities being access to conflicting information collected in the social media.

Mainardes, Raposo and Alves [63] emphasize the importance of identifying and aligning stakeholders with the strategic objectives of their institutions, given that they themselves play a vital role in the development of managemen<sup>t</sup> strategies. Therefore, any serious and reputable entity needs to develop and implement its strategy through specific expert structures created with the objective of directing relations with its audiences. Due to the powerful position and performance they entail [64], proactive care of these can become a huge advantage for the reputation of the o fficial medical colleges.

Therefore, an express knowledge of the stakeholders and the relationship that must exist between them is essential [65]. Next, the following Figure 2 establishes the public map that relates to the official medical colleges. Beginning with the main audience to which they are directed as their own members are, guiding them in good ethical practices, in technological advances and in health research. Continuing with healthcare professionals such as nurses, psychologists, therapists, physiotherapists, etc., including the providers where pharmacists and health engineers will be highlighted and ending with patients, their families, health institutions, hospitals, governmen<sup>t</sup> or the media and society itself in general. In short, once the map of the stakeholders is represented, the prioritized objectives will be established in order to design the communication strategies and policies appropriate to each one of said audiences.

**Figure 2.** Stakeholders of Spanish o fficial medical colleges. Source: Adapted from Freeman [66].

For this reason, this study focuses on the degree of knowledge that such professional college have regarding current communication tools, among which social media plays an influential role that a ffects the information that reaches its stakeholders. The Spanish o fficial medical colleges must continue transmitting reliable information using language that is appropriate for the whole population. Therefore, the existence of specialized communication professionals who are at the vanguard of communication languages, mechanisms and strategies is so important.
