The Importance of Genuineness in Public Engagement-An Exploratory Study of Pediatric Communication on Social Media in China.

There is a growing need for the public to interact with pediatricians through social media in China, and genuineness is a crucial factor contributing to effective communication, but few studies have examined the relationship between genuineness and its effect on public engagement. This study developed a four-dimension framework including self-disclosure, genuine response, functional interactivity, and genuineness in Chinese culture to investigate the effect of genuineness in the communication of Chinese social media influencers in pediatrics on public engagement. Content analysis was employed to examine these dimensions and the related public engagement in 300 social media posts on the largest microblogging site in China. The findings indicate that genuine response was positively associated with the number of comments and positive comments, while negatively related to the number of shares. Functional interactivity made the site more appealing, resulting in likes and shares. Genuineness in Chinese culture was reflected in engagement through sharing posts by the public. This study is the first to develop an integrated framework to measure genuineness in online health communication and contributes to the understanding of the effect of genuineness on Chinese public engagement in social media.

1. Introduction

Child health and development has been one of the biggest issues in the World Health Organization. In recent years, Chinese president Xi Jinping has put public health at the center of the country’s policy-making agenda, clarifying the need to include public health in official government policy. “The Healthy China 2030 Planning Outline”, issued by the Chinese State Council, is the first long-term strategic plan of public health developed at the national level in China [1]. One of the aims in the plan is to enhance children’s health and reduce children’s mortality by the construction of pediatrics and the prevention of pediatric critical diseases [2]. As an important area of study in public health, children health advocates the prioritization of children healthcare in public health community as a basis for the improvement of national health [3]. Concerning this great emphasis on children’s health, sustainable investment and efforts have been put into relevant fields, especially online.

Chinese Premier Li Keqiang once put forward a guideline named “Internet+,” aiming to integrate online resources with other domains including education, logistics, and health care. Social media is of particular importance in disseminating health information and promoting health communication as China records the world’s largest number of registered social media users [4,5,6]. Of all the social media in China, Sina-microblog (aka Weibo) is one of the most popular platforms for health communication, with 516 million active online users at the end of 2019 [4]. In recent years, the number of doctors’ accounts in Weibo has been booming. It is estimated that Weibo has more than 50,000 registered doctors and generated 70 million followers in total, which facilitates the dissemination of high-quality health information [7].

These online doctors are coined as social media influencers (SMI) in our study. SMI refers to those who are well connected with social network users and persuasive in the sphere in which they exert opinion leadership to affect users’ decision-making process [8,9]. They play a crucial role in forming public views and impacting the spread of information in social media [8]. It is their expertise, ease of access, and social ties on social media platforms that enable them to influence followers [9]. In this regard, social media influencers in pediatrics (SMIP) are more convenient for consultations, as they use social media to address parents’ concerns. This includes opening online clinics, spreading children’s health knowledge online, responding to questions online, sharing thoughts of children’s health issues in blogs, and more. Likewise, owing to their expertise and the ease of access for their followers, SMIP play an essential role in the circulation of children’s health knowledge, formation of public opinion, and the behavioral effect of online followers [10]. Given that acquiring children healthcare information from, interacting with, and following SMIP online is becoming more commonplace, attention should be paid to the quality of health information and the effectiveness of SMIP’s health communication.

1.1. Previous Studies on Health Communication via Chinese Social Media

In recent years, health communication via social media has received extensive attention from international academic communities and health practitioners. Moorhead et al. [6] reviewed 98 worldwide research studies to identify the benefits, limitations, and uses of social media (e.g., Twitter, Facebook) for health communication among the general public, which provides insights for future health communication research. Given that social media have been widely used in China, scholars began to place more emphasis on health communication with the public via Chinese social media. Previous studies have identified possible factors affecting online health communication in China. These studies mainly focus on the analysis of non-content factors. For instance, Gao et al. [11] argued that Chinese users’ perceived credibility of health information related to participants’ involvement level and prior knowledge. Jiang [12] illustrated that the presence of interactive functions in Chinese social media contributed to productive communication between health care organizations and the public. Moreover, prior study found that social networks and social support affected how Chinese people viewed the health issue and disseminated specific information [13]. A few studies looked into the content of health information on social media. Jiang and Beaudoin [14] studied the smoking information posted from an organization’s account on Weibo. The results uncovered that perceived risk and self-efficacy content positively influenced audience engagement. Liu et al. [15] illustrated that messages emphasizing the benefits of recommended healthy practices and harmful outcomes of unhealthy practices were associated with a Chinese user’s behavior, such as shares and comments. Tian et al. [16] analyzed online messages indicating depression, which provided insights for medical practitioners to better communicate with people suffering from depression in China.

To sum up, we found that most of the studies fell into the following three categories: (1) the effectiveness of health information provided by Chinese organizations and non-professional online users [13]; (2) typical health problems, such as depression, smoking addiction, and HIV in China [16]; (3) positive effects of Chinese social media on health communication [6]. However, few empirical studies focused on health information provided by Chinese doctors via social media, especially pediatricians. Likewise, the effectiveness of driving factors in Chinese SMIP’s communication on public engagement has not been sufficiently discussed. Public engagement is important because it reflects the public’s attitude and affects their trust and relationship with involved members [17,18]. When there is a high level of public engagement, the public’s panic, anxiety, and uncertainty will be minimized and the trust on the SMI will be improved [19,20]. Therefore, the study of the effectiveness of driving factors in Chinese SMIP’s online communication on public engagement is highly warranted. The study can help pediatricians, and other doctors, better understand the constituent parts of online messages to be employed when they attempt to engage the public in health conversations through social media. Moreover, a better understanding of how people view doctors’ online health communication would strengthen the value of the principles that guide good communication.

1.2. The Importance of Genuineness and Its Role in Health Communication

Among all the driving factors in health communication, genuineness has been suggested as a contributing factor in effective medical communication, especially in patient-centered psychotherapy [21]. Norcross and Newman [22] pointed out that health practitioners considered doctors’ genuineness as “important for significant progress in psychotherapy, and, in fact, fundamental in the formation of a working alliance” (p. 104). Likewise, therapists’ characteristics, especially genuineness, authenticity and honesty can enhance their credibility which was essential for promoting therapeutic alliance and patients’ trust [23,24,25]. Genuineness has been widely studied in face-to-face communication between doctors and patients. Little attention has been paid on the importance of genuineness on health communication in the context of social media. Due to the absence of concrete operational dimensions in studying genuineness, we developed an integrated framework that included four dimensions-- “self-disclosure”, “genuine response”, “functional interactivity” and “genuineness in Chinese culture”, for examining genuineness in social media communication based on previous studies in health communication, dialogic communication, and the study of Chinese culture. The first three are universal dimensions that occur regardless of the cultural context while the fourth dimension is a cultural determined dimension which is essential to Chinese communication.

1.2.1. Self-Disclosure

There is no universally agreed-upon definition of genuineness. However, the common features of genuineness focus on “self-dimension,” referring to transparency, realness, and the authenticity of one’s mind and behavior. In the medical field, Landreth stated, “the most significant resource the therapist brings to therapy relationship is the dimension of self. Skills and techniques are useful tools, but therapist’s use of their personalities is their greatest asset” ([26], pp. 104–105). Egan also specified that genuineness is “beyond professionalism and phoniness” ([27], p. 55). It refers to an attitude or behavior that can only be expressed if the doctor is self-aware [28]. Similarly, studies have noted that doctors’ genuineness could be conceptualized as being real, being their true authentic self, and getting rid of dishonest and false behavior [29]. Nevertheless, how to concretely perceive genuineness via “self” has been understudied. Previous studies once demystified the idea that “self-dimension” of doctors’ genuineness could be identified by self-disclosure during the health care process [30,31,32].

Self-disclosure is defined as being willing to consciously and intentionally reveal personal feelings, life experiences, and professional knowledge in the process of communication to establish a positive relationship [30]. Self-disclosure has received extensive attention in medical research because of its benefits to patients’ positive health practices and doctor-patient relationships [31]. Previous research [30,31,32] found three main types of self-disclosure being preferred by the doctors, namely the disclosure of personal thoughts/feelings, disclosure of personal life, and disclosure of personal expertise (e.g., pediatrics, neurology and psychiatry). A study reported [31] that patients liked their doctors more when doctors disclose personal feelings and thoughts. Patients viewed an act of expressing feelings and thoughts from doctors as friendly and helpful because it encouraged patients to participate in a dialogue and enhance patient’s self-exploration [31]. Another study suggested that when a doctor disclosed his/her own lifestyle (e.g., positive health behaviors or daily activities), patients considered the doctor to be more credible and approachable [32]. Likewise, patients particularly valued when doctors disclosed the accumulated skills, experience, and specific expertise in the field [28,29,30]. Expanded on the previous studies, our study aims at investigating these three types of self-disclosure exhibited in the SMIP communication, and how public responded to different types of disclosure.

1.2.2. Genuine Response

In addition to self-disclosure, prior studies [33,34,35,36] confirmed that genuineness could be manifested when healthcare workers communicate consistently and provide expertise and emotional support to patients. In the health communication, a consistent response from doctor matters because it reflects “the degree to which one person is functionally integrated in the context of the relationship with another, such that there is an absence of conflict or inconsistency between their total experience, their awareness, and their overt communication in their congruence in the relationship” ([34], p. 12). A genuine response is not a response that simply expressed Yes or No answer or a simple act of reaction (e.g., smile/cry). It emphasizes on the recognition of interlocutors’ concerns, thereby providing professional and emotional support to address their problems [33,34,35,36]. A genuine response to a patient’s question or concern, is useful for building a positive therapeutic relationship [35].

Yet, an absence of an analytical framework for examining genuine response was noted. As such, we have modified frameworks from previous studies [33,36] on health communication studies and proposed three main sub-dimensions to measure genuine response: (1) consistency, (2) knowledge, skill, experience and treatment advice, and (3) facilitation of hopefulness. Consistency emphasizes on whether patients’ concerns are well understood, and the response is on the right track [33,36]. Van et al. [36] noted that healthcare workers often rephrase or repeat the patient’s questions or concerns before providing follow-up treatment and explanation to demonstrate their understanding on patients’ needs. Bottorff et al. [33] pointed out that nurses who responded with expert knowledge, such as treatment and medical advice were able to reduce patients’ anxiety and uncertainty. They suggested that such responses enable patients to make informed decision-making and be more actively involved in a dialogue [33]. Moreover, previous research [33,35,36] indicated that nurses usually communicated emotional support through facilitation of hopefulness with patients during a therapeutic process. Bottorff et al. [33] and Van et al. [36] found that facilitation of hopefulness that nurses adopted in interactions contributed to reassuring patients and avoiding escalation of emotional instability, thereby leading to positive outcomes of treatment. In view of these, we intend to investigate and reveal genuine responses in SMIP messages by examining the three sub-dimensions adapted from previous studies on health communication [33,36].

1.2.3. Functional Interactivity

In addition to health communication studies, this study drew on insights from dialogic communication theory in public relation and communication studies where functional interactivity serves as one of the principle elements in creating a genuine and dialogic communication online [37]. Functional interactivity refers to the interface’s elements that allow an online user to interact with someone/an organization and build a dialogue between interlocutors [38]. Such elements include hyperlinks, multimedia, live-chat rooms, and questions [39]. Functional interactivity is of particular importance in social media communication where dynamic, two-way interactive communication is advanced by the proliferation of social media [40,41].

For a genuine and dialogic communication to emerge [37,40], interactive functions including “generation of return visits,” “conservation of visitors,” and “dialogic loop” were deemed necessary. The “generation of return visits” emphasizes on the return visit of the public while the “conservation of visitors” highlights the importance of connecting the public to the SMI. Both “generation of return visits” and “conservation of visitors” could be achieved by providing external links and hashtags to engage the public [41,42]. “Dialogic loop” placed much attention on promoting dialogue between SMI and the public where strategies including providing frequent responses, asking questions, and using multimedia are most employed [41,42]. Subsequently, this study examines the use of interactive functions for building genuine dialogue in SMIP communication and their association with public engagement.

1.2.4. Genuineness in Chinese Culture

If the first three dimensions of genuineness are universal dimensions that occur regardless of the cultural context, the fourth dimension can be identified as a cultural determined aspect which is essential in Chinese communication. In Chinese culture, honesty and kindness are viewed as necessary components for developing genuine dialogue [43,44,45,46], and therefore, are of particular value to the Chinese audience.

Honesty is the essence of Confucianism and has a deep impact on the moral personality development [47]. Kindness, along with compassion, care, friendliness, righteousness, and affection, is one of the Confucian values about a “good person” in Chinese culture [48]. A kind individual is positively related to excellent job performance [49]. Zhang et al. [50] also illustrated that the kinder a nurse is, the more satisfied patients are.

The genuineness in SMIP communication that attributes to the portrayal of a positive personality trait [46,47], could be measured by the use of lexical indicators for the expression of honesty and kindness [43,44,45,46]. Honesty in the Chinese culture is denoted as the moral quality of being consistent in words and deeds; opposite to hypocrisy; loyalty and open-mindedness; no lying, no fraud, no exaggeration, no distortion of facts [51]. As such, we postulate that lexical indicators related to (1) reasoning and explanation (e.g., because, so), (2) personal sharing and views (e.g., I think, I contend, I prefer), and (3) truth/facts (e.g., In fact, the truth is, the evidence reveals) are important in expressing honesty. Kindness in the Chinese culture denotes personalities of being friendly, harmonious, kind-hearted and nice, and behaviors of altruistic, affectionate, righteous, and caring [52,53]. In SMIP communication, we expected kindness to be expressed through the use of lexical indicators related to (1) caring (e.g., is that okay, are you satisfied, is this clear for you), (2) friendliness (e.g., hello, could you please, welcome), (3) gratitude (e.g., thanks, appreciate it), (4) blessing (e.g., wish you, no worries, everything will be fine), and (5) compliment (e.g., good question, you are right).

1.3. Public Engagement in Social Media

In our study, public engagement refers to the public’s responses to the content communicated via social media which reflects the public’s cognition and attitude on a particular issue [54]. Different level of public engagement on social media reveals their trust and relationship with involved members [20,55]. Previous research has studied public engagement in different contexts with varied definitions. In corporate-stakeholder communication, Bruce and Shelley defined public engagement as “the interaction between an organization and those individuals and groups that are impacted by, or influence, the organization” ([56], p. 30). In CEO communication, Men et al. conceptualize public engagement “as a behavioral construct focusing on publics’ interactions with CEOs” ([57], p. 87). In government communication, public engagement refers to the involvement of citizens in public affairs [58]. In this aspect, public engagement aims to boost mutual understanding and build up a good relationship between the local government and the public [58].

In recent years, scholars have started to study public engagement and perception in an online context due to the arrival of global social media platforms [59,60], such as Weibo, YouTube, Twitter, and Facebook, which all include the common feature of real-time public interaction. Social media includes a variety of functions to engage with the public (e.g., blogs, photo sharing, video sharing, live chatting, and co-generation of content), and offers the ability to express attitudes via reaction buttons, appearing at the bottom of the relevant content: Like, Share, and Comment [60]. “Like” is an indicator to express awareness and interest, which can be used to identify the popularity of messages [61,62]. “Share” provides the opportunity to connect the organizational message to one’s social group, and “Comment” enables direct dialogue with organizations [61]. These engagement indicators fall into different engagement levels. Like is the lowest level of engagement as it requires less cognitive effort and commitment than other indicators [62]. Share has a higher engagement level [63], as it can be viewed not only as an important indicator of user recognition but as user recommendation. This indicates that sharing requires certain time to evaluate the post’s value [64]. A comment is the highest level of public engagement, as it requires more effort by the public to figure out the meaning of posts and directly respond to the messages with words or descriptors [61]. The number of likes and shares may indicate an overall positive effect but analyzing constituting parts embedded in comments helps estimate outcomes more concretely and accurately [65]. For instance, Fan [66] argued that how people perceive products could be revealed in the comments thread. By studying the comments, the organization will know the weaknesses and affordances of products. Public perceptions towards the content can also be amplified or constricted by reviewing other users’ comments [67]. Therefore, comments can be quite persuasive on affecting public opinions [68]. The present research categorizes comments as the high, shares as the intermediate, and likes as the low level of public engagement indicators.

Beyond the three engagement indicators, we paid particular attention to the valence of positive user comments. Kim and Yang [63] found that positive comments towards an organization are more likely to affect how people remember the organization, and further influence the organization’s reputation. In tourism, for example, positive e-comments on businesses strongly influence travelers who read e-comments when they decide to select a hotel [69]. In the health field, positive online comments were positively associated with the effectiveness of anti-smoking persuasion on the public’s attitudes [70].

1.4. Development of Research Questions

Given the impact of SMIP on public views and boosting children’s health, we aim to identify the effectiveness of genuineness, one of the most influential driving factors in health communication, in SMIP’s online communication. The paper employs the coding framework of four genuineness dimensions generated from dialogic communication, health communication and Chinese cultural studies to examine the association between genuineness and public engagement. Further, it provides an in-depth understanding on the relationships between genuineness and public reception indicators (i.e., likes, shares, comments, and positive comments).

For the first research question (RQ), we aim to investigate the association between the four dimensions of genuineness and public engagement, therefore the following research question is put forward:

RQ1: What is the association between the four dimensions of genuineness (“self-disclosure”, “genuine response”, “functional interactivity” and “genuineness in Chinese culture”) and public engagement?

To fully understand the relationship within sub-dimensions in each dimension and public engagement, our second set of research questions is formulated as follows:

RQ2a: What are the associations within the sub-dimensions of “self-disclosure” (“disclosure of personal life”, “disclosure of personal thoughts and feelings”, and “disclosure of personal expertise in pediatrics”) and public engagement?

RQ2b: What are the associations within the sub-dimensions of “genuine response” (“consistency”, “knowledge, skill, experience and treatment advice”, and “facilitation of hopefulness”) and public engagement?

RQ2c: What are the associations within the sub-dimensions of “functional interactivity” (“the generation of return visits and conservation of visitors”, and “dialogic loop”) and public engagement?

RQ2d: What are the associations within the sub-dimensions of “genuineness in Chinese culture” (“honesty” and “kindness”) and public engagement?

2. Materials and Methods

2.1. Sample Selection

First, we employed a self-developed Python program programmed by our research assistant with a postgraduate degree in computational science to identify the top pediatricians based on their number of followers in Weibo, one of the largest microblogging sites in China. The crawler is designed to search and identify verified pediatrician using the keywords “pediatrician” and the label “V-users”. “V-users” referred to verified users where doctors need to submit their medical certificates to Weibo to prove their authenticity. Once approved, the letter “V” with a yellow badge will be assigned to these doctors’ profile pictures. Verified pediatricians are preferred in our study, as they are much more influential in the social media community than non-verified ones [71]. The identified pediatricians with the highest number of followers in March are recognized as social media influencers in pediatric (SMIP) in our study as they are well connected and persuasive in their field.

2.2. Data Collection

As an exploratory study, we scrutinized the number of posts published by these top 10 SMIP for six months (from March 1 to August 31, 2019), to ensure that they are active communicators online. Subsequently, we replaced two inactive users who published fewer than two posts/day on average with the next two SMIP on the list. Table 1 presents the final list of Top 10 SMIP.

Table 1

Top 10 SMIP in Sina Weibo and the total number of their postings and followers.

Rank	Name of the SMIP (English Translation)	V label in Sina Webo	Total No. of Posts (Mar 1 to Aug 31, 2019)	Average No. of Posts/Day	Followers(as of Mar 1, 2019)
1	崔玉濤(Cui Yu Tao)	Pediatrician	368	2	7,700,000
2	蝦米媽咪(Xia Mi Mommy)	Pediatrician	430	2.337	4,870,000
3	鮑秀蘭診室(Bao Xiulan clinic)	Pediatrician	5160	28.044	4,630,000
4	張思萊醫師(Physician Zhang Silai)	Pediatrician	12,915	70.19	3,330,000
5	小兒外科裴醫生(Pediatric Surgeon Doctor Pei)	Pediatrician	759	4.125	1,840,000
6	醫生媽媽歐茜(Doctor Mommy Ou Qie)	Pediatrician	688	3.739	1,720,000
7	兒童營養師劉長偉(Child nutritionist Liu Changwei)	Pediatrician	523	2.842	1,330,000
8	兒科醫生雨滴(Pediatrician Yu Di)	Pediatrician	2661	14.462	990,000
9	兒科醫生魚小南(Pediatrician Yu Xiaonan)	Pediatrician	436	2.37	930,000
10	張亞停醫生(Doctor Zhang Yating)	Pediatrician	1580	8.587	890,000

Unlike Twitter, Weibo tends to change its open API at times for the purpose of data security and timely technical updates. Moreover, Weibo has a strict “restrictions on the API usage rate and unsolicited data requests” ([72], p. 597). Therefore, we had to manually collect the SMIP posts, record the number of comments, likes and shares and analyze positive comments for our study. Due to the complexity of the ten sub-dimensions embedded in the four dimensions of genuineness, we decided to code the sub-dimensions manually to ensure an accurate interpretation [54] on the use of genuineness in the SMIP posts. Taking all these into considerations, we decided to harvest a sample size of 300 posts to represent the target population. We have employed the sample size calculator developed by the Australian Statistics Bureau [73] to estimate a sample size of 300, giving a confidence level of 95%, a confident interval of 0.056, and standard error of 0.029. Through systematic random sampling, we randomly sampled 30 posts from each SMIP’s Weibo account between March 1 and August 31 in 2019 for content analysis.

2.3. Coding Scheme and Procedure

Content analysis was employed to examine the four dimensions of genuineness adopted in the 300 posts of the top 10 SMIP on Weibo. Content analysis is a widely employed method in the study of media communication [74] and can be applied to “virtually any form of linguistic communication to answer the classic questions of who says what to whom, why, how, and with what effect” ([75], p. 268). It is concerned with the context where the occurrences of words, signs, and sentences are examined to provide in-depth understanding [74,76]. Researchers could adapt and integrate framework from previous research for conducting coding in content analysis [74,76]. In this study, we have drawn insights from health communication, dialogic communication and Chinese cultural studies (see Section 1.2.1, Section 1.2.2, Section 1.2.3 and Section 1.2.4) to develop a four-dimension framework in genuine communication for pediatricians. A code book that includes the four dimensions of genuineness, the ten sub-dimensions, and descriptors to investigate the genuineness in SMIP’s communication has been developed (see Table 2). The coding procedure of each dimension is listed below:

Table 2

The major dimensions, sub-dimensions and descriptors of the code book.

Dimensions	Sub-Dimensions	Descriptors
Self-disclosure	Disclosure of personal life	Share daily life (e.g., habit, activity, behavior)
	Disclosure of personal thoughts and feelings	Uncover the views and attitudes towards something
	Disclosure of personal expertise in pediatrics	Share the content related to pediatrics and children’s health
Genuine response	Consistency	Rephrase or repeat public’s questions and expressions to ensure their concerns are well understood
	Knowledge, skill, experience and treatment advice	Provide treatment advice with elaborations for public concerns; Provide medical knowledge and experience to raise public health awareness
	Facilitation of hopefulness	Express a sense of hope, e.g., “you can handle that”, “no worries”, “I can help you”
Functional interactivity	Generation of return visits and conservation of visitors	Provide links/hashtags to the pediatrician’s clinic/organization/own Weibo page; Provide links/hashtags to other social networks in which the Pediatrician is present; Provide links/hashtags to other Weibo pages
	Dialogic loop	Reply by the pediatrician to a user’s comment on a post/comment thread; Multimedia (type: text, live chat, video, audio); Encourage more enquiry; Ask questions
Genuinenessin Chinese culture	Honesty	Lexical indicators related to reasoning and explanation, e.g., because, so; Lexical indicators related to personal sharing and views, e.g., I think, I contend, I prefer; Lexical indicators related to truth/facts, e.g., In fact, the truth is, the evidence reveals
	Kindness	Expressions of care, e.g., is that okay, are you satisfied, is this clear for you; Expressions of friendliness, e.g., hello, could you please, welcome; Expressions of gratitude, e.g., thanks, appreciate it; Expressions of blessing, e.g., wish you, no worries, everything will be fine; Expressions of compliments, e.g., good question, you are right.

For the dimension of “Self-disclosure”, we coded the pediatrician’s willingness to disclosure information related to his/her: (1) personal life, (2) personal feelings and thoughts, and (3) personal expertise in pediatrics [30,31,32] in the post on sentence basis.

For the dimension of “Genuine response”, we coded to reveal if the pediatrician demonstrates: (1) consistency, (2) knowledge, skill, experience and treatment advice, and (3) facilitation of hopefulness in his/her response in comment thread on sentence basis [33,34,35,36].

For the dimension of “Functional interactivity”, we coded the number of interactive elements (e.g., links, hashtag, multimedia, responses) used to facilitate: (1) “the generation of return visits and conservation of visitors,” and (2) creation of “dialogic loop”. Refs. [37,39,41,42] in the post and comment thread.

For the dimension of “Genuineness in Chinese culture”, we coded the number of lexical indicators that demonstrates pediatrician’s personality: of (1) honesty, and (2) kindness [43,45,46]; Refs. [50,51,52,53] in the post and comment thread.

To ensure a high accuracy of analysis, a face-to-face meeting was held by the first author and the second author before the coding exercise. The authors identified the related descriptors, including lexical indicators and features in each dimension. Relevant examples were retrieved from the database collected to guide the coders in the process of coding. The first author and a well-trained research assistant who possesses a MA in communication conducted the coding in this study. Table 2 presents the four dimensions, ten sub-dimensions, and descriptors of the code book. The related examples extracted from the database could be found in Appendix A.

For the evaluation of public engagement, the number of shares, likes, comments, and positive comments were identified. Beyond three engagement indicators, we paid particular attention to the valence of positive user comments, as positive comments can contribute to the excellent reputation of social media influencers and enhance public trust [65,77]. Online positive comments are characterized by the expression of compliment and affirmation, admiration and gratitude, usefulness and goodness [78]. In the corpus of this study, the comments, such as “thank you doctor,” “beneficial advice,” “great,” and “feel the same way” were recorded.

2.4. Interrater Reliability

The coding was conducted by the first author, the primary coder, and a well-trained research assistant who possesses a MA in communication. To ensure inter-rater reliability on the coding of “self-disclosure”, “genuine response”, “functional interactivity”, “genuineness in Chinese culture”, and public engagement, the coders were highly trained on the coding scheme. Any disagreement between the two coders was discussed in the coding process until the agreement was achieved. The measure of interrater reliability was based on the co-coding of 60 posts from the top two SMIP (20% of the total number of posts studied). For all categories, the average agreement was higher than 0.95, and the average Cohen’s Kappa was greater than 0.9, indicating an almost perfect agreement [79]. Please refer to Table 3 for the interrater reliability of all categories.

Table 3

Summary of Inter-Rater Reliability Statistics.

Dimensions/Public Response	Sub-Dimensions	Percent Agreement	Scott’s Pi	Cohen’s Kappa	Krippendorff’s Alpha
Self-disclosure	Disclosure of personal life	95%	0.91	0.91	0.912
	Disclosure of personal thoughts and feelings	96.7%	0.969	0.969	0.97
	Disclosure of personal expertise in pediatrics	98.3%	0.807	0.807	0.808
Genuine response	Consistency	91.7%	0.896	0.896	0.897
	Knowledge, skill, experience and treatment advice	95%	0.845	0.845	0.846
	Facilitation of hopefulness	95%	0.923	0.923	0.923
Functional interactivity	Generation of return visits and conservation of visitors	96.7%	0.928	0.928	0.929
	Dialogic loop	93.3%	0.867	0.867	0.868
Genuineness in Chinese culture	Honesty	96.7%	0.934	0.934	0.935
	Kindness	100%	1	1	1
Public response	Shares	100%	1	1	1
	Likes	100%	1	1	1
	Comments	100%	1	1	1
	Positive comments	93.3%	0.867	0.867	0.868

2.5. Data Standardization and Statistical Analysis

Since the content in posts and responses in comment threads varied from two words to 140 words, all coded data have been standardized, especially the coding done on sentence basis. As such we have standardized the coding data of the sub-dimensions in “self-disclosure” and “genuine response” by dividing the number of sentences yielded in each sub-dimension in every post by the overall number of sentences in each post. As for the sub-dimensions of “functional interactivity” and “genuineness in Chinese culture”, we standardized the data by dividing the number of features harvested in each sub-dimension in every post by the total count of features in each post.

As likes, shares, comments, and positive comments are count outcomes, Poisson regression was employed for statistics analysis. However, we found overdispersion exhibited when testing for assumptions in Poisson regression. Then we decided to employ negative binomial regression to replace Poisson regression as suggested in previous research [80,81].

Negative binomial regression (NB2) fits various types of data arising in communication research [81], and “the negative binomial model is a more general model compared with the Poisson regression model that relaxes the strong assumption that the underlying rate of the outcome is the same for each included participant” [82] (p. 3). Moreover, negative binomial regression allows various information to be included [82]; it is appropriate for the data in this study, especially in the presence of overdispersion. Thus, RQ1 and RQ2 were examined via negative binomial regression in which likes, shares, comments, and positive comments were taken as dependent variables. For the examination of associations between the four dimensions and public engagement in RQ1, standardized data in the sub-dimensions were summed up in the related dimension. For instance, the data in “disclosure of personal life”, “disclosure of personal feelings and thoughts”, and “disclosure of personal expertise” were combined to form the “Self-disclosure”.

As for RQ2, we used the standardized data in the sub-dimensions to examine if there was a significant association between sub-dimensions in each genuineness dimension and public engagement.

3. Results

In this section, we aim to reveal the association between the four dimensions of genuineness and public engagement and then identify different levels of impact of sub-dimensions in each genuineness dimension on public engagement. In response to RQ1, the NB2 findings indicated the number of “genuine response” was positively associated with the number of comments and positive comments, but negatively related to number of shares. For every extra sentence on “genuine response”, 1.344 times more comments were generated, a statistically significant result (p < 0.0001). Similarly, there was a 16% increase in the number of positive comments for each extra sentence on “genuine response” (p = 0.0001). Likewise, a positive association was found between the occurrence of “functional interactivity” and shares, whereas there was a negative correlation with comment and positive comments. A 19.8% increase in the number of shares is expected for every extra feature in “functional interactivity” found (p = 0.0001). In addition, the frequency of “genuineness in Chinese culture” was positively related to the number of shares. For every extra lexical indicator in “genuineness in Chinese culture”, 1.122 times more shares were generated (p = 0.003). Table 4 summarizes the negative binomial regression results on the four dimensions of genuineness and public engagement.

Table 4

Negative Binomial Regression Results on the Four Dimensions of Genuineness and the Number of Shares, Likes, Comments and Positive Comments.

Dimensions	Number of Shares			Number of Likes			Number of Comments			Number of Positive Comments
	B	SE	Exp(b)	B	SE	Exp(b)	B	SE	Exp(b)	B	SE	Exp(b)
Self-disclosure	−0.037	0.05	0.964	0.029	0.05	1.030	0.068	0.04	1.070	0.014	0.03	1.014
Genuine response	−0.247 ***	0.05	0.782	0.038	0.05	1.039	0.296 ****	0.04	1.344	0.148 ***	0.04	1.160
Functional interactivity	0.180 ****	0.05	1.198	0.015	0.04	1.015	−0.158 ***	0.04	0.854	−0.090 *	0.04	0.914
Genuineness in Chinese culture	0.115 **	0.04	1.122	0.064	0.04	1.067	−0.007	0.03	0.993	0.052	0.03	1.054

p < 0.05 *, p < 0.01 **, p < 0.001 ***, p < 0.0001 ****.

The results above show that three sub-dimensions of genuineness, namely “genuine response”, “functional interactivity” and “genuineness in Chinese culture”, have significant associations with public engagement on social media. Therefore, we intend to further examine the association between the sub-dimensions in the four genuineness dimensions and public engagement. Table 5 summarizes the negative binomial regression results on the sub-dimensions of “self-disclosure”, “genuine response”, “functional interactivity”, “genuineness in Chinese culture” and the number of shares, likes, comments and positive comments.

Table 5

Negative Binomial Regression Results on the Sub-dimensions of “Self-disclosure”, “Genuine response”, “Functional interactivity”, “Genuineness in Chinese Culture” and the Number of Shares, Likes, Comments and Positive Comments.

Dimensions	Number of Shares			Number of Likes			Number of Comments			Number of Positive Comments
	B	SE	Exp(b)	B	SE	Exp(b)	B	SE	Exp(b)	B	SE	Exp(b)
Self-disclosure
Disclosure of personal life	0.209 **	0.07	1.232	0.229 ***	0.06	1.257	−0.083	0.07	0.921	0.055	0.07	1.057
Disclosure of personal thoughts and feelings	−0.068	0.09	0.935	−0.016	0.08	0.984	−0.116 *	0.06	0.890	−0.084	0.07	0.919
Disclosure of personal expertise in pediatrics	0.125 **	0.04	1.133	0.017	0.03	1.017	−0.036	0.03	0.965	0.003	0.03	1.002
Genuine response
Consistency	−0.189	0.12	0.828	0.338 ***	0.09	1.402	0.458 ****	0.10	1.581	0.298 ***	0.09	1.347
Knowledge, skills, experience and treatment advice	−0.145	0.08	0.865	0.039	0.06	1.039	0.294 ****	0.07	1.342	0.153 *	0.06	1.166
Facilitation of hopefulness	−0.598 ***	0.18	0.550	−0.298 *	0.13	0.742	0.035	0.15	1.036	−0.073	0.13	0.929
Functional interactivity
Conservation of visitors and generation of return visits	0.354 ***	0.10	1.425	0.197 *	0.08	1.218	−0.194 *	0.08	0.824	−0.032	0.07	0.969
Dialogic loop	0.078	0.07	1.018	−0.004	0.05	0.996	−0.170 **	0.06	0.844	−0.132 *	0.055	0.876
Genuineness in Chinese culture
Honesty	0.147 ***	0.05	1.158	0.100 ***	0.03	1.106	0.039	0.04	1.039	0.068 **	0.03	1.070
Kindness	0.047	0.12	1.048	−0.005	0.09	0.995	−0.119	0.09	0.888	0.053	0.07	1.055

p < 0.05 *, p < 0.01 **, p < 0.001 ***, p < 0.0001 ****.

In response to RQ2a, we found that in the dimension of “self-discourse”, “disclosure of personal life” had positive effects on the number of user shares and likes, while “disclosure of personal expertise in pediatrics” is positively associated with number of shares. For every extra sentence in “disclosure of personal life” and “disclosure of personal expertise in pediatrics”, 1.23 (p = 0.003) and 1.13 (p = 0.005) times more shares were generated. For every extra sentence in “disclosure of personal life”, 1.26 times (p = 0.0003) more likes were expected. However, the “disclosure of personal thoughts and feelings” was negatively associated with the number of comments. For every extra sentence in “disclosure of personal thoughts and feelings”, 0.89 times (p = 0.033) fewer comments were expected (See Table 5).

Regarding the sub-dimensions in “genuine response” (RQ2b), our findings revealed that “consistency” had positive effect on the total number of likes, comments, and positive comments. 1.402 times more likes (p = 0.0003), 1.581 times more comments (p < 0.0001) and 1.347 times more positive comments (p = 0.001) were witnessed for every extra sentence on “consistency” provided. Similarly, the sub-dimension of “knowledge, skill, experience and treatment advice” was positively associated with the number of comments and positive comments. For each extra sentence on “knowledge, skill, experience and treatment advice”, 1.342 times more comments (p < 0.0001) and 1.166 times more positive comments (p = 0.013) were yielded. However, the sub-dimension of “facilitation of hopefulness” was negatively associated with the number of likes and shares. For every extra sentence on “facilitation of hopefulness”, 0.55 times fewer shares (p = 0.001) and 0.742 times fewer likes (p = 0.023) were generated, as presented in Table 5.

For the dimension of “functional interactivity” (RQ2c), the “generation of return visits and conservation of visitors” had positive effects on the total number of shares and likes, whereas “dialogic loop” had a negative association with the number of comments and positive comments.

For every additional “conservation of visitors and the generation of return visits” included, the shares and likes increased by 43% (p = 0.001) and 22% (p = 0.018) respectively while comments and positive comments decreased by 84% (p = 0.005) and 88% (p = 0.015) for every extra feature of “dialogic loop” provided, as shown in Table 5.

Last but not least, “honesty” in the dimension of “genuineness in Chinese culture” (RQ2d) had a positive association with the number of shares, likes, and positive comments in contrast to kindness, which showed no significant association. For every extra lexical indicator on “honesty”, 1.158 times more shares (p = 0.001), 1.106 times more likes (p = 0.0004), and 1.07 times more positive comments (p = 0.007) were generated, as presented in Table 5.

4. Discussion

Our results revealed that a variety of genuineness dimensions was employed by the SMIP to communicate with the public on social media. The findings yielded insights into how the “genuine response” alongside “functional interactivity” and “genuineness in Chinese culture” played an active role in engaging the public.

4.1. Strong Effect of Genuine Response on Public Shares and Comments

Corroborated with previous studies [33,36,83], our findings revealed that responses with high level of consistency and expert knowledge were positively associated with public engagement (Table 5). A doctor responded by acknowledging the public’s need helps develop a trustful relationship [84], even in online doctor-public communication. Furthermore, response with medical knowledge and treatment advice indicates the doctor’s understanding of patient’s concerns and his/her intention to address the issues [85]. This could be the reasons attributing to the positive association between “genuine response” and the number of likes and comments, especially the positive comments.

“Genuine response” that aimed to address patients’ concerns created more opportunities for the public to express feelings (e.g., grateful, satisfied) in the comment threads, and allowed them to continually ask questions if their concerns were not fully addressed. The phrases “thanks, doctor,” “beneficial advice,” “learn a lot,” “really appreciate your patient guidance” and “what I need to do in the next step” were frequently unveiled under the comment threads.

4.2. Interactive Features Promote Public Shares

In line with previous studies [37,40,42,57], our results also revealed the strong effect of “functional interactivity” on public shares (Table 4 and Table 5). We found a range of interactive features, in the form of links/hashtags, such as “#SIMP name+topic#”, “@+other online users name” and “link to other Weibo pages”, employed on the SMIP posts which foster the public’s access to various and detailed information.

Hashtags lead users to daily hot topics where users can make synchronous conversations, discuss relevant issues with others, and share insightful ideas [57]. Links enable users to return the site and increase the time of stay when reading messages [42]. Owing to word limit on Weibo, the SMIP messages may not explain the ins and outs of a health problem thoroughly. The offering of external links expands messages in greater detail and strengthens the usefulness of corresponding posts, thereby fostering information sharing. Given that the act of sharing can potentially reach out to a large audience, online doctors can adopt interactive elements to express genuineness and extend their influences.

4.3. Honesty is Highly Valued in Chinese Culture

Noticeably, the sub-dimension “honesty” positively engendered public engagement of likes, shares and positive comments (Table 5). The expressions in honesty mainly involve verbs and adverbs related to explanation, personal views, and facts, such as “for instance,” “include,” “I think,” “I suggest,” “according to,” and “the document shows.” Tuckett [86] specified that “honesty” is “perceived as truth-telling” (p. 500), and the extent to which truth-telling is preferred is highly related to culture and context. As noted in previous study [86], “honesty” is a fundamentally ethical principle in doctor-patient relationships. The majority of patients in China demonstrate that they want truthfulness and authenticity about their illness, which could enable them to manage uncertainty and make decisions independently [50]. This might also explain the negative association between sub-dimension of “facilitation of hopefulness” in the “genuine response” and shares and likes. To some extent, expression of hopefulness is intended to comfort patients instead of telling the whole truth [33,36], and the truthfulness of such expressions often arises suspicion.

Also, the shared post represents the user [62]. A previous study [87] found that online self-presentation was a crucial part of impression management, in which the public carefully evaluated someone by how he presented himself. This suggests that sharing requires more cognitive effort [64]. Given that “honesty is the traditional morality of Chinese nationalities and is regarded as the basis of the making of a man” ([88], p. 177), it is not surprising to see the public’s willingness in sharing “honest” so as to promote positive personality traits on social media.

4.4. Self-Disclosure as a Controversial Communication Behavior

Despite previous studies suggested doctor’s “self-disclosure” may have a positive impact on patients’ reactions and foster a stronger therapeutic relationship, our results reveal that “self-disclosure” has no significant association with any level of public engagement (Table 4). Beach et al. [89] argued that doctors’ personal disclosure to patients have sometimes been regarded as a boundary transgression. Doctors should be more careful about disclosing personal information [86]. “Self-disclosure” has been viewed as a positive intervention in doctor-patient communication but it could also hinder effective communication and lead to negativity [90]. Kelly and Achter [91] found that patients concerned the helpfulness and benefits of the disclosure information from doctors for their decision on engagement. If they think the information would be useful for their situations, they are willing to further interact with doctors and listen to their suggestions [92]. However, given that “self-disclosure” messages in this study mainly involve personal life, opinions, and feelings that may not be relevant to the public’s concerns and problems, a lower level of public engagement is expected. Forest and Wood [90] commented that it is not surprising that people may disapprove or doubt the information provided by therapists who share personal opinions and experience frequently. Likewise, disclosure of personal expertise may involve the discouraging expressions [92], which makes the public feel sad and stressful. In addition, McDaniel et al. [93] found that the frequent statements about the doctor’s personal life (e.g., family, habit) and professional information are, occasionally, of little value to impair the doctor-patient relationship because they may result in fewer opportunities for patients to express themselves. General information is prevalent in SMIP’s posts on Weibo as each post is limited to 140 words, but there are a variety of followers with different needs. In other words, the posts cannot meet everyone’s demands even though SMIP want to provide detailed information. Therefore, the public may not react to some information that is not tailored to their problems.

5. Conclusions

Academically, this study contributes to the research of health communication in the following aspects: (1) developed an integrated framework to conceptualize and measure genuineness in social media communication and (2) shed lights in the understanding of effect of genuineness on Chinese public engagement in SMIP online communication.

In terms of practical implications, this study provides insights to health information providers such as pediatricians in engaging public on social media communication. For instance, the use of “genuine response” could raise public awareness which in turn facilitates the fostering of a healthy lifestyle.

This study also has strong social implications. In recent years, the Chinese government has placed public health at the center of the country’s entire policy-making agenda and initiated a national long-term strategic public health plan. One of the missions is to improve the well-being of citizens by spreading health knowledge and promoting quality medical care. Sustainable investment and efforts have been put into relevant fields, especially online, because in China, the Internet is becoming increasingly important in health care and offers a great number of platforms for patients to seek health information and conduct medical consultations. Therefore, this research provides insights into the formation of high-quality health information and productive medical services.

Given the ongoing interaction between the public and SMIP on Weibo, further scrutiny on SMIP communication is highly warranted. Future studies could expand the database and include multiple social media outlets such as Wechat, TouTiao, and Baidu to fully examine the associations between different dimensions of genuineness and public engagement. With regard to the coding procedure, the data were not exhaustively coded as double coding within dimension was not allowed in this study. Lastly,“genuineness in Chinese culture”in this study was measured based on the lexical markers derived from the Chinese dictionary and relevant studies. To ensure a higher level of objectivity, we could harvest the most used words on content and style of genuineness by interviewing/surveying social media users that have interacted with the SMIP on Weibo.