Perceptions towards orthodontic marketing through social media among young adults seeking orthodontic treatment: a qualitative study
Pubblicato online: 24 apr 2024
Pagine: 73 - 84
Ricevuto: 01 ago 2023
Accettato: 01 ott 2023
DOI: https://doi.org/10.2478/aoj-2023-0034
© 2024 Amalina Adanan et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
Consumer decision-making patterns have evolved because of the Internet and online-based social media, which have provided consumers with new means for searching, evaluating, selecting, and purchasing goods and services. The increased use of social media marketing and advertising1,2 within dentistry, as well as the increased availability of oral health-related online information,3 has enabled patients to take a greater role in their oral health decision-making process. Although patients would traditionally rely heavily on their health care provider to deliver oral health information, the presence of social media has enabled third parties to have a greater influence on an individual’s decision-making through online reviews, trending posts or social media influencers. Currently, there are thousands of social media sites available for users to access for personal or business purposes, the most notable of which are Facebook, Twitter, Instagram, Telegram, TikTok, and YouTube.
Social media marketing in dentistry is a divisive topic. Although clinicians from across the globe have adopted a level of social media marketing of their dental practices, many are still unsure or reluctant to embrace its use due to concerns related to security, privacy, and potential damage to the profession’s image.4 Unlike traditional marketing strategies, social media has the power to disseminate information to a much wider audience, and removing content can be nearly impossible once it has been uploaded into the online world. The freedom and anonymity that social media offers have led to social problems related to the spread of false and misleading information,5 cyberbullying, fraud,6 identity theft, defamation, intrusion, and abuse of personal information. False information regarding oral health can mislead the public due to insufficient knowledge or awareness to ensure the validity of such content, which leads down the pathway of erroneous oral health decisions. In a survey conducted by the Malaysian Communications and Multimedia Commission (MCMC) in 2016, 82.7% of Malaysians either completely trusted or mostly trusted the health information found online regardless of the source.7
The vulnerability of consumers falling prey to misleading information is of particular interest in Malaysia as ‘fake braces’, also known as ‘beauty braces’, are commonly advertised and promoted on social media platforms.8 ‘Fake braces’ is a niche problem, particularly in Southeast Asia. It refers to fixed orthodontic appliances that are fitted on customers by individuals, who have no dental qualifications. Typically, these providers learn to fit the braces by watching YouTube videos or by attending short training courses provided by industry personnel. Local orthodontists have also been known to use social media marketing but their online activities are regulated by a code of ethics that seeks to maintain the integrity of the profession and the standard of dental care in the country.4
Although there are reported studies relating to social media use in dentistry, there is a lack of scientific evidence regarding social media marketing in orthodontics from the perspective of patients. The majority of the studies in this field of research are cross-sectional in nature and are related to questionnaire-based surveys that provide useful information but may not allow for an in-depth investigation of patients’ perspectives.9,10 Qualitative studies are useful to explore and gain a deeper understanding of patients’ experiences in using social media and whether social media influences their decision-making process. The information gained from the present study may be useful for dentists and orthodontists to improve their delivery of oral health related patient information as well as to understand the factors that influence patients’ oral health decisions. Therefore, the aim of the present study was to explore perceptions towards social media marketing by young adults seeking orthodontic treatment in Malaysia and to explore factors that influenced their decision-making process.
This qualitative study employed semi-structured in-depth interviews of young adults seeking orthodontic treatment to answer the following two research questions; (1) What are young adults’ perceptions of orthodontic marketing through social media ? and (2) What factors affect the decision-making process of young adults in relation to orthodontic marketing through social media? Ethical approval was obtained from the Faculty of Dentistry Medical Ethics Committee (FDMEC) from Universiti Malaya (UM) (DF CD1913/0062(P)) and Universiti Teknologi MARA (UiTM) Research Ethics Committee (REC/08/2020 (MR/180). The methodology was reported based on the COREQ checklist for qualitative research.11
The inclusion criteria for participants were young adults aged between 19- and 30-years old who were seeking orthodontic treatment at either tertiary government institutions or private dental clinics in the Klang Valley. Patients who were up to six months into their orthodontic treatment were also included as any information-seeking behaviour was considered to be recent. Potential participants were screened by answering several simple questions regarding their social media use. Participants had to be active social media users, having logged into their social media accounts within the last 48 hours. They also had to have actively used platforms such as Facebook or Instagram to search and purchase products or services, not limited to orthodontics in the recent past. These two social media platforms were chosen as both were being used for the marketing of orthodontics as well as ‘fake braces’.7,12 The sample was limited to patients who had a good command of either the English or Malay language and had actively requested or sought orthodontic treatment rather than patients referred by other dentists or specialists as it was inferred that this sample of patients may not have had full autonomy in their decision-making process. For similar reasons, younger patients were excluded from the present study. Patient selection was not exclusive to patients who had used social media to select their current provider as this may have led to a positive bias towards social media use. Patients who had used other means to determine their preferred clinic may provide insight into the disadvantages of using social media.
Purposive sampling was applied to ensure heterogeneity of the sample related to gender, ethnicity, and the type of clinic, i.e. private or tertiary public institutions. To ensure adequate representation from different demographic backgrounds, it was determined that the minimum sample size would be 12 participants whereas the final sample size would be determined by theoretical saturation of the data. Participants were recruited from two tertiary public dental institutions (the Faculty of Dentistry, Universiti Malaya or the Faculty of Dentistry, Universiti Teknologi MARA) and seven private clinics from the Klang Valley, Malaysia. The Klang Valley is an urban conglomeration in Malaysia, and sits within the borders of Selangor, Kuala Lumpur and Putrajaya. In 2020, the composition of the Klang Valley was 7.7 million people, which was 23.8% of the entire Peninsular Malaysia, making it a highly populated region and an appropriate site to conduct the present study.13 Representatives from each participating clinic were responsible for identifying and recruiting suitable participants. Consenting subjects were then contacted by the researcher (AA) via a telephone call to confirm their eligibility and to arrange an interview date. Prior to the interviews, participants were required to complete the consent form and a short online survey to gather demographic information relevant to the study. The participant interviews were conducted online via Zoom application or a face-to-face meeting within the clinic environment depending on patient preference and the Covid-19 pandemic restrictions. To ensure the rigour of the study, field notes and participant’s feedback were also taken. The interviewer (AA), a postgraduate orthodontic resident, underwent training and conducted pilot interviews to identify flaws and limitations within the interview design. Based on the pilot interviews, several modifications were made to the interview guide prior to commencing the main study.
The interviews were semi-structured in format, using an interview guide (Table I) developed based on previous literature and input from a panel of experts.9,10 Social media templates in the form of screenshots of two social media pages, were used to initiate conversation with the participants. One template consisted of an Instagram page offering ‘fake braces’ whereas a second template was an actual dental clinic Instagram page offering orthodontic treatment. The interviews ranged between 40 and 60 minutes each. Immediately after each interview, all audio and video recordings, field notes and participant’s feedback were transcribed verbatim into Microsoft Word format by a hired qualified transcriber. The transcripts were also sent to the participants to confirm their responses. Transcribed interviews were coded using NVivo 12 software and evaluated using thematic analysis by two researchers (AA and YK). Codes and themes were then presented to the rest of the research team (NA and ADB) to be discussed and confirmed. Only relevant quotes were translated and grammatically corrected when necessary for data display to assist the reader.
Interview Guides
| Opening questions | Probing questions |
|---|---|
| Can you describe your experience using social media platforms to search for clinics offering orthodontic treatment ? | I’m interested to know what have you seen on social media when searching for orthodontic treatment ? |
| Are there any individuals/ groups/ posts that would influence your decision in choosing a clinic ? | Can you elaborate how do they influence your decision? |
| These are two social media pages that you might came across on social media (Template 1 & 2). How would you choose from which clinic you would prefer to seek treatment? | Do the contents on these pages contribute to your decision in choosing that clinic? |
Fifteen participants aged between 22- and 30-years old were interviewed. Figure 1 shows the sociodemographic data of the participants whereas Figure 2 shows the emerging themes.
Figure 1.
Sociodemographic data of the participants..
Figure 2.
Main themes and sub themes.
To answer the first research question, themes were divided into two main areas defining positive and negative perceptions. It was evident that more sub-themes evolved under positive perceptions (source of information; marketing strategy; convenience; connection and communication) compared to negative perceptions (false and misleading information; disingenuous profile), suggesting that young adults had an overall positive attitude towards social media marketing in orthodontics. Table II shows the emergent themes and subthemes together with the frequency of their occurrence and representative quotes.
Frequency of sub-themes and representative quotes showing perceptions of young adults towards orthodontic marketing through social media
| Themes | Sub-themes and frequency cited | Examples of quotes |
|---|---|---|
| Positive | Source of information |
|
| Marketing Strategy |
||
| Convenience |
||
| Connection and Communication |
||
| Negative | False and Misleading Information |
|
| Ingenuine Profile |
All participants positively regarded social media as a source of information. They either directly used it to seek information or acknowledged other social media users who were using this medium to search for information. Social media was regarded as an easy and fast way to deliver updated information to the public. Apart from gaining information regarding potential dental clinics, most of the participants found social media to be a source of oral health information. One participant, however, acknowledged that not all information could be delivered via social media, as it was still felt that certain types of information such as details of surgery needed to be delivered directly by healthcare professionals.
Social media marketing was seen as a crucial part of modern marketing strategies, and that dental clinics should not avoid its use. Participants talked about how having a social media page was good marketing strategy for dental clinics, and if done correctly, could showcase the clinic in a positive light. This was particularly true for new dental clinics that used social media to promote their services, thus allowing the public to recognise their new establishment. The power of advertising was also discussed with the participants. Promotions advertised on social media were seen as positive and were likely to result in the participants contacting the clinic or supplier for further information or services.
Due to good marketing strategies on social media such as attractive designs and arrangements of the posts and catchy phrases, four of the participants admitted to being attracted to dental products such as clear aligners and even ‘fake braces’. One participant explained how pictures displayed on a ‘fake braces’ account page showcased braces that appeared to be of good quality and clean, therefore increasing confidence in the product. Another participant explained how she was attracted to one particular clear aligner brand due to appealing advertisements promising painless treatment.
Participants also discussed the convenience of social media, and its capability of being accessed anywhere and at any time, usually on their mobile phones. This allowed for the fast delivery of information which was considered timesaving by the participants. Social media was compared to traditional methods of driving around the neighbourhood in a car to search for a suitable clinic. In contrast, participants described the ease of using social media to compare services and prices between clinics with the click of a button. Real time announcements of clinic closure due to public holidays or unexpected reasons were seen as time saving, potentially avoiding a fruitless trip to the dental clinic. One participant explained how he liked the targeted marketing by online platforms as it assisted in his online searches.
The majority of the participants recognised that social media can be a positive medium to foster good patient-dentist relationships. Educational posts shared by their dentists on the platform were considered important in increasing dental knowledge and confidence in the clinician. Some participants even admitted to using social media to gauge their dentist’s character and personality by personally communicating with them online prior to deciding on whether they would visit the clinic. This included following their dentist’s personal social media page. Two participants, however, did not see the need to follow their dentist’s personal page unless they were having a close relationship or required specific information.
Twelve participants were aware that information found on social media could potentially be misleading or false, resulting in confusion. This was considered as a main disadvantage of social media marketing. Eight out of 12 participants who introduced this theme were aware of the ability of social media pages to practice the ‘buying’ of followers. Participants were also aware that the number of followers, likes and positive reviews could be manipulated by staff, friends, or family members. Two of the participants considered the issue of defamation, in which an individual could potentially spread false information with the malicious intention of sabotaging a rival clinic. The participants felt that this could easily happen and alluded to the lack of legal action and accountability related to online crime.
Nine out of 15 participants recognised that one of the risks of social media advertising was the presence of disingenuous profiles. It was expressed that identifying false profiles on social media was not always easy. Furthermore, the authenticity of official clinic profiles of dental professionals can be confused with the availability of illegal orthodontic services that thrive on social media platforms.
Seven main themes were identified when discussing factors affecting the decision-making process of young adults in relation to orthodontic marketing through social media. These themes were social media features, online trends, clinic location, third parties, treatment costs, knowledge and information availability. Table III shows the frequency of emergent themes and subthemes that evolved, with representative quotes.
Frequency of sub-themes and representative quotes showing factors affecting the decision-making process of young adults in relation to orthodontic marketing through social media
| Themes and frequency cited | Representative quotes |
|---|---|
| Social media features |
“… reviews from other customers influence me the most. Because no matter how good they advertise their services, at the end of the day, feedback from the clients is more reliable.”(IDI 10, 30-year-old Chinese male) |
| Treatment costs |
“As for me, I already have a budget, let’s say around RM 5000 only. So, I can’t go for treatment costing higher than that.” (IDI 9, 28-year-old Malay male) |
| Third parties |
“I trust my friend. Because my friend has already finished his treatment. So, I trust him.” (IDI 2, 25-year-old Malay male) |
| Location |
“Social media is helpful in terms of location as well. Sometimes we don’t realize about a newly opened clinic. So, when they market on social media, I think it’s helpful because most people want to do their braces nearby their house because it is convenient for them to go” (IDI 5, 26-year-old Malay female) |
| Current trends |
“…What kind of dental clinic people prefer ? I mean, which clinic is famous ? This is what t I have searched for before.” (IDI 15, 26-year-old Indian female) |
| Uncertainty and lack of knowledge |
“We don’t know which one is fake, which one is real… we don’t know how to differentiate that” (IDI 6, 24-year-old Indian female) |
| Information Availability |
““ I think it’s still lacking, the information on the knowledge-sharing part… they are more keen to sell their services rather than share information”” (IDI 10, 30-year-old Chinese male) |
There were two distinct social media features that influenced a young adult’s oral health decisions, which were feedback or reviews, and the number of followers. All participants commented on the issue of using reviews, feedback or complaints found on social media when deciding on a clinic to seek treatment. Two of the participants indicated that they placed greater emphasis on reviews by the public rather than the doctor’s credentials.
Five out of 14 participants acknowledged that the number of followers positively influenced their decision. It either stimulated their interest to follow the page or gave them the confidence to visit the clinic. Some even felt that the number of followers determined the quality of the clinic and reflected good marketing strategies. However, some participants were indifferent to the number of followers which was not considered a determining factor in their decision. More emphasis was placed on good patient-clinician relationships, good reviews and the quality of treatment. It was noted that the number of followers would be influenced by the number of years the clinic had been established or had been present on social media. Some even recognised that the number of followers could be influenced by marketing strategies such as the ‘buying’ of followers, thus they did not put great emphasis on the number of followers.
Young adults’ decisions were also influenced by current trends. In the context of the present study, this referred to social media pages that were ‘trending’ in the online world at a particular time. Facebook and Instagram features such as the number of shares, likes, hashtags, re-posts and mentions boost more attention, often leading to increased visibility and influence directed at their target audience. Young adults were more attracted to contents that were compelling and personally relevant, especially those with a strong social media presence.
Location was a factor that influenced a decision on the clinic from which to receive orthodontic treatment, and social media marketing was able to assist in this context. Although most participants agreed that they would prefer a clinic closer to home for convenient access, this was not always the case. One participant claimed that she had chosen her current clinic even though it was farther away, as she was influenced by the online reviews she had read on Instagram.
It was found that the decision-making process of young adults was influenced by third parties such as celebrities or influencers, family members, friends, and their dentists. Most of the participants who mentioned this theme acknowledged that they decided to seek treatment based on their family or friend’s recommendation. Some participants expressed that they would blindly follow their friend’s suggestion without doing any background research as they had full confidence in their friend’s opinion. Considering the amount of conflicting information on social media, apart from validating the information through their own research for credible information, some participants turned to their dentists for clarification of information or as their first source of information. Participants described supplementing the knowledge they received from their dentists through their own social media search or turning to their dentist only to clarify certain online information that they found confusing. As one participant explained,
Nine out of the 15 participants mentioned the issue of treatment costs and their effect on the decision-making process. For those on a tight budget, the choice of treatment was heavily reliant on cost. Another participant confessed that she had considered wearing ‘fake braces’ as it was the cheapest option. Five out of the nine participants indicated the issue of treatment costs on dental pages being vague and not adequately disclosed to the public. Frustration was expressed about the inability to gain this information through social media. Most of the participants wanted the treatment costs to be clearly displayed, as it would make it easier for them to make a decision.
Of the 15 participants interviewed, nine expressed their uncertainty regarding information found on social media. This matched their lack of knowledge to interpret or validate the information available. Three participants commented that the large number of dental pages that appeared upon searching made it difficult to differentiate between real dental clinics and ‘fake clinics’ offering illegal orthodontic services, due to insufficient knowledge to distinguish between the two. Others expressed concerns over their inability to identify false reviews and testimonials. This sentiment was explored earlier, under negative perceptions
The presence or absence of information on social media pertaining to orthodontic marketing also contributed to young adults’ decision-making processes. Twelve of the 15 participants identified this aspect during the interviews while five felt that there was a lack of information, either related to oral health information or the details of treatment provided. This sentiment was also explored under the earlier ‘cost’ sub-theme. Participants favoured clinic pages that were updated and had a high frequency of posts. Two of the participants stated that they were more likely to follow a page that was considered active on social media. Four participants were aware of the laws and regulations pertaining to doctors posting on social media and recognised the existence of these boundaries.
The present study revealed that young adults have positive perceptions towards social media marketing and consider it an effective advertising tool. Young adults are used to immediate gratification and social media can fulfil these social needs. Some participants, however, felt that the social media presence of dental clinics was still lacking, and pages were often inactive or overlooked required information such as treatment costs. Until recently, dental clinics in Malaysia were prohibited from publicly displaying treatment costs. To facilitate prospective patients in their decision making, the implementation of the new Dental Act in 2018 may address these issues as treatment costs can now be displayed. There is a wide global variation regarding social media usage for marketing purposes among professionals.4,14–17 A lack of time and knowledge and concerns over online ethical and professional conduct have been raised as barriers against widespread use.17–19 However, it is projected that marketing through this platform will continue to escalate1,20 as dental professionals recognise that social media has great potential to attract future clients.18
The concept of marketing a dental practice is questionable as earlier codes of ethics condemned all forms of advertising as it was considered damaging to the noble image of the profession.21 Many professionals still believe that advertising commercialises and hence, devalues professional services despite having more freedom to advertise in modern society.22 This is particularly difficult for clinicians in the private sector as they must navigate the fine line between managing their commercial business interests as well as professional obligations. The present study showed that young adults were influenced by attractive online promotions. This characteristic may be linked to their need to search for low-cost treatment due to financial constraints early in their careers. The offer of treatment promotions such as discounts or limited time offers, however, are considered unethical as patients are pressured to seek treatment based on cost rather than need. It is a concern that this monetary value may detract from the core value of dentistry as a healing service.21 Illegal orthodontics such as ‘fake braces’ or ‘Do-It-Yourself’ clear aligners have been shown to rely heavily on online promotions and unsubstantiated claims to attract potential customers.8,23 Several studies have also confirmed that social media pages of dental clinics are not always compliant with local regulatory guidelines on advertising, therefore potentially leaving the profession’s image at risk.24,25
The term marketing is broad and not limited to the traditional sense of advertising which can take many forms. Nowadays, it is common for dental professionals to upload informational videos or posts to, not only spread dental awareness, but to attract new patients through ‘likes’, ‘follows’, or ‘shares’. Participants of the present study seemed receptive to such videos and spoke favourably of the substantial amount of oral health information found on social media. It is important to appreciate that while such advertisements may have educational value, and be superficially empowering, advertising is mainly intended to sell, not to educate. Online information can be industry- or experience-driven rather than evidence-based, thus potentially misleading to patients.5 A study by Knosel and Jung (2011) found that the greatest proportion of orthodontic related online videos was posted by patients, and these videos generated the most views.26 An additional study showed poor quality and misleading content on YouTube videos.27 This finding calls for further structural development of health information technology as well as public reference to credible sources by professionals as the quality of the information on the internet appears to be highly variable.28 When used correctly, multimedia information through social media can greatly enhance patients’ knowledge and supplement chairside advice.29,30
Marketing has traditionally been conducted through conventional media such as television, billboards, and pamphlets, which do not allow dental practices to engage with patients. A direct interaction between patient and clinician was seen as favourable by most of the participants in the present study. It was noted as an easy and convenient way to foster a good dentist-patient relationship. Previous studies have shown that social media creates an avenue for more equal communication between a patient and healthcare professional, thus allowing the patient to feel more confident in their relationship.31 Contrary to previous reports, participants in the present study placed greater emphasis on good reviews and the character of the dentist, rather than dental qualifications.9,32,33 Other studies have indicated that a healthcare professional’s caring attitude is the most important factor in deciding on a practice.34,35 Young adults evaluated these values through social media posts, how the doctor addressed complaints or reviews, and from the reviews of past patients. Some participants admitted to following the private pages of their clinician to evaluate their interactions and behaviour in a non-professional setting. This behaviour, however, risks blurring the boundaries of professional patient-dentist relationships and raises potential privacy concerns involving both parties.
Young adults seem to place great emphasis on the opinions of third parties when making decisions regarding their oral health. With the presence of social media, third parties are no longer limited to family and friends but involve the opinions of strangers through reviews and feedback. Young adults seem to be greatly influenced by current trends and majority opinion. They perceive third party reviews as an honest way to gauge the quality and service of a particular clinic. Reviews and the number of followers, however, can be manipulated. In Australia, testimonials are prohibited under National Law due to the risk of manipulating potential patients with dishonest reviews.36 Participants in the present study acknowledged that they were not confident in spotting false reviews, which is similar to a previous report.21 Social media fraud companies (SMF) offer services to generate likes, followers and views on social media platforms to fake popularity and demand on online social networks.5 The public awareness of such scams is required, so that consideration occurs during decision making.
Due to the inherent nature of qualitative studies, generalising the findings is not feasible. Nevertheless, unlike quantitative studies, qualitative studies focus on understanding individual experiences rather than aiming for broad generalisation. For representation, participants were sampled from a densely populated and diverse region in Malaysia. The sample size of fifteen participants was considered substantial for conducting in-depth interviews within this context. Furthermore, it is acknowledged that the interviewer, having a dental background may have potentially imposed bias, however, no other interviewer-related biases were identified. Despite these limitations, the findings provide valuable insights regarding how young adults use social media and the factors influencing their decision making when seeking orthodontic treatment. Dental practitioners can tailor their advertising and information sharing strategies to reach and engage with potential patients. To enhance the research, future studies could enrich perspectives by assessing participants from different regions and include quantitative data collection.
The present study’s findings indicated that young adults generally have a positive perception of orthodontic marketing on social media. They recognised its benefits as a convenient source of oral health information, a useful marketing strategy and a platform for connecting and communicating with clinicians. However, two negative perceptions emerged: concerns about deceptive and untruthful online information, as well as the presence of false social media profiles. Factors influencing their decision-making process included social media features (such as reviews, number of followers, third-party endorsements), online trends, clinic location, treatment costs, knowledge information availability. The findings from the present study provide important insights for dental practitioners, policymakers, and stakeholders on how young adults use social media, and the factors that influence their decision-making process when searching for orthodontic treatment.