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‘23 and ½ h’ goes viral: top 10 learnings about making a health message that people give to one another
  1. Michael F Evans
  1. Correspondence to Michael F Evans, Family Medicine and Public Health, University of Toronto/Health Design Lab Scientist, Li Ka Shing Knowledge Institute, Staff Physician, St Michael's Hospital, Toronto, Canada; mfe5{at}

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In my day job as a Family Physician, I often wonder, ‘Is this bacterial or viral?’ In my other job, where I try to innovate on how to engage patients in more meaningful ways, my question is slightly different: ‘How can we make this viral instead of bacterial?’

A Healthy Virus

‘23 ½ hours: what is the single most important thing you can do for your health?’1 (referred to as ‘23.5’ below and figure 1) is a video I posted on YouTube in December 2011. My objective in making the video was twofold: 1) to experiment in creating a new way of engaging patients about their health and 2) to answer what is the most important thing we can do for our health? I am a family doctor, not a sports medicine expert, so I was intrigued that my answer is exercise. I was intrigued as activity is something I ask my patients about but it is not something I have systematically assessed and counselled upon in my practice in the same way as other clinical problems such as blood pressure or cholesterol.

Like any good virus, my primary objective was spread. At the time of writing (22 February 2012) 23.5 has had 2 million people sit down and view it, has averaged about 25 000 views a day, generated over 1000 comments and has been ‘liked’ by over 16 000 people (and ‘disliked’ by 190). It has already been translated by the ‘community’ into Spanish and Italian and five more translations are in the works.

Other than creating compelling media, we had no dissemination strategy. In fact, I loaded the video on YouTube at a hockey rink while watching one of my kid's practices on a Monday and I remember remarking to my daughter on the Wednesday, likely to improve my currency with a teenager, that it ‘already had 360 views!’

It is interesting to look at the competition on YouTube. First of all, it is humbling as 7 year olds and kittens far eclipse the viral spread of 23.5. Second, it is depressing. Our competition in the top educational viral videos were UFO sightings and learning to pole dance, and when I Google ‘Health and YouTube’, the top hit is a live show of an LA band called Health. Depressing perhaps, but also an opportunity to fill a void.

Considering this, I suppose we see a reflection of human nature on YouTube that includes our fascination with fame or the quick laugh or sex or the cringe worthy, but I also think we see the failure of medicine to go where the people are. The numbers are staggering – 3 billion daily views of YouTube videos and 150 years of video shared every day on Facebook. Estimates of the ecology of where care happens reveals that 75% of care happens at home and only 0.1% ends up in a large academic health centre.2 In medicine, we do very little to support the 75%, and data from the Pew Internet and Life Project shows that even though we have not brought the two worlds together, the public is increasingly adept at interweaving support from both clinicians and Dr Google and their social networks to improve their health.3 Patient engagement, not just education, has become a critical theoretical linchpin for the holy grails of behaviour change and chronic disease management.4 23.5 is but one small example of how we can engage and support people where they are.

Top 10 learnings from 2 million video views (to date)

  1. Peer-to-Peer Healthcare is becoming the new norm.5 The eureka here for health communication is that instead of getting the 23.5 message from an organisation, or even a healthcare provider, it is coming from a friend. Over 15 000 people have posted the 23.5 video on their Facebook pages, and many more have sent it to the people they care about. (PS: Feel free to do that yourself, it's free for non-commercial use!).

  2. Think ‘collaboratory’ when you make health media. Having Nick (the director), Liisa (the illustrator) and Dave (the sound editor) made all the difference with 23.5. Expand your production team, and if you want to engage around a particular illness, include patients.

  3. There is something about combining the visual with text and auditory that enhances the learning experience. There is limited evidence on learning styles, but what data there are tell us that multimodal is better.6

  4. Stories trump data. Relationships trump stories. In 23.5 h, we shared the evidence7 using stories.8 We inserted 23.5 into the relationships of care. Could be a friend to friend, or a doctor to patient, or daughter to father.

  5. If you can get conversations going, people come to watch. Commentary is not something that we are used to in academia. Most articles get one or two comments. 23.5 already has a 1000 comments on YouTube, which are often conversation threads. Conversations make your media interactive and interactive makes your media real.

  6. Build your tribe. My sense is that a big part of the viral aspect of this particular video is that exercise is a religion for many. This is good in that they can become apostles for your media, but I believe it also means that more secular topics, such as hypertension, may have less viral potential. Seth Godin argues the Internet has ended mass marketing and revived a human social unit from the distant past: tribes.9 A tribe where membership is voluntary and where active members do more than just show up.10 Members of the 23.5 tribe decided that we needed versions in other languages. So they discussed, translated, edited and posted.10 In February 2012, we already have translations up in Italian and Spanish, and five more languages are planned.

  7. Why, not just what. We tell people what to do all the time. We need to explain why more often. The ‘what’ in 23.5 was nothing new, but reviewing the evidence was.

  8. The old message had a new message. Most obesity messaging focuses on losing weight. Based on the work of Dr Steven Blair and others, we gave a different message that proposed a fundamental change towards focusing on activity rather than just the weight scale.11 12

  9. Make the change doable. Dr Karim Khan wondered in a BJSM editorial whether we can ‘limit our sitting and sleeping to just 23 and ½ h’.13 We used that concept to help viewers say, ‘Hey, I can do that’.

  10. Shape the path and rally the herd.14 We now have a format that makes behaviour contagious and we are going to stick with it and partner appropriately to make a series for other health conditions.

The old model of patient education consisted of developing a pamphlet and putting it in the waiting room, and now this might also include posting online. While I still think there is a need for this, the experience of 23.5 tells me that the new model is co-designing patient engagement and letting the public and media distribute. I think we also have to consider how to embed the media at the point of care so patients can engage where, how and when they want. If exercise is medicine, we need to make our new prescription fit the communication channels that are so accessible globally in 2012.



  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.