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Would You Tell Everyone This? Facebook Conversations as Health Promotion Interventions

Would You Tell Everyone This? Facebook Conversations as Health Promotion Interventions Background: Health promotion interventions on social networking sites can communicate individually tailored content to a large audience. User-generated content helps to maximize engagement, but health promotion websites have had variable success in supporting user engagement. Objective: The aim of our study was to examine which elements of moderator and participant behavior stimulated and maintained interaction with a sexual health promotion site on Facebook. Methods: We examined the pattern and content of posts on a Facebook page. Google analytics was used to describe the number of people using the page and viewing patterns. A qualitative, thematic approach was used to analyze content. Results: During the study period (January 18, 2010, to June 27, 2010), 576 users interacted 888 times with the site through 508 posts and 380 comments with 93% of content generated by users. The user-generated conversation continued while new participants were driven to the site by advertising, but interaction with the site ceased rapidly after the advertising stopped. Conversations covered key issues on chlamydia and chlamydia testing. Users endorsed testing, celebrated their negative results, and modified and questioned key messages. There was variation in user approach to the site from sharing of personal experience and requesting help to joking about sexually transmitted infection. The moderator voice was reactive, unengaged, tolerant, simplistic, and was professional in tone. There was no change in the moderator approach throughout the period studied. Conclusions: Our findings suggest this health promotion site provided a space for single user posts but not a self-sustaining conversation. Possible explanations for this include little new content from the moderator, a definition of content too narrow to hold the interest of participants, and limited responsiveness to user needs. Implications for health promotion practice include the need to consider a life cycle approach to online community development for health promotion and the need for a developing moderator strategy to reflect this. This strategy should reflect two facets of moderation for online health promotion interventions: (1) unengaged and professional oversight to provide a safe space for discussion and to maintain information quality, and (2) a more engaged and interactive presence designed to maintain interest that generates new material for discussion and is responsive to user requests. (J Med Internet Res 2014;16(4):e108) doi: 10.2196/jmir.3231 KEYWORDS social media; chlamydia; health promotion http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al campaign by the English Department of Health and the Health Introduction Protection Agency (now Public Health England) entitled “Sex Worth Talking About”. Background We collected quantitative data on the volume of interaction and Health promotion interventions on social networking sites (SNS) qualitative data on its content. We sought to identify and study harness user-generated content and the power of networks to what stimulated and maintained interaction on this improve health [1]. They reach large numbers of people and Facebook-based sexual health promotion campaign with have the capacity to communicate tailored messages quickly particular attention to the role of the moderator in stimulating [2]. Stimulating user-generated content is important to the interaction and the role of users in modifying messages. Our success of this approach because interactivity influences reach research question was “What elements of moderator and with new participants joining the conversation as they observe participant behavior stimulated and maintained interaction with the activity of their online friends [3]. Observing or participating a sexual health promotion site on Facebook?” in such conversations shares information on the beliefs and experience of peers, an important influence on behavior [4], Setting and Approach and interaction with health promotion information, Chlamydia trachomatis is the most commonly diagnosed (commenting, challenging, modifying) facilitates engagement bacterial sexually transmitted infection in the United Kingdom. with this material and therefore learning from it [5]. The prevalence is highest among young people aged 15-24 and User-generated content personalizes generic health promotion infection is usually asymptomatic [14]. The English National messages and adapts them for specific populations, increasing Chlamydia Screening Programme aims to offer all sexually their relevance to new audiences [6]. active young people under the age of 25 years testing for this Although user-generated content has important advantages, it infection annually or on change of sexual partner [15]. may also lead to widespread sharing of poor quality information The “Chlamydia Worth Talking About” strand of the “Sex and material that is offensive to individuals or groups [6,7]. As Worth Talking About” Campaign was a multimedia campaign sharing of personal experience is an integral part of online launched in January 2010 that aimed to encourage (1) open community activity, SNS health promotion interventions carry discussion about chlamydia and (2) acceptance of a chlamydia risks for participants. These risks are potentially high where test when offered by a health professional. they involve sharing of sexual health information between young people [8], and interventions of this sort require careful The campaign included television, radio, and billboard moderation to prevent harmful activity. advertisements and a Facebook page that encouraged discussion about chlamydia testing, entitled “Say Yes to the Test”. The Although the interactivity of SNS health promotion interventions Facebook site was promoted via a separate digital media is an important element of their capacity to deliver health strategy. The target audience for the campaign was young people promotion messages, they have been variably successful in (male and female) in England aged 15-24 years. Advertisements stimulating and/or supporting user-generated content and many (traffic drivers) placed on sites used by young people suggested remain inactive [9]. Levels of interactivity are likely to reflect either that chlamydia “knew” someone they knew or that it had individual or group motivations for engaging with the site, the “poked” them. It was anticipated that curiosity arising from technology required to access it, the relationships formed within these ads would cause the user to click on them. The welcome the group, and the structures for interaction including the page for the health promotion intervention offered options to presence of a moderator and moderator behavior [10-12]. The become a fan of the page and post comments on the “comment role of the moderator in health promotion campaigns on SNS wall”. This gave users the opportunity to affirm their positive are not fully understood [13], with a perceived trade-off being attitude among their own friends, spreading the word and between encouraging activity and retaining control of content. encouraging conversations. A recent systematic review of the use of SNS for health The moderation style employed on the “Say Yes to the Test” promotion identified a lack of evidence on effective approaches site was non-interventionist. Only comments that were to stimulating interaction [9]. Although there is significant completely unrelated to sexual health or that were directly literature on interactions within online communities, particularly offensive were removed. Factually incorrect comments were those that are business oriented, there is less research in relation left on the site giving the peer group opportunity to respond to health promotion interventions. before the moderation team intervened. The key metrics to understand interactions on social networking Facebook Environment sites are the number of posts and their content [12]. To understand the factors that facilitate interaction on SNS for A Facebook community page is organized around a publically health promotion, we looked at the volume, pattern, and content displayed wall where new content (messages, media, or links) of interaction within a national health promotion campaign can be added by the owner (or moderator) and other Facebook using the SNS site, Facebook. The health campaign, “Say Yes users [16]. Any form of interaction, whether liking or posting to the Test”, aimed to encourage testing for genital chlamydia content, can be seen on the user’s newsfeed. This may be shared infection among young people in England between January and automatically with people within their network depending on June 2010 by generating discussion on chlamydia and chlamydia the level of interaction that they have specified with the other testing. The SNS page was one element of a larger multimedia user [17]. http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al together to ensure consistency. Disagreements were discussed Methods until a consensus was reached. All coding was done using NVivo The literature on online communities suggests that the key metrics for evaluation of this type of intervention are the volume We completed an initial process of familiarizing ourselves with of member contributions and the quality of the online the data by reading and re-reading the posts, and from this, we relationships formed [12]. We therefore used a combination of identified an initial set of themes to describe interaction with quantitative data to describe the volume of contributions and the site: (1) patterns of posting, and (2) content of posts. From completed a qualitative analysis of the content of the interaction. this, we developed three coding strategies each building on the We described the users and their patterns of use and analyzed previous one (Table 1). We kept the two main elements of the text posted. We looked at data from the first 5 months of coding—patterns and content—constant. the campaign from January 18 to June 27, 2010, as this was the We applied for ethical approval for this study from a local period of highest activity on the “Say Yes to the Test” site. The National Health Service Research Ethics Committee. The total number of fans, wall posts, and comments over time, fan committee reported that ethical approval was not required since demographics (gender, age, and country where page was our analysis was of publically available data that we did not accessed) were obtained from the Facebook page administrators. link to personal profiles. Our use of the data is consistent with Google analytics were used to document numbers using the site guidelines on the ethical conduct of qualitative research on and viewing patterns. We captured the page content from within online communities [18]. Furthermore, we have followed recent the study period using the NCapture function of NVivo 10 recommendations from research in similar contexts and used software and used simple counting to describe user and non-verbatim quotes to prevent identification of the users moderator content, discussion thread patterns, and moderator through a search engine [19]. These were constructed through intervention. interchanging the words from several posts from different The qualitative analysis was completed by 2 investigators (JS authors that were thematically similar. and PB) using the framework approach and initially coding Table 1. Coding categories. Patterns of posting Content of posts Round 1 coding: simple descrip- Conversation length: conversations coded by Attitudes to chlamydia/testing tion of patterns and content of number of posts Experience of testing interaction (content codes) Offensive/stigmatizing/inaccurate material Conversation source: content coded by source of Requests for information/advice posts (users/moderator) Round 2 coding: factors that Conversation length: factors associated with Responses to inaccurate information, challenges to key messages triggered interactivity (response longer conversation length or stigmatizing or offensive material codes) Conversation source: factors that triggered user Responses to key messages (eg, questioning/endorsing) or moderator intervention Round 3 coding: responses to Interactivity: patterns of questions and answers Content of unresolved and complex issues and moderator re- initial interactions between users and other users, and users and the sponses to these moderator. to the 68,174 “likes” for the site, content interaction received a Results much smaller number with 483 “likes” for 156 posts or comments. Patterns of Interaction Most users interacted once (77.6%) and fewer than 2% posted There were 191,072 page views during the 5-month study more than five times, with 17 posts the highest number of period. The largest cumulative total number of fans was 68,174 interactions from a single user. fans at Week 7. Two-thirds (64%) of the fans were female, 96% of fans were aged 13-24 years (Table 2), and 95% of fans were There were 164 threads where one or more users commented from the United Kingdom. on an original post. These were usually short (one comment followed by one post), although a minority were longer with The number of fans increased from the launch of the site until the longest being made up of 56 comments. Week 7, when the advertising ceased and when the total number of fans accumulated during this 7-week period reached 68,174 The number of fans and posts related closely to the advertising (6/3/2010). It subsequently decreased by about 100 fans per campaign and activity decreased very rapidly once the week (Figure 1). The majority of the activity was seen between advertising stopped, suggesting that the interactions on the site Weeks 2 and 6 (Figure 2). themselves were insufficient to maintain user input or to generate new participants. We collected 888 interactions (508 posts, 380 comments) from 576 unique users; 93% of content was from users. In contrast http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al Table 2. Age of fans of “Say yes to the test” by sex. Age range Male, % Female, % All, % 13-17 43 54 50 18-24 54 43 47 25-34 2 2 2 35-44 <1 <1 <1 55+ <1 <1 <1 The proportion in each age group calculated on a daily basis and averaged across the data collection period. Figure 1. Total fans, Weeks 1 (18/01/2010) to 10. Figure 2. Total wall posts/comments and unique page views, Weeks 1(18/01/2010) to 10. http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al is important but contested. It is very difficult to measure Content of Interaction accurately and not completely resolved by treatment. Overview the result was.....positive. no kids for me   shammmme Conversations covered key issues on chlamydia and chlamydia init [Poster 1] testing including the lack of symptoms, consequences of oviously twat [Poster 2] infection, and experience of getting tested and treated. u cn still have kids if u get it treated [Poster 3] Attitudes to Chlamydia Testing Results of Getting Tested Posts endorsed chlamydia testing as the right thing to do, often reproducing the campaign message “Say Yes to the Test”. Most of those who discuss their experience of testing report Sixty-two posts encouraged others to get tested for peace of their results as negative and celebrate this (71/128) with “I’m mind because it is easy to do and to prevent subfertility: clean” (63/128) and “never thought I had it and now I know I don’t” as common posts associated with a tangible sense of Bout time peeps startd tikin about this…y not go gt relief after the anxiety of waiting for results. check 4eurything its 20mins out ur life…tht ultimately cud save ur life and tht of ur future children and new Many fewer comments (28/128) report a positive chlamydia partners...sense...people..gud on ya if ya dne it...an test. Most of these fall into the “just joking” category, often if u ant y…x [Poster 1] emphasizing “I don’t care” or “I’m pleased” or exaggerating the consequences, for example, “my penis will drop off”. The Although testing is generally presented as the “right thing to minority of posts that asked for help were important do”, there was disagreement about its implications. Some opportunities for participants to offer support and challenge participants felt that testing suggests risk of infection through stigma: multiple partners with either negative implications (promiscuity) or positive ones (sexual experience). Others suggested that it im really worried because I think I have chlamydia, signals irresponsible behavior (no condoms used), carelessness … WHAT SHOULD I DO?! [Poster 1] (poor condom use), or bad luck. Some felt that it is a routine have u got any symptoms like a rash or anything like part of looking after yourself: urination being different ive added u ive had it b4 ill People who say like “oh im not ashamed, I have this chat to u if u like im xxxxxx unlike some idiots on here test all the time”...stop having sex with so many diff [Poster 2] men, then you wouldn’t need to have it done all the There were marked differences in approach to the topic between time =] those who were seriously concerned about chlamydia, from a It’s making it “shameful” that prevents people from personal or public health perspective, and those who used the going and getting tested. The skanky ones are the topic as an opportunity to post in a joking manner. ones that don’t get tested you fool. If anything Modification and Repetition of Health Promotion everyone that is a fan of this group are the absolute Messages opposite. Many posts and comments (n=158) contained messages that I went for it   its all good. I got the all clear too. just adapted but were consistent with key campaign messages about go on a random moment, just means your looking testing and condom use, for example, “dont be fool wrap your after yourself tool, strap up before you whack up boys”. Uncertainty Around Testing Messages Whether to share personal information in a public forum was User-generated content identified and did not resolve uncertainty discussed referencing both the need for openness to provide around some aspects of chlamydia testing. This maintained information and support and the personal consequences of conversations by generating disagreement and encouraged sharing information online where it is accessible by both those sharing personal experience. It identified questions that were from offline social networks and strangers: important to participants but failed to resolve them because the had it, got rid of it, get tested few times a year just approach to moderation was simple, factual responses without coz I can [Poster 1] engaging in conversation. why wud u tell everyone this?? Nice lass u r eh!! well The effectiveness of condoms in preventing chlamydia was an I see u deleted ur comment nd I mean why wud u want example of this and a subject of concern. If condoms protect everyone to know u had chlamydia twice?? Just makes against chlamydia, why should those who use condoms u look like a skank tbh them things are usually kept consistently still be tested? Similarly, users were confused about private [Poster 2] the risk of subfertility following chlamydia infection. Some posters reported that after a single episode of infection becoming Harmful or Offensive Messages pregnant was impossible and that chlamydia infection could There were 39 posts classified as potentially harmful or therefore be used as a method of contraception. embarrassing, as a named individual or poster of a previous None of these questions have simple answers since the message was the subject of offensive language or inappropriate effectiveness of condoms depends on how consistently and remarks. We were unable to establish the tone of many of the carefully they are used. The impact of chlamydia on subfertility challenging messages without further context including http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al knowledge of the relationship between posters, for example, “I Discussion got chlamydia off Stevey ”. Some harmful posts were ignored by the moderator to discourage continued posting. We were Principal Findings unable to view those deleted with a private warning message. We aimed to study what stimulated and maintained interaction Of all 164 comment threads, harmful or offensive comments on a sexual health promotion site on Facebook with particular appeared in 31 (18.9%) of them at least once. Of these message emphasis on the role of the moderator. The stated aim of the chains, 40 had four or more comments following an original site studied was to promote chlamydia testing, to reinforce key post. Of these 40 longer threads, offensive content appeared in messages about chlamydia infection, and to promote the attitudes 12 (30%) at least one or more times. We had hypothesized that that make testing more likely [20]. The potential outcomes of potentially harmful content or challenges of key messages might participation included information exchange, social support and stimulate message chains, but this content did not appear to social interaction [12], as well as better sexual health through drive longer threads. increased likelihood of chlamydia testing. The potential risks The Role of the Moderator of participation include the consequences of sharing personal information online and exposure to harmful online behavior Of all 888 posts and comments, 62 (6.9%) were by the such as the posting of inflammatory, hostile, or insulting moderator. The approach adopted was to choose from a list of behavior. standardized responses and repeat these as the same issue occurred. There was no attempt to engage in the conversation, The “Say Yes” site attracted a very large number of potential stimulate discussion, or reproduce the language used by posters. users, but there was no evidence of sustained interaction. Single This means that the tone of posts by the moderator was very visits to the site could have provided information on testing but different from that of the users. The moderator did not respond more active engagement with the site (repeat visits or posting) to misinformation posted on the site immediately but allowed would be more likely to change attitudes [4]. More sustained time for other posters to correct it and then endorsed the interaction from a significant number of people would be corrections: associated with the development of an online community, either self-sustaining or supported by new stimuli for discussion from Hi xxx! Just to clarify, neither chlamydia infection or the moderator. One definition of an online community is “a the health consequences of untreated chlamydia collective group of entities, individuals or organizations that infection would lead to penis amputation! However, come together either temporarily or permanently through an untreated chlamydia can cause painful inflammation electronic medium to interact in a common problem or interest in one or both testicles… To find out how it is space” [21]. The idea of a shared area of interest is important important to “Say yes to the test” log on to…. for our discussion. If online communities must make a transition Of the moderator’s interactions, 53/62 (85%) were a response from early engagement to self-sustaining interaction [22] and to an existing conversation. Of these comments, 43/53 (81%) if key metrics to monitor the success of online communities were the last or second to last comment in the thread. include the volume of member contributions and the quality of Users appreciated moderator comments with 192 likes (40%) the online relationships formed [12], our analysis suggests that for moderator interactions. The highest number of likes for a this intervention was not successful in making the transition to user interaction was 10 and for a moderator interaction 63. There a mature online community. There was a low volume of posts were no cases where the posters expressed dissatisfaction with once the advertising ceased and the development of superficial comments from the moderator. relationships as evidenced by the short discussion threads and lack of continued engagement. A total of 80% (51/64) posts or comments that challenged campaign messages or contained inaccurate information or Major influences on the amount and type of interaction with questions were corrected, with 47 (73%) responses within four SNS-based health promotion interventions include the structure posts, that is, appearing in the same window as the post on of relationships between users [10], the role of the moderator Facebook newsfeeds. Over half of these responses came from [11], and the content of the online discussion [23]. Drawing on users: this work, we propose that barriers to sustained interaction could include an audience that did not have a sufficiently shared where you get free test from?? [Poster 1] approach to this topic, a lack of new content from the moderator, from the docs just go and ask for one or go sex health a definition of content that was too narrow to hold the interest clinc x [Poster 2] of participants, and a lack of moderator responsiveness to boots do them for free aswell x [Poster 3] participant needs. The evidence for these proposals from our study are explored below. any boots? [Poster 1] You can order one online. Its great. You get a pippette On the “Say Yes” site, there was some indication of shared :D [Poster 4] interest in chlamydia as users had “liked” the site and there was reference to a common experience of chlamydia testing among i got mine from school, they were giving them out some of those who posted. People join online discussions where [Poster 5] they identify others with similar interests and viewpoints [21,24]. An effective online community will attract users with sufficient common interest to provide a safe space for discussion http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al and sufficient difference to provide material for conversation. this material could encourage repeated posting, we recommend Our findings suggest marked differences in approach to the that it be removed. While personally offensive responses were topic, for example wide differences in how seriously they removed, the moderator could not respond to private offensive approached the content with some users sharing personal messages on individual Facebook pages. More information is experience of and concerns about chlamydia infection while needed to quantify the risk to participants of sharing information others ridicule the idea of sexually transmitted infection. Since in this way and the responsibilities of the public health agencies support from others is an important incentive to stay engaged who run this type of intervention. with online communities [24,25], the lack of a supportive We did not set out to measure the impact of the intervention. environment from some users might have limited the willingness The impact of the whole media campaign (of which this of those who did post topics for discussion to pursue their intervention was one element) on chlamydia testing rates has interest in this forum. been evaluated and shown to be associated with an increased We think that the nature of the subject matter, a mainly number of positive tests linked to increased testing of high risk short-term condition that is easily treated, meant that the individuals although not an increased number of tests overall incentives to stay engaged with the site are very different from [25]. We do not know what impact, if any, was related those that support users with long-term conditions. Strategies specifically to the SNS intervention; however, the site did have to maintain engagement could have included broadening the some characteristics of an effective health promotion discussion to other areas of sexual health over time so that new intervention. Those who visited the site and reviewed the content was generated for discussion, providing a greater conversation would have received correct information on incentive to stay engaged and a promise of more information chlamydia, information on attitudes to chlamydia and chlamydia on new, but related topics. testing among their peers including normalization of chlamydia testing, reassurance that chlamydia can be easily treated, The approach to moderation was reactive (it did not generate signposting to additional sources of information, and promotion new material), unengaged (it provided simple factual responses), of condoms to prevent chlamydia infection. They would also tolerant (it gave participants time to respond to inaccurate or have had an opportunity to actively engage with this material, challenging material), simplistic (it ignored controversial or modifying and personalizing it—both are activities associated complex material and repeated simple health promotion with active learning and effective health promotion interventions messages), and professional in tone. This fulfilled the important [5]. function of maintaining the quality of information on the site [6] and provided space for user-generated content, but it was Limitations also repetitive and ultimately uninteresting and did not provide Our findings are limited by our lack of data on those who sufficient encouragement for interaction at this early stage of participated on this site. Without this, we do not know how they online community development. In particular, it did not respond are similar or different from the rest of the population targeted directly to the needs of users, other than with repetitive health by this campaign. Similarly, we have no data on interactions promotion messages and it was not part of a strategy that with the site that did not involve posting, for example, we do acknowledged the changing role of the moderator as an online not know how long each participant spent on the site, what community develops [12]. The idea that online communities material they read or whether they returned to the site, except progress from small groups with a common interest and informal where they returned to the site to post. In addition, we were not rules to larger and more established ones with more formal rules able to obtain data on posts that were removed by the moderator and high levels of participation is well documented [12,22]. or warnings sent to individual participants. Finally, we have no Groups of the sort that we studied that are created by advertising data on the impact of this SNS campaign on the knowledge, for a purpose identified by an external agency may follow a attitudes, and behaviors of those who viewed or participated in different pattern of development closer to online communities this intervention. developed for consumers by businesses (eg, [26]). Here the Conclusions early stages of online community development are described slightly differently with an “on board” stage where the Our findings suggest this health promotion site provided a space community is highly dependent on founder participation and for single user posts but not a self-sustaining conversation. the nature of participation is unclear, to an “established” stage Possible explanations for this include little new content from where relationships within the membership base have been the moderator, a definition of content that was too narrow to established and are less reliant on founder participation. hold the interest of participants, and limited responsiveness to user needs. Delaying response was important to provide space for user-generated content but also carries risks. Users answered Implications for health promotion practice include the need to almost all of the questions posed by other users but corrected consider a life cycle approach to online community development only a third of the inaccurate information posted. With only the for health promotion and the need for a developing moderator last four comments of a discussion thread appearing on strategy to reflect this. This strategy should reflect two facets Facebook newsfeeds, inaccurate content should be corrected of moderation for online health promotion interventions: (1) within three comments but this risks closing down discussions. unengaged and professional oversight to provide a safe space Leaving material that is potentially harmful to a named for discussion and to maintain information quality and (2) a individual is dangerous [8,27-29] and, from our analysis, is not more engaged and interactive presence designed to maintain associated with stimulating conversation. Although removal of http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al interest that generates new material for discussion and is responsive to user requests. Acknowledgments This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors would like to thank Pippa Pollard as well as Rebecca Humphreys for comments on the initial analysis of the qualitative data. Conflicts of Interest PB, SW, and CM have worked for the English National Chlamydia Screening Programme. CM worked on the development of the “Say Yes to the Test” Campaign. References 1. Hughes B, Joshi I, Wareham J. Health 2.0 and Medicine 2.0: tensions and controversies in the field. J Med Internet Res 2008;10(3):e23 [FREE Full text] [doi: 10.2196/jmir.1056] [Medline: 18682374] 2. Chou WY, Prestin A, Lyons C, Wen KY. 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URL: https://www.facebook.com/unsupportedbrowser [accessed 2014-01-03] [WebCite Cache ID 6MMQlrhkt] 17. Facebook: How News Feed Works. URL: https://www.facebook.com/unsupportedbrowser [accessed 2014-01-03] [WebCite Cache ID 6MMPrh8rV] 18. Eysenbach G, Till JE. Ethical issues in qualitative research on internet communities. BMJ 2001 Nov 10;323(7321):1103-1105 [FREE Full text] [Medline: 11701577] 19. Bond CS, Ahmed OH, Hind M, Thomas B, Hewitt-Taylor J. The conceptual and practical ethical dilemmas of using health discussion board posts as research data. J Med Internet Res 2013;15(6):e112 [FREE Full text] [doi: 10.2196/jmir.2435] [Medline: 23748147] http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 8 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al 20. Department of Health. 2009. Teenage Pregnancy and Sexual Health Marketing Strategy URL: http://www.nhs.uk/ sexualhealthprofessional/Documents/Sexual_Health_Strategy_2009.pdf?wt.mc_id=21103 [accessed 2014-04-08] [WebCite Cache ID 6OgRuyrXg] 21. Plant R. Online communities. Technology in Society 2004 Jan;26(1):51-65. [doi: 10.1016/j.techsoc.2003.10.005] 22. Andrews DC. Audience-specific online community design. Commun. ACM 2002 Apr 01;45(4):64-68. [doi: 10.1145/505248.505275] 23. Wise K, Hamman B, Thorson K. Moderation, Response Rate, and Message Interactivity: Features of Online Communities and Their Effects on Intent to Participate. J Comp Mediated Comm 2006 Oct;12(1):24-41. [doi: 10.1111/j.1083-6101.2006.00313.x] 24. Porter CE. A typology of virtual communities: A multi-disciplinary foundation for future research. Journal of Computer-Mediated Communication 2004;10(1):00. [doi: 10.1111/j.1083-6101.2004.tb00228.x] 25. Gobin M, Verlander N, Maurici C, Bone A, Nardone A. Do sexual health campaigns work? An outcome evaluation of a media campaign to increase chlamydia testing among young people aged 15--24 in England. BMC Public Health 2013 May 17;13(1):484 [FREE Full text] [doi: 10.1186/1471-2458-13-484] [Medline: 23683345] 26. Mashable. Mashable. How to: Manage a sustainable online community URL: http://mashable.com/2010/07/30/ sustainable-online-community/ [accessed 2014-04-08] [WebCite Cache ID 6OgDyMDbZ] 27. Juvonen J, Gross EF. Extending the school grounds?--Bullying experiences in cyberspace. J Sch Health 2008 Sep;78(9):496-505. [doi: 10.1111/j.1746-1561.2008.00335.x] [Medline: 18786042] 28. Ybarra ML, Mitchell KJ. How risky are social networking sites? A comparison of places online where youth sexual solicitation and harassment occurs. Pediatrics 2008 Feb;121(2):e350-e357 [FREE Full text] [doi: 10.1542/peds.2007-0693] [Medline: 18227194] 29. Ybarra ML, Mitchell KJ, Wolak J, Finkelhor D. Examining characteristics and associated distress related to Internet harassment: findings from the Second Youth Internet Safety Survey. Pediatrics 2006 Oct;118(4):e1169-e1177 [FREE Full text] [doi: 10.1542/peds.2006-0815] [Medline: 17015505] Abbreviations SNS: social networking site Edited by G Eysenbach; submitted 07.01.14; peer-reviewed by A Moorhead, R Webster; comments to author 31.01.14; revised version received 05.03.14; accepted 24.03.14; published 11.04.14 Please cite as: Syred J, Naidoo C, Woodhall SC, Baraitser P J Med Internet Res 2014;16(4):e108 URL: http://www.jmir.org/2014/4/e108/ doi: 10.2196/jmir.3231 PMID: 24727742 ©Jonathan Syred, Carla Naidoo, Sarah C Woodhall, Paula Baraitser. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.04.2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included. http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 9 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Medical Internet Research JMIR Publications

Would You Tell Everyone This? Facebook Conversations as Health Promotion Interventions

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Abstract

Background: Health promotion interventions on social networking sites can communicate individually tailored content to a large audience. User-generated content helps to maximize engagement, but health promotion websites have had variable success in supporting user engagement. Objective: The aim of our study was to examine which elements of moderator and participant behavior stimulated and maintained interaction with a sexual health promotion site on Facebook. Methods: We examined the pattern and content of posts on a Facebook page. Google analytics was used to describe the number of people using the page and viewing patterns. A qualitative, thematic approach was used to analyze content. Results: During the study period (January 18, 2010, to June 27, 2010), 576 users interacted 888 times with the site through 508 posts and 380 comments with 93% of content generated by users. The user-generated conversation continued while new participants were driven to the site by advertising, but interaction with the site ceased rapidly after the advertising stopped. Conversations covered key issues on chlamydia and chlamydia testing. Users endorsed testing, celebrated their negative results, and modified and questioned key messages. There was variation in user approach to the site from sharing of personal experience and requesting help to joking about sexually transmitted infection. The moderator voice was reactive, unengaged, tolerant, simplistic, and was professional in tone. There was no change in the moderator approach throughout the period studied. Conclusions: Our findings suggest this health promotion site provided a space for single user posts but not a self-sustaining conversation. Possible explanations for this include little new content from the moderator, a definition of content too narrow to hold the interest of participants, and limited responsiveness to user needs. Implications for health promotion practice include the need to consider a life cycle approach to online community development for health promotion and the need for a developing moderator strategy to reflect this. This strategy should reflect two facets of moderation for online health promotion interventions: (1) unengaged and professional oversight to provide a safe space for discussion and to maintain information quality, and (2) a more engaged and interactive presence designed to maintain interest that generates new material for discussion and is responsive to user requests. (J Med Internet Res 2014;16(4):e108) doi: 10.2196/jmir.3231 KEYWORDS social media; chlamydia; health promotion http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al campaign by the English Department of Health and the Health Introduction Protection Agency (now Public Health England) entitled “Sex Worth Talking About”. Background We collected quantitative data on the volume of interaction and Health promotion interventions on social networking sites (SNS) qualitative data on its content. We sought to identify and study harness user-generated content and the power of networks to what stimulated and maintained interaction on this improve health [1]. They reach large numbers of people and Facebook-based sexual health promotion campaign with have the capacity to communicate tailored messages quickly particular attention to the role of the moderator in stimulating [2]. Stimulating user-generated content is important to the interaction and the role of users in modifying messages. Our success of this approach because interactivity influences reach research question was “What elements of moderator and with new participants joining the conversation as they observe participant behavior stimulated and maintained interaction with the activity of their online friends [3]. Observing or participating a sexual health promotion site on Facebook?” in such conversations shares information on the beliefs and experience of peers, an important influence on behavior [4], Setting and Approach and interaction with health promotion information, Chlamydia trachomatis is the most commonly diagnosed (commenting, challenging, modifying) facilitates engagement bacterial sexually transmitted infection in the United Kingdom. with this material and therefore learning from it [5]. The prevalence is highest among young people aged 15-24 and User-generated content personalizes generic health promotion infection is usually asymptomatic [14]. The English National messages and adapts them for specific populations, increasing Chlamydia Screening Programme aims to offer all sexually their relevance to new audiences [6]. active young people under the age of 25 years testing for this Although user-generated content has important advantages, it infection annually or on change of sexual partner [15]. may also lead to widespread sharing of poor quality information The “Chlamydia Worth Talking About” strand of the “Sex and material that is offensive to individuals or groups [6,7]. As Worth Talking About” Campaign was a multimedia campaign sharing of personal experience is an integral part of online launched in January 2010 that aimed to encourage (1) open community activity, SNS health promotion interventions carry discussion about chlamydia and (2) acceptance of a chlamydia risks for participants. These risks are potentially high where test when offered by a health professional. they involve sharing of sexual health information between young people [8], and interventions of this sort require careful The campaign included television, radio, and billboard moderation to prevent harmful activity. advertisements and a Facebook page that encouraged discussion about chlamydia testing, entitled “Say Yes to the Test”. The Although the interactivity of SNS health promotion interventions Facebook site was promoted via a separate digital media is an important element of their capacity to deliver health strategy. The target audience for the campaign was young people promotion messages, they have been variably successful in (male and female) in England aged 15-24 years. Advertisements stimulating and/or supporting user-generated content and many (traffic drivers) placed on sites used by young people suggested remain inactive [9]. Levels of interactivity are likely to reflect either that chlamydia “knew” someone they knew or that it had individual or group motivations for engaging with the site, the “poked” them. It was anticipated that curiosity arising from technology required to access it, the relationships formed within these ads would cause the user to click on them. The welcome the group, and the structures for interaction including the page for the health promotion intervention offered options to presence of a moderator and moderator behavior [10-12]. The become a fan of the page and post comments on the “comment role of the moderator in health promotion campaigns on SNS wall”. This gave users the opportunity to affirm their positive are not fully understood [13], with a perceived trade-off being attitude among their own friends, spreading the word and between encouraging activity and retaining control of content. encouraging conversations. A recent systematic review of the use of SNS for health The moderation style employed on the “Say Yes to the Test” promotion identified a lack of evidence on effective approaches site was non-interventionist. Only comments that were to stimulating interaction [9]. Although there is significant completely unrelated to sexual health or that were directly literature on interactions within online communities, particularly offensive were removed. Factually incorrect comments were those that are business oriented, there is less research in relation left on the site giving the peer group opportunity to respond to health promotion interventions. before the moderation team intervened. The key metrics to understand interactions on social networking Facebook Environment sites are the number of posts and their content [12]. To understand the factors that facilitate interaction on SNS for A Facebook community page is organized around a publically health promotion, we looked at the volume, pattern, and content displayed wall where new content (messages, media, or links) of interaction within a national health promotion campaign can be added by the owner (or moderator) and other Facebook using the SNS site, Facebook. The health campaign, “Say Yes users [16]. Any form of interaction, whether liking or posting to the Test”, aimed to encourage testing for genital chlamydia content, can be seen on the user’s newsfeed. This may be shared infection among young people in England between January and automatically with people within their network depending on June 2010 by generating discussion on chlamydia and chlamydia the level of interaction that they have specified with the other testing. The SNS page was one element of a larger multimedia user [17]. http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al together to ensure consistency. Disagreements were discussed Methods until a consensus was reached. All coding was done using NVivo The literature on online communities suggests that the key metrics for evaluation of this type of intervention are the volume We completed an initial process of familiarizing ourselves with of member contributions and the quality of the online the data by reading and re-reading the posts, and from this, we relationships formed [12]. We therefore used a combination of identified an initial set of themes to describe interaction with quantitative data to describe the volume of contributions and the site: (1) patterns of posting, and (2) content of posts. From completed a qualitative analysis of the content of the interaction. this, we developed three coding strategies each building on the We described the users and their patterns of use and analyzed previous one (Table 1). We kept the two main elements of the text posted. We looked at data from the first 5 months of coding—patterns and content—constant. the campaign from January 18 to June 27, 2010, as this was the We applied for ethical approval for this study from a local period of highest activity on the “Say Yes to the Test” site. The National Health Service Research Ethics Committee. The total number of fans, wall posts, and comments over time, fan committee reported that ethical approval was not required since demographics (gender, age, and country where page was our analysis was of publically available data that we did not accessed) were obtained from the Facebook page administrators. link to personal profiles. Our use of the data is consistent with Google analytics were used to document numbers using the site guidelines on the ethical conduct of qualitative research on and viewing patterns. We captured the page content from within online communities [18]. Furthermore, we have followed recent the study period using the NCapture function of NVivo 10 recommendations from research in similar contexts and used software and used simple counting to describe user and non-verbatim quotes to prevent identification of the users moderator content, discussion thread patterns, and moderator through a search engine [19]. These were constructed through intervention. interchanging the words from several posts from different The qualitative analysis was completed by 2 investigators (JS authors that were thematically similar. and PB) using the framework approach and initially coding Table 1. Coding categories. Patterns of posting Content of posts Round 1 coding: simple descrip- Conversation length: conversations coded by Attitudes to chlamydia/testing tion of patterns and content of number of posts Experience of testing interaction (content codes) Offensive/stigmatizing/inaccurate material Conversation source: content coded by source of Requests for information/advice posts (users/moderator) Round 2 coding: factors that Conversation length: factors associated with Responses to inaccurate information, challenges to key messages triggered interactivity (response longer conversation length or stigmatizing or offensive material codes) Conversation source: factors that triggered user Responses to key messages (eg, questioning/endorsing) or moderator intervention Round 3 coding: responses to Interactivity: patterns of questions and answers Content of unresolved and complex issues and moderator re- initial interactions between users and other users, and users and the sponses to these moderator. to the 68,174 “likes” for the site, content interaction received a Results much smaller number with 483 “likes” for 156 posts or comments. Patterns of Interaction Most users interacted once (77.6%) and fewer than 2% posted There were 191,072 page views during the 5-month study more than five times, with 17 posts the highest number of period. The largest cumulative total number of fans was 68,174 interactions from a single user. fans at Week 7. Two-thirds (64%) of the fans were female, 96% of fans were aged 13-24 years (Table 2), and 95% of fans were There were 164 threads where one or more users commented from the United Kingdom. on an original post. These were usually short (one comment followed by one post), although a minority were longer with The number of fans increased from the launch of the site until the longest being made up of 56 comments. Week 7, when the advertising ceased and when the total number of fans accumulated during this 7-week period reached 68,174 The number of fans and posts related closely to the advertising (6/3/2010). It subsequently decreased by about 100 fans per campaign and activity decreased very rapidly once the week (Figure 1). The majority of the activity was seen between advertising stopped, suggesting that the interactions on the site Weeks 2 and 6 (Figure 2). themselves were insufficient to maintain user input or to generate new participants. We collected 888 interactions (508 posts, 380 comments) from 576 unique users; 93% of content was from users. In contrast http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al Table 2. Age of fans of “Say yes to the test” by sex. Age range Male, % Female, % All, % 13-17 43 54 50 18-24 54 43 47 25-34 2 2 2 35-44 <1 <1 <1 55+ <1 <1 <1 The proportion in each age group calculated on a daily basis and averaged across the data collection period. Figure 1. Total fans, Weeks 1 (18/01/2010) to 10. Figure 2. Total wall posts/comments and unique page views, Weeks 1(18/01/2010) to 10. http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al is important but contested. It is very difficult to measure Content of Interaction accurately and not completely resolved by treatment. Overview the result was.....positive. no kids for me   shammmme Conversations covered key issues on chlamydia and chlamydia init [Poster 1] testing including the lack of symptoms, consequences of oviously twat [Poster 2] infection, and experience of getting tested and treated. u cn still have kids if u get it treated [Poster 3] Attitudes to Chlamydia Testing Results of Getting Tested Posts endorsed chlamydia testing as the right thing to do, often reproducing the campaign message “Say Yes to the Test”. Most of those who discuss their experience of testing report Sixty-two posts encouraged others to get tested for peace of their results as negative and celebrate this (71/128) with “I’m mind because it is easy to do and to prevent subfertility: clean” (63/128) and “never thought I had it and now I know I don’t” as common posts associated with a tangible sense of Bout time peeps startd tikin about this…y not go gt relief after the anxiety of waiting for results. check 4eurything its 20mins out ur life…tht ultimately cud save ur life and tht of ur future children and new Many fewer comments (28/128) report a positive chlamydia partners...sense...people..gud on ya if ya dne it...an test. Most of these fall into the “just joking” category, often if u ant y…x [Poster 1] emphasizing “I don’t care” or “I’m pleased” or exaggerating the consequences, for example, “my penis will drop off”. The Although testing is generally presented as the “right thing to minority of posts that asked for help were important do”, there was disagreement about its implications. Some opportunities for participants to offer support and challenge participants felt that testing suggests risk of infection through stigma: multiple partners with either negative implications (promiscuity) or positive ones (sexual experience). Others suggested that it im really worried because I think I have chlamydia, signals irresponsible behavior (no condoms used), carelessness … WHAT SHOULD I DO?! [Poster 1] (poor condom use), or bad luck. Some felt that it is a routine have u got any symptoms like a rash or anything like part of looking after yourself: urination being different ive added u ive had it b4 ill People who say like “oh im not ashamed, I have this chat to u if u like im xxxxxx unlike some idiots on here test all the time”...stop having sex with so many diff [Poster 2] men, then you wouldn’t need to have it done all the There were marked differences in approach to the topic between time =] those who were seriously concerned about chlamydia, from a It’s making it “shameful” that prevents people from personal or public health perspective, and those who used the going and getting tested. The skanky ones are the topic as an opportunity to post in a joking manner. ones that don’t get tested you fool. If anything Modification and Repetition of Health Promotion everyone that is a fan of this group are the absolute Messages opposite. Many posts and comments (n=158) contained messages that I went for it   its all good. I got the all clear too. just adapted but were consistent with key campaign messages about go on a random moment, just means your looking testing and condom use, for example, “dont be fool wrap your after yourself tool, strap up before you whack up boys”. Uncertainty Around Testing Messages Whether to share personal information in a public forum was User-generated content identified and did not resolve uncertainty discussed referencing both the need for openness to provide around some aspects of chlamydia testing. This maintained information and support and the personal consequences of conversations by generating disagreement and encouraged sharing information online where it is accessible by both those sharing personal experience. It identified questions that were from offline social networks and strangers: important to participants but failed to resolve them because the had it, got rid of it, get tested few times a year just approach to moderation was simple, factual responses without coz I can [Poster 1] engaging in conversation. why wud u tell everyone this?? Nice lass u r eh!! well The effectiveness of condoms in preventing chlamydia was an I see u deleted ur comment nd I mean why wud u want example of this and a subject of concern. If condoms protect everyone to know u had chlamydia twice?? Just makes against chlamydia, why should those who use condoms u look like a skank tbh them things are usually kept consistently still be tested? Similarly, users were confused about private [Poster 2] the risk of subfertility following chlamydia infection. Some posters reported that after a single episode of infection becoming Harmful or Offensive Messages pregnant was impossible and that chlamydia infection could There were 39 posts classified as potentially harmful or therefore be used as a method of contraception. embarrassing, as a named individual or poster of a previous None of these questions have simple answers since the message was the subject of offensive language or inappropriate effectiveness of condoms depends on how consistently and remarks. We were unable to establish the tone of many of the carefully they are used. The impact of chlamydia on subfertility challenging messages without further context including http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al knowledge of the relationship between posters, for example, “I Discussion got chlamydia off Stevey ”. Some harmful posts were ignored by the moderator to discourage continued posting. We were Principal Findings unable to view those deleted with a private warning message. We aimed to study what stimulated and maintained interaction Of all 164 comment threads, harmful or offensive comments on a sexual health promotion site on Facebook with particular appeared in 31 (18.9%) of them at least once. Of these message emphasis on the role of the moderator. The stated aim of the chains, 40 had four or more comments following an original site studied was to promote chlamydia testing, to reinforce key post. Of these 40 longer threads, offensive content appeared in messages about chlamydia infection, and to promote the attitudes 12 (30%) at least one or more times. We had hypothesized that that make testing more likely [20]. The potential outcomes of potentially harmful content or challenges of key messages might participation included information exchange, social support and stimulate message chains, but this content did not appear to social interaction [12], as well as better sexual health through drive longer threads. increased likelihood of chlamydia testing. The potential risks The Role of the Moderator of participation include the consequences of sharing personal information online and exposure to harmful online behavior Of all 888 posts and comments, 62 (6.9%) were by the such as the posting of inflammatory, hostile, or insulting moderator. The approach adopted was to choose from a list of behavior. standardized responses and repeat these as the same issue occurred. There was no attempt to engage in the conversation, The “Say Yes” site attracted a very large number of potential stimulate discussion, or reproduce the language used by posters. users, but there was no evidence of sustained interaction. Single This means that the tone of posts by the moderator was very visits to the site could have provided information on testing but different from that of the users. The moderator did not respond more active engagement with the site (repeat visits or posting) to misinformation posted on the site immediately but allowed would be more likely to change attitudes [4]. More sustained time for other posters to correct it and then endorsed the interaction from a significant number of people would be corrections: associated with the development of an online community, either self-sustaining or supported by new stimuli for discussion from Hi xxx! Just to clarify, neither chlamydia infection or the moderator. One definition of an online community is “a the health consequences of untreated chlamydia collective group of entities, individuals or organizations that infection would lead to penis amputation! However, come together either temporarily or permanently through an untreated chlamydia can cause painful inflammation electronic medium to interact in a common problem or interest in one or both testicles… To find out how it is space” [21]. The idea of a shared area of interest is important important to “Say yes to the test” log on to…. for our discussion. If online communities must make a transition Of the moderator’s interactions, 53/62 (85%) were a response from early engagement to self-sustaining interaction [22] and to an existing conversation. Of these comments, 43/53 (81%) if key metrics to monitor the success of online communities were the last or second to last comment in the thread. include the volume of member contributions and the quality of Users appreciated moderator comments with 192 likes (40%) the online relationships formed [12], our analysis suggests that for moderator interactions. The highest number of likes for a this intervention was not successful in making the transition to user interaction was 10 and for a moderator interaction 63. There a mature online community. There was a low volume of posts were no cases where the posters expressed dissatisfaction with once the advertising ceased and the development of superficial comments from the moderator. relationships as evidenced by the short discussion threads and lack of continued engagement. A total of 80% (51/64) posts or comments that challenged campaign messages or contained inaccurate information or Major influences on the amount and type of interaction with questions were corrected, with 47 (73%) responses within four SNS-based health promotion interventions include the structure posts, that is, appearing in the same window as the post on of relationships between users [10], the role of the moderator Facebook newsfeeds. Over half of these responses came from [11], and the content of the online discussion [23]. Drawing on users: this work, we propose that barriers to sustained interaction could include an audience that did not have a sufficiently shared where you get free test from?? [Poster 1] approach to this topic, a lack of new content from the moderator, from the docs just go and ask for one or go sex health a definition of content that was too narrow to hold the interest clinc x [Poster 2] of participants, and a lack of moderator responsiveness to boots do them for free aswell x [Poster 3] participant needs. The evidence for these proposals from our study are explored below. any boots? [Poster 1] You can order one online. Its great. You get a pippette On the “Say Yes” site, there was some indication of shared :D [Poster 4] interest in chlamydia as users had “liked” the site and there was reference to a common experience of chlamydia testing among i got mine from school, they were giving them out some of those who posted. People join online discussions where [Poster 5] they identify others with similar interests and viewpoints [21,24]. An effective online community will attract users with sufficient common interest to provide a safe space for discussion http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Syred et al and sufficient difference to provide material for conversation. this material could encourage repeated posting, we recommend Our findings suggest marked differences in approach to the that it be removed. While personally offensive responses were topic, for example wide differences in how seriously they removed, the moderator could not respond to private offensive approached the content with some users sharing personal messages on individual Facebook pages. More information is experience of and concerns about chlamydia infection while needed to quantify the risk to participants of sharing information others ridicule the idea of sexually transmitted infection. Since in this way and the responsibilities of the public health agencies support from others is an important incentive to stay engaged who run this type of intervention. with online communities [24,25], the lack of a supportive We did not set out to measure the impact of the intervention. environment from some users might have limited the willingness The impact of the whole media campaign (of which this of those who did post topics for discussion to pursue their intervention was one element) on chlamydia testing rates has interest in this forum. been evaluated and shown to be associated with an increased We think that the nature of the subject matter, a mainly number of positive tests linked to increased testing of high risk short-term condition that is easily treated, meant that the individuals although not an increased number of tests overall incentives to stay engaged with the site are very different from [25]. We do not know what impact, if any, was related those that support users with long-term conditions. Strategies specifically to the SNS intervention; however, the site did have to maintain engagement could have included broadening the some characteristics of an effective health promotion discussion to other areas of sexual health over time so that new intervention. Those who visited the site and reviewed the content was generated for discussion, providing a greater conversation would have received correct information on incentive to stay engaged and a promise of more information chlamydia, information on attitudes to chlamydia and chlamydia on new, but related topics. testing among their peers including normalization of chlamydia testing, reassurance that chlamydia can be easily treated, The approach to moderation was reactive (it did not generate signposting to additional sources of information, and promotion new material), unengaged (it provided simple factual responses), of condoms to prevent chlamydia infection. They would also tolerant (it gave participants time to respond to inaccurate or have had an opportunity to actively engage with this material, challenging material), simplistic (it ignored controversial or modifying and personalizing it—both are activities associated complex material and repeated simple health promotion with active learning and effective health promotion interventions messages), and professional in tone. This fulfilled the important [5]. function of maintaining the quality of information on the site [6] and provided space for user-generated content, but it was Limitations also repetitive and ultimately uninteresting and did not provide Our findings are limited by our lack of data on those who sufficient encouragement for interaction at this early stage of participated on this site. Without this, we do not know how they online community development. In particular, it did not respond are similar or different from the rest of the population targeted directly to the needs of users, other than with repetitive health by this campaign. Similarly, we have no data on interactions promotion messages and it was not part of a strategy that with the site that did not involve posting, for example, we do acknowledged the changing role of the moderator as an online not know how long each participant spent on the site, what community develops [12]. The idea that online communities material they read or whether they returned to the site, except progress from small groups with a common interest and informal where they returned to the site to post. In addition, we were not rules to larger and more established ones with more formal rules able to obtain data on posts that were removed by the moderator and high levels of participation is well documented [12,22]. or warnings sent to individual participants. Finally, we have no Groups of the sort that we studied that are created by advertising data on the impact of this SNS campaign on the knowledge, for a purpose identified by an external agency may follow a attitudes, and behaviors of those who viewed or participated in different pattern of development closer to online communities this intervention. developed for consumers by businesses (eg, [26]). Here the Conclusions early stages of online community development are described slightly differently with an “on board” stage where the Our findings suggest this health promotion site provided a space community is highly dependent on founder participation and for single user posts but not a self-sustaining conversation. the nature of participation is unclear, to an “established” stage Possible explanations for this include little new content from where relationships within the membership base have been the moderator, a definition of content that was too narrow to established and are less reliant on founder participation. hold the interest of participants, and limited responsiveness to user needs. Delaying response was important to provide space for user-generated content but also carries risks. Users answered Implications for health promotion practice include the need to almost all of the questions posed by other users but corrected consider a life cycle approach to online community development only a third of the inaccurate information posted. With only the for health promotion and the need for a developing moderator last four comments of a discussion thread appearing on strategy to reflect this. This strategy should reflect two facets Facebook newsfeeds, inaccurate content should be corrected of moderation for online health promotion interventions: (1) within three comments but this risks closing down discussions. unengaged and professional oversight to provide a safe space Leaving material that is potentially harmful to a named for discussion and to maintain information quality and (2) a individual is dangerous [8,27-29] and, from our analysis, is not more engaged and interactive presence designed to maintain associated with stimulating conversation. 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Examining characteristics and associated distress related to Internet harassment: findings from the Second Youth Internet Safety Survey. Pediatrics 2006 Oct;118(4):e1169-e1177 [FREE Full text] [doi: 10.1542/peds.2006-0815] [Medline: 17015505] Abbreviations SNS: social networking site Edited by G Eysenbach; submitted 07.01.14; peer-reviewed by A Moorhead, R Webster; comments to author 31.01.14; revised version received 05.03.14; accepted 24.03.14; published 11.04.14 Please cite as: Syred J, Naidoo C, Woodhall SC, Baraitser P J Med Internet Res 2014;16(4):e108 URL: http://www.jmir.org/2014/4/e108/ doi: 10.2196/jmir.3231 PMID: 24727742 ©Jonathan Syred, Carla Naidoo, Sarah C Woodhall, Paula Baraitser. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.04.2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included. http://www.jmir.org/2014/4/e108/ J Med Internet Res 2014 | vol. 16 | iss. 4 | e108 | p. 9 (page number not for citation purposes) XSL FO RenderX

Journal

Journal of Medical Internet Research – JMIR Publications

Published: Apr 11, 2014

Keywords: social media; chlamydia; health promotion

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