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There is increasing interest in using social media sites such as Facebook to deliver health interventions so as to expose people to content while they are engaging in their usual social media habit. This formative intervention development study is novel in describing a preliminary test of using the secret group feature of Facebook to deliver a behavioral intervention targeting users of indoor tanning beds to reduce their risk of skin cancer. Intervention content was designed to challenge body image-related constructs associated with indoor tanning through the use of dissonance-inducing content.
To evaluate engagement with and acceptability of using a secret Facebook group to deliver a healthy body image intervention to young women engaged in indoor tanning.
Seventeen young women completed a baseline survey and joined a secret Facebook group with intervention content delivered via daily posts for 4 weeks. Engagement data was extracted and acceptability was measured via a follow-up survey.
The study had a high retention rate (94%, [16/17]). On average, posts were viewed by 91% of participants, liked by 35%, and commented on by 26%. The average comment rate was highest (65%) for posts that elicited comments by directly posing questions or discussion topics to the group. Average intervention acceptability ratings were highly positive and participants reported feeling connected to the group and its topic. Average rates of past 1-month indoor tanning reported following the intervention were lower than the baseline rate (
This study is novel in demonstrating participant engagement with and acceptability of using Facebook secret groups to deliver a dissonance-inducing intervention approach that utilizes group-based discussions related to body image. The study is also unique within the field of skin cancer prevention by demonstrating the potential value of delivering an indoor tanning intervention within an interactive social media format. The findings suggest that Facebook metrics of intervention post engagement (ie, likes and comments) may vary based on post types and that designing specifically labeled discussion posts may be helpful for soliciting engagement as well as challenging beliefs.
Social media allows for the unlimited exchange of information, images, and interactive peer communication. Researchers have begun to utilize Facebook, the most popular social media site [
The intervention approach is guided by body image theories that demonstrate cultural experiences can negatively impact how young women view their bodies and may lead to a preoccupation with obtaining an unrealistic, culturally-derived ideal appearance [
The purpose of this proof-of-concept study was to test engagement with and acceptability of delivering a dissonance-based, body image focused intervention to reduce indoor tanning using Facebook secret groups. For this intervention, content was posted daily on the group page for four weeks and group members were encouraged to share and discuss their opinions about the posts. We also examined the preliminary efficacy of the intervention by comparing rates of participants’ tanning bed use before and after the intervention.
Participants were 18 to 25-year-old women who used Facebook at least once a day and a tanning bed at least once in the past year. Recruitment utilized multiple methods including: emailing study invitations to participants from our prior focus group study on tanners’ intervention preferences; distributing recruitment flyers to students on a large northeastern US college campus; posting study flyers on social media accounts (including investigators’ personal Facebook and Twitter pages); and ads on local Craigslist pages. Research staff conducted study screening phone calls with interested participants to evaluate study eligibility. A total of 17 participants were enrolled (6 recruited from prior focus groups, 3 campus flyers, 6 social media and Craigslist, and 2 referrals from enrolled participants).
Study procedures included a baseline survey, participation in a four-week Facebook group, and a post-intervention survey 5 weeks after baseline. The study was conducted from July to August 2016. Enrolled participants were emailed a link and a unique PIN to complete the online baseline survey. Participants received a US $30 gift card for each survey and those who completed both were entered in a US $100 gift card raffle. The university’s Institutional Review Board approved all study procedures and participants provided online consent.
The intervention consisted of a secret invitation-only Facebook group named “RU Facebook Project”. The group feature of Facebook is designed to connect and share information with a subset of Facebook users based on shared interests. With Facebook secret groups, Facebook users receive a private invitation to join a group, which in this study was used to post the intervention messages. Further, secret group membership and content is limited to invited group members and their group membership and in-group activities are not publicly viewable to outside Facebook users. A study Facebook account was created and used to deliver all intervention content via daily group posts. Two authors, JS and AD, joined the group with study-specific Facebook user accounts to provide a “face” for the researchers and increase study credibility. Our involvement was purposefully limited to include: encouraging initial comments and responses to discussion questions by JS and AD—commenting once each on the first “icebreaker” post and AD commenting once on each of the next two discussion posts—and liking comments from participants throughout the study to reinforce participation.
The goals of the dissonance-based Facebook intervention approach mirrored those of existing interventions for disordered eating and indoor tanning [
Intervention receipt was defined as the percent of posts viewed by participants. Engagement was assessed as interactions with group posts (ie, likes and comments). Engagement results are presented both as “post engagement”, defined as the mean number of likes and comments received by post types, and “participant engagement”, defined as the number of likes and comments averaged across participants. Facebook data was manually extracted from the group newsfeed after the posting period ended.
Intervention acceptability was measured on the follow-up survey in two ways. First, four general intervention evaluation items assessed the extent participation in the Facebook intervention was interesting, understandable, useful, or positive (measured on an 11-point scale anchored with 0=
Description of intervention content delivered in Facebook group posts.
Description of content within each post type | Number (total %) | Source(s) | Example post |
Information-based content intended to provide context for the intervention content and counter-perspectives to idealistic thinking. Designed to raise participants’ awareness of their thoughts, feelings, and actions with regard to their appearance, including the sociocultural experiences that lead to an overemphasis on appearance and cause body dissatisfaction. | 9 (32%) | Adapted from disordered eating [ |
“We’ve talked about the excessive use of Photoshop to create images of ‘ideal’ women by making body parts thinner or changing the appearance of skin by smoothing wrinkles, removing blemishes, and often altering skin tone to appear tanner. One reason that the use of Photoshop is so common is that images of ‘ideal’ women are used to sell products. For example, fashion magazine covers, articles, and images are designed to make a woman feel bad about her looks. These magazines try to convince women that something is wrong with how they look and that they can fix the problem by buying the products in the magazine ads. The worse the images make women feel, the more money the magazine makes in advertising sales.” This post included a link to a web article showing celebrity photographs before and after they were altered with Photoshop. |
Inspirational or humorous quotes related to resisting idealistic thinking, empowerment, or body activism. | 9 (32%) | Images curated from internet searches or sharing postings from other Facebook pages, for example [ |
A meme with a quote from Tina Fey describing her view on the female body image. |
Questions or discussion topics that elicited comments and responses from group members. Posts were clearly identified with the label: “Your Thoughts **Please read and comment**”. Designed to encourage comments that were critiques of or counterarguments against unrealistic beauty ideals. | 8 (29%) | Adapted from disordered eating [ |
“Several members have mentioned the “ideal” for women in their comments and now we would like to define the ideal to understand exactly what we are talking about. What are we told that the ideal or perfect woman looks like?” |
Skill-building, homework-type activities were programmed with online survey software. Appeared as a webpage accessed with an outside link from Facebook posts. Given the personal nature of some questions, participants’ responses to homework were not directly viewed by the group. Designed to promote media literacy and self-acceptance. | 2 (7%) | Adapted from disordered eating [ |
A positive body image task that asks participants to create a top ten list of their own best attributes. |
Second, participants answered several Facebook-specific evaluation items related to their perceptions of their experience as members of the Facebook group [
Number of past 1-month tanning sessions was measured on the baseline and follow-up assessment using an expert-recommended survey item (“How many times in the past month have you used a tanning bed or booth?”) [
Descriptive statistics are presented for the Facebook engagement metrics and the intervention acceptability measures. A paired-sample 2-tailed t-test was used to compare mean differences in baseline and follow-up responses to the preliminary indoor tanning outcome measure.
Participants reported a mean age of 20.8 years (SD 1.7) and 9 out of 17 (53%) were White, 5 out of 17 (29%) were other/multiracial, 2 out of 17 (12%) were Asian, and 1 out of 17 (6%) refused to answer. Five out of seventeen participants identified as Hispanic (29%). Most participants were currently enrolled in college (82% [12/17]) with the remaining having a bachelor's degree or higher (18% [3/17]). Eleven out of seventeen (65%) participants used Facebook multiple times a day and 5 out of 17 (29%) reported daily use at baseline.
All enrolled participants completed the baseline assessment and accepted our invitation to join the Facebook group. Sixteen out of seventeen participants completed the post-intervention survey, producing a 94% study retention rate.
Twelve out of seventeen participants (70.6%) viewed every post and an additional four (23.5%) viewed at least 75% of posts. An average of 91.4% participants viewed each post (See
Descriptive statistics for post views and engagement metrics by post type.
Engagement Metric and Post Type | Mean percentage (SD) | |
Alla | 91.4 (7.1) | |
Psycho-educational | 90.2 (7.2) | |
Inspirational | 89.5 (7.1) | |
Your Thoughts | 94.9 (6.6) | |
All | 34.6 (21.1) | |
Psycho-educational | 42.5 (11.3) | |
Inspirational | 50.3 (12.5) | |
Your Thoughts | 8.1 (7.7) | |
All | 26.2 (28.7) | |
Psycho-educational | 13.0 (14.3) | |
Inspirational | 5.2 (4.6) | |
Your Thoughts | 64.7 (14.4) |
aHomework posts are not included in descriptive statistics given the low number of posts relative to other post types and the nature of the posts that contained links to an external webpage for participants to leave comments.
Perceptions of the Facebook group intervention experience. Survey items were measured with a 5-point, Likert-type response scale: 1=
Survey Type and Items | Mean (SD) | ||
I could identify with a lot of the posts. | 4.3 (0.6) | ||
The posts were relevant to me. | 4.4 (0.5) | ||
I could identify with other people in the group. | 4.3 (0.6) | ||
I felt connected to the other people in the group. | 3.9 (0.7) | ||
I paid attention to other people’s comments in the group. | 4.4 (0.6) | ||
I felt like I was actively involved in the Facebook group. | 4.2 (0.8) | ||
I enjoyed expressing my opinions in the group. | 4.2 (1.0) | ||
I enjoyed reading other people’s comments in the group. | 4.2 (0.7) | ||
I enjoyed reading the posts made in the Facebook group. | 4.4 (0.5) | ||
I felt comfortable participating in the study. | 4.6 (0.8) | ||
It was easy to participate in the Facebook study. | 4.8 (0.5) | ||
The study was too time consuming. | 2.2 (1.3) | ||
I would be willing to continue as part of the Facebook group if the study were to continue. | 4.8 (0.5) |
Participants provided favorable ratings on general intervention evaluation items including: interesting (mean 7.5 [SD 1.7]); understandable (mean 9.1 [SD 1.3]); useful (mean 8.2 [SD 1.7]); and positive (mean 9.1, [SD 1.5]). Means for Facebook-specific evaluation items indicated a general level of agreement with regard to perceived connectedness to the group (
The mean number of reported past 1 month indoor tanning sessions was lower at the post-intervention assessment (mean 0.7 [SD 2.3]) compared to baseline (mean 2.3 [SD 4.4]) although this difference was not significant at the α=.05 level (t15=1.90,
Intervention receipt was high as a typical post was viewed by 91.4% of participants. In addition, the majority of participants (70.6% [12/17]) viewed every post, and an additional 23.5% [4/17] viewed at least 75% of posts. Post engagement, measured by likes and comments, differed according to post type. Posts specifically designed to elicit comments by posting questions and discussion topics to the group (ie, those titled,
Ratings on general measures of intervention acceptability (eg, interesting) were favorable and comparable to other tanning interventions delivered via booklet or website [
This formative study has some notable limitations. First, the study had a single arm design, small sample size, and was not fully powered to detect behavior change or examine psychosocial intervention mediators. Second, the sample was primarily recruited from a single geographic area using specific inclusion criteria that reduce generalizability of the findings. Our discussion posts were adapted from in-person, group-based disordered eating interventions that utilize discussion questions designed specifically to generate counter-attitudinal responses to challenge image ideals [
In conclusion, social media represents an unexplored platform for delivering dissonance-based interventions for disordered eating and indoor tanning. The current formative study demonstrates the feasibility and acceptability of using Facebook as a delivery mechanism for these types of interventions. The use of Facebook groups to deliver dissonance-based interventions capitalizes on features key to the success of these interventions including group-based discussions and peer support. Embedding the intervention into the target population’s social media routine facilitates both engagement and reaches with less expense than in-person groups and developing websites incurs. The utilization of Facebook groups for delivering group-based interventions is appealing given the potential for creating highly sustainable intervention approaches with strong potential for dissemination across multiple geographic locations.
This research was supported in part by grants from the National Cancer Institute to Jerod Stapleton (K07 CA175115 & R01 CA218068). The sponsors did not influence the design or conduct of the study, the collection, management, analysis or interpretation of the data, or the preparation, review, or approval of the manuscript. This article is dedicated to Rebecca Garrison-Sokoloff who lost her 7-year battle with melanoma on November 12, 2011, at the age of 34.
None Declared.