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TBM

Engagement of young adult cancer survivors

within a Facebook-based physical activity intervention

Carmina G. Valle, PhD, MPH,

1

Deborah F. Tate, PhD

1,2

Abstract

Few studies have examined how young adult cancer survivors use online social media. The objective of this study was to characterize Facebook engagement by young adult cancer survivors in the context of a physical activity (PA) intervention program. Young adult cancer survivors participated in one of two Facebook groups as part of a 12-week randomized trial of a PA intervention (FITNET) compared to a self-help comparison (SC) condi-tion. A moderator actively prompted group discussions in the FITNET Facebook group, while social interaction was unprompted in the SC group. We examined factors related to engagement, differences in engagement by group for-mat and types of Facebook posts, and the relationship between Facebook engagement and PA outcomes. There were no group differences in the number of Facebook comments posted over 12 weeks (FITNET, 153 vs. SC, 188

p= 0.85) or the proportion of participants that reported engaging within Facebook group discussions at least 1– 2 days/week. The proportion of participants that made any posts decreased over time in both groups. SC partic-ipants were more likely than FITNET particpartic-ipants to agree that group discussions caused them to become physically active (p= 0.040) and that group members were sup-portive (p= 0.028). Participant-initiated posts elicited significantly more comments and likes than moderator-initiated posts. Responses posted on Facebook were sig-nificantly associated with light PA at 12 weeks (β= 11.77,

t(85) = 1.996,p= 0.049) across groups. Engagement within Facebook groups was variable and may be associ-ated with PA among young adult cancer survivors. Future research should explore how to promote sustained en-gagement in online social networks.ClinicalTrials.gov identifier: NCT01349153

Keywords

Young adults, Cancer survivors, Physical activity, Social media, Social support

INTRODUCTION

Young adult cancer survivors (YACS), diagnosed be-tween the ages of 18 and 39, have unique psychosocial and medical needs that occur during the developmen-tal transition into adulthood [1,2]. Long-term and late effects of cancer treatment, including increased risks for cardiovascular disease, diabetes, obesity, recur-rence, and second cancers, may present significant

challenges to this population over the course of their lives [1, 3, 4]. Healthy lifestyle behaviors, such as regular physical activity (PA) and maintaining a healthy weight, have the potential to reduce these risks and improve quality of life in cancer survivors [5,6]. However, about 60% of young adults diagnosed with cancer during adolescence or young adulthood are not meeting PA guidelines of 150 min/week of moderate-to-vigorous-intensity PA for cancer survi-vors [7], and the prevalence of obesity in this popula-tion is higher than among peers without a history of cancer (31 vs. 27%) [3]. Although PA interventions have demonstrated benefits for cancer survivors, in-cluding improvements in cardiovascular fitness [8], depression [9], fatigue [10], and quality of life [10,

11], few have focused on YACS [12–15].

eHealth interventions for PA have demonstrated effectiveness among a variety of populations [16–18], and social media and social networking sites (SNS) are emerging as potentially effective approaches for PA and weight-related interventions [19–22] and for can-cer prevention and control [23]. SNS have the poten-tial to broadly reach individuals and engage users in interactive discussions, and young adults are some of 1

Department of Health Behavior, Gillings School of Global Public Health,

University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

2

Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Correspondence to: C Valle carmina.valle@unc.edu

Cite this as:TBM2017;7:667–679 doi: 10.1007/s13142-017-0483-3

#Society of Behavioral Medicine 2017

Implications

Practice:Participant-initiated posts by cancer sur-vivors may prompt more engagement than moderator-initiated posts and could assist with pro-moting physical activity in the context of a social media-based intervention for young adult cancer survivors.

Policy: Given the widespread use of social net-working sites, a better understanding of how cancer survivors use and benefit from existing online so-cial networks is needed to develop effective public health programs with potential for wider dissemi-nation.

Research: Research is needed to examine how cancer survivors engage within social networking sites and to capitalize on common experiences in ways that facilitate improvements in health behav-ior change.

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the most active users of sites such as Facebook and Twitter [24]. Use of social media is especially prevalent among YACS, who often turn to social media for health information, peer support, and to engage with other cancer survivors and numerous cancer-specific organizations focused on YACS [25,26]. While YACS continue to seek online information about healthy behaviors [27], few studies have examined how SNS are used by young adult survivors [25]. Overall, there is a need to better understand how cancer survivors use social media [25,28] and how to best utilize online social networks to promote positive behavior change [21,29].

A growing number of published studies have used SNS to deliver interventions related to PA or weight loss [13,20, 30–32]. Systematic reviews of studies to date have demonstrated modest evidence supporting the efficacy of these approaches in promoting PA or weight control [18–22] and concluded that the isolated effect of SNS on behavior change is largely unknown [19, 21, 22]. The few studies that examined engage-ment within the context of these SNS interventions have found positive associations between online social network use and health-related outcomes. Turner-McGrievy and Tate [33] found that increased engage-ment with Twitter (i.e., number of tweets) predicted greater weight loss in the context of a mobile-delivered weight loss intervention. In a randomized controlled trial of an Internet-delivered intervention to promote social support for PA, Cavallo et al. [34] demonstrated that PA outcomes in the online social networking arm were more strongly associated with individuals’ Facebook use than with the use of the structured Facebook intervention group. Engagement with a Facebook page used to deliver a weight loss interven-tion to college students was variable among partici-pants and decreased over the first 21 months of the 2-year study [35]. Polls and pictures posted by the study’s health coach received the most responses from participants. Another study by Hales et al. [36] dem-onstrated that higher engagement with Facebook was associated with greater weight loss during the mainte-nance phase after an initial behavioral weight loss intervention. Additionally, this study identified the most engaging types of Facebook posts, finding that polls elicited the highest use and counselor-initiated posts prompted more engagement than participant-initiated posts [36]. Developing and prompting discus-sions to promote health and maintain continued en-gagement with SNS present challenges, and the role of the counselor or moderator in sustaining these discus-sions is not well understood [37]. Although several online social networks focused specifically on PA exist, little is known about how users engage with various features and outcomes related to engagement [38].

Among studies that have examined engagement of cancer survivors within Internet-delivered interven-tions or social media, most have focused on online support groups, message boards, or researcher-built interventions [39–41]. Characterization of active con-tributions, such as posts or messages to online support

groups, has demonstrated low levels of engagement among cancer survivors, with participants posting less than one message per week on average over the course of 12- to 16-week interventions [42–44]. Few studies have examined the ways that cancer survivors engage within existing social media platforms, such as Facebook, that are commonly used by cancer survi-vors and the general population alike [26,45]. Further-more, little is known about how to use social media to facilitate support in the context of a behavioral inter-vention for cancer survivors. Overall, research is need-ed to examine how cancer survivors engage within online SNS [39], to elucidate how engagement with social media by cancer survivors may relate to health outcomes [46], and to better understand how social media can be used to promote healthy behaviors among cancer survivors [28].

Thus, the objective of this study was to describe how YACS engaged within a Facebook group in the con-text of a SNS-based PA intervention program. Under-standing how YACS use SNS can inform the design and implementation of future interventions for this population. This study sought to answer the following research questions:

1. Do levels (objective and self-reported measures of interactions) and perceptions of participant engagement with a Facebook group differ by group format (moderator-led vs. participant-led)? 2. Do baseline characteristics predict level of Facebook engagement or differ among types of participant engagement (active, somewhat active, reader, inactive)?

3. Is there an association between level and types of participant engagement with a Facebook group and PA outcomes (weekly minutes of moderate-to-vigorous-intensity PA and light PA)?

4. Do levels of participant engagement with a Facebook group vary by type of prompt (catego-ry of prompt, moderator-initiated or participant-initiated post)?

METHODS

Participants

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39 at study entry; diagnosed with cancer (excluding non-melanoma skin cancer) at age 18 or older; ≥ 1 year beyond date of diagnosis; completed cancer treatment; English-speaking; no medical condition(s) that precluded unsupervised exercise; not currently engaging in at least 150 weekly minutes of moderate-intensity exercise; and had Internet access and an active Facebook account. All participants provided informed consent, and study procedures were ap-proved by the institutional review board of the partic-ipating university.

Procedures and intervention conditions

Details and primary outcomes of the intervention study are presented elsewhere [13]. The FITNET in-tervention aimed to increase moderate-to-vigorous-intensity PA (MVPA) levels among YACS to 150 weekly minutes, the guidelines for cancer survivors [47]. After completing a baseline online questionnaire, participants were randomized to one of two groups: FITNET intervention or self-help comparison (SC) (Table1). FITNET participants received four main components, based on social cognitive theory [48] constructs: (1) 12 weekly Facebook messages with enhanced, theory-based behavioral lessons on PA after cancer and links to publicly available websites related to PA and/or cancer survivorship; (2) access to a secret Facebook group, where the study moderator posted discussion prompts to promote interaction (e.g., ques-tions, videos, electronic resources); (3) access to a goal-setting and self-monitoring website, which had a week-ly goal-setting feature, exercise tracker, and graphs with feedback on progress; and (4) a pedometer to self-monitor steps. The Facebook messages received by FITNET participants offered behavioral strategies and educational lessons on PA (e.g., goal-setting, over-coming barriers, enlisting social support). Examples of the various posts the study moderator made to the FITNET Facebook group wall are presented in Table2. The SC group was designed to equate mes-sage contact time, attention, and pedometers with the intervention group. Participants in this group received the following: (1) 12 weekly Facebook messages with general exercise information and website links, (2) access to a secret Facebook group without prompts for interaction, and (3) a pedometer. The Facebook

messages received by SC participants included the same publicly available websites given to FITNET participants and general tips on PA (e.g., benefits of PA). The main differences between the groups were in the lesson content, type of discussion within the Facebook group, and access to the self-monitoring website (Table1). Communications with study partic-ipants took place online, and particpartic-ipants completed online questionnaires at baseline and after 12 weeks. Participants received a $30 gift card as an incentive after completion of the follow-up online questionnaire. As previously reported, there were no group differ-ences in self-reported MVPA over 12 weeks, while the FITNET group increased light activity by 135 min compared with the SC group (FITNET, 164 min/week vs. SC, 29 min/week;p =0.032) [13].

Measures

Demographics and health-related variables

At baseline, participants were asked to report their age, gender, race/ethnicity, marital status, education, em-ployment status, whether living alone or with a child in the home, cancer type and treatment, date of diagno-sis, height, and weight. Body mass index was calculat-ed as weight (kg)/height × height (m2).Physical activity was measured using the Godin Leisure-Time Exercise Questionnaire [49,50], a previously validated measure commonly used in studies of PA among cancer survi-vors [51–53].

Facebook engagement

Table 3 describes the objective and subjective mea-sures of interactions within the Facebook secret groups. Facebook content (posts, comments, videos, website links, etc.) was collected from both groups for each participant on a daily basis by a doctoral student in public health, who served as the study coordinator.

Objective measures—of Facebook engagement for

each participant were summed over the course of the study and defined at the post-level as follows.Response

postswere those made by a participant in response to

or interacting with a post initiated by either the study moderator or a peer. Posts comprised either commenting or answering moderator prompts (

re-sponses to moderator-initiated posts) or commenting on

Table 1| Description of FITNET intervention and self-help comparison group components

Delivery mode FITNET intervention Self-help comparison

In-person Pedometer Pedometer

Facebook 12 weekly Facebook messages 12 weekly Facebook messages

•Links to publicly available websites Links to publicly available websites

•Lessons with guidance on physical activity and behavioral strategies (e.g., self-monitoring, enlisting social support)

•Basic information and tips on physical activity

Facebook group with moderated discussion prompts Facebook group without discussion

prompts Website Self-monitoring website with goal-setting tool, exercise

tracker, and personalized feedback graphs

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posts by peers (responses to participant-initiated posts).

Likes, or the number of times that a participant clicked

the like button next to a post, were summed for each participant.Participant-initiated postswere the number of posts made by participants to the Facebook group that were independent of the moderator prompting discussion.Interactionsfor each participant were calcu-lated from the sum of response posts, initiated posts, and likes. All objective measures were summed at the end of the study, based on the data collected every day, and did not account for whether a post or like was subsequently deleted orBunliked^ after initial daily data collection.

Self-report measures—Prior Facebook usewas assessed at

baseline with a single item from the Facebook Intensi-ty Scale (0 =less than 10 minto 5 =more than 3 h) [54]. In the post-intervention questionnaire, all participants were asked to report how often they engaged in four different interactions with Facebook, with response options ranging from 1 =less often or neverto 6 =several

times a day. Self-reported Facebook engagement questions

asked both FITNET and SC group participants,BOver the last twelve weeks, how often did you do the fol-lowing?: read Facebook group discussions; post re-sponses to questions the study coordinator (SC: other participants) posted; post a status, comments, ques-tions or information to the Facebook group wall; click

‘like’button next to other people’s comments on the Facebook group wall.^ Participants with missing re-sponses at 12 weeks (n = 20) were coded as never engaging. At 12 weeks, participants were asked if they recalled any questions posted by the study coordinator (SC: other participants) on the Facebook group wall to prompt group discussion. Study completers who an-sweredByes^(n= 52, 60.5% of sample) were asked six additional questions about the group discussions, with responses ranging from 1 =not at allto 5 =completely; those who answeredBno^were coded as 1= not at all. Questions on perceptions of Facebook group discussions asked whether participants found information in Facebook group discussions to be designed especially for me and my needs; important to me personally; applies to my life; caused me to become physically active; motivating; and trust that information was ac-curate. Perceptions of Facebook group members were assessed at 12 weeks by asking participants how much they agreed with statements about members of their Facebook group (i.e., were motivating, were support-ive). Responses ranged from 1 = strongly disagree to

5 =strongly agree.

Type of engagement—We further characterized

partici-pants by degree of engagement, based on both objec-tive (posts, likes) and self-report (read group discus-sions) measures, categories used in previous studies [33–35], and a dichotomous cutpoint (median total Facebook interactions). Active participants were de-fined as those who interacted with Facebook at least twice over the course of the study and reported read-ing group discussions at leastB1–2 days per week.^ Participants who interacted with Facebook at least twice but reported rarely reading discussions were

Ta b le 3 | Me asures of Facebo ok enga gement M e a sure D escription of obj e ct ive intera ction w ith Fa ce boo k Descrip tion o f self-repo rted interaction w ith Facebook “ Ove r the last 1 2 w e e ks, how often did you d o th e fol low ing ” : (1 = less often or neve r to 6 = severa l times a day ) R e sponse to m o de rat o r-i n itia te d p os ts Part ici p a nt inte racti o ns w it h Fa ce b ook p osts by st udy m ode rator. M ea sure d wit h th e num be r o f com me nts in res po nse to a po st b y th e m od e rato r Post respons e s to q uestions the st u dy coordinat o r p ost e d o n the Facebook g roup w all (FIT N ET only) R e sponse to participant-ini tiated p ost P artici p a nt intera cti o ns wi th Facebook post init ia te d b y p ee r. Me asured w ith the numb e r o f co m m e nt s in re sponse to p art icipa nt -ini ti at ed p o st Post respons e s to q uestions ot her p articipants p osted o n th e Fa ceb o ok gr o u p w al l (SC onl y) Likes P artici p a nt interacts w ith e ithe r m ode rator or pe er po sts b y cl icking o n “ Like ” icon nex t to post. M eas u red w ith the n u mber of li k e s for original pos t, o r a n y com m e nts on the p os t. Like s for in itia te d post s a re ta ll ie d o nl y from o riginal post s, not including li k e s o n comme nts rel a ted to the o riginal p o st Click the “ Like ” button next to other p e o p le ’ sc o m m e n tso n the Face b oo k g roup wa ll Par ticipant-initiated p osts Pa rtic ip ant initia te s int e ra ct io n w ith Fa ceb ook gro u p b y po s ti ng co mm ent , quest ion, or resource. M easured w it h the number of posts n ot in respons e to a d iscuss ion q u estio n or pro m pt posted by th e m o derator P o st a sta tu s, co mm en ts , q u e st ion s, o r inf orm at ion to th e Facebook g roup w all R e a d Fac e bo ok gr oup d is cu ssio n Read Facebook group d iscuss ion

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classified asSomewhat Active.Those who reported read-ing group discussions but interacted less than twice were categorized asReaders, while those who neither posted regularly, nor read discussions regularly, were consideredInactive.

Types of initiated posts—All posts initiated by the

mod-erator or participants were coded by content into one mutually exclusive category, as described in Table2. Six types of moderator-initiated posts were designed a priori to promote group discussion and elicit peer support within the FITNET group. In month 1, the moderator posted two discussion questions per week and some introductory information about study logistics (e.g., Facebook privacy, self-monitoring website). In months 2 and 3, discussion questions were tapered to one per week. To categorize participant-initiated posts, three coders (doctoral students in public health) reviewed the text of all Facebook posts and developed codes for common themes that emerged from participants’posts. Each participant-initiated post was then categorized, based on codes applied by at least two of the three coders, as one of eight post types described in Table2. For post-level analyses, we tallied the numbers of related comments and likes in response to each initiated post.

Statistical analysis

To characterize Facebook engagement, we calculated descriptive statistics for participant posts and likes and compared study groups on these and self-reported Facebook interactions. Differences in levels of engage-ment between the moderator-led and participant-led group formats were assessed using chi-square or Fish-er’s exact tests for categorical variables or Mann-WhitneyUtests for continuous variables, due to the skewed nature of the data. Related samples Wilcoxon signed rank tests were used to examine change over time in the number of participant interactions with Facebook. Spearman correlations were conducted to examine the association between objective and self-reported measures of Facebook engagement. Next, linear regression was used to examine predictors of levels of Facebook engagement, including baseline demographics, PA, and prior Facebook use. We exam-ined baseline characteristics among the four types of Facebook engagement by conducting chi-square anal-yses for categorical variables or ANOVA with Tukey’s HSD for post hoc analyses of continuous variables. To address the third research question, we explored whether engagement with Facebook was associated with PA outcomes after the 12-week study across study groups. We examined residualized change in PA among the four categories of Facebook engagement by conducting Kruskal-Wallis tests with Dunn-Bonferroni adjustment and performed linear regres-sion analyses, controlling for baseline activity and age. Analyses were intent-to-treat, including all partici-pants, with baseline observations carried forward for any missing post-intervention data (n= 20). Finally, we analyzed post-level data by examining differences in

Facebook engagement (i.e., number of comments and likes) among the types of initiated posts using Kruskal-Wallis tests and post hoc pairwise comparisons with Dunn-Bonferroni adjustment. We used Mann-WhitneyUtests to compare the number of comments and likes between moderator-initiated and participant-initiated posts. All analyses were conducted using SPSS 23.0 (SPSS Inc., Chicago, IL).

RESULTS

Baseline characteristics of study participants are de-scribed in Table4. Eighty-six YACS were randomized to participate in the 12-week intervention trial. A total of 66 (77%) participants completed post-intervention assessments with no difference in retention between study arms. Participants were mostly female (91%), non-Hispanic white (91%), and survivors of hemato-logic cancer (31%) with a mean age of 31.7 ± 6.2 years. On average, participants were overweight and almost 5 years beyond diagnosis. Study groups were compa-rable on baseline characteristics, with the exception of daily Facebook use, which was slightly higher in the FITNET group.

Do levels and perceptions of Facebook engagement differ by study group format?

Facebook engagement by study groups is shown in Table5. Over the course of the 12-week study, partic-ipants engaged in 443 total Facebook interactions, including 341 posts and 102 likes. FITNET partici-pants posted a total of 153 comments to the Facebook group compared to 188 comments by SC participants in the participant-led group. Over two thirds of partic-ipants posted at least once during the study (67.4%; n= 58/86; FITNET, 71.1%; SC, 63.4%), and over one third liked at least one post (34.9%; n = 30/86; FITNET, 28.9%; SC, 41.5%). Among those that posted or liked a post, median posts per person was 4 (1, 6.3) (range 1–36), while median likes per person was 2 (1, 3) (range 1–26). There were no differences between study groups in the median number of response posts or likes by participants. However, the SC group had significantly more participant-initiated posts than the FITNET group (p= <0.0005). The proportion of par-ticipants that made any interactions decreased over time in both groups; over half interacted in the first

month (FITNET, 71.1% vs. SC, 63.4%; χ2(1,

n= 86) = 0.579,p= 0.447), and few posted in month 2 (11.1 vs. 12.2%;p= 1.000) or month 3 (8.9 vs. 7.3%; p= 1.000). Across both groups, the number of inter-actions was significantly lower in month 2 (Z= 31.00, p= <0.0005) and month 3 (Z = 0.00,p= <0.0005) compared to month 1 (Fig.1).

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other people’s comments. Fewer than 10% of partici-pants reported initiating posts with comments, ques-tions, or information. Objective measures of Facebook engagement were significantly correlated with self-reported measures in both groups (response posts: rs = 0.443; p< 0.0005; initiated posts: rs = 0.364;

p= 0.001; likes:rs= 0.429;p< 0.0005).

Among study completers, both groups had compa-rable perceptions of information in the Facebook group discussions (Table5). Most SC group partici-pants had favorable perceptions, reporting that the information was somewhat-completely designed espe-cially for me, important to me personally, applies to my life, motivating, and caused them to become phys-ically active. Compared to the FITNET group, signif-icantly more SC group participants endorsed that in-formation in the group discussions caused them to become physically active (FITNET, 28.1% vs. SC, 52.9%,p= 0.040) and found members of the FITNET group to be supportive (FITNET, 40.6% vs. SC, 67.6%,p= 0.028).

Do baseline characteristics predict level of Facebook engagement or differ among reported types of participant engagement?

Baseline demographic characteristics were not associ-ated with Facebook interactions (total posts and likes over the 12-week study), and neither was baseline Facebook use. Among study groups combined, over

half of participants were Active or Somewhat Active with Facebook (n= 44, 51.2%), with another 10% (n= 9) reporting that they consistently read Facebook discussions. Baseline characteristics did not significant-ly differ among the four types of engagement groups (data not shown), and there were no differences be-tween study groups in the proportion of participants categorized by type of engagement (Table 5). The proportion of participants that completed the 12-week study differed by type of engagement (χ2(3, n = 66) = 18.5, p= <0.0005); all Active (n = 22, 100%) and Reader participants (n= 9, 100%), while only 77.3% of Somewhat Active (n= 17) and 54.5% of Inactive (n= 18) participants, completed the study.

Is there an association between level of Facebook engagement and physical activity changes at 12 weeks? In exploratory analyses of the relationship between Facebook engagement and PA outcomes at 12 weeks, there were significant differences among the four en-gagement groups in change in weekly minutes of MVPA (χ2(3,n= 86) = 11.323,p= 0.010). Pairwise comparisons showed that the Active group reported significantly greater change in MVPA than the Some-what Active (Mdn = 18.5 vs. −48.4, U = 23.773,

p = 0.009) and Inactive groups (Mdn = 18.5 vs.

−46.5, U = 18.500, p= 0.042), but not the Reader group (Mdn = 18.5 vs. 11.6,U= 13.480,p= 1.000). Change in light PA over 12 weeks did not differ by

Table 4| Baseline demographic characteristics by study group

Characteristics FITNET Intervention

(n= 45)

Self-help comparison (n= 41)

pvalue

Age (years), (mean + SD) 30.8 (5.7) 32.7 (4.2) 0.078

Sex [n(%)]

Female 41 (91.1) 37 (90.2) 1.000

Male 4 (8.9) 9 (0.8)

Race/ethnicity [n(%)] 0.470

Non-Hispanic white 42 (93.3) 36 (87.8)

Marital status [n(%)]

Married or living as married 21 (46.7) 22 (53.7) 0.517

Not married 24 (53.3) 19 (46.3)

Education [n(%)]

Less than college degree 9 (20.0) 10 (24.4) 0.624

≥College graduate 36 (80.0) 31 (75.6)

Annual income [n(%)] 0.960

<$50,000 20 (44.4) 18 (43.9)

≥$50,000 25 (55.6) 23 (56.1)

Employed full-time, % 20 (44.4) 20 (48.8) 0.687

Living alone 7 (15.6) 7 (17.1) 0.849

Responsible for children <18 years 17 (37.8) 16 (39.0) 0.905

Months since diagnosis 63.2 (52.1) 52.7 (32.7) 0.261

Body mass index (kg/m2), mean (SD) 28.4 (8.2) 29.1 (8.9) 0.721

≥3 h daily Internet use, % 25 (55.6) 27 (65.9) 0.329

Daily Facebook use,amean (SD) 2.6 (1.4) 2.0 (1.0) 0.049

MVPA (min/week), mean (SD) 109.3 (125.0) 118.4 (126.3) 0.739

Mild PA (min/week), mean (SD) 78.3 (91.8) 81.0 (78.5) 0.887

MVPAmoderate-to-vigorous-intensity physical activity,PAphysical activity

a0 = less than 10 min, 1 = 1030 min, 2 = 3160 min, 3 = 12 h, 4 = 23 h, 5 = more than 3 h

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engagement groups. In linear regression analyses adjusting for baseline light PA and age, response posts on Facebook significantly predicted light PA at 12 weeks, such that every increase of one response post in Facebook was associated with an increase of approximately 12 min/week in light-intensity PA (β= 11.77,t(85) = 1.996,p= 0.049).

Do levels of Facebook engagement differ by type of prompt or initiated posts?

There were 55 moderator-initiated and 58 participant-initiated posts during the study (Table6). Among the

six types of moderator-initiated posts, there were sig-nificant differences in response comments (p< 0.0005) and likes (p< 0.0005). Cancer-related discussion ques-tions received the most responses from participants and were more engaging compared to reminder (p = 0.013) and study logistic (p = 0.035) posts. Moderator-initiated discussion questions about PA were the second most engaging and also received more comments relative to posts with reminders (p= 0.002) or study logistics (p= 0.009). Response comments on participant-initiated posts also signifi-cantly differed among the six categories of posts

(p = 0.046), while likes did not. Compared to

Table 5| Interactions with Facebook and types of participant engagement by study group (n= 86)

Variable Total

(n= 86)

FITNET intervention (n= 45)

Self-help comparison (n= 41)

pvalue

Objective engagement

Number of interactions 443 204 239

Median (IQR) per participant 2 (0, 7) 2 (0, 5.5) 2 (0, 7) 0.947

Mean (SD) per participant 5.15 (8.50) 4.53 (7.33) 5.83 (9.68)

Number of response posts 283 147 136

Median (IQR) per participant 1 (0, 4) 2 (0, 5) 0 (0, 3.5) 0.120

Mean (SD) per participant 3.29 (5.65) 3.27 (4.43) 3.32 (6.80)

Number of participant-initiated posts 58 6 52

Median (IQR) per participant 0 (0, 1) 0 (0, 0) 1 (0, 2) <0.0005

Mean per participant 0.67 (1.32) 0.13 (0.51) 1.27 (1.66)

Number of likes 102 51 51

Median (IQR) per participant 0 (0, 1) 0 (0, 1) 0 (0, 1) 0.262

Mean per participant 1.19 (3.38) 1.13 (3.97) 1.24 (2.63)

Self-reported engagement

Number reporting engaging 1–2 days/ week or more,n(%)

Read group discussion 31 (36.0) 14 (31.1) 17 (41.5) 0.318

Post responses to group wall 11 (12.8) 3 (6.7) 8 (19.5) 0.075

Post status, comments, questions 7 (8.1) 3 (6.7) 4 (9.8) 0.704

Like other peoples comments 10 (11.6) 3 (6.7) 7 (17.1) 0.183

Perceptions of Facebook group discussionsa Number reporting somewhat-completely,n(%)

Designed especially for me 33 (50) 14 (43.8) 19 (55.9) 0.323

Important to me personally 34 (51.5) 16 (50.0) 18 (52.9) 0.811

Applies to my life 35 (53.0) 16 (50.0) 19 (55.9) 0.632

Caused me to become active 27 (40.9) 9 (28.1) 18 (52.9) 0.040

Motivating 32 (48.5) 13 (40.6) 19 (55.9) 0.215

Trust information was accurate 35 (53.0) 18 (56.3) 17 (50.0) 0.611

Perceptions of Facebook group membersa Number reporting agree-strongly agree,n(%)

Members were motivating 25 (37.9) 10 (31.3) 15 (44.1) 0.281

Members were supportive 36 (54.5) 13 (40.6) 23 (67.6) 0.028

Types of participant engagementb

Number of participants,n(%) 0.624

Active 22 (25.9) 11 (24.4) 11 (26.8)

Somewhat active 22 (25.9) 12 (26.7) 10 (24.4)

Reader 9 (10.5) 3 (6.7) 6 (14.6)

Inactive 33 (38.4) 19 (42.2) 14 (34.1)

IQRinterquartile range,SDstandard deviation aSample includes study completers (

n= 66: FITNET,n= 32; SC,n= 34)

bActive:2 interactions with FITNET group and reported reading group discussions at least 12 days/week; Somewhat active:2 interactions with FITNET group and read group discussions <1–2 days/week; Reader: <2 interactions with FITNET group and read group discussions at least 1–2 days/week; Inactive: <2 interactions with FITNET group and read group discussions <1–2 days/week

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moderator-initiated posts, participant-initiated posts elicited significantly more response comments (p= 0.003) and likes (p= 0.002).

DISCUSSION

This study characterized engagement with Facebook by YACS participating in a PA intervention, showing that total number of interactions was comparable be-tween moderator-led and participant-led discussions implemented in an existing popular online SNS. Ob-jective measures of engagement (i.e., Facebook com-ments and likes) were variable among participants and declined over time in both study groups. Over half of participants posted at least two comments to the Facebook groups, with another 10% reporting that they regularly read Facebook group discussions. While self-reported engagement with Facebook was similar between groups, the SC group had more participant-initiated posts compared with the FITNET group, and SC participants were more likely to report that group discussions caused them to become physi-cally active and that other group members were sup-portive. Furthermore, across both groups, participant-initiated posts garnered significantly more response comments and likes than moderator-initiated posts. Participants who were active within Facebook (i.e.,≥ 2 comments and regularly read group discussions) reported greater changes in MVPA over time com-pared with somewhat active and inactive participants. Overall, results from this study suggest that engage-ment within a Facebook group may be associated with PA in YACS, and participant-led discussions, in partic-ular, hold potential for encouraging interaction and support for behavior change.

Given that the FITNET intervention was designed to encourage social support through moderator prompts to encourage interaction, our finding that overall Facebook interactions did not differ between groups was unexpected. The SC group represents the

interactions that naturally emerged through participant-initiated posts without any prompting by a study moderator or counselor. Interestingly, the SC group had a comparable number of total posts over 12 weeks and significantly more participant-initiated posts relative to the FITNET group. Combined with the finding that participant-initiated posts elicited more responses than moderator-initiated posts, our results suggest that when peers initiated posts or discussion prompts, these posts may have been just as encourag-ing, or perhaps even more so, as when prompted by a study moderator. Whereas a participant-led Facebook group appeared to be more well received than a mod-erated one among this sample of YACS, a previous study found that moderated online support groups elic-ited more responses and reading of content than peer-led online support groups for breast cancer survivors [55]. Similarly, engagement with Facebook (i.e., com-ments, likes, views) was significantly higher for counselor-initiated posts compared with participant-initiated posts among participants that joined Facebook support groups after a weight loss study [36]. A possible explanation for the positive perceptions and higher self-initiated engagement in the SC group is a comfort level or experience among some participants who may have previously interacted with peer survivors in other pop-ular Facebook groups, such as those hosted by non-profit cancer organizations. Indeed, YACS have specif-ically expressed interest in peer support in the context of health interventions [56] and indicated meeting peer survivors as an unmet need [57]. Thus, SC participants may have had greater motivation to connect with peers and respond to their prompts and could have perceived support to be more relevant when it came from a peer, rather than from a moderator.

We previously reported no difference in MVPA minutes per week between the FITNET and SC groups, with both groups improving on this primary outcome over time. In the current analyses, contrary to what we anticipated, SC participants were more likely to report that participation in the Facebook 0

20 40 60 80 100 120 140 160 180

Month 1 Month 2 Month 3

FITNET Posts SC Posts FITNET Likes SC Likes

Fig. 1| Number of Facebook posts and likes by study group over time. Note: Posts include both response and participant-initiated posts.FITNETFITNET intervention group,SCself-help comparison group

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group caused them to become physically active and that they felt supported by group members. Although previous research has demonstrated that cancer survi-vors may derive benefits from peer-led online support communities, such as improvements in well-being, depression, empowerment, and hope [58–60], some have shown no improvements [61] or worse outcomes associated with participation in peer-led online com-munities [62] compared to controls. Most studies have been among breast cancer survivors. The current study provides evidence for the potential of peer-led online groups in SNS to encourage interaction and support for increased PA. It is unknown how SC

participants would have engaged with additional com-ponents, such as the self-monitoring website; it is pos-sible that the additional intervention strategies re-ceived by the FITNET group were overwhelming or distracted them from participation in the Facebook discussions. Since the number of posts was compara-ble between groups, it is also possicompara-ble that reading moderator posts could have taken away from the time FITNET participants might have otherwise spent post-ing or respondpost-ing to peers and perhaps suggests some threshold of engagement. Overall, future research is needed to compare the capacity of moderators and peers to elicit support for and influence positive health

Table 6| Number of comments and likes by moderator-initiated and participant-initiated post types from both study groups

Type of post Number

of posts

Number of comments in response to post Median (IQR) Mean (SD)

Number of likes in response to post Median (IQR) Mean (SD)

Moderator-initiated posts 55

Cancer-related discussion question 4 3.5 (1.3, 23.8)a

9.5 (13.8)

0 (0, 0) 0 (0)

Physical activity discussion question 13 2 (1, 4)b

3.5 (4.2)

0 (0, 0) 0.08 (0.3)

Physical activity resource/information 6 0.5 (0, 1.3)

0.7 (1.4)

1 (0, 1)c 0.7 (0.5)

Cancer-related news 8 0 (0, 0.8)

0.6 (1.4)

0 (0, 0) 0 (0)

Reminder (Thursday) 12 0 (0, 0)

0.2 (0.6)

0 (0, 0) 0 (0)

Study logistics, technical support information 12 0 (0, 0)

0.7 (2.0)

0 (0, 0) 0 (0)

pvalue for difference among post types <0.0005 <0.0005

Participant-initiated posts 58

PA information/CA news 4 0.5 (0, 1.8)

0.8 (1.0)

0 (0, 1.5) 0.5 (1.0)

Introduction 20 1 (0, 2)

1.5 (2.4)

0 (0, 1) 0.5 (0.8)

Question about study logistics, technical support 9 3 (1, 4)

3.2 (2.2)

0 (0, 0) 0 (0)

Question about cancer, treatment 2 2.5 (2, 3)

2.5 (0.7)

0 (0, 0) 0 (0)

Check-in 10 1.5 (1, 5)

3.7 (4.7)

0 (0, 1) 0.4 (.5)

Physical activity accomplishment 9 3 (1, 8.5)

5.2 (6.5)

1 (0, 2.5) 1.3 (1.5)

Physical activity goal 4 1 (0.3, 1.8)

1 (0.8)

0.5 (0, 1.8) 0.8 (1.0)

pvalue for difference among post types 0.046 0.153

Total responses to moderator-initiated posts 0 (0, 2)

1.9 (4.7) Range 0–30

0 (0, 0) 0.1 (0.3) Range 0–1

Total responses to participant-initiated posts 1 (0, 3.3)

2.7 (3.8) Range 0–19

0 (0, 1) 0.5 (0.9) Range 0–4

pvalue for moderator vs. participant initiated 0.003 0.002

IQRinterquartile range,SDstandard deviation aSignificantly different from Reminder (

p =0.013) and Study logistics (p =0.035) based on post hoc pairwise comparisons with Dunn-Bonferroni adjustment bSignificantly different from Reminder (

p =0.002) and Study logistics (p =0.009) based on post hoc pairwise comparisons with Dunn-Bonferroni adjustment cSignificantly different from five other groups (

ps =0.006 to <0.0005) based on post hoc pairwise comparisons with Dunn-Bonferroni adjustment

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behavior change in the context of SNS and to isolate the effects of engagement within online social network-ing groups from other intervention components.

Over half of participants interacted with the Facebook group at least twice; the median level of engagement was higher than that of female undergraduate students that participated in a 12-week SNS intervention as part of a randomized trial to promote PA [34]. Among the 67 women that received an intervention that included a Facebook group, participants engaged in a median of approximately one interaction (i.e., post, like) within the group. In the current study, over two thirds of YACS posted at least one comment, similar to engagement by college students participating in weight loss interven-tions delivered via Facebook [32,35].

In studies of online support groups in cancer survi-vors, engagement, as measured by mean posts or com-ments per person, has been higher compared with four posts over 12 weeks in the present study. In a moder-ated online support group for gynecologic cancer sur-vivors with psychoeducational materials, participants posted an average of eight comments over 12 weeks [44], while breast cancer survivors posted 20 and 12 times over 12 weeks in moderated and peer-led online support groups, respectively [55]. Our study differs from these others among cancer survivors in that the Facebook group was only one of multiple intervention components over which participants may have divid-ed their time and participation. Similar to many be-havioral interventions using SNS, participant engage-ment with Facebook declined over time [21,22,33– 35]. While there were no differences in demographic characteristics across the categories of engagement, there were differences in rates of study completion, with all Active and Reader participants completing the study. Previous studies among cancer survivors have also found that demographic characteristics have not differed between participants that actively partici-pated in online support groups and those that were passive readers (i.e., lurkers) [55,63]. Given that all of the Reader participants completed the study and that evidence shows that lurkers may experience some benefits, such as improved psychosocial well-being, from participation in online cancer communities [63], studies should examine how lurkers can benefit from engagement in popular SNS, as well as how lurkers can best be encouraged to improve PA and other health behaviors. Additionally, research is needed to identify strategies to increase and sustain engagement with behavioral interventions in the context of SNS that are commonly used in everyday life.

The participants who were most actively engaged with Facebook reported significantly higher changes in MVPA levels than those that were Somewhat Active or Inactive. Previous studies of SNS interventions have also found that higher engagement with Facebook or Twitter was associated with improvements in PA [34] or weight control [33,36]. It is unclear why response posts within the Facebook group predicted increased light PA, but not MVPA. Given their exploratory nature, these results should be interpreted with

caution, as some other unmeasured variable may ex-plain variance in light PA. Taken together, our findings provide evidence to suggest that engagement with a Facebook group focused on providing support and encouragement may be associated with PA in YACS.

Engagement within the Facebook group varied by the type of moderator-initiated post, with discussion questions about cancer experiences and PA receiving the most responses from participants. Similar to other social media-based interventions for weight control, posts that prompted participants to provide responses were more engaging. Previous studies have shown poll votes and event invitations, Facebook features that enable specific responses, to be the most engaging among participants in weight-related interventions [32,36]. In future studies using SNS groups to encour-age peer support and interaction among cancer survi-vors, engagement may be improved by posting specif-ic prompts, such as questions and discussion questions that invite responses from participants. Future re-search should also examine how to best involve cancer survivors and peers to encourage engagement in social networks, such as training peers to lead discussions or using a combination of moderator- and peer-led ap-proaches. Studies that recruit or capitalize on existing social networks of cancer survivors to promote healthy behaviors may also be warranted.

This is the first study to examine the group format and types of posts that elicit Facebook engagement by YACS in the context of a PA intervention program. Strengths of this study include the use of both objective and self-report measures of engagement within an existing popular SNS. The study design allowed us to compare moderated and participant-led group formats, and the SC group received an active intervention through Facebook, allowing for a more robust test of the effects of the intervention components on PA out-comes. Although our study has several strengths, a number of limitations should be considered when interpreting results. At the time of the study, other objective measures of Facebook engagement were not available, including the number of times posts were viewed or shared. Participants may have spent time reading posts or received support from other Facebook friends outside of the study, which we were unable to objectively assess and account for in analyses. Because of the multicomponent interventions, we were unable to isolate the effects of Facebook engagement and peer support from other intervention components. Given the relatively small and homogeneous sample, findings may have limited generalizability to the diverse popu-lation of YACS. Study participants were limited to those with existing Facebook accounts and may have been more engaged on SNS than other YACS. Finally, there may have been other unmeasured factors, such as style of coping, which possibly moderated the association between engagement with Facebook and perceptions of group discussions and outcomes [60].

In summary, we found that a Facebook group was feasible for facilitating communication and support among YACS. Among the SC group, a minimal inter-vention and an unmoderated participant-led Facebook

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group was utilized, on topic, and well received. Overall, our findings suggest that peer-led Facebook group dis-cussions have potential for promoting interactions among YACS. In the future, research should continue to evaluate ways to capitalize on SNS features and func-tionalities that promote engagement and support in peer-led groups. Further defining valid metrics of en-gagement, intervention adherence, and interactions on SNS are also important areas to advance the science of SNS-based behavioral interventions. Exploration of on-line social networking-based approaches that may facil-itate social support, longer-term adherence, and positive behavior changes in larger samples is warranted.

Acknowledgements:We gratefully acknowledge the staff and students of the UNC Weight Research Program for their valuable support, including Candice Alick, Loneke Blackman, and Rachel K. Bordogna, who provided excellent research assistance. We are also most grateful to the young adult cancer survivors who participated in the study.

Compliance with ethical standards

Disclosure:A portion of the findings in this manuscript was previously reported during conference presentations at the International Society of Be-havioral Nutrition and Physical Activity 2013 Annual Meeting, the International Society for Research on Internet Interventions 2013 Scientific Meeting, and the 2014 Biennial Cancer Survivorship Research Conference.

Conflict of interest:The authors declare that they have no conflict of interest.

Ethical approval:All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Statement on the welfare of animals:This article does not contain any studies with animals performed by any of the authors.

Informed consent:Informed consent was obtained from all individual participants included in the study.

Funding:This study was supported by a 2011 Society of Behavioral Medicine Distinguished Student Award for Excellence in Research, the UNC Lineberger Cancer Control Education Program (National Institutes of Health/National Cancer Institute funded; R25 CA057726), and the UNC Communications for Health Applications and Interventions Core (funded through the Gillings School of Global Public Health Nutrition Obesity Research Center (National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases funded; P30 DK56350) and the Lineberger Comprehensive Cancer Center (National Institutes of Health/National Cancer Institute funded; P30 CA16086)).

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