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Social networking sites (SNSs) such as Facebook have the potential to enhance online public health interventions, in part, as they provide social exposure and reinforcement.
The objective of the study was to evaluate whether social exposure provided by SNSs enhances the effects of online public health interventions.
As a sample intervention, we developed Food Hero, an online platform for nutritional education in which players feed a virtual character according to their own nutritional needs and complete a set of virtual sport challenges. The platform was developed in 2 versions: a "private version" in which a user can see only his or her own score, and a "social version" in which a user can see other players’ scores, including preexisting Facebook friends. We assessed changes in participants’ nutritional knowledge using 4 quiz scores and 3 menu-assembly scores. Monitoring feeding and exercising attempts assessed engagement with the platform.
The 2 versions of the platform were randomly assigned between a study group (30 members receiving the social version) and a control group (33 members, private version). The study group's performance on the quizzes gradually increased over time, relative to that of the control group, becoming significantly higher by the fourth quiz (
This work focused on isolating the SNSs' social effects in order to help guide future online interventions. Our results indicate that the social exposure provided by SNSs is associated with increased engagement and learning in an online nutritional educational platform.
With the significant amount of time people spent engaging with digital media [
Social networking sites (SNSs) are a major component of Internet use by young adults [
Currently, the most popular SNS in the world is Facebook [
There is a tremendous opportunity to leverage the potential of SNSs to promote public health issues in general, and obesity prevention in particular. Obesity is associated with many of the most common and costly medical problems in Western society [
A literature review from 2010 identified only one controlled intervention study on social media and health outcomes [
The goal of this study is to evaluate whether the social exposure provided by SNSs can increase the effect of online public health interventions, specifically by evaluating its influence on the learning curve for nutritional knowledge.
In order to conduct this study, we developed a game-based educational platform called
In the
Feeding screen of Food Hero guided by nutritional information cards.
Feeding screen of Food Hero guided by status bars.
We developed 2 different versions of the platform, a “private version” and a “social version,” and assigned these versions randomly to different users. In the private version, only the user's own score is presented, without any information about the performance of other players. In the social version, the user’s performance is presented in the context of other players, a high-score bar shows the scores of the 5 best players, while another shows the top 5 scores from within the user's Facebook friends (
Home screen of the social version, showing the high-score bars.
Nutritional information was obtained from the US Department of Agriculture's official database for dietary guidelines, “My Pyramid.” This information included the definition of the 5 food groups, a list of food items along with their nutritional value, and the formulas to calculate the proper intake of calories and desired level for each food group (adjusted for sex, age, weight, and exercise habits) [
Participants were Facebook users who chose to install the platform and agreed to join the study by completing a consent form presented as part of the app installation process. For reasons of legal consent, all study participants were older than 18 years of age, as stated in the participation consent form. Exclusion criteria included users that did not provide consent to participate in the study, users that did not report their age or reported an age younger than 18 years, and users that installed the software, but did not actively start to use it (ie, did not complete the first game day).
The distribution of the platform took place over a 2-month period, starting in April 2012, and was spread through the SNS by peer-to-peer message dissemination. The distribution was initiated by a single message recommending
All data for the study were collected electronically within the
On the 15th game day, at the end of the follow-up period, a final questionnaire was presented to evaluate each user’s impressions of how the SNS influenced his or her use of the platform and the effect the platform had on approach and behavior regarding nutrition. Participants who did not complete the full follow-up period received a request to answer the questionnaire by email. Questions regarding the social network influence were presented to the control group members hypothetically—what effect they would expect if they could have seen their friends' performance. The final questionnaire is provided in
Descriptive statistics and comparison of groups were performed using SPSS Statistics 18.0. Comparison of quantitative variables between study groups was performed using the
The Ethics Committee for Human Studies of the Hebrew University of Jerusalem approved the project.
Of the 70 Facebook users who installed the platform successfully during the 2-month distribution period, 7 were excluded from the data analysis (2 did not enter their age, 5 did not start active use of the app). A total of 63 users, of which 30 belonged to the study group and 33 to the control group, were included in the analysis. No significant differences were found between the basic characteristics (age, sex, body mass index; BMI, etc) of the study participants in both groups (
Study participants’ character by study group.
Participants’ character | Study group | Control group | |
Number | 30 | 33 | |
Age (average in years) | 29.0 | 31.4 | |
Sex (male percentage), n (%) | 13/28 (46) | 10/33 (30) | |
BMIa (average) | 22.0 | 23.2 | |
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Hebrew | 26/30 (87) | 27/33 (82) | |
English | 2/30 (7) | 4/33 (12) | |
Other | 2/30 (7) | 2/33 (6) | |
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Did not complete/completed high school | 3/30 (10) | 1/33 (3) |
Studying for/completed first degree | 15/30 (50) | 14/33 (42) | |
Completed graduate degree | 12/30 (40) | 18/33 (55) | |
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0-0.5 | 8/30 (27) | 7/32 (22) | |
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0.5-2 | 6/30 (20) | 7/32 (22) |
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Over 2 | 16/30 (53) | 18/32 (56) |
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Nonsmokers | 25/30 (83) | 28/32 (88) |
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Former smokers | 3/30 (10) | 2/32 (6) |
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Current smokers | 2/30 (7) | 2/32 (6) |
Facebook friends playing |
2.9 | 2.6 |
aBMI was calculated according to height and weight reported by users.
Study participants played an average of 8.8 game days, with no significant difference between persistence rates in both study groups (
As stated, quiz grades were chosen to be the primary variable to assess knowledge change with platform use. The average grade of the first quiz, presented to players in the second game day in order to document the basic knowledge of the users, was practically identical between study groups, with both groups answering 57% (average of 4.6/8 correct answers) of the questions correctly. The later quiz grades were analyzed by calculating a set of quiz grade improvement variables, measuring the improvement of each quiz score relative to the first quiz the player had answered. Analysis of these variables revealed a trend of greater improvement over time among the study group. For control group members, the average of the second quiz improvement variable was positive, meaning improvement relative to the first quiz, but in further quizzes there was a gradual decrease in performance (
As with quiz grades, unguided menu assembly scores were analyzed by calculating the improvement relative to the performance of each player on the first unguided menu assembly day. These scores were then converted to standardized z-scores, because the original scores ranged in unlimited scale, including negative numbers. The study group exhibited a positive improvement in both the second and third unguided menu assembly scores, whereas the control group exhibited deterioration in performance over time. The average z-score of the second and third unguided menu assembly days was 0.18 above the first menu assembly day in the study group, compared with -0.26 in the control group.
Average quiz grade improvement by study group (relative to the first quiz grade). Each point includes all participants that answered the relevant quiz, in comparison to the grade the same participants received in the first quiz. (a)
Difference between average quiz grade improvement between study groups. (a)
Members of the study group also invested greater time and effort trying to progress through the stages of the educational platform, and they spent an average of 3 minutes and 40 seconds on each menu assembly, as opposed to 2 minutes and 50 seconds in the control group. In addition, study group members performed an average of 1.42 attempts to build the menu on each game day, compared with 1.37 attempts in the control group. The average number of sport challenges the user tried to complete in each game day (reflecting the user's motivation to advance through the game levels) was 1.58 in the study group and 1.21 in the control group (
The final questionnaire demonstrated that most participants, from both study groups (with no statistically significant difference), perceived that being able to watch other players' performance can encourage engagement with the platform. Overall, 64% (14/22) of respondents expressed a medium or high level of agreement with a statement that they were interested in other players’ performance. A total of 67% (14/21) expressed a medium or high level of agreement that other players’ performance encouraged their engagement with the platform and increased their motivation to succeed. Almost all respondents (95%, 20/21) expressed a low level of agreement with a statement that other players' performance discouraged engagement with the platform.
The questionnaire also included statements designed to obtain an initial indication of whether
The results of this study indicate that users of an online educational platform who were exposed to the performance of their friends on the social network exhibited increased improvement in their nutritional knowledge, as well as increased engagement with the platform, compared to those who were not exposed to their friends' performance. It is plausible that these players' greater engagement with the platform is due not only to their ability to see their peers' performance, but also to their understanding that their performance is equally visible to their peers.
Many studies have examined the potential correlation between nutritional knowledge and dietary behavior, with many studies reporting that no such correlation was found [
Although using online social media for promoting public health has been increasingly studied in recent years [
There are several limitations of this study. First, we did not focus on broad participant recruitment, but rather on the natural diffusion of the app through Facebook. The effects were large enough to produce statistically significant differences between study groups, and future work will further study factors that increase the distribution of the platform, building on relevant prior work such as that of Cobb et al [
In this study, we sought to evaluate whether SNS exposure can be used to enhance online public health interventions by isolating the effects of the SNS component. The results indicate that when people have the ability to see the performance of their peers, and assume their performance is similarly exposed to their peers, the engagement with the online nutritional educational platform increases, and they gain more knowledge in the process. These findings strengthen the motivation to leverage the enormous time spent on SNSs for beneficial purposes such as health promotion. Further research is needed to include more participants from heterogeneous populations and other age groups in order to increase external validity, and to assess the effect of SNSs on actual behavioral change. While not every attempt at online health promotion intervention will gain popularity and become widely used, once the initial investment is made and a successful intervention is developed, the potential number of individuals impacted can be very large. Therefore, understanding how to maximally leverage the power of social networks to make online interventions as effective as possible has the potential to have a significant impact on public health.
Food Hero screen shot: Consent and personal information form.
Food Hero screen shot: Character selection screen.
Food Hero screen shot: Home screen of the private version.
Food Hero screen shot: Home screen of the social version.
Food Hero screen shot: Popup message (exists only for the social version).
Food Hero screen shot: Feeding screen (guided by nutritional information cards and status bars).
Food Hero screen shots: Example of menu assembly process for a full day (including three meals and one snack).
Food Hero screen shot: Menu assembly feedback screen.
Food Hero screen shots: Different examples of menu assembly feedback screens (according to different outcomes).
Food Hero screen shot: Accessories shop screen.
Food Hero screen shot: Sport challenges selection screen.
Food Hero screen shots: Different sport challenges (running, swimming and cycling challenges).
Food Hero screen shot: Quiz screen.
Final Questionnaire.
Body Mass Index
Mann-Whitney test
social networking site
The authors thank Yehuda Neumark for his early input on this study. This work was funded in part by the National Library of Medicine grant 5R01LM009879.
None declared.