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Background: 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. Objective: The objective of the study was to evaluate whether social exposure provided by SNSs enhances the effects of online public health interventions. Methods: 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. Results: 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 (P=.02). Furthermore, the study group's menu-assembly scores improved over time compared to the first score, whereas the control group's performance deteriorated. Study group members spent an average of 3:40 minutes assembling each menu compared to 2:50 minutes in the control group, and performed an average of 1.58 daily sport challenges, compared to 1.21 in the control group (P=.03). Conclusions: 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. (JMIR Serious Games 2015;3(2):e7) doi: 10.2196/games.4002 KEYWORDS nutrition requirements; obesity; public health; social networking sites http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al A literature review from 2010 identified only one controlled Introduction intervention study on social media and health outcomes . There are 2 systematic reviews published recently that found Online Public Health Interventions only 16 studies overall exploring the influences of SNSs on With the significant amount of time people spent engaging with health behavior change [17,18]. Most of these studies reported digital media , the Internet presents an ideal opportunity for some significant influence, but with considerable heterogeneity. health education. Research on Internet-delivered public health Yet, the vast majority of these studies evaluated the overall interventions is an emerging field that has gained momentum effectiveness of an intervention involving a component of SNSs, in recent years . While most studies of online interventions but did not isolate the specific effect of social exposure within (computer games, Internet sites, Facebook applications; mobile the SNSs. apps, etc) have focused on evaluating the overall effect of the Objective intervention, very few studies have tried to isolate the effects of specific intervention characteristics [2,3]. The goal of this study is to evaluate whether the social exposure provided by SNSs can increase the effect of online public health Leveraging Social Networking Sites for Public Health interventions, specifically by evaluating its influence on the Purposes learning curve for nutritional knowledge. Social networking sites (SNSs) are a major component of Internet use by young adults , partly due to their ability to Methods engage the human need for social reinforcement . The use of these networks involves an element of “social exposure,” in The Food Hero Platform for Nutrition Education which users observe and exchange feedback on one another's In order to conduct this study, we developed a game-based activities. For example, social exposure has been used to educational platform called Food Hero, focused on nutrition successfully and dramatically increase organ donation education. The Facebook network was chosen as the SNS for registration . The specific impacts of social connections on developing the app due to its widespread popularity . weight , and of social support on obesity preventing behavior In the Food Hero platform, the user begins by choosing a virtual  have been previously demonstrated outside the framework character. During each game day, the user must assemble an of SNSs. optimal food menu for the virtual character, based on the user’s Currently, the most popular SNS in the world is Facebook , real-world caloric and nutrient composition needs (calculated which reports over 1.2 billion active users . As much as 57% according to the user's sex, age, weight, and exercise habits). of American adults have a Facebook account, with each The user is presented with a selection of food items for each of individual connected to an average of 338 friends in the network 3 meals and 1 snack, along with detailed nutritional information . cards for each item (Figure 1). During menu selection, the user is able to monitor the progress of daily requirements through a There is a tremendous opportunity to leverage the potential of set of status bars (Figure 2). After assembling the menu, the SNSs to promote public health issues in general, and obesity user receives feedback on his or her performance, including a prevention in particular. Obesity is associated with many of the numerical score of performance-based points. The user may most common and costly medical problems in Western society perform repeated attempts to select the optimal menu for each [11,12], reaching epidemic proportions and affecting roughly game day, until the user is satisfied. At the end of each game one-third of US young adults aged 20-39 . In light of these day, the user is given the opportunity to complete a set of virtual alarming trends, there is a critical need for interventions aimed running, cycling, and swimming challenges. The character's at preventing obesity in young adults. Although the direct ability to complete these challenges is directly dependent on association between nutritional knowledge and dietary behavior both the speed with which the user presses specific keys on the is debated , it is plausible that such knowledge is required keyboard in order to make the character move and the quality once an individual aspires to improve his or her nutrition. A of that day's menu selections; too much or too little food, or an statement by the American Heart Association argues that social imbalanced diet will slow the character down in the sports networks may be critical to shaping young people’s eating challenges. The user can also use accumulated performance behaviors, and emphasized the scarcity of interventions targeting points to acquire accessories for the virtual character, thus SNSs . further assisting in completing the various sports tasks. http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Figure 1. Feeding screen of Food Hero guided by nutritional information cards. http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Figure 2. Feeding screen of Food Hero guided by status bars. another shows the top 5 scores from within the user's Facebook Study Groups friends (Figure 3). The social version also shows pop-up We developed 2 different versions of the platform, a “private messages any time one of the user's friends successfully version” and a “social version,” and assigned these versions completes a level. Users randomly assigned to the social version randomly to different users. In the private version, only the comprised the study group, whereas users randomly assigned user's own score is presented, without any information about to the private version formed the control group. Additional the performance of other players. In the social version, the user’s screen shots of the Food Hero platform are provided in performance is presented in the context of other players, a Multimedia Appendices 1-13. high-score bar shows the scores of the 5 best players, while http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Figure 3. Home screen of the social version, showing the high-score bars. 18 years of age, as stated in the participation consent form. Nutritional Information Exclusion criteria included users that did not provide consent Nutritional information was obtained from the US Department to participate in the study, users that did not report their age or of Agriculture's official database for dietary guidelines, “My reported an age younger than 18 years, and users that installed Pyramid.” This information included the definition of the 5 food the software, but did not actively start to use it (ie, did not groups, a list of food items along with their nutritional value, complete the first game day). and the formulas to calculate the proper intake of calories and The distribution of the platform took place over a 2-month desired level for each food group (adjusted for sex, age, weight, period, starting in April 2012, and was spread through the SNS and exercise habits) [19,20]. by peer-to-peer message dissemination. The distribution was Study Participants and Recruitment Process initiated by a single message recommending Food Hero, published by a seed individual, one of the research team Participants were Facebook users who chose to install the members, to a group of Facebook friends. The rest of the platform and agreed to join the study by completing a consent distribution was based on users recommending the platform to form presented as part of the app installation process. For their friends, and on automatic messages published by the reasons of legal consent, all study participants were older than http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al platform on users' Facebook walls. This method of distribution nutrition. Participants who did not complete the full follow-up was chosen to ensure that study members would have Facebook period received a request to answer the questionnaire by email. friends among the study population, expecting that watching Questions regarding the social network influence were presented the performance of known acquaintances will have more social to the control group members hypothetically—what effect they impact than that of strangers' . would expect if they could have seen their friends' performance. The final questionnaire is provided in Multimedia Appendix Data Collection All data for the study were collected electronically within the Statistical Analysis Food Hero platform. During the platform installation process, each user was presented with a consent form for participation Descriptive statistics and comparison of groups were performed in the study, and a personal information form including age, using SPSS Statistics 18.0. Comparison of quantitative variables sex, weight (in kilograms/pounds), height (in between study groups was performed using the t test, or the centimeters/inches), mother tongue, education level, hours of nonparametric Mann-Whitney test (M-W) when the sample size weekly physical activity, and smoking status. To address the was small and was not normally distributed. The connection research question, it was necessary to track the users' nutritional between 2 qualitative variables was evaluated using the knowledge throughout the course of the study's follow-up period. chi-square test, or the Fisher exact test in cases of limited For this purpose, we developed 4 quizzes, each containing 8 number of observations in a cell. All the statistic tests were different multiple-choice questions that had not been seen by two-tailed, and a P value of 5% or less was considered the user before, and were based on information introduced statistically significant. within the platform before the relevant quiz. The quizzes were Study Approval presented to users during game days 2, 6, 10, and 14. A The Ethics Committee for Human Studies of the Hebrew secondary variable to assess user nutritional knowledge was the University of Jerusalem approved the project. score of the first menu assembly attempt on 3 fixed game days—days 4, 8, and 12—during which the user was required Results to build a menu in an unguided manner, without the help of the usual nutritional information cards and status bars. In order to Study Participants measure user engagement with the educational platform, we recorded the time spent choosing each menu, the number of Of the 70 Facebook users who installed the platform successfully repeat attempts to build the menu in each game day, and the during the 2-month distribution period, 7 were excluded from number of sport challenges the user tried to complete in each the data analysis (2 did not enter their age, 5 did not start active game day. 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 On the 15th game day, at the end of the follow-up period, a final analysis. No significant differences were found between the questionnaire was presented to evaluate each user’s impressions basic characteristics (age, sex, body mass index; BMI, etc) of of how the SNS influenced his or her use of the platform and the study participants in both groups (Table 1). the effect the platform had on approach and behavior regarding http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Table 1. 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) BMI (average) 22.0 23.2 Mother tongue (rate from study group), n (%) Hebrew 26/30 (87) 27/33 (82) English 2/30 (7) 4/33 (12) Other 2/30 (7) 2/33 (6) Education level (rate from study group), n (%) 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) Physical activity (rate from study group in weekly hours), n (%) 0-0.5 8/30 (27) 7/32 (22) 0.5-2 6/30 (20) 7/32 (22) Over 2 16/30 (53) 18/32 (56) Smoking status (rate from study group), n (%) Nonsmokers 25/30 (83) 28/32 (88) Former smokers 3/30 (10) 2/32 (6) Current smokers 2/30 (7) 2/32 (6) Facebook friends playing Food Hero (average) 2.9 2.6 BMI was calculated according to height and weight reported by users. trend of greater improvement over time among the study group. Application Use For control group members, the average of the second quiz Study participants played an average of 8.8 game days, with no improvement variable was positive, meaning improvement significant difference between persistence rates in both study relative to the first quiz, but in further quizzes there was a groups (P=.25, t test). The full follow-up period of 15 game gradual decrease in performance (Figure 4). For members of days was completed by 32% (20/63) of the participants. A total the study group, however, average scores for quizzes 2-4 were of 40% (25/63) of study participants answered the final improved relative to quiz 1, with the greatest improvement questionnaire. Naturally, more quiz grades and unguided menu present in the final quiz (Figure 4). The difference between the assembly scores were accumulated for participants that improvement variables of both study groups increasingly completed more game days. Statistical analysis of these variables diverged over time (Figure 5), becoming statistically significant included all the participants that reached the game day in which by the fourth quiz (P=.02, t test). they were examined. As with quiz grades, unguided menu assembly scores were Change in Nutrition Knowledge by Study Group analyzed by calculating the improvement relative to the performance of each player on the first unguided menu assembly As stated, quiz grades were chosen to be the primary variable day. These scores were then converted to standardized z-scores, to assess knowledge change with platform use. The average because the original scores ranged in unlimited scale, including grade of the first quiz, presented to players in the second game negative numbers. The study group exhibited a positive day in order to document the basic knowledge of the users, was improvement in both the second and third unguided menu practically identical between study groups, with both groups assembly scores, whereas the control group exhibited answering 57% (average of 4.6/8 correct answers) of the deterioration in performance over time. The average z-score of questions correctly. The later quiz grades were analyzed by the second and third unguided menu assembly days was 0.18 calculating a set of quiz grade improvement variables, measuring above the first menu assembly day in the study group, compared the improvement of each quiz score relative to the first quiz the with -0.26 in the control group. player had answered. Analysis of these variables revealed a http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Figure 4. 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) P=.02 (t test). Figure 5. Difference between average quiz grade improvement between study groups. (a) P=.02 (t test). Gr.= Group. menu assembly, as opposed to 2 minutes and 50 seconds in the Platform Engagement by Study Group control group. In addition, study group members performed an Members of the study group also invested greater time and effort average of 1.42 attempts to build the menu on each game day, trying to progress through the stages of the educational platform, compared with 1.37 attempts in the control group. The average and they spent an average of 3 minutes and 40 seconds on each http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al number of sport challenges the user tried to complete in each could also potentially lead players to improve their nutritional game day (reflecting the user's motivation to advance through habits. A substantial rate of respondents reported that the the game levels) was 1.58 in the study group and 1.21 in the platform positively affected their desire to improve their eating control group (P=.03, M-W). habits, and positively affected their actual eating habits. Although it is widely accepted that the reliability and validity Participants' Perception of the Social Networking Sites' of self-reported health habits is limited [22,23], these results Effect encourage further research on the effects of this educational The final questionnaire demonstrated that most participants, platform and SNSs in general on changes in eating habits. from both study groups (with no statistically significant Comparison With Prior Work difference), perceived that being able to watch other players' Although using online social media for promoting public health performance can encourage engagement with the platform. has been increasingly studied in recent years [17,18,24], we Overall, 64% (14/22) of respondents expressed a medium or found very few studies that tried to characterize which specific high level of agreement with a statement that they were factors make online public health interventions successful. interested in other players’ performance. A total of 67% (14/21) Specifically, we found that most SNS health-related studies did expressed a medium or high level of agreement that other not isolate the social effect of the SNS. Bramlett et al  found players’ performance encouraged their engagement with the that a Facebook page had greater impact on food-safety attitudes platform and increased their motivation to succeed. Almost all and practices, compared to a traditional lecture, but did not respondents (95%, 20/21) expressed a low level of agreement study the SNS's effects as opposed to other online interventions. with a statement that other players' performance discouraged Graham et al  did compare 2 online interventions for engagement with the platform. smoking cessation, but the arm of the study that included a Platform Effects on Nutritional Approach and social network also included other added elements such as Behavior tailored content, thus masking the isolated effect of the SNS. Cavallo et al  attempted to isolate the effect of the SNS. The questionnaire also included statements designed to obtain They compared the effect of an educational website encouraging an initial indication of whether Food Hero also has effects physical activity to a combination of the website with a beyond changes in knowledge. Players' answers suggested that Facebook group meant to provide support. This study did not the platform may have the potential to influence individuals’ find an added effect of the Facebook group, a fact the writers nutritional approach and behavior (with no statistically partially attribute to the participants' recruitment process that significant difference between study groups): 43% (9/21) of all did not include individuals along with a subset of their existing respondents answered that the platform had highly affected their friends. In our study, participant recruitment occurred using desire to improve their eating habits, and another 38% (8/21) peer-to-peer messaging, and thus ensured that each participant answered they were moderately affected. On questioning had an average of 2.75 Facebook friends enlisted in the study, whether the platform actually improved eating habits, 32% which may have enhanced the social element and contributed (7/22) and 45% (10/22) answered they were affected to a high to the difference between the study groups. Foster et al  did or moderate degree, respectively. Questions exploring specific manage to isolate the SNS's effect and demonstrate its advantage behavioral changes received the highest levels of positive by comparing 2 groups of 5 formerly acquainted nurses using responses: 73% (16/22) and 55% (12/22) of respondents stated a pedometer, with and without the ability to see the number of that their attention to food composition and caloric values were steps performed by their peers. We expect that characterization highly improved, respectively. of specific successful elements of online interventions, as we attempted to do, will be the focus of more future studies. A Discussion study is currently being conducted by Cobb et al  to study Principal Results the factors affecting the diffusion of an online intervention for smoking cessation through Facebook. The results of this study indicate that users of an online educational platform who were exposed to the performance of Limitations their friends on the social network exhibited increased There are several limitations of this study. First, we did not improvement in their nutritional knowledge, as well as increased focus on broad participant recruitment, but rather on the natural engagement with the platform, compared to those who were diffusion of the app through Facebook. The effects were large not exposed to their friends' performance. It is plausible that enough to produce statistically significant differences between these players' greater engagement with the platform is due not study groups, and future work will further study factors that only to their ability to see their peers' performance, but also to increase the distribution of the platform, building on relevant their understanding that their performance is equally visible to prior work such as that of Cobb et al . The authors recognize their peers. that developing a successfully “viral” online product is a Many studies have examined the potential correlation between challenge even for commercial organizations such as nutritional knowledge and dietary behavior, with many studies professional game companies, so realistic expectations for a reporting that no such correlation was found [ 14]. Although not scientific research project are set accordingly. Second, our study the main purpose of this study, we attempted to obtain an initial population was relatively homogeneous in terms of education indication of whether an educational platform like Food Hero level and native language, probably because the app was http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al distributed by peer-to-peer messaging to ensure that participants in the process. These findings strengthen the motivation to had existing friends in the study. Finally, due to requirements leverage the enormous time spent on SNSs for beneficial of research consent, the study excluded participants under the purposes such as health promotion. Further research is needed age of 18. Future studies will explore ways to study younger to include more participants from heterogeneous populations populations such as teenagers within the consented research and other age groups in order to increase external validity, and framework. to assess the effect of SNSs on actual behavioral change. While not every attempt at online health promotion intervention will Conclusions gain popularity and become widely used, once the initial In this study, we sought to evaluate whether SNS exposure can investment is made and a successful intervention is developed, be used to enhance online public health interventions by the potential number of individuals impacted can be very large. isolating the effects of the SNS component. The results indicate Therefore, understanding how to maximally leverage the power that when people have the ability to see the performance of their of social networks to make online interventions as effective as peers, and assume their performance is similarly exposed to possible has the potential to have a significant impact on public their peers, the engagement with the online nutritional health. educational platform increases, and they gain more knowledge Acknowledgments 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. Conflicts of Interest None declared. Multimedia Appendix 1 Food Hero screen shot: Consent and personal information form. [JPG File, 41KB-Multimedia Appendix 1] Multimedia Appendix 2 Food Hero screen shot: Character selection screen. [JPG File, 34KB-Multimedia Appendix 2] Multimedia Appendix 3 Food Hero screen shot: Home screen of the private version. [JPG File, 70KB-Multimedia Appendix 3] Multimedia Appendix 4 Food Hero screen shot: Home screen of the social version. [JPG File, 58KB-Multimedia Appendix 4] Multimedia Appendix 5 Food Hero screen shot: Popup message (exists only for the social version). [JPG File, 47KB-Multimedia Appendix 5] Multimedia Appendix 6 Food Hero screen shot: Feeding screen (guided by nutritional information cards and status bars). [JPG File, 40KB-Multimedia Appendix 6] Multimedia Appendix 7 Food Hero screen shots: Example of menu assembly process for a full day (including three meals and one snack). [JPG File, 93KB-Multimedia Appendix 7] http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Multimedia Appendix 8 Food Hero screen shot: Menu assembly feedback screen. [JPG File, 53KB-Multimedia Appendix 8] Multimedia Appendix 9 Food Hero screen shots: Different examples of menu assembly feedback screens (according to different outcomes). [JPG File, 118KB-Multimedia Appendix 9] Multimedia Appendix 10 Food Hero screen shot: Accessories shop screen. [JPG File, 70KB-Multimedia Appendix 10] Multimedia Appendix 11 Food Hero screen shot: Sport challenges selection screen. 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BMJ Open 2014;4(1):e004089 [FREE Full text] [doi: 10.1136/bmjopen-2013-004089] [Medline: 24448847] Abbreviations BMI: Body Mass Index M-W: Mann-Whitney test SNS: social networking site http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Dagan et al Edited by G Eysenbach; submitted 03.11.14; peer-reviewed by A Shaban-Nejad, S Capra; comments to author 21.04.15; revised version received 10.06.15; accepted 08.07.15; published 05.10.15 Please cite as: Dagan N, Beskin D, Brezis M, Reis BY JMIR Serious Games 2015;3(2):e7 URL: http://games.jmir.org/2015/2/e7/ doi: 10.2196/games.4002 PMID: 26441466 ©Noa Dagan, Daniel Beskin, Mayer Brezis, Ben Y Reis. Originally published in JMIR Serious Games (http://games.jmir.org), 05.10.2015. 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 JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2015/2/e7/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e7 | p. 13 (page number not for citation purposes) XSL FO RenderX
JMIR Serious Games – JMIR Publications
Published: Oct 5, 2015
Keywords: nutrition requirements; obesity; public health; social networking sites
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