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E-Word-of-Mouth on health social networking sites: An opportunity fortailored health communication

BO LIANG* and DEBRA L. SCAMMON

Department of Marketing, University of Utah, USA

ABSTRACT

Because of the limitation of time and resources, health professionals are often not able to provide support for consumers via personalcommunication. Consumers are increasingly active in managing their own health. E-word-of-mouth (eWOM), or consumer-generatedcontent, on health social networking sites (SNSs) provides a new opportunity for health communication tailored to consumers personalneeds. Using netnography, a well structured internet-based ethonography, we analyze discussion threads posted to an obesity support groupon a popular health SNS based in the US. We classify e-group members as support seekers and providers. Our results identify two major features of eWOM on health SNSs that facilitate tailored health communication. First, eWOM on health SNSs provides the types of support (informational and emotional) that help support seekers actively cope with heath-related problems and strains. Second, eWOM on healthSNSs contains massages rich with personal experiences of support providers that offer solutions for problems that support seekers facein everyday situations. As support seekers participate in SNSs, their opportunity for learning means that they can become information elite ,evolving from support seekers to support providers. We discuss important implications for policymakers and marketers for learning from

and participating in eWOM on health SNSs.Copyright 2011 John Wiley & Sons, Ltd.

INTRODUCTION

Health communication is an important factor in diseaseprevention and health promotion. Research on health commu-nication has shown that the most effective health communica-tion is tailored health communication (THC). That is, messageframing should be congruent with individual messagereceivers needs and characteristics (e.g. health locus of

control), skills (e.g. reading skill), abilities (e.g. informationliteracy), and motivations (Salovey and Williams-Piehota,2004; Rimer andKreuter, 2006; Rothman etal ., 2006; Hibbardet al ., 2007; Updegraff et al ., 2007).

In today s healthcare environment, it is dif cult for consu-mers to get all the support they need through communicationwith their doctors within a 20-minute clinic visit. Socialnetwork sites (SNSs) as virtual communities in which an individual canidentify and communicate with friends or informed others(Boyd and Ellison, 2007) are becoming a common means for health communication. Nearly half of internet users who havesearched for online health information reported that they haveparticipated in health-related communication (reading or postingmessages) on SNSs (Fox and Jones, 2009). SNSs may be of value in facilitating tailored health communication.

Previous research has demonstrated the bene ts of healthcommunication for consumers via early SNSs (e.g. usenet and bulletin board systems), including psychosocial (e.g.decreasing stress Sharf, 1997; Braithwaite et al ., 1999; Monnier et al ., 2002; Maloney-Krichmar andPreece, 2005; Im and Chee,2006; Donelle and Hoffman-Goetz, 2008; Eichhorn, 2008;Ginossar, 2008; Macias and McMillan, 2008) and instrumentalbene ts (e.g. 24-hour availability and anonymity) (Cline andHaynes, 2001). Early SNSs have limited functions for personal

interaction compared with current SNSs. Thus, studies on earlySNSs have primarily focused on the analysis of individual mes-sages (postsor emails) andignored theanalysisof the interactionamong users. Examination of user interactions on current SNSscanprovide insights into the ways in whichuser bene ts are gen-erated and experienced, and the extent to which responses from others are tailored to the questions that individual users ask.

There are a variety of platforms for electronic World-

Of-Mouth (eWOM), a marketing concept de ned as consumer-generated content posted on the internet, such as product review websites and SNSs (Bronner and De Hoog, 2010).Previous research on eWOM has been heavily focused oneWOM about high-tech and media products (e.g. movie andvideo games) on product review platforms (e.g. amazon.com;Chen and Xie, 2008). There has been little research on eWOMrelated to medical- and health-related products and issues onsocial-networking platforms. This study contributes to the

elds of health communication and marketing by providingtheoretical insights and empirical evidence about the major features of eWOM on health SNSs, focusing speci cally onthe discussion/interaction among users. In doing so, this studyexamines the types of social support and the content of messages transmitted via health SNSs and the extent to whichthese are tailored to users individual needs.

THEORETICAL BACKGROUND AND PROPOSITIONS

We rst provide some theoretical context for examining theinteraction between users on health SNSs (e.g. patientslikeme.com that are specialized for health-related issues). In dealingwith health-related issues, it is important to understand the

strategies individuals may employ to cope with their problemsand concerns. In understanding the role that health SNSsmay play in such coping, it is useful to examine both the social

*Correspondence to: Bo Liang, Department of Marketing, University of Utah, USA.E-mail: [email protected]

Copyright 2011 John Wiley & Sons, Ltd.

Journal of Consumer Behaviour , J. Consumer Behav. 10 : 322 331 (2011)Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cb.378


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support and the content of messages that are transmitted onthese sites.

Social support tailored to coping strategiesThe major activity of users on health SNSs is to post messages in a speci c thread. Individual posters can ask for support in one thread and respond to a request for support in another thread. Thus, individual posters may be bothsupport seekers and providers depending on the content of the messages they post. Two types of support can betransmitted through online communities: informationalsupport (e.g. advice, suggestions, or useful information)and emotional support (e.g. comfort, relief, and encourage-ment) (Maloney-Krichmar and Preece, 2005; Donelle andHoffman-Goetz, 2008; Ginossar, 2008).

According to Folkman and Lazarus (1980), people usetwo major coping strategies: problem-focused and emotion-focused coping. Problem-focused coping aims to remedyor conquer the stress-producing problem itself (Weiten

et al ., 2003: 120). Problem-focused coping includes four steps: identifying the problem, nding and evaluatingalternative courses of action, selecting the most appropriatecourse of action, and taking actions (Weiten et al ., 2003:120). We argue that health communication via SNSs canassist participants in navigating these steps. First, support seekers initiating threads about their problems are identifyinga problem. Second, information about solutions to problemsfrom support providers can assist in nding out about andevaluating alternative courses of action. After discussingproblems with support providers, support seekers may havesuf cient information about alternative courses of action that

they have the con dence to make a choice and take action.Emotion-focused coping is aimed at reducing or managing emotional distress that is associated with (or cuedby) the situation (Carver et al ., 1989). Previous research hasshown that people who get emotional support demonstrateless emotional distress (Kulik and Mahler, 1993; Krumholzet al ., 1998; Alferi et al ., 2001). However, people do not always accept all the emotional support they receive; theymay selectively attend to emotional support from the right persons at the right time (Taylor, 2003). In daily life, peoplepassively receive emotional support from members of closesocial networks, such as families and intimate friends, whichmay lead them to feel overburdened by the amount of adviceand sympathy they receive (Taylor, 2003). By initiatingthreads, support seekers actively seek support from virtual friends , thus, the emotional support they receive may befrom the right persons at the right time.

The theory of motivated reasoning suggests that copingstrategies are shaped by individuals motivations. Consumers

motivations create both accuracy and directional goalswith regard to information search (Kunda, 1990). Indivi-duals are motivated to acquire information that providesa reasonable solution to their health problems and support that sustains them through the process of dealing withtheir health problem (Mason and Scammon, 2011). For

these reasons, they are likely to turn to trusted sources.SNSs may be a highly trusted source for both informa-tional and emotional support.

Thus, our rst proposition is discussed as follows:eWOM on health SNSs facilitates tailored health commu-

nication by providing the types of support that participantsneed for both emotion-focused and problem-focused coping.Speci cally, eWOM on SNSs provides informationalsupport for problem-focused coping and emotional support for emotion-focused coping.

Message content tailored to learning strategiesSituated learning is a learning strategy by which knowledgeand skills are learned in the contexts where they are appliedin everyday situations (Lave and Wenger, 1991). Educationresearch has shown that online social interaction can be aneffective context for situated learning, where students not only learn from each other but also actively apply what hasbeen learn to real situations (e.g. Hung, 2002 and Halverson,2009). In the environment of health SNSs, support seekerslearn health knowledge when they seek solutions to real-lifeproblems, such as how to balance medical (e.g. taking

medicine or surgeries) and nonmedical (e.g. exercising)treatments. Therefore, we argue that health communicationthrough health SNSs facilitates situated learning.

Personal stories and experiences are one of the keystonesof SNSs. Patients are experts in the experience with their symptoms, and physicians are dependent on patients for thisexpertise (Bensing et al ., 2000). A major feature of thecontent of communications on health SNSs is users personalexperiences with treatments and other issues related withspeci c health problems or symptoms. Participants in healthSNSs have expertise based upon their personal experiencesgiving them credibility that may exceed that of health

professionals.Patients are also experts in their experience with doctors.Traditionally, consumers rely on WOM from family andfriends and physician referrals to choose doctors (Tu andLauer, 2008). Now, eWOM on health SNSs has becomeanother source of information about doctors. Bensing et al .(2000) proposed two types of interactions between patientsand doctors: cure systems, which are task-focused, and care systems, which are socioemotion-focused(as cited inOng et al ., 1995: 906). Because patients often have negativeemotions, such as anxiety and fear (Marks et al ., 2005), theyneed care from doctors. Cure systems can be evaluated byobjective measures, such as treatment effectiveness, whereas care systems can only be evaluated by patients self-report of their experiences with doctors. We argue that based onpersonal experience with doctors, consumers are likely todiscuss their doctors in terms of the care systems theyprovided. Health SNSs thus can be effective channels for WOM about the care environment participants will nd withindividual doctors.

Further, as SNSs are online communities for people whoshare interests or activities; users of health SNSs may havesimilar backgrounds (e.g. demographics and health condi-tions) and thus similar personal experience. Social compari-son theory (SCT) suggests that similar others are the most

effective support-givers

(Thoits, 1995: 67) because of empathic understanding (Thoits, 1986: 420) and collectivewisdom (Davison et al ., 2000: 206). It has been suggested

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Copyright 2011 John Wiley & Sons, Ltd. J. Consumer Behav. 10 : 322 331 (2011)DOI: 10.1002/cb


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that patients who have embarrassing, socially stigmatizing,or dis guring illnesses, such as obesity and HIV, areespecially likely to seek support from similar others (Davisonet al ., 2000: 213). The support transmitted via health SNSsmight be highly applicable for the situations that consumersneed to address for speci c diseases or symptoms.

Support seekers can learn from support providers, andsupport providers can also learn as they read posts by other support providers. Thus, both support seekers and providerscan be learners. By accumulating health knowledge duringtheir tenure on SNSs, both support seekers and providersmay evolve into information elites , the agents with the most valuable knowledge (van Alstyne and Brynjolfsson, 1995).

Thus, our second proposition is discussed as follows:eWOM on health SNSs facilitates tailored health commu-

nication by providing messages with personal experiencewith speci c health problems or symptoms that participantsneed for situated learning.

METHODOLOGY

To examine ourpropositions,we conducted a single case studyemploying netnography, or internet-based ethnography, as theresearch method. Hine (2000) rst called her study of theculture of online communities virtual ethnography . Subse-quently, researchers have developed this methodology, giving

it different names, such as digital ethnography (Murthy,2008). Kozinets (2002) was the rst to propose proceduralguidelines for the study of the interaction of users on publiclyavailable online forums calling the method netnography .Netnography has become a widely accepted methodology inthe eld of consumer and marketing research. Researchershave used netnography to explore a wide range of topics, suchas consumers responses to brand advertising for video games(Nelson et al ., 2004) and innovative learning in onlinecommunities (Hemetsberger and Reinhardt, 2006). Usingnetnography, our research proceeded in three steps: (i) prelim-inary analysis from which we developed a coding plan,(ii) downloading and coding online data including completethreads and related information, such as date and time of posting, and (iii) analyzing the data to explore the major features of eWOM on health SNSs.

Coding schemeWe developed coding schemes based on past studies of

online communities (Maloney-Krichmar and Preece, 2005;Donelle and Hoffman-Goetz, 2008; Ginossar, 2008) as wellas our preliminary analysis of 15 randomly selected threadeddiscussions generated by the users of a health socialnetworking site. As Table 1 shows, we coded posts into threecategories: informational support-seeking/giving, emotionalsupport-seeking/giving, and a combination of informationaland emotional support-seeking/giving posts. We de ned

Table 1. Coding scheme for posts

Category Subcategory Description Example

Types of help seeking 1-Informational helpseeking

Asking for information (e.g.suggestions or comments)

Please tell me if you have tried Alli and how it worked for you

2-Emotional helpseeking

Expressing negative emotions(e.g. embarrassment) to seekhelp

I am so huge and I just wish I could die, eventhough I have a loving family . . .

3-Informational andemotional help seeking

Asking for information andexpressing negative emotions

I m terri ed I will die of obesity relatedcomplications. I have two very small children, ages5years and 6 months and can t comprehendleaving them any time in the next 30 or 40 yearsand knowing the pain of losing my own mother asa teenager, I want to spare them but I m just sittingdoing nothing. Does anyone feel this sameway. . .? That they will die if they can t motivatethemselves?

Types of help giving 1-Informational helpgiving

Offering information (e.g.suggestions)

Not sure about Xenical but I do take Phentermine.I have been on it a little over a month and have lost like 18 pounds so far

2-Emotional helpgiving

Expressing positive emotions(e.g. hope) to provide help

I m almost 500 pounds and I understand thewanting to die, everyone feels that way sometimes,but its not really how you feel. After three years of depression and all kinds of not nice stuff. I m moving forward slowly trying to get my life back together and I really want to live. Be strong, thereis people all around you that wants to help.

3-Informatoinal andemotional help giving

Offering information andexpressing positive emotions

I lost 20 pounds by exercise within 4 months. I m proud of myself. I think you can do the same asme. Be strong! Never give up!

Types of responsesby help seekers

1-Informationalresponses

Asking for further informationor indicating thoughts or next actions based on help providers

responses

I ll talk with my doctors about your suggestionsand then make a decision.

2-Emotional responses Expressing certain emotions(e.g. grati cation)

Thank you for your suggestions.

324 B. Liang and D. L. Scammon



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informational support as the behavior of providing advice,guidance or information and emotional support as thebehavior of showing respect, love, caring, andconcern (Bloom et al ., 2001). Table 2 presents the basic features of threads andposts along four dimensions including length of discussionthreads, length of posts, timeliness of responses, and identitiesof posters. We coded themes of threads into three major cate-gories including medical treatments, nonmedical treatments,and general discussions; further, we identi ed subcategoriesunder each theme category (Table 3).

Data collectionDailystregth.org, founded by three entrepreneurs in the US in2006, is a well-recognized health social networking site withhigh traf c: around 280,000 average daily visitors by Aprilof 2011 (Compete.com, 2011). This site contains more than500 online communities that deal with different medicalconditions and life challenges. Obesity is one of the major

health concerns facing US consumers: more than 20%of adults are obese, and 30% of adults are overweight (Pi-Sunyer, 2002). Thus, we selected the obesity group asthe object of this research. At the time the data for this studywere collected, the group had 520 members.

In assembling the data for this study, a lot of informationwas available on the Dailystrength website. The web page of the obesity support group displayed the titles of all thediscussion threads ordered by date. Clicking on the title of each thread showed the thread page and the data used for thisstudy including the complete text of each post, the totalnumber of posts in each thread, the posting time of each post,

and the name of individual posters. A hyperlink from eachposter s name to each poster s pro le page was alsoavailable. From the pro le page, we collected data includingthe poster s gender, age, and membership time. In addition,we used Google Ad Planner (a tool for advertisers to obtaininformationabout sites) to collect dataabout average educationlevel and annual household income of the site members.

From our preliminary analysis, we found that posts in onethread are usually generated within one month of initiation of the thread. Thus, we downloaded all posts in one threadgenerated within one month following the date the threadwas initiated. We collected data in reverse order from the most recent threads generated one month before our study started tothe oldest without considering seasonality. Posts included inour dataset span the years from 2006 to 2010. We downloadeda total of 90 threads with 882 postings. Each thread containedat least three posts, so that we could conduct meaningfulanalysis of each thread. Data collection continued until nonew insights could be developed from the data.

Data analysisThe unit of analysis used in previous work on social net-working communication has been one message generatedby one individual. However, because netnography is a wayto understand interaction among online community members( Kozinets, 2002: 64), the primary unit of analysis employed

in this study is one discussion thread containing one initialpost by a support seeker and several subsequent respondingposts by support providers.

Using SPSS, we performed quantitative analysis of codeddata and the data from posters pro les. An individual poster may post more than one post in the same or different threads.Thus, for the analysis of data categories about posts (types of support giving/seeking posts, length of threads and posts,timeliness of responses, and themes of posts), each post iscounted; and for the analysis of data categories about posters(identities, age, and membership time of posters), onlyunique posters (i.e. having the same user ID) are counted.

We

rst computed descriptive statistics for each data category. We then conducted correlation analysis (two-wayPearson s chi-square analysis) between the types of initialposts and their responding posts (informational, emotional,or the combination of informational and emotional types).In addition, we conducted qualitative analysis of the text message data to discover themes.

Table 2. Coding scheme for basic features of threads and posts

Category Subcategory Description

Length of threads 1-Short Threads with no more than 5 posts2-Medium Threads with 6 to 15 posts3-Long Threads with more than 15 posts

Length of posts 1-Short Posts with no more than ve lines of messages2-Medium Posts with 6 to 15 lines of messages3-Long Posts with more than 15 lines of messages

Timeliness of responses

1-Early Responding to help seeking posts within 6 hours

2-Late Responding to help seeking posts between 7 to 12 hours3-Very late Responding o help seeking posts after 12 hours

Identities of posters

0-Not sure Posters did not indicate their identities.

1-Participants self-identi ed as overweight or obese Posters indicated that they were suffering overweight or obesity.2- Families of overweight or obese individuals Posters indicated that their families (e.g. husbands/wives,

sons/daughters) were suffering overweight or obesity.3- Friends of overweight or obese individuals Posters indicated that their friends were suffering overweight

or obesity.4- Healthcare professionals Posters indicated that they were healthcare professionals(e.g. physicians and therapists)




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FINDINGS

We proposed that eWOM on health SNSs facilitates tailoredhealth communication. We present the ndings about thecharacteristics and contents of threads containing support seeking and giving posts illustrating the ways in which socialsupport was tailored to the coping and learning strategies of support seekers and providers.

Characteristics of support seeking, giving, and follow-upSupport seekingOur dataset included support-seeking posts as follows: 25informational posts, 5 emotional posts, and 60 posts that

were a combination of informational and emotional. Thecombination type of support seeking was the most dominant,consistent with previous studies that suggest that when

dealing with dif cult health situations, most support seekers needed both informational and emotional support (e.g. Taylor, 2003).

We found that the type of support-seeking post in uencesthe length of threads (i.e. the number of responding posts).Threads initiated by informational support-seeking posts ledto the highest percentage of short-length threads (one to veposts; 27%) but the lowest percentage of long threads (morethan fteen posts; 0%). Threads initiated by emotionalsupport-seeking posts led to the highest percentage of longthreads (20%). Threads initiated by the combination typeposts led to a high percentage of long (20%) and medium-length threads (6 to 15 posts; 65%) but with the lowest

percentage of short-length threads (15%). Different types of support-seeking posts appear to elicit different requirementsfor their responding posts. Informational support-seeking

Table 3. Coding scheme for themes of threads

Category Subcategory Description Example

Medicaltreatment

M1-Sugeries Surgeries for weight loss(e.g. gastric bypass surgeries)

Looking for information from people who have actually hadstomach banding/stapling/whatever.

M2-Drugs Drugs for weight loss (e.g. Alli) Xenical ..does it work? Non-medicaltreatment

N1-Self-support Treating overweight or obesityby oneself (e.g. exercises andwriting)

This may sound a bit of a stupid suggestion but is anyoneinterested in a penpal for support with dieting, talking about fears and problems, a bit of motivation on paper? Let me know .

N2-Commercialweight-lossprograms

Treating overweight or obesityby commercial programs (e.g.Weight Watchers, Jenny Craig)

has anyone here lost & maintained their weight loss with weight watchers

Generaldiscussion

G1- Weight loss Discussions about the motivationsand effective ways to lose weight

I want to lose weight because I don t want to have people say tome you have such a pretty face . One thing that a fat womandoesn t want to hear is that her face is PRETTY!!!!!! Or howabout you re beautiful on the inside !!!! You know, I don t care that I m Miss Universe on the inside, I m quite happy to yin on my broom, cause my mischief and then y home again - aslong as I m looking sensational while doing it . :)

G2-Health andMedical problems

Discussions about health problemsor diseases caused by overweight or obesity

Many diseases -- diabetes, heart disease, hypertension, etc. --blame obesity for their problems. But what if the AmericanMedical Association were to declare that obesity itself is a disease? Most people are balk when the idea is posited that obesity is a disease. We simply don t want to view obesity asa disease. Why?

G3- Social anxiety Discussions about overweight or obese individuals anxiety (e.g.depression, worry) about socialsituations/ interactions with others.

I was wondering if any of you worried about what other peoplethought about you? that is one of my biggest things. i let what other people think bother me. if this happens to you how doyou deal with it?

G4- Parenting Discussions about how parents helptheir overweight or obese children

I have come here in search of answers. I have 3 daughters of 11,9and 6. My 6 year old is obese according to our family doctor. Sheeats the same as everyoneelse she just doesn t like to move aroundas much. I try to encourage sports but it is a no go. She simplyrefuses. I cannot do anything. What can i do?

G5- Doctors Discussions about attitudes andbehaviors of doctors

we live in a country where doctors don t even assist patients inneed, such as obese patients. Reminds me that we have to be incontrol of our own future!

G6- Products Discussions about the demand for the products tailored to the needsof overweight or obese individuals

It

s terribly depression to go into store after store and not

ndanything to t right and compliment your body. I thoughmaybe it wouldn t be so bad to nd a 16, 18 sizes but I waswrong. It is and nothing is more depression than to look at your naked body or clothed body in a store mirror .

G7- Public policy Discussions about the support bypublic policy and programs

One of the things I m sure we ve all noticed is that eating healthyis a lot more expensive than eating poorly. The government saysthat we have an obesity epidemic. DUH!!! Maybe if prices for good, healthy food weren t so high, it would be easier for everybody to get their weight under control. The govt. is willingto subsidize a whole lot of other industries. How about lobbyingCongress to subsidize the healthy food industry?




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posts display clear questions simply requiring answers to thequestions. However, emotional support-seeking posts revealfeelings, such as embarrassment about weight and do not specify the type of help needed from responders. As a result,support providers contribute a variety of responses to thistype of post. The combination type of support-seeking postsallows responders more exibility to develop their ideas,resulting in a high percentage of long and medium threads.

Support givingSupport providers offered support that matched the request and featured precision, timeliness, credibility, and depth.Correlation analysis showed that the types of support-givingposts were signi cantly associated with the types of support-seeking posts, w2 (4, N= 882) = 131.70, and p < .01. Among234 posts responding to informational support seeking, thehighest percentage (56%) were informational support givingposts; among 52 posts responding to emotional support seeking, the highest percentage (59%) were emotional

support giving posts; and among 596 posts responding tothe combination type of support-seeking posts, the highest percentage (55%) were combination support giving posts.These ndings show that the social support from support providers matches the requests from support seekers.

Second, our data show that among support-giving posts,more than 60% were short (posts with one to ve lines of message), and morethan 98% were timely (posted within12 hours of the initial posts). Short posts appear to serveone major function, which is to solve the problems support seekers face in a timely manner. This single function leadsto posts with highly concentrated and brief information.

Because information exchange is the major function of eWOM, the domination of short messages by which support seekers and providers exchange information represents theef ciency of eWOM on health SNSs.

Third, we found that support providers responded withmessages with credible cues. Support providers were veryclear about what they knew and what they did not know withregard to the questions posted by support seekers, thusassisting support seekers in assessing the credibility of messages they received. For example, one support seeker asked about Alli, a weight-loss drug, and one support provider rst advised the support seeker to avoid high-fat food instead of taking any medication (what he knew) andthen expressed his concern about the treatment effects of the drug (what he did not know).

I thought of giving it a try but I know it s just a means todiscourage one s overconsumption of high-fat food -- I think I can do that myself without the aid of (an expensive)medication. Plus, I m quite concerned about its treatment effects -- i.e. oily diarrhea and pant soiling. I d love tohear from anyone who has success with it though .

Finally, support providers offered extensive advice that went beyond the question in the initial request. For example,when support providers answered questions about the effect

of weight loss surgeries, in addition to surgeries, they alsotalked about how they changed their life style (e.g. eatinghabits and exercise routines) after they had surgeries. One

support seeker s question can evoke others to identify morequestions about the topic. Thus, support providers may extendthe original question by answering questions and then askingfurther questions about the topic under discussion. For example, one support seeker asked about lap band surgery.One support provider replied, I would like to know more,too....is it covered by health insurance plans ?

Follow-upWe also observed that support seekers gave feedback tosupport providers by posting follow-up posts. Our data showthat over half of initial support-seeking posts had follow-upposts in the same thread discussion. Sixty- ve percent of follow-up posts showed support seekers gratitude to support providers. The remaining follow-up posts showed support seekers further thoughts as illustrated by this example:

Initial post Hi, My doctor recommended for me to go on Alli. . . Does anyone out there know anythingabout this product? . . .Tell me if you have tried it and how it worked for you . . .

Responding post I use it and yes it has those side effectsbut I think it helps me a lot. Give it a shot for a month .

Follow-up post Thank you so much everyone for your comments. It is very helpful for me. My doctor said to take my vitamins, and b3, and sh oil at night before bed so they could go into mysystem before my next dose of Alli. Anythoughts on this ?. . .

This thread demonstrates that with the help of the support provider, the support seeker engaged in problem-focusedcoping. In the initial post, the support seeker identi ed a problem, that is, how Alli could work for him. In theresponding post, he received information about his problem,and the follow-up post reveals that the information wasuseful. This thread also shows that the support seeker combined the support received with information from another source (doctor) helping to build con dence in taking Alli.

Research has shown that overweight or obese people mayhave low self-esteem (Straus, 2000; Gluck et al ., 2001;Wadden and Stuckard, 2004; Franklin et al ., 2006.). In our data, many participants engaged in discussions about problemscaused by low or uctuating self-esteem. The followingdialogue between one support seeker (initial and follow-uppost) and one support provider (responding post) about theproblem of body image disturbance caused by low self-esteem exempli es an emotion-focused coping strategy:

Initial post I am so huge and I just wish I could die, eventhough I have a loving family . . .

Responding post Don t give up honey. You can do this. Weall have struggled with weight and other issuestoo. It is not going to always be easy, but youcan accomplish anything you set your mind to . . .

Follow-up post

Thanks so much for your encouragement and support. That is exactly what I needed to hear !




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In the initial post, the support seeker reveals her depres-sion over her body image. In the responding post, the support provider shows sympathy and encouragement. The follow-up post demonstrates that the support seeker felt that thesupport was exactly what she needed to relieve stress.

To summarize, our ndings demonstrate that interactionson health SNSs facilitate tailored health communication byproviding the types of support (informational and emotional)that help support seekers actively cope with heath-relatedproblems and strains (Proposition 1).

Message content Similar personal background Our data show that support seekers and providers share similar life experiences.First, support seekers andproviders in this com-munity shared similar health conditions. Our data reveal that 93% of participants self-identi ed as overweight or obese. Thiscommonality maybe oneof theprimary attractionsof joining anon-line support group.Second, support seekers and providers inthe obesity group shared similar demographic backgrounds(e.g. age, gender, education, and income). Consistent with previ-ous research, we found that most support seekers and providerswere middle-age females (average age = 39.7years). Becausefemales in this segment are also likely to be the primary care-givers for their families, their engagement in communicationon health SNSs will bene t not only their own health but alsothat of their families. Our data also show that 79% of support seekers and providers had college degrees and 69% had annualhousehold incomes of $50,000+. Notably, individuals withlow education and income as well as young males are not currently participating in the online health network world.

Message themesSupport seekers and providers posted messages with a widerange of themes relevant to their personal experiences. Withinour dataset, there were a total of 11 threads on medical treat-ments with a focus on surgeries (e.g. gastric bypass surgeries)and drugs (e.g. Alli), 19 threads on nonmedical treatments witha focus on self-support (e.g. exercise, penpal and healthyeating) and commercial weight loss programs (e.g. Slim-Fast and WeightWatchers ), and 60 threads on a diversity of issuesincluding weight loss (e.g. the motivation for weight loss),

health and medical problems (e.g. diseases caused byoverweight or obesity), self-esteem (e.g. depression causedby poor self-esteem), parenting (e.g. childhood obesity),doctors (e.g. relationships between doctors and obese patients),products (e.g. comfortableclothes and airlines seat), and publicpolicy (e.g. Medicaid) (see Figure 1). The popularity of non-medical treatments over medical treatments that we observedis coroborated by the data provided by the obesity groupwebsite. According to Dailystrength.org (2010), the top tentreatments discussed most by the community users includedonly two medical treatments (gastric bypass surgery and Alli),while the other eight werenonmedical treatments (e.g. physicalexercise and WeightWatchers ).

In using nonmedical treatments, individuals primarily relyon their own efforts to achieve their desired health goals. Thepopularity of self-support shows that support seekers wereanxious to learn effective weight loss methods from thepersonal experiences of support providers. With these per-sonal examples as guidance, support seekers were in a better

position to take actions to lose weight. We argue that one bigattraction of communication on health SNSs is the fact that,by posting questions, support seekers can get personalizedhelp (especially ideas for self-support) that they could not get from doctors.

These data also reveal that there were more threads onsocial issues than threads on treatments, suggesting that participants seek solutions to social problems. It appears that through participation in SNSs users can learn from other consumers with similar personal experience. In the following,we present major themes demonstrating the ways in whichsupport seekers learn from support providers to deal with

problems in their everyday lives.

Situated learningTreatments. In the obesity support group, support seekersoften expressed concerns about commercial weight-lossprograms (e.g. Weight Watcher ). We identi ed three major concerns that support seekers had about packaged mealscommonly used in commercial programs, including highprices, short-duration effectiveness, and lack of diversity. Asa result, support providers offered advice about substitutesfor diet meals. For instance, one support seeker asked about the effectiveness of Nutrisystem , a commercial dieting product.

Figure 1. Number of threads with different topics.




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One support provider replied that he was using Hoodoba that was about 1/3 of the price of Nutrisystem. Other support providers suggested that they enjoyed cooking their ownhealthy meals instead of buying packaged meals.

Another support seeker asked about how to t exerciseinto a busy schedule, a problem that many overweight or obese people face. Support providers offered usefuladvice from their own experience as illustrated in thefollowing thread:

Initial post I m trying to get more exercise into my daily rou-tine. I leave the house for work at 8:00 in themorning and I don t usually get home until lateat night . . . Does anybody have any ideas how to t any kind of exercise into a busy schedule ?. . .

Responding post It s hard for people that work a full time job. Have you thought about getting a video. I hate getting up early, but I would rather domy exercise in the morning or I have trouble

falling asleep . . .

Doctors. In our data, eWOM about doctors primarily focusedon two topics, when to see a doctor and how to choose a doctor. When a person experiences symptoms, she/he might not be very clear about whether to wait and see how thesymptoms develop, engage in self-treatment, or go to see a doctor. Deciding when to see a doctor can be dif cult for some people. Some critics argue that relying upon the adviceavailable on SNSs may lead individuals to delay seeing a doctor. However, our data suggest that when support seekers

asked about whether they should see a doctor when theydeveloped illusive health problems, such as headache, back pain, and depression, most support providers suggestedseeing a doctor. This suggests that eWOM on health SNSsmay facilitate support seekers seeing a doctor in a timelymanner. Whether appropriate utilization of doctors is facili-tated by SNSs is an empirical question.

Care systems may be especially important for overweight and obese persons because they frequently not only havehealth problems but also psychological problems. Peoplemay tend to show biases toward overweight or obese persons,and healthcare professionals are not exempted (Puhl andBrownell, 2001; Schwartz et al ., 2003). With the help of eWOMrecommendations, individualsmay increase their visitsto doctors who demonstrate caring. We found that somesupport seekers felt uncomfortable seeing a doctor and, as a result, tried to avoid seeking health care from doctors.One helpseeker initiated a thread looking for a fat-friendly doctor inher area. She said, I have been avoiding the doctor for over 12 years and I know it is very unhealthy. I am overweight and I am scared of being judged at the doctor s of ce . Onesupport provider, although unfamiliar with the area where thesupport seeker lived, offered practical advice about how toget information about the care system of doctors by checkingwith the State Board of Disciplinary of ce to see if there have

been any complaints led against a doctor

, and talking to people who have visited the doctors as they can tell you what their personality is like .

Thoughts and feelings. Support seekers and providers alsoexchanged information about their thoughts and feelingsabout overweight or obesity. For example, some support seekers did not want to be regarded by others as beingoverweight or obese and were very sensitive to certain wordsas one support seeker noted:

Anyone ever wonder why the word obesity? I personallyhate that word. I would rather hear chubby, pleasantly plump, overweight, even fat . Anyway I just wondered isn t that the most offensive description? I think so and waswondering what you thought .

One support provider used his own experience to showhow to deal with the term obesity :

I don t fall into the morbid range, but the very term obesity has been a hard one for me to admit to myself. I ve always thought of myself as a little heavy --but no, I m obese. Joining this group and saying so has been amajor step for me in acknowledging my issues and takingthe steps to do something about them ?

Continuing learningOur dataset includes a total of 882 posts made by 410 uniqueusers; on the average, one user made 2.15 posts. This ndingillustrates the opportunity for continued learning amongusers who post frequently. We identi ed the top 10 most active users based on the number of posts they made. Wefound that the average time one of these users had been a

member of this obesity group was nine months, suggestingthat knowledge was gradually accumulated over time. Asan example, one active user became a member of this groupin December of 2006. Our data showed that, in 2007, thisuser made a support-seeking post asking for suggestionsabout how to keep on her diet plan, and in 2008, she madetwo support giving posts about the effectiveness of Alli andmotivation to keeping dieting.

These ndings about learning process provide evidencefor our proposition 2. Users in health SNSs with sharedpersonal experiences seek and/or provide support for problems that they face in everyday situations. By continuingto learn from other users, they can become informationelite , as suggested by the transformation of their roles from support seekers to support providers.

DISCUSSION AND IMPLICATIONS

Our analysis suggests that the basic features of eWOM onhealth SNSs translate into important bene ts for consumers fa-cilitating health communication tailored to their coping andlearning strategies. These bene ts can accrue not only for ac-tive users who read and post messages but also for passiveusers who just read but do not post any messages. Within

threaded discussions, this one-to-many communication canspread a health message broadly among a large population.Because health SNSs run 24/7, health information can spread




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in a timely manner through eWOM on health SNSs. Inaddition, as most health SNSs including Dailystrength.orgprovide a search function, consumers can easily nd thediscussion topics they are interested in by simply typingkeywords into search engines.

As interest and participation in SNSs has grown, suchsites provide an important additional resource for consumers.In healthcare speci cally, these sites can provide support groups for consumers dealing with health problems and con-cerns. These sites likely will not replace interactions withhealthcare professionals, family, friends, or even live support groups. However, they may provide the right support from the right person at the right time facilitating emotionalcoping.

It is important that policymakers and marketers assesshow they can better serve consumers using eWOM onhealth SNSs. The most direct way to use health SNSs is tolearn from the contents of threaded discussions. As thesediscussions are open to the public, policymakers and market-

ers can have easy access to rich rst-hand information about consumers health and medical opinions and problems.Further, by forming their own groups on SNSs, policymakersand marketers can actively communicate with consumerswithout interrupting the existing communities. From our observation of the health-related activities on popular generalSNSs (e.g. Facebook) and health SNSs (e.g. Dailystrength),the major online health-related activity of policymakers andmarketers is to release information on their group pages. TheUS Centers for Disease Control (CDC) has formed groups onSNSs, suchas Twitter, Facebook, and Dailystrength. However,the onlyactivity that CDC engages in on their group pages is to

release health information. An important opportunity exists for such organizations to engage in more interaction on SNSs.Considering the value of the information and support

available on health SNSs, policymakers and marketersshould also aim to improve the quality and quantity of eWOM messages on health SNSs. One effective way is toadvise consumers on how to nd health SNSs matching their personal needs and how to read and post messages on their selected health SNSs.

FUTURE STUDY

The present research focused on the basic features of eWOMon health SNSs, especially on how communication amongusers is tailored to users personal needs. This research hastwo limitations that suggest directions for future research.First, more research is needed to investigate consumer differences with regard to their social ties with onlinecommunities and interests in online activities. Consistent withKozinet s study, we found that consumers in our studydiffered in the extent and manner in which they participated.Additional research is needed to investigate the characteristicsof different types of participants. Studying participants onlinepublic pro les that include personal information, such as

participants

online activities, journals, personal goals, andfriends, may provide insights about important differencesacross participant groups.

A second limitation of this research relates to the in u-ence of eWOM on consumer decision making processes.eWOM on health SNSs has become an important healthinformation source for consumers. This new source of in-formation may provide new and/or different informationwhich then may be factored into a decision. Future re-search is needed to investigate how information obtainedthrough eWOM on health SNSs impacts decision-making,particularly how consumers combine information receivedfrom different sources to make health decisions.

BIOGRAPHICAL NOTES

Bo Liang is a PhD student in the Department of Marketing in theDavid Eccles School of Business at the University of Utah. Boholds a Master s degree in Business Administration (MBA) from Clemson University. Her research interests include health commu-nication and social networking.

Debra L. Scammon, PhD, is the Emma Eccles Jones Professor of

Marketing in the David Eccles School of Business at the Universityof Utah. Her research interests include patients access to and use of information in decisions about their health and healthcare. Current projects include evaluation of strategies for primary care clinics tocollect patient-generated information and to provide patient self-management tools through Internet portals.

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