**The Direct and Indirect E**ff**ects of Online Social Support, Neuroticism, and Web Content Internalization on the Drive for Thinness among Women Visiting Health-Oriented Websites**

## **Nikol Kvardova \*, Hana Machackova and David Smahel**

Faculty of Social Studies, Masaryk University, 60200 Brno, Czech Republic; hmachack@fss.muni.cz (H.M.); smahel@fss.muni.cz (D.S.)

**\*** Correspondence: nikol.kvardova@fss.muni.cz

Received: 31 December 2019; Accepted: 1 April 2020; Published: 2 April 2020

**Abstract:** One of the debates about media usage is the potential harmful effect that it has on body image and related eating disturbances because of its representations of the "ideal body". This study focuses on the drive for thinness among the visitors of various health-oriented websites and online platforms because neither has yet been sufficiently studied in this context. Specifically, this study aims to bring more insight to the risk factors which can increase the drive for thinness in the users of these websites. We tested the presumption that web content internalization is a key factor in this process, and we considered the effects of selected individual factors, specifically the perceived online social support and neuroticism. We utilized survey data from 445 Czech women (aged 18–29, M = 23.5, SD = 3.1) who visited nutrition, weight loss, and exercise websites. The results showed a positive indirect link between both perceived online social support and neuroticism to the drive for thinness via web content internalization. The results are discussed with regard to the dual role of online support as both risk and protective factor. Moreover, we consider the practical implications for eating behavior and weight-related problems with regard to prevention and intervention.

**Keywords:** drive for thinness; health-oriented websites; online social support; neuroticism; web content internalization

## **1. Introduction**

Considering Western culture and its orientation toward appearance, young girls and women are susceptible to the desire to be thin so they would achieve an ideal body shape [1,2]. According to the Tripartite Influence Model [3], women internalize idealized thin body shapes from the media, which includes traditional mass media and the internet, including health-oriented websites. Exposure to thin-ideal content can have a negative impact on women because it is associated with their drive for thinness and eating disturbances [4,5].

In this study, we focus on the drive for thinness, which is motivation for a thin or thinner body and the desire to lose weight [1,6]. It is considered a risk factor for well-being because it is associated with decreased psychological health and the later development of anorexia and bulimia nervosa [7,8]. Because of its potential harm, it is crucial to understand the factors that are associated with the drive for thinness. Although previous studies investigated the role of the media in relation to the drive for thinness [1,5,9], there is a lack of evidence for health-oriented websites and the role they play in promoting weight loss. We intend to contribute to this area by focusing on these types of websites within the theoretical framework of the Tripartite Influence Model [3]. Moreover, our aim is to enrich this model, which posits socio-cultural influences on eating disturbances, by including the role of the individual factors associated with the drive for thinness. Specifically, we examine the role of these

websites for the perceived online social support, neuroticism, and internalization, and their direct and indirect effects on the drive for thinness.

As a result, our aim is to extend the knowledge about the role of health-related websites in the development of eating disorders by showing how and for whom these online spaces pose a risk. Based on our conclusions, we propose recommendations for prevention and intervention efforts.

## *1.1. Drive for Thinness and Health-Oriented Websites*

The drive for thinness is a motivational orientation toward having a thin or thinner body and a desire to lose weight [1,6]. It emerges as a motivated behavior in order to reduce body-related discontent [10], which is manifested by eating restraint and a preoccupation with body shape and weight [11]. It is considered a risk factor to women's health because it is associated with decreased psychological well-being, like body dissatisfaction [10], body-related anxiety [12], lower self-esteem [8], or perceived stress [13]. Moreover, the drive for thinness is one of the diagnostic criteria for anorexia and bulimia nervosa, and it is associated with the later development of both [7,8,11]. The ideal of thinness [1], the drive for thinness, and related eating disorders are more prevalent in women than in men [14]. Therefore, we focused the study on women.

Considering the potential detrimental effects, it is important to understand the factors which exacerbate the drive for thinness. According to the Tripartite Influence Model [3], there are three main influences on disordered eating: parents, peers, and the media. The role of the media has been highly debated in relation to disordered eating. In the past two decades, substantial attention has been given to the role of new technologies, such as social networking sites, eating- and exercise-related websites, personal blogs with pro-eating disorder content, and various health-related discussion forums [15]. We focus on websites related to weight loss, nutrition, and exercise. These websites act as important sources for general online information related to nutrition, fitness, weight loss, and a healthy lifestyle. There are plenty of websites that address these topics, including personal blogs, informational websites for particular health-related themes, discussion forums, and social-networking groups [16,17]. Websites can be focused on weight loss, body shaping, healthy lifestyle, eating, dieting, nutrition plans for specific illnesses, recipes, and exercising [15,18,19]. Visitors may go through content, read articles, make and read comments, and obtain advice and inspiration. Moreover, websites can serve as a social environment where people interact with messages, comments, and evaluations, and they are places where people can receive support from other visitors [20–22].

However, these websites can have a negative impact on women because they display content that is associated with the drive for thinness, body dissatisfaction, and eating disturbances [4,5,23,24]. Specifically, some of these websites display pro-ED (pro-eating disorder) content that suggests that maintaining an eating disorder is a positive lifestyle choice [25]. They also contain positive comments about being thin, guilt-inducing messages related to food, stigmatization about weight, and expressions of negativity about being fat or overweight. They include content related to dieting and eating restraint, and the promotion of a thin-ideal appearance [18,26]. This appearance-oriented content can have a negative effect on women through the maintenance of weight- and appearance-related concerns [27].

The current study focuses on young female visitors of health-oriented websites in the Czech Republic. According to the data from Eurostat [28], 54% of Czech women aged 16 to 29 searched for online health-related information in 2016, which is the year when the data for our study was collected. The European average during that time was 60% of young women. Concerning the general usage of the internet, 95% of Czech women aged 16 to 29 stated that they used the internet in the preceding three months in 2016, whereas the European average was 96% [29]. This means that the usage of the internet and the online health seeking behavior among Czech women is similar as in other European countries.

## *1.2. Internalization*

The negative effect of the exposure to the appearance-related online content can be explained with the Tripartite Influence Model, which suggests that the link between exposure to media ideals and eating disorders is not direct. It proposes that internalization of the appearance ideals serves as a mediating factor interfering association between media effect and disordered eating [30]. Media impact on disordered eating via internalization, as proposed by Tripartite Influence Model, was examined and supported by previous studies [31–35]. In the context of developing and maintaining eating disturbances, internalization is the process of adopting socially and culturally defined norms about body shape, which are commonly maintained as body ideals in everyday social interactions and in the media. By internalizing these ideals, one's conception of self could be affected because the ideals can come to represent personal standards against which one could appraise self and others [34]. Since the idealized appearance depicted by the media does not always correspond with one's real body shape, inconsistencies can emerge between the internalized norm and the actual body. Internalized ideals and perceived discrepancies can lead to consideration about how to obtain this ideal body [1]. This in turn results in disordered eating.

Several studies investigated specifically drive for thinness and how it is related to internalized appearance ideals in adolescent girls and young adult women. Internalization is a significant factor associated with the drive for thinness in both categories [1,8,15,35,36]. Moreover, the mediational role of internalization in the association between media exposure and the drive for thinness was supported [15,35]. However, less attention has been given to the individual factors which may be salient in this process and help explain who is susceptible to internalize media content. Therefore, in this study, we focus on two factors: online social support and neuroticism.

## *1.3. Online Social Support*

Research has shown that seeking support from others is a frequent motivation for using health-oriented websites and participating in health-related online groups [37–39]. The online space offers various ways to get in touch with others, so there are also diverse ways to seek help and receive support. Social support, which in this context is mostly provided as emotional support, is expressed through emotions, empathy, and as informational support, like sharing knowledge regarding eating or fitness activities [21,40].

Online social support has been investigated as an important factor among people who struggle with eating disorders. For instance, women who engaged in an internet weight loss community mentioned encouragement, motivation, information, and shared experiences as significant resources. They appreciated the accessibility, the anonymity, and the non-judgmental interactions as unique characteristics of internet-mediated support [21]. Moreover, examinations of ED discussion forums and ED-oriented support groups have revealed that these online sites provide relevant information, emotional support, personal disclosure, help, friendship, peer support, and a safe space to ventilate feelings [20,22,39,41].

Though receiving social support is, in many occasions, a very beneficial process, we also examine its potential for the reinforcement of the drive for thinness via increased internalization. This process can be described with two theories: Social Identity Theory, which refers to an individual's knowledge of belonging and the perceived emotional and value significance of group membership [42]; and the Self-Categorization Theory [43,44], which depicts how membership in social groups affects an individual's behavior. Social identity refers to an individual's knowledge of belonging and perceived emotional and value significance of group membership [42]. Social identity can act as the basis for both giving and receiving social support. Perceived social support can additionally promote the sense of shared identity and the subjective importance of one's group membership [19,42,45,46]. Subsequently, social identity and group membership are associated with the internalization of group norms. The norms and attitudes shared within the group are internalized as personal standards and the individuals act accordingly [47]. On websites related to weight loss, nutrition, and exercise, users share body-appearance standards, which are demonstrated by the website content, and have discussions about ideal appearance and figure [18]. With these shared interests, the goals, the mutual interaction, and the social support that are exchanged among visitors, the websites have a social

character. Thus, consistent with the Social Identity Theory approach, the perceived social support from the health-oriented websites can promote a sense of shared social identity and the perception of salience within the website group membership. Consequently, norms and standards regarding body appearance can be internalized even more.

## *1.4. Neuroticism*

Neuroticism is defined in terms of the inclination to emotional reactivity, instability, perceived anxiety, and high vulnerability when coping with stress [33,48,49]. Individuals who are high in neuroticism are excitable, easily upset, and prone to experiences that are unpleasant [50]. They are also more sensitive to criticism; they experience higher levels of rejection; and they have lower self-esteem [51]. In prior research, neuroticism has been connected to the increased drive for thinness in women [52,53], to heightened food and body preoccupation [54], to body dissatisfaction [55], to the self-regulation of eating attitudes (e.g., food temptation) [56], and even to eating disorder diagnosis [48,57] and binge eating [58,59]. According to Fischer, Schreyer, Coughlin, Redgrave, and Guarda [52], the facets of neuroticism, including irritability and difficulty with emotional regulation, are risk factors for developing an ED. Moreover, disordered eating is associated with neuroticism because it can serve as a coping mechanism with which neurotic individuals deal with negative feelings [58,60].

In this study, we examine neuroticism as a risk factor for increased internalization, which can lead to a stronger drive for thinness. The link was proposed by Scoffier-Mériaux et al. [56], who hypothesized internalization as a mediator between neuroticism and unhealthy dieting behavior. This model was subsequently tested by Martin and Racine [49], who examined the mediating roles of thin and athletic-ideal internalization in association between neuroticism, body dissatisfaction, and compulsive exercise. Using the sample of 531 college students (58% women) aged 18–44, they found that thin-ideal internalization mediated the link between neuroticism and body dissatisfaction, and the internalization of athletic ideals mediated the effect of neuroticism on compulsive exercise. Moreover, several prior studies have found that neuroticism is associated with higher internalization [49,50,56,61]. To explain this link, Roberts and Good [50] suggest that women with increased neuroticism compare themselves to attractive people, and this comparison is more likely to result in negativity due to their emotional liability. This negative effect, which arises from the incongruity between the internalized body ideal and the actual body shape, can result in an increased drive for thinness, as has been proposed by previous studies [52,53]. Therefore, we hypothesize that internalization may be a mechanism through which neuroticism is positively linked to the drive for thinness in women.

## *1.5. Research Goals*

This study focuses on the drive for thinness, which is considered a risk for women's well-being. It aims to enhance our understanding of the risk factors that contribute to its development, specifically with regard to the influence of media and the role of individual factors in young women. Previous studies have shown that the media can have a negative effect on women because exposure to its content is associated with their desire to have a thin body shape [1,5,9]. However, these studies mainly investigated traditional media (i.e., TV, magazines) and pro-eating-disorder websites. There is a lack of research in health-oriented websites, which are currently popular. These websites display content that is associated with the drive for thinness, body dissatisfaction, and eating disturbances [4,5,23,24]. Therefore, our aim is to fill this gap and bring more insight into the association between visiting health-related websites and the drive for thinness among women. Furthermore, our study aims to enrich the Tripartite Influence Model [3], which is the theoretical framework that explains eating disturbances with socio-cultural factors, by incorporating neuroticism and perceived social support as individual factors. Specifically, we test whether web content internalization mediates the effect of these factors. We propose that increased neuroticism and perceived online social support positively affects

web content internalization, which in turn affects the drive for thinness. Considering that disordered eating can be related to age and Body Mass Index [62–64], we also control for both of these factors.

## **2. Materials and Methods**

## *2.1. Study Sample*

This study uses data from a project which focused on the visitors of websites oriented toward nutrition, weight loss, and exercise. The data were collected through an online survey between May and October 2016. Participants were recruited with an invitation on 65 Czech websites, web magazines, social networking sites, blogs, and discussion forums that focused on weight loss, diet, eating habits, and exercise. The original sample comprised of 1002 respondents (81.6% women, aged 13 to 62, M = 24.8, SD = 6.9). The project was approved by the Research Ethics Committee of the University.

The current study focuses on a subsample of 445 young adult women, aged 18 to 29 (M = 23.5, SD = 3.1). Because the ideal of thinness is aimed mainly at women [1] and the drive for thinness and eating disorders are more prevalent in women [14], we focused on women in our study. Moreover, young adult women were the major part of the health-oriented website visitors in the project, and we did not have a sufficient amount of data from participants of other ages and genders. The original sample of women in the age range from 18 to 29 comprised of 632 participants. We excluded respondents based on their motivation for visiting health-oriented websites and because of missing data. We excluded women who reported that the reason for their website visits was because of the health issues of someone else (as indicated by the question *Do you visit the sites about nutrition or sports not for yourself, but mainly because you want to help with the nutrition or sport of another person (partner, child, parent, etc.)*?) (N = 37). In addition, participants with a substantial number of missing values for the key variables (N = 150) were excluded, and there were no significant age differences between our sample and excluded respondents (t = 0.37, *p* = 0.71)).

## *2.2. Measures*

## 2.2.1. Perceived Online Social Support

Perceived online social support was assessed using three items adapted from Graham, Papandonatos, Kang, Moreno, and Abrams [65]: *I get advice and support here that I would not get elsewhere*; *It is encouraging to know that there are other people making similar e*ff*orts (with regard to nutrition or sport)*; and *I feel that other visitors (or authors) of sites are giving me support*, with answers that ranged from 1 = Definitely does not apply to 4 = Definitely applies. A higher score indicated higher perceived support. The internal consistency was acceptable (ř = 0.72, M = 2.8, SD = 0.7).

## 2.2.2. Neuroticism

We measured neuroticism with three items from the short 15-item Big Five Inventory [66]. The items were *I worry a lot*; *I get nervous easily*; and *I remain calm in tense situations* (reverse scored). Participants answered on a six-point scale that ranged from 1 = Does not apply to 6 = Definitely applies. A higher score indicated higher neuroticism. The internal consistency was acceptable (ř = 0.67, M = 3.7, SD = 1.1).

## 2.2.3. Web Content Internalization

Internalization was measured using the question "To what extent do the following statements apply to you in regards to these sites?" with three items that were adapted from Cusumano and Thompson [67]: *I compare my appearance with people on these sites*; *I try to look like the people on these sites*; and *The content on these sites inspires me in how to look attractive*. Participants answered on a six-point scale that ranged from 1 = Does not apply to 6 = Definitely applies. A higher score indicated higher web content internalization. The internal consistency was satisfactory (ř = 0.81, M = 2.4, SD = 0.8).

## 2.2.4. Drive for Thinness

The Drive for Thinness subscale from Eating Disorder Inventory-3 [68] was used. The scale consisted of seven items (e.g., *I feel extremely guilty after overeating*; *I am preoccupied with the desire to be thinner*). Participants responded on a six-point scale that ranged from 1 = Never to 6 = Always. A higher score indicated a higher drive for thinness. The internal consistency was satisfactory (ř = 0.86, M = 3.4, SD = 1.2). The latent variable was constructed with the parceling approach; specifically, we made three parcels, combining low-loading and high-loading items [69]. Parcels were computed as a mean of the items.

## 2.2.5. BMI

Participants provided information about their current weight (in kilograms) and height (in centimeters). BMI was computed as follows: Weight (kg)/Height (m)2.

## **3. Results**

We examined the correlations among the variables (Table 1): perceived online social support, neuroticism, web content internalization, and the drive for thinness. The results were as expected: the drive for thinness was positively correlated with online social support (*r* = 0.11, *p* = 0.03), web content internalization (*r* = 0.51, *p* < 0.001), and neuroticism (*r* = 0.23, *p* < 0.001). Web content internalization was positively associated with online social support (*r* = 0.24, *p* < 0.001) and neuroticism (*r* = 0.16, *p* < 0.001). Additionally, the drive for thinness was positively associated with BMI (*r* = 0.20, *p* < 0.001), but not with age (*r* = 0.02, *p* = 0.67).


**Table 1.** Correlations among variables.

Note: \* designates *p* < 0.05.

To test our presumptions, Structural Equation Modeling (SEM) was used with a Robust Maximum Likelihood (MLR) estimator. We used R software, and lavaan, semTools, and semPlot packages. We tested a model with indirect effects, predicting drive for thinness. We included neuroticism and online social support as predictors, the web content internalization as a mediator of the effect of neuroticism and social support, and age and BMI as controls. The model had an acceptable fit, CFI = 0.98, TLI = 0.97, RMSEA = 0.04. Results are displayed in Figure 1 and Table 2.

**Figure 1.** Path diagram with standardized regression coefficients (β). Note: \* designates *p* < 0.05.

Perceived online social support from health-oriented websites predicted web content internalization (β = 0.28, *p* < 0.001). Perceived online social support did not have a strong direct effect on the drive for thinness, though the effect was weak and marginally significant (β = −0.11, *p* = 0.06; CI = −0.61; 0.01). Moreover, we found a significant indirect effect for online social support on the drive for thinness via web content internalization (β = 0.16, *p* = 0.001).

Neuroticism predicted web content internalization (β = 0.24, *p* < 0.001), and it had a direct effect on the drive for thinness (β = 0.14, *p* = 0.01). Moreover, we found a significant indirect effect for neuroticism on the drive for thinness through web content internalization (β = 0.14, *p* < 0.001). Therefore, the link between neuroticism and the drive for thinness was partially mediated by the web content internalization. Regarding controls, BMI positively predicted the drive for thinness (β = 0.17, *p* = 0.001), but there was no association between age and the drive for thinness (β = 0.02, *p* = 0.60).


**Table 2.** Structural Equation Modeling (SEM) predicting the drive for thinness and web content internalization.

## **4. Discussion**

In our study, we examined the factors associated with the drive for thinness in young adult women who visited websites oriented toward weight loss, nutrition, and exercise. Specifically, we investigated the perceived online social support of other website visitors, the neuroticism, and the web content internalization of the body appearance standards, and their direct and indirect effects on the drive for thinness. Our objective was to investigate whether the web content internalization mediates the links among the perceived online social support, the neuroticism, and the drive for thinness. We found support for our presumption: both online support and neuroticism were positively linked with the tendency for internalization, which, in turn, increased the drive for thinness.

In our data, we found a substantial connection between internalization and the drive for thinness. Our findings are in line with the Tripartite Influence Model [3,31–33], which suggests that body image concerns and eating disorders are affected by socio-cultural factors (e.g., media pressure, parental criticism, peer criticism) and indirectly through the internalization of the medialized body ideals. Moreover, we enriched the propositions of the Tripartite Influence Model [3] by including individual factors. This line of research was recently developed in studies that focused on perfectionism, self-esteem, depression, and anxiety [30–34,70]. This focus helps to better understand the risk factors, which strengthen the tendency for internalization.

Specifically, we found that perceived support increased the drive for thinness via its reinforcement of internalization. Our findings correspond to knowledge regarding ED (eating disorders) online groups, in which perceived support was connected to a higher sense of belonging and the acceptance of thin-ideal norms [20,22,39,71]. ED online groups and communities act as an important source of support that can be difficult to obtain elsewhere for individuals who struggle with ED and body image concerns [39,41]. However, support received from these online groups can be detrimental to women's health because it endorses negative attitudes toward their bodies and promotes extremely thin body shapes as attainable standards. Haas et al. [72] examined the social support on pro-anorexia websites and discovered that visitors received support for eating restraint and reinforcement for their negative views of themselves and their bodies. Sowles et al. [73] pointed out that members of the pro-ED online community disseminate images that depict thin body shapes and promote the thin ideal by labeling them as their desired goals. Similar findings emerged from a study by Marcus [40], who found that members of a pro-anorexic community shared photos of extremely thin bodies to motivate users to maintain their diets and to outline the beauty standards of the group. In this manner, women are encouraged to adopt body appearance standards that lead to a desire for a thin body. The findings of our study suggest that these processes apply not only to ED online groups, but to health-related websites as well.

Health-oriented websites, with their opportunities for social interaction (e.g., discussion with other users about specific health-related topics, personal messages, inspiration, sharing experiences, memories, feelings), enable visitors to receive social support. The perceived social support is associated with the acceptance of group norms due to the higher subjective salience of the social group to which the individuals belong [40,44,47]. In line with social identity theory [44], the stronger identification with a group would result in the acceptance of group norms and, in the case of websites focusing on nutrition and fitness—these probably supported the thin and fitness-oriented images of the ideal body. Thus, though the perceived support is often seen as a positive aspect of online interaction, in these instances, it may result in negative outcomes. However, when interpreting these results, the limitations of this study should be taken into consideration. Due to the correlational nature of the data used, it was not possible to draw causal conclusions. Thus, the association between online social support and the drive for thinness may work in the opposite direction, meaning that women with a stronger drive for thinness may more often seek social support for their goals and efforts in the online space and, specifically, via health-oriented websites.

Moreover, this finding should also be compared to the results for the direct effect of support on the drive for thinness. This effect was rather weak and just marginally significant; however, it may indicate that the role of support is diverse. If we disentangle the indirect effect that positively affects the drive for thinness from the direct effect, we find that support negatively affected the drive for thinness. To interpret this finding, we should acknowledge that perceived support helps to increase overall well-being [74–76], which decreases the tendency for unhealthy and disordered eating habits [77,78]. Thus, perceived online social support can actually function as both a risk and a protective factor. On one

hand, it may contribute to the development of the drive for thinness via increased internalization. On the other hand, it may also serve as a buffer for this negative effect, probably via the increase of overall well-being, which was not included in this study. This presumption could be pursued in future examinations.

Thus, we still need to consider other factors which underlie the internalization of the web content. Our study focused on neuroticism, which showed to be positively linked to the drive for thinness and also had an indirect effect via internalization. Therefore, the effect of neuroticism on women's drive for thinness was partially mediated by the internalization of the body appearance standards displayed on health-oriented websites. In line with prior studies [49,50,52,53,56,61], our findings showed that people with heightened neuroticism are more prone to accepting the norms, and, probably because of the increased tendency for social comparison, tend more to strive to be thin.

However, besides the mediated effect, we also found a direct positive link to the drive for thinness. This suggests that increased internalization is not the only mechanism through which people with neurotic traits can be more at risk. However, considering that we found support for the tendency for heightened internalization from the websites, and upon the propositions of the Tripartite Influence Model [3], we could expect that the mechanism could be similar in relation to parental and peer norms, which have not been measured in this study. This poses one of the limitations for our study.

Concerning other limitations, it should be stressed that we used cross-sectional correlational data based on a sample that was self-selected through health-oriented websites. Thus, though we examined the proposed model for the mechanisms to increase the drive for thinness, the research design complicates drawing causal conclusions. Future research should implement a longitudinal research design to make more reliable causal conclusions and to capture potential reciprocal associations. Moreover, we were not able to control for the effects of additional variables on the drive for thinness. These are factors (e.g., body dissatisfaction) [79] that are related to the drive for thinness and disordered eating, and it would be appropriate to control for their effects to obtain more accurate results. Furthermore, we do not have information about the specific content that respondents encountered. It would be useful to incorporate objective measures and directly observe the effects of participants' exposure to online content. Finally, although the thin ideal displayed in the media and the related drive for thinness is more prominent in women [1], future research could focus on men, their internalization of the body appearance norms, and their motivations for body change.

In the current study, our aim was to propound a model that comprises of the individual factors that affect women's drive for thinness. Based on our findings, we can formulate several implications. According to the theory and the available data, we propose the following processes: online social support from the visitors of health-oriented websites and neuroticism affect the drive for thinness, and these links are mediated by the internalization of body appearance standards. Thus, alongside previous research in this area [1,8,15,35,36], our study supported the predictive role of internalization in the drive for thinness among women. Specifically, our study provided insight into the internalization of the content of health-oriented websites, which had not been sufficiently investigated and had not been taken into account in relation to women's drive for thinness. Our results imply that it is crucial to acknowledge health-oriented websites and their potential impact on women, especially in the context of the internalization of body appearance norms. Health-oriented websites, which are not generally acknowledged as harmful to women's body image, can be a significant source of body appearance norms and subsequent body image concerns [18]. As was discovered in the current study, women internalize body ideals from health-oriented websites and this, in turn, increases their drive for thinness. This connection should be actively acknowledged by health-care professionals. It is important for professionals to ask their clients who have ED-related problems about their technology usage and to provide them with space to talk about it [80]. Thus, in the context of the current study, health-care professional should discuss with clients who are struggling with EDs their usage of health-oriented websites, specifically with a focus on their exposure to the thin- or fitness-ideal content.

We also showed that both online support and neuroticism present risk factors because they can increase the tendency for internalization and, in turn, increase the drive for thinness. Therefore, it is important to be aware of the possible negative effect that online social support may have on women and to address it when preventing or reducing the drive for thinness. However, the findings of this study showed that online social support can function both as a risk and a protective factor. Thus, when discussing the use of health-oriented websites with ED clients, it is important to disentangle the different forms of social support that women receive from the visitors of these platforms. In addition, neurotic individuals experience higher levels of negative emotions and stress, which makes them more susceptible [52,53]. Based on our results, we suggest that preventive health programs, intervention, individual psychotherapy, counseling, and other health policies can be focused on the reduction of the negative emotions and stress in women. These can also help the reduction of the internalization of the body appearance standards promoted on health-oriented websites.

## **5. Conclusions**

This study focused on the factors associated with the drive for thinness in young adult women who visited weight loss, nutrition, and exercise websites. These platforms are currently of high use, yet they have not been sufficiently studied in relation to eating disturbances. We examined the direct and indirect effects of perceived online social support from fellow website visitors, neuroticism, and the web content internalization of the body appearance standards on the drive for thinness. Our findings supported the predictive role of web content internalization on the drive for thinness in women. Moreover, we showed that the perceived online support from the health-oriented websites and neuroticism can pose risk factors because they are associated with a higher tendency for internalization and, in turn, with a stronger drive for thinness. Our results indicate that it is crucial to acknowledge health-oriented websites and their potential impact on women and their drive for thinness, especially in the context of the internalization of body appearance standards. We also discuss the role of social support, and its double role of risk and protection. Our findings can be used to establish prevention and intervention efforts to help individuals who struggle with body image and eating disturbances.

**Author Contributions:** Writing—original draft preparation, N.K.; writing—review and editing, N.K., H.M. and D.S..; supervision, H.M. and D.S.; project administration, H.M. and D.S.; formal analysis, N.K. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research and the APC were funded by Czech Science Foundation, grant number 19-27828X (project FUTURE).

**Conflicts of Interest:** The authors declare no conflict of interest.

## **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

## *Commentary* **Evolving Role of Social Media in Health Promotion: Updated Responsibilities for Health Education Specialists**

## **Michael Stellefson 1,\*, Samantha R. Paige 2, Beth H. Chaney <sup>1</sup> and J. Don Chaney <sup>1</sup>**


Received: 26 December 2019; Accepted: 8 February 2020; Published: 12 February 2020

**Abstract:** The use of social media in public health education has been increasing due to its ability to remove physical barriers that traditionally impede access to healthcare support and resources. As health promotion becomes more deeply rooted in Internet-based programming, health education specialists are tasked with becoming more competent in computer-mediated contexts that optimize both online and offline consumer health experiences. Generating a better understanding of the benefits and drawbacks to using social media in the field is important, since health education specialists continue to weigh its advantages against potential concerns and barriers to use. Accordingly, this Special Issue aims to explore social media as a translational health promotion tool by bridging principles of health education and health communication that examine (1) the method with which social media users access, negotiate, and create health information that is both actionable and impactful for diverse audiences; (2) strategies for overcoming challenges to using social media in health promotion; and (3) best practices for designing, implementing, and evaluating social media forums in public health. In this commentary, we discuss the updated communication and advocacy roles and responsibilities of health education specialists in the context of social media research and practice.

**Keywords:** social media; health education; health promotion

## **1. Introduction**

Our understanding of health and the impact of behavioral, sociocultural, and system-level factors on health outcomes has evolved significantly over the past several decades [1]. Advances in technology are central to this evolution, as adoption of mobile devices connected to the Internet continues to grow across sociodemographic groups and geographic regions. One technological advancement accessed regularly is social media, which is used by 2.82 billion people worldwide [2]. Social media is defined as activities, practices, and behaviors among communities of users who gather online to share information, knowledge, and opinions using conversational media [3]. There are tens of thousands of health-promotion-related social media websites that are currently available to the public [1]. In health promotion, social media is commonly accessed for networking and community building purposes, as well as for informing healthcare decision-making between patients and providers [4].

The use of social media in public health education and promotion has been increasing in the United States (U.S.), due, in part, to its ability to remove physical barriers that traditionally impede access to healthcare support and resources. In 2017, Dr. Zsuzsanna Jakab, The World Health Organization (WHO)'s Regional Director of Europe, described the intersection of electronic health (eHealth) in public health as a "beautiful marriage" that celebrates the global commitment and dedication towards reaping the benefits of eHealth for all [5]. Patients, clinicians, mobile health, and social media all play unique roles in health promotion, highlighting the need to for secure data management that can facilitate more personalized medicine and more equitable public health policies [5]. Today, it is difficult to imagine public health without social media. Although social media is viewed as acceptable and usable among multiple audiences and shows much promise in promoting health equity among disadvantaged populations (e.g., low income, rural, and older adults) [6], there remains inconsistent empirical evidence on the effectiveness of social media to improve public health outcomes and trends [7,8]. In order to optimize the potential of social media to improve public health, there is a need to effectively leverage these technological tools to create scalable, culturally adapted health promotion programs and campaigns. Unfortunately, evidence remains limited on how to do this within the field of health promotion [6,9]. Generating a better understanding regarding the benefits and drawbacks to using social media in health promotion is important, since health education specialists weigh its advantages against potential concerns over misinformation being shared to the public at large [10].

Central to social media is interactivity. Social media facilitates greater information sharing and opportunities for community building through an Internet-mediated dialogue that allows users to create their own content (e.g., blogs, online discussion boards). This content, in turn, can become invaluable for health education specialists who are seeking formative research to design, adapt, and evaluate programs and campaigns with priority audiences. Consistently, social media hosts opportunities for consumers to exchange strategic health messages on popular social media channels, including Facebook, YouTube, and Pinterest, through various modalities (e.g., text, image, video, and gif) [11]. Moreover, recent analytic advancements have strengthened the capacity of researchers and practitioners to compute and analyze metrics that evaluate the process of implementing social media, as well as any health-related impacts and outcomes associated with its implementation. As such, new collaborative evaluation methods are being deployed to improve the integration of social media within health-related interventions. While progress is being made, there remain significant challenges inhibiting the widespread acceptance, adoption, and use of social media in health promotion [4,12,13]. Further examining the impact of communication and advocacy within social-media-based interventions and campaigns is central to this endeavor.

Health education specialists play a critical role in creating, managing, and monitoring health promotion programs. As health promotion becomes more deeply rooted in Internet-based programming, health education specialists are tasked with becoming more competent in computer-mediated contexts that optimize both online and offline consumer health experiences. Accordingly, this Special Issue aims to explore social media as a translational health promotion tool by bridging principles of health education and health communication that examine: (1) the method with which social media users access, negotiate, and create health information that is both actionable and impactful for diverse audiences; (2) strategies for overcoming challenges to using social media in health promotion; and (3) best practices for designing, implementing, and evaluating social media campaigns and forums in public health. In this commentary, we discuss updated communication and advocacy roles and responsibilities of health education specialists in the context of using social media in research and practice.

## **2. Updated Social-Media-Related Roles and Responsibilities of Health Education Specialists**

The National Commission for Health Education Credentialing, Inc. (NCHEC) and the Society for Public Health Education (SOPHE) recently co-sponsored a new health education specialist practice analysis. A panel of 17 individuals with diverse backgrounds (i.e., work setting, experience level, education background, demographics, and geographic settings) that affect the practice of health education conducted a validation study, known as *Health Education Specialist Practice Analysis II (HESPA II 2020)* to re-verify the entry- and advanced-level responsibilities, competencies, and subcompetencies that provide the foundation for the professional preparation and development of all health education specialists [14]. A broad cross-section of both certified and noncertified health education specialists

from all 50 U.S. states volunteered to participate in the study. Study participants were contacted via existing lists of the sponsoring organizations with additional assistance provided by the Coalition of National Health Education Organization (CNHEO) and national and state affiliates of major health education associations. Two online surveys, one focusing on competencies and one focusing on knowledge areas, were available for a three-month window from November 2018 to January 2019, resulting in 3,851 usable surveys [14].

Findings from this research provided significant implications for professional preparation, continuing education, and practice for the health education profession. Moreover, *HESPA II 2020* produced a new hierarchical model with eight areas of responsibility, 35 competencies, and 193 subcompetencies [13]. Within these new areas of responsibility, Advocacy (Area V) and Communication (Area VI) were designated as standalone areas of responsibility that contained a variety of new competencies and subcompetencies that reflected the increasing importance of using social media in the process and practice of health education. Table 1 outlines these two areas of responsibility with five associated health education specialist competencies and six subcompetencies that directly mention social media use.

**Table 1.** HESPA II 2020 competencies and subcompetencies that address health education specialist use of social media.


<sup>1</sup> Advanced 1 subcompetency not included in the entry-level, Certified Health Education Specialist (CHES®) examination. Subcompetency will be included in the Master Certified Health Education Specialist (MCHES®) examination.

## *2.1. Engage Coalitions and Stakeholders in Addressing Public Health Issues Using Social Media*

Health education specialists are tasked with specifying strategies, timelines, and roles and responsibilities to address proposed policy, system, or environmental changes through social media. Social media allows for synchronous and asynchronous communication in a centralized, readily accessible digital location where a high degree of transparency exists. Social media can assist health education specialists in building a network of supporters, particularly for advocacy efforts [15]. These interactive, digital tools can be used to effectively expand the reach and inclusivity of advocacy campaigns to engage stakeholders to support public health issues, regardless of geographic location and timing [16]. Specifically, when used with traditional, relationship-building strategies, social media can bolster outreach approaches and reinforce relationships among stakeholders, including public health education coalition groups. This is done through promoting dialogue between leaders and supporters, as well as increasing collaborative communication among stakeholder groups. Additionally, social media tools are highly cost-effective for expanding communication among stakeholders and

coalition groups interested in supporting public health education and promotion issue(s) [17,18]. Therefore, social media technologies have potential to improve communication among stakeholders in order to further engage supporters for successful social change. However, building relationships with stakeholders and coalitions through traditional communication channels, while supporting these relationships through the use of social media technologies, is ideal for fostering lasting and productive stakeholder relationships for addressing public health issues [18]. This allows for the opportunity to develop and nurture collaborative relationships among decision makers, which can include diverse stakeholders such as community members, organizations, and policymakers.

## *2.2. Engage in Health Policy Advocacy Through Leveraging Social Media*

Social media has become a critical tool in advocating for health policy, including its development, planning, and reform. Engagement with advocates is a key element in advocating for health policy, and social media provides a platform for new supporters and the general public to become aware of the important issues [19]. In addition, social media tools create widespread access to public officials, many of whom have their own social media websites, for the opportunity to share information regarding health policy issues impacting constituents. While these technologies create the digital platform to increase awareness and evoke support for health policy advocacy, health education specialists must strive to promote actions that results in social change through advocacy efforts. Social media can complement traditional advocacy approaches to shift policy priorities for supporting health policy. In a framework developed by Scott and Maryman [18], social media and advocacy are aligned through empowerment and organization theories for shifting policy priorities. Specifically, the model suggests that quality social media presence must involve 1) critical awareness —engaging supporters through awareness of an issue that drives the desire to actively support the cause, 2) relationship building—creating relationships in a digital space and with face-to-face interactions that move passive supporters to active supporters, and 3) mobilizing action—creating action through both social media-supported online and offline forms of political engagement [18]. Successful social media campaigns for health policy advocacy require health education specialists to utilize planning and evaluation skills to effectively assess the use of social media in this capacity.

## *2.3. Determine Factors that A*ff*ect Health Communication on Social Media with the Identified Audience(s)*

It is important for health education specialists to identify communication channels, such as social media, that are available to and used by their intended audience. Being digital-media-proficient means being able to meet priority populations where they are to bring about change within the physical, social, and online environments in which they live, work, and play. There are many challenges to effectively using digital media platforms, such as social media, within health education/promotion interventions and campaigns. These challenges are directly tied to the nature of social media itself, where health education specialists cannot fully control what, when, and how health information is shared. In some respects, social media can be considered the "wild west" for health information. Users can freely engage and interact with health information that may or may not be accurate or supported by empirical evidence. While challenges are to be expected, engagement can be maximized on social media through managing misinformation, reducing agency barriers to use, measuring audience reach and impact of posted messages/content, and keeping up with new trends in social media adoption and use. To effectively engage diverse audiences, there are several steps that can be followed to adopt a more strategic approach to social media use in health promotion: 1) understand how the priority population uses social media, 2) identify evidence-based social media strategies, 3) select appropriate communication times and channels, and 4) determine which types of social media apps will engage your audience most often in a meaningful way [20].

## *2.4. Deliver Health Message(s) E*ff*ectively Using Social Media*

As reflected in *HESPA II 2020* competencies and subcompetencies, health education specialists are tasked with fine tuning their message delivery to ensure that intended audiences are being reached. This involves using current and emerging communication tools and digital media (e.g., social media management tools and platforms) to engage audiences. There are various social media tools, guidelines, and best practices that health education specialists can use for this purpose [20,21]. For example, health education specialists should stay abreast of new forms of social media that are accessed regularly (i.e., daily or almost daily) by intended users. Next, consider adopting a social media policy. A formal social media policy on relevant topics such as hashtag use, tagging, communicating, and updating content can limit destructive posts that adversely impact online communities [21]. Moreover, policy implementation facilitates productive interactivity that respects the diversity of user demographics, cultural backgrounds, and opinions. Finally, try to keep social media activity both lively and relevant. Skilled social media moderators are essential for maintaining social media pages and maximizing engagement through scheduling messages and responding promptly to user posts about current public health issues that are of concern. Moderators can provide invaluable social support that clinicians are often unable to offer, such as sharing insight about how to effectively communicate with healthcare providers [20].

## *2.5. Evaluate Health Promotion Activity Occurring on Social Media*

Evaluation is a fundamental element of most all social media activities within the field of health promotion [20]. Process evaluation, or the measurement of factors that influence the success or failure of social media use (i.e., tracking social media analytics and performance indicators), is the most relevant type of evaluation to assess use of social media as part of an intervention or as a standalone tool [19]. Data from process evaluation enables key decision makers and other stakeholders to monitor program inputs (e.g., messages, videos, and chat sessions) and outputs (e.g., number of followers, number of likes, and number of comments left) of social media activity [11]. Tools such as social media analytics and data mining software can assist health education specialists in assessing the reach and dose of communication messages [22]. Analytics also help to extract useful patterns of user activity to measure the engagement, experience, and moderator responsiveness within online communities [23]. This type of social media data enables decision makers to learn from mistakes, make health promotion program modifications, monitor progress towards program goals, and justify the success of achieving desired health-related outcomes [20].

## **3. Conclusions**

Social media provides an outlet to increase and promote translational health communication strategies and effective data dissemination, in ways that allow users to not only utilize but also create and share pertinent health information. Moreover, the use of social media for advocacy and communications in health promotion offers exciting new prospects for broader reach, greater efficiency, and lowered costs of communication and advocacy campaigns. As with other technological innovations in healthcare, these efficiencies may be viewed by those providing funding as an opportunity to decrease budgets and increase the scope of health promotion activity delivered by health education specialists and their organizations. This very may well result in a reduction in the use of more established communication channels (e.g., TV, radio, and print-based media) traditionally used for health promotion.

Although the application of social media in public health and health promotion has yielded some success in terms of generating support structures and networks for effective health behavior change, there are challenges and complications associated with social media use that also need to be addressed (e.g., managing misinformation, ensuring compliance with user privacy protections). While it is relatively straightforward to view social media use as a universal communication channel,

especially for those who already use social media, the risk of using social media lies in reducing health information access among those who are not technologically ''connected". Social media is not likely to be an effective option for population subgroups include the elderly; the physically and cognitively disabled; and those with low text, technical, and eHealth literacy.

As health education specialists, we need to be wary of designing social media interventions or campaigns that are most suited to population segments that are comfortably well off, and text-, tech- and eHealth-literate. In addition, the use of social media by health education specialists faces significant headwinds from individuals or entities using social media to promote alternative views on health-related issues (e.g., anti-vaccinations, pro fad diets, and advocating for exclusionary healthcare policies). Some social media platforms have belatedly taken action to limit some of these discussions (e.g., Facebook with anti-vaccination groups), but the response is unlikely to be timely. We acknowledge that these types of completing voices are usually far better resourced than health education specialists who have limited resources to support robust social-media-based advertising campaigns. Therefore, we must be vigilant in monitoring and evaluating public health advocacy and communication that occurs on various popular social media websites.

Our Special Issue begins to tackle these important issues by bringing together international, multidisciplinary scholars who employed innovative methodologies to better understand how social media is used by multiple audiences for the purposes of health promotion and engagement. Specifically, these articles delve into the sociocognitive and affective factors that mediate the relationship between social media use, community engagement, and positive health outcomes. This was achieved by augmenting our understanding of traditional health education approaches with theories rooted in the complementary yet distinct disciplines of health communication. We sincerely hope that the new empirical knowledge generated within this Special Issue will help academic health education specialists, as well as other public health professionals, use more pragmatic paradigms for planning, implementing, and evaluating social media interventions and campaigns in the field of health promotion.

**Author Contributions:** Conceptualization, M.S. and S.R.P.; methodology, M.S. and S.R.P.; formal analysis, M.S., S.R.P., B.H.C., and J.D.C.; writing—original draft preparation, M.S. and S.R.P.; writing—review and editing, B.H.C. and J.D.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** We would like to thank the *IJERPH* editorial staff and manuscript review board members for their support and contributions during the preparation of this Special Issue.

**Conflicts of Interest:** The authors declare no conflict of interest.

## **References**


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