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CONTENTS Abstract ...... 5 Preface and Acknowledgements...... 7 1. Introduction ...... 9 2. Definitive and sensitizing concepts ...... 12 2.1. Definitive concepts ...... 12 2.1.1. E-health ...... 12 2.1.2. Social Connectors ...... 12 2.1.3. Word of Mouth Marketing ...... 12 2.2. Sensitizing Concepts ...... 13 2.2.1. E-health programs ...... 13 2.2.2. E-health reach ...... 14 2.2.3. Social Connectors ...... 14 2.2.4. Facebook – Mediated Activities ...... 15 3. Aim and research questions ...... 16 4. Theoretical Framework ...... 17 5. Research Methods……………………………………………………………………………………………………21

5.1. Research sub-question 1: Literature review ...... 20 5.1.1. Review Protocol ...... 20 5.2. Research sub-question 2: Literature review ...... 24 5.3. Research sub-question 3: Empirical research ...... 26 5.3.1. research population and Sampling method ...... 26 5.3.1.1. Limitations ...... 28 6.0. Findings from the literature review ...... 32 6.1. Introduction…… …………………………………………………………………………………………………………………32 6.1.1. Narrative Summary of Relevant Literature ...... 32 6.2. Introduction ………………………………………………………………………………………………………………………37 6.2.2. opinion leaders: The influential messengers ...... 38 6.2.2.1. Practices for identifying opinion leaders ...... 38 6.2.2.2. Practices for reaching opinion leaders ...... 41 6.2.2.3. Influencing the influencers: Practices for motivating opinion leaders to spread the word ...... 42 6.2.2.4. Word of Mouth Marketing best practices that do not target opinion leaders directly . 49

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6.2.3. Engineering contagious messages: properties of the message itself ...... 52 6.2.3.1. Social Currency ...... 53 6.2.3.2. Triggers ...... 57 6.2.3.3. Emotion ...... 59 6.2.3.4. Public ...... 61 6.2.3.5. Practical Value ...... 64 6.2.3.6. Stories ...... 65 6.2.4. Measuring effects ...... 66 7.0. Empirical Findings ...... 67 7.1. Introduction………………………………………………………………………………………………………………69

7.2. Summary ...... 70 7.3. Personal Involvement; “Facebook reflects my lifestyle” ...... 78 7.3.1. Activities of interest to health promotion reflected on Facebook ...... 79 7.3.2. Personal Involvement and willingness to share health promotion content...... 80 7.4. Favorable image construction ...... 83 7.4.1. The content is expected to reflect positively on the sharer ...... 83 7.4.2. Content is expected to reflect negatively on the sharer ...... 87 7.5. Practical Value ...... 91 7.5.1. The content is perceived to be Useful ...... 92 7.6. Emotional Arousal ...... 106 7.7. Social benefits ...... 107 7.7.1. being close to Specific Others ...... 108 7.7.2. Connecting with Similar Others ...... 109 8.0. Conclusion and discussion ...... 113 8.1. Reflection…………………………………………………………………………………………………………………………113 8.2. Notable results and dissagreements in evidence ...... 116 8.3. The added value of Facebook ...... 141 8.4. Summary of selected strategies ...... 141 8.5. Other themes in research ...... 143 Appendix A ...... 145 Appendix B ...... 148 Appendix C ...... 151 INFORMATION SHEET ...... 151 Interview guide______...... 153 3

Appendix D ...... 156 List of publications included in our literature research ...... 156 Appendix E ...... 161 References ...... 165

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ABSTRACT

M OTIVATION The internet has revolutionized communication and this holds interesting implications for health promotion as well. E-health programs are internet delivered health promotion interventions, with a focus on prevention and with a focus on lifestyle. These programs have been shown to be effective in producing cognitive and behavioral outcomes, like actual changes in physical activity or smoking cessation. Free and flexible access are thought to make e-health programs attractive for users while their potential high reach implies high cost effectiveness for health promotion organizations, if said potential is redeemed.

PROBLEM AND GAP OF K NOWLEDGE Evidence from efficacy trials shows that exposure rates or participation in e-health programs is generally low; hence their high reach potential is not being expressed. Previous research at the PhD level stresses the need for future research to address e- health programs’ successful dissemination and concludes that using the equivalent of word of mouth marketing strategies in response to this problem seems very promising.

AIM Our research aim was to identify Facebook mediated Word of Mouth Marketing strategies that can be used to increase the reach of e-health programs.

METHODS Using diffusion of innovations theory as our theoretical framework, qualitative methods were used to meet the research aim of this study. These methods included: (1) A literature review of evidence and practice-based literature to explore best word of mouth marketing practices in the commercial arena as well as their recruitment for the benefit of health promotion. (2) Semi-structured in-depth interviews, supported by simultaneous Facebook activity log screen sharing through Skype, to explore and map factors that condition social connectors’ choices to share general and health promotion content on Facebook.

RESULTS Evidence based antecedents of output word of mouth from the standpoint of the communicator are summarized and six evidence based principles that have been shown to make online content more likely to be shared are presented. An overview of best Word of Mouth Marketing practices is given, mainly drawing on practice-based literature from the commercial arena. Evidence regarding the uses of viral strategies for health promotion is scarce, but these pioneering studies exhibit promising results. Available empirical evidence and visionary studies are summarized.

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Our empirical results show that factors that condition social connectors’ choices to share general and health promotion content on Facebook relate to ”Personal Involvement”, “Favorable Image Construction”, “Practical Value”, “Emotional Arousal” and “Social Benefits” which are further grouped into three main themes: “I consider me”, “I consider you” and “I consider us”. A breakdown of themes and factors is presented, as well as how these factors relate to specific Facebook sharing activities (Post, Like, comment, PM). Health promotion content is further operationalized and relationships between these categories and factors are indicated, explaining whether this content is likely to be shared on Facebook and through which sharing activities may this likely be.

C ONCLUSIONS There is vast untapped potential of using Facebook for Word of Mouth Communication of e-health programs or other health promotion initiatives and objectives, be they online or offline. A number of Facebook mediated Word of Mouth Marketing strategies are indicated which can be used to increase e-health programs’ reach. To our knowledge, this is the first study to explore social connectors’ preconditions for sharing health promotion content on Facebook.

A number of issues, like who is more likely to share health promotion content on Facebook, which are the content characteristics that make health promotion content more likely to be shared, in which ways and when are illuminated and implications are indicated. Notable results and disagreements in evidence, gaps in the literature as well as other themes for future research are also discussed.

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PREFACE AND ACKNOWLEDGEMENTS To write this preface I had to take some time to remember who was I when I started this thesis, what were my expectations and motivation and how was this research shaped in the process that also shaped me.

I am Greek and 34, so not one of the students who grew up with the internet. When I first discover it, I fell in love; I could not believe that I could now learn whatever I wanted, no matter how specific or trivial, with such speed. Sixteen years later and I still cannot get used to this luxury; I think it is the greatest revolution of our times and I am thankful for it every single day. Then, being a health promoter I developed an interest in e-health programs; this is an excellent and cheap way I thought, to bring tailored health communication that can be developed in one country and have a great impact on the whole world. My long –lasting interest in them decided my thesis topic.

I treated Crutzen‘s PhD dissertation on e-health programs as my summer novel; I have to thank him for this source of knowledge and inspiration. From Crutzen ‘s work good news were that e-health programs were shown to be effective, bad news were that people were not using them. There was clearly a dissemination problem and Crutzen was suggesting that using Word of Mouth Marketing techniques seems promising. That came right after Noelle Aarts and Hanneke Nijland introduced me to the classic “Tipping point” and showed me the way to the exciting work of Nicolas Christakis, who managed a major breakthrough in diffusion science. Thank you all for letting me step on your shoulders to see a tiny bit further.

With what was still a vague idea I visited Laura Bouwman, who helped me in so many ways. First, Laura bursts with positive energy, which is utterly motivating. Placing good old Roger’s diffusion theory on her desk and linking me to other scientific resources was nothing compared to giving me a memorable real life example of what empowerment means; the living example of her working style was for me a much more effective lesson than any facilitation course or empowerment lecture. Paying attention to what she made relevant in our discussions, her positive creative focus and her motivating tendency to build on my stronger points before setting out the limits, was inspiring; further it helped me realize that less is more, more or less.

However, this is not reflected in my report. I apologize for its length. To my defense, as funny as it may seem, I had a wrong impression of the Dutch standards when it comes to MSc thesis reports’ length. Moreover, I got over enthusiastic with the word of mouth marketing literature I had the privilege to read, often from authors that spent their lives on the topic and wanted to spread the word. It is a topic as hot in Marketing as understudied and promising for Health Promotion. I also soon realized that studying Word of Mouth is in essence understanding what people talk about in everyday life and

7 why; and that is also what readers should expect to learn and reflect on. Like in my case, this might change the way you make sense of everyday conversations, including your own words, and realize their power in shaping our lives.

You should also expect to read a lot about Facebook, which might give your next log –ins a more analytical view. You might also find out that you have a better idea of what stands more chances to be “Liked”. That part of the research is based on 15 interviews with Facebook social connectors from different parts of the world. I really enjoyed doing the interviews and, strangely enough, also transcribing them. Interviewees shared their Facebook screens with me on Skype, and indeed their activity logs, not just their walls. I am thankful to all of you for the precious insights and time, for allowing me to your private virtual space and opening up your minds and hearts. You have changed the way I view things, to an extent that goes further than the purposes of this thesis. Finally, there was another great lesson to be learned; based on my feelings and your feedback, I came to see that you were happy to be of help and share your opinions and thoughts. That gives me an optimistic glance into what I consider the future of health promotion practice, a practice that is participative, co-creative and harvesting collective intelligence, while allowing for the pleasurable rewards of thinking together with others to create solutions. Last but not least, I want to thank my little sister, who took a whole night helping me in a last minute panic with her graphic design skills.

I also want to thank in advance anyone reading my report; I hope you will enjoy reading it as much as I enjoyed working on it. I will be happy to hear from anyone that wants to give a remark, share a thought, or ask a question.

Daferera Maria

21/10/2014

[email protected]

Facebook: Dafy Maria

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1. INTRODUCTION Internet has revolutionized communication by removing physical barriers like space, time needed to communicate with a large number of people and communication costs, thus making information flow incredibly faster. Diffusion of innovation was never so promising, as the internet forms a communication medium that can greatly accelerate an innovation’s rate of adoption (Emmanuel, 2000; E. M. Rogers, 2003; Rosen, 2010). Therefore, internet use has been seen as a major opportunity that can serve in maximizing the reach and adoption of various health promotion initiatives (Bernhardt & Hubley, 2001). The fact that the internet is an open medium twenty four hours a day and seven days a week, as well as the potential it offers in combining high reach with targeted or even tailored health communication at a very low cost, has attracted a lot of attention among scholars (Brouwer et al., 2011; Crutzen, 2009). It has been proven that “web based interventions” which aim at promoting a healthy lifestyle can be effective in behavioral change (de Nooijer, Veling, Ton, de Vries, & de Vries, 2008; Van den Berg, Schoones, & Vlieland, 2007; Vandelanotte, Spathonis, Eakin, & Owen, 2007) and significant funds are routinely spent by public health organizations for the development and renewal of websites with youth-focus, tested content (B. Freeman & Chapman, 2008). Nevertheless, evidence from efficacy trials show that exposure rates or participation is generally low (Nooijer et al., 2005) and in real life, exposure rates might be even lower (Evers, Cummins, Prochaska, & Prochaska, 2005). The PhD dissertation on Internet delivered health behavior change interventions titled “Hard to Get, Hard to Keep”, is consistently stressing the fact that exposure to such interventions is low and that future research should address questions regarding successful dissemination and adoption of such interventions (Crutzen, 2009).

Given the fact that said web based interventions have not yet been adopted or rejected by their intended users makes them new, or else innovative to the perception of these users (E. M. Rogers, 2003). Therefore, questions that seek to address their popularity actually refer to a diffusion problem. Trying to solve problems related to diffusion of innovations requires an understanding of social structures through which said innovations diffuse. According to Rogers, the most common way to use a network is to recognize and use opinion leaders, whose most prominent characteristic is their influential, unique position in the system’s communication structure: “They are at the center of interpersonal communication networks” (Rogers, 2003, p.27). There is a vast amount of evidence proving the effectiveness and importance of utilizing opinion leaders in health interventions. Rogers (2003) cites eight randomized controlled trials that reported significant effects of using opinion leaders, with regard to behavioral change, in various health interventions (Celentano et al., 2000; Earp et al., 2002; J. A. Kelly, 2004; J. A. Kelly, Janet S St. Lawrence., Yvonne Stevenson., Allan C Hauth., Seth C. Kalichman., Yolanda E. Diaz., Ted L Brasfield, Jeffrey J koob, Michael J. Morgan, 1992; J. A. Kelly et al., 1997;

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Lomas et al., 1991). For example, a randomized control trial comparing the adoption rate of practice guidelines that recommend vaginal birth delivery among doctors, which used opinion leaders in the experimental condition versus an alternative approach in the control condition, showed an 85% increase of vaginal birth delivery in the opinion leader’s condition, as compared to no measurable results of the alternative approach (Lomas et al., 1991).

Alternative advertising techniques successfully employed by commercial marketing, namely “Word of Mouth Marketing”, which is an umbrella term that encompasses: “Viral Marketing”, “Buzz marketing”, Word of Mouth Marketing disguised as “Market Research” and “Social Network Marketing” 1 devote vast amounts of monetary and human resources in identifying and utilizing opinion leaders in the social networks they target (Cooke & Buckley, 2008; B. Freeman & Chapman, 2008; Keller & Berry, 2003). In this way they can maximize their reach and persuasiveness among their target groups by only targeting directly a small number of people and thus also minimizing their costs (Helm, 2000). Currently, 88% of the fastest growing private corporations use Word of Mouth techniques (Ferguson, 2008). Except for utilizing existing social network structures to their benefit, Word of Mouth marketing employs a number of other principles in order to produce messages that provoke dialogue, so those will easier spread through social networks (e.g. J. Berger, 2013; Kirby & Marsden, 2006 ; B. Freeman & Chapman, 2008(J. Berger, 2013; Kirby & Marsden, 2006). This rationale is also in accordance with a number of authors’ view in the health promotion field, that support that health promotion interventions are much more effective when they spark interpersonal discussions among their target audience and therefore suggest that message design should focus more on encouraging dialogue rather than on influencing individuals directly (Boulay, Storey, & Sood, 2002); (Anne Hafstad & Aaro, 1997; A Hafstad, Aarø, & Langmark, 1996; Moreau, Bajos, & Bouyer, 2002; Noar, 2006; Wakefield, Loken, & Hornik, 2010). Noar (2006) notes that it is important that health campaign messages spark interpersonal discussions, as they are therefore more likely to persuade “influencers”, “individuals important to the target audience” (Noar, 2006, pg. 25).

To our knowledge, however, similar approaches have not yet been applied in the field of internet delivered health promotion activities. A relevant publication by Freeman& Chapman suggests that “it is essential that public health practitioners and researchers "catch up" and exploit these same media for health promotion purposes” (B. Freeman & Chapman, 2008). The same article highlights the need to seize the potential currently offered by the emergence and ever growing popularity of social media, and particularly Facebook (B. Freeman & Chapman, 2008). The “phenomenon” of Facebook, which was a social epidemic itself, has prepared the ground and set the prerequisites for more social

1 These terms will be shortly explained in the “definitive concepts” section, where a set of definitions will be given. 10 epidemics to take place (Ferguson, 2008; Ginger, 2007). According to Freeman & Chapman, the tremendous popularity of the platform should be seen as an opportunity for health promotion purposes: “there is an untapped potential to exploit the existing infrastructure and audience of these sites and to channel funds to developing and promoting provocative (health promotion) content...” (2008, p.781)

The online social network Facebook was part of the main foci of this research. If our main interest is how are we going to get Web 2.0. 2 users talking about specific topics, how we can steer conversations and social interaction towards a specific direction, then it makes sense to hold our inquiries where most e-conversations are already being held: Facebook is monumental as an online platform, in the sense that it has concentrated social capital in an unprecedented way; the numbers are dazzling while continuing to grow: 1.28 billion users from all around the world (Facebook, 2014) that are already interconnected and spend considerable amounts of time on the site. Beyond any doubt, Facebook use has gone viral itself and has achieved youth engagement, creating the prerequisites for a lot of other content to go viral in the same online environment. As stated by Freeman and Chapman, the possibilities that lie with the use of Facebook as an online social network suggest that “it cannot be ignored by those interested in the health of young people” (B. Freeman & Chapman, 2008) and an exploration of possible uses of its existing infrastructure should be given some priority in future research.

The current thesis report provides insight into Facebook mediated ways that may facilitate Word of Mouth communication of health promotion content. In order to gain said insight we have scoped the literature for existing relevant studies on Word of Mouth Marketing best practices of products and services in general and in the context of e- health in particular. Further, we have interviewed individuals with a central position in Facebook social networks 3, mapping what conditions their choices to share general and health promotion content on Facebook. Finally, our findings from the literature and empirical research are discussed, indicating how gained insights can be translated in strategies that can increase e-health programs’ reach.

2 Web 2.0. 3 As will be further explained under the Research Methods chapter, interviewees had a central position in individual Facebook social Networks and not in “ The Social Network”, due to no access to the “Big Data”. 11

2. 0. DEFINITIVE AND SENSITIZING CONCEPTS In the current section, a set of definitive and sensitizing concepts will be discussed.

Definitive concepts refer to definitions (Blumer, 1954) of terms that are central for this research.

2.1. DEFINITIVE CONCEPTS

2.1.1. E-HEALTH “E-health” refers to “any Web-based program with a visible relationship to health. This could be symptom recognition tools for public use (e.g., WebMD, NHSDirect), electronic database management for national health systems, public health data for general use, online records or documents (e.g., e-prescriptions), learning programs, therapeutic programs (e.g., computer-based cognitive behavioral therapy), or research tools” (Ruggeri, Farrington, & Brayne, 2013).

2.1.2. SOCIAL CONNECTORS “Social connectors” are defined by WolframAlpha as "someone who connects together groups of one’s friends that are otherwise disconnected. Social connectors typically appear as bridges between separate clusters of one’s friends. In the language of graph theory, social connectors have a high betweenness centrality, which is defined as the fraction of shortest connecting paths across the network that pass through an individual" ("Wolfram|Alpha Personal Analytics for Facebook," 2013). “High betweenness centrality” is one of the methods used to identify the most centrally located nodes within a network (L. C. Freeman, 1977; Newman, 2003). “Nodes” simply refer to individuals in a network (e.g. (Fowler & Christakis, 2008b)

2.1.3. WORD OF MOUTH MARKETING “Word of Mouth” is ‘‘the act of consumers providing information to other consumers’’ (Word of Mouth Marketing Association, 2007).

“Word of Mouth Marketing” refers to strategies purposefully employed by companies in order to commercialize this commonplace human practices, i.e. word of mouth (Cooke & Buckley, 2008). Following, a set of definitions of terms that fall under the umbrella of Word of Mouth Marketing, namely “Viral Marketing”, “Buzz marketing” and “Social Network Marketing” will be presented here, to give background information.

2.1.3.1. VIRAL MARKETING “Viral Marketing” is unpaid “peer to peer communication of provocative content originating from an identified sponsor using the internet to persuade or influence an audience to pass along the content to others” (Porter & Golan, 2006). Otherwise, viral marketing is when word of mouth becomes “word of mouse” (Helm, 2000, p.159). The term “Viral Marketing” is commonly used for any Word of Mouth Marketing activity that

12 takes place online (Kirby, 2006; Kirby & Marsden, 2006). Viral marketing’s goal is “to manufacture a marketing message - typically online and in a tangible format such as a video clip or e mail-that can spread among consumers quickly and exponentially (Balter & Butman, 2006).

2.1.3.2. BUZZ MARKETING “Buzz marketing” is not defined consistently throughout the literature (Ahuja, Michels, Walker, & Weissbuch, 2007). Some marketing experts support that the “buzz marketing” term is used to describe marketing activities that are designed to be “outrageous” and worthy of publicity, while providing information about a new product. Their goal is to generate excitement and spark dialogue among consumers about the product (Balter D, 2006).

The term “buzz agents” refers to commercially motivated internet users that are trained to ask particular questions or post interesting comments in order to encourage interesting discussions in online forums around a product or brand (Freeman, 2008).

2.1.3.3. S OCIAL NETWORK MARKETING Lastly, “Social Network Marketing (B. Freeman & Chapman, 2008) refers to advertisement in social network sites, such as Facebook. Facebook, in 2007 launched “social advertisements”, which are actually highly targeted ads paired with one’s interests. Anyone can create a professional page, a group, an event or share an application or website with others free of charge, where a product or service is advertised. However, when these same actions are sponsored, i.e. one pays to advertise them, sensitive targeting features can be enabled that can significantly increase their reach. To be more specific, advertisers pair ads based on location, gender, age, relationship status, workplace, education, news feed activities, preferences and listed interests or similar interests and traits, “likes”, apps they use, keywords on their or their friends’ timeline, and more (Facebook, 2013)

2.2. SENSITIZING CONCEPTS

2.2.1. E-HEALTH PROGRAMS By the use of “e-health programs” in this research project, I refer to any internet delivered health promotion intervention, with a focus on prevention, and with a focus on lifestyle. These internet delivered health promotion interventions, or else “web-based interventions” could be targeting cognitive outcomes - knowledge, understanding, intention, self – efficacy or behavioral outcomes – such as changes in diet, in physical activity, smoking cessation, moderating alcohol consumption and more. The term “e- health initiatives” refers to the same notion and will be used interchangeably.

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2.2.2. E-HEALTH REACH The term “e-health reach”, whenever used in this thesis, refers to the dissemination of e- health programs to their target groups and to the exposure of the target groups to the e- health program. The concepts of dissemination and exposure are presented below.

2.2.2.1. DISSEMINATION Successful dissemination rests on the source, the target population and the intervention itself (Rogers, 2003). Although successful dissemination of e-health programs is a requirement for exposure of the target group to e –health programs and the use of their components, it is not adequate. Throughout this thesis, “dissemination” refers to the distribution of the “e-health program” among the target population, including bringing the e-health program to the attention of the target population.

2.2.2.2. EXPOSURE “Exposure” involves paying attention to the e-health program content, use of the e- health program and elaboration to some extent (Crutzen, 2009). In terms of e-health programs, three different facets with reference to exposure can be distinguished: 1) first visit 2) staying long enough to process the information and use its components and 3) revisiting the e-health program, which can be important, as there is a possible dose- response relationship between times of visit and behavioral change (Crutzen, 2009; (Lenert et al., 2003) (Verheijden, Jans, Hildebrandt, & Hopman-Rock, 2007) (Zebrack, Mitchell, Davids, & Simpson, 2005)

2.2.3. SOCIAL CONNECTORS Another main focus of this research, as discussed earlier, are individuals that occupy a structurally central position in social networks, as this allows them to have larger social influence (Fowler & Christakis, 2008b). Throughout this thesis report, we are going to refer to these individuals using the terms “Social Connectors” or “Opinion Leaders”. Readers however should note that the extensive discussions around “node centrality” in the diffusion literature, as well as the preoccupation of marketing literature with these central, influential individuals has given birth to a lot of names: the terms “Central Nodes”, “Community Leaders”, or “Bridges” are also to be found in the diffusion literature (Arbesman & Christakis, 2010; P. V. Marsden, 2002). Marketing jargon on the other hand includes terms such as Alphas, Hubs, Connectors, Influentials, Sneezers, Influencers, Consumer Evangelists and Enthusiasts (Kirby & Marsden, 2006; P. Marsden, 2006; Nyilasy, 2006). To explain the terms most commonly used throughout this report a bit further, the term “Social Connectors” in this research refers to individuals that have a central position in interpersonal communication networks. The empirical research presented in this report consists of interviewing Facebook Social Connectors, identified by the Social Network Analytics software tool “WolframAlpha”, using a measure of centrality 4 . “Social

4 More details can be found in our “Research Methods” section. 14 connectors” are defined by WolframAlpha as "someone who connects together groups of one’s friends that are otherwise disconnected. Social connectors typically appear as bridges between separate clusters of one’s friends. In the language of graph theory, social connectors have a high betweenness centrality, which is defined as the fraction of shortest connecting paths across the network that pass through an individual" ("Wolfram|Alpha Personal Analytics for Facebook," 2013). “High betweenness centrality” is one of the methods used to identify the most centrally located nodes within a network (L. C. Freeman, 1977; Newman, 2003). “Nodes” simply refer to individuals in a network (e.g. (Fowler & Christakis, 2008b) Christakis associates “node centrality” with “leadership” and refers to “central nodes”, identified with the method of high betweenness centrality, as “community leaders”.

Another term used interchangeably in this thesis report along with “Social Connectors” is the term “Opinion Leaders”. Rogers states that “opinion leaders’ most prominent characteristic is their influential, unique position in the system’s communication structure: They are at the center of interpersonal communication networks” (Rogers, 2003, p.27). However, as it emerges from our literature review, opinion leadership apart from suggesting a “connected and respected” profile, also suggests involvement and expert knowledge on a given topic/category. Opinion leadership can be understood as a knowledge based trait that predicts output word of mouth; in efforts for opinion leaders’ profiling, the most consistent finding was their enduring involvement with a product or service category. Opinion leaders knew a lot about this category, for some reason it was important in their lives, they were involved in it, and that is what made them talk (Nyilasy, 2006; Richins & Root-Shaffer, 1988). However, an opinion leader in one category, may or may not be an opinion leader in another, especially if these correspond to different rather than similar interests. To make this concept more explicit, a social connector who is recognized as an opinion leader in beauty cosmetics may or may not be an opinion leader in organic agriculture. Therefore opinion leaders’ profiling should be category and market situation specific (Nyilasy, 2006; Richins & Root-Shaffer, 1988) .

2.2.4. FACEBOOK – MEDIATED ACTIVITIES When using the term “Facebook mediated activities”, I refer to activities such as “sharing” content on one’s wall, or on friends’ walls, or by personal messages, or by somehow reacting to content “posted” by others on the Facebook environment, by “liking” or commenting on it. Other activities that are included here and indicate interaction with posted content are joining Facebook groups, liking or commenting on Facebook pages, or pages outside Facebook, when this activity is fed into one’s timeline and is visible on Facebook.

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3. AIM AND RESEARCH QUESTIONS Our research aim is to identify Facebook mediated Word of Mouth Marketing strategies that can be used to increase the reach of e-health programs.

In order to reach our research aim, the following research objectives were formulated:

1. To report on previous uses of viral strategies for health promotion. 2. To indicate Word of Mouth Marketing best practices. 3. To map factors that condition social connectors’ choices to share general and health promotion content on Facebook, at the moment of choice.

A main research question and three sub questions were formulated to guide our research work towards reaching these objectives and fulfilling our aim.

Main Research Question: How can Facebook – mediated Word of Mouth Marketing be used to increase the reach of e –health programs?

Sub-questions:

1. What is the state of evidence regarding the uses of viral strategies for health promotion? 2. What is the state of the evidence on Word of Mouth Marketing best practices? 3. At the moment of choice, what are the main factors that condition social connectors’ choices to share general and health promotion content on Facebook?

The specific steps that we followed in order to answer each research question and thus meet our objectives and research aim are discussed in chapter 5, i.e. “Research Methods”.

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4.0. THEORETICAL FRAMEWORK Given the fact that said e-health programs have not yet been adopted or rejected by their intended users makes them new, or else innovative to the perception of these users (E. M. Rogers, 2003). Therefore, questions that seek to address their popularity actually refer to a diffusion problem. Diffusion is fundamentally a social process that encompasses interpersonal communication relationships. Studying and utilizing a network’s structure, within which said interpersonal communication relationships evolve, is very important when one attempts to facilitate or impede diffusion of innovation (E. M. Rogers, 2003). As quoted by Valente and Davis in their article titled “Accelerating the Diffusion of Innovations Using Opinion Leaders”, (1999, p.56), “a network… can be used, rather than ignored, when creating [diffusion] programs”. Rogers (2003) also suggests that the most common way to use a network is to recognize and use opinion leaders. An opinion leader is influential to his interpersonal network, and can serve as a social model. People tend to imitate his behavior while he/she is adopting or rejecting an innovation. Thereafter, news spread fast by “word of mouth” which is the oldest advertising -or else communication- technique (Rogers, 2003).

Rogers also describes that there is a vast difference in the influencing ability between a change agent, such as a health promoter and that of a member of the community who is placed in a central and influential position of the system’s structure, i.e. an opinion leader. Therefore change agents often employ or otherwise seek opinion leaders’ help when organizing diffusion activities. Another barrier in “change agents’” efforts is that effective communication of an innovation is facilitated when occurring between homophilous individuals, i.e. people that perceive each other as being similar. Change agents such as health promoters are often perceived as being heterophilous with the average user of the innovation they are promoting, because of their professional training and the social status that comes along with it; this subsequently poses problems in effective communication of an innovation and impedes diffusion. To overcome this barrier and facilitate diffusion, “change agents” often hire “aides”, members of the targeted social system that are perceived to be more homophilous to the average user, even if they are not positioned centrally in the network, to act as intermediaries (E. M. Rogers, 2003).

As cited in the 5th edition of his book “Diffusion of Innovation” (Rogers, 2003), evidence from eight randomized control trials show robust effects of opinion leaders in health intervention diffusion programs (Celentano et al., 2000; Earp et al., 2002; J. A. Kelly, Janet S St. Lawrence., Yvonne Stevenson., Allan C Hauth., Seth C. Kalichman., Yolanda E. Diaz., Ted L Brasfield, Jeffrey J koob, Michael J. Morgan, 1992; J. A. Kelly et al., 1997; Lomas et al., 1991); (R. L. Miller, Klotz, & Eckholdt, 1998); (Puska et al., 1986; Tessaro et al., 2000). Although these diffusion programs were not computer –mediated but evolved in real life interpersonal networks, it could be hypothesized that the same principles could be 17 applied in online social networks; an assumption that is central to our research. Current research has shown that communication via the internet can be as personal as face to face communication. (Norman & Russell, 2006). Moreover, research indicates that online word of mouth is considered to be more credible than mass media (Bickart & Schindler, 2001; Polonsky, 1996) as it is both independent and tailored (Silverman, 2011). Moreover, it has been shown that when it comes to internet delivered health interventions, users tend to be suspicious with regard to the information provided and check for contradicting or confirmatory information on the web rather than checking on the source; they are not suspicious, however, if a friend refers them to it (Crutzen, 2009).

The PhD dissertation by Crutzen (2009) on dissemination of and exposure to internet- delivered health behavior change interventions aimed at adolescents reported that there was no agreement among experts on a gold standard regarding successful dissemination and stressed the need for further research in order to gain insight in ways that will serve to maximize the public health impact of internet delivered health interventions. Although there was no agreement on a gold standard for successful dissemination, there was a high degree of consensus among experts on the importance of a positive recommendation by word of mouth. The same result was reported from the analysis of focus group discussions with five adolescent groups, which were also published in this dissertation. Adolescents in all groups said that their social network influenced their decision to visit an internet delivered intervention and that, furthermore, they had a strong preference for receiving recommendations for internet delivered interventions by friends. Note by, that this did not only concern friends in the old fashioned way, but also friends that they knew only online, through social networking sites (Crutzen, 2009). Based on these findings, as well as on previous research with similarly positive outcomes (Bickart & Schindler, 2001; Buttle, 1998; Silverman, 2011) Crutzen concludes that word of mouth communication of e-health interventions via “tell a friend services” is promising and should be used to facilitate diffusion of health related web based interventions (Crutzen, 2009).

Alternative advertising techniques successfully employed by commercial marketing, namely “Word of Mouth Marketing”, “Viral Marketing”, “Buzz marketing”, Word of Mouth Marketing disguised as “Market Research” and “Social Network Marketing” largely depend on identifying and utilizing influential people in the social networks that they target (Cooke & Buckley, 2008; B. Freeman & Chapman, 2008; Keller & Berry, 2003). In this way they can maximize their reach and persuasiveness among their target groups by only targeting directly a small number of people and thus also minimizing their costs (Helm, 2000). Some researchers estimate that just a 10% of consumers influence the whole consumers’ population choices (Cooke & Buckley, 2008). Subsequently, marketers that can attract the interest of these central, influential people can maximize their reach (Freeman, Chapman, 2008).

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According to Gladwell, "Ideas and products and messages and behaviors spread like viruses do" (2000, p. 7). In his best seller book “The tipping point”, Gladwell describes “the rule of the few”, according to which the success in spreading social epidemics depends to a very large extend in the involvement of a few people with particular social gifts. He then goes on to frame these crucial human agents as connectors, mavens and salesmen. Connectors hold a great deal of bridging social capital, i.e. they are connected with a lot of types of people, e.g. with different socioeconomic and educational status, and that is why they are so important in order for ideas, messages and behaviors to spread (Gladwell, 2000).

Nikolas Christakis and James Fowler, analyzing network data from large, longitudinal studies, managed to prove that behavior, like altruism or quitting smoking, health states, like obesity, emotions, i.e. happiness and loneliness, or trends and information, can be spread through social networks up to three degrees of separation (Cacioppo, Fowler, & Christakis, 2009; Hill, Rand, Nowak, & Christakis, 2010a; Christakis & Fowler, 2007; Christakis & Fowler, 2008; Fowler & Christakis, 2010(Hill, Rand, Nowak, & Christakis, 2010b). Put simply, this means that not only what one’s friends do affects him/her, but also what his friends’ friends’ friends do can have a significant impact on him/her; so people he/she might not even know. These studies have clearly visualized social networks and diffusion patterns have been analyzed with scrutiny: it is now evident that trends, information, health statuses and behavior spread through social networks in a way that is similar to disease transmission (Hill et al, 2010). Social network analysis has also emphasized the importance of central nodes, i.e. individuals that a have a central position in interpersonal human networks.

Central individuals (as measured by ways such as high betweenness centrality) are fewer steps away from the average person in the network (Christley et al., 2005; Kitsak et al., 2010; Mossong et al., 2008) and therefore, in a number of ways, including behavioral, informational, emotional or even viral spread, they are more influential. Being central also implies that they will themselves be affected earlier by any kind of viral spread. When, however, we are not interested in phenomena that arise spontaneously, but are interested in willful dissemination of phenomena, trends, behaviors and so on, then initial activation of these central nodes would facilitate diffusion.

Therefore, interviewing people that are centrally positioned in virtual social networks in order to map their requirements for sharing e –health communication content through social media seems relevant. Interviewing them will help tap the social intelligence of lay people on this topic, and indeed lay people that have been shown to be of particular importance in diffusion of innovation.

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5.0. RESEARCH METHODS

The research methods employed to answer the previously mentioned research questions involved literature review and empirical data collection and analysis. More specifically, literature review was the research method used to answer research sub-questions one and two; however different review protocols were followed for each. The third sub question was addressed through empirical research; 15 semi-structured interviews with Facebook social connectors were conducted, transcribed and analysed bottom up. Finally, answering the fourth research sub-question involved combining, elaborating on and discussing insights that emerged both through the primary and secondary data analysis.

Following, more detailed information will be given on the research methods employed in answering each research sub-question.

5.1. RESEARCH SUB -QUESTION 1: LITERATURE REVIEW In October 2013 we searched the literature guided by the research sub question: “What is the state of the evidence regarding the uses of viral strategies for health promotion?”

The rationale of this review question has been described earlier in this paper. In short, there is some evidence suggesting that e-word of mouth communication strategies may be promising in addressing e-health programs’ low reach problem (Crutzen, 2009). This question aimed at clarifying whether such methods, i.e. viral strategies or else online Word of Mouth practices have been already tested in the field of e-health promotion and if so, what are the lessons to be learned from there. Since our focus was on online rather than offline Word of Mouth, we used the phrase “viral strategies” when framing this research question. However, our research strategy included all relevant terms falling under the umbrella term Word of Mouth Marketing combined with terms that refer to online environments or Facebook in particular, so relevant studies would not be missed. A more detailed description of our review protocol is given below.

5.1.1. REVIEW PROTOCOL In this review protocol we will describe the search strategy employed, the inclusion and exclusion criteria and the literature review process.

5.1.1.1. SEARCH STRATEGY In October, 2013 we searched the databases PubMED, PsycINFO and Web of Science using the following query: (“WOMM” OR “Word of Mouth Marketing” OR “Word of Mouth Communication” OR “Viral Marketing” OR “viral spread” OR “Buzz Marketing” OR “Social Network Marketing”) AND (Internet* OR web* OR online* OR Facebook) AND (prevention OR intervention OR “health promotion” OR “health education” OR “health communication” OR “web-based intervention*” OR “e-health program*” OR (behav*

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AND change)). The search was limited to the time period September 2006 – October 1, 2013 5 and to literature in English.

Since Facebook is one of the main foci of this research, the date when it went public, i.e. anyone above 13 years old with a valid e- mail address could become a Facebook member, was taken into account when deciding on the selection criteria. Moreover, in order to meet the selection criteria for this literature review, an article had to be published in a peer reviewed journal. Articles that described original studies, reviews and meta-analyses were included for the review; editorials, commentaries, book reviews, bibliographies, handbooks, errata or conference proceedings and abstracts were excluded.

In total, 117 articles were retrieved using said search strategy; these articles were filtered based on the inclusion and exclusion criteria described below. To see a summary of our search strategy and the publications finally included for the analysis, please see tables 1 and 2, pages 22 and 23 respectively.

5.1.1.2. INCLUSION CRITERIA Articles were included for the analyses when describing or proposing: • Online health promotion interventions that involve the target group in their dissemination process. • Online health promotion interventions that focus on generating dialogue and debate among the target group in online settings • Use of seeding methods to better reach their online target group, i.e. identification and involvement of opinion leaders in an online setting. • Online health promotion interventions that use Facebook to involve their target group or the target groups’ opinion leaders through interactive processes.

5.1.1.3. EXCLUSION CRITERIA . Articles were excluded from the analyses when describing:

• Traditional health promotion interventions in offline settings • Traditional health promotion interventions in offline settings that kept a Facebook page where they simply posted information on the intervention. • Web – based interventions, i.e. internet delivered health promotion interventions that involved the users in no other way than consuming the online content, even when those embodied some features of interactivity. • Internet delivered health promotion interventions that involved the user only in filling in pre-tests and evaluations. • Internet delivered health promotion interventions that involved small scale, non- targeted formative research.

5 which is when this literature research was initiated 21

In summary, in order to be included for the analyses, the articles had to describe or propose internet delivered health promotion interventions that involve the target group in optimizing the intervention’s reach, i.e. by involving them in the dissemination process, in the creative process or else triggering word of mouth by involving them in online discussions and debates, thus creating buzz around the intervention or its health promotion messages. Moreover, one of the inclusion criteria was the use of seeding practices, i.e. the identification and involvement of opinion leaders in online settings for reach optimisation; however it should already be noted that we found no studies to have tested this approach. The results of the literature review conducted with these methods are presented under 6.1.

TABLE 1: SEARCH STRATEGY EMPLOYED TO ANSWER RESEARCH SUB – QUESTION 1

SEARCH STRATEGY (N=117 PUBLICATIONS )

Time search was performed October, 2013 Databases searched PubMED, PsycINFO and Web of Science Query (“ WOMM” OR “Word of Mouth Marketing” OR “Word of Mouth Communication” OR “Viral Marketing” OR “viral spread” OR “Buzz Marketing” OR “Social Network Marketing”) AND (Internet* OR web* OR online* OR Facebook) AND (prevention OR intervention OR “health promotion” OR “health education” OR “health communication” OR “web- based intervention*” OR “e-health program*” OR (behav* AND change))

Search limited to Articles published V In English V in peer reviewed journals V between September 2006 and October 1, 2013 V Articles that described original studies, reviews and meta-analyses X Editorials, commentaries, book reviews, bibliographies, handbooks, errata or conference proceedings and abstracts were excluded

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TABLE 2: EVIDENCE ON VIRAL STRATEGIES FOR HEALTH PROMOTION

PUBLICATIONS INCLUDED FOR THE ANALYSIS FOLLOWING THE INCLUSION AND EXCLUSION CRITERIA

AUTHORS AND PUBLICATION TITLE AIM AND LOCATION OF RESEARCH PUBLICATION YEAR AND TYPE OF STUDY 1 Gosselin & Poitras, Use of an Internet To test new and innovative marketing tools for a 2008 “Viral” Marketing health promotion website in Canada. Software Platform in Health Promotion.

Action Research 2 Thériault et al., Use of Web 2.0 to To (1) compare the impact of various advertising 2012 Recruit Australian Gay strategies on recruiting MSM participants to an Men to an Online online HIV/AIDS survey, and (2) explore the feasibility HIV/AIDS Survey of using a social network service (SNS) for study advertising. Action Research Australia 3 Adam et al., 2011 Hivstigma.com, an This paper reports on the creation, implementation innovative web- and evaluation of an innovative web-supported supported stigma stigma reduction intervention for gay and bisexual reduction intervention men. Said campaign focused on reducing HIV stigma for gay and bisexual and reaching a number of relevant objectives by men. provoking dialogue among the Canadian gay and bisexual men community. Action research Canada 4 Thackeray, Neiger, Hanson, & Enhancing Promotional To provide an overview of how to incorporate Web McKenzie, 2008 Strategies Within Social 2.0 social media into one specific aspect of the social Marketing Programs: marketing plan, i.e. the promotional strategy. Use of Web 2.0 Social Media USA

Descriptive study 5 Freeman & Chapman, 2008 Gone viral? Heard the This paper provides an overview of new media buzz? A guide for public advertising methods, particularly via popular Web 2.0 health practitioners and sites, and details examples relevant to chronic researchers on how disease control. Web 2.0 can subvert advertising restrictions Australia and spread health information. Descriptive study

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5.2. RESEARCH SUB -QUESTION 2: LITERATURE REVIEW In November 2014 we run a desk research in order to answer our second research sub- question, namely: “What is the state of the evidence on Word of Mouth Marketing best practices?”

The rationale of this review question has been described earlier in this paper. In short, there is some evidence suggesting that using the equivalent of Word of Mouth Marketing strategies may be promising in addressing e-health programs’ low reach problem (Crutzen, 2009).

Word of Mouth Marketing strategies have been widely and successfully used in the commercial arena to increase the dissemination and adoption of products, services, trends e.t.c. (Helm, 2000). It was therefore deemed appropriate to look for successful commercial marketing practices that could perhaps lend themselves to e-health promotion as well; a premise for later discussing such implications was to delve into marketing literature, reviewing and narratively summarising Word of Mouth Marketing best practises.

Starting off by reading scholarly marketing books citing relevant case studies and other empirical research was deemed appropriate. As the list of seemingly relevant, widely cited books was long, two key informants, i.e. professors at the Marketing and Consumer behaviour group of Wageningen University were asked for a recommendation of the most relevant books in terms of expert authorship and inclusion of relevant case studies. As a result, the books “Connected Marketing” (Kirby & Marsden, 2006) and “Contagious” (J. Berger, 2013) were used as our points of departure. References of these resources were followed up based on certain inclusion and exclusion criteria 6. Following, a schematic representation of said literature review process is given, and the inclusion and exclusion criteria are listed.

6 To see the full list of 115 included publications, as well as a summary of publication types used, accompanied with examples, please go to Appendix D. The resulting narrative literature review is given under 6.2.

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TABLE 3: SCHEMATIC REPRESENTATION OF THE LITERATURE REVIEW PROCESS

Asking 2 key informants (Professors WUR Marketing & Consumer Behavior group) for book recommendations

Stated criteria of interest: - Expert authorship - Case studies showcasing best WOMM practices in the commercial arena - Citing scholarly research

“Connected Marketing” (Kirby & “Contagious” (J. Berger, 2013) Marsden, 2006)

51 references followed based on 64 references followed based on inclusion/exclusion criteria inclusion/exclusion criteria

5.2.1. INCLUSION CRITERIA Publications were included for the analyses when: • Describing good practices for identifying, reaching and motivating opinion leaders to spread the word for the benefit of a product/service/brand. • Describing good practices for igniting positive word of mouth among consumers for the benefit of a product/brand, which either focus on online communication or can be partly or entirely applied in online settings. • Reporting on evidence based antecedents and consequences of output word of mouth from the standpoint of the communicator, i.e. what makes people talk. • Shedding light to what makes content more likely to be talked about in social circles, be that online or offline. • Describing available evaluation practices for viral marketing campaigns.

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5.2.2. EXCLUSION CRITERIA . Publications were excluded from the analyses when:

• Describing Word of Mouth Marketing practices focusing on offline communication, e.g. street theatre, live buzz marketing, street marketing, PR based on based on offline “hook” events, or stealth/undercover marketing. • Reporting on evidence based antecedents and consequences of input word of mouth from the standpoint of the receiver, i.e. what makes people listen and related effects.

5.3. RESEARCH SUB -QUESTION 3: EMPIRICAL RESEARCH Except for reviewing secondary data, this project aimed at collecting and analysing primary data through face to face or Skype semi-structured interviews. The first steps in primary data collection were taken in December 2013: Constructing and pre-testing the interview guide, recruiting participants, i.e. interviewees, editing and sending them an introductory information sheet and an informed consent form to be signed and posted back to the interviewer. Next, the interviews were conducted, transcribed and analysed to finally answer research sub question number three, i.e. “At the moment of choice, what are the main factors that condition social connectors’ choices to share general and health promotion content on Facebook?“

Following, aspects that relate to our empirical research methods, i.e. the sampling process, the data collection process and finally the analyses will be discussed in more detail.

5.3.1. RESEARCH POPULATION AND SAMPLING METHOD Our research population consists of Facebook social connectors, i.e. highly connected Facebook users that are situated centrally in the Facebook network. Modern Social Network Analysis software tools (SNAs) have made visualization of large complex networks possible, as well as identification of individuals that are positioned centrally in a network, among many other features (e.g. Network X, NetMiner 4). For those who, for example, have access to the entire Facebook Data, mapping the entire Facebook network or a more specified target market based on certain characteristics and identifying crucial human agents by using measures of centrality is now possible (Bonneau, Anderson & Danezis, 2009). For common Facebook users though, like ourselves, access to this “big data” is hampered by privacy settings. The list of all centrally located Facebook users is inaccessible to us; therefore random selection of Facebook social connectors is not possible. An additional note should be made here; Facebook data mining by third parties is by no means impossible or unheard of and a number of methods exist, should one wish to employ them (Bonneau, Anderson, & Danezis, 2009). However, such approaches are

26 inconsistent with user’s expectations of Facebook data privacy (Bonneau et al., 2009) and raise ethical considerations.

Due to the afore mentioned practical constraints and ethical considerations Facebook Social connectors interviewed for this study were drawn by convenience sampling. All Facebook users can make use of SNA tools to analyse their own Facebook network legitimately. In this research we made use of the free Social Network Analysis software tool “WolframAlpha Personal Analytics for Facebook to identify central nodes in egocentric Facebook networks, i.e. social connectors in individuals’ Facebook networks. To be more specific, what we mean is that the first author used WolframAlpha Personal Analytics for Facebook to analyse her own Facebook network as well as the Facebook networks of 13 Facebook friends of hers, to identify their “top social connectors”. “WolframAlpha Personal Analytics for Facebook” defines “top social connectors” as "someone who connects together groups of one’s friends that are otherwise disconnected. Social connectors typically appear as bridges between separate clusters of one’s friends. In the language of graph theory, social connectors have a high betweenness centrality, which is defined as the fraction of shortest connecting paths across the network that pass through an individual". “High betweenness centrality” is one of the methods used to identify the most centrally located nodes within a network (L. C. Freeman, 1977; Newman, 2003). Note by that “nodes” simply refer to individuals in a network (e.g. (Fowler & Christakis, 2008b)

Therefore, the inclusion criterion for our interviewees was their identification as a “top social connector” in another user’s Facebook network by the use of WolframAlpha Personal Analytics for Facebook.

The sampling process, as described above and shown in Figure 1, resulted in a list of 193 “Top Social Connectors”, out of which 15 were interviewed for this study.

This qualitative study aimed to explore a variety of perspectives. Previous research has shown that there are no general demographic (Feick & Price, 1987), psychographic or sociological predictors in response to the problem of opinion leaders’ identification and profiling. However, it has been shown that culture (Money, 2000) influences output word of mouth. The sample of fifteen participants drawn for this qualitative study had a diverse cultural background; participants came from Greece, Netherlands, Mexico, Poland, and Brazil.

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Convenience sample of 13 Facebook friends

SNA tool

193 social connectors

15 interviewees (Brazil, Poland, Greece, NL, Mexico)

FIGURE 1: SAMPLING PROCEDURE

5.3.1.1. LIMITATIONS Employing a convenience sampling method will undeniably bias and limit our research findings. However, as explained before, ethical considerations and lack of resources justify our inability to access the “big data”, which was a prerequisite to random sampling. Even if ethical considerations were overlooked and data mining was used to make random sampling possible, the issue of how to approach these Facebook Social Connectors next and explain to them how they were recruited would remain; as Facebook data is supposed to be private and inaccessible to third parties (Bonneau et al., 2009) such a method would most likely be considered intrusive.

No claims are made for sample representativeness, also in line with the general character of qualitative research. Results from this study should not be generalised but be seen as a grounded indication of a research phenomenon worthy of further attention and research over a larger data corpus.

5.3.2. DATA COLLECTION

The empirical data collection process involved constructing the interview guide, contacting prospective interviewees and arranging interview appointments, preparing and sending out introductory information sheets and informed consent forms and finally, conducting, recording and transcribing the interviews.

The first step was constructing the interview guide. When informing our decisions as to what should be included, insights from the literature review were taken into account, as

28 well as insights from two exploratory and unstructured interviews with Facebook social connectors that were conducted for this purpose. Next, the interview guide was composed and pre-tested. Limitations of the initial version were discussed among the researchers on the basis of observations made by the interviewer and feedback provided by the interviewees. Following, the initial interview guide was adjusted, and tested again to be found satisfactory. This last version of the interview guide contains 16 questions, instructions regarding the handling process during the interview as well as a list of possible probes per question, in order to make sure that all interview topics would be covered and all interviewees would be treated equally. To see the information sheet, the informed consent form, the interview guide, the interview handling process, the general probing techniques used and all possible probes per interview question, please go to appendix C.

Following, appointments for 15 interviews were set. Out of these 15 interviewees, 11 or 73% were women. Moreover, 11 of them were Greek whereas the rest participants came from Brazil, Netherlands, Mexico and Poland. Interviews with Greek participants were conducted in Greek while the rest were conducted in English. Five interviews were conducted face to face while 10 were conducted through Skype. As the interview process required that the interviewee discusses shares from his/her Facebook activity log and that captions of discussed content are taken, participants that were interviewed through Skype were sent a short tutorial prior to the interview explaining how to access their Facebook activity log, and how to share their screens with the interviewer through Skype. This information was included in the “Information Sheet” sent to them before the interview, along with the informed consent form which they had to print, sign, scan, and e- mail back to the interviewer.

Before each face to face or Skype interview began, the interviewer checked that the interviewee had indeed read and understood all points included in the introduction and the informed consent form and made sure that there were no questions or ambiguities. Next, each interview would start with two opening questions. Thereafter, the interviews consisted of two parts: in the first part the interviewee shared his/her Facebook activity log screen with us real time or through Skype screen sharing, pointing at content (s)he enjoyed sharing and probed to explain why when necessary. Note by that one’s “Facebook activity log” is a record of one’s previous Facebook activity; content social connectors had posted, liked or commented on appeared there. This step was taken to make said previous activity more accessible and help recreate the moment of choice when social connectors decided to share said content; triggered by the visual stimuli of previously shared content, social connectors were invited to talk about something they enjoyed sharing and explain why. Following, interviewees were asked to look in their activity log for content that in their minds was related to health, so we could discuss two such content items next. 29

In the second part of the interview, four health promotion links were sent to the interviewees; the questions during this part involved whether the interviewee would share the links on Facebook, i.e. post, like, comment or send them by PM. The health promotion links were a web-based intervention on exercise followed by a YouTube video on exercise that had gone viral, as apparent from its views. The third link was a web based intervention on smoking cessation and the fourth a smoking cessation video that had gone viral as well. For a more elaborate description of the health promotion links used in the second part of the interview, please see Appendix A.

The duration of the interviews ranged from forty minutes to one hour and twenty minutes. Fifteen interviews were conducted, which were enough to reach saturation. All interviews were digitally recorded and transcribed to word level accuracy, including grammatical errors and short or long pauses. Four screenshots taken during the first part of each interview, capturing two content items the interviewees “enjoyed sharing” and two content items in their activity log that they perceived as being related to health, were also included in the transcripts. Finally, all transcripts were anonymised and merged into a single document for the analysis.

5.3.3. ANALYSIS

Categorical - content analysis was performed to analyse the transcriptions. The analysis consisted of a long process that begun with data familiarisation, followed by bottom up coding, axial coding, organising the data into themes and subthemes and finally drawing inferences from the data. The qualitative analysis software tool Atlas.ti was used to organise the data. All interviews, including the ones conducted in Greek, were coded in English.

By data familiarisation we mean that the unified transcript document was read through several times to achieve immersion in the data and obtain a sense of it as a whole (Borkan, 1999) (W. L. Miller & Crabtree). Notes on reoccurring themes were kept based on these initial impressions.

Next, the transcripts were coded bottom – up: the interviews were read again one by one, and open codes were assigned to all fragments of text that could be of value in finally answering our research question. In this initial stage, codes were either assigned in vivo, i.e. words used by the interviewee himself/herself were used as codes, or in any case codes were kept as close to the original quotation as possible, avoiding any further interpretation. However, it should be noted that although coding was performed bottom –up, reviewing relevant literature prior to conducting the empirical research surely increased our theoretical sensitivity for coding concepts emergent from the data. The bottom up coding step of the analysis was very time consuming and performed with scrutiny; in the end 329 codes were generated which were linked to 723 quotations.

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In order to organise this large number of codes, axial coding was performed. The codes were read again and again while elaborating on differences and similarities in order to cluster them in code “families”. This process resulted in generating 33 families; however it was often the case that smaller families could be next clustered to bigger families with the same topic. At this point of the analysis, a sample of the coded transcripts, i.e. two interviews where open and axial coding was performed, were sent to another researcher to check if there was sufficient agreement on the coding schemes. Agreement between the researchers was found to be satisfactory and the first author proceeded with the analysis.

As the number of code families was still large, further categorisation of the data was needed in order to structure the data in main themes and draw and present inferences from the analysis (Burnard, 1991) Once again, we had to immerse ourselves in the data; as in reality, many concepts were linked with each other, making their separation quiet challenging. It required a lot of elaboration to decide and come down to a number of common themes that emerged from the data; these themes are presented in chapter 7 of this report.

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6.0. FINDINGS FROM THE LITERATURE REVIEW

6.1. INTRODUCTION This chapter is guided by the research question: “What is the state of the evidence regarding the uses of viral strategies for health promotion?”

Although the search strategy employed retrieved 117 publications, none of them fully met all the previously stated inclusion criteria (please see 5.1.1.3.). Some articles described interventions that met the first two inclusion criteria while the two latter were not met by any of the publications; meaning these methods were not found to have been tested in the health promotion arena by our literature review. However and in line with our starting point, some publications described the use of such methods, in short seeding to opinion leaders and Facebook marketing, in the commercial arena and underlined the need and potential of their use in the health promotion arena as well (B. Freeman & Chapman, 2008; Thackeray et al., 2008). Most of the articles were excluded, as they described traditional health promotion interventions that occasionally published information on their intervention on a Facebook page, as a means of their combined promotional strategy. Many web –based interventions were described as well; however, only one used a viral strategy to address dissemination (Gosselin & Poitras, 2008), therefore meeting the first inclusion criterion and none of them used targeted seeding methods, i.e. worked through “opinion leaders”, “social connectors”, “bridges” to better reach their target group. Articles that described web – based interventions that viewed users as passive consumers of the webpage content 7, that did not involve users in the dissemination processes, for example by means of tell – a – friend services or other strategies, neither focused on provoking dialogue among users, were excluded from the analysis.

6.1.1. NARRATIVE SUMMARY OF RELEVANT LITERATURE Although the uses of viral strategies have been a very hot topic in commercial marketing the current and past decade (B. Freeman & Chapman, 2008; Gosselin & Poitras, 2008; Thackeray et al., 2008), according to our results this area is definitely understudied in the field of health promotion. Our results show that viral strategies were only tested once as a tool for health promotion content dissemination, in a Canadian study published in 2008 (Gosselin & Poitras, 2008). Another, very small study trying to recruit participants for an online HIV/AIDS survey also tried to influence their target audience by first seeding the information to peers, but had too many limitations in their study design to reach reliable conclusions (Thériault, Bi, Hiller, & Nor, 2012). Another study that was included in this

7 The use of formative research, of pre-tests and forms of feedback or evaluation that were not targeted or widely distributed and publicly available, as well as the inclusion of some interactive features as part of the learning procedure, although invite participation, were not considered relevant for the purposes of this research and were therefore excluded. 32 narrative review, satisfied the second inclusion criterion, i.e. it described an online health promotion intervention that focused on generating dialogue and debate among the target group in online settings (Adam et al., 2011).

Further, viral strategies for health promotion were discussed in a limited number of descriptive studies that suggested and supported their use (B. Freeman & Chapman, 2008; Thackeray et al., 2008)

The Canadian study mentioned above that experimented with viral strategies for health promotion content dissemination had markedly positive outcomes that the authors frame as “epidemic self-dissemination” (Gosselin & Poitras, 2008, pg. 6). A viral marketing platform software solution, which was previously used with success in the commercial arena, was adjusted for health promotion use, to build traffic and recognition for the Canadian Health Network’s website, as well as increase subscribers to their bimonthly newsletter. The viral marketing software had the form of an online game that used the metaphor of a healthy activity, i.e. a foot race between friends; and each user that registered was encouraged to invite friends to participate as well. Immediate, inexpensive as well as more tangible rewards such as “healthy prizes” were offered, and the online game worked as a Trojan horse that in the process communicated important public health messages, got thousands of users acquainted with the Canadian Health Network’s website and managed in two weeks to get as many subscribers as the Network had managed to get using other ways in the previous six years.

No seeding techniques were used in this experiment, i.e. the organizers did not identify and use influential people to start off; the online game was simply sent first to stuff of the organizations involved in the Canadian Health Network. 215 people were initially sent the link to the online game through e- mail and in two weeks, with no additional activity or media support, 110.200 unique users from various age groups had registered and 439.275 invitations had been sent. The campaign was terminated before reaching saturation to respect the fixed budget of 50.000 Canadian dollars, as healthy prizes, i.e. a reusable water bottle, a healthy cooking book and a shoe bag were offered to race winners. As the authors note, this approach reached far more many people and with markedly lower per person cost than would advertising alternatives. The experiment was repeated the following year and as the authors note, although the campaign reached people in different age groups/other demographics, in terms of the number of people reached it was once more a clear success. The study also had a literature review component and reported that this was the first study utilizing online peer to peer dissemination techniques for health promotion. However and despite the reported success of the experiment, according to our findings and up to the time of our literature review, no other health promotion initiative followed in their footsteps; except for a very small study that will be described below.

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Said study focused on recruiting participants for completing an online HIV/AIDS survey and part of their promotional strategy was to approach Men that have Sex with Men and ask them to promote the study on their personal Facebook pages and thus indirectly influence their peers, i.e. MSM (Thériault et al., 2012). However, as mentioned by the authors, no seeding techniques were used based on social leader characteristics; rather 10 MSM were approached randomly and asked to participate. In the end, only two people participated in the study; moreover, it could be hypothesized that these two participants did not have a central position in their network but rather found themselves towards the periphery end; the Facebook contacts of both volunteers added together were only 100, when as cited by the authors, the average Facebook user at that time had 130 friends (Facebook, 2010). The authors conclude that “In this study, the SNS marketing strategy did not appear to create a viral effect and it had a relatively poor yield” (Thériault et al., 2012).

Another relevant study described an online health promotion intervention that focused on generating dialogue and debate among the target group in an online forum; however it should be noted that the campaign also had offline components (Adam et al., 2011). Said campaign focused on reducing HIV stigma and reaching a number of relevant objectives by provoking dialogue among the Canadian gay and bisexual men community. To achieve that, the campaign focused on asking a “provocative” question that appeared along with a catchy graphic designed by a marketing firm, in all online and offline promotional material: “If you were rejected every time you disclosed, would you?”. The campaign priorities, theme and said central question were decided upon by a broad community based consortium, in which HIV positive gay and bisexual men were strongly represented. The consortium members were drawn from diverse ethno racial communities and also involved health professionals, governmental officials, a marketing firm and the Gay Men’s Sexual Health Alliance. The approach was based on the “community mobilisation model”, which as cited by the authors (Adam et al., 2011) has been shown in past interventions to bring a cultural shift in favour of safer sex, greatly reducing HIV transmission in gay communities. In this intervention, members of the target group were engaged early in the creative process; such an early involvement, having a say in decision making or a stake in the creative part is thought to evoke a sense of ownership to the participating target group representatives thus greatly increasing the chances they will talk about and advocate the campaign to their peers. This word of mouth provoking process was further facilitated by providing an online public space for dialogue. On the designated website, a short video featuring a gay actor was giving some facts related to HIV stigma, there were links to information, referrals and a short interactive quiz game. However, the components considered most relevant here, specifically targeting the generation of online word of mouth and community participation was the prominent use of the question “if you were rejected every time you

34 disclosed, would you?” used to trigger thought and generate discussion as well as, very importantly, the incorporation of 8 blogs and facilitators that could be considered a parallel to the role of buzz agents in commercial marketing. Buzz agents are trained to ask specific questions and post comments to encourage interesting discussions 8 in online forums. Markedly, all blog facilitators were HIV positive and HIV negative gay men and they moderated lively and lengthy blog discussions for 5 months; people visiting the website had also the chance to see a thumbnail picture of every blog facilitator and a video where they shortly explained in their own words the issues related to the campaign objectives. Unique visitors to the site were 20.844 with some 4.384 returning more than 10 times to the site and the pre-test post-test evaluation showed a statistically significant shift towards reduced stigma related attitudes and behaviour among those aware of the campaign (Adam et al., 2011).

Lastly, in the descriptive studies that support the use of viral strategies for health promotion the authors mostly draw on empirical findings and current practice in the commercial arena to suggest designing similar studies and promotional strategies for health promotion as well (B. Freeman & Chapman, 2008; Thackeray et al., 2008). However, a few examples of viral strategies employed by health promotion organizations are cited there as well (Thackeray et al., 2008). Promotional strategies are seen as facilitating virality by the authors when they involve the priority audience in either distributing online, or even generating health promotion content. The one example given with regard to user generated content in health promotion refers to teens participating in a contest run by a tobacco-free organization for which they develop anti-smoking ads; the winning entry is selected by the organization and an advertising company to be produced and aired on television. All other strategies mentioned and said to facilitate virality are all features that either invite participation or are providing tools that make it virtually effortless to share information. Examples given for the latter are CDC’s powerful bones powerful girls instant messaging icons, the availability of online public spaces where one can pose or respond to questions and share ideas, like the Mum2Mum page on fruitandveggiesmattermore.org site, CDC’s electronic e-cards around pregnancy, flu, or healthy lifestyles which can also be personalized before sending, or social media sharing buttons that make it virtually effortless to share content with peers, as is the case with content available on YouTube. An example of a YouTube video for health promotion comes from the Jade Ribbon campaign about Hepatitis B, which had 170.000 views at the time of the publication’s data collection (Thackeray, 2007) and 613.254 views at the time this thesis report was authored. The article “Gone Viral? Heard the buzz? A guide for public health practitioners and researchers on how Web 2.0 can subvert advertising restrictions and spread health information” (B. Freeman & Chapman, 2008) suggests that health promotion agencies should enter content agreements with YouTube in the same way as commercial entities do: they pay to have their videos preferentially featured on

8 Around a product or a brand 35 the homepage or when certain search terms are entered. The same article suggests that health promotion organizations should have a more strategic presence on Facebook and brings up the example of New York State Smoker’s quit line that has paid to have their page featured on Facebook (Freeman and Chapman, 2008). To shortly reflect on this evidence, our literature review returned very little empirical evidence having tested the use of viral strategies for health promotion. Moreover, strategies tested, described or suggested by authors for health promotion all have a common point: they invite greater participation from the target audience, that in any case goes much further than simply consuming products and services made for them by specialists. Involving the target group might be in terms of content dissemination, in encouraging and/or moderating dialogue and debate among them or might go many steps further to involve the priority audience in the creative process. The members of the target group that are going to somehow participate in the creative process are much more likely to not only talk about but also advocate the final product or service to their peers (Thackeray et al., 2008). Other than inviting target group participation, other strategies described to facilitate virality are encouraging online discussions by providing an inviting online space and asking the right questions. Finally, from Gosselin and Poitras’ study (2008), as well as from descriptive studies on the topic, it becomes apparent that providing tools that make it virtually effortless or even better provide incentives for users to forward content to their peers are an important element that facilitates viral communication.

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6.2. INTRODUCTION This chapter is guided by the research question: “What is the state of the evidence regarding Word of Mouth Marketing best practices? Word of mouth practices have been used with success in optimizing the launch and diffusion of products and services in the marketing arena; and this chapter is focusing on what has been found to work best. In line with the old question: “Why can’t you sell brotherhood like you sell soap?” (Wiebe, 1951), our inquiry is motivated by the wish to identify practices that can lend themselves to health promotion as well. To answer this question we will introduce and utilize the marketing terminology. We are going to talk about “products”, and “launch optimization practices” here, before discussing their implications for e-health. After all, e-health programs are also products although usually not framed as such.

As Justin Kirby, author of “Viral Marketing” explains, there are three core components to any viral marketing campaign; the creative material, seeding and tracking (Kirby, 2006). Indeed, best word of mouth marketing practices identified and discussed under this chapter include seeding practices, premises to be used when engineering contagious messages and tracking, or else, evaluation practices.

Seeding best marketing practices most often involve opinion leaders directly; practices for identifying, reaching and motivating opinion leaders to spread the word and advocate for a product or service will be presented. Next, a number of successful Word of Mouth Marketing Practices that do not target opinion leaders directly will be discussed, namely branded contact detail cards , business blogs, the use of buzz agents and practices for deterring negative word of mouth (Blodgett, Granbois, & Walters, 1994; Blodgett, Wakefield, & Barnes, 1995; Brown, 2006; Corcoran, Marsden, Zorbach, & Röthlingshöfer, 2006; P. Marsden, 2006; Mulhall, 2006; Nyilasy, 2006; Richins, 1983; Rusticus, 2006; Singh, 1990). Following, we will present six research based principles on what makes the creative material more likely to catch on and be shared (J. Berger, 2013). These key principles should be taken into account when crafting content we aspire to go viral.

However, as it will be further elaborated throughout this chapter, developing the creative material does not have to be a separate process that has to be finalized before seeding is started. On the contrary, there are many benefits in involving the opinion leaders, to which the viral agent will be seeded to, already from the creative process (File, Judd, & Prince, 1992; Kirby & Marsden, 2006; P. Marsden, 2006; Thackeray et al., 2008). The creative material can be influenced to a varying degree by opinion leaders’ input; opinion leaders may be asked to vote on certain aspects, may be asked for feedback when the material is ready or almost ready, or may be involved right from the beginning in a bottom-up co-creation of the material (P. Marsden, 2006; Thackeray et al., 2008). Choices on which way to go will also depend on time allocation, budget or other priorities.

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The chapter closes with “tracking” methods. Tracking is necessary in order to measure the viral campaign results, provide accountability and check whether the campaign was successful or not (Kirby, 2006).

6.2.2. OPINION LEADERS : THE INFLUENTIAL MESSENGERS To confirm our starting point, Word Of Mouth Marketing best practices described in the literature largely focused on opinion leaders or else social connectors and on ways to identify them, reach them and motivate them to spread the word on the topic of interest.

Opinion leaders go by many names in the marketing jargon: Alphas, Hubs, Connectors, Influentials, Sneezers, Influencers, Consumer Evangelists and Enthusiasts (P. Marsden, 2006; Nyilasy, 2006) are some of the names we encountered while scoping the literature.

No general demographic (Feick & Price, 1987), psychographic or sociological predictors have emerged in response to the problem of opinion leaders’ identification and profiling. Not surprisingly, however, a positive correlation was shown between opinion leadership and social leadership. (Myers & Robertson, 1972; Robertson & Myers, 1969). Opinion leaders have a “connected and respected” profile (P. Marsden, 2006) but further, their “profiling should be category and market situation specific”(Nyilasy, 2006).

That is to say that an opinion leader in one product category may or may not be recognized as an opinion leader in another, especially if these categories correspond to different rather than similar interests (P. Marsden, 2006; Nyilasy, 2006; Richins & Root- Shaffer, 1988). For example, an opinion leader in organic agriculture may or may not be an opinion leader in beauty cosmetics. Indeed, this conclusion is reflected in the peer reviewed, validated opinion leadership scales available, which access the likelihood that the screened individuals would offer or be elicited for category –related advice (Childers, 1986; Flynn et al., 1996; King & Summers, 1970; Miled & Le Louarn, 1994).

What makes opinion leaders talk is their enduring involvement with the product category. Opinion leaders are interested in these categories; for some reason they are important to them, and their enduring involvement makes them knowledgeable, experts on the topic (P. Marsden, 2006; Nyilasy, 2006; Richins & Root-Shaffer, 1988). They therefore often offer or are elicited for category – related information or advice.

6.2.2.1. PRACTICES FOR IDENTIFYING OPINION LEADERS In the pages that follow, we summarize five marketing practices used to identify opinion leaders. These are self-designation, professional activity, digital trace, use of key informants, sociometry and social network analytics.

Self – designation: Screening for opinion leaders in a product category often comprises of asking existing “customers” or “prospective buyers” to complete a short questionnaire. Although such techniques are open to self - reporting bias, there is a number of peer

38 reviewed opinion leadership scales that are validated and found to be reliable (Childers, 1986; Flynn et al., 1996; King & Summers, 1970; Miled & Le Louarn, 1994). An overview of these scales is given in appendix B. Commercial companies often employ such scales or variants of these with the same objective.

For example, the consumer goods giant Procter and Gamble uses an online questionnaire to identify influential teenagers; users are asked, among other things, how many people, friends, family or acquaintances, do they communicate with every day. The most sociable teens 9, are invited to join the “Tremor network”, which is presented to them as a canal to influence companies while being the first of their friends to try “cool” new products. In fact, the “Tremor”network is Procter & Gamble’s launch optimisation strategy for products targeting teenagers. In other words, “Tremor”teens participate in Procter & Gamble’s seeding trials, i.e. they are the first to sample a product or service. This practise, which will be further elaborated on in the next chapter, is shown to generate up to double –digit sales increase for the company (MarketingSherpa, 2003; P. Marsden, 2006; Mathew, 2005; Oetting, 2006; Wells, 2004).

To give another example, the Australian company Soup employs an online questionnaire that profiles users depending on their hobbies, occupation, interests, numbers of e-mail and mobile phone contacts, how often these users endorse products to friends and how important it is for them to be the first to try new products; moreover, users are asked about whether they see themselves as leaders among their peers. Again, members that are found to be influential for a product category are invited as “lucky”members to participate in “exclusive”seeding trials and events.

1. Professional activity: Another practice in commercial marketing used in identifying opinion leaders is looking for professional groups whose job title suggests involvement with the product category. Although this practice is less scientific than the self – designation techniques described above, it offers a more economical solution, in terms of time and money invested, in identifying opinion leaders (P. Marsden, 2006).

A classic example of this practice in the commercial arena, is 3M’s 10 optimization launch for post –it – notes. The well-known yellow sticky notes were thought to be an industrial failure in the beginning, as they were far from popular; in fact, no one seemed to be able to find a use for them. Luckily for 3M, the following launch optimization strategy managed to turn post it notes from a failed idea to a multi-million dollar profit product. An effort was made to identify opinion leaders for office supply products based on professional activity; the people involved came down to sending boxes of post – it notes to large companies’ CEO secretaries across the USA. A lot of other launch optimization strategies had been tried already, and the company was unwilling to invest more of the

9 “Tremor teens” have an average of 170 names in their address books when the average teen has 30 10 3M is an office supplies’ company 39 budget for their promotion. Along with the samples, there was a request sent to the secretaries, to come up with ideas on how these sticky notes could be used. This really worked and the rest is history, as they say (P. Marsden, 2006).

2. Digital trace: Another approach in identifying opinion leaders in a specific category is by analyzing category related blogs, online discussion forums, websites, newsgroups, discussion lists etc. Frequent contributions from individual members in the form of category specific information, advice, or other support, as well as responses by the opinion seekers which indicate endorsement of said support can serve in identifying online opinion leaders. For example, Siemens mobile searched in mobile phone review forums to identify e-fluentials and invite them to a seeding trial for their new phone. As opinions are increasingly shared online, companies look for the digital trace left by opinion leaders in the category of their interest (P. Marsden, 2006). 3. Use of key informants: Another practice often employed in commercial marketing to identify opinion leaders is to ask people that are assumed to be knowledgeable about the patterns of influence in the target market about who they would designate as an opinion leader. This practice is usually employed in small markets or individual organizations; however there are examples of its practice in larger scale promotional efforts as well.

Such an example is cited by Rogers in the fifth edition of diffusion of innovations (E. M. Rogers, 2003). The case study refers to Hasbro’s 11 viral marketing campaign in order to launch their new portable game console called POX. Hasbro hired a market research company that went out to video arcades, playgrounds and skate parks around Chicago asking children “Who is the coolest kid you know?” (E. M. Rogers, 2003). When the researchers got a name, they went in search of that cool kid only to ask him 12 the same question. They thus climbed the hierarchy of kid – “cool” until someone responded “me!”. Hasbro recruited 1600 opinion leading boys aged 8 -13 this way and invited them to a focus group discussion. The opinion leading boys, called “Alpha Pups” by Hasbro, left the focus group interview with 30$ and ten POX game consoles each, to distribute them to friends and kick – start word of mouth in the 1400 schools in the area of Chicago. Rogers describes the method of using key informants as a combination of the sociometric and self – designation methods. Indeed, Rogers notes that “often a handful of informants can identify the opinion leaders in a system with a precision that is almost as accurate as sociometric techniques, especially when the system is small and the informants are well informed” (E. M. Rogers, 2003).

4. Sociometry: The sociometric method consists of asking people in a given network, community, organization etc. about who they have sought or would

11 Hasbro is a multinational toy manufacturer and board game company. 12 Note that Hasbro was only targeting boys. 40 hypothetically seek for advice or information on a given topic. Nodes that receive the greatest number of sociometric choices with this system are nominated as opinion leaders for the topic in question (E. M. Rogers, 2003). This way word of mouth patterns are mapped and influence hubs are identified, revealing the “unofficial leaders” in a given social network. However this method is time intensive and costly and it is mostly employed by individual organizations for management change purposes (P. Marsden, 2006). 5. Social Network Analytics: According to Zeng et al. (Zeng, Chen, Lusch, & Li, 2010), ‘‘social media analytics is concerned with developing and evaluating informatics tools and frameworks to collect, monitor, analyze, summarize, and visualize social media data, usually driven by specific requirements from a target application.’’ They are software solutions that allow gathering of “big data”, visualization of large social networks, word of mouth monitoring and indeed in relation to a product category, brand or other topic and identification of crucial human agents based on said analysis (Quinton & Fennemore, 2013). As noted by Quinton and Fennemore, this is an important technological development that can be used efficiently in the nonprofit arena as well, in order to better know and relate to target audiences (Quinton & Fennemore, 2013). However, as discussed before, mining of Facebook data is possible but would raise ethical concerns as profiles are usually protected by privacy settings, and thus are supposed to be inaccessible to third parties (Bonneau et al., 2009). That said, producing trend analysis and network visualization from big data for word of mouth monitoring and the identification of opinion leaders would also require expertise and investment.

6.2.2.2. PRACTICES FOR REACHING OPINION LEADERS So after managing to identify opinion leaders in a product category and before using ways to influence them and gain their cooperation, there comes another challenge: how to reach them.

How can companies or organizations explain to the opinion leaders their personal interest in them and gain their attention? Seeding trials, that will be discussed next, and suggest getting feedback from individuals in the name of market research for a new or developing product or even for its promotion, offer a good excuse for contacting them. Moreover, in this way, tangible incentives are offered, such as free samples (J. Berger, 2013; Holmes & Lett, 1977; P. Marsden, 2006; Nyilasy, 2006; Thackeray et al., 2008). If the opinion leaders are identified after opting in to complete a self –designating questionnaire, contacting them is facilitated, as it is a continuation of their input. Marketing experts advise companies and organizations to partner with online research firms to host the survey 13 online (Cakim, 2006). Thereafter, opinion leaders are often treated as experts, which can also provide intrinsic rewards such as ego enhancement (Nyilasy, 2006). Another practice is to frame targeted

13 For opinion leader identification 41 individuals as “lucky participants” who were randomly chosen for a rare opportunity to trial the product, often along with their friends and for free (Kirby & Marsden, 2006).

However it should be noted that besides the how to reach them problem, the question of how many of them to reach remains. Paul Marsden of London School of Economics and Associate director of Word of Mouth Marketing agency Spheeris, suggests that as many as 10% of opinion leaders in a target market, which translates into 1% of the entire target market population should be reached for an “appreciable sales uplift” (Marsden, 2006, p. 17). However, as the author discusses next, this may infer prohibitive costs; in this case, reaching a minimum of 250 opinion leaders per major urban center is suggested as a rule of thumb (P. Marsden, 2006).

6.2.2.3. INFLUENCING THE INFLUENCERS : PRACTICES FOR MOTIVATING OPINION LEADERS TO SPREAD THE WORD After finding and reaching opinion leaders in a target market, the next obvious question is how can one engage them, how can one ensure they will not only talk about but will actually advocate a given product or service.

The most common practice for doing so in commercial marketing is engaging opinion leaders in seeding trials. But before presenting this practice, it would be useful to give some information on what is known about motivating output word of mouth. By the term “output” word of mouth we imply that the research findings that are going to be shortly described here have a focus on the communicator rather than on the receiver 14 ; and on relevant research that has explored the antecedents and consequences of said facet of communication. This stream of research is very relevant when looking at what motivates opinion leaders to spread the word.

F ACTORS THAT MOTIVATE OUTPUT WORD OF MOUTH Antecedents of output word of mouth, or else variables that were found to predict word of mouth from the standpoint of the communicator include opinion leadership (Nyilasy, 2006), satisfaction or dissatisfaction with the product or service (Blodgett et al., 1994; File et al., 1992; Gremler, Gwinner, & Brown, 2001; Halstead, 2002; Mangold, Miller, & Brockway, 1999; Maxham III, 2001; Richins, 1984, 1987; Singh, 1990; Susskind, 2002; Swan & Oliver, 1989; Swanson & Kelley, 2001)., the provision of incentives (Gosselin & Poitras, 2008; Hennig ‐Thurau, Gwinner, Walsh, & Gremler, 2004); (Wirtz & Chew, 2002), consumer participation in a service (File et al., 1992), and promotional efforts (Day, 1971). The market type (Webster Jr, 1970) and culture (Money, 2000) were also found to influence output word of mouth. Moreover, research has shown that most of the conversations held are “me” focused (Dunbar, Marriott, & Duncan, 1997); (Naaman, Boase, & Lai, 2010) and that people find it intrinsically rewarding to talk about their own experiences (Tamir & Mitchell, 2012).

14 Input word of mouth 42

Opinion leadership can be understood as a knowledge based trait that predicts output word of mouth. In efforts for opinion leaders’ profiling, the most consistent finding was their enduring involvement with a product or service category. Opinion leaders knew a lot about this category, for some reason it was important in their lives, they were involved in it, and that is what made them talk (Nyilasy, 2006; Richins & Root-Shaffer, 1988)

But not only opinion leaders talk; also satisfied or dissatisfied consumers are very likely to share their experience with a product or service (Blodgett et al., 1994; File et al., 1992; Gremler et al., 2001; Halstead, 2002; Mangold et al., 1999; Maxham III, 2001; Richins, 1984, 1987; Singh, 1990; Susskind, 2002; Swan & Oliver, 1989; Swanson & Kelley, 2001). Studies have shown that even a single incident of product or service usage can be enough to trigger word of mouth behavior and in fact, some studies have shown that even purchase intention can be enough in triggering WOM (Arndt, 1968). Generation of output word of mouth is not going to be beneficial for a “brand” not matter what though; on the contrary only positive word of mouth can drive sales or lead to diffusion of a product or service while negative word of mouth has respectively negative outcomes (Blodgett et al., 1994; File et al., 1992; Gremler et al., 2001; Halstead, 2002; Mangold et al., 1999; Maxham III, 2001; Richins, 1984, 1987; Singh, 1990; Susskind, 2002; Swan & Oliver, 1989; Swanson & Kelley, 2001). In fact, some evidence suggests that negative word of mouth can be more potent even than positive WOM (Burzynski & Bayer, 1977). Obviously, an opinion leader can also be satisfied or dissatisfied with a product or service and that will lead to influential word of mouth, for good or for worse 15 . Another study found that consumer participation in the delivery of a service increased their word of mouth output for said service. In fact, the variety of ways and the intensity of end users’ involvement in the service delivery were found to predict the occurrence of positive WOM and referrals (File et al., 1992).

In all cases described above, personal involvement is a common feature; opinion leadership requires personal involvement, satisfaction or dissatisfaction presupposes a firsthand experience while consumer participation again equals involvement. As already mentioned before, other research has shown that most of the conversations held are “me” focused, with 40% of output word of mouth concerning one’s personal experiences or relationships (Dunbar et al., 1997); similarly, other research has shown that half of the Tweets concern either something one is currently doing or something that has happened to him/her (Naaman et al., 2010). To be talking about something that one is personally involved in has been found to be intrinsically rewarding for the communicator. A Harvard neuroscience study using brain scanners while asking participants to share opinions and experiences of their own or opinion and experiences of another person found that sharing one’s own attitudes and experiences activates the same brain circuits that

15 Please note that practises to deter negative word of mouth will be discussed later, under 6.2.2.4., p. 49 43 respond to rewards like money and food. The authors suggest that this answers why people talk so much about their own attitudes and experiences 16 ; they are actually wired to find it pleasurable. The researchers also tested and proved that people were willing to forgo a small amount of money in order to disclose such personal information (Tamir & Mitchell, 2012); this interesting finding points out that maybe instead of giving people a penny for their thoughts, we could be paid a penny for listening (J. Berger, 2013). Further, external incentives have also been found to be predictive of output word of mouth in several studies (Gosselin & Poitras, 2008; Hennig ‐Thurau et al., 2004); (Wirtz & Chew, 2002). For example, Wirtz and Chew run a 3 x 3 x 2 experiment testing the effect of incentives, satisfaction and tie strength for output word of mouth. The incentives provided were zero, twenty five and one hundred American dollars respectively; when incentives were provided they were found to significantly increase the likelihood of generating WOM, even in the second condition (25$), especially for participants with high deal proneness (Wirtz & Chew, 2002).

Finally, variables that relate to the content, such as surprise as an emotional state (Derbaix & Vanhamme, 2003) have also been found to predict output word of mouth; these however will be presented separately under 6.2.3.

Further, to understand what motivates opinion leaders to advocate for a product or service, we also have to look at the consequences, or else effects that output word of mouth has on the communicator. Research using qualitative motivational analysis methods (Dichter, 1966; Stuteville, 1968) has shown that consequences for the communicator of word of mouth include ego – enhancement and cognitive dissonance reduction. Talking about a previous purchase of a product or service, one can reassure himself/herself that (s)he has made the right decision and thus get rid of negative feelings associated with cognitive dissonance. Moreover, sharing information that may be helpful for other human beings makes one feel good about oneself; in addition one might entertain the thought that (s)he is knowledgeable or competent on something, resulting in a rewarding sense of ego-enhancement.

Moreover, as we discussed previously, discussing about something personally relevant, as about a category that one is involved with or a service or product someone has a direct experience with, is intrinsically rewarding for the communicator (Tamir & Mitchell, 2012). The communicator will find it pleasurable to share his/her experience. However, this is by no means to guarantee that (s)he will advocate for it; if one has a negative attitude or experience, word of mouth will be negative as well. Following, we will present best Word of Mouth Marketing practices for motivating opinion leaders to advocate for a service or product.

16 Previous research has shown that 30-40% of speech output concerns the communicator’s personal experiences or attitudes (Dunbar et al., 1997; Emler, 1990, 1994); (Landis & Burtt, 1924) 44

SEEDING TRIALS As already indicated at several points throughout this chapter, the most common Word of Mouth Marketing practice in the commercial arena in order to motivate opinion leaders not only to talk about, but rather to recommend and advocate for a product or service, is to include them into seeding trials of said products or services (J. Berger, 2013; Kirby & Marsden, 2006; P. Marsden, 2006).

Seeding trials are targeted sampling initiatives of a product or service which are often conducted in the name of research or eliciting feedback (J. Berger, 2013; B. Freeman & Chapman, 2008; Kirby & Marsden, 2006; P. Marsden, 2006). But rather than randomly distributing samples for free, a usual product launch marketing strategy, seeding trials involve sampling to the opinion leaders identified in a target market, as well as engaging with them in dialogue, usually in the name of research, and asking for their opinion and feedback. The objective of this launch optimization strategy is not only to elicit or use feedback though; rather it is expected to create goodwill and advocacy among the opinion leading consumers, promoting a sense of ownership of the product/service that will ultimately drive sales (J. Berger, 2013; P. Marsden, 2006; Thackeray et al., 2008).

Said sense of ownership is created when inviting consumers to participate in the creative process of a product or service or by giving them a say in how this product/service will be marketed (Kirby & Marsden, 2006; P. Marsden, 2006; Thackeray et al., 2008). The case studies we have reviewed show that the degree of consumer participation in such seeding trials can largely vary. Some companies ask for feedback on the product/service before its official launching takes place, some go as far as involving end users in the creative process and some put the product/service in their opinion leaders’ hands and give them a say in how it will be marketed. The latter may be done either in an open, more elaborate format that gives more room for participation, either by giving them some options to vote from e.g. choose among three logos or promotional video soundtrack songs. Although more elaborate participation seems to be beneficial, with research indicating that intensity and variety of consumers participation in a service delivery is predictive of their WOM and referral behavior (File et al., 1992), other authors suggest that pre – release “VIP” or in any case “exclusive” voting options given to consumers work better than lengthy discussions or surveys. The authors suggest that in this way, with a couple of mouse clicks, participants get the sense of having contributed to the end project, without being burdened with time-consuming work that may not fit with their daily routine (Marsden, 2006).

S OME SEEDING TRIAL EXAMPLES IN THE COMMERCIAL ARENA There are numerous case studies describing the practice of seeding trials from commercial entities to optimize their product launch and drive sales; Procter & Gamble, Hasbro, Microsoft, Google, Unilever, Coke, Pepsi, EMI, Dreamworks SKG, Ford, Sony, Siemens, and Motorola are some of the big names employing the practice while seeding

45 trials are also very common and established in the pharmaceutical industry (Brown, 2006; P. Marsden, 2006). And although different names are used in different market sectors, like for example phase IV trials in pharmaceutical companies or beta testing in the software industry, the rationale and procedure followed is the same: opinion leaders are provided with free samples and/or exclusive information and special benefits or treatment and asked for their feedback and advice. Paul Marsden of London School of Economics and Associate Director of the Word of Mouth Marketing agency Spheris suggests that the Hawthorne effect is at work (Mayo, 2013), when discussing the success of this practice in creating goodwill and advocacy among research participants for whatever it is that they are asked to trial and reflect on and quotes: “By turning opinion leading target buyers into product or service evangelists using the Hawthorne effect, a brand can create a powerful volunteer sales force” (P. Marsden, 2006). Some examples of using this practice in the commercial arena will be given below. Pharmaceutical companies for instance have been long using seeding trials to turn opinion leading physicians into adopters and loyal advocates of their new medicines. This launch optimization practice has been so established in the health care sector that seeding trials got their own industry standard code name: phase IV trials. New medicine has to go through many stages of research before entering the market; such a permission is given after the completion of research phase III, when the new medicine is tested on a large sample of people suffering from the condition it is supposed to treat, compared against placebo or/and existing therapies, and its side effect profile as well as its relative financial value as compared to alternative therapies is evaluated. When this phase is successfully completed, the new medicine is cleared for launch by market authorities. Launching often begins with Phase IV trials: opinion leading physicians are approached and asked to prescribe the new medicine to a number of patients and provide the company with feedback. In reward, the physicians are given free access to the medicine for their patients, exclusive yet to be released information and sometimes supportive services or/and financial remuneration. It is a win-win situation for both the doctors and the company; the physicians maintain their opinion leadership status through participating in these exclusive trials and gain some rewards and the company secures valuable feedback while having seeded their new product to influential nodes, thus optimizing their product launch (P. Marsden, 2006). Seeding trials are quiet established as a practice in the software industry as well, where they go by the name beta-testing. Beta testing stands for free sampling of pre-release software in order to capture feedback, but also to diffuse the new product by providing it to opinion leaders and engaging with them in research dialogue. To give an example of beta testing, Microsoft ran a big seeding trial with 450.000 opinion leading PC users, i.e. 5% of their target market when launching Windows 95. A sample pre-release copy of the software was sent to them asking for feedback; the strategy was very successful, making

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Windows 95 the fastest selling software of all times 17 (Rosen, 2010). Gmail gives another shining example; by sending their yet to be released email and chat service to 1000 opinion leaders and allowing them to invite friends, and their friends to invite their friends through an invitation only policy, while giving them a say in how the service was to be commercialized, they managed to drive Word of Mouth and generate demand (Juliet Chung, 2004; P. Marsden, 2006). As cited by Marsden (2006), Gmail got three million users in three months, and is one of the most well-known email services in the world, getting as many mentions online as their heavily advertised and far more established competitor, Yahoo email . All that was accomplished with no advertisement spent, by sampling an online service and asking for feedback and advice from participants that never received any tangible reward for their participation; indeed, this invitation only participation was valued to such an extent by some users that invitations were found to be sold in the online black market for up to 200 $ (J Chung, 2004). To give a last example of seeding trials employed by commercial companies we will refer to the consumer goods giant Procter and Gamble and their “Tremor teens” and Tremor Mums” panels, which, as discussed before, employ 250.000 opinion leading teenagers and 500.000 opinion leading mothers respectively. The “Tremor network” is presented to them as a canal to influence companies while being the first of their friends to try “cool” new products. In fact, the “Tremor”network is Procter & Gamble’s launch optimisation strategy for products targeting teenagers or mothers. In other words, “Tremor”teens and mums participate in Procter & Gamble’s seeding trials, i.e. they are the first to sample a product or service and they are asked for feedback, advice or other input on how the product should be marketed (MarketingSherpa, 2003; P. Marsden, 2006; Mathew, 2005; Oetting, 2006; Wells, 2004). Most often, they are given a say in the way the product/service will be marketed through “VIP” votes between several options. For example, they might be asked to vote for a marketing logo or promotional message, the background song in a commercial, the fashion model representing a brand, choosing a name for a movie and many many more. Except for being given “VIP” votes, “Tremor” teens and mums are treated as VIPs by the company in many more ways, like for example by being given “exclusive” pre-launch samples 18 and sneak previews, invitation only tactics, or “inside scoops” 19 . The point is to show the opinion leaders that you value their views and opinions and make them feel like insiders. This practise is shown to generate up to double –digit sales increase for the company (MarketingSherpa, 2003; P. Marsden, 2006; Mathew, 2005; Oetting, 2006; Wells, 2004), making a number of third –parties like Sony, AOL, Toyota, Warner Brothers, Kraft and Verizon queuing up to also use Procter and Gamble’s panel to optimise their product and service launches and drive sales (Wells, 2004).

17 A million copies of Windows 95 were sold in the first four days after launch, breaking the previous record of 40 days to sell a million copies (Rosen, 2010) 18 Also called “pre-launch freebies”; the act is also called “get it first sampling” or “tryvertising”. 19 Inside scoops are described by Marsden (2006) as exclusive behind the scenes stories and material or buzzworthy information. 47

Apart from sampling products and services to opinion leaders, thus providing them with a first hand experience with those, seeding trials work because they invite participation and engage opinion leaders in dialogue instead of advertising monologue. As Paul Marsden from London School of Economics and Associate Director of the Word of Mouth Marketing agency Spheris puts it, you got to “Market with them, rathen than at them” (2006, p.20). From VIP votes to more elaborate participation in the promotional plan, to getting involved in the creative process or going as far as to creating user generated content, the key ingredient is consumer participation, in order to create goodwill and ownership among them, igniting advocacy (File et al., 1992; Kirby & Marsden, 2006; P. Marsden, 2006; Thackeray et al., 2008) By putting the product or service in their hands and giving them a say in how it will be marketed a firm is effectively inviting influential end users to become part of their marketing department, creating a powerful sense of ownership that will drive word of mouth. In the words of Tremor executive Ted Woehrle: “We offer them the inside scoop and influence. If you get the right 1%, you have the critical mass required to make a difference” (Marsden, 2006, p.14). Another key aspect linked to participation and dialogue is that participants feel valued (Mayo, 2013), or that they feel like insiders. As mentioned before, seeding trial participants may be given inside scoops, i.e. behind the scenes or other exclusive buzzworthy information that is supposed to make them feel like insiders, increasing their bond with a firm. (Brown, 2006; Cakim, 2006; Corcoran et al., 2006; P. Marsden, 2006; Oetting, 2006). To illustrate efforts made by commercial entities to connect with customers on that level, making them feel like insiders, we will discuss the example of personalized branded cards, i.e. that feature branded artwork on one side and customer contact details on the other. This strategy may be used independently or in combination with a seeding trial. For example, in a seeding trial conducted by Unilever, participants were provided not only with samples of Unilever’s new Axe body wash, but also with personalized contact cards, featuring branded artwork on one side and their personal contact details on the other (Rusticus, 2006); (P. Marsden, 2006). Handing out these cards has been shown by follow up research to stimulate discussions about the brand in 65% of the cases (Rusticus, 2006); moreover, in Unilever’s Axe body wash case described here, opinion leaders had an extra reason to discuss and advocate the brand, as said cards had a double functionality, serving as one euro discount vouchers as well (Rusticus, 2006); (P. Marsden, 2006). Paul Marsden recommends that while seeding samples to opinion leaders, it would very useful to also seed anything else that would help the participants spread the word: vouchers, discounts, special invitations to share with friends, branded merchandise, promotional gifts, or further samples to hand out. All of the above would give an excuse, a reason and a supportive medium to the participating opinion leaders to advocate for a brand and recommend it to their friends (Marsden, 2006).

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6.2.2.4. WORD OF MOUTH MARKETING BEST PRACTICES THAT DO NOT TARGET OPINION LEADERS DIRECTLY Besides seeding trials, a number of other practices are used in the marketing arena to make customers feel like “insiders” and generate positive word of mouth: issuing branded contact detail cards, publishing business blogs, and the use of buzz agents. These practices are not targeting opinion leaders directly; they are open to the public. However, opinion leaders that are active in a product category due to personal interest and enduring involvement are more likely to be active in interacting with firms through these practices and therefore may be identified in the process (Cakim, 2006). Other than practices that motivate positive word of mouth, marketing practices for deterring negative word of mouth are also discussed here.

BRANDED CONTACT DETAIL CARDS The use of branded cards that feature branded artwork on one side and the customer’s contact details on the other side have become a common Word of Mouth Marketing practice in the commercial arena (P. Marsden, 2006; Rusticus, 2006). Although this tactic was shortly discussed under seeding trials, as it can be part of their implementation, it is also discussed separately as in most cases it is not targeted to opinion leaders directly; usually such cards can be ordered by any customer online, who can then recommend them to a friend using the “tell a friend” functionality (Rusticus, 2006).

A case study around “Cosmogirl Icecards” showed that 70% of the people who ordered cards also used the forward to a friend functionality, inviting an average of 2.4 friends to also order the cards. Besides using the “tell a friend” button, card holders are very likely to discuss the brand when handing out the cards, which has been shown to be the case at a rate as high as 65% (Rusticus, 2006). A note printed on the cards reading “get your own personalized cards at…” followed by the link, further helped creating the viral effect. Besides igniting word of mouth, this practice has also been shown to drive sales, enhance brand recognition and boost traffic to the commercial website.

Examples of commercial use of this Word of Mouth Marketing Practice include Fevercards (P. Marsden, 2006; Rusticus, 2006) and Icecards (Rusticus, 2006), which are basically the same thing, only given different commercial labels. Fevercards are cards as described above used by the brand Adidas; a case study by Sven Rusticus describes how 1 million “Fevercards” were ordered from 180 countries in only 46 days with no additional activity to promote them. This campaign also enabled Adidas to generate a Customer Relationship Management Database of 50.000 people. The author suggests that only people with an affinity with the brand would be willing to have the brand’s artwork on their contact detail card, which makes the option of ordering them online an excellent opportunity to automatically generate a quality Customer Relationship Management Database, knowing who already advocates for your brand; an important piece of information for future promotion and Word of Mouth Marketing initiatives. In that way, a brand or organization would know who already would be willing to spread positive word 49 of mouth for them. Icecards, as mentioned before, also refer to this same concept; case studies document their use by a number of well-known commercial entities like L’Oreal, O’Neill, Bacardi and MSN. According to Rusticus, CEO of the European marketing communications agency Icemedia and author of “Creating brand advocates” (2006), “Icecards have proved to be hugely popular in the teens to twenties market, with over 40 million cards ordered in the first 36 months since the idea was commercialized” (2006, p. 51).

BUSINESS BL OGS ; A WAY FOR CORPORATE ENTITIES TO SHOW A HUMAN FACE Another common, not targeted Word of Mouth Marketing practice that has proven beneficial, engaging end consumers in dialogue and making them feel like insiders are business blogs. Business or corporate blogs are usually written by business executives or other employees and their core subjects evolve around business matters as well; at the same time though, like all blogs they are written in an informal manner that resembles personal journals and reflects the personality of the writer. They allow the business target group to see the people behind the company, which suggests a higher level of intimacy and gives a human dimension to faceless corporations (Corcoran et al., 2006). Examples include the popular blogs “Fastlane” written by Bob Lutz, vice chairman of the corporate giant General Motors or the blog “Scobleizer”, written by Robert Scoble, who is Microsoft’s “technical guru”. As blogs have the infrastructure necessary to promote dialogue, allowing readers to post comments, feedback or questions, they open a genuine channel of interaction which differs markedly from the advertising monologue displayed on commercial websites or traditional advertisement media (Corcoran et al., 2006). In “Fastlane” for example, a business blog campaign started in 2004 to stimulate online word of mouth, readers can discuss directly with company vice presidents and senior executives engaging in conversations and sharing opinions (Motors, 2014). The campaign involved senior executives from the car manufacturer publishing their personal thoughts in the form of online diaries, as well as their predictions and opinions in relation to their industry. These diaries were written in an open, informal and honest manner avoiding marketing or industrial jargon and they attracted a large daily readership (H. Green & Baker, 2005).

BUZZ MARKETING AND THE USE OF BUZZ AGENTS Another common Word of Mouth Marketing practice that has been shown to be effective in stimulating online output word of mouth is the use of buzz agents (Brown, 2006; Kirby & Marsden, 2006). Buzz agents, or brand pushers are trained to ask particular questions or post interesting comments in online forums in order to stimulate discussions for the benefit of a brand. Buzz agents work towards steering conversations in chat rooms, video sharing websites, blogs or other forums where their target group gathers enhancing and directing buzz around a product, service or brand (Brown, 2006).

Buzz agents might initiate discussions in these online forums but will also search for conversations already held online about the product, service or brand they want to 50 advocate for. This task requires web searching and WOM monitoring. Unlike offline word of mouth that disappears without leaving any record or trace, online word of mouth is measurable. For example, IBM utilizes a word of mouth measurement software called “Web Fountain” which does not only capture the buzz going on around a brand, but also matches that to sales data (Baker & Green, 2005). The online trace left behind by such product, service or brand specific discussions can also be very helpful in identifying brand advocates and product or service category opinion leaders (Cakim, 2006; Oetting, 2006; Rusticus, 2006). Opinion leaders in a category who are active online are most probably already talking about the subject on the web; further they will most likely be enticed by buzz agents’ questions to share their opinions on their topic of expertise (Cakim, 2006). Addressing questions to whoever knows can therefore help identify online opinion leaders, who are people with knowledge and interest in discussing a certain topic (Nyilasy, 2006) while giving them a good chance to come back with answers that make them look good, exercising and publicly demonstrating their expertise on a topic (Cakim, 2006). The so called buzz agents or brand pushers may perform these activities while revealing their affiliation with the company; however most often they work undercover. Although this entails a risk for negative word of mouth at the expense of the brand in case the buzz agent’s role is uncovered, companies often choose to do so as any known affiliation with the company will most probably reduce the agent’s credibility when advocating the brand, service or product (Brown, 2006; Foxton, 2006; Oetting, 2006).

D ETERRING NEGATIVE WORD OF MOUTH As noted earlier in this chapter, generation of output word of mouth is not going to be beneficial for a “brand” not matter what; on the contrary only positive word of mouth can drive sales or lead to diffusion of a product or service while negative word of mouth has respectively negative outcomes (Blodgett et al., 1994; File et al., 1992; Gremler et al., 2001; Halstead, 2002; Mangold et al., 1999; Maxham III, 2001; Richins, 1984, 1987; Singh, 1990; Susskind, 2002; Swan & Oliver, 1989; Swanson & Kelley, 2001). In fact, some evidence suggests that negative word of mouth can be more potent even than positive WOM (Burzynski & Bayer, 1977).

A customer that had a firsthand experience with a brand, service or product will find it pleasurable to share his/her experience (Tamir & Mitchell, 2012); however, this is by no means to guarantee that (s)he will advocate for it; if one has a negative attitude or experience, word of mouth will be negative as well. It is therefore relevant, after having presented the best Word of Mouth Marketing practices for generating and enhancing positive word of mouth for a service, product or brand, to mention the best practices for preventing negative word of mouth episodes as well. In summary, research has shown that making complaining to the company as easy as possible and responding to customers’ feedback in a way that they will perceive as fair treatment can make a

51 difference in deterring negative word of mouth (Blodgett et al., 1994; Blodgett et al., 1995; Mulhall, 2006; Nyilasy, 2006; Richins, 1983; Singh, 1990).

Studies have shown that the easier customers can complain to the company, the less likely it is they will spread negative word of mouth (Blodgett et al., 1995; Richins, 1983; Singh, 1990). Liam Mulhall, in his case study “Brewing buzz” explains how putting an e- mail link on the first page of the company website, while encouraging customers to send in any complaints or feedback was a very important and effective strategy (Mulhall, 2006). By using strategies such as providing forms to complain to the company, customers can “let the steam off” ending up complaining less to their friends (Nyilasy, 2006). Moreover, the efforts company representatives make to set things right for a dissatisfied customer have also been shown to be helpful. Studies have shown that “perceived justice” can discourage consumers from spreading negative word of mouth (Blodgett et al., 1994; Blodgett et al., 1995) while satisfaction with the way their feedback was handled and the recovery process can generate positive word of mouth (Maxham III, 2001; Maxham III & Netemeyer, 2002; Susskind, 2002).

6.2.3. ENGINEERING CONTAGIOUS MESSAGES : PROPERTIES OF THE MESSAGE ITSELF Although our review has largely focused on opinion leaders and their role in the diffusion of products or services, existing literature on Word of Mouth Marketing best practices equally stresses the importance of focusing on the message architecture in order to craft messages that motivate people to pass them on (J. Berger, 2013; J. Berger & Milkman, 2012; J. Berger & Schwartz, 2011; Heath & Heath, 2008). Our review would be incomplete without an overview of message characteristics that have been found to facilitate virality. If a campaign aspires to “hit all buttons” then best proven practices with regard to engineering contagious messages should be considered as well.

Jonah Berger, Harvard college professor of psychology and author of the book “Contagious” (2013), which comprehensively summarizes the state of the art on viral message characteristics, points out that by focusing so much on the messengers we tend to neglect another equally important variable, which is the message itself. He puts it as following: “To use an analogy, think about jokes. We all have friends that are better joke tellers than we are. Whenever they tell a joke the room bursts out laughing. But jokes also vary. Some jokes are so funny that it doesn’t matter who tells them. Everyone laughs even if the person sharing the joke isn’t all that funny. Contagious content is like that – so inherently viral that it spreads regardless of who is doing the talking. Regardless of whether the messengers are really persuasive or not and regardless of whether they have ten friends or ten thousand”(Berger, 2013, p. 13).

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Berger spent years scoping the literature on viral marketing and analyzing thousands of articles, YouTube videos and word of mouth on thousands of products and brands to come down to six key principles that were shown to make content contagious, i.e. more likely to spread. According to Berger (2013), enhancing these components in messages, which are summarized in the acronym STEPPS, can drive said messages to become popular. STEPPS stands for the following principles: Social Currency, Triggers, Emotion, Public, Practical Value and Stories. A short overview of these principles and related findings or illustrative examples will be given below.

6.2.3.1. SOCIAL CURRENCY The principle of social currency suggests that people are more willing to share messages that make them look good to others, i.e. that provide them with social currency. Just like dress code or other lifestyle choices affect how people see us, so does what we choose to talk about. So while communicating information, we also say something about ourselves and surely we prefer to share content that reflects positively on us. Sharing clever or entertaining content for example, makes us look more clever and entertaining, so crafting content that helps people achieve these desired impressions will most likely be passed on (J. Berger & Heath, 2008); (J. Berger, 2013; J. Berger & Heath, 2007). Under the umbrella term “Social Currency”, Berger summarizes a lot of elements that have been shown to make something more talked about and popular; further he organizes these elements into three subthemes that he calls finding inner remarkability, leveraging game mechanics and making people feel like insiders. All these are ways that make people look good to others and feel special and that is what makes them successful in driving word of mouth (J. Berger, 2013).

F INDING INNER REMARKABILITY Finding inner remarkability in a product or service means finding an element that makes it novel, surprising, extraordinary, unusual, extreme or just plain interesting; worthy of attention or notice, so that people will want to talk about it. Research has shown that products, services or brands that were rated as “remarkable”, as previously defined, get twice as talked about than less remarkable ones (J. Berger & Iyengar, 2012), that more remarkable tweets are shared more (Bakshy, Hofman, Mason, & Watts, 2011) and that more interesting or surprising articles are more likely to make it to New York Times most emailed list (J. Berger & Milkman, 2012). Moreover, research has shown that people like to share unusual stories and they are prepared to exaggerate the details of a story in order to make them more extreme, so as to entertain and impress their peers (Burrus, Kruger, & Jurgens, 2006). Of course, not all products or services have such novel, extraordinary or surprising elements one can focus on; good news is that this does not have to be the case. Such elements can then be incorporated in a creative promotional plan or message (J. Berger, 2013; Magazine, 2009; Morgan, 2007; Nyilasy, 2006). For example, a promotional video on a “boring” conventional product such as a blender can also become viral; Blend Tec’s

53 case study illustrates how this may be done. A low budget YouTube video series called “Will it blend?”, featuring a man in a lab coat trying and managing to turn into sawdust items like Nintendo Wii controllers, Bic lighters, iPhones, Justin Bieber’s CDs, glow sticks and even an iPad, was so unconventional and extraordinary, that people could not help sharing it; the series received more than 300 million views and retail blender sales were increased by 700% within two years (J. Berger, 2013). Evoking surprise can be achieved by breaking a pattern people have come to expect (Heath & Heath, 2008), and by doing so the BlendTec series managed to generate surprise and drive output word of mouth.

ADVERGAMES AND LEVERAGING GAME MECHANICS Games have always functioned as opportunities to involve, inform and educate people in an engaging way. They are entertaining, require focused attention, are thought provoking and often constitute social exercises. Already from our earliest educational steps, social play and games have served as fundamental learning processes. Teachers leverage game mechanics by asking “who can answer a question first”, “who found what is wrong with a picture” or by assigning a puzzle to teams. Games engage participants in an interactive experience that requires proactive and undivided attention (Curran, 2006).

When discussing best Word of Mouth Marketing Practices that concern the message itself, and specifically the creative material format, online branded games or else advergames are cited by experts as the most populous format (Curran, 2006; Kirby, 2006). Advergames are online branded promotional games; they are built specifically to promote a brand, service or product either from scratch either by customizing an already existing game. By populous we imply that the game format gives the agent higher chances to become popular, however it is not necessary that it will; there is a sheer volume of largely mediocre advergames in the market. Trade marketing news lists always feature viral campaigns that use advergames nowadays and in order to differentiate themselves and stand out, companies and organizations have to be more innovative and creative than their competitors. Note by, that apart from creating promotional games specifically for brand or product promotion, product placement in already existing online computer games is also a usual practice (Curran, 2006)

The reason that sharing online games can provide with “Social Currency” is that performing well when playing a game and marking progress in absolute or relative terms, i.e. as compared to one’s previous performance or to how others perform, makes one feel good about oneself. Securing such “bragging rights” motivates one to talk about the game or invite peers to play along with him/her (J. Berger, 2013). Moreover, many advergames are multiplayer, meaning that they allow for multiple players, either friends or strangers to interact in an online social setting. In any case, games have an inherent connectivity, and advergames are much more likely to be shared with friends and acquaintances than commercial messages or traditional advertisements (Curran, 2006).

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Using a viral agent such as advergames has been shown to have important benefits, eliciting reciprocal responses to players in return for the value of the game-playing experience. Advertisers have found that viral campaigns integrating advergames routinely get 50-75% of the participants opting in for future promotions and messages; further, participants are much more likely to submit personal information, helping generate rich customer relationship management databases. Moreover, valuable data can be gathered by offering players in game-choices related to the product, that allow advertisers to build sophisticated psychographic customer profiles which can be used to improve products and future promotions (Curran, 2006; Kirby & Marsden, 2006). Advergames can be created quiet fast; in months, even weeks and the cost of entry can be as low as 5.000 to 15.000$. Many international brands are using advergames for years as an integral part of their marketing mix; Coca-Cola, Nokia, Nabisco, Procter & Gamble, to name just a few (Curran, 2006).

But apart from advergames, there are many other examples of Word of Mouth Marketing best practices that leverage game mechanics to induce word of mouth. Game mechanics are “the elements of a game, application, or program—including rules and feedback loops—that make them fun and compelling” (J. Berger, 2013). For example, one gets points for doing well in solitaire, or gets tangible evidence of his/her progress when advancing to the next level of Sudoku. We enjoy achieving things, and seeing discrete markers of our progress motivate us to work harder, especially when we are close to achieving a goal or subgoal (Amir & Ariely, 2008; Heath, Larrick, & Wu, 1999; Kivetz, Urminsky, & Zheng, 2006). We are also more motivated in the context of social comparison, so as to do better than others (J Solnick & Hemenway, 1998). As Berger puts it, to leverage game mechanics, companies or organizations have to quantify performance, engineer discrete markers of progress and issue visible symbols of status associated with them. These discrete markers of progress have to allow people to reflect on how they are doing at any moment as well as how they are doing in relation to others. To give some illustrative examples, community message boards sometimes use built in metrics to indicate with e.g. icons, how much each user has contributed to the community (J. Berger, 2013). Local cafes use coffee punch cards that award a free coffee to customers that have collected ten coffee stamps, i.e. have bought ten coffees from that same place; a practice that has been shown to accelerate sales, especially when the customer is getting closer to the reward (Kivetz et al., 2006). Credit card companies issued “Gold cards” as a visible symbol of status for customers that spent heavily; as soon as companies started freely distributing “gold cards” to everyone though, customer motivation associated with social comparison was compromised and platinum, sapphire and diamond cards were issued to distinct really wealthy customers (J. Berger, 2013). To give another example of leveraging game mechanics to motivate customer loyalty and output word of mouth, we will refer to the use of bonus miles by airline companies. By keeping track of miles flown and rewarding those at predefined intervals with tangible

55 rewards and status level nominations (Petersen, 2014), airlines provide customers with social currency and make them talk. When referring to one’s golden status in an airline for example, said customer seeks to impress others rather than promote or advertise the airline; however in doing so one also mentions the airline along the way (J. Berger, 2013). To leverage game mechanics, a company or organization also needs to help people make their achievements public; and by achievements we also refer to any distinction. Although someone can always talk to their peers about how well they did, it makes things better when one has a visible, tangible symbol that can be displayed to others. To illustrate this with an example, the location –based social networking site “Foursquare” lets users check in at restaurants, bars, airports or any other place they are at and has devised a large number of distinctions and badges that users can use as visible symbols of status. Someone may check in to a location more than anyone else in a two month period and be crowned as the “Mayor” of the location. Or check in five different airports to get a “Jetsetter” badge. Foursquare offers more than one hundred badges and users predominantly post them on their Facebook pages, indicating that even an award indicating one is being a fixture in the corner bar can be proudly proclaimed as a mark of distinction (J. Berger, 2013). Setting up contests is another way of leveraging game mechanics. Giving awards provides customers with “bragging rights”, motivating word of mouth. As receiving an award provides one with social currency, the chances one will talk about that are maximized, but while doing so he/she will also mention who gave it to him/her. But word of mouth can also be motivated by the voting process itself, in case of course there is one set up in order to give the award. Deciding the winner by popular vote has the advantage that contestants are very likely to drum up support for themselves; but at the same time they are spreading awareness about the product, service or brand sponsoring the contest (J. Berger, 2013).

MAKING PEOPLE FEEL LIKE INSIDERS Another way to motivate output word of mouth is to make people feel like insiders. Having insider knowledge is social currency; for example knowing about something that a few people know or being connected to people who do, or having access to something that is not freely available to everybody; all the above can motivate word of mouth because they provide with social currency. In this way people feel special, privileged, and thus inclined to talk about that (J. Berger, 2013; Kirby & Marsden, 2006).

A usual practice for making customers feel like insiders and thus motivating output word of mouth is using scarcity, exclusivity, limited access or making access difficult in the beginning and then relaxing the restrictions later on (Aronson, 1997);(Fromkin, Olson, Dipboye, & Barnaby, 1971; Verhallen, 1982; Worchel, Lee, & Adewole, 1975) (Aronson & Mills, 1959; Sela & Berger, 2012). The principle behind this is that people can feel special when they have something that others do not (J. Berger, 2013).

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Practices in the commercial arena that make use of this premise include “invitation only” access to e.g. e-shopping opportunities, i.e. a new customer has to know an existing user to get access to the e-deals, or “membership – only” models, in which for example e- shopping opportunities are only available for registered members (J. Berger, 2013).

6.2.3.2. TRIGGERS Content that is engineered to provide people with social currency is much more likely to be shared, resulting in immediate word of mouth. However, it can soon be old news; as we discussed before one of the most important elements of remarkability is the newness of information. Something that is surprising or remarkable is very likely to be discussed between a pair or group of people at least once; but in order to have ongoing word of mouth, triggers are more important. In short, social currency gets people talking but triggers are what makes people keep on talking (J. Berger, 2013; J. Berger & Fitzsimons, 2008; J. Berger & Schwartz, 2011; J. A. Berger & Heath, 2005; Rosen, 2010).

People talk to manage others’ impressions of them, but they also talk just to fill in conversational space. We rather talk than stay silent in the company of other people and we usually talk about whatever comes to mind, expressing our more accessible thoughts (Anderson, 2013; Collins & Loftus, 1975; Tory Higgins, Rholes, & Jones, 1977). To illustrate the concept of triggers and its applications, we will give some examples of its practice, not only in the commercial arena but also in public health.

Triggering thoughts that relate to products can drive demand for said products (J. Berger & Fitzsimons, 2008; Kellaris, 2003) (North, Hargreaves, & McKendrick, 1997) (White, 1997) and as we will argue and elaborate on, driving demand and thus purchase behavior will also drive word of mouth, as people most often talk about whatever it is that they do (Arndt, 1968; Tamir & Mitchell, 2012). To name just a few of the numerous examples regarding the use of triggers in the commercial arena, we will refer to intentional and unintentional associations that have drove demand and word of mouth for the products Kit Kat, Mars and Cheerios.

Kit Kat in two of its well-known campaigns built slogans that managed to build associations of the product with prevalent triggers: first breaks 20 , then with coffee 21 . Campaigns were successful, with people consuming Kit Kat during breaks and while drinking coffee (J. Berger, 2013; Wikipedia). To give another example of how triggers can drive demand, even unintentionally, sales figures for the chocolate bar Mars rose substantially while NASA’s pathfinder mission on planet Mars was ongoing and receiving a lot of media publicity. The company did nothing to build the association; executives

20 The slogan was: “Give me a break, give me a break, break me off a piece of that Kit Kat bar!” 21 Kit Kat and coffee were associated through slogans and imagery. 57 were even surprised and puzzled by the unexpected uplift in demand while no promotional activity was running (White, 1997). Lastly, studies have shown that not only interesting products receive a lot word of mouth; on the contrary, environmental triggers like actual product consumption can better drive word of mouth (Arndt, 1968; J. Berger & Schwartz, 2011). To give an example, a study that measured word of mouth on Twitter showed that a “boring” breakfast cereal brand like Cheerios receives more word of mouth than more exciting brands like Walt Disney; interestingly, this word of mouth follows a pattern. The first references to Cheerios on Twitter usually occur around 5 am, they peek somewhere between 7.30 and 8.00 and diminish around 11.00; the pattern even shifts slightly on weekends showing nicely how references follow people’s breakfast time eating patterns (J. Berger & Schwartz, 2011).

The use of triggers has not only been found to be effective in the commercial arena. To give an example from the health promotion field, an initiative trying to get college students living on campus to eat more fruit and vegetables, that used prevalent triggers from said target group’s environment in their slogan framing, i.e. trays and dining halls, was found to be successful with regard to behavioral change. This was despite the fact that students did not find the slogan attractive and preferred a more generic alternative 22 ; said alternative however had no impact on their behavior (J. Berger, 2013).

Further, more examples from the health promotion field include cases when triggers were used to subvert pervasive unhealthy product marketing, like advertisements and product placements of e.g. the tobacco industry or the soft drink industry (Cialdini et al., 2010). Owing to the disproportional financial investment these industries place for their promotion, competing with these messages can be very hard. An interesting idea in such cases is to use the industry’s messages as triggers for your own. This technique is mentioned as “the poison parasite” in the literature, because it inserts an opposing message into a competitor’s message, turning it into a trigger that serves your interests instead (Cialdini et al., 2010). To illustrate this idea we will refer to an anti –tobacco promotional image created by California’s department of health services that made use of a classic Marlboro advertisement imagery: using a photo featuring two Marlboro cowboys that seem to be talking to each other on their horses, a caption is added that reads: “Bob, I ‘ve got emphysema”. The rationale was that whenever people that have been exposed to said anti-smoking image encounter a Marlboro advertisement, it will trigger them to think of the anti-smoking message instead (see figure 2 below) (J. Berger, 2013; Cialdini et al., 2010). To give a last example of the same strategy used in public health, an anti-soda video advertisement created by the New York City Department of Health featured a man opening a soda can and out came what seemed to be disgusting, slimy fat the man swallowed. The ad concluded with an anti-soda message: ”Drinking one

22 Generic slogan: “Live the healthy way, eat five fruits and veggies a day.” Slogan using triggers: “Each and every dining-hall tray needs five fruits and veggies a day.” Note by that participants were living on campus. 58 can of soda a day can make you 10 pounds fatter a year; so don’t drink yourself fat” 23 . This approach also aimed at evoking feelings of disgust, in order to be memorable and talked about (J. Berger, 2013); a concept that will be discussed next. At the same time though, the campaign also aimed at triggering people to think of their anti-soda message whenever people saw or thought about consuming a soda can(J. Berger, 2013; Cialdini et al., 2010).

FIGURE 2: PREVENTION FOCUSED HEALTH PROMOTION MESSAGE BASED ON THE “POISON -PARASITE ” TECHNIQUE

6.2.3.3. EMOTION Encountering content that evokes feelings makes people want to share said content, and crafting promotional messages that focus on emotion rather than on laying out facts can pay off (J. Berger, 2013; J. Berger & Milkman, 2012; Heath & Heath, 2008). Sharing emotional content helps us connect with other people when it evokes the same emotional response to the audience or recipient (Peters & Kashima, 2007). Feeling the same way about some content highlights similarities between the sharer and the recipient and underscores their connection. For example, sharing a video with a coworker that makes both of them burst into laughter, or sharing a political article with a friend that makes both feel very angry; sharing emotion can strengthen and maintain relationships by reminding people how much they share in common or underscoring the fact they share the same views (Peters & Kashima, 2007). Even if people live far away from each other, the fact that they feel the same way bonds them together (J. Berger, 2013).

However, research has shown that not all emotions increase output word of mouth equally and in fact, that some emotions make sharing less likely. Likelihood of whether some content is going to be shared depends on two dimensions: first, on whether the emotions evoked are positive or negative or else pleasant or unpleasant and second, from whether they bring the subject to a state of physiological arousal or not (J. Berger & Milkman, 2012).

Content that evokes positive emotions is shared more. Although conventional wisdom wants bad news to appeal more and be shared more often, as indicated by the old news

23 To see the video, go to: http://www.youtube.com/watch?v=-F4t8zL6F0c&feature=kp 59 saying “if it bleeds it leads”, research shows that in reality positive content is 13% more likely to be shared with peers (J. Berger, 2013; J. Berger & Milkman, 2012). Sharing positive emotions reflects positively on the sharer also providing him/her with “social currency”(J. Berger, 2013). So although, as we will discuss next, both positive and negative feelings that bring us in a state of physiological arousal make it more likely that we will talk and share, positive arousal is to be preferred than negative arousing emotions when crafting content we aspire to go viral. That is, although both feelings of amusement and disgust can increase sharing, humorous content is likely to be shared more (J. Berger, 2013; J. Berger & Milkman, 2012).

The second dimension that predicts whether emotional content will be shared relates, as already mentioned, to whether said content evokes arousing emotions or not. All arousing emotions, like amusement, excitement, awe, anger, anxiety, disgust, so both positive and negative, have been found to boost word of mouth. On the contrary, low arousal emotions make sharing less likely. Content that evokes sadness was found to be 16% less likely to be shared. Note that positive, low arousal feelings, like contentment also make it less likely for people to talk and share; these feelings deter people from taking action, including word of mouth (J. Berger & Milkman, 2012).

Interestingly, the state of physiological arousal was found to increase word of mouth even when it preexisted, i.e. was not evoked by the content itself but by a previous condition unrelated to the content, such as being exposed to other, emotional content previously or even physical exercise; still in these cases physiologically aroused subjects were much more likely to share content they were presented with (J. Berger, 2011). This finding has interesting implications not only in informing choices on which emotions to use in e.g. advertisements and promotional efforts but also about when and where these advertisements should be placed (J. Berger, 2013). For example a promotional message placed after a popular entertainment scene causing anxiety to the audience, is more likely to be talked about.

To illustrate this with an example from commercial marketing, the famous car manufacturer BMW created an advertisement series featuring police chases and near death experiences that boosted word of mouth for the firm, attracted more than 11 million views in four months, and increased sales by 12% (J. Berger, 2013). But as we discussed above, word of mouth may be boosted for promotional messages placed right after these ones as well (J. Berger, 2011).

Negative or unpleasant arousing feelings can also be useful when crafting messages for public health (J. Berger & Milkman, 2012). It is often hard to put a positive spin on most topics that focus on prevention, such as tobacco cessation. Another example already discussed earlier, under “triggers”, shows how the feeling of disgust was used to deter people from drinking soda; the “Man drinks Fat” anti-soda advertisement aimed at letting 60 feelings of disgust be triggered at the sight of soda cans or soda commercials, while boosting word of mouth and video shares (J. Berger, 2013).

But bear in mind that positive arousing feelings can be even more effective. Take for example the feeling of awe; recent research has shown that content that evokes awe is 30% more likely to be shared (J. Berger & Milkman, 2012). Awe encompasses inspiration and admiration and can be evoked from numerous things; from great works of music or art to religious experiences; breathtaking natural landscapes or human achievements of daring and discovery. Awe is defined by Keltner and Haidt as “the sense of wonder and amazement that occurs when someone is inspired by great knowledge, beauty, sublimity or might”. Further, they note: “It is the experience of confronting something greater than yourself. Awe expends one’s frame of reference and drives self-transcendence” (Keltner & Haidt, 2003). Jonah Berger, in his book “Contagious” cites the viral, well known video of Susan Boyle in Britain’s got talent as an awe - inspiring one, i.e. the first audition video of a Scottish singing contestant in her fifties that accumulated more than 100 million views 24 . As Berger quotes, “It is hard to watch this video and not be awed by her strength and heart (…) So powerful, so beautiful that it makes the hair on the back of your neck stand up.” (J. Berger, 2013). That said, Susan’s Boyle video is not only awe –inspiring but also surprising. In the words of the first judge commenting after the performance: “Without a doubt, that was the biggest surprise I have got in three years in this show. When you stood there with that cheeky grin and you said I wanna be like Elaine Paige everyone was laughing at you. No one is laughing now, that was a stunning, an incredible performance” 24 . Our knowledge in that arousing emotions can boost word of mouth can also be applied in deterring negative word of mouth before it escalates (J. Berger, 2013). Monitoring online word of mouth on issues relevant to public health for example, with the use of automated processes that spot emotional verbs and words that relate to feelings of anger, anxiety etc. (Pennebaker & Francis, 1996), may help treating situations early on (J. Berger, 2013), as could be for example responding to unfounded rumors for a new vaccine.

6.2.3.4. PUBLIC Another premise that should be taken into account when crafting messages, products or services that will be talked about is to make them as observable as possible (J. Berger, 2013; J. Berger & Schwartz, 2011). Social influence drives people to imitate and conform to what others seem to be doing (Burnkrant & Cousineau, 1975; Christakis & Fowler, 2009; Goldstein, Cialdini, & Griskevicius, 2008; Grinblatt, Keloharju, & Ikäheimo, 2008; Nickerson, 2008; Provine, 1992; R. H. Thaler, 2012; Zhang, 2010); however, in order for that to be possible, it should be easy for people to observe said behavior. Behavior that occurs in public, that is visible in public, is much more likely to be talked about and copied

24 http://www.youtube.com/watch?v=jca_p_3FcWA 61 than behavior that stays private. Another reason for that is that by observing a certain behavior, a product or service people are reminded of it; they are therefore triggered to talk about it or use it (J. Berger, 2013; J. Berger & Schwartz, 2011). A very common example of the use of that premise in commercial marketing is the use of trademarks and logos (J. Berger, 2013; Kirby & Marsden, 2006). “Lacoste” for example has a small alligator on all its shirts, making their consumption easily observable. “Apple” has a characteristic bitten apple on all its products. Large logos work on the same premise. Further, companies create branded merchandise like branded T-shirts, key holders, cups and many more reusable items that are meant to stick around in the consumer’s environment (J. Berger, 2013; Kirby & Marsden, 2006). Some of them are said to be more effective than others: a high quality cosmetic bag for example, is likely to be used by women offered said promotional gift, but in the privacy of their bathroom, whereas a e.g. reusable plastic shopping bag with a large logo might be much cheaper to produce and far more observable by other people. This has the advantage that not only the person using the promotional gift is triggered to think of the company but also others that see it; moreover it is much more likely that a discussion around the brand is triggered this way or/and that the consumption behavior is copied (J. Berger, 2013; J. Berger & Schwartz, 2011; S. Gosling, 2009).

Facebook use has also facilitated observability of behavior or even attitudes. Users let others know what they do and what they think by joining events, communities, liking pages or products and more (J. Berger, 2013). By doing so they provide with behavioral residue; traceable evidence others can find later on (J. Berger, 2013; S. Gosling, 2009). ABC news found that simply installing the Facebook “Like” button on their page increased their Facebook traffic by 250% (Gelles, 2010). Public visibility or observability is important; when something is built to show, it is built to grow (J. Berger, 2013). Social influence is stronger when behavior is more observable (J. Berger & Schwartz, 2011; Goldstein et al., 2008); on the other side, when it is hard to see what others are doing, it is hard to imitate it. It is also much more likely that people will start talking about things that are more visible and the easier they are to see, the more they will be talked about (J. Berger, 2013; J. Berger & Schwartz, 2011; Christakis & Fowler, 2009).

To give an example from public health, we will refer to the “Movember” movement, that managed to turn support for a cause, i.e. men’s health and cancer research, into a very observable symbol: a moustache grown and kept by men endorsing the cause throughout the month of November. Starting from 30 men growing moustaches in Melbourne, Australia, in 2003, the movement grew to 450 men in 2004, 9.000 in 2005 and 50.000 in 2007. By then, events took place everywhere from Denmark and Ireland to South Africa and Taiwan. By turning an attitude usually kept private, i.e. support for the cause of cancer research and men’s health into a public, visible symbol everyone can see, the “Movember” movement hasn’t only managed to spark conversations and draw enormous 62 attention to the topic; the organization has also raised more than 174$ worldwide for the cause. Men sporting a moustache throughout the month of November become walking, talking billboards of the cause. As quoted on Movember’s website: “Through their actions and words they [participants] raise awareness by prompting private and public conversations around the often-ignored issue of men’s health”. And while men talk and explain to their peers the reasons behind the new facial hair, they share the social currency this entails and generate new devotees, spreading not only the word but the behavior as well (J. Berger, 2013; Movember, 2014).

Generating public signals for private actions, choices and opinions can be very helpful. In the following example, we will underscore how in some cases people may want to behave healthier, but end up doing otherwise because they observe others doing so and feel their views aren’t supported; even when this is not the case. For example, although many college students may be personally against binge drinking, they might end up doing so as they observe others bingeing and therefore assume that said norm is accepted rather than rejected by their peers. Such an example indicates pluralistic ignorance, i.e. when most people in a group privately reject a norm but hold the incorrect assumption that others accept it; as they can observe such behavior but are unaware of others’ thoughts. These college students may even change their behavior for the worse when they feel their views aren’t supported (Prentice & Miller, 1993). In such cases, crafting messages that make such private thoughts public by stating true norms can make a big difference. For example, Johanessen, a health promoter in Arizona, managed to decrease students’ heavy drinking behavior by almost 30%, by investigating students’ attitudes and behavior and stating the true norm in her messages, i.e. exposing the pluralistic ignorance: that most students only had one or two drinks, and 69% had four or fewer drinks when they party. By focusing on this social information instead of health consequences of bingeing, she let students know that others felt the same way as them, thus supporting them in drinking less (Schroeder & Prentice, 1998). In the same way, crafting messages that make unhealthy or otherwise undesired behavior public may cause said behavior more likely to be copied and spread (J. Berger, 2013; Christakis & Fowler, 2008, 2009). Berger argues that when trying to prevent a behavior we should do exactly the opposite; make others’ behavior less observable (J. Berger, 2013). To give an example of how discussing the occurrence of a behavior we want to prevent may have the adverse effect, an anti-drug campaign against marijuana use among adolescents managed to increase drug use among the target group instead; the analysis showed that adolescents exposed to the campaign were actually more likely to smoke marijuana (Hornik, Jacobsohn, Orwin, Piesse, & Kalton, 2008). As quoted by the first author of said research: “Our basic hypothesis is that the more kids saw these ads, the more they came to believe that lots of other kids were using marijuana. And the more they came to believe that other kids were using marijuana, the more they became interested in using it themselves” (Nealle, 2008). Therefore the premise of making the private public holds only for promotion, not prevention (J. Berger, 2013). 63

As a last note on how to handle messages that focus on prevention, a way around this would be to try and highlight what people should be doing instead; underscore the positive effects of not enacting the harmful behavior, rather than on what others are doing (J. Berger, 2013; Cialdini et al., 2006).

6.2.3.5. PRACTICAL VALUE People like to share useful information; content of practical value. Research has found that New York articles coded as useful were 30% more likely to make it to the most e- mailed list. This can be content, products or ideas that may save someone time, money, improve one’s health or help one have good experiences. It is content that helps people do what they want to do, i.e. achieve their goals, or encourage them to do what they should do (J. Berger, 2013).

Sharing practical, useful information is a quick and easy way to help someone out. If content that provides “social currency” is more about the sharer and how the content shared makes him/her look, content of “practical value” is more about the recipient; of course sharing useful information also makes the sharer feel good and even reflects positively on him/her, providing one with a bit of social currency along the way as well. But at its core, sharing content of practical value is motivated by our desire to help others (J. Berger, 2013).

Passing along useful information also helps establish and strengthen social bonds. Sharing a new recipe we found special to a friend that we know that is into cooking, helps bring us closer together. Our friends see that we know and remember them, they enjoy our attention and care and we enjoy being helpful; thus sharing brings us closer together (J. Berger, 2013).

However, there is a vast amount of useful content out there and people are inundated with information; therefore not all useful content out there is likely to be shared. Content that is narrower, content format that makes going through the content easy, fast or pleasant, or content that points out that something is a particularly good deal is more likely to be shared (J. Berger, 2013; Kahneman, 2011).

Since useful information is more likely to be passed on, one could assume that generally helpful content, or content of interest to a wider audience will be more likely to be shared. However in reality narrower content is more likely to be shared. People are more likely to think of a specific friend if some content is tailored to one’s unique goals or interests. So one may have a lot of friends that are interested in football, but exactly because of that, it could be that no one strongly comes to mind when encountering football related content (J. Berger, 2013).

Another aspect that is important in making useful content shareable content is the content format; the way the information is packaged. Is the content a rumbling four page

64 article touching a number of topics or is it a short, concise bullet list focusing around a key topic, possibly followed by a couple of links? Is it a one hour video or is it a plain image? As Berger puts it, “We need to package our knowledge and expertise so that people can easily pass it on”. The content format and structure, or else the way the information is packaged will play a key role on whether the content will be viewed, then shared (J. Berger, 2013).

Lastly, in order for helpful information to be shared, there has to be a particularly good deal about it, monetarily or otherwise. Consumers are bombarded with offers, discounts and actions in an everyday basis, so what would make such useful content stand out in order to be passed on? Many marketing techniques have evolved in an effort to make deals appeal more to consumers (Aronson, 1997; Aronson & Mills, 1959; Fromkin et al., 1971; Jeffrey Inman, Peter, & Raghubir, 1997; Kahneman, 2011; Kahneman & Tversky, 1979; Schindler, 1998; Sela & Berger, 2012; R. Thaler, 1985; Verhallen, 1982; Worchel et al., 1975). An elaborate discussion of marketing strategies and ways to make a product or service look like a particularly good deal exceeds the scope of this thesis. Briefly, managing consumers’ expectations as proposed by the prospect theory, i.e. giving them a surprising offer, as compared to the consumers’ reference point, even when said reference point is set during the same promotional effort, has been shown to be effective. For example, giving an initial price, then significantly reducing it, or offering more items/services for the same price (Kahneman, 2011; Kahneman & Tversky, 1979; R. Thaler, 1985), or a special price for a limited number or certain people (Schindler, 1998). Restricting availability with regard to quantities offered or time frames they are made available through scarcity and exclusivity have also been shown to make deals appeal more to consumers (Aronson, 1997; Aronson & Mills, 1959; Fromkin et al., 1971; Jeffrey Inman et al., 1997; Sela & Berger, 2012; Verhallen, 1982; Worchel et al., 1975).

6.2.3.6. STORIES Another way to craft messages that will be talked about is to embed them into stories. Stories often encase lessons and messages; they act as vessels that carry information. Further, they allow people acquire a lot of knowledge in a vivid and engaging manner (Baumeister, Zhang, & Vohs, 2004; J. Berger, 2013).

Wrapping up our message in a narrative has many benefits. As the reader gets absorbed in a narrative he is less likely to bring counterarguments. For example, when reading a personal narrative, it is much harder to disagree with a specific thing described to have happened to a specific person under a certain set of circumstances. In the end, the reader is more likely to be persuaded. Moreover, messages embedded in narratives are more memorable and thus easier to share (Kardes, 1993). Stories are also easier to share than plain information because they are wrapped up in context; outside triggers in a conversation, people need a reason to bring the information up, and stories already

65 embed the context that facilitates sharing. People usually share stories, not just plain pieces of information (J. Berger, 2013).

Interesting, special, useful, surprising or emotional carrier narratives that mention a product or idea along the way and that make this product or idea integral to the narrative, so integral that people can’t tell the story without it, will have a higher chance to be shared and talked about (J. Berger, 2013).

6.2.4. MEASURING EFFECTS At the end of a seeding trial, or other viral marketing campaign, the results need to be evaluated. Therefore, there needs to be a mechanism in place that allows accessing the effectiveness of a seeding trial or other Word of Mouth Marketing strategy. In marketing, which is the focus of this chapter, these strategies are actually sales acceleration tools and are usually evaluated based on the sales uplift they generate (Kirby, 2006).

Practices suggested in the literature in order to measure impact on sales, is for example to use a control region where the seeding trial or other WOMM strategy was not implemented and check the differential sales performance (Kirby, 2006).

When the objective is online sales increase, providing participants with a discount pass –it –on promotional code is suggested, so digital tracking is enabled while friends forward it to friends, who forward it to friends and so on. When the viral agent created is a standalone video, tracking capabilities exist that provide a precise quantified picture of its spread (Kirby, 2006).

Other, softer measures, are also suggested, such as measuring effects in terms of awareness levels. In order to do this, including an online dimension is suggested, such as a website, blog or discussion list so the number of unique visitors can be used as a measure. Alternatively or additionally measuring column inches in traditional and online press is suggested, so as to measure the buzz that is generated and calculate the reach of these column inches based on readership (Kirby, 2006).

Finally, a simple pre-post poll measuring changes in advocacy rates may be used among participants, such as the opinion leaders involved in the campaign, or within the wider target market (Kirby, 2006).

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7.0. EMPIRICAL FINDINGS

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7. EMPIRICAL FINDINGS 7.1. INTRODUCTION

The purpose of this qualitative study was to answer the third research sub question i.e.:

At the moment of choice, what are the main factors that condition social connectors’ choices to share general and health promotion content on Facebook?

By “sharing” we refer to posting content on one’s wall or on friends’ walls, commenting previously shared content, use of the “Like” button, as well as sharing content through personal messages.

The bottom up coding resulted in 329 codes that were then grouped to 33 families. These families were further merged based on common denominators and ultimately three main themes emerged from the categorical content analysis: “I consider me”, “I consider you”, “I consider us”, that involve the main factors of our inquiry, so the factors that condition social connectors choices to share general and health promotion content on Facebook. These factors are framed as Personal Involvement, Favorable Image Construction, Practical Value, Emotional Arousal and Social Benefits. All factors were relevant for sharing “general content” on Facebook. However, with regard to “health promotion content” that we distinct as “viral health promotion videos” and “e-health programs” as well as to “health related content”, we found that the relevance of each factor differed per health promotion “category”, which is why the distinction is made.

The terms mentioned above are explained under 7.1.1. below. Table 4 gives an overview of content grouped in each of these categories. The factors that were found to be more relevant for each of these categories are also named there.

Under 7.2., a summary of the themes and the five main factors they involve is given in text. Next, a graphical representation of the themes, the main factors and sub factors is given (See table 5).

Under 7.3. to 7.7., a more elaborate presentation of each factor is given, enriched with a large number of quotations extracted from the interviews, on which the factors are grounded on; these quotations are meant to serve as illustrative examples, making concepts less abstract.

7.1.1. Sensitizing concepts

At this point, we consider of value to provide with a set of sensitizing concepts that are important for the analysis that follows. We will explain what we mean by “general content” and “health promotion content” as well as how this differs from “health related content”, as it will be framed throughout the analysis; finally, it will be explained how these concepts relate to points in the interview guide. 68

7.1.1.1. General & Health related content

When we refer to “general” and “health related content” throughout the analysis it should be clear that we refer to content that was already shared by interviewees on Facebook, which was discussed during the first part of the interview. Prior to posing our questions, we asked interviewees to go to their Facebook profile and then to their activity log. One’s Facebook activity log is a record of one’s previous Facebook activity, where one can see what (s)he has posted, “Liked” or commented on. This step was taken with the objective of using the visual stimuli of content recently shared by the social connectors themselves to avoid memory bias and help recreate the moment of choice; when social connectors chose to share the content discussed. Triggered by the content, interviewees were invited to share whatever came to mind about two content items they “enjoyed sharing”; content indicated following this question is going to be framed as “general content”. Interestingly enough, at times “general content” was profoundly health related. Following, interviewees were asked to look for and discuss two shares that in their mind were related to health; throughout the chapter said content is going to be framed as “health related content”, to make a clear distinction from “health promotion content” to which they were exposed later in the interview and which is treated differently, as described below.

7.1.1.2. Health promotion content

At the second part of the interview interviewees were exposed to a set of four health promotion links; this is the “health promotion content” we refer to. We inquired into whether and why they would/would not share the health promotion links they were presented with, in order to define what conditions their choices to share or not to share health promotion content at the moment they are exposed to it, i.e. at the moment of choice 25 . The health promotion links were matched per theme, i.e. two pro-exercise and two anti-smoking, so a promotion focus and a prevention focus theme would be included. Moreover, one link from each theme was an e-health program developed and promoted by the National Health Organization of England, matched with a YouTube video for each theme that had gone viral, as apparent from their unique views. The viral videos had a markedly different duration, i.e. 10 minutes and 1.5 minute respectively, in order to check if said variable conditions social connectors’ choices to share health promotion content on Facebook.

The analysis showed that most of the times e-health programs and viral videos on matched themes were not treated equally; in the numerous instances when this is the

25 To see the main questions and probes per question, please go to appendix C.

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case we will refer to “the viral videos” and “the e-health programs” separately instead of referring to “health promotion content” in general.

TABLE 4: WHAT DO WE REFER TO BY GENERAL , HEALTH RELATED AND HEALTH PROMOTION CONTENT & MAIN FACTORS THAT RELATE TO EACH CATEGORY .

General Content Content interviewees “enjoyed All factors sharing”; indicated items included health related content. Health related Content already shared by the Personal Involvement content interviewees and indicated as Social Benefits “health related”. Usually generated by the users or their Facebook friends. Viral Health 23 and 1/2 hours: What is the single Favorable Image Health promotion promotion Health Promotion best thing we can do for our Construction Videos health? Emotional Arousal content SMOKING KID Practical Value

E-health NHS choices: Health and Fitness Practical Value

programs SMOKEFREE NHS Social Benefits

7.2. SUMMARY The main themes that emerged from the analysis are framed as “I consider me”, “I consider you” and “I consider us”. As shown in figure 3 below, the factors “Personal Involvement” and “Favorable Image Construction” focus on considerations about oneself, “Practical Value” mainly concerns considerations of Facebook friends, and “Emotional Arousal” and “Social Benefits” refer to collective considerations.

All these factors were found to condition social connectors choices to share or not to share general content on Facebook. With respect to “health related content” and “health promotion content” as previously defined, it should be stressed that “Personal Involvement” and “Social Benefits” were especially relevant to “health related content” already shared by the interviewees on Facebook. The factors “Emotional Arousal” and “Favorable Image Construction” coupled with “Practical Value” were found to condition social connectors’ choices to share the viral health promotion videos, while “Practical Value” and “Social Benefits” emerged to facilitate or hinder sharing e-health programs.

Each factor also holds a varying degree of relevance for different ways of sharing; for example Favorable Image Construction is a prerequisite for posts while Practical Value is especially relevant for sharing through Personal Messages; so linking health promotion categories with specific factors also helps understand and predict how such content may be shared on Facebook. The relevance of each factor for different Facebook sharing 70 activities will also be discussed in the summary below; while also visually summarized with figure 4.

FIGURE 3: THE THREE MAIN THEMES AND FIVE MAIN FACTORS

7.2.1. “I consider me”

The factors “Personal Involvement” and “Favorable Image Construction” are grouped together as they emerge to both relate to considerations about oneself. The main difference is that “Personal Involvement” refers to something the social connector had a direct experience with or relates to his/her lifestyle (profession, studies, free time activities); most commonly this was content generated by the users themselves or their Facebook friends and they were often depicted or otherwise tagged in it. When interviewees were asked to point to health related content from their activity log, they most commonly pointed to such content; pictures or videos of them sporting, pictures of food taken by friends, sport related Facebook pages or Facebook pages on organic agriculture, pictures of “healthy babies” or of social gatherings, to give but a few examples. Content grouped under favorable image construction was content found elsewhere on the internet, so not generated by them or their Facebook friends, but which embodied characteristics users seemingly wanted to be associated with, such as content perceived to be “smart” or “special”. The viral health promotion videos embodied favorable content characteristics as opposed to e-health programs, and that was increasing the chances users would post them on their walls. Personal involvement or favorable image construction were factors that conditioned social connectors’ choices to post content on their walls, which is a virtual space for positive self – presentation. A short summary of content coded under “Personal Involvement” and under “Favorable Image Construction” is given below.

Personal involvement: Whether the content relates to something the user is personally involved with, or else with a direct experience of his/hers works as a facilitating factor. Content one was personally involved with was content the social connector was depicted or tagged in, or content one otherwise felt part of, as in instances when one contributed or were present during its creative process. A sense of personal involvement also seems 71 to be generated when someone has insider knowledge or when the content relates to one’s profession/hobbies/studies or otherwise relates to one’s lifestyle . The factor of personal involvement was found to be very relevant with regard to posting content on one’s wall, while also influencing the rest of sharing activities (Like, comment, PM).

Favorable image construction : Choices on whether to share or not certain content also depended on social connectors’ expectations about whether shared content would reflect positively on them. When it came to deciding on sharing content on their walls, expecting the content would reflect positively on them was set as a prerequisite. The same premise held when deciding on whether to post content on friends’ walls; said content had to reflect positively on them as well; i.e. the content had to make them look good.

Expectations on whether some content will reflect positively on them depended on perceived content characteristics; content that was perceived to be smart or funny for example, is expected to reflect positively on the sharer, making one look more smart or funny as well; social connectors predominantly shared and stated they were more willing to share positive and pleasant rather than negative or unpleasant content. Moreover, content that was unconventional was more likely to be shared. Such characteristics were often attributed to the health promotion viral videos reviewed in this qualitative study by users that viewed them in a positive way and were more willing to post them on Facebook.

On the other hand, social connectors would not share content when they perceived it might reflect negatively on them. That could again depend on content characteristics; for example, perceiving content to be “superficial”, dictative, “preaching” or “ pointing out flows in others’ behavior ”. Moreover, conventional, common content with no special characteristics was less likely to be shared, especially on walls. Note that these characteristics were mostly attributed to the e-health programs reviewed in this qualitative study; almost always users were unwilling to post them on Facebook, while there were also few instances when such unfavorable characteristics were attributed to the viral health promotion videos as well 26 . Further, when health promotion content was inconsistent with social connectors’ behavior or image they would not post it, as it would bring them in a state of cognitive dissonance before their audience. They would not post, for example pro-exercise content if they were not fit or anti-smoking content when they were smokers, even if they liked the content a lot.

26 For example, in the case of the “Smoking Kid” because of the prevention focused, “unpleasant” topic, or in the case of the pro-exercise viral video, when it was seen as “being about diseases”, which were indeed referenced in its introduction, or when seen as “dictative”. 72

7.2.2. “I consider you”

Practical value refers to considerations of Facebook friends. These considerations are mainly expressed by forwarding content in Personal Messages, when some content is thought to be helpful to a specific recipient; less commonly they can be expressed by posting content on one’s wall, when content is thought to be of practical value to a larger audience. However, the latter is mostly the case when “Practically Valuable” content is coupled with content characteristics that add to one’s Favorable Image Construction or evoke Emotional Arousal; as it was often the case with the viral health promotion videos. E-health programs on the other hand were typically framed as practically valuable alone; almost always social connectors said they would forward them in Personal Messages to help others, either uninvited to partners or family ties either to Facebook friends that had expressed the desire to change, i.e. had expressed the desire to exercise more or quit smoking. Below we present a breakdown of content characteristics that decide whether some content may be viewed as practically valuable or not.

Practical value: By practically valuable content we mean content that is perceived to be useful to a recipient, when sent through a PM, or to an audience, when posted on one’s wall. Content perceived to be useful offered informational or emotional support; content thought to save people money, time, improve health, offer them positive experiences, motivate and inspire them or help them deal with stress. Further, perceived usefulness of the content also seemed to depend on whether the content was coming from trustworthy sources.

Essentially, content was thought to be useful when it was personally relevant and indeed tailored to the recipient or audience. Deciding on relevance to a recipient seems to depend on the level of content personalization; i.e. the extent to which the content matches the recipient’s profile in terms of professional and personal interests or other individual characteristics. Further, on whether the content helps one with his/her current concerns and goals; when deciding on whether to forward health promotion content for example, social connectors seemed to ask themselves not only if said content suits one’s current goals and concerns but further, whether it matches one’s behavioral change stage. Most commonly, perceived relevance to a recipient was linked to a previously held conversation; bringing up a topic seemed to be greatly facilitated when already discussed before. When deciding on relevance to an audience, i.e. when choosing whether to post useful content on one’s wall, localisation was the primary factor to be considered, i.e. whether the content was linguistically and contextually adapted to audience characteristics (Gibb & Matthaiakis, 2007); in other words, if it was regionally accessible.

Deciding on whether some content was practically valuable also depended on the content structure and format; the content being quick and pleasant to review was found to act as a facilitating factor, as it is saving people time and energy. Images, short text and 73 short videos, up to three minutes, were found to be social connectors’ preferred format, followed by Facebook pages.

Similarly, content that was not thought to be useful was less likely to be shared. Content time and energy consuming that was providing with a lot of information, such as long text, long videos, content in a foreign or difficult language, e.g. use of scientific or industrial jargon, were all found to hinder sharing on Facebook. Moreover, content that was not perceived to be personally relevant to the audience/recipient, or even tailored to one’ current goals and concerns were thought to have low practical value. Lastly, social connectors were less likely to share content when they perceived the source to be commercially motivated; in this case the content was considered less trustworthy and thus less practically valuable.

Note by that practically valuable content is likely to be posted on walls when it reflects positively on the sharer(s). Content that is perceived to be practically valuable but does not have a special, extraordinary, or other aspect that will make the sharer look good to others will most likely be shared in private, through a PM.

7.2.3. “I consider us”

“Emotional Arousal” and “Social Benefits” are both factors that relate to Facebook sharing activities that help underscore similarities and connections between Facebook users. Emotional arousal seems to be bringing people that feel the same way about something closer together, acting as a common denominator. When discussing one of the health promotion viral videos, i.e. “The Smoking Kid”, emotional arousal was found to be a commonly mentioned facilitator for all ways of sharing. Similarly, the factor “Social benefits” relates to sharing activities that are motivated by one’s wish to connect with specific and similar others, as will be further explained below.

Emotional arousal: Content evoking arousing emotions was shown to facilitate all ways of sharing. Such emotions involved awe or admiration, surprise, excitement, amusement, or thrill; clearly, positive emotional arousal prevailed, however, there were instances where anger or anxiety was also expressed.

Social benefits: This last factor refers to sharing activities that were motivated less by content characteristics and more by one’s desire to connect with specific and “similar” others.

Users follow, “Like” and comment on content posted by ties they want to keep in touch with or get closer to, i.e. specific others ; therefore their choices to share content in these ways is also influenced by whether they are interested in the Facebook user that posted the content.

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It was also shown that social connectors follow “similar others”, i.e. peers or experts in a field of interest; the distinction from specific others is made here because the emphasis was put on content consistently shared by these experts or peers, content that was useful to social connectors because of personal or professional interests. By following these users, social connectors seemed to satisfy their need to learn and grow in their field of interest, (e.g. healthy cooking, organic agriculture, acro-yoga) or/and their need to belong in a community with similar others. This factor is mainly relevant to reactive Facebook sharing activities, i.e. use of the “Like” button or commenting, and less to posting content on one’s wall.

Note that Social Benefits were especially relevant to “health related” content posted by other Facebook users who were “Personally Involved” with the content.

Social Benefits were also mentioned as a factor conditioning some interviewees’ choices to share an e-health program, i.e. some said they would “Like” or comment on the links when these were shared by another Facebook friend; this would be difficult however, when almost no one was willing to take the proactive step of posting them.

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FIGURE 4: HOW THEMES RELATE TO FACTORS AND DIFFERENT FACEBOOK SHARING ACTIVITIES

The blue area mainly concerns considerations of oneself. It is motivated by one’s need for self presentation. Such content is to be found on one’s wall.

1. Personal Involvement: The content expresses one’s direct experiences or otherwise reflects one’s lifestyle. 2. Favorable Image construction: The content is perceived to embody characteristics the source would like to be associated with.

The grey area mainly concerns considerations of Facebook friends. It is motivated by one’s need to help others. Such content will usually be forwarded in Personal Messages.

3. Practical Value: The content is perceived to be useful for a recipient/audience, matching their profile characteristics and current concerns and goals.

The green area mainly concerns collective considerations. It is motivated by one’s need to connect with specific and similar others.

4. Social Benefits: Mainly concerns reactive Facebook activities (Like, comment), expressive of an audience’s interest to a source. 5. Emotional arousal: Facilitates all ways of sharing (Post, PM, Like, Comment). Content perceived to evoke emotional arousal both to a source/audience works as a common denominator, bringing them closer together.

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Table 5. Breakdown of themes and factors

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7.3. PERSONAL INVOLVEMENT “F ACEBOOK REFLECTS MY LIFESTYLE ”

One of the main factors that emerged from the categorical content analysis to condition social connectors’ choices to share content on Facebook was personal involvement. All participants said they shared, i.e. posted, liked or commented on content they were personally involved with and that was reflected in their activity log. Partly, content coded under personal involvement was content interviewees were depicted in, or tagged in, so said content would appear on their walls. Other forms of involvement mentioned were being the one who took a picture posted on Facebook [I9], digitally creating the content [I3], being present during the content creative process [I3] or reading the description of a real life activity posted in a small, exclusive group 27 they are members of [I6]. Important to note, the overwhelming majority of content discussed during the first part of the interview, i.e. content social connectors had already shared, was user generated 28 . However content coded as personally relevant did not always depict the interviewees or have their names tagged in, so as to associate them with the content, neither was it always user generated content. Still, content under personal involvement reflected their lifestyle and current activities. By that we mean that content shared by social connectors was linked to current direct experiences of theirs; to their free time activities, their profession, their studies, or to other aspects of their lifestyle and daily routines. How often each subtheme from the ones mentioned above emerged is presented in the figure below.

Content relates to one’s free time activities [I1 – I15 ]

Content relates to one’s profession [ I7 – I13, I15 ]

Content relates to one’s studies [I3, I5, I7, I15 ]

Content that otherwise relates to one’s lifestyle [I1, I4, I5, I13 ] (e.g. eating behavior, child rearing, living environment)

FIGURE 5: MAIN FACILITATORS GROUPED UNDER PERSONAL INVOLVEMENT AND INTERVIEWS IN WHICH THEY EMERGED

27 Said social connector referred to a family celebration dinner schedule posted a closed family group; the user said that even though her family was on the other side of the Atlantic, she felt involved in the celebration. 28 Just to give an indication of the extent to which this was the case in our small qualitative study, 73% of all content discussed during the first part of the interview was user generated; from that 42% were pictures, short text (17%), images digitally made by the users (2%), user generated videos (3%), Facebook groups and Facebook pages (10%). 78

7.3.1. ACTIVITIES OF INTEREST TO HEALTH PROMOTION REFLECTED ON FACEBOOK Free time activities or even professional activities 29 discussed on Facebook naturally included activities that are of interest to health promotion, as these are part of some users’ lifestyle, such as healthy cooking, organic agriculture, outdoor physical activities and sports. These topics were brought up both when general and health related content from users’ activity logs were discussed.

7.3.1.1. F REE TIME ACTIVITIES Social connectors’ free time activities were reflected on Facebook and sometimes these were related to health. A social connector that views healthy cooking as her hobby for example, “Liked” a picture of “healthy cookies” a friend made, that she considers as an expert cook, as well as a Facebook page of a local humus shop that she often has breakfast at; a corner shop she trusts for being really healthy. Another social connector that practices yoga for years “Liked” a picture posted by her yoga teacher, where she is depicted among a big group of people doing yoga as well as a Facebook page called “Yoga inspiration” that she described as “ mostly posting images that will give you some inspiration, or that will remind you of something (…)”. Most participants that practiced a sport said that they would post something related to that on Facebook [I7, I10 , I13 ] or that they have many times done so already [ I3, I 8, I 11 , I 12 ] or that they have let [ I5] or would let [ I1] such content appear on their wall if someone else tagged them.

7.3.1.2. PROFESSIONAL ACTIVITIES Social connectors that had a health related profession, i.e. two sports teachers and an organic agriculture producer predominantly shared relevant content; it actually happened that these three users discussed only content that related to their profession, so related to the sports they taught and practiced, organic agriculture and cooking, during the interview. At some cases they made it clear that said shared content was linked to their professional goals; targeting tangible rewards, like for example recruiting more students for a yoga class or getting people to subscribe to an outdoor activity they promoted. At other points they seemed to share such content because the same activities were part of their free time activities as well, and reflected their views; they were passionate about these sports and organic agriculture, respectively, and in their personal life they were practicing what the preached. Add to that, that some interviewees that were involved with sports in their free time also happened to mention that they were tagged in content, i.e. almost always pictures depicting them sporting, posted on Facebook by physical educators [I5, I8, I11, I12 ].

29 In the case of three participants whose profession was health related: an organic agriculture producer and two sports teachers; all of them promoted these activities on Facebook. 79

7.3.1.3. HEALTH RELATED ACTIVITIES ARE REFLECTED ON F ACEBOOK JUST LIKE ANY OTHER ACTIVITY WOULD The health related topics mentioned above came up both when interviewees were asked to discuss general content they enjoyed sharing, so before the health topic was introduced, and when they were asked to discuss previously shared content that in their minds was related to health. There did not seem to be a difference among health related hobbies and professions and other, not health related ones.

To give a couple of examples of sharing activities coded under personal involvement that are not related to health, at least not in the narrow sense defined here for the purposes of this thesis, an interviewee that was into a video game posted a video that related to it that she just saw; another interviewee posted a music list she just heard and liked; another shared a poem written by a friend or a funny picture from 9GAG 30 ; two professional actors said they often post content that relates to their work. Almost always free time or professional activities they were involved with and which they mentioned when asked to discuss content they enjoyed sharing were the same or similar with the ones they chose to discuss when they were asked for content that in their minds were related to health.

To make this a bit more clear, when the question “I would now like you to scan through your activity log and look for a share that to your mind is related to health” came up, some responded right away, while some found it difficult to answer and had to be probed: “Think of what is health for you; then find something that relates to that”. These same categories that participants were used to sharing were then framed as being relevant to health; 9GAG is good for your health because it makes you laugh; music is good for your mental health; pictures that bring happy memories with friends reflect and support social health; creativity is health, so that creative picture or article I shared reflects health; relaxation is health; so any free time activity that helps one relax is healthy.

7.3.2. PERSONAL INVOLVEMENT AND WILLINGNESS TO SHARE HEALTH PROMOTION CONTENT During the second part of the interview, when interviewees were presented with 4 health promotion links, two pro-exercise and two anti-smoking content items 31 , and questions on whether and why they would or would not share them, personal involvement seemed to again influence their choices. Findings will be presented per health promotion theme, i.e. pro-exercise and anti-smoking content.

30 “9GAG” is a popular website featuring funny content like pictures, videos and more. Users can upload content that is user generated or found elsewhere on the web, up vote or down vote content, add it to lists and more (Wikipedia, 2014) 31 To see said content, go to Appendix A. 80

7.3.2.1. PR O -EXERCISE CONTENT AND PERSONAL INVOLVEMENT Firstly, most of the participants that perceived themselves not to exercise or exercise very little, suggested that they expected users whose behavior was already in line with the content to be more willing to post the pro-exercise content they were presented with [I 1

– I3, I 9, I 14 , I 15 ], i.e. users who were “already active” or were “into health and fitness” or into other sports mentioned in the content. Indeed, participants that perceived themselves as physically active seemed more likely to share pro-exercise health promotion content. Out of these 7 participants, 5 [I5,I6, I9, I10 , I13 ] stated they might share either an article from link 1 that was tailored to their personal interests, or link 2 – a whiteboard animation video that discussed the benefits of exercise for health- or both. Whether they were willing to share either of them or both also related to other factors discussed throughout the analysis.

It also emerges that personal involvement influences whether social connectors would spend the time going through the health promotion content in the first place.

Below, some illustrative examples:

I5; while discussing link 1

Iee: Yes, if an article, let’s say like this one [see Fig. 20], interests me, that it does actually because I also do exercise on my own, I would share it.

FIGURE 6: SUB LINK FOUND IN LINK 1

I15 ; while discussing link 1

Ier: Is this the reason? That you don’t do it yourself?

Iee: I don’t know, I am not into it, it is not among the areas that... at this specific period I am interested to... read an article...or post, because I have read it and I am really interested in something in it... when I was doing spinning... I put something on spinning ...[7 lines omitted] I wouldn’t share it, I wouldn’t look for that specific site at this stage of my life, this month...this period...yes.

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I3; while discussing link 2

Iee: eeeh really nice what he was saying I mean indeed important and all but… I don’t know I got bored to see it (all)… Look, for a period I was going to the gym for two months… This period I would see it, but now I am bored.

I14 ; while discussing link 1

Iee : I know it (NHS) because I went there...otherwise...look if I was involved with... running...with exercise in general because now I don’t do it, and I was also looking for stuff like that in the internet, yes, I would share it because...eee I think it has good things, I mean it won’t be something stupid to share...so ...yes.

Ier : So a prerequisite for you to share that as far as I understand is that you have to first be involved yourself, is that right?

Iee : yes... Otherwise (laugh) there is no point... yes...

I3; while discussing link 2

Ier: You have told me what would make you share that on Facebook, as far as I understand, basically you would have to first do it yourself.

Iee: Yes, yes, primarily yes. Primarily yes. (Ok.) To post something that I don’t do or does not immediately concern me, there is no reason for someone to do this.

Whether social connectors had a firsthand experience with the pro-exercise content and were happy with it was also brought up as a factor that conditioned their choices to share or not to share said content. For example, while discussing their intentions to share the “what ‘s your sport test”, a sub link in link 1, several participants noted that whether they would share it would depend on whether they had taken the test themselves and were satisfied with the result [I 3, I4, I5, I11 , I15 ].

7.3.2.2. ANTI - SMOKING CONTENT AND PERSONAL INVOLVEMENT Personal involvement might also work as a facilitating factor for sharing anti-smoking content on Facebook. A couple of participants noted that the people who they would expect to be more willing to post anti-smoking content would be people who had managed to quit themselves [I 1, I3], especially if they had a firsthand experience with the same web –intervention –as far as link 3 is concerned- and were happy with it. Note that the one and single participant that had recently quit said she was indeed interested in sharing the smoking cessation content as she “really supports this cause, that we do not smoke ”[I8 ].

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7.4. FAVORABLE IMAGE CONSTRUCTION Often, social connectors’ choices on whether to share health promotion content were conditioned by perceived content characteristics and whether they would like to be associated with those. This holds primarily for content shared on walls. Social connectors predominantly shared and stated they were more willing to share positive and pleasant rather than negative or unpleasant content. Content that is perceived to be smart or funny for example is expected to reflect positively on the sharer, making one look more smart or funny as well. Moreover, it seemed important that the content has a special or else unconventional attribute to it.

Similarly, social connectors would not share content when they perceived said content might reflect negatively on them. That could again depend on content characteristics; for example, perceiving content to be boring, dictative, “preaching” or “ pointing out flows in others’ behavior ”, to give but a few examples. Moreover, social connectors would not share content that might bring them in a state of cognitive dissonance before their audience, as for example pro-exercise content when they are not fit or anti – smoking content when they smoke.

7.4.1. THE CONTENT IS EXPECTED TO REFLECT POSITIVELY ON THE SHARER

7.4.1.1. UNCONVENTIONAL CONTENT IS MORE LIKELY TO BE SHARED A factor that was shown to condition social connectors’ choices to share or not to share some content on Facebook, and especially on their wall, related to whether there was a special, unconventional element to the content. From the analysis it emerged that unconventional content facilitates sharing [I1– I4, I6 – I9, I11 – I13, I15 ]. Under the family code unconventional a number of codes describing the content were grouped, like “exotic”, “special”, “inventive”, “creative”, “extreme” , “innovative”, and more that were closer to the content descriptions in vivo. For a full list of those codes, see Figure 7. Similarly, conventional, common content with no special characteristics was less likely to be shared, especially on walls.

The concept that unconventional content facilitates sharing emerged both during the first

[I3, I8 I9, I12, I13 ] and the second part of the interview [I1– I3, I4, I6, I9]. For example, the acro –yoga teacher that shared a lot of content related to his profession repeatedly stressed that this sports subject is very uncommon in Greece and that there are very few people busy with it. In turn, the organic vegetable grower talked about growing organically versus growing in “ the conventional way ” and shared a site that “ has very very nice recipes and... and usually special, with biological products some of them, or in any case with products... that we do not use in our everyday life, we are not used to look for in

83 our everyday life”. To give another example, one user that posted a lot of things related to a hobby of hers, yoga, said:

I8; while discussing one’s exercise related status

Ier: Do you do other sports other than yoga?

Iee: I do Tai Chi, I dance, I bike, I swim...

Ier: Would you post anything related to that?

Iee: Yes, I post quiet often about yoga... ok... like, what now, post about swimming? Haha

Swimming is a very common activity in Greece where the interviewee and her audience lives. The same thing might be exotic somewhere else. For example, other participants have commented on posts giving a “Japanese point of view” or have posted a Dutch approach to a topic “because in Greece we don’t do such things”. Likewise with regard to health related and health promotion content, content that is regarded as conventional in a certain context is somehow not “Facebook material”. Below, some examples:

I7; while discussing one’s exercise related status

Ier: What about that? Would you share something related to running on Facebook?

Iee: Aaah, not really! (Laughs) It is not so interesting for other people!

I4; while discussing link 1

Iee: Well, probably I wouldn’t post it on my wall, either like it I guess, because this doesn’t feel like it is so special or unusual.. (Ok.) I don’t know, because I did not really go through this website, from the first sight, from what I can see, there’s plenty of websites like that. I don’t think anything special so I would share it or like it, or comment it or anything.

The quotation above refers to the pro-exercise e-health program. This participant’s view well represents almost all participants’ view of e-health programs. Although, unlike this social connector, others noted that they might “Like” or comment on e-health program contents when these would be posted by Facebook friends, this would be obviously difficult when almost no one appeared to be willing to post them in the first place.

As we will further discuss under “Practical Value” (see 7.5.), both e-health programs and viral health promotion videos were often perceived to be practically valuable, which facilitates sharing on Facebook. However, while e-health programs were seen as “Practically Valuable” alone, the viral health promotion videos were coupled with characteristics that added to one’s favourable image construction, or evoked emotional 84 arousal. That seemed to make a critical difference in social connectors’ willingness to post them on their wall. From the analysis emerges that in order for content found on the internet to be posted on walls, there has to be a creative, innovative, or provocative aspect in the content, an aspect that would make the content stand out. That can relate to the content format, e.g. whiteboard animation video instead of plain text, or to an innovative approach, as with the “smoking kid” video that used kids in a surprising manner that brought people in a state of cognitive dissonance. If the content is perceived to be useful for a real life issue but is not perceived to include such a creative/innovative component, people seemed to prefer sending it in a PM to someone it seems relevant to instead of posting it on their walls.

V The content is perceived to be extreme V The content is perceived to be abnormal V The content is perceived to be provocative V The content is not perceived to be conventional/common V The content is perceived to be exotic V The content is perceived to be inspiring V The content is perceived to be special V The content is perceived to be impressive V The content is perceived to be innovative V The content is perceived to be inventive V The content is perceived to be creative

FIGURE 7: PRIMARY CODES IN FAMILY CODE “UNCONVENTIONAL CONTENT ”

7.4.1.2. POSITIVE CONTENT IS MORE LIKELY TO BE SHARED Social connectors almost always shared and stated they were more willing to share positive and pleasant rather than negative or unpleasant content. Out of the 60 shares discussed during the first part of the interview, only a few exceptions leaned towards the negative end of the continuum: a poem on relationship related stress [ I1], an image and an article of political content [ I9 ], and a short, user generated text disapproving a certain anti-social behavior that occurred in a self organized public event [ I10]. Except for social connectors’ preference to share positive content being reflected in the content they actually shared on Facebook, several interviewees also made this idea explicit [ I2, I7, I10,

I11]. For example, a social connector [ I10] says: “ Generally on Facebook I like to… to… share my good moments… mostly (…)”. The quotations linked to this point mostly relate to social connectors’ reactions to the anti-smoking content, which was the prevention topic included in this study and in a couple of instances to link number two (pro-exercise content) which was perceived as “ didactic ” or being “ about diseases ” by no more than a couple of interviewees. Below, some quotations are extracted to illustrate this point.

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I10 ; while discussing link 2

Iee: I don’t know if I would post it...at some points it is very didactic...ok I agree with his opinion of course but very didactic and I think that people do not need to be told...”so...do this because smoking the whole day and lying down all day does not help you”. Eee... I mean people I think react a bit to showing them in the mirror how they have become...just tell them....what is good...without showing them the bad...I don’t know...that’s how I feel..

I11; while discussing link 3

Ier: So on a scale from 0 to ten, how likely would it be…

Iee: To post it? Not much, around 7-8, not because I do not like it, simply because… I think that… to make someone healthy… exercise all these, you shouldn’t mention something about smoking, if he smokes, you have to let that go, take him with you go to the mountain, go that way, to see that everybody does not smoke and feel disadvantageously that he smokes..if you send him something…if I post something on my wall about smoking, I don’t want to post…It is not the method I work with, do you understand? Even if it was something against smoking, I probably wouldn’t post it…because it would have the word smoking there.. smoke.. I wouldn’t post it on my wall… not I wouldn’t post it, I would think about it veeery much, I would have to like what I read really a lot…to post it (Nice.) I wouldn’t say…No, I wouldn’t mention smoking anywhere. I would post for example an excursion in the mountain, instead of posting this on smoking. Interestingly though, results from our empirical study show that link 4, the short anti- smoking viral video had the most favorable responses from participants, despite its prevention focused theme. If the interview ended with link 3, then we might have been left with the impression that smoking cessation is not a topic that can be communicated through Facebook, except maybe through personal messages to family ties, partners or people that one knows they want to quit. However, link 4, a “smart” short anti-smoking video that evoked emotion and was “not preaching” was rated as most participants’ favorite link, which they were willing to post on their wall, like or comment upon. However, it is rather true that smoking cessation in itself is a topic that hinders sharing. The fact that link 4 was so well accepted was not because of its topic; it was despite of it. Our interpretation is that prevention focus content can hinder sharing on Facebook and that link 4‘s success was rather due to other facilitating factors; seemingly, it is possible to confine this obstacle by hitting other buttons.

Choosing whether one will or will not share some content seems to also depend on perceived content characteristics and whether these are thought to add to one’s positive self –presentation (J. Berger, 2013; Schlenker, 1980). It could be hypothesized that some general, positive characteristics will overall facilitate sharing; most people would like to look more smart or funny than otherwise for example (J. Berger, 2013); however, content characteristics that facilitate sharing also depend on social connectors identity and the way they wish to construct their image; they can therefore differ per user (Schlenker, 1980).

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To come back to link 4, the short video evoked emotion but further, it was described as

“smart ” by several participants [ I3, I5, I8, I12, I15], and by others as “amazing” [ I1], 32 “impressive ” [ I9] or “ pedagogic ” [I11 ]. Over half of participants that did not perceive themselves as smokers were willing to post the content on their wall; this is quite interesting, as while link 3 was discussed, a smoking cessation web intervention, almost no one was willing to post it on his/her wall, because of its topic, i.e. smoking cessation. Two illustrative quotations are extracted below:

I5; while discussing link 4

Ier: So why this one yes and the previous one [link 3] no?

Iee: Because the second was smart and touching and I know in the beginning I said I wouldn’t post the first one because if someone wants to quit he will manage only if he decides on his own but the second video was too touching and smart not to post it.

Another social connector, that again said he would not share link three because of its topic, noted:

I12 ; while discussing link 4

Iee: The only reason I would post this video, is for the smart bit of having children …ask a lighter from… smokers, and bring them on the spot to realize what is going on.

Note, however, that just below half of the participants that did not perceive themselves as smokers still said they were likely to “Like” it, but not post it, because of the topic; they explained that they either did not feel personally involved with the topic [ I4, I14, I15 ] or that they would rather post something more positive on their wall [ I7, I11 ].

7.4.2. CONTENT IS EXPECTED TO REFLECT NEGATIVELY ON THE SHARER On the other side of the coin, when users perceive risk in relation to the content, i.e. they perceive it to be disfavored or not in line with the way they construct their image, they would not like to be associated with it, so as to avoid a disfavored image or one that does not help them express their identity. They would therefore avoid sharing such content and especially posting it on their walls.

The content has to be in line with one’s current behavior and image. Social connectors were reluctant to post content when said content was inconsistent with their behavior or image, bringing them in a state of cognitive dissonance before their audience; doing so could compromise their self – presentation. They would not post, for example, pro-

32 By a participant that identified himself as a pedagogue. 87 exercise content if they were not fit or anti-smoking content when they were smokers, even if they liked the content a lot.

Note again that this factor primarily influences posts on one’s wall; it is less relevant to “liking”, commenting, or sending content through a PM.

7.4.2.1. NEGATIVE OR OTHERWISE DISFAVORED CONTENT IS LESS LIKELY TO BE SHARED Our interview guide structure did not allow for the emergence of disfavored content characteristics with regard to general content, but inquired into favorable or disfavored perceived characteristics of health promotion content alone.

Examples of given health promotion content characterizations social connectors wanted to avoid being associated with was “boring” content, such as long text [ I2], content “of bad taste” [I15], “preaching” content [ I8, I10], or “didactic” and “strict” [I10]. Most of these characterizations referred to the e-health programs, with the exception of a social connector that noted that she would not post link number two, a pro-exercise video, as she found it “very didactic” and “preaching” [I10]. Similarly, another social connector said she would post the anti-smoking viral video on her wall because, among other reasons, she “liked the approach, that was not preaching , like you should quit smoking because of this and this and this, but with a smart way , made people themselves speak out the cons of smoking and confront this paralogism”.

Previously, we have seen that personal involvement is a factor that conditions social connectors’ choices to share or not to share content on Facebook; however one chooses which of the different activities (s)he is involved with should be discussed on Facebook. Choices signal identity (J. Berger & Heath, 2007, 2008) and social connectors would choose not to share some content on their wall when at the moment of choice they attributed characteristics to it they did not want to be associated with themselves. Even if said content fell under the themes they were personally involved with or commonly shared, it seems that they would likely not post it if they did not perceive it to add to their positive self-presentation.

For example, a social connector that typically posts content on yoga, said she would not share “the guide to yoga”, a sub link to be found in the NHS’s pro-exercise e-health program, as she perceived it to be “superficial” and “giving “a commercial impression”; however, she would “Like” it if someone else posted it.

I8; while discussing link 1

Iee: Because…I exercise many years and I want something more specialized, I mean I do Yoga many years… so… a guide to yoga I mean… It is very…superficial…but for someone else this might be very interesting.

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Similarly, a sports teacher that commonly shares content around sports and was remarkably positive in posting the pro-exercise whiteboard animation viral video, was at the same time remarkably negative with regard to sharing NHS’ pro-exercise e-health program, as he perceived it to be “commercial”, “not professional”, “written by ignorants” and as having “no identity”.

7.4.2.2. C ONTENT INCONSISTENT WITH ONE ’S BEHAVIOR OR IMAGE WILL NOT BE POSTED Social connectors were reluctant to post content inconsistent with their behavior or image, which could bring them in a state of cognitive dissonance before their audience, thus compromising their self – presentation.

All interviewees that perceived themselves as smokers or as not currently fit, mentioned they would not post anti-tobacco or pro–exercise content respectively [ I1 – I3, I8 – I10,

I13 – I15 ] even if they agreed with and liked the content a lot, exactly because it was not in line with their own behavior and image. We stress again that this emerged to be a strong barrier for posting content on one’s wall only . It was not related to “Liking”, commenting or forwarding content in a PM.

With only one exception [ I4 ]: when while the participant did not exercise, she said that she would post link number two as she perceived it to be personally relevant (“I thought, oh girl that’s a message for you, you are a couch potato hahaha”), as well as because of its practical value for the audience.

Below, some examples extracted from the interviews that illustrate this point.

I1; while discussing link 1

Ier: I want you to take a look and tell me if you would share that on Facebook .

Iee: mmm...no. (Why not .) I would read it, I would explore it, but ....because I do not usually make such posts. And it would be very weird I think.

Ier: What are “such posts”, could you describe this?

Iee: To describe....this...like I told you, because I do not usually make such posts and it is not like I show such an image of the healthy person that (missing, not audible word) for exercise? ....that promotes healthy life...eee yes, let’s say, it is not something that my audience expects from me.

Ier: What do you usually post? What does your audience expect from you?

Iee: I usually post more artistic or even political articles, or otherwise, that reflect the character and lifestyle I have outside Facebook... so based on these characteristics and very importantly my public interests, my audience would expect something of the sort

Ier: However, you do exercise; during the interview you mentioned yoga, pilates and dance

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33 Iee: I do. I just don’t go public with it... Not until my look resembles fitness

I3; while discussing link 4

Iee: Wow psychological war! Really! Wonderful video! Wow, ok, I have goose bumps, wonderful! Indeed...yes, this I would post!

Ier: Ok, same questions, on a scale from 0 to ten how likely would you be to post this?

Iee : eee ten out of ten!

Ier: On your wall?

Iee : Let‘s say nine out of ten because right now I don’t even want to quit let’s say..

Ier: Yes?

Iee At this stage I am right now I wouldn’t post it. Let’s say neither do I wanna quit. (1 line omitted) If I was either at the stage when I had quit or I wanted to quit I would post it 10/10.

I1; while discussing link 3

Ier: In which case would you share that?

Iee: If I quit smoking. (Why? )

Iee: Why...If I quit smoking I would post it? ( Yes. )

Iee: Because I think it would be ridiculous to post something like that since I am smoking

I13 ; while discussing link 4

Ier: so...tell me, why like it and not on your wall?

Iee: Because I am a smoker! (Laugh) Basically I do agree with the whole idea, and with the way they presented it, and that is how it is of course, and you know it is like that...but simply.. While you know it is like that, you continue doing it... there is no logic in the whole thing... so it would be kind of stupid to post it on my wall.... hahaha ....

Ier: Hahaha, I understand, ok, so on a scale from 0 to 10 how likely would you be to post this, how likely would you be to like it..

Iee: For a like, I would say 9...(Yes...) To post it on my wall.... 3 let’s say....

33 Note that the interviewee is obese 90

7.5. PRACTICAL VALUE Practical value refers to considerations of Facebook friends. All users expressed the idea that perceiving some content as practically valuable for an audience/recipient facilitates sharing on Facebook.

Practically valuable content offers trustworthy informational or emotional support that is tailored to a specific recipient or audience and conveyed in a content format that is quick and pleasant to review. For a full breakdown of the factor “Practical Value” to its contributing components, please see table 5.

When the health promotion content was on the table, social connectors often talked of its practical value. There were certain content characteristics that influenced their perception of said value; this related to whether they viewed them as generally useful, which depends on factors described below, importantly on whether some content was tailored to a recipient or audience, as well as on the trustworthiness of the source.

Based on these main evaluation points, the four health promotion links reviewed during the second part of the interview were seen as more or less practically valuable.

When comparing e-health programs with the viral health promotion videos, we see that in the case of e-health programs “Practical Value” is almost always the only value attributed to them or otherwise made relevant; that is there are often cases when content characteristics of e-health programs are brought up as compromising practical value as well.

We say “almost always” because there were cases when specific contents of the e – health programs were seen as more relevant, not due to practical value, so value for a Facebook friend, but due to personal involvement, i.e. relevance to oneself and his self presentation, as noted earlier in the report.

However, the overwhelming majority of social connectors interviewed for this study seemed to be scanning the e-health programs thinking if some of the content could be helpful for someone they know or if it fitted with a recently held conversation in order to send it to them with a PM.

The viral health promotion videos were also seen as practically valuable but this was not the only value attributed to them. They were also seen as adding to a favorable image construction, while the anti-smoking viral video was also seen as evoking emotion. That seemed to be giving them a clear advantage over the e-health programs. That said, the viral health promotion videos were most often seen as more practically valuable as well; their content format and way of conveying their message was less time and energy consuming, a sub factor that affects whether some content will be viewed as practically valuable or not. Their sources were clearly stated and profoundly not commercially

91 motivated, adding to the trustworthiness of the source. Finally, they were more often seen as “motivating” and “effective”, further adding to their practical value.

7.5.1. T HE CONTENT IS PERCEIVED TO BE USEFUL Content perceived to be useful seemed to offer informational or emotional support; content thought to save people money, time, improve health, motivate and inspire them or help them deal with stress. Content structure and format that made the content quick and pleasant to review was seen as more useful, as it was saving the recipient(s) time and energy. Further, perceived usefulness of the content also seemed to depend on whether the content was coming from trustworthy sources.

The pro-exercise e-health program was in some cases seen as useful, in providing with informational support [ I5, I10, I12 ]. A couple of quotations are extracted below:

I12 ; while discussing link 1

Iee: There are some people that do not know and do not have the money to go to a specialist that will show them how to compose an exercise schedule, what they can do, the good thing is... here you can find various programs to start working out, to ... start move your body... eeh...also some smart photos, some beautiful photos will attract someone’s eye ...to read the article and to be able to... think oh wow, like, what a body, I could also have such a body so I ‘ll start working out.

I5; while discussing link 1

Iee: I would share this, the “get fit for free” [sub link in link 1]. Because a lot of my friends tell me let’s go run there, let’s go run here... eeeh... this if it could find some stadium or some gym that runs all day etcetera, or where the guys won’t pay, as they are bachelors and sort in cash, I would post it immediately. If it was in Greece.

However, it should also be noted that the pro-exercise e-health program was the least well accepted or endorsed as useful. There were a lot of constructive remarks relating to its format and structure; A point that, as will be further discussed later, negatively affects perceived content utility.

The viral pro-exercise video was often seen as useful; it was described as being “ of general concern ”, “ encouraging ”, “ motivating ” and “ with a big message” about “a real life issue ” [ I2, I4, I6, I9, I11, I12 ].

With regard to the smoking cessation e-health program, all social connectors but two said that it would be useful for someone that already wants to quit [ I1– I6, I8– I11, I13 – I15 ] and in that case they would gladly send it with a PM. See for example the quotation below.

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I4; while discussing link 3

Iee: If I would know someone who had trouble with quitting smoking then I‘d probably send a message and I would send this link to him, for sure! If I would know someone like that, but I wouldn’t post it on my wall!

Also nonsmokers that had family ties or a partner that smokes said that they thought it would be useful to send them this link:

I9; while discussing link 3

Iee: My girlfriend that is so close to me… that I want her to quit smoking… and I find it useful…maybe…yes, I would recommend it to her. But I would probably send it to her with a PM though.

The remaining two participants also referred to the concept of utility but on the other side of the coin: they said that they did not find the anti-smoking e-health program useful, as they did not believe that one needs support to quit smoking, but one should just quit on his/her own [I7, I12 ]. Note that when one of these participants was informed that this is a free service, she became more positive to it.

I7; while discussing link 3

Iee: Because you just... pay for the product when you don’t really need it, I think...

Ier: No, this is not a product, this is a service from the National Health Organization of England, ehm…they support you in your effort to quit. [1 line omitted]

Iee: But it’s a free service. [Yes, it is a free service...for England] Aah... Ok, maybe I should share it...then let’s give it a 7.

Link 4, the short anti-smoking viral video was also described as useful by some participants in the sense that it affects one on an emotional level, thus making the content effective in bringing its message across [I1 – I3, I5 –I8, I12, I14 ]. See below for some illustrative extracts.

I14 ; while discussing link 4

Ier: Why yes? Why is it better than the previous page?

Iee [4 lines omitted ] it attracts you more than ...the page, e...and ... yes.. it is also shorter and it brings the message right through, that you have to quit...... e... that cigarettes don’t do you any good, you know it yourself, because let’s say as a smoker you would also say to a child to not eee.. I don’t give you a light... it is more striking...you understand? (Striking?) The message is direct... you understand? At once they make you realize your mistake.

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I6; while discussing link 4

Ier: Ok. So why do you give it a ten?

Iee: Because it’s a really consist message, I mean short time, very expli...explicativo... explicative... and because.... I think it‘s.... most of my friends will feel touched with that, so...like me... like made me think...and I am not really smoker... so I think they can reflect from theirselves...haha

7.5.1.1. KNOWING AND TRUSTING THE SOURCE Another factor that seemed to influence whether some content would be viewed as practically valuable or not, related to whether social connectors trusted the source. When users perceived the source to hold commercial interests they did not trust the content; accordingly, in these instances [ I4, I7– I9, I11, I12 ] after the interviewer informed them that no commercial interests were involved, their attitude became more positive and their intention to share increased.

Perceiving the source to hold commercial interests usually concerned either the pro- exercise e-health program as a whole or the “what’s your sport” test, with the exception of one user that had a similar perception of link three. An illustrative example is given below:

I4; while discussing what’s you sport test

Iee: I don’t believe it so much. I see only a (missing word) here, I see a game, a commercial photo … I don’t really trust their judgment here. Because you know, the idea is you made the test and the test tells you what sports would be best for you. (Yea!) Yea...But I don’t really believe in that, because I know how the game is played. It’s a commercial (missing word). So it’s going to pomp up, because they pay for it. It doesn’t really matter if it’s really good for you or maybe not. They’re just going to put these places there because it’s just a pure commercial. (Aha) That is what I think.

Ier: That is not the case with this site, this site is from the National Health Organization in England, so it’s not commercial at all, there’s no commercial financing involved.

Iee: Ok, so that makes it different. So, yea... maybe I would share it or comment it…

When the barrier of the source being perceived as holding commercial interests emerged for the 6 th time for an NHS e-health program, with all quotations but one referring to the pro-exercise e-health program, the interviewer again explains that there are no commercial interests involved and asks the interviewee why this might be; “It gives a

94 commercial impression” responds the interviewee [ I8]. In this study, it seems that NHS’ ambition to host an attractive, fully illustrated designer page kind of backfired.

On the other hand, the one participant that was familiar with the source (National Health Service of England) held a positive attitude towards the pro-exercise e-health program:

I14 ; while discussing link 1

Iee : I know it (NHS) because I went there...otherwise...look if I was involved with... running...with exercise in general because now I don’t do it, and I was also looking for stuff like that in the internet, yes, I would share it because...eee I think it has good things, I mean it won’t be something stupid to share...so ...yes.

But why is it that none of the viral health promotion videos were perceived to be commercially motivated? A possible explanation is that in these YouTube videos, a channel where everybody can upload videos for free, the source was explicitly mentioned and even depicted in a personalized manner. More specifically, the pro-exercise viral video is presented by the source who introduces himself right at the beginning: “ Hi, I ‘m Doctor Mike Evans and welcome to the visual lecture I call 23 and a half hours”; while a sketch of him appears in the whiteboard animation video (see figure 8). He then continues by saying “ I have a big interest in preventative medicine ” and concludes that the best thing one can do for his health is exercise, such as walking. It is clear that no commercial interests are involved. Same for the anti-smoking viral video, that clearly states a public foundation as its source (i.e. the Thai Health Promotion Foundation), and conveys a public health message pronounced by the public, and elicited by its young associates, who are again featured before the curtain falls (see figure 9). The anti smoking video is also profoundly low budget, as noted by one of the interviewees “ And it’s real cheap advertisement, you don’t have, you know, to spend a lot of money on that ”.

FIGURE 8: DR. EVANS FIGURE 9: THE “SMOKING KID ” PROTAGONISTS

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7.5.1.2. CONTENT STRUCTURE AND FORMAT Deciding on whether some content is practically valuable seems to also depend on the content structure and format. The content being quick and pleasant to review was found to act as a facilitating factor, as it is saving people time and energy.

When looking at content already shared by the social connectors interviewed for this study, we see content format that is quick and pleasant to review; details on that will be given next.

When looking at their responses during the second part of the interview, we see that the viral health promotion videos hold a major advantage over the e-health programs because they are in a video format. That makes them faster and more pleasant to review than the busy, textual e-health programs, but besides the video format other creative, pleasant elements are also at work here. The objective is that the content does not take long to review and is not tiring, so short text might very well be preferred than long videos. Perceived long video duration and fast information flow was shown to hinder sharing on Facebook; the main findings is that the message has to be concise.

7.5.1.2.1. CONTENT QUICK &P LEASANT TO REVIEW Over half of the content discussed from interviewees’ activity logs was either plain images or images that involved short text, e.g. quotes, brief information or messages. From these images, half were photos taken by Facebook users and the rest images found elsewhere on the internet. Other than images, the most common content format shared was short text, Facebook Pages and short videos. Videos that were shared by social connectors in this study had a mean duration of 1.9 minutes, with the shortest one being five seconds long and the longest one 3 minutes and 44 seconds. Figure 10 presents the content already shared by social connectors, which they chose to discuss with us during the study, in terms of content format characteristics.

3% 2% Images

10% Images with short text 28%

Short videos 16%

Music 3% 7% 30% Short text

FIGURE 10: CONTENT FORMAT ANALYSIS OF ALL CONTENT SHARED DURING THE FIRST PART OF THE INTERVIEW . 96

Videos seem to appeal to Facebook social connectors as a content format, especially when they are short and concise. During the second part of the interview, when interviewees were presented with four health promotion links, it emerged that videos as a content format facilitate sharing [ I1, I2, I4 – I6, I9, I13 – I15 ]. In several instances participants brought up this facilitator while comparing it with long text, as this is another, “ boring ” way to give a lot of information.

I2; while discussing link 2

Iee: Ahhh, well this one I like it, because for example it’s a video, so it’s more like… active, and I really love this kind of video, that they, like, start to write and then they talk and then I don’t know. It’s better than to read anything or whatever. It’s not so boring I think...

I4; while comparing links 1& 2

Iee: First of all, this is a video, it can, I guess, appeal to everybody. There is maybe a few people who can say they really exercise as much as they want and they don’t realize how small they have to do, to make a change and the other website is especially like, England oriented and has a lot, I don’t know, of information that you actually have to search for. This video is only 9 minutes, everybody is going to enjoy watching it, and with a big message, international message that can apply to everybody. That’s why I‘d share this video instead of this other website [i.e. the pro-exercise e-health program].

I5; while discussing link 2

Iee: Also it is easy to follow, it talks about an issue that usually is boring and nobody bothers and he managed to make it, through sketch and caricature, much easier to follow...

I14 ; while comparing links 3& 4

Ier: Why yes? Why is it better than the previous page?

Iee: Eee... and for me... and for those I would share it with, it is simpler, it is a video, you do not need to sit down and read, you put in on, it is very short, you see it and...it is over...rather than sitting down and reading a whole article in a webpage and indeed one that might have more...not terminology but you understand....that is more difficult...this is a video...you see a child doing something...it attracts you more than ...the page, e...and ... yes.. it is also shorter and it brings the message right through, that you have to quit...... e... that cigarettes don’t do you any good, you know it yourself, because let’s say as a smoker you would also say to a child to not eee.. I don’t give you a light... it is more striking...you understand? (Striking?) The message is direct... you understand? At once they make you realize your mistake

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7.5.1.2.2. C ONTENT TIME & ENERGY CONSUMING

While discussing the e-health programs during the second part of the interview, it emerged that long text is seen as a barrier, as it is providing with too much information. Said barrier especially came up while the pro-exercise e-health program was discussed

[I1, I3, I4 I5, I9, I15 ], which comprised of numerous articles, categories and subcategories, applications, pictures and many more that were related to exercise. Generally, this link seemed to appeal the least to the social connectors interviewed for this study. Except for being commented as “busy” in terms of textual information overload, it was also noted that the site was full of pictures and intense colors, so one “can’t really focus anywhere”.

Just before leaving the e-health program page to move to the next interview topic, the interviewees’ attention was brought to a sublink within it, called “what ‘s your sport” with a caption reading “find out which sport you ‘re best suited to with this short psychological and aptitude test”. The interviewer was explaining that the test, other than indicating which sport fits one best, also gives information on where could one practice it, based on place of residence. There was a marked difference in social connectors’ responses on sharing the test alone as compared to sharing the busy pro-exercise e-health program containing it. Importantly, although the test was very well accepted and many participants would be willing to share it on Facebook, only one participant noticed it in the busy site before the interviewer particularly drew their attention to it.

I15 ; while discussing “what’s your sport test”, within link 1.

Iee: Yes, I might share it, yes. If it was, not this whole page but this particular one, more clear this particular part of the webpage, yes. Because it is interesting.

More extracts that pertain to “what ‘s your sport test”, shedding light to characteristics that make it “interesting” or Facebook material will be given under 7.5.2.

The video format was apparently preferred over long text; however giving too much information still emerged to be a barrier, even when it was given in such a format. When the ten minute pro-exercise viral video was reviewed, only six out of fifteen participants got engaged enough to see the whole video. Note that everybody was told he/she can watch as much as he likes beforehand. The nine participants that did not watch the whole video saw an average of 3 minutes, with a range between two and a half and four and a half minutes. Video duration was mentioned both as a factor that hinders sharing, while discussing the pro-exercise viral video [I8, I10, I12, I13 ], and as a facilitator, when discussing the anti-smoking viral video, which was a ninety seconds long [I1, I6, I13, I14 ]. Below, some extracts that illustrate this point.

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I12 ; while discussing link 2

Iee: The only reason I wouldn’t post it, and that is why I say 3, is that it is long. There is no chance that they would sit down...that a fairly big percentage of people would sit down.... from those that I have on Facebook, my friends, to see such a long video. (Very nice) They prefer a picture or a very small video...it is not a song, that you can let it play and be busy with something else, you have to be there, for ten minutes.

I13 ; while discussing link 2

Iee: If it was around three minutes, I would most probably sit and watch it all (Aha...) Because I saw it was around nine minutes and it went really fast, I gave up.

Fast information flow was also seen as a barrier by some participants. As noted in the extract above, apart from its duration, the whiteboard animation video was also perceived to “ go really fast ” and be “ tiring ” to some [ I13 – I15 ]. However, most participants found the video useful and the content format pleasant [ I1 – I6, I9, I11, I12 ]. Maira, for example, a participant from Brazil, said:

I2; while discussing link 2

Iee: I think this kind of information they are like, very important because normally they are just in scientific paper, the population cannot eehh, I mean, they can read, but for example, I would never read aaah, a scientific paper about health. Because I have to read a lot of other scientific papers, in my area (laughs)... but this is true, when you‘re like...free, you don’t want to read scientific papers, you just want to read like...things in the internet that you like it, bla di bla, and when people find this kind of information in a funny video, real huh...how to say...easy to understand, with numbers, graphs... and then make things more like...ah...attractive, and then you can get more information. Because you don’t need to read the scientific paper with all the methods and bla bla bla, so it’s very nice.

7.5.2. THE CONTENT IS PERCEIVED TO BE RELEVANT TO THE AUDIENCE /RECIPIENT All participants at some point during the interview mentioned they would be willing to share content on their wall, on a friends’ wall or through a PM if they found said content to be personally relevant to a specific audience or recipient respectively [ I1– I15 ]. Essentially, what users described as useful or personally relevant to the audience/recipient largely co-occurred. Clearly, users thought that it was useful to share content personally relevant to their Facebook friends, thus offering them tailored informational or emotional support.

PM S TO HELP FRIENDS All participants mentioned they were willing to forward content that they found relevant, i.e. useful or otherwise interesting to someone they know in a PM [ I1 – I15 ]. Most commonly, participants would be willing to share content with someone in a PM if said

99 content related to a previously held discussion [ I1, I3, I5, I9, I10, I12 ]. Moreover, users described content as personally relevant to someone when said content was relevant to their profession [ I2, I9, I11 ], their hobbies [ I1, I3, I5, I6, I11 ], other personal interests [ I2,

I14 ], personal characteristics [ I9] or special needs [ I2, I9]. Further, when some content was in line with the recipient’s views [ I2].

P OSTING PERSONALLY RELEVANT CONTENT TO A FRIEND ’S WALL The above also seem to facilitate sharing content on a friend’s wall. However, we should note that in order to post content on a friend’s wall, said content needs to also reflect positively on that friend; content that is useful for him/her but is not unconventional, surprising or making him/her look good in any way, would likely be sent through a PM instead.

P OSTING CONTENT USEFUL TO ONE ’S AUDIENCE ON HIS /HER WALL Further, all interviewees mentioned that they would share content on their wall when they found some content to be personally relevant to a wider audience, or else for big part of their Facebook friends, as well as the other way around [I1 - I15 ]. That often was related to whether social connectors perceived a lot of their friends would be interested in a given topic or not, to whether the content was only relevant for certain countries or regions, or to whether it was in a language most of their friends did or did not speak. Localisation of content, i.e. whether the content was linguistically and contextually adapted to be accessible to a local audience was an important factor to be considered when deciding on whether to post content on one’s wall. For example, content posted on walls and considered to be relevant to the audience related to activities at one’s living environment, e.g. at one’s hometown [ I1, I2, I5, I6, I13 ]. To give a more specific example, a social connector posted a poster of a book bazaar in her city that she attended; one of the reasons she gave for that is that given that most of her Facebook friends also live there, it would be useful for them to know about the bazaar, that had interesting books in very low prices [I13 ]. Another social connector said that she had Facebook friends’ lists categorized by country of residence and she noted that she posts content only for the groups said content would be relevant to [I6].

7.5.2.1. H EALTH PROMOTION CONTENT : WHEN WAS IT SEEN AS RELEVANT TO AN AUDIENCE /RECIPIENT The concept of relevance to the recipient or wider audience emerged numerous times while reviewing the health promotion links.

While reviewing the pro-exercise e-health program, half of the participants noted that they might share something that related to a recent discussion or is otherwise relevant to

100 someone they know with a PM [ I1– I3, I9, I10, I12, I13 ] and two of them mentioned they might, under conditions, post a sublink they found relevant to a wider audience on their wall. Below, some illustrative examples:

I3; while discussing link 1

Iee: Let’s say that the previous day I had a discussion with John let’s say about gyms etcetera and food and fitness and all the rest, and the next day I bombed into this, I would sent it, let’s say, like... check this out let’s say, like a continuation of the talk we had yesterday.

I5; while discussing link 1

Iee: I would share this, the “get fit for free” [sub link in link 1]. Because a lot of my friends tell me let’s go run there, let’s go run here... eeeh... this if it could find some stadium or some gym that runs all day etcetera, or where the guys won’t pay, as they are bachelors and sort in cash, I would post it immediately. If it was in Greece.

Further, the “what’s your sport” test was often described as interesting exactly because it was giving a personal, tailored result to everyone [ I1, I10, I12, I13 – I15 ], indicating which sports fit one best. That made the “what is your sport” test seem relevant to a wider audience and thus “wall material”.

I1; while discussing “what’s your sport” test

Iee: Yes, I would post it. It is a test so there are more chances that someone gets engaged and spends time with it. Everyone looks for ways to define themselves, even in such ways.

I10 ; while discussing “what’s your sport”

Iee: Yea, sure, I would share it... for what reason (Tell me) Because... there are a lot of people that... are bogged down by their lifestyle and routine and ... have no inspiration on what to do to feel better.

When it comes to informational support, “what’s your sport” was often referenced as being useful [ I2, I4, I5, I12, I14 ]; or even as offering emotional support [ I10, I14 ]. It should also however be noted that several participants said that whether they perceived the “what is your sport” test as useful and were thus willing to recommend it to others would also depend on whether they had a direct experience with it and were satisfied with the result [ I3, I4, I5, I11, I15 ], while one participant said the same about link 3, i.e. the smoking cessation web intervention [ I3].

However, the “what is your sport test” had another feature participants were informed of; it asked test takers to submit their town of residence and referred them to the local

101 sport centres they could practice the sport found to fit them best. Being located in the National Health Service of England website, the test incorporated a drop down list with British regions. Several users noted that it would definitely be an advantage or that they would only share the test when countries where their friends lived in were included, so that relevant, localized information would be provided to them [I2, I4, I5, I6, I10 I12 I14 ].

Similarly, several participants noted that they found the pro-exercise viral video to be of

“general interest”, so relevant to a wider audience [I2, I4, I5, I6, I9, I11 ] and said that they would post it on their wall; except for one participant that would only “Like” it, as “she doesn’t like to share a lot of things on her wall”. One of the reasons the fourth interviewee gave for example for willing to post it was that it has “a big message, international message that can apply to everybody ”. The anti-smoking viral video was also viewed as of general appeal, especially among social connectors that either had a lot of friends that smoked or were otherwise concerned with the topic [I2, I5, I6, I8, I9].

7.5.2.1.1. A CCESSIBILITY OF LANGUAGE Whether some content would be perceived as relevant to the audience or recipient was also found to depend on linguistic factors; put simply, on whether the content was in a language the audience understands [ I2, I3, I5, I6, I9]. That relates to the language barrier, so whether the audience, or the recipient in the case of a PM, speaks the language written/spoken in the content and secondly, to the accessibility of the language used in terms of scientific terminology or otherwise “ difficult language ”. As noted by interviewees, if the content is “ easy to understand ” it can be more “ attractive ”, thus facilitating sharing. A couple of illustrative examples are given below.

I2; while discussing link 4

Iee: This one is nice; if it had subtitles in Portuguese, I would share in my timeline

I6; while discussing link 2

Iee: the information is very complete...I mean …..Something basic...I mean everybody knows that exercise is good, they say it in a way which is scientific, also, and with a common language, so I think it could be very interesting for most of the people.

7.5.2.1.2. I S THE CONTENT TAILORED TO ONE ’ S BEHAVIORAL CHANGE STAGE & HAVE SOCIAL CONNECTORS BEEN “ INV ITED ” TO HELP ? A factor that seemed to condition social connectors’ choices on whether to share health promotion content with their friends was whether said content was not only relevant, but tailored to their current concerns and goals or even matched with their current behavioral change stage. Almost all users agreed that they would only send link 3 in a PM 102 to someone that they knew that already wants to quit smoking; most of them also took the time to explain they thought it would be useless to forward smoking cessation content to people that are not already in the stage they want to quit. Below, some illustrative examples:

I4; while discussing link 3

Iee: I think this website would be good for people who actually decided to quit smoking.. or they feel uncomfortable with smoking.. They wanna do something about it. Because in general, for any smoker, they won’t probably take time to go deeper in it, cause they don’t feel like quitting.

I10 ; while discussing link 3

Iee: I would only share it if someone asked me for help around this. Because like I said before, I think when you say something to someone that he is not concerned with at the moment, he is not going to listen.

Interestingly, in another instance, while discussing the “Smoking Kid” video, a user said that it would be useless to forward it to a user that already wants to quit.

I1; while discussing link 4

Ier: To your friend that tries to quit smoking ... and failed after three hours [ The interviewer refers to something mentioned during the first part of the interview ] would you send... Iee: Probably not. (Why not?) Because she is already trying to quit, which means she understands why she wants that, I do not need to convince her that she forgets while the children...what the video shows, that they don’t remind themselves. She is already in that stage ”.

To give a final example, this time from the part of the interview when posting the pro- exercise viral video was discussed (i.e. link 2), a participant that was already for years into exercise, and so were most of her friends, commented that the video did not have much to add for them, so she did not “need” to post it. See below for the quotation in vivo.

I8; while discussing link 2

Iee: So for two and a half minutes he was talking about the problems for which he has the solution, and now I think he wants to say that the solution is exercise. (Nice, that’s what he will say indeed ) I agree... but I know that....and also most of my friends know that... so I do not think I need to post this Hahaha”.

7.5.2.1.3. T IE STRENGTH IMPORTANCE IN PRIVATELY SHARING PREVENT ION HEALTH PROMOTION MATERIAL Previously, we discussed our finding regarding to how health promotion content is made relevant to friends according to whether it matches their current behavioral change stage and according to whether they have expressed willingness to change. This is a condition under which social connectors appeared to be happy to forward health promotion content to Facebook friends.

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Especially with regard to forwarding the anti-smoking e-health program, almost all social connectors spoke of either friends that already want to quit either of partners and family ties [I2, I3, I4, I7, I9, I15 ]; even close friends were mentioned only twice and sharing would always be private, through a PM. About the underlying mechanisms forming this condition, the social connectors participating in this study spoke of utility, i.e. they said that it would be useless to sent the anti-smoking e-health program to someone that does not want to quit, but also spoke of social risk and motivation to help; the idea was that first, offering help uninvited might compromise social relations with weaker ties. Tie strength seems to be important when deciding on forwarding or not such content. Moreover, they seemed more motivated to help their family ties and partners to quit, and some noted that in these cases they were also “affected” by it, i.e. by their loved ones smoking behavior. Some illustrative extracts are given below:

I9; while discussing link 3

Ier: Tell me what comes to mind about this; tell me if you would share it.

Iee: Well, I find it quite useful… eh..I am not a smoker to be troubled or concerned… for myself, I might go through it to see if I can give some advice or address my mother primarily, or someone else from my friends… mostly from my family actually, or at most my girlfriend…. Yes, yes to my girlfriend that also has Facebook cause my parents don’t [4 lines omitted] My girlfriend that is so close to me, that I want her to quit smoking…and I find it useful… maybe…yes, I would address it to her. I would probably send it to her with a PM though.

I7; while discussing link 3

Ier: Anyone that you care about that smokes?

Iee: Not really, no one in my family smokes.

I15 ; while discussing link 3

Ier: Any people that you love and smoke?

Iee : I know people that smoke but loved ones loved ones… I have my brother… but I don’t see him every day … every day I mean, to have a problem in front of my eyes, let’s put it like this… ehm… I know that smoking is a problem… but I know that everyone starts… it starts from yourself to quit… otherwise no matter how much the other person tries he cannot manage anything… it has to be you that… if Sergio ( i.e. her partner) smoked, I might be struggling with this more… but… that I live with him, we live together etcetera… Ier : Under which circumstances do you think you would share that? Iee : If my boyfriend smoked and I wanted to make him quit let’s say, something like that… (…)

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Below, another extract that refers to the concept of tie strength importance in sharing smoking cessation content: During the first part of the interview, the participant mentions a Facebook friend that tried to quit and gave up after three hours; in the extract below, the user responds to the interviewer’s question on whether she would share link 3 with this friend.

I1; while discussing link 3

Iee: Maybe but more as a joke. It’s also a matter of relationship, what kind of relationship do I have with this girl. If she was a friend that was closer to me maybe I would do it more easily, now...mostly if we were talking and laughing about that, I would do it.

There were three exceptions, when social connectors were willing to PM the anti- smoking e-health program with friends uninvited [ I14 ], or willing to post it on their wall

[I6, I8] for their friends to see.

The social connector that said she would share link 3 with a PM to friends uninvited explained: “ I have friends that smoke and I would like to encourage them to quit ”. When she is asked if she would send it without them having told her that they want to quit, she responds: “No , I would send it like this…Why should I ask them, haha !” Another two social connectors said they would be willing to post the anti-smoking e-health program on their walls. One of them had recently quit smoking herself and would like to motivate her friends to quit, too. The second one said she would send it to a couple of friends she knows they want to quit smoking, but she would additionally post it on her wall. As she explains in the extract below:

I6; while discussing link 3

Iee: Because, well, a lot of my friends smoke and I don’t know, but I am quite sure that many of them, they have tried to quit sometime in their life. So maybe if they are interested, they will open it and they will read more.

If she would post link 3 on her wall, she could also tag the couple of friends she said she knows they want to quit smoking; but she will not, she will send it through a PM, separately. She notes:

I6; while discussing link 3

Iee: Because I won’t put their names in…in...how you say? That everybody can see .. That I am sending to them, no it’s not proper.

If Facebook walls are spaces for positive self-presentation, then it is understandable that tagging friends in content that points out flaws in their behavior, thus making it publicly visible on their wall, would not be “proper”. All participants mention that in the cases 105 that they would send smoking cessation content to someone, they would do so in private, with a PM.

7.6. EMOTIONAL AROUSAL Another finding of this study is that sharing content on Facebook is facilitated when said content arouses emotion [I1 – I3, I5, I6, I9, I10, I12 – I14 ].

As it emerges from the first part of the interview, i.e. when social connectors’ recent Facebook sharing activities were discussed, almost half of social connectors either disclosed their current emotional state through posts or liked/commented on said content to express empathy or otherwise emotional contagion in response to their friends’ self – disclosure [ I1 – I3, I5, I6, I10 ]. Users also shared content they found on the internet that evoked arousing emotions. In half of these cases this was content they found funny; besides amusement, arousing emotions evoked by content shared include surprise, awe, excitement, anger, relationship related stress, studies’ related stress, fear or embarrassment [I1, I2, I5, I6, I9, I13, I14 ].

Note that while content that related to “specific others”, like content that brought good memories with friends, was often described as content that evoked emotion, it will be discussed later in the analysis; in these cases the emotions described were linked more to the source or people depicted in the content rather than the content itself.

Whether some content evokes arousing emotions seems to condition social connectors’ choices to share health promotion content as well. During the first part of the interview, a health promotion video that evoked emotion was discussed; that was a 3:40 minute you tube video by the Mimi foundation; a profoundly emotional and surprising video, part of their cancer awareness campaign. The item was first posted on Facebook by one of the social connectors’ friends, then shared again on her wall. But said factor especially emerged when the anti-smoking viral video, i.e. “The Smoking Kid” was reviewed.

The “Smoking Kid” is a 96 seconds you tube video, part of Thailand’s anti-smoking campaign and in this study it was rated as all but three participants’ favorite link, which they were willing to post on their wall, like or comment upon. Out of these three participants, one still gave the video a high rating but just preferred the “what’s your sport” test, clearly because of the prevention focus of the topic. Moreover, out of the couple of participants that said they did not intend to share this link one noted: “ I wouldn’t post it, I don’t know if anyone would be touched with this ” only to highlight that content that evokes emotion indeed facilitates sharing.

Whether the health promotion links evoked emotion was not a topic in the interview guide; nevertheless the point that the “Smoking Kid” evoked emotion was brought up as 106 a facilitating factor by most participants [I1 – I3, I5, I6, I10, I12, I14 ]. Other factors that seemed to contribute to its popularity were that the content was perceived to be smart and that it had an unconventional, surprising approach.

I5; while discussing link 4

Ier: So would you share that on Facebook?

Iee: Yes! Yes! 10, because I found it very very smart, very very smart, and it is also a bit, you know.... not touching, you know, it gets you here [the interviewee puts her palm on her heart] in a way that...wow! Hold on! I child gave me something ...that clearly says I m a hypocrite... so why shouldn’t I give to him? What ‘s the difference?

Moreover, often participants pointed out that they considered this approach to be more effective [I1 – I3, I5 –I8, I12, I14 ]. In a way, one can say that evoking emotion to the audience is speaking in a language the audience understands.

I6; while discussing link 4

Ier: Ok. So why do you give it a ten?

Iee: Because it’s a really consist message, I mean short time, very expli...explicativo... explicative... and because.... I think it‘s.... most of my friends will feel touched with that, so...like me... like made me think...and I am not really smoker... so I think they can reflect from theirselves...haha

I14 ; while discussing link 4

Ier: Why yes? Why is it better than the previous page?

Iee: Eee... and for me... and for those I would share it with, it is simpler, it is a video, you do not need to sit down and read, you put in on, it is very short, you see it and...it is over...rather than sitting down and reading a whole article in a webpage and indeed one that might have more...not terminology but you understand....that is more difficult...this is a video...you see a child doing something...it attracts you more than ...the page, e...and ... yes.. it is also shorter and it brings the message right through, that you have to quit...... e... that cigarettes don’t do you any good, you know it yourself, because let’s say as a smoker you would also say to a child to not eee.. I don’t give you a light... it is more striking...you understand? (Striking?) The message is direct... you understand? At once they make you realize your mistake.

7.7. SOCIAL BENEFITS This last factor refers to sharing activities that were motivated less by content characteristics and more by one’s desire to connect with specific and “similar” others.

Users follow, “Like” and comment on content posted by ties they want to keep in touch with or get closer to, i.e. specific others ; therefore their choices to share content in these 107 ways is also influenced by whether they are interested in the Facebook user that posted the content.

It was also shown that social connectors follow “similar others”, i.e. peers or experts in a field of interest; the distinction from specific others is made here because the emphasis was put on content consistently shared by these experts or peers, content that was useful to social connectors because of personal or professional interests. By following these users, social connectors seemed to satisfy their need to learn and grow in their field of interest, (e.g. healthy cooking, organic agriculture, acro-yoga) or/and their need to belong in a community with similar others. This factor is mainly relevant to reactive Facebook sharing activities, i.e. use of the “Like” button or commenting, and less to posting content on one’s wall.

Note that Social Benefits were especially relevant to “health related” content posted by other Facebook users who were “Personally Involved” with the content.

Social Benefits were also mentioned as a factor conditioning some interviewees’ choices to share an e-health program, i.e. some said they would “Like” or comment on the links when these were shared by another Facebook friend [I2– I4, I8]; and indeed depending on whether (s)he was a good friend or whether (s)he was known to indeed be interested and involved with the topic [ I3 ]. It would be challenging to “Like” or commend on e-health programs posted by Facebook friends however, when almost no one was willing to take the proactive step of posting them.

Summarizing, we found that reactive Facebook sharing activities, i.e. “Liking” and commenting on Facebook were often motivated by social connectors’ desire for “Social Benefits”, namely being close to “specific others” as well as connecting with “similar others” to learn, grow and belong.

7.7.1. BEING CLOSE TO SPECIFIC OTHERS A sub factor that seems to condition social connectors’ choices to share general and health related content on Facebook was “being close to specific others”. That relates to the goal of nurturing existing relationships, so keeping in touch with specific others or to the goal of getting closer to specific people one is interested in. This concept emerged in all but three interviews [ I1– I11, I14 ]. Following we will present a few illustrative examples; in the first example, the participant shared content, i.e. commented with short text, to come closer to weak ties she is interested in. After explaining to me about the initial post and her comment she referred to her motivation to share it:

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I6; general share 2:

Iee: ... Now you are going to ask why did I enjoy that... (Why?) Because I never made a comment to... with this girl, who I met recently, and because she is a common friend between me, Petros and Kostas, eeee, I wanted to comment on this status, I mean besides what I wrote, that is true, ...... eeh, yes, that. I wanted to comment because.... it would bring me closer in a relationship on Facebook, to be able to comment on each other. You understand? (Who is Petros and Kostas?) Petros is a boy I am interested in and Kostas is a friend of mine.

In the following example, the participant “Liked” content which brought good memories with a friend. Indeed, content that brought good memories with friends was very commonly shared. [I2– I5, I7– I11, I14 ].

I4; general share 1

Iee: Do you see that photo where there’s an old man with a girl playing chess? (Yes, I see it) Yes, I enjoyed this a lot because this is a situation from many years ago; and this is my very good friend; and she was playing chess with this old man, it was cute. It brings me memories; I liked it.

7.7.2. C ONNECTING WITH SIMILAR OTHERS Differentiating between “specific” and “similar others” throughout the analysis depended on what seemed to drive the interaction; was it the urge to interact with specific people, either those were strong or weak ties or was it homophily, i.e. the drive to communicate with people with common interests and characteristics as oneself?

In many instances during the interviews it was clear that the shared content fostered connecting with a group of Facebook users holding a common interest and the emphasis was put on said interest rather than on the people involved [I4, I5 I7, I8, I12, I13, I15 ]. Most of the times, this seemed to serve in improving one’s understanding in a topic of interest or was linked to a rewarding sense of community between people of the like profession/hobby etcetera.

There were several instances when users referred to content that fostered connecting with a group of “similar others" of the like profession or hobby [I4, I5 I7, I8, I12, I13, I15 ]. Interestingly, in this study most of the times these referred to health related professions and hobbies [I4, I8, I12, I13, I15 ], while there were still some examples related to other professions and hobbies [ I5, I7, I9, I10 ] as well. Below, two illustrative examples:

I5; General share 1; discussing a video she posted about a video game she plays.

Ier: Why did you enjoy sharing that? Because

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Iee: Because I learned that the two people that commented on the video had the same interest as myself and we started talking about this game and I also learned to play better through this.

The following example refers to a post the user made, asking a question around a trendy card game’s rules. The user could not find the information online, and because she “ knew that many people play ” she decided to ask on her Facebook wall. The post got 38 comments.

I5; General share 2

Ier: Why did you enjoy sharing that?

Iee: Eeh, because I saw that people that play Titsou etcetera, when they see something, at once they respond...they want to respond. I mean, even if they don’t know me well, they‘ll take the time to respond.

Ier: Which words come to your mind when you see all this?

Iee: All this? Collectivity. Because so many people took the time and responded at once, that maybe... in the street I may greet them and they might not even see me. And here they respond, and sat down and read all this and looked for the answer themselves to respond.

As noted before, in this study, when users referred to content that fostered connecting with a group of “similar others" of the like profession, hobby or other characteristics [i.e. gender, I13 ], they usually pointed at health related content [I4, I8, I12, I13, I15 ]. Below, some illustrative examples:

The first example is quoted by the acro-yoga teacher and refers to a picture featuring an acro- yoga pose where he was tagged along with 26 more acro – yoga instructors [Figure 11].

FIGURE 11: THE ACRO -YOGA PROFESSIONAL WAS TAGGED IN THIS PICTURE BY ANOTHER ACRO -YOGA PROFESSIONAL , ALONG WITH 26 SIMILAR OTHERS .

I12 ; General share 1

Ier: Let’s spend some time on this; tell me the whole story.

Iee: So...this particular photo is a photo posted by a friend in Thessaloniki...... who I met through the Acroyoga community. Eeeh...Acroyoga is the field I am working on, it is a subject that not many people do in

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Greece, and the fact that we have become one team and eeeh, she has the kink to post various photos and tag me and the whole group... it is something that on the one hand I like it because it indicates that we are a team and on the other hand it is good for the impact on my profile, on my wall, because it shows that I am also involved in [professional] activities outside the region.

To give another example, the organic vegetable producer discussed a Facebook page she “Liked”, owned by a regional biological food association. She explained that she follows the page to get updated with issues of interest; as she explains, with reference to biological food growing, until a year ago she ¨ did not even know what was going on¨ and following such Facebook pages was helpful; guided her in finding relevant pieces of information and get a better understanding of her topic of interest.

Social connectors holding health related professions referred very often to shares connecting with similar others. Four of the four shares discussed with the acro-yoga teacher during the first part of the interview related to similar others, namely acro – yoga professionals or his students. Same in the organic vegetable grower’s case; four out of the four shares discussed related to either customers or peers. We should note that these professionals stressed the fact that they spend an extensive amount of time on Facebook for professional reasons. Their responses indicated that their sharing activities were motivated by their wish to promote their products and services as well as connect with their customers and mentors on the field [ I12, I15 ].

Apart from the participants that held a health related profession, participants that held a health related hobby also seemed interested in “similar others” of the like hobby or even professionals of the sort. For example, a participant that referenced healthy cooking as her “new hobby” seemed attracted to other users that she perceived to be experienced cooks and said interaction seemed to improve her understanding and skills in her topic of interest. While discussing one of her shares, i.e. a picture of “healthy cookies” she says:

I4; General share 2

Iee: They looked really good, and since I started cooking, I love cooking since I moved to Krakow, I started cooking a lot, like crazy, I cook every day, can you imagine? I didn’t even know how to.. make eggs, fried eggs before and now I do like…crazy shit..? So my friend made these cookies and they are healthy for babies, and I enjoyed it cause I thought oh, it might be good to make some for Vicky [i.e. her baby daughter ], cause she likes sweets and I don’t want to give her only chocolate and stuff like that [4 lines omitted ].

Aaaam, so Angela I like her recipes, because she is the mum of two kids and she just had her second one, and she was always, since I remember like fanatic of cooking, she had all these books and stuff and I was… oh wow, cause I didn’t know how to do shit, so that’s why I like it, because I know she cooks a lot for her babies and she enjoys it, and since it’s my hobby right now, that is why it’s good to look up into her kitchen and see what is new.

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While the interview moves on to discussing health related shares, this participant chooses to discuss a humus restaurant Facebook page that she “Liked”. The “cooking adventure” story she tells involves a lot of cooking mavens, like the owners of the humus restaurant.

I4; Health share 2

Ier: So tell me whatever comes to your mind about this.

Iee: Ok, so I really like that because it reminds me of how my... (Subtle laugh) adventure started with cooking here in Krakow, I met two good friends of mine that really are into healthy way of cooking but really crazy healthy, so...huh.. Very crazy and they were telling me about this and...let ´s say markets or events I could go because they were going to any one of them or even find some products there.. So I started going to these events with them and through them I met this couple…The couple that runs this restaurant.

Interacting with people that have the same hobby as herself, on Facebook or offline, like with the couple that runs the “small humus restaurant” apparently helps her grow in her field of interest:

Ier: Do you also make your own humus at home?

Iee : (sounds excited) I did! After meeting her, I actually made my own humus! I love it.

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8.0. CONCLUSION AND DISCUSSION

8.1. REFLECTION The aim of this research was to identify Facebook mediated Word of Mouth Marketing strategies that can be used to increase the reach of e-health programs.

In doing so, literature research has been performed to provide insight into successful Word of Mouth Marketing strategies. We found a number of strategies that have been proven to be successful in the commercial arena, and could perhaps lend themselves to health promotion purposes as well. These strategies mainly focus on interactions with opinion leaders or existing “customers”, or on the viral agent development, i.e. the message content itself. We think they are relevant for but not limited to Facebook mediated Health Promotion communication. Health promoters can test the effectiveness of these strategies in generating word of mouth that is beneficial for health promotion purposes, be that online or offline. These results are presented under 6.2.

Moreover, literature research has been performed to provide insight into the state of the evidence regarding the use of viral strategies for health promotion in specific. Results show that there is a lot of room for future research in this area. Although testing viral strategies’ effectiveness for health promotion is strongly recommended by some authors that discuss the great unexploited potential of their use (B. Freeman & Chapman, 2008; Thackeray et al., 2008), studies having tested such approaches were extremely scarce. These unique studies however exhibit highly promising and positive results (Adam et al., 2011; Gosselin & Poitras, 2008), with the exception of one study that was poorly designed (Thériault et al., 2012). Besides the fact that these studies tested specific viral strategies for health promotion, leaving plenty of room for testing more strategies and techniques, it is important to note that no study has tested viral strategies for health promotion while seeding a viral agent to opinion leaders. This can be very important, with studies showing that targeted seeding to well-connected individuals can be up to 8 times more potent than other seeding methods (Hinz, Skiera, Barrot, & Becker, 2011). This gap in knowledge calls for the application of relevant, innovative research that will test this strategy. Although we think that Facebook is a suitable online environment to experiment with or apply viral strategies targeted to opinion leaders, it should be noted that these could be tested or applied in any other online environment as well.

Further, we performed an original empirical study. It is the first study in the health promotion field shedding light into what conditions social connectors’ choices to share health promotion content on Facebook, at the moment of choice. We believe it lays the foundations for understanding who might be more willing to share, what and how when it comes to health promoting content. We indicate not only which factors make health

113 promoting content more likely to be shared on Facebook, but also in which ways of sharing will this likely be (Post, Like, Pm, Comment). Motivations and consequences of these sharing activities are also illuminated. These results have been presented in a previous chapter. We believe that the knowledge produced can be used in follow up research or in health promotion practice that uses Facebook as an asset for empowerment, be that online or offline based.

Apart from inquiring into what conditions social connectors choices to share health promotion content, we also inquired into what conditions their choices to share general content. The three identified themes, the main factors and the contributing factors alike were found to be relevant to sharing general content as well. We believe that these results add to the general “Facebook literature”, strengthening the current comprehension of how choices are generally made when deciding to share some content on Facebook and how (Post, Like, Comment, PM). They are therefore not only health promotion specific. To our knowledge, this is the first qualitative study that used Social Network Analytics to recrew central, influential nodes in individual Facebook networks before interviewing them in depth on what conditions their choices to share content on Facebook. Another strong point of this qualitative research is that the 15 social connectors interviewed came from 5 different countries and two different continents. Further, another innovative aspect of this study is its focus on an important facet of content sharing on Facebook from the standpoint of the communicator; i.e. the moment of choice. In our knowledge this was the first study that was designed to allow the interviewees to speak freely about the content shared or to be shared on Facebook, while said content was reviewed real time through shared screens.

To reflect on the weaker points of our empirical study, we remind that a convenience sample was used. The reasons underlying this choice are explained in detail under our data collection limitations. Choosing for convenience sampling led to a high homogeneity of the sample; all interviewees either had or were working towards their university degree and all were within the 20-35 age range. Further, the fact that some interviewees personally knew the interviewer may have affected their choices as to what content from their activity logs they chose to discuss. Interviewees discussed profoundly health related content not only when asked to point to content that to their minds was health related but also when they were asked for content they “enjoyed sharing”. We place this as an interesting finding. However, knowing the interviewer is involved in health related studies may have made health related content more accessible and likely to be talked about during the interviews, even before the health topic was introduced. To avoid this and other memory bias, the interview was not performed simply vis-à-vis with the interviewee; interviewees were responding as to what they enjoyed sharing with reference to their activity logs, which were used as visual triggers to guide the first part of

114 the interview. Although we think this strategy has been very useful, it could still be that selection of content from their activity logs was influenced by the interviewer’s “exposed” agenda. If this was the case, then this bias might have affected our conclusions with respect to said finding.

With respect to weaker points of our literature research component, although we systematically researched the literature dealing with Facebook in relation to health promotion, there is an enormous body of interdisciplinary research dealing with Facebook users’ motivations and behavior that was not systematically researched. That was not part of our research questions, although additional research was performed to get acquainted with the state of the art and check for similar study designs. Ideally, if time resources allowed, a thorough and comprehensive Facebook literature review would have been performed, so as to be perfectly confident that there is no relevant insight we might be missing from another discipline.

To come back to our research aim, we believe that a wealth of potential strategies have been indicated both in our literature and empirical study results, that can be experimented with in a Facebook mediated communication that aims to increase the reach of e-health programs. The purpose of this chapter is not to repeat results presented in previous chapters; although some key strategies will be summarized here as well. In the current chapter, we will rather focus on indicating the added value of using Facebook when employing Word of Mouth Marketing strategies to increase the reach of e-health programs. Although these strategies aim at optimizing e-health programs’ reach, they may not only involve e-health programs’ dissemination, but also their development, as their poor reach may have deeper underlying causes.

But before indicating how these strategies may be used through Facebook, we will look at some notable results and disagreements in evidence.

8.2. NOTABLE RESULTS AND DISAGREEMENTS IN EVIDENCE

8.2.1. PERSONAL INVOLVEMENT

If we had to point to one essential ingredient all our research findings boil down to, that would certainly be personal involvement. All our literature and empirical findings suggest that if there is one thing that will make people talk that will be personal involvement, be that offline or online. When we look at Facebook in particular, content one was personally involved with was to be found on his/her wall, a space that increases a content item’s visibility and has the power to kick off public discourse.

The call to involve the target audience is not new and the associated benefits are certainly not restricted in generating positive word of mouth; as cited by Koelen for 115 example (Koelen & Lindström, 2011), actively involving the target audience in everyday life settings and public participation are main principles health promotion is based on (Ashton, 1988). However, in health promotion practice many health promotion communication outings use messages and materials decided and composed by a team of health professionals and communication specialists (van Woerkum & Bouwman, 2014); this begs to question, when the benefits of bottom up co-creation are already well recognised, why are these processes still so often done in a top- down manner?

We suggest that involving opinion leaders with an e-health program by giving them a say in its development or/and marketing or simply by facilitating that they have a first-hand experience with the end product in the pre-launch stage while asked for feedback can be key to e-health programs’ success. Future research may experiment with the cost- effectiveness of involving opinion leaders in earlier, intermediate or later stages of an e- health program’s development. We suggest that formative research that is targeted to a sufficient number of opinion leaders might lead to a marked improvement of an e-health program’s reach and adoption. Conducting targeted formative research with opinion leaders and inviting them to participate in the project right from the beginning by engaging with them in dialogue and giving them a stake in decision making, can have tremendous advantages both for the program’s diffusion and quality, by harnessing collective intelligence (Thackeray et al., 2008) and triggering the Hawthorne effect among opinion leading participants (P. Marsden, 2006; Mayo, 2013). However, as noted above, involving opinion leaders in the pre-launch stage, following the paradigm of “seeding trials” is another option. In this case they would be asked to sample the pre-release version of the e-health program and provide with their opinion and feedback.

8.2.2. HEALTH PROMOTING CONTENT : WHO MIGHT BE MORE WILLING TO SHARE WHAT , HOW AND WHEN This research begun with the first author’s naive assumption that all there had to be done was to bring e-health programs to social connectors’ attention who would undoubtedly appreciate their value and post them on their wall, for more people to benefit from their consumption. This oversimplified assumption could not be further from the truth. Along the way though, important lessons were learned with regard to sharing health related and health promotion content on Facebook, as previously defined. A number of novel insights are offered with respect to who might be more willing to share what, when and how when it comes to health promoting content on Facebook.

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8.2.2.1. WHO MIGHT BE MORE WILLING TO SHARE ; AND HOW DO WE FIND THEM Social connectors that were more willing to share content relevant to promoting a certain healthy behaviour were the ones that were already enacting said behaviour. This was definitely the case for Facebook wall posts, i.e. enacting the promoted behaviour was set as a prerequisite. That is understandable, as Facebook walls are a medium for self- presentation, which indeed has been shown to be a quiet accurate one (Back et al., 2010). Therefore users’ lifestyle is reflected there and some of the activities publicized and discussed are of interest to health promotion, as we have already illustrated.

An important thing to stress here is that willingness to share or not is health promotion behaviour specific and this behaviour might be defined in quiet narrow terms.

A social connector that is talking about healthy nutrition on Facebook might not talk or be willing to talk about smoking cessation or sports. Someone that talks about yoga might have no interest in talking about football, or might even only be willing to talk about a specific kind of yoga and of a certain practice level.

This finding allows the offering of a concluding remark that can be useful in follow up health promotion research or practice; health promoters interested in promoting a certain behaviour should not look for social connectors in the sense that we did, i.e. try to identify individuals with a central position in the network of interest alone. Rather, we propose that it would pay off to look for opinion leaders as described in the marketing literature. As concluded in the marketing literature, opinion leaders have a “connected and respected” profile (P. Marsden, 2006) but further, their profiling should be “category and market situation specific” (Nyilasy, 2006). It is also explained that what makes opinion leaders talk is their enduring involvement with the product category. Opinion leaders are interested in these categories, as for example healthy nutrition; for some reason they are important to them, and their enduring involvement makes them knowledgeable, experts on the topic (P. Marsden, 2006; Nyilasy, 2006; Richins & Root- Shaffer, 1988). They therefore often offer or are elicited for category – related information or advice.

The method we have used, i.e. Social Network Analysis, can capture centrality but cannot capture the specific interests of these users which define what they will often choose to talk about, and by doing so lead others’ opinions or behavior. Based on the above, we suggest that the most suitable tool in attempts to recruit opinion leading advocacy of health promoting behaviors are opinion leadership scales, examples of which are provided in appendix B. We suggest that follow up health promotion research or practice makes use of this tool instead.

Facebook users’ interests and what they are willing to talk about are indicated by what they already talk about and other listed interests or “Likes”. Therefore, when looking for

117 people in a community that would be likely to advocate for a healthy nutrition e-health program for example, it would be useful to digitally or manually trace users already engaged in relevant discussions, based on specific keywords they use; practical advice for doing so is provided in appendix E, following extra desk research work we have performed. Due to the fact that Facebook has attracted social capital in unprecedented numbers and users’ walls function as self –presentation accounts reflecting their lifestyle, opportunities for tracing and reaching health promotion advocates in a community today are unique.

Our results show that people might talk of health promoting topics when these are related to their profession, their studies or simply their hobbies; but in any case these are people who practice what they preach. It was obvious, for example, that social connectors that smoke would by no means post anti-smoking content but they could at the same time be very busy with posting content on yoga, given that they were busy with yoga offline. Similarly, social connectors that were not perceived to be physically active would not post pro-exercise content. Respectively, it seemed that participants were more willing to post pro-exercise content when they were physically active and anti- smoking content when they were non-smokers or had managed to quit. However it should be understood that although this works as a facilitator, in the majority of the cases it was not a sufficient condition. That is to say that someone who is prone to posting content on physical activity in general or on yoga in particular would not post anything related to physical activity or yoga, but might be quiet selective in doing so. Which brings us to what social connectors are more likely to share, how and when.

8.2.2.2. WHAT IS MORE LIKELY TO BE SHARED ON F ACEBOOK , HOW AND WHEN As we have elaborately discussed in the previous chapter, “health related” content was viewed differently than “health promotion” content and further, the viral health promotion videos were viewed differently than the e-health programs. The different characteristics attributed to them helped us understand what kind of content is more likely to be posted on Facebook walls and when is health promotion content more likely to be sent in a PM and to who.

ABC OF GETTING H EALTH PROMOTION CONTENT ON FACEBOOK WALLS In short, Facebook walls are a place for positive self-presentation; what is likely to be posted there is content social connectors were personally involved with. Further, content that leads to a favourable image construction, content that evokes arousing emotions, and last but not least, content that is quick and pleasant to review.

E-HEALTH PROGRAMS AND PERSONAL INVOLVEMENT : “NO , THIS IS NOT ABOUT ME !” We have previously described content social connectors were personally involved with as content linked with a direct experience of theirs, but we have also noted that it can be 118 content relating to their lifestyle, so to their professional or free time activities. However, with the exception of one participant that said she might post a link from the pro-exercise e-health program on “top ten gym exercises done incorrectly” because “she also exercises on her own”, the overwhelming majority of social connectors did not find something personally relevant enough so as to post it on their walls, even if they practised yoga and there was “a guide to yoga” sublink included, for example. Our impression is that social connectors needed to present themselves in much more specific terms, and would need much more personalised content for their self presentation than could be found even in the most elaborate and fragmented website, as was the pro- exercise e-health program.

For example, a social connector that predominantly posted content on her wall about yoga, said she would not post the “guide to Yoga” from the NHS e-health program because “she practices yoga for many years, and she needs something more specialised, whereas this is very superficial… but for someone else this might be very interesting”, she explains. It seemed that the content does not fulfil her self-presentation needs; consequently she would not post it; she would definitely “Like” it though, if someone else posted it, she explains.

When looking at health related content shared by social connectors on their walls, we usually see user generated content, which naturally can describe what they are doing much better and to which they can relate much more than to any readymade e-health program link.

However, there was one sub link in the pro-exercise e-health program that was generally well accepted as “Facebook wall material”. That was the “what is your sport” test, a “short psychological and aptitude test” that was coming up with a result on which sport suits one best. Many participants noted that they would post it on their wall, while some added that they would only post it if they took the test and were happy with the result, or else if the test “figured them out”.

This last example indicates that features of interactivity that leverage game mechanics to actively involve users and deliver personalised results in a time effective way might make content more attractive to users, and that such content will stand much better chances to be posted on Facebook walls. However, in order to be noticed, such content items should be brought to users’ attention as standalone pieces, because although the test was well accepted, only once was it noticed in the busy NHS site before the interviewer drew participants’ attention to it. This is important and needs to be emphasised: in order to be shared on Facebook walls, content should be quick and pleasant to review.

Moreover, involving opinion leaders in the e-health programs by conducting formative research with them or following the paradigm of seeding trials may also result in their

119 higher willingness to post them on their walls and advocate for them. Another lesson to be learned here is that it may pay off to encourage opinion leaders’ contributions in e- health programs in the form of user generated content. This can be success stories authored by them, pictures they took or are depicted in, or contributions of any other form.

THE VIRAL HP VIDEOS MIGHT BE POSTED BUT THE E - HEALTH PROGRAMS WON ’T; WHAT CAN WE LEARN ? E- health programs had none of the attributes that were shown to make content “Wall material”; they were seen as conventional, they did not evoke emotion and they were sometimes seen as dictative, preaching or strict, to mention some of the characteristics mentioned by the interviewees; characteristics they obviously did not want to be associated with.

The viral videos on the other hand were most often viewed as “Wall material”. They both had an unconventional approach, were most often viewed as embodying favourable characteristics and they were in a content format quick and pleasant to review; indeed the video format alone seemed to play an important, positive role, especially when compared with the lengthy textual format of the e-health programs. To give some specific examples of the attributes that made the viral videos more likely to be posted on walls, the anti-smoking commercial was surprising, it had a fresh approach, breaking a pattern people have come to expect, such as for example “preaching” anti-tobacco messages that simply lay out facts. Importantly, it was considered to be clever, making the people who shared it look more clever as well. Further, it evoked arousing emotion, which is shown to be an important facilitator for all ways of sharing on Facebook, including posting content on one’s wall. The whiteboard animation video on exercise was also “wall material”; it was viewed as practically valuable and of general concern, but was also adding to one’s favourable image construction, as it embodied favourable characteristics; it was seen as creative, and given in an unusual and pleasant format. The whiteboard animation video however was also seen by some participants as “didactic” or “being about diseases”, or even as too long and tiring; these participants were consequently unwilling to post it. Still, there was a marked difference with respect to social connectors’ reported willingness to post these videos as compared to the e-health programs.

So when crafting content we aspire to see on Facebook walls, it would pay off to craft unconventional, not preaching content, or/and evoking emotional arousal, preferably positive. Note here that usual use of emotion in health promotion risk communication likely does not meet this conditions; it usually focuses on negative emotions and involves a pattern that people have come to expect. Moreover, it helps a lot if the content embodies favorable characteristics; lastly, the content format should be quick and pleasant to review. 120

C OMMUNICATING E -HEALTH PROGRAMS TO HELP OTHERS ; WHAT IS HELPFUL & WHO MIGHT IT BE OFFERED TO As we have previously explained, in the view of e-health programs social connectors did not seem to consider whether they would post them on their wall. As we discuss above, this was probably because they were not seen as relevant for their self-presentation.

What they seemed to consider when reviewing them was to who, if and when would these e-health programs be of help for, so they would send them in a PM. There were only a couple of exceptions when participants said they might post something they found useful to a wider audience on their wall, which have been discussed in the previous chapter.

Attributes of the e-health programs that were valued in order for them to be viewed as useful in the first place was that they were free of charge. That was seen as an important advantage, along with being run by public organizations. It was clear that perceived trustworthiness of the content was greatly enhanced when participants knew the e- health programs were not commercially motivated. As we have previously explained, flashy websites might be associated with commercial entities. Public health organizations might devote considerable human and monetary resources to follow the otherwise successful marketing paradigm and make e-health programs’ interfaces more attractive for users. However, appearing flashy and having a commercial appearance might backfire; participants seem to not trust these sites on first site which might result into not spending time with them or not forwarding them to a friend that they would otherwise found them useful for. We therefore suggest that e-health programs’ web development may benefit more by being kept simple or that some attention is given to differentiation from commercial entities at first sight; future research can address which factors define these impressions’ formation, so they can be manipulated for the benefit of e-health programs. We also suggest that it would be beneficial for e-health programs to clearly state a public health organization as their source and display it on a clearly visible point for the first time visitor.

However, meeting these preconditions does not mean that a Facebook user exposed to an e-health program he finds useful will start sending it to all his friends. There were several conditions that influenced social connectors’ choices about when and to who would they offer help to by forwarding the e-health programs. Interestingly, they would not offer help uninvited to anyone but family ties or partners. If they had family ties or a partner they wanted to motivate to quit smoking for example, they would share the link with them. For the rest though, the context seemed to be very important; they would be willing to send it to someone with whom they had a relevant discussion recently or to someone they knew (s)he is trying to quit smoking or is interested in starting new physical activities, for instance. There is also a great emphasis put on whether the content

121 is tailored enough to match one’s individual characteristics and behavioral change stage when filtering health promotion content and deciding on whether to send it to someone or not.

This is very interesting because it indicates that friend recommendations might be highly tailored; personalized and timely, in a way that no traditional advertising technique can be. No advertiser can know exactly who and when might be interested in an e-health program and whether this would be part of one’s current concerns and goals. Facebook friends are much more likely to have this information as a result of previous Facebook or/and offline interactions. And when they do, they are motivated to help; with respect for their friends’ need for autonomy, they will with pleasure send them useful information that is relevant to them at the time they are interested in it, and they will do so for free. Finally, from the receiver’s perspective, personalized messages coming from trusted sources, such as friends are much more likely to be given the required attention (Crutzen, 2009).

The closest an advertiser can get to the timeliness of friends recommendations would be, in our view, to use the alternative advertising strategy of Facebook advertisements. Using Facebook advertisements that target specific keywords can bring e-health programs to the attention of users interested in them at the time and/or to the attention of friends also engaged in the discussion, so timely and in context. We therefore suggest that this strategy is tested for improving e- health programs’ reach.

Said strategy holds great potential advantages, as it can offer timely information from trusted sources, reducing ambiguity that relates to issues of interest to health promotion and improving health literacy of users engaged in a relevant discussion. We suggest that said opportunity is used wisely on Facebook; our empirical findings show that the content format and structure is very important when it comes to word of mouth communication on Facebook. Health promotion messages linked to keywords have to be concise, quick and pleasant to review. Long text that gives detailed in depth information runs the risk of not being shared and not being reviewed in the first place; while interested readers can always follow a link when engaged to learn more. For a detailed discussion of content format characteristics that were found to facilitate exposure and sharing activity on Facebook, please see 7.5.1.2.

8.2.3. FACEBOOK : AN ASSET FOR EMPOWERMENT

Our main conclusion is that health promotion is already being practiced on Facebook, which in our view is an asset that holds great potential for empowerment. Healthful behavior is already being spread by “health promoters” with or without formal education,

122 who advocate for said behavior on Facebook while in the offline world they practice what they preach.

All in all, we suggest that Facebook mediated peer health communication holds great potential in supporting sustainable behavioral changes and has an especially important function in bridging the intention - behavior gap. In this section, we will discuss this conclusive point on the grounds of our empirical findings, the social learning theory (Bandura & McClelland, 1977), Rogers’ diffusion of innovations theory (E. Rogers, 1983; E. M. Rogers, 2003), Nicholas Christakis’ empirical findings and other findings from the literature, the self determination theory (Ryan, Patrick, Deci, & Williams, 2008), and the life course perspective (van Woerkum & Bouwman, 2014). Our line of thought, which will be well argumented in the following pages, is summarized in the following points:

1. Healthful practices adopted by social connectors are likely reflected on their Facebook walls. 2. Making these practices public influences specific and similar others. Similar others already hold healthful intentions and Facebook mediated communication with people that already practice the healthful behavior they aim for empowers them in achieving their goal. 3. Support provided in this way is more likely to be effective in translating intentions into healthful practices than conventional health promotion communication. 4. Peer health promotion communication on Facebook exhibits qualities that according to the self determination model can cause subjects to internalize a healthful behavior and sustain the behavior over time. 5. Although healthful practices reflected and “copied” on Facebook tend to be behavior specific, internalizing one healthful behavior can make other healthful practices seem more compatible and thus more likely to be adopted next.

All in all, we propose that health promoters with formal education are not the only ones interested or competent in promoting health and that a lot can be gained by focusing on these informal networks. Apart from finding ways to empower them and further facilitate their activities and potential, we suggest that we let them empower us. Although insights shared here can be useful in increasing the reach of e-health programs or informing their development, they are certainly not limited to this purpose. We propose that Facebook is a promising asset for empowerment and its use should be legitimized in professional health promotion settings.

8.2.3.1. ACTIVE PROMOTERS OF HEALTHFUL PRACTICES ON F A CEBO OK During the first part of the interviews, when users shared their Facebook screen with us and discussed content they “enjoyed sharing” or that was related to health, it was apparent that health promoting content was part of those. For example, some social 123 connectors predominantly shared and discussed with us content relating to healthy cooking, organic agriculture and physical activity, when these were part of their professional or free time activities. Examples include a short, user generated music video featuring freestyle snowboarding, a picture of a poster promoting a skiing excursion, pictures from yoga classes or of friends practicing slackline, a Facebook page of a local, organic “humus corner”, a vegan Facebook group and many more. We reference examples relating to health promotion in the narrow classical sense, as previously defined here for the purposes of this thesis. However it should be noted that our interviewees did not treat the topic of health and its promotion in the same way, but referenced a much wider range of content posted on Facebook as “healthy”, when asked to point to content that “in their minds was related to health”; we will however return to this point later in the discussion.

When users were practicing healthy behaviors as described above, relevant content was likely to appear on their walls, reflecting their lifestyle. Interestingly, they would likewise not display or advocate for some behavior if they were not currently practicing it in their everyday lives.

These findings are in agreement with earlier findings in the literature, which show that self-presentation is a basic motive driving Facebook use (Nadkarni & Hofmann, 2012; Seidman, 2013; Stolz; Zhao, Grasmuck, & Martin, 2008). Although users will engage in strategic self-presentation (Utz, Tanis, & Vermeulen, 2012), meaning they will choose which aspects of their lifestyles they will focus on (J. Berger, 2013; Schlenker, 1980), self – presentation on Facebook has been shown to be quiet accurate; expressing real rather than idealized personalities and “versions of oneself” (Back et al., 2010; S. D. Gosling, Gaddis, & Vazire, 2007; Moreno et al., 2012). On Facebook real life acquaintance usually precedes online friendship. Interacting even with part of one’s audience in offline settings can likely explain why identity construction is found to be much more realistic on Facebook than online identity constructed in anonymized social networks, where chances one may meet the people (s)he interacts with are much lower (Zhao et al., 2008).

What Facebook users do by posting content on their walls reflecting their healthful practice is also to promote said practice. In his “hierarchy of effects” attributed to each stage of the Innovation –Decision process, Rogers notes that a communication effect occurring in the “confirmation” stage is the promotion of the innovation to others. In the context of healthful behaviors, that would mean that an individual that has integrated the behavior in his/her ongoing routine will promote the behavior to others as well (E. M. Rogers, 2003); which is indeed what we saw happening on Facebook. However, these “health promoters” that found themselves in the “confirmation” stage, as Rogers puts it, or in the “maintenance” stage, as similarly explained by Porchaska (Prochaska, 124

DiClemente, & Norcross, 1992), were not only empowering others but were also being empowered themselves by other “promoters” of the behavior of interest in their network. The confirmation stage 34 (E. M. Rogers, 2003), is explained as a terminal stage when behavior is consolidated, which essentially suggests that practices are fixed or kept constant. Our findings showcase that this may be an oversimplified interpretation of the process as these practices are likely not cemented, but dynamic in nature. Individuals holding healthful practices may still need to learn and grow, and as we will see interacting with similar others can feed their interest and guide their personal development. In a way, a need to grow can be seen as setting new behavioral intentions or else increasingly higher goals.

8.2.3.2. FACEBOOK CAN HELP HEALTHFUL PRACTICES SPREAD TO OTHERS According to our empirical findings, users that “Like” or comment on content posted by the “health promoters” described above, might also practice the healthful behavior themselves. However, “Liking” or commenting, as opposed to posting content does not presuppose personal involvement. These reactive Facebook sharing activities should be interpreted as indicating either affiliation with the source, either endorsement of the content or both. In any case however, we argue that exposure or/and positively reacting to such content facilitates forming favorable attitudes or behavioral intentions towards the healthful practice and even, as we will argue in the next section, translating these intentions into practice.

In posting content that reflects healthful practices, these health promoting social connectors essentially make these practices more observable to their Facebook friends, and thus easier to imitate. Facebook facilitates making choices “public”, as Berger puts it (Berger, 2013), an idea already expressed by Rogers, who uses the term “observability” (Rogers, 2003). Observability is, according to Rogers, one of the five most essential innovation characteristics in explaining rate of adoption (Rogers, 2003). Behaviors that are made public, or otherwise more observable are more likely to diffuse and to be talked about (Berger, 2013; Rogers, 2003). In doing so, Facebook can help healthful behaviors spread to others.

Nicholas Christakis and James Fowler, using longitudinal data and models previously used to visualize viral spread, managed to show that behavior, like altruism or quitting smoking, health states, like obesity, emotions, i.e. happiness and loneliness, or trends and information, can be spread through social networks up to three degrees of separation (Cacioppo, Fowler, & Christakis, 2009; Hill, Rand, Nowak, & Christakis, 2010a; Christakis & Fowler, 2007; Christakis & Fowler, 2008; Fowler & Christakis, 2010(Hill, Rand, Nowak, & Christakis, 2010a). Physical propinquity is rightfully regarded as important to diffusion

34 However this note is irrelevant to Prochaska ’s “maintenance” stage, which deals with addictive behaviors. 125

(Fowler & Christakis, 2008a; E. M. Rogers, 2003), however we argue that by increasing observability of behaviors, Facebook could in theory facilitate influence among ties that have been separated by geographical distance or busy schedules.

8.2.3.2.1. A ND WHAT ABOUT UNHEALTHFUL PRACTICES ? And what about unhealthful practices, one may say? Facebook may facilitate their diffusion, as well. That is true, posting content that reflects unhealthy lifestyle practices on Facebook will likely influence others as well (Hornik et al., 2008). Moreover, commercial entities that hold interests in promoting unhealthy lifestyle behaviors, such as tobacco companies or alcoholic beverage firms are also on Facebook, and their presence there can negatively impact public health (B. Freeman & Chapman, 2008; McCreanor et al., 2013). It is only natural that existing social norms will be reflected on social media, or that commercial entities will try to also exploit this popular medium in their efforts for ever increasing profits. Fighting against commercial entities that have found their way around existing advertising restrictions requires new regulations (B. Freeman & Chapman, 2008) or/and strategies such as the poison parasite defense (Cialdini et al., 2010) but subverting social norms will in turn require discursive work (Bate, 2004; Ford, 1999; Ford, Ford, & McNamara, 2002; van Woerkum & Bouwman, 2014).

Instead of focusing on problems, we could focus on opportunities for health communication on Facebook and on the people who seem to already promote healthy practices. These will likely be the ones willing to do the required discursive work to promote them and they should be empowered in doing so. Bringing the focus more towards healthful practices can already take the focus away from unhealthful ones. Further, internalizing healthful practices can make unhealthful ones seem incompatible with the new behavior (E. M. Rogers, 2003).

Adopting a salutogenic approach is well justified when using Facebook as an asset for empowerment. Berger suggests that positive content as well as positive emotions are more likely to be shared, as they reflect positively on the sharer (Berger, 2013), and our findings as well as previous findings in the literature (Sas, Dix, Hart, & Su, 2009; Utz et al., 2012) suggest that this is also the case with Facebook walls. Positive content is generally more likely to be shared on Facebook. These findings indicate that Facebook users may be generally more likely to discuss their strong points and healthful behaviors on Facebook rather than otherwise; however this statement should be handled with caution; choices on what to share also depend on how one chooses to construct his/her identity before an audience (Schlenker, 1980) as well as on what is viewed as positive, based on attitudes and existing social norms.

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Although there were several instances in our study when interviewees suggested that prevention content might in itself hinder sharing on Facebook, we cannot appear to be conclusive on this point. There is some indication that people who have quit smoking themselves might be more willing to promote smoking cessation on Facebook, but this should be a topic for future research. In any case, it was clear that positive framing played a positive role. Taking this point into account, as well as that enhancing public focus on prevention messages might actually trigger the undesired behavior (Berger, 2013, Hornik et al, 2008), a useful approach could be to try and highlight what people should be doing instead or underscore the positive effects of not enacting the harmful behavior (J. Berger, 2013; Cialdini et al., 2006) in facebook mediated health communication. Another interesting approach is what Cialdini calls the poison parasite defense (Cialdini, 2010) which uses commercial opponents’ messages, such as of tobacco companies (see figure 2), to trigger health promotion messages. This approach can be funny or/and surprising, possibly increasing the chances opinion leaders would post it on Facebook, while it would trigger a health promotion message in the view of unhealthy commercial promotional messages. Finally, we suggest that in crafting such messages, an opportunity should be seen to involve opinion leaders in coming up with ideas and co-creating the message.

8.2.3.3. SIMILAR OTHERS AND THEIR ROLE IN TRANSLATING HEALTHY INTENTIONS INTO HEALTHFUL PRACTICES As we have already noted, some social connectors were following similar others to learn and grow with regard to a healthful practice. Interacting with similar others that already practice the healthful behavior seemed to empower them in their goal to either translate healthy intentions into healthy behavior either to further advance their healthful behavior and grow.

In reaching these goals, communicating with similar others seems resourceful; providing with inspiration and a crucial process orientation. This process also seems to be driven or facilitated by admiration for the source posting the content someone likes/comments upon. The source impersonates one’s desirable outcome expectancies, often while facing similar life challenges or living in the same local environment; it is therefore deemed useful to follow these social models to uncover and copy their process orientation which apparently leads to rewarding results.

Following similar others to uncover their process of “getting things done” can equip someone holding healthful intentions with practical strategies, information that is often localized, and shortcuts about how to behave. These practical strategies, localized tips and shortcuts can be seen as reducing not only uncertainty (E. M. Rogers, 2003; van Woerkum & Bouwman, 2014) but also perceived complexity of the healthful behavior. A lack of complexity is according to Rogers, one of the five most important innovation characteristics in explaining rate of adoption (Rogers, 2003). Indeed, uncomplicatedness

127 in healthful practices, such as healthful eating has been found to be valued and prioritized by consumers by previous research (L. Bouwman, 2009).

In the pages that follow, we will illustrate how Facebook mediated communication may support one in translating healthy intentions into healthy practices as well as why following similar others is more likely to effectively support one in doing so than conventional health promotion communication. In an effort to shed light into these processes, we will shortly go back to our data and discuss them in the light of the everyday life perspective (van Woerkum & Bouwman, 2014), which in our view is most appropriate for better explaining the role of similar others in bridging the intention- behavior gap.

Further, we will discuss the role of homophily, one of our main starting points and will offer an alternative interpretation of why similar others are more influential in this particular stage of behavioral change.

R ELEVANCE OF THE EVERYDAY LIFE PERSPECTIVE The everyday life perspective deals with these cases where there exists a gap between healthful intentions and unhealthful practices; it is based on three main principles: “(i) healthful behavior consists of a chain of activities, routines that are (ii) embedded in social practices, (iii) and deserve therefore individually induced social change, including the required discursive work”. It views changing routines and practices from the perspective of an individual with a healthful intention, who is often uncertain about the procedure, of how to “get things done”, uncertain about how others will react and also about the outcome (van Woerkum & Bouwman, 2014). In these cases it is important that the client gets a process orientation of how the new behavior can be organized in his specific situation and context; what would be the route or the chain of activities leading to the desirable outcome. The authors suggest that most health promotion interventions act disjointedly on the client, the physical or social environment, and treat healthful behavior as an isolated activity; when in fact a healthful practice depends on a chain of activities that are often embedded in social practices and influenced by the dynamics of everyday context. These dynamics are complex and suggest that different practical strategies are needed for everyone to match his/her everyday life situation at any given moment. Woerkum and Bouwman suggest that disjointed approaches leave clients uncertain and incompetent about how to “get things done” and emphasize that a lot can be gained from focusing on said process (van Woerkum & Bouwman, 2014). However, the authors note, these solutions cannot be designed from “behind a desk”, when they need to fit one’s unique and specific situation; rather clients should be supported in organizing their own means to act in their specific situation and context. Further, according to the everyday life perspective, gathering social support is key for achieving behavioral change in everyday life. Finally, in managing to bring change it is 128 important that one is competent in carrying out the required discursive work to advocate for and negotiate these practices within his social circle (van Woerkum & Bouwman, 2014). We hold that the everyday life perspective is most relevant in our case. It sheds light into why we found Facebook connectors following similar others to translate their healthful intentions into practice instead of turning to health promotion professionals or respective online material. We argue that conventional health promotion communication most often holds a rather reductionist view or might be too general to satisfy these process orientation needs while interacting with similar others can provide with insights regarding helpful strategies, relevant to specific life challenges one is facing and to specific contexts, such as one’s local environment. In this way, several uncertainties are dealt with. We argue that turning to similar others that face similar challenges but already practice the healthful behavior and have reached desirable outcomes is chosen by people with healthful intentions as being most relevant and effective. Uncertainties about the outcome lessen; one can argue that their outcome expectations are reflected in the real life example of the person they follow, often driven by admiration. Following them makes observing and copying 35 their behavior possible, which in turn responds to uncertainties about how to “get things done”. Social support can also be gathered when interacting with similar others in social settings, which as we found, also serves one’s need to belong, while it is merely absent in the “professional support” provided by health promotion professionals. Gathering social support with similar others might also imply engaging in more relevant discussions, hence exercising one’s competence with regard to the required discursive work that needs to be done (van Woerkum & Bouwman, 2014). However, as we will discuss later, health promotion professionals might find a place here, a facilitative, empowering role in the arrangement of collective tools that can improve one’s discursive competence.

L OOKING BACK TO OUR DATA To place previous and following statements in context and make them more explicit, we shall go back to our data and share some of our interviewees’ stories.

Marina, for example, became interested in healthy cooking when she was about to become a mother, a time period when, according to the life course perspective, women are much more likely to be motivated to improve their nutritional behavior (Szwajcer, Hiddink, Koelen, & van Woerkum, 2007). However, she was completely inexperienced as a cook and interacting with similar others, on Facebook and offline helped her translate her healthy intentions into practice, as well as further advance this practice and grow as a

35 Note that by copying we do not mean mimicking, but extracting the essential elements that are relevant to their own situation (Bandura & McClelland, 1977) 129 cook and a healthy food provider. While discussing content she “enjoyed sharing”, Marina pointed to a picture of “healthy cookies” posted by a friend.

I4; General share 2

Iee: They looked really good, and since I started cooking, I love cooking since I moved to Krakow, I started cooking a lot, like crazy, I cook every day, can you imagine? I didn’t even know how to.. make eggs, fried eggs before and now I do like…crazy shit..? So my friend made these cookies and they are healthy for babies, and I enjoyed it cause I thought oh, it might be good to make some for Vicky [i.e. her baby daughter ], cause she likes sweets and I don’t want to give her only chocolate and stuff like that.

[4 lines omitted ] Aaaam, so Angela I like her recipes, because she is the mum of two kids and she just had her second one, and she was always, since I remember like fanatic of cooking, she had all these books and stuff and I was oh wow cause I didn’t know how to do shit, so that’s why I like it, because I know she cooks a lot for her babies and she enjoys it, and since it’s my hobby right now, that is why it’s good to look up into her kitchen and see what is new.

This social connector appears to look up to her friend who is in a similar life situation as herself, she is the mother of two children and she just had her second one; our interviewee also has a baby and mentions trying to have a second one. “Looking up” into her kitchen helps her grow towards her new goal, and the help she gets is very relevant to her own life situation. If Angela made these cookies they must be healthy for babies, this is working as a shortcut; what is more Angela cooks a lot but also enjoys cooking for her babies, she is not only efficient but also manages her goal in an effortless way, while facing similar everyday life challenges as herself. It is therefore useful to “copy” her. Interacting with her on Facebook empowers her in managing her goal; Angela can provide with informational and social support that helps her move from her healthy intentions [not give her only chocolate and stuff like that] to “getting things done” (van Woerkum & Bouwman, 2014).

While the interview moves on to discussing health related shares, this participant chooses to discuss a humus restaurant Facebook page that she “Liked”. The “cooking adventure” story she tells involves a lot of cooking mavens, like the owners of the humus restaurant she “often has breakfast at”.

I4; Health share 2

Ier: So tell me whatever comes to your mind about this.

Iee: Ok, so I really like that because it reminds me of how my... (Subtle laugh) adventure started with cooking here in Krakow, I met two good friends of mine that really are into healthy way of cooking but really crazy healthy, so...huh.. Very crazy and they were telling me about this and...let ´s say markets or events I could go because they were going to any one of them or even find some products there.. So I started going to these events with them and through them I met this couple…The couple that runs this restaurant.

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Interacting with people that have the same interest in healthy cooking as herself, even though they are already in a far more advanced “crazy” level in doing so, or perhaps exactly because of that helps her find her process orientation in successfully practicing her “new hobby” in her new city of residence, Krakow. These mavens take her to markets with biological products and events she would very unlikely could have learned from e- health programs and other conventional health promotion communication outings. This results to buying biological products and bringing them to her house, learning the market’s schedule and place, having healthy cooking related conversations along the way and meeting more people that hold her interest as “the couple that runs this restaurant”. Besides the fact that she seems to be gathering social support by interacting with similar others, she now has a “favorite” place for breakfast in Krakow, where healthy made humus is conveniently available. She mentions that she trusts the owner always tries to find the best grown biological products she can and that as a result of their interaction she also started making her own humus at home.

To give another example, a social connector teaching acro-yoga often referenced other acro-yoga professionals he was connected with and who he seemed to look up to and view as “mentors”. These professionals were often posting content of interest to him; therefore he was following them on Facebook. Likewise, he was posting content that his own students followed and “Liked”. Even if an e-health program on physical activity was so elaborate that it incorporated all sports including the specific interest of Acro-yoga, it would be very difficult to give support and engaging input tailored to one’s level, be that the student that wants to start practicing the sport or the acro-yoga professional that also needs to be empowered. But even if all this information could be made centrally available, how could it be organized to be retrieved in a way that is not time and energy consuming? Getting information or inspiration from one’s contacts instead can be an effective shortcut; further it is not disconnected but helps making the next step in the chain of activities needed to actually practice acro-yoga in an engaging way. Connecting with other professionals and students on Facebook seemed to also support and reflect offline activities that were organized through the medium and resulted in initiating or maintaining and advancing the practice of acro-yoga in social settings.

There were many other instances when interviewees mentioned interacting with similar others that they viewed as experts or peers in a field of interest and said interaction seemed to empower their audience or themselves. Most of the times, these were people social connectors had first met offline and Facebook helped them keep in contact, share content online as well as organize activities offline; but there were also cases when Facebook was actually used to identify similar others. For example, an organic agriculture producer interviewed in our study, explained she used Facebook’s search functions to find other Facebook users or groups in the region that were also concerned with

131 biological food. She explained that following these users empowered her by giving her access to relevant information, as “a year ago, she did not even know what was going on”. She also used Facebook to find audiences that might be interested in consuming her products, as was a Facebook “vegan group”. Except for being empowered by other Facebook users in her region, she also seemed to empower her audiences; posting for example “special” recipes with biological products, that she indeed also made available to them or even distributed to their doors. That is, in our view, a lot of support when compared to providing healthful advice and communicating behavioral objectives that are easier said than done.

That said, we found that people were following experts or peers that were practicing what they preached and whose practices were observable and accessible to them through online and offline interactions. Seeing these practices embedded in the living example of others, can give one a more holistic perspective of “how to get things done”, especially when these experts or peers face similar life challenges and objectives, such as child rearing, or seeking accessibility of organic food conveniently in their local environment.

A RE WE REALLY HIGHER STATUS , OR ARE WE JUST NOT AS EFFECTIVE ?

R ELEVANCE OF DIFFUSION THEORY AND VIEWS OF HOMOPHILY One of the main starting points in our theoretical framework was that communication for bringing about change is more effective when occurring between homophilous individuals, i.e. people that perceive each other as being similar. This, according to Rogers explains the poor, often, results of health promoters’ and other “change agents’” attempts to change individuals into a more healthful direction; he argues that they are often seen as heterophilous with the change subject, because of their professional training and expertise and the social status that comes along with it (E. M. Rogers, 2003). With reference to the intention –behavior gap (Amireault, Godin, Vohl, & Pérusse, 2008; Sheeran, 2002; Webb & Sheeran, 2006), which Rogers calls the “KAP-gap”, the author indeed notes that change agents can only work indirectly at this particular stage, stressing the importance of near peer networks in said stage of behavioral change (Rogers, 2003).

Rogers consistently stresses the idea that change agents’ technical expertise and the social status that comes with it create social distance from the average “client”, which impedes diffusion. In times of academic inflation (K. Robinson, 2006) we suggest that holding a university degree might not be the main reason that “clients” in the developed world will likely turn to their social circles for support instead. Rather, it might be that health promoters’ technical competence is regarded as irrelevant because it has little or no practical value in the stage of translating their intentions into practice; at this stage what “clients” need is a process orientation of how the new behavior can be organized in

132 their everyday lives, in their specific situation and context (van Woerkum & Bouwman, 2014).

We argue that the reason people are more likely to be influenced from near peers at this point is that observing others who are facing similar life challenges but manage to practice the healthful behavior and reach favorable outcomes is more relevant. These challenges may simply refer to living in the same local environment; for example with regard to healthy nutrition or physical activity, convenience in accessibility of food and facilities can play an important role. Or they may refer to a busy schedule due to combining work with child rearing. But a health promoter can also live in a community with “clients”, may also work and have children. Reaching out to one’s social circles is likely due to the fact that time spent and social contact intensity helps uncover details concerning the process of “getting things done” (van Woerkum & Bouwman, 2014). This is made possible through observational learning and verbal communication which are mediated by the social contact’s accessibility.

However we have to note that this is an interpretation based on a specific sample and context of study. Our convenience sampling resulted in a homogeneous sample of young people that either had or were working towards their university degree. However the vast majority of Facebook users have at least some college degree (Duggan & Brenner, 2013) and our social connectors seemed to follow experts and peers pretty much irrespectively of their formal education; however this might of course differ in dissimilar contexts. However, Rogers also notes elsewhere that time spent and social contact intensity, which is mediated by homophily, lies behind influence and change but still suggests that change agents’ technical competence is a main factor in creating social distance (Rogers, 2003). It might be; however we suggest that technical competence at this stage might act as a barrier if emphasized when it is in fact irrelevant. We argue that people at this stage need to interact with similar others to a sufficient degree in order to observe their lifestyle choices and everyday practices that work; while verbal communication and even joint activities are also, essentially, facilitated. Health promoters cannot generally fulfill these needs, not only owing to the nature of conventional health promotion practice, but also because of their limited time resources which in turn allow for closer interaction with a finite number of people. If we add to that that not all health promoters practice what they preach, we can realize the limited practical value of turning to them at this particular stage.

Facebook can make lifestyle choices and practices more observable among Facebook friends, while verbal communication is also facilitated. As quoted by almost all interviewees in the context of the opening interview questions, a major advantage of Facebook is that it allows one to see how and what are friends doing in a time efficient way, which is quiet important in the context of busy schedules. Add to that that although

133 the Facebook network counts many bridges, with users being connected to each other in less than 6 hops, it is also shown that the vast majority of one’s Facebook friends reside within a short geographical distance (Backstrom, 2011) which allows for exchanging practical strategies relevant to one’s local environment or even organizing joint offline activities.

R ELEVANCE OF SOCIAL LEARNING THEORY The social learning theory (Bandura & McClelland, 1977), just like the diffusion of innovations theory (Rogers, 2003), views communication as a cause of behavioral change. The social learning theory suggests that people learn through observational modeling, so by observing others and then doing something similar; but also owing to verbal communication. Rogers notes that social modeling 36 frequently occurs in diffusion networks. In fact, the two theories share much in common and few differences; a part written on the differences took little space in Rogers’ 3 rd edition of diffusion of innovations (E. Rogers, 1983), closed up noting that these differences may be artifacts of discipline and method and was removed altogether by the 5 th edition (E. M. Rogers, 2003). In our view, both theories lend support to our third statement, i.e. that support provided in this way [: Facebook mediated communication with people that already practice the healthful behavior] is more likely to be effective in translating intentions into healthful practices than conventional health promotion communication.

Further, we suggest that it is the accessibility of the model, in providing an holistic lifestyle view, which in turn depends on the extend of self –exposure on Facebook that can define whether the model is more likely be copied rather than his or her formal expertise.

8.2.3.4. I NTENTIONS TRANSLATED INTO SUSTAINED , INTERNALIZED BEHAVIORS We previously saw that peer health communication, which can indeed be facilitated by Facebook, can help individuals translate healthful intentions into healthful practices as well as to further advance these practices and grow. Next, we will argue that said peer health communication exhibits qualities that according to the self-determination model (Ryan et al., 2008) can cause subjects to internalize the healthful behavior and sustain the results over time. First, peer health communication on Facebook and offline, as illustrated in our study shows respect for one‘s need for autonomy. When an intention for change is formed autonomously, this means the individual has come to value and personally endorse the behavior himself/herself. Any external control or pressure that detracts one from a sense of individual agency or choice interferes with the need for autonomy (Ryan et al., 2008).

36 A concept also expressed in his theory, framed as “re-invention” of an innovation 134

Interestingly, almost all participants said that they would be happy to send health promotion content, such as the smoking cessation e-health program to friends that had autonomously expressed the desire to change, but almost no one would send such content uninvited. This shows respect for the need of autonomy. Interestingly, several participants said they might privately send smoking cessation content uninvited to partners or family ties; to offer some possible interpretations for this phenomenon, participants may intuitively believe that only in this case their advice might be effective; perceived lack of effectiveness was generally emphasized when explaining why they would generally not share such content uninvited. Another explanation might be that social risk is lower with these ties. Or, perhaps, the fact that by living with their partners or family ties they were also affected by their smoking habits; all these are possibilities that can be explored by future research. Second, peer health communication on Facebook and offline seems to satisfy a need for competence. In order for someone to experience confidence and competence to change, he/she needs to be equipped with skills and tools for change and supported to overcome barriers when these emerge. It is also stressed that clients should not be over challenged, but rather helped and supported in experiencing mastery in the behavior they want to engage in (Ryan et al., 2008). As we argued previously, following similar others that have already managed to practice the desire behavior and reach desired outcomes helps resolve uncertainties, which may likely cause one to experience confidence about the procedure of “getting things done” (van Woerkum & Bouwman, 2014). By following accessible others that have already obtained a level of mastery in their desired behavior in similar contexts or while facing similar challenges, one can obtain skills and tools for change that are likely relevant to his/her own situation and in a rather pleasant and uncomplicated way. Uncomplicatedness is important in consumer perception (L. Bouwman, 2009) and making it easier for people to make healthy choices is an essential health promotion goal (Koelen & Lindström, 2011). Lastly, obtaining feedback and advice to overcome emerging barriers is also facilitated by Facebook mediated communication. Third and final, peer health communication on Facebook and offline can satisfy one’s need for relatedness, arguably much more that professional health related practices can. According to the self-determination model, people are much more likely to adopt and internalize behaviors promoted by those to who they feel connected and in who they trust (Ryan et al., 2008). As we elaborated on earlier, following similar others does not only serve one‘s need to learn and grow, but also one‘s need to belong. In any case, either one is affected by “specific” or “similar” others, the need for relatedness is much more likely to be fulfilled in one’s social circles rather than in professional health care settings.

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Finally, we argue that although healthful practices reflected and “copied” on Facebook tend to be behavior specific, internalizing one healthful behavior creates favorable conditions for the establishment of other healthful behaviors as well, as the integration of one healthful behavior will likely make other healthful practices be perceived as compatible and thus more likely to be more rapidly adopted (Rogers, 2003).

8.2.3.5. CONCLUDING POINTS AND REMARKS We conclude that Facebook is already functioning as a health promoting environment and can be further exploited as an asset for empowerment by health promotion officials. We consider that it is already very encouraging to see that topics of interest to health promotion are discussed and given attention on Facebook walls. Considering the engagement of young people and time spent on the social network one can argue that these are likely more influential than most official health promotion initiatives.

We propose that Facebook use is legitimized in professional health promotion settings. In our view, the Facebook environment involves groundbreaking opportunities for health promotion; never before there existed an asset more expressive of people’s lifestyle choices while interconnecting people and making everyone’s choices public. Connecting and communicating with the right people on Facebook might require significant time investment, might however prove rewarding and fruitful. Moreover, we suggest that Facebook is an appropriate medium not only for evidence to inform practice but also for practice to inform evidence (L. W. Green, 2006).

KEY POINTS

V Facebook is a useful asset for empowerment and its use should be legitimised in health promotion professional settings V Informal health promoting networks exist on Facebook; we suggest formal health promoters focus their efforts on empowering and being empowered by opinion leading “health promoters” in their local, or global communities. V Engaging in communicative actions with Facebook “health promoters” can increase the reach of e-health programs and inform their development. However, implications are certainly not limited to this purpose.

8.2.3.5.1. LET THEM EMPOWER US Engaging in dialogue and exchanging information with opinion leaders and the target audience at large at lay online settings, such as Facebook holds many advantages; it can provide health promotion organisations with vital insights regarding population needs and preferences, identify opportunities and available resources and get valuable feedback

136 while on the other hand, it can essentially improve health literacy (M. Robinson & Robertson, 2010).

Based on such input, health promotion interventions may be designed to better fit clients’ needs. According to Rogers, diagnosing clients’ needs is one of the most difficult and important roles of a change agent, and their success is positively related to the degree to which their programs are compatible with said needs; diffusion programs often fail because “they scratch where their clients do not itch” (Rogers, 1983, pg. 319).

The opportunities that lie for research are also substantial, i.e. for practice to inform evidence (L. W. Green, 2006). As other authors suggest, instead of using models of attitude and behavioural change in efforts to directly influence the social system within which clients live in, we could use empirical research to see what clients already do that works and then mirror these practices to wider audiences (van Woerkum & Bouwman, 2014).

Finally, engaging in health promotion related discussions on Facebook lay settings, privately or through participation in relevant Facebook groups and the light touch moderation this entails, gives some control to health promoters, as there lies an opportunity to respond to unfounded rumours and false constructs that raise quality concerns; a disadvantage in the otherwise advantageous use of social media for health communication (Moorhead et al., 2013; M. Robinson & Robertson, 2010).

W HO ' S I N CONTROL H ER E ? A recent review of the uses, benefits and limitations of social media use for health communication concludes that limitations of their use primarily involve quality and reliability concerns (Moorhead et al., 2013). Although these concerns may be substantial, we argue that they are outweighed by the potential benefits. That said, these conversations will be kept with or without our presence, and we propose that adapting to rather than trying to control such lay environments might pay off and also allow some interference in the form of light touch moderation.

We have discussed before that the lay paradigm in peer health communication shows respect for autonomy. Social connectors would not forward or post promotion content that they perceived as dictative or preaching and they would not appear dictative themselves, by forwarding prevention content uninvited. We propose that we follow this paradigm. Further, instead of focusing on control, we can focus on making room for participation and in control distribution, which calls for more flexibility.

Connecting with opinion leaders on Facebook and engaging with them in dialogue should show respect for their opinions and views, even for their expertise. We suggest that our professional expertise might pose a barrier if emphasised; there seems to be a paradox between being an expert and being dedicated to empowerment (Koelen & Lindström, 137

2011). We propose that we should not make use of our authority or use scientific jargon, but rather focus on similarities and our common interest in the health promoting behaviour. We propose that using informal language and asking appreciative questions might work much better than telling people what to do. Instead of imposing our help, we can, with respect for their autonomy, simply let them know we are at their disposal when and if they need it 37 . Our interference may have to depend on their priorities. As quoted by Aarts “change management is much more adaption than controlling” (Aarts, 2013, p.8).

8.2.3.5.2. H OW CAN WE EMPOWER THEM Connecting with and empowering opinion leaders on Facebook can help health promoters in their empowerment role, as it entails economy of effort; i.e. contacting a system’s opinion leaders takes much less of a health promoter’s time and energy than would be required to consult all clients in the community/system (Rogers, 1983). Further, Facebook mediated communication can in part, at least, substitute face to face contacts which would undeniably require radically different time investments.

Opinion leaders in a health promotion category are likely interested in news and state of the art information regarding the topic, and they enjoy being the first ones to know (Nyilasy, 2006). Health promoters having links with higher institutes and organisations can provide with relevant links and material. What we suggest though is not to bombard opinion leaders with scientific news uninvited; we rather propose that we present ourselves at their disposal, need they find information currently discussed within their social circles. When such information is provided, it should be localised; translated in the local language and with points relevant to a particular context being highlighted. Also, the writing style and vocabulary may need to be popularised.

E-health programs are tools that may be of interest to opinion leaders and should be brought to their attention. They should at least be aware of their availability, as they are by definition often elicited for relevant information and advice, so could potentially refer to them. E-health programs should be localised, to fit an opinion leader’s local audience needs. Bringing e-health programs to opinion leaders’ attention is also a great opportunity to ask for feedback and make relevant adjustments that can improve both e- health programs’ quality and reach.

We previously saw that the “viral videos” were generally much better accepted as Facebook wall material than e-health programs. The creation and optimally, the co- creation of such material, i.e. that is quick and pleasant to review, extraordinary, evokes arousing, preferably positive emotions or involves other positive favourable attributes can be a very useful tool that can be handed on to them. Or, we stress again, co created

37 Examples of how we can be of help will be given next. 138 by them. Such videos, images, games or other attractive content can be used as “Trojan horses” to either promote the lengthier e-health programs either for other purposes, such as kicking off public discourse around a health promotion topic.

Such attractive tools can be seen as enhancing these unofficial health promoters’ discursive competence; enabling them 38 to bring the topic of their interest to the attention of other people that are not so involved with the topic as they are (Petty & Cacioppo, 1986), making it more likely to persuade them and/or kick off valuable discursive work.

Another way to empower them by enhancing their discursive competence is suggested by Bouwman and Woerkum (L. I. Bouwman & van Woerkum, 2009) the authors suggest that short videos can be created showing the discursive work that needs to be done, in negotiating a healthy practice within one’s social circles. This is also material that it would be beneficial to hand over or co-create with opinion leaders.

All or some of the above supportive materials can be produced by global health promotion organisations or initiatives and cooperative networks; that can further increase their cost-effectiveness. However, obtaining feedback on a local basis and making adjustments in order to localise (Gibb & Matthaiakis, 2007) said content is very essential.

N ETWORK BUILDING AND LOCALISATION OF CONTENT In our view, network building should be a priority in health promotion. We have previously argued that health promotion officials are not the only ones interested or competent in promoting health. In our study we saw and heard of a wide array of professionals that held some role in empowerment. The organic vegetable and mushroom producer, the self –organised vegan group, the local humus corner owners, the mothers. The yoga teachers, their yoga teachers, the yoga students, their tempted friends, the physical educator, the snowboarders and slackline fans. Specific interest groups already exist but we suggest that it could be an idea to stimulate and facilitate the organisation of all interested actors per theme, not only on local basis but also interlinking those with the help of health promotion counterparts abroad. Of course in practice many difficulties may be encountered and not everybody will be willing to join, but we stand that it is a venture worth tested. We believe that health promoters have a lot to gain from facilitating the initiation, interlinking and joining such groups as well as by being interconnected with each other, something that is also currently lacking. Such an initiative may have important benefits for health professionals as well, as they also need to be empowered (Koelen & Lindström, 2011).

38 According to the Elaboration Likelihood Model 139

According to Pepper, the process of communication is not a tool that will help us organise, rather, “Communicating and organising are two sides of the same coin” (1995, pg. 7). We hold that official health promoters have a lot to gain by communicating with each other and all other interested actors in promoting health. Joining such groups 39 with an informal attitude can help “change agents” enter the system; Roger quotes that “a social system is a set of interrelated units that are engaged in joint problem solving to accomplish a common goal” (Rogers, 2003, pg 37) and explains that a common problem is that change agents are considered as external to the system. In the words of Rogers “homophily occurs when similar individuals belong to the same groups, live or work near each other, and share similar interests” (Rogers, 2003).

Building international networks per theme of interest can help bring engaging conversations into a sustained existence. Our study shows that being unconventional is a content attribute that is highly valued on Facebook, and can get content on Facebook walls. What we have also learned is that this can vary from place to place, we remind for example posts in Greece giving “a Dutch perspective”, and referenced as “unusual”, or others giving “a Japanese point of view”. We suggest that interconnecting interested actors in international networks can feed these users’ needs to learn and grow on the topic and may provide them with simulative content, suitable for circulation within their local Facebook networks. Our findings point out that people on Facebook are very interested in different perspectives, while they would be less likely to mention something conventional or usual in their settings.

We argue that to appreciate such attributes is to desire to expand one’s personal or cultural horizons. We feel this way of communication can only favour development, and cannot disagree more with authors that suggest that Facebook has very little educational use (Hew, 2011) –which is apparently narrowly defined- on the grounds that it is mainly used to keep in touch with known individuals. What this communication brings should not be overlooked.

L OCALISATION OF CONTENT E-health programs that are produced by a health promotion organization in one country could be in theory adjusted for use by health promotion organizations in more countries as well, further increasing their cost-effectiveness when seen from a global health perspective. Cooperation of e-health program developers and administrators and organization of e-health program material in open access international databases for professionals is in our view of tremendous importance. Thereafter health promoters from all around the world can use the ready-made health promotion material to educate their local target audiences. Adjustments to be made can require relatively small time and

39 Also groups that already exist of course 140 monetary investment; however it is very important that they are not neglected; localisation of content should be a priority.

To be appreciated as practically valuable, promotional messages such as the “Trojan horses” we have previously proposed as well as the e- health programs they promote should be localized to be accessible to local audiences or individual recipients. It is important that said material is in the target audience’s language or subtitled and that there is local access to offline services offered. Moreover, adjustments may need to be made according to specific cultural requirements by developers that have such “insider” knowledge (Gibb & Matthaiakis, 2007).

8.3. THE ADDED VALUE OF FACEBOOK Many of the strategies described previously can be used or experimented with in any online environment or even offline. Which is however the added value of Facebook in using Word of Mouth Marketing strategies to increase the reach of e-health programs?

Firstly, Facebook can be of great value in identifying opinion leaders in categories relevant to a health promotion topic, that are already talking about it on Facebook and are linked to an audience that comprises of – most of the times- real life acquaintances. Essentially, an opportunity exists to address already interconnected groups instead of individuals.

Reaching and connecting with these opinion leaders on Facebook, can facilitate a rather informal communication, that should allow opportunities for cooperation and eliciting feedback; for example in the form of formative research or seeding trials, or arranging meetings offline, all in a more time economic way.

Another strategy that is unique to Facebook is the ability to target conversations, allowing for sponsored messages to appear timely and in context. This is important, as interviewees seemed willing to share the e-health programs when relevant discussions were held, and Facebook advertisements are very affordable (Facebook, 2014a; Villiard & Moreno, 2012). Hence, we propose that e-health programs’ reach can be increased by targeting ads carrying their links to keywords used on Facebook.

Finally, Facebook can facilitate the initiation of valuable discursive work, that can bring e- health programs also to the attention of less involved individuals and groups. However, in order for that to happen, Facebook “Trojan horses” need to be crafted.

8.4. SUMMARY OF SELECTED STRATEGIES The aim of this research was to identify Facebook mediated Word of Mouth Marketing strategies that can be used to increase the reach of e-health programs.

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Many practical strategies have been already indicated; in this section, we will try to summarize a number of key strategic points.

¢ When aspiring to craft content that will be shared on Facebook walls by some users, health promotion organizations should focus on employing characteristics that have been described under “Social Currency” or “Favorable Image Construction”, craft content that evokes arousing emotions, preferably positive, and take care that said promotional message as well as the e-health program contents it promotes are localized to fit their target group’s characteristics. Essentially, as already described, it is important to invite opinion leaders’ participation by involving them in the e-health program in various ways, while engineering ways to facilitate making their involvement public, or even better, turn it into visible symbols of status 40 . ¢ Text incorporated in the e-health program that carries their signature, like for example a personal narrative, a picture they took, an idea they had, an element they voted for; anything published in the e-health program they were directly involved with or carries their name, could be posted on their Facebook page (push method) or be brought to their attention along with share on Facebook buttons, (pull method; for example via Facebook personal messages) 41 . Also, buttons can be created to encourage such contributions (see for example Figure 12). Previously (under 6.2.3.6.) we have elaborated on the importance of stories in word of mouth communication; asking program users, or especially opinion leaders to author success stories would give them the opportunity for personal involvement and favorable image construction, and making these stories public and thus easier to imitate could have clear advantages for the program’s or the desirable behavior’s diffusion. ¢ Our empirical research shows that the most usual criterion used by social connectors when deciding if an e-health program was relevant to a Facebook friend, and therefore whether they would share it with him/her, was whether said user has engaged on another similar discussion. Facebook advertisements targeting specific keywords allow for selected links, such as links to e-health programs, subunits of those or short messages linked with those to appear on Facebook profiles of users that engaged in posting or commenting using these keywords. Said practice holds great potential advantages, as it can offer timely information from trusted sources, reducing ambiguity that relates to issues of interest to health promotion and improving health literacy of users involved. We

40 Inexpensive examples of those include badges, icons, rating stars, etc. 41 Both methods are used in commercial marketing; which is more effective in our case remains to be tested. 142

suggest that said opportunity is used wisely on Facebook; our empirical findings show that the content format and structure is very important when it comes to word of mouth communication on Facebook. Health promotion messages linked to keywords have to be concise, quick and pleasant to review. An image accompanied with a short message, a short text, a short video, preferably not more than 3 minutes long, a Facebook page or an advergame. Long text that gives detailed in depth information runs the risk of not being shared and not being reviewed in the first place; while interested readers can always follow a link when engaged to learn more. ¢ E-health programs should incorporate “Like” and “Share on Facebook” buttons, so satisfied users can make their choice public. ¢ In testing the effectiveness of using opinion leaders in increasing the reach of e- health programs, future research can make access to the pre-release versions of e-health programs possible with the use of promotional codes that will be unique for each opinion leader; this will allow tracking and evaluation of the approach.

FIGURE 12: EXAMPLE OF BUTTONS THAT ENCOURAGE CREATIVE CONTRIBUTIONS FROM USERS

8.5. OTHER THEMES IN RESEARCH This research allows the offering of a couple recommendations for future research, that although not relevant to our particular research questions, may deserve some attention in future research.

First, interviewees indicated as “health related” a much wider range of content than narrowly defined for the purposes of this thesis. Other themes, such as beauty, art, and positive emotions were referenced. To make this a bit more clear, when the question “I would now like you to scan through your activity log and look for a share that to your mind is related to health” came up, some responded right away, while some found it

143 difficult to answer and had to be probed: “Think of what is health for you; then find something that relates to that”. These same categories that participants were used to sharing were then framed as being relevant to health; 9GAG is good for your health because it makes you laugh; music is good for your mental health; pictures that bring happy memories with friends reflect and support social health; creativity is health, so that creative picture or article I shared reflects health; relaxation is health; so any free time activity that helps one relax is healthy. Future research can further explore how health is defined in a bottom up way and the meaning these associations hold in reflecting clients’ priorities.

Second, it was clear that Facebook walls are a place for positive self presentation. Lifestyle related topics were predominantly discussed and although representations of users’ lifestyle seem realistic, also according to previous research (Back et al., 2010; S. D. Gosling, Gaddis, & Vazire, 2007; Moreno et al., 2012), users are likely to focus and emphasize on the positive aspects of their behavior than otherwise. This may indicate that Facebook could be used as a salutogenic environment, where healthful practices can be seen as a starting point for future research, inquiring into which assets and resources lead to or result from referenced healthful practices.

Further, Facebook could be explored as a potential environment for appreciative inquiry, in an effort to enhance and amplify healthful practices and their publication on Facebook. For example, mechanisms that leverage game mechanics could be tested in encouraging users to upload user generated content relating to healthful practices, bringing the focus even more to such content.

Lastly, we hold that it would be interesting to explore the use of triggers on Facebook. To give but one example, future research can experiment with regard to how exposure to visual triggers, such as healthy snacks around lunch time, e.g. pictures of fruits, could increase their consumption.

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APPENDIX A

DESCRIPTION OF THE HEALTH PROMOTION LINKS ; CONTENT FORMAT & OTHER CHARACTERISTICS

This section gives a short description of the health promotion links that were discussed during the second part of the interview.

The first site was a pro-exercise web –intervention by the National Health Sector of England 42 . This first site had a large amount of information available in text and pictures, indexed under numerous categories that referred to different sports, age groups, applications and many, many more.

From all the information available on the site, the interviewees’ attention was next drawn on a specific link on the site reading: “What’s your sport? Find out which sport you are best suited to with this short psychological and aptitude test” (Figure 13)

FIGURE 13: THE “WHAT ‘S YOUR SPORT TEST ” WAS PART OF LINK 1, TO WHICH

INTERVIEWEES ’ ATTENTION WAS ESPECIALLY DRAWN TO . The next link discussed was a ten minute whiteboard animation video on you tube, on the benefits of exercise for health 43 (Figure 14) that has gone viral, managing to approximate 4 million views.

42 http://www.nhs.uk/livewell/fitness/Pages/Fitnesshome.aspx 43 https://www.youtube.com/watch?v=aUaInS6HIGo 145

FIGURE 14: CAPTION FROM LINK 2, A 10 MINUTE WHITEBOARD ANIMATION YOU TUBE VIDEO

The third link was a smoking cessation web intervention from the National Health Sector of England 44 (Figure 15).

Finally, the fourth link was a 96 seconds you tube video, part of Thailand’s anti-smoking campaign 45 (Figure 16) that has gone viral. The video featured a couple of children walking to smokers and asking them for a lighter with a cigarette in their hands. A hidden camera was capturing their response, while they were giving children a variety of facts and reasons for which they shouldn’t smoke. Finally, the children were asking them: “So, why do you smoke?” and left them being surprised and with an anti-tobacco leaflet in their hands.

44 http://www.nhs.uk/smokefree 45 http://www.youtube.com/watch?v=CO0qwl5k9R4 146

FIGURE 15: CAPTION FROM NHS’ SMOKING CESSATION WEB INTERVENTION .

FIGURE 16: CAPTION FROM LINK 4

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APPENDIX B In this part of the appendix, we give an overview of three available peer reviewed opinion leadership scales. These scales are validated and found to be reliable; we therefore suggest that health promoters make use of them to identify opinion leaders in a given category of interest and target “market”.

As the reader can see, opinion leadership scales inquire into a specific category of interest, which can be replaced according to the health promoter’s interest, or come with gaps, exactly for that reason, i.e. in order for the topic of interest to be completed accordingly. As we have discussed before, opinion leaders’ profiling should be category and market situation specific (Nyilasy, 2006; Richins & Root-Shaffer, 1988) . Profoundly, an e- health program dealing with healthy nutrition in England and trying to optimize its launch through opinion leaders cannot possibly work with the same people that were identified as opinion leaders in relation to HIV prevention in Brazil; therefore the topic of interest to health promoters is to be completed prior to the scale’s distribution in the “market” of interest. Below, the available opinion leadership scales are copied and their sources are given. SOURCE : (FLYNN , GOLDSMITH , & EASTMAN , 1996 )

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SOURCE : (CHILDERS , 1986)

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SOURCE : (KING & SUMMERS , 1970)

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APPENDIX C

INFORMATION SHEET This information sheet gives a short introduction to the interview. The informed consent form, which is also attached, will be used to indicate whether we have your permission to proceed with the interview as indicated below. Please read through the points carefully. Once we start our video call, you can let me know if everything was clear and whether or not you have any questions. Of course, you can always write to me before. Firstly, all information provided during this interview is confidential and will only be used for the purposes of my Master thesis and for writing a scientific article. A phrase from this interview may be published in my MSc thesis or in the scientific article, but you will remain anonymous. The interview duration can vary from 40 minutes to a maximum of one hour.

You can see this interview as a normal conversation on specific topics, with one exception: I will not share my opinions, because this conversation is all about you. I will only talk to ask you short questions in order to encourage you to express yourself. Some questions might seem funny or, perhaps, difficult to answer, but please remember that there can be no wrong or right answers here. What you are asked to do, is answer as openly and honestly as you can about what comes to your mind. All we are interested in is your opinion and your personal experiences.

Now, about what we are going to discuss: We are going to discuss what you enjoy sharing on Facebook. And when I say sharing, I do not only mean what you usually post on your wall, but also what you “like”, what you comment on, whatever you do that is visible on your activity log . So we are going to discuss what you enjoy sharing in general, and then what you enjoy sharing on a specific topic.

In order to have this discussion, we will need some visual aid, to help you remember and get you talking but also to give me a better idea of what we are talking about. In order for that to happen, I will ask you to share your screen with me while you view your activity log. For a very short tutorial showing how you access your activity log and how you share your screen on Skype , click here .

Captions of your activity log may be used in my MSc thesis report or in the scientific article, but your Facebook name, your friends’ Facebook names and your facial characteristics will not be visible.

Finally, as this interview will take quite some time, it will be impossible for me to remember or write everything you say. I therefore would like to record this interview; do I have your permission to do so?

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Please indicate whether you agree or not on these points by using the informed consent form. I will also be happy to answer any questions you might have. Thank you for agreeing to be interviewed and I am looking forward to seeing you on Skype!

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INTERVIEW GUIDE ______A. Opening questions 1. Did you read the introduction to the interview? 2. Was everything clear? Do you have any questions? 3. Do I have your permission to proceed with the interview? 4. Do you often go on Facebook? 5. Can you tell me something that you think that is good about Facebook?

http://www.nhs.uk/LiveWell/Fitness/Pages/Fitnesshome.aspx 153

https://www.youtube.com/watch?v=aUaInS6HIGo 2http://smokefree.nhs.uk/ 3http://www.youtube.com/watch?v=CO0qwl5k9R4

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APPENDIX D As explained under 5.2., two Word of Mouth Marketing books were used as starting points of our literature research for answering : “What is the state of the evidence on Word of Mouth Marketing best practices?” References and citations of these resources were followed up leading to a list of 121 relevant publications used in our narrative literature review. In this part of the appendix, we give the full list of included publications. In summary, these publications comprise of:

V Books V Scientific articles published in peer reviewed magazines (e.g. the Journal of Marketing Research, the Journal of Advertising Research or the Journal of Cognitive Psychology) V Marketing research institutes’ publications, like from “Marketing Sherpa Inc”. V Business magazines like “Forbes” and “BusinessWeek”. V Conference proceedings like papers presented at the “Proceedings of the 2010 ACM conference on Computer supported cooperative work” or at the “fourth ACM international conference on Web search and data mining”. V Newspapers like The New York Times and the Arizona Republic. V Websites like the ca.movember.com

LIST OF PUBLICATIONS INCLUDED IN OUR LITERATURE RESEARCH

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14. Wells, M. (2004). Kid nabbing. Forbes, 173 (2), 84-88. 15. Rogers, E. M. (2003). Diffusion of innovations/Everett M. Rogers: New York., NY, Free Press. 16. Holmes, J. H., & Lett, J. D. (1977). Product sampling and word of mouth. Journal of Advertising Research . 17. Cakim, I. (2006). Online opinion Leaders: A predictive guide for viral marketing campaigns. Connected Marketing: the Viral, Buzz and Word-of-mouth Revolution , 107-118. 18. Blodgett, J. G., Granbois, D. H., & Walters, R. G. (1994). The effects of perceived justice on complainants' negative word-of-mouth behavior and repatronage intentions. Journal of Retailing, 69 (4), 399-428. 19. File, K. M., Judd, B. B., & Prince, R. A. (1992). Interactive marketing: the influence of participation on positive word-of-mouth and referrals. Journal of Services Marketing, 6 (4), 5-14. 20. Gremler, D. D., Gwinner, K. P., & Brown, S. W. (2001). Generating positive word-of-mouth communication through customer-employee relationships. International Journal of Service Industry Management, 12 (1), 44- 59.

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APPENDIX E

IDENTIFYING AND REACHING OPINION LEADERS ;DIGITAL TRACE ON FACEBOOK

F ACEBOOK ADVERTISEMENTS LINKING TO OPINION LEADERSHIP SCALES A strategy to identify and reach opinion leaders on Facebook in an non obtrusive manner, could be the use of Facebook advertisements, targeting specific keywords, stated interests, or even professions as a first step, while inviting users to complete a linked opinion leadership scale next 46 . Placing such advertisements is very affordable, and health promotion organizations can experiment with using this new medium for reaching their audiences (Facebook, 2014a; Villiard & Moreno, 2012). To give an example, a health promotion organization looking for opinion leading individuals that will help diffuse an e- health initiative on healthy nutrition, might want to use a Facebook advertisement targeting the interest “Cooking/Baking”, or target people in a specific region whose education is listed under “healthy nutrition”, or target keywords on their timeline such as “cooking” or phrases such as “healthy diet”, or a combination of those, to name but a few options. That will allow a Facebook advertisement linked to the health promotion organization’s professional page, Facebook group, event, application or website to appear on the timelines of Facebook users who are already talking about the topic with e.g. posts or comments, or who have similar listed interests, or professions.

MANUAL SEARCH ; USING A PERSONAL OR PROFESSIONAL PAGE AS A STARTING POINT Another option for health promoters is to make use of their personal Facebook network as a starting point, or a Facebook network created around a page linked to the organization they work for. In the case that health promoters in a community are interested in using their personal or professional Facebook account and network to initiate community mobilization and kick off public discourse, they could use the Facebook search field to search for “friends that like” e.g. pages relevant to the topic of interest. For example, one could look for “Friends that like cooking/baking” and get a number of recommendations for similar keywords and groups along the way. Looking for e.g. “Friends of friends that like cooking/baking is also possible (see figure 17); further, a large number of filtering options are also provided in such searches and by changing the “Friendship” filtering option to “Not my friends” one can get a much greater number of users having a particular interest 47 , using a specific app, and much more, while also being able to further filter those results per current city of residence, gender and more. To see a full list of these options, click on “See more filters” on the bottom of the basic filtering list (also see figure 18). This search function and filtering options are free of charge; in that

46 Three peer-reviewed, validated opinion leadership scales (Flynn, Goldsmith, & Eastman, 1996; (Childers, 1986; King & Summers, 1970; Miled & Le Louarn, 1994) are made available for the reader in appendix B.

47 There is actually a shorter route to obtain these same results: By typing “People who are not my friends and like Cooking/Baking” on the Facebook search field. 161 case however communicating with these users and inviting them to complete an opinion leadership scale would require sending them a Personal Message. In this case, one should note that the default Facebook inbox filtering option only allows messages from friends and friends of friends to appear in one’s inbox. Messages sent to people that are not your Facebook friends or friends of your friends will be directed to their “Other” folder, and users will not receive a notification for them. However, there are some ways to work around this. Your message will go to one’s regular inbox folder, for which they will be notified, if you are a member of a Facebook group they are also members of, or if you send these messages through the Facebook “Messenger Application” (Facebook, 2014b).

Note that in order to use the Facebook Messenger application, one has to connect either through an android or apple Smartphone, either from a regular computer using the Firefox browser. Using the messenger application is possible even for people that are not registered with Facebook (Black, 2014).

Finally, paying Facebook to ensure that all messages are routed to users’ inbox instead of their “other” folder is also an option (Facebook, 2014b)

However, as is the case with all push advertising messages coming from unknown sources, these messages can be regarded as spam by the users, decreasing the chances they will respond to them (Crutzen, 2009). A possible alternative in order to overcome this problem, at least in the case of friends of friends, would be to ask your connecting friend to mediate and send the message on your behalf; in theory this would decrease the chances that the message is considered as spam, as it will be coming from a friend of theirs instead of an unknown source (Crutzen, 2009). In the end, in all cases described above, the objective is to identify opinion leaders that may be able to participate in your project, so opinion leadership scales should be linked to these messages, to be filled in by these users. As marketing experts advise, health promotion organizations can partner with online research firms to host the survey online (Cakim, 2006).

U SE OF KEY INFORMANTS In the case that a team of health promoters will decide to use their own personal or professional Facebook network as a point of departure, another option to identify opinion leaders would be to ask their Facebook friends who they would nominate as an opinion leader on a specific category, or else who they would turn for advice to when looking for information or other support on a specific topic. People nominated as opinion leaders on a specific category could be asked the same question, i.e. who would they turn to themselves (P. Marsden, 2006; E. M. Rogers, 2003); finally, results obtained by this method could be triangulated with the use of opinion leadership scales.

If the opinion leaders are identified after opting in to complete a self –designating questionnaire, contacting them is facilitated, as it is a continuation of their input.

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FIGURE 17: FACEBOOK SCREENSHOT ; WHILE LOOKING FOR “FRIENDS OF FRIENDS ” THAT LIKE COOKING /BAKING .

FIGURE 18: GETTING RESULTS BEYOND ONE ’S PERSONAL OR PROFESSIONAL NETWORK USING THE FILTERING OPTIONS

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