qualitative research methods for media studies

3rd Edition

Qualitative Research Methods for Media Studies

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This fully updated third edition provides students and researchers with the tools they need to perform critically engaged, theoretically informed research using methods that include interviewing, focus groups, historical research, oral histories, ethnography and participant observation, textual analysis and digital research. Each chapter features step-by-step instructions that integrate theory with practice, as well as a case study drawn from published research demonstrating best practices for media scholars. Readers will also find in-depth discussions of the challenges and ethical issues that may confront researchers using a qualitative approach. With new case studies and examples throughout, this third edition also includes updated and expanded material on digital technologies and platforms, how to perform social media research, how to analyze a variety of multimedia texts, and reflections on the use of big data. A comprehensive and accessible guide for those hoping to explore this rich vein of research methodology, this book provides students and scholars with the all tools they need to be able to work in today’s convergent media environment.

Table of Contents

Bonnie S. Brennen is Professor Emerita of Journalism and Media Studies at Marquette University and Editor-in-Chief of Journalism Practice . Her research addresses relationships between media, culture, technology and society. She is the author/editor of eight books and one novel, and her research has been published in edited books and academic journals. In October 2015 she was inducted into the University of Iowa School of Journalism and Mass Communication Hall of Fame.

Critics' Reviews

PRAISE FOR THE SECOND EDITION "Written in clear, jargon-free language, this remarkable and engaging textbook is extraordinarily valuable for beginners and experienced qualitative researchers. Brennen deftly makes complex concepts accessible and understandable, giving students the skills and the courage to undertake challenging research studies." Margaret Duffy , Professor of Strategic Communication, Missouri School of Journalism, and Executive Director of the Novak Leadership Institute, USA "Brennen covers the breadth of qualitative research in media studies thoroughly and accessibly, drawing on numerous examples to knit together the conceptual concerns of method with the practical experiences of research in action. This is a valuable text for both students new to research to learn the craft of qualitative research and for prompting even the most experienced researchers with helpful conceptual and practical reminders towards its best practices." Jason Pridmore , Associate Professor of Media and Communication and Vice Dean of Education for the School of History, Culture and Communication, Erasmus University Rotterdam, Netherlands

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Qualitative Research Methods for Media Studies

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This book introduces the essential qualitative methods used in media research, with an emphasis on integrating theory with practice. Each method is introduced through step-by-step instruction on conducting research and interpreting research findings, alongside in-depth discussions of the historical, cultural, and theoretical context of the particular method and case studies drawn from published scholarship. This text is a comprehensive and accessible introduction to qualitative methods, ideal for media and mass communication research courses.

TABLE OF CONTENTS

Chapter 1 | 12  pages, getting started, chapter 2 | 13  pages, doing qualitative research, chapter 3 | 33  pages, interviewing, chapter 4 | 34  pages, focus groups, chapter 5 | 31  pages, chapter 6 | 35  pages, oral history, chapter 7 | 33  pages, ethnography and participant observation, chapter 8 | 40  pages, textual analysis.

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Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organization?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

• Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organization to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Qualitative Research Methods for Media Studies 3rd Edition

• Author(s) Bonnie S. Brennen
• Publisher Routledge

Qualitative Research Methods for Media Studies

By bonnie s. brennen.

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Qualitative Research Methods for Media Studies 3rd Edition

This fully updated third edition provides students and researchers with the tools they need to perform critically engaged, theoretically informed research using methods that include interviewing, focus groups, historical research, oral histories, ethnography and participant observation, textual analysis and digital research.

Each chapter features step-by-step instructions that integrate theory with practice, as well as a case study drawn from published research demonstrating best practices for media scholars. Readers will also find in-depth discussions of the challenges and ethical issues that may confront researchers using a qualitative approach. With new case studies and examples throughout, this third edition also includes updated and expanded material on digital technologies and platforms, how to perform social media research, how to analyze a variety of multimedia texts, and reflections on the use of big data.

A comprehensive and accessible guide for those hoping to explore this rich vein of research methodology, this book provides students and scholars with the all tools they need to be able to work in today’s convergent media environment.

• ISBN-10 0367641534
• ISBN-13 978-0367641535
• Edition 3rd
• Publication date October 26, 2021
• Language English
• Dimensions 6 x 0.79 x 9 inches
• Print length 264 pages
• See all details

Editorial Reviews

PRAISE FOR THE SECOND EDITION

"Written in clear, jargon-free language, this remarkable and engaging textbook is extraordinarily valuable for beginners and experienced qualitative researchers. Brennen deftly makes complex concepts accessible and understandable, giving students the skills and the courage to undertake challenging research studies."

Margaret Duffy, Professor of Strategic Communication, Missouri School of Journalism, and Executive Director of the Novak Leadership Institute, USA

"Brennen covers the breadth of qualitative research in media studies thoroughly and accessibly, drawing on numerous examples to knit together the conceptual concerns of method with the practical experiences of research in action. This is a valuable text for both students new to research to learn the craft of qualitative research and for prompting even the most experienced researchers with helpful conceptual and practical reminders towards its best practices."

Jason Pridmore, Associate Professor of Media and Communication and Vice Dean of Education for the School of History, Culture and Communication, Erasmus University Rotterdam, Netherlands

About the Author

Bonnie S. Brennen is Professor Emerita of Journalism and Media Studies at Marquette University and Editor-in-Chief of Journalism Practice . Her research addresses relationships between media, culture, technology and society. She is the author/editor of eight books and one novel, and her research has been published in edited books and academic journals. In October 2015 she was inducted into the University of Iowa School of Journalism and Mass Communication Hall of Fame.

Product details

• Publisher ‏ : ‎ Routledge; 3rd edition (October 26, 2021)
• Language ‏ : ‎ English
• Hardcover ‏ : ‎ 264 pages
• ISBN-10 ‏ : ‎ 0367641534
• ISBN-13 ‏ : ‎ 978-0367641535
• Item Weight ‏ : ‎ 1.43 pounds
• Dimensions ‏ : ‎ 6 x 0.79 x 9 inches
• #5,858 in Media Studies (Books)
• #30,977 in Communication & Media Studies
• #140,623 in Social Sciences (Books)

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Bonnie brennen.

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Introduction to qualitative research methods – Part I

Shagufta bhangu.

Department of Global Health and Social Medicine, King's College London, London, United Kingdom

Fabien Provost

Carlo caduff.

Qualitative research methods are widely used in the social sciences and the humanities, but they can also complement quantitative approaches used in clinical research. In this article, we discuss the key features and contributions of qualitative research methods.

INTRODUCTION

Qualitative research methods refer to techniques of investigation that rely on nonstatistical and nonnumerical methods of data collection, analysis, and evidence production. Qualitative research techniques provide a lens for learning about nonquantifiable phenomena such as people's experiences, languages, histories, and cultures. In this article, we describe the strengths and role of qualitative research methods and how these can be employed in clinical research.

Although frequently employed in the social sciences and humanities, qualitative research methods can complement clinical research. These techniques can contribute to a better understanding of the social, cultural, political, and economic dimensions of health and illness. Social scientists and scholars in the humanities rely on a wide range of methods, including interviews, surveys, participant observation, focus groups, oral history, and archival research to examine both structural conditions and lived experience [ Figure 1 ]. Such research can not only provide robust and reliable data but can also humanize and add richness to our understanding of the ways in which people in different parts of the world perceive and experience illness and how they interact with medical institutions, systems, and therapeutics.

Examples of qualitative research techniques

Qualitative research methods should not be seen as tools that can be applied independently of theory. It is important for these tools to be based on more than just method. In their research, social scientists and scholars in the humanities emphasize social theory. Departing from a reductionist psychological model of individual behavior that often blames people for their illness, social theory focuses on relations – disease happens not simply in people but between people. This type of theoretically informed and empirically grounded research thus examines not just patients but interactions between a wide range of actors (e.g., patients, family members, friends, neighbors, local politicians, medical practitioners at all levels, and from many systems of medicine, researchers, policymakers) to give voice to the lived experiences, motivations, and constraints of all those who are touched by disease.

PHILOSOPHICAL FOUNDATIONS OF QUALITATIVE RESEARCH METHODS

In identifying the factors that contribute to the occurrence and persistence of a phenomenon, it is paramount that we begin by asking the question: what do we know about this reality? How have we come to know this reality? These two processes, which we can refer to as the “what” question and the “how” question, are the two that all scientists (natural and social) grapple with in their research. We refer to these as the ontological and epistemological questions a research study must address. Together, they help us create a suitable methodology for any research study[ 1 ] [ Figure 2 ]. Therefore, as with quantitative methods, there must be a justifiable and logical method for understanding the world even for qualitative methods. By engaging with these two dimensions, the ontological and the epistemological, we open a path for learning that moves away from commonsensical understandings of the world, and the perpetuation of stereotypes and toward robust scientific knowledge production.

Developing a research methodology

Every discipline has a distinct research philosophy and way of viewing the world and conducting research. Philosophers and historians of science have extensively studied how these divisions and specializations have emerged over centuries.[ 1 , 2 , 3 ] The most important distinction between quantitative and qualitative research techniques lies in the nature of the data they study and analyze. While the former focus on statistical, numerical, and quantitative aspects of phenomena and employ the same in data collection and analysis, qualitative techniques focus on humanistic, descriptive, and qualitative aspects of phenomena.[ 4 ]

For the findings of any research study to be reliable, they must employ the appropriate research techniques that are uniquely tailored to the phenomena under investigation. To do so, researchers must choose techniques based on their specific research questions and understand the strengths and limitations of the different tools available to them. Since clinical work lies at the intersection of both natural and social phenomena, it means that it must study both: biological and physiological phenomena (natural, quantitative, and objective phenomena) and behavioral and cultural phenomena (social, qualitative, and subjective phenomena). Therefore, clinical researchers can gain from both sets of techniques in their efforts to produce medical knowledge and bring forth scientifically informed change.

KEY FEATURES AND CONTRIBUTIONS OF QUALITATIVE RESEARCH METHODS

In this section, we discuss the key features and contributions of qualitative research methods [ Figure 3 ]. We describe the specific strengths and limitations of these techniques and discuss how they can be deployed in scientific investigations.

Key features of qualitative research methods

One of the most important contributions of qualitative research methods is that they provide rigorous, theoretically sound, and rational techniques for the analysis of subjective, nebulous, and difficult-to-pin-down phenomena. We are aware, for example, of the role that social factors play in health care but find it hard to qualify and quantify these in our research studies. Often, we find researchers basing their arguments on “common sense,” developing research studies based on assumptions about the people that are studied. Such commonsensical assumptions are perhaps among the greatest impediments to knowledge production. For example, in trying to understand stigma, surveys often make assumptions about its reasons and frequently associate it with vague and general common sense notions of “fear” and “lack of information.” While these may be at work, to make such assumptions based on commonsensical understandings, and without conducting research inhibit us from exploring the multiple social factors that are at work under the guise of stigma.

In unpacking commonsensical understandings and researching experiences, relationships, and other phenomena, qualitative researchers are assisted by their methodological commitment to open-ended research. By open-ended research, we mean that these techniques take on an unbiased and exploratory approach in which learnings from the field and from research participants, are recorded and analyzed to learn about the world.[ 5 ] This orientation is made possible by qualitative research techniques that are particularly effective in learning about specific social, cultural, economic, and political milieus.

Second, qualitative research methods equip us in studying complex phenomena. Qualitative research methods provide scientific tools for exploring and identifying the numerous contributing factors to an occurrence. Rather than establishing one or the other factor as more important, qualitative methods are open-ended, inductive (ground-up), and empirical. They allow us to understand the object of our analysis from multiple vantage points and in its dispersion and caution against predetermined notions of the object of inquiry. They encourage researchers instead to discover a reality that is not yet given, fixed, and predetermined by the methods that are used and the hypotheses that underlie the study.

Once the multiple factors at work in a phenomenon have been identified, we can employ quantitative techniques and embark on processes of measurement, establish patterns and regularities, and analyze the causal and correlated factors at work through statistical techniques. For example, a doctor may observe that there is a high patient drop-out in treatment. Before carrying out a study which relies on quantitative techniques, qualitative research methods such as conversation analysis, interviews, surveys, or even focus group discussions may prove more effective in learning about all the factors that are contributing to patient default. After identifying the multiple, intersecting factors, quantitative techniques can be deployed to measure each of these factors through techniques such as correlational or regression analyses. Here, the use of quantitative techniques without identifying the diverse factors influencing patient decisions would be premature. Qualitative techniques thus have a key role to play in investigations of complex realities and in conducting rich exploratory studies while embracing rigorous and philosophically grounded methodologies.

Third, apart from subjective, nebulous, and complex phenomena, qualitative research techniques are also effective in making sense of irrational, illogical, and emotional phenomena. These play an important role in understanding logics at work among patients, their families, and societies. Qualitative research techniques are aided by their ability to shift focus away from the individual as a unit of analysis to the larger social, cultural, political, economic, and structural forces at work in health. As health-care practitioners and researchers focused on biological, physiological, disease and therapeutic processes, sociocultural, political, and economic conditions are often peripheral or ignored in day-to-day clinical work. However, it is within these latter processes that both health-care practices and patient lives are entrenched. Qualitative researchers are particularly adept at identifying the structural conditions such as the social, cultural, political, local, and economic conditions which contribute to health care and experiences of disease and illness.

For example, the decision to delay treatment by a patient may be understood as an irrational choice impacting his/her chances of survival, but the same may be a result of the patient treating their child's education as a financial priority over his/her own health. While this appears as an “emotional” choice, qualitative researchers try to understand the social and cultural factors that structure, inform, and justify such choices. Rather than assuming that it is an irrational choice, qualitative researchers try to understand the norms and logical grounds on which the patient is making this decision. By foregrounding such logics, stories, fears, and desires, qualitative research expands our analytic precision in learning about complex social worlds, recognizing reasons for medical successes and failures, and interrogating our assumptions about human behavior. These in turn can prove useful in arriving at conclusive, actionable findings which can inform institutional and public health policies and have a very important role to play in any change and transformation we may wish to bring to the societies in which we work.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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Article Contents

Introduction, challenging some common methodological assumptions about online qualitative surveys, ten practical tips for designing, implementing and analysing online qualitative surveys, acknowledgements, conflict of interest statement, data availability, ethical approval.

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Methodological and practical guidance for designing and conducting online qualitative surveys in public health

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Samantha L Thomas, Hannah Pitt, Simone McCarthy, Grace Arnot, Marita Hennessy, Methodological and practical guidance for designing and conducting online qualitative surveys in public health, Health Promotion International , Volume 39, Issue 3, June 2024, daae061, https://doi.org/10.1093/heapro/daae061

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Online qualitative surveys—those surveys that prioritise qualitative questions and interpretivist values—have rich potential for researchers, particularly in new or emerging areas of public health. However, there is limited discussion about the practical development and methodological implications of such surveys, particularly for public health researchers. This poses challenges for researchers, funders, ethics committees, and peer reviewers in assessing the rigour and robustness of such research, and in deciding the appropriateness of the method for answering different research questions. Drawing and extending on the work of other researchers, as well as our own experiences of conducting online qualitative surveys with young people and adults, we describe the processes associated with developing and implementing online qualitative surveys and writing up online qualitative survey data. We provide practical examples and lessons learned about question development, the importance of rigorous piloting strategies, use of novel techniques to prompt detailed responses from participants, and decisions that are made about data preparation and interpretation. We consider reviewer comments, and some ethical considerations of this type of qualitative research for both participants and researchers. We provide a range of practical strategies to improve trustworthiness in decision-making and data interpretation—including the importance of using theory. Rigorous online qualitative surveys that are grounded in qualitative interpretivist values offer a range of unique benefits for public health researchers, knowledge users, and research participants.

Public health researchers are increasingly using online qualitative surveys.

There is still limited practical and methodological information about the design and implementation of these studies.

Building on Braun and Clarke (2013) , Terry and Braun (2017) and Braun et al . (2021) , we reflect on the methodological and practical lessons we have learnt from our own experience with conducting online qualitative surveys.

We provide guidance and practical examples about the design, implementation and analysis processes.

We argue that online qualitative surveys have rich potential for public health researchers and can be an empowering and engaging way to include diverse populations in qualitative research.

Public health researchers mostly engage in experiential (interpretive) qualitative approaches ( Braun and Clarke, 2013 ). These approaches are ‘centred on the exploration of participants’ subjective experiences and sense-making’ [( Braun and Clarke, 2021c ), p. 39]. Given the strong focus in public health on social justice, power and inequality, researchers proactively use the findings from these qualitative studies—often in collaboration with lived experience experts and others who are impacted by key decisions ( Reed et al ., 2024 )—to advocate for changes to public health policy and practice. There is also an important level of theoretical, methodological and empirical reflection that is part of the public health researcher’s role. For example, as qualitative researchers actively construct and interpret meaning from data, they constantly challenge their assumptions, their way of knowing and their way of ‘doing’ research ( Braun and Clarke, 2024 ). This reflexive practice also includes considering how to develop more inclusive opportunities for people to participate in research and to share their opinions and experiences about the issues that matter to them.

While in-depth interviews and focus groups provide rich and detailed narratives that are central to understanding people’s lives, these forms of data collection may sometimes create practical barriers for both researchers and participants. For example, they can be time consuming, and the power dynamics associated with face-to-face interviews (even in online settings) may make them less accessible for groups that are marginalized or stigmatized ( Edwards and Holland, 2020 ). While some population subgroups (and contexts) may suit (or require) face-to-face qualitative data collection approaches, others may lend themselves to different forms of data collection. Young people, for example, may be keen to be civically involved in research about the issues that matter to them, such as the climate crisis, but they may find it more convenient and comfortable using anonymized digital technologies to do so ( Arnot et al ., 2024b ). As such, part of our reflexive practice as public health researchers must be to explore, and be open to, a range of qualitative methodological approaches that could be more convenient, less intimidating and more engaging for a diverse range of population subgroups. This includes thinking about pragmatic ways of operationalizing qualitative data collection methods. How can we develop methods and engagement strategies that enable us to gain insights from a diverse range of participants about new issues or phenomenon that may pose threats to public health, or look at existing issues in new ways?

Advancements in online data collection methods have also created new options for researchers and participants about how they can be involved in qualitative studies ( Hensen et al ., 2021 ; Chen, 2023 ; Fan et al ., 2024 ). Online qualitative surveys—those surveys that prioritize qualitative values and questions—have rich potential for qualitative researchers. Braun and Clarke (2013 , p. 135) state that qualitative surveys:

…consist of a series of open-ended questions about a topic, and participants type or hand-write their responses to each question. They are self-administered; a researcher-administered qualitative survey would basically be an interview.

While these types of studies are increasingly utilized in public health, researchers have highlighted that there is still relatively limited discussion about the methodological and practical implications of these surveys ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ). This poses challenges for qualitative public health researchers, funders, ethics committees and peer reviewers in assessing the purpose, rigour and contribution of such research, and in deciding the appropriateness of the method for answering different research questions.

Using examples from online qualitative surveys that we have been involved in, this article discusses a range of methodological and practical lessons learnt from developing, implementing and analysing data from these types of surveys. While we do not claim to have all the answers, we aim to develop and extend on the methodological and practical guidance from Braun and Clarke (2013) , Terry and Braun (2017) and Braun et al . (2021) about the potential for online qualitative surveys. This includes how they can provide a rigorous ‘wide-angle picture’ [( Toerien and Wilkinson, 2004 ), p. 70] from a diverse range of participants about contemporary public health phenomena.

Figure 1 aims to develop and extend on the key points made by Braun and Clarke (2013) , Terry and Braun (2017) and Braun et al . (2021) , which provide the methodological and empirical foundation for our article.

: Methodological considerations in conducting online qualitative surveys.

Harnessing interpretivist approaches and qualitative values in online qualitative surveys

Online qualitative surveys take many forms. They may be fully qualitative or qualitative dominant—mostly qualitative with some quantitative questions ( Terry and Braun, 2017 ). There are also many different ways of conducting these studies—from using a smaller number of questions that engage specific population groups or knowledge users in understanding detailed experiences  ( Hennessy and O’Donoghue, 2024 ), to a larger number of questions (which may use market research panel providers to recruit participants), that seek broader opinions and attitudes about public health issues ( Marko et al ., 2022a ; McCarthy et al ., 2023 ; Arnot et al ., 2024a ). However, based on our experiences of applying for grant funding and conducting, publishing and presenting these studies, there are still clear misconceptions and uncertainties about these types of  surveys.

One of the concerns raised about online qualitative surveys is how they are situated within broader qualitative values and approaches. This includes whether they can provide empirically innovative, rigorous, rich and theoretically grounded qualitative contributions to knowledge. Our experience is that online qualitative surveys have the most potential when they harness the values of interpretivist ‘Big Q’ approaches to collect information from a diverse range of participants about their experiences, opinions and practices ( Braun et al ., 2021 ). The distinction between positivist (small q) and interpretivist (Big Q) approaches to online qualitative surveys is an important one that requires some initial methodological reflection, particularly in considering the (largely unhelpful) critiques that are made about the rigour and usefulness of these surveys. These critiques often overlook the theoretical underpinnings and qualitative values inherent in such surveys. For example, while there may be a tendency to think of surveys and survey data as atheoretical and descriptive, the use of theory is central in informing online qualitative surveys. For example, Varpio and Ellaway (2021 , p. 343) explain that theory can ‘offer explanations and detailed premises that we can wrestle with, agree with, disagree with, reject and/or accept’. This includes the research design, the approach to data collection and analysis, the interpretation of findings and the conclusions that are drawn. Theory is also important in helping researchers to engage in reflexive practice. The use of theory is essential in progressing online qualitative surveys beyond description and towards in-depth interpretation and explanations—thus facilitating a deeper understanding of the studied phenomenon ( Collins and Stockton, 2018 ; Jamie and Rathbone, 2022 ).

Considering the assumptions that online qualitative surveys can only collect ‘thin’ data

The main assumptions about online qualitative surveys are that they can only collect ‘thin’ textual data, and that they are not flexible enough as a data collection tool for researchers to prompt or ask follow-up questions or to co-create detailed and rich data with participants ( Braun and Clarke, 2013 ; Terry and Clarke, 2017 ; Braun et al ., 2021 ). While we acknowledge that the type of data that is collected in these types of studies is different from those in in-depth interview studies, these surveys may be a more accessible and engaging way to collect rich insights from a diverse range of participants who may otherwise not participate in qualitative research ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ). Despite this, peer reviewers can question the depth of information that may be collected in these studies. Assumptions about large but ‘thin’ datasets may also mean that researchers, funders and reviewers take (and perhaps expect) a more positivist approach to the design and analytical processes associated with these surveys. For example, the multiple topics and questions, larger sample sizes, and the generally smaller textual responses that online qualitative surveys generate may lead researchers to approach these surveys using more descriptive and atheoretical paradigms. This approach may focus on ‘measuring’ phenomena, using variables, developing thinner analytical description and adding numerical values to the number of responses for different categories or themes.

We have found that assumptions can also impact the review processes associated with these types of studies, receiving critiques from those with both positivist and interpretivist positions. Positivist critiques focus on matters associated with whether the samples are ‘representative’, and the flaws associated with ‘self-selecting convenience’ samples. Critiques from interpretivist colleagues question why such large sample sizes are needed for qualitative studies, seeing surveys as a less rigorous method for gaining rich and meaningful data. For example, we have had reviewers query the scope and depth of the analysis of the data that we present from these studies because they are concerned that the type of data collected lacks depth and does not fully contextualize and explain how participants think about issues. We have also had reviewers request that we should return to the study to collect quantitative data to supplement the qualitative findings of the survey. They also question how ‘representative’ the samples are of population groups. These comments, of course, are not unique to online qualitative surveys but do highlight the difficulty that reviewers may have in placing and situating these types of studies in broader qualitative approaches. With this in mind, we have also found that some reviewers can ask for additional information to justify both the use of online qualitative surveys and why we have chosen these over other qualitative approaches. For example, reviewers have asked us to justify why we have chosen an online qualitative survey and also to explain what we may have missed out on by not conducting in-depth interviews or quantitative or mixed methods surveys instead.

Requests for ‘numbers’ and ‘strategies to minimize bias’

While there is now a general understanding that attributing ‘numbers’ to qualitative data is largely unhelpful and inappropriate ( Chowdhury, 2015 ), there may be expectations that the larger sample sizes associated with online qualitative surveys enable researchers to provide numerical indicators of data. Rather than focusing on the ‘artfully interpretive’ techniques used to analyse and construct themes from the data ( Finlay, 2021 ), we have found that reviewers often ask us to provide numerical information about how many people provided different responses to different questions (or constructed themes), and the number at which ‘saturation’ was determined. Reviewer feedback that we have received about analytical processes has asked for detailed explanations about why attempts to ‘minimize bias’ (including calculations of inter-rater reliability and replicability of data quality) were not used. This demonstrates that peer reviewers may misinterpret the interpretivist values that guide online qualitative surveys, asking for information that is essentially ‘meaningless’ in qualitative paradigms in which researchers’ subjectivity ‘sculpts’ the knowledge that is produced ( Braun and Clarke, 2021a ).

The benefits and limitations of online qualitative surveys for participants, researchers and knowledge users

As well as a ‘wide-angle picture’ [( Toerien and Wilkinson, 2004 ), p. 70] on phenomenon, online qualitative surveys can also: (i) generate both rich and focused data about perceptions and practices, and (ii) have multiple participatory and practical advantages—including helping to overcome barriers to research participation ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ). For researchers , online qualitative surveys can be a more cost-effective alternative ( Braun and Clarke, 2013 ; Terry and Braun, 2017 )—they are generally more time-efficient and less labour-intensive (particularly if working with market research companies to recruit panels). They are also able to reach a broad range of participants—such as those who are geographically dispersed ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ), and those who may not have internet connectivity that is reliable enough to complete online interviews (a common issue for individuals living in regional or rural settings) ( de Villiers et al ., 2022 ). We are also more able to engage young people in qualitative research through online surveys, perhaps partly due to extensive panel company databases but also because they may be a more accessible and familiar way for young people to participate in research. The ability to quickly investigate new public health threats from the perspective of lived experience can also provide important information for researchers, providing justification for new areas of research focus, including setting agendas and advocating for the need for funding (or policy attention). Collecting data from a diverse range of participants—including from those who hold views that we may see as less ‘politically acceptable’, or inconsistent with our own public health reasoning about health and equity—is important in situating and contextualizing community attitudes towards particular issues.

For participants , benefits include having a degree of autonomy and control over their participation, including completing the survey at a time and place that suits them, and the anonymous nature of participation (that may be helpful for people from highly stigmatized groups). Participants can take time to reflect on their responses or complete the survey, and may feel more able to ‘talk back’ to the researcher about the framing of questions or the purpose of the research ( Braun et al ., 2021 ). We would also add that a benefit of these types of studies is that participants can also drop out of the study easily if the survey does not interest them or meet their expectations—something that we think might be more onerous or uncomfortable for participants in an interview or focus group.

For knowledge users, including advocates, service providers and decision-makers, qualitative research provides an important form of evidence, and the ‘wide-angle picture' [( Toerien and Wilkinson, 2004 ), p. 70] on issues from a diverse range of individuals in a community or population can be a powerful advocacy tool. Online qualitative surveys can also provide rapid insights into how changes to policy and practice may impact population subgroups in different ways.

There are, of course, some limitations associated with online qualitative surveys ( Braun et al ., 2021 ; Marko et al ., 2022b ). For example, there is no ability to engage individuals in a ‘traditional’ conversation or to prompt or probe meaning in the interactive ways that we are familiar with in interview studies. There is less ability to refine the questions that we ask participants in an iterative way throughout a study based on participant responses (particularly when working with market research panel companies). There may also be barriers associated with written literacy, access to digital technologies and stable internet connections ( Braun et al ., 2021 ). They may also not be the most suitable for individuals who have different ways of ‘knowing, being and doing’ qualitative research—including Indigenous populations [( Kennedy et al ., 2022 ), p. 1]. All of these factors should be taken into consideration when deciding whether online qualitative surveys are an appropriate way of collecting data. Finally, while these types of surveys can collect data quickly ( Marko et al ., 2022b ), there can also be additional decision-making processes related to data preparation and inclusion that can be time-consuming.

There are a range of practical considerations that can improve the rigour, trustworthiness and quality of online qualitative survey data. Again, developing and expanding on ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ), Figure 2 gives an overview of some key practical considerations associated with the design, implementation and analysis of these surveys. We would also note that before starting your survey design, you should be aware that people may use different types of technology to complete the survey, and in different spaces. For example, we cannot assume that people will be sitting in front of a computer or laptop at home or in the office, with people more likely to complete surveys on a mobile phone, perhaps on a train or bus on the way to work or school.

: Top ten practical tips for conducting online qualitative surveys.

Survey design

Creating an appropriate and accessible structure

The first step in designing an online qualitative survey is to plan the structure of your survey. This step is important because the structure influences the way that participants interact with and participate through the survey. The survey structure helps to create an ‘environment’ that helps participants to share their perspectives, prompt their views and develop their ideas ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ). Similar to an interview study, the structure of the survey guides participants from one set of questions (and topics) to the next. It is important to consider the ordering of topics to enable participants to complete a survey that has a logical flow, introduces participants to concepts and allows them to develop their depth of responses.

Before participants start the survey, we provide a clear and simple lay language summary of the survey. Because many individuals will be familiar with completing quantitative surveys, we include a welcoming statement and reiterate the qualitative nature of the survey, stating that their answers can be about their own experiences:

Thank you for agreeing to take part in this survey about [topic] . This survey involves writing responses to questions rather than checking boxes.

We then clearly reiterate the purpose of the survey, providing a short description of the topic that we are investigating. We state that we do not seek to collect any data that is identifiable, that we are interested in participants perspectives, that there are no right or wrong answers, and that participants can withdraw from the survey at any time without giving a reason.

Similar to Braun et al . (2021) , we start our surveys with questions about demographic and related characteristics (which we often call ‘ participant/general characteristics ’). These can be discrete choice questions, but can also utilize open text—for example, in relation to gender identity. We have found that there is always a temptation with surveys to ask many questions about the demographic characteristics of participants. However, we caution that too many questions can be intrusive for participants and can take away valuable time from open-text questions, which are the core focus of the survey. We recommend asking participant characteristic and demographic questions that situate and contextualize the sample ( Elliott et al ., 1999 ).

We generally start the open-text sections of these surveys by asking broad introductory questions about the topic. This might include questions such as: ‘Please describe the main reasons you drink alcohol ’, and ‘W hat do you think are the main impacts of climate change on the world? ’ We have found that these types of questions get participants used to responding to open-text questions relevant to the study’s research questions and aims. For each new topic of investigation (which are based on our theoretical concepts and overall study aims and research questions), we provide a short explanation about what we will ask participants. We also use tools and text to signpost participant progress through the survey. This can be a valuable way to avoid high attrition rates where participants exit the survey because they are getting fatigued and are unclear when the survey will end:

Great! We are just over half-way through the survey.

We ask more detailed questions that are more aligned with our theoretical concepts in the middle of the survey. For example, we may start with broad questions about a harmful industry and their products (such as gambling, vaping or alcohol) and then in the middle of the survey ask more detailed questions about the commercial determinants of health and the specific tactics that these industries use (for example, about product design, political tactics, public relations strategies or how these practices may influence health and equity). In relation to these more complex questions, it is particularly important that we reiterate that there are no wrong answers and try to include encouraging text throughout the survey:

There are no right or wrong answers—we are curious to hear your opinions .

We always try to end the survey on a positive. While these types of questions depend on the study, we try to ask questions which enable participants to reflect on what could be done to address or improve an issue. This might include their attitudes about policy, or what they would say to those in positions of power:

What do you think should be done to protect young people from sports betting advertising on social media? If there was one thing that could be done to prevent young people from being exposed to the risks associated with alcohol, cigarettes, vaping, or gambling, what would it be? If you could say one thing to politicians about climate change, what would it be?

Finally, we ask participants if there is anything we have missed or if they have anything else to add, sometimes referred to as a ‘clean-up’ question ( Braun and Clarke, 2013 ). The following provides a few examples of how we have framed these questions in some of our studies:

Is there anything you would like to say about alcohol, cigarettes, vaping, and gambling products that we have not covered? Is there anything we haven’t asked you about the advertising of alcohol to women that you would like us to know?

Considering the impact of the length of the survey on responses

The length of the survey (both the number of questions and the time it takes an individual to complete the survey) is guided by a range of methodological and practical considerations and will vary between studies ( Braun and Clarke, 2013 ). Many factors will influence completion times. We try to give individuals a guide at the start of the survey about how long we think it will take to complete the survey (for example, between 20 and 30 minutes). We highlight that it may take people a little longer or shorter and that people are able to leave their browser open or save the survey and come back to finish it later. For our first few online qualitative surveys, we found that we asked lots of questions because we felt less in control of being able to prompt or ask follow-up questions from participants. However, we have learned that less is more! Asking too many questions may lead to more survey dropouts, and may significantly reduce the textual quality of the information that you receive from participants ( Braun and Clarke, 2013 ; Terry and Clarke, 2017 ). This includes considering how the survey questions might lead to repetition, which may be annoying for participants, leading to responses such as ‘like I’ve already said’ , ‘I’ve already answered that’ or ‘see above’ .

Providing clear and simple guidance

When designing an online qualitative survey, we try to think of ways to make participation in the survey engaging. We do not want individuals to feel that we are ‘mining’ them for data. Rather we want to demonstrate that we are genuinely interested in their perspectives and views. We use a range of mechanisms to do this. Because there is no opportunity to verbally explain or clarify concepts to participants, there is a particular need to ensure that the language used is clear and accessible ( Braun and Clarke, 2013 ; Terry and Clarke, 2017 ). If language or concepts are complex, you are more likely to receive ‘I don’t know’ responses to your questions. We need to remember that participants have a range of written and comprehension skills, and inclusive and accessible language is important. We also never try to assume a level of knowledge about an issue (unless we have specifically asked for participants who are aware and engaged in an issue—such as women who drink alcohol) ( Pitt et al ., 2023 ). This includes avoiding highly technical or academic language and not making assumptions that the individuals completing the survey will understand concepts in the same way that researchers do ( Braun and Clarke, 2013 ). Clearly explaining concepts or using text or images to prompt memories can help to overcome this:

Some big corporations (such as the tobacco, vaping, alcohol, junk food, or gambling industries) sponsor women's sporting teams or clubs, or other events. You might see sponsor logos on sporting uniforms, or at sporting grounds, or sponsoring a concert or arts event.

At all times, we try to centre the language that we use with the population from which we are seeking responses. Advisory groups can be particularly helpful in framing language for different population subgroups. We often use colloquial language, even if it might not be seen as the ‘correct’ academic language or terminology. Where possible, we also try to define theoretical concepts in a clear and easy to understand way. For example, in our study investigating parent perceptions of the impact of harmful products on young people, we tried to clearly define ‘normalization’:

In this section we ask you about some of the perceived health impacts of the above products on young people. We also ask you about the normalisation of these products for young people. When we talk about normalisation, we are thinking about the range of factors that might make these products more acceptable for young people to use. These factors might include individual factors, such as young people being attracted to risk, the influence of family or peers, the accessibility and availability of these products, or the way the industry advertises and promotes these products.

Using innovative approaches to improve accessibility and prompt responses

Online qualitative surveys can include features beyond traditional question-and-answer formats ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ). For example, we often use a range of photo elicitation techniques (using images or videos) to make surveys more accessible to participate in, address different levels of literacy, and overcome the assumption that we are not able to ‘prompt’ responses. These types of visual methodologies enable a collaborative and creative research experience by asking the participant to reflect on aspects of the visual materials, such as symbolic representations, and discuss these in relation to the research objectives ( Glaw et al ., 2017 ). The combination of visual images and clear descriptions helps to provide a focus for responses about different issues, as well as prompting nuanced information such as participant memories and emotions ( Glaw et al ., 2017 ). We use different types of visuals in our studies, such as photographs (including of the public health issues we’re investigating); screenshots from websites and social media posts (including newspaper headlines) and videos (including short videos from social media sites such as TikTok) ( Arnot et al ., 2024b ). For example, when talking about government responses to the climate crisis, we used a photograph of former Australian Prime Minister Scott Morrison holding a piece of coal in the Australian parliament to prompt participants’ thinking about the government’s relationship with fossil fuels and to provide a focal point for their answer. However, we would caution against using any images that may be confronting for participants or deliberately provocative. The purpose of using visuals must always be in the interests of the participants—to clarify, prompt and reflect on concepts. Ethics committees should carefully review the images used in surveys to ensure that they have a clear purpose and are unlikely to cause any discomfort.

Survey implementation

Thinking carefully about your criteria for recruitment

Determining the sample size of online qualitative studies is not an exact science. The sample sizes for recent studies have ranged from n = 46 in a study about pregnancy loss ( Hennessy and O’Donoghue, 2024 ), to n = 511 in a study with young people about the climate crisis ( Arnot et al ., 2023b ). We follow ‘rules of thumb’ [( Braun and Clarke, 2021b ), p. 211] which try to balance the needs of the research and data richness with key practical considerations (such as funding and time constraints), funder expectations, discipline-specific norms and our knowledge and experience of designing and implementing online qualitative surveys. However, we have found that peer reviewers expect much more justification of sample sizes than they do for other types of qualitative research. Robust justification of sample sizes are often needed to prevent any ‘concerns’ that reviewers may raise. Our response to these reviews often reiterates that our focus (as with all qualitative research) is not to produce a ‘generalisable’ or ‘representative’ sample but to recruit participants who will help to provide ‘rich, complex and textured data’ [( Terry and Braun, 2017 ), p. 15] about an issue. Instead of focusing on data saturation, a contested concept which is incongruent with reflexive thematic analysis in particular ( Braun and Clarke, 2021b ), we find it useful to consider information power to determine the sample size for these surveys ( Malterud et al ., 2016 ). Information power prioritizes the adequacy, quality and variability of the data collected over the number of participants.

Recruitment for online qualitative surveys can be influenced by a range of factors. Monetary and time constraints will impact the size and, if using market research company panels, the specificity of participant quotas. Recruitment strategies must be developed to ensure that the data provides enough information to answer the research questions of the study. For our research purposes, we often try to ensure that participants with a range of socio-demographic characteristics are invited to participate in the sample. We set soft quotas for age, gender and geographic location to ensure some diversity. We have found that some population subgroups may also be recruited more easily than others—although this may depend on the topic of the survey. For example, we have found that quotas for women and those living in metropolitan areas may fill more quickly. In these scenarios, the research team must weigh up the timelines associated with recruitment and data collection (e.g. How long do we want to run data collection for? How much of our budget can be spent on achieving a more equally split sample? Are quotas necessary?) versus the purpose and goals of the research (i.e. to generate ideas rather than data representativeness), and the study-specific aims and research questions.

There are, of course, concerns about not being able to ‘see’ the people that are completing these surveys. There is an increasing focus in the academic literature on ‘false’ respondents, particularly in quantitative online surveys ( Levi et al ., 2021 ; Wang et al ., 2023 ). This will be an important ongoing discussion for qualitative researchers, and we do not claim to have the answers for how to overcome these issues. For example, some individuals may say that they meet the inclusion criteria to access the survey, while others may not understand or misinterpret the inclusion criteria. There is also a level of discomfort about who and how we judge who may be a ‘legitimate’ participant or not. However, we can talk practically about some of the strategies that we use to ensure the rigour of data. For example, we find that screening questions can provide a ‘double-check’ in relation to inclusion criteria and can also help with ensuring that there is consistency between the information an individual provides about how they meet the inclusion criteria and subsequent responses. For example, in a recent survey of parents of young people, a participant stated that they were 18 years old and were a parent to a 16-year-old and 15-year-old. Their overall responses were inconsistent with being a parent of children these ages. Similarly, in our gambling studies, people may tick that they have gambled in the last year but then in subsequent questions say they have not gambled at all. This highlights the importance of checking data across all questions, although it should be noted that time and cost constraints associated with comprehensively scanning the data for such responses are not always feasible and can result in overlooking these participants.

Ensuring that there are strategies to create agency and engage participants in the research

One of the benefits of online qualitative surveys compared to traditional quantitative surveys is the scope for participants to explain their answers and to disagree with the research team’s position. An indication that participants are feeling able to do this is when they are asked for any additional comments at the end of the survey. For example, in a survey about women’s attitudes towards alcohol marketing, the following participant concluded the survey by writing: ‘I think you have covered everything. I think that you need to stop shaming women for having fun’. Other participants demonstrate their engagement and interest in the survey by reaffirming the perspectives they have shared throughout the survey. For example, in a study with young people on climate, participants responded at the end that ‘it’s one of the few things I actually care about’ , while another commented on the quality of the survey questions, stating, ‘I think this survey did a great job with probing questions to prompt all the thoughts I have on it’ .

We also think that online qualitative surveys may lead to less social desirability in participants’ responses. Participants seem less wary about communicating less politically correct opinions than they may do in a face-to-face interview. For example, at times, participants communicate attitudes that may not align with public health values (e.g. supporting personal responsibility, anti-nanny state, and neoliberal ideologies of health and wellbeing), that we rarely see communicated to us in in-depth interview or focus group studies. We would argue that these perspectives are valuable for public health researchers because they capture a different community voice that may not otherwise be represented in research. This may show where there is a lack of support for health interventions and policy reforms and may indicate where further awareness-raising needs to occur. These types of responses also contribute to reflexive practice by challenging our assumptions and positions about how we think people should think or feel about responses to particular public health issues. Examples of such responses from our surveys include:

"Like I have already said, if you try to hide it you will only make it more attractive. This nanny-state attitude of the elite drives me crazy. People must be allowed to decide for themselves."

Ethical issues for participants and researchers

Researchers should also be aware that some of the ethical issues associated with online qualitative surveys may be different from those in in-depth interviews—and it is important that these are explained in any ethical consideration of the study. Providing a clear and simply worded Plain Language Statement (in written or video form) is important in establishing informed consent and willingness to participate. While participants are given information about who to contact if they have further questions about the study, this may be an extra step for participants, and they may not feel as able to ask for clarification about the study. Because of this, we try to provide multiple examples of the types of questions that we will ask, as well as providing downloadable support details (for example, for mental health support lines). A positive aspect of surveys is that participants are able to easily ignore recruitment notices to participate in the study. They are also able to stop the survey at any time by exiting out of the browser if they feel discomfort without having to give a reason in person to a researcher.

While the anonymous nature of the survey may be empowering for some participants ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al. , 2021 ), it can also make it difficult for researchers to ascertain if people need any further support after completing the survey. Participants may also fill in surveys with someone else and may be influenced about how they should respond to questions (with the exception of some studies in which people may require assistance from someone to type their responses). Because of the above, some researchers, ethics committees and funders may be more cautious about using these studies for highly sensitive subjects. However, we would argue that the important point is that the studies follow ethical principles and take the lack of direct contact with participants into the ethical considerations of the study. It is also important to ensure that platforms used to collect survey data are trusted and secure. Here, we would argue that universities have an obligation to investigate and, where possible, approve survey providers to ensure that researchers are using platforms that meet rigorous standards for data and privacy.

It is also important to note that there may be responses from participants that may be challenging ( Terry and Braun, 2017 ; Braun and Clarke, 2021 ). Online spaces are rife with trolling due to their anonymous nature, and online surveys are not immune to this behaviour. Naturally, this leads to some silly responses—‘ Deakin University is responsible for all of this ’, but researchers should also be aware that the anonymity of surveys can (although in our experience not often) lead to responses that may cause discomfort for the researchers. For example, when asked if participants had anything else to add to a climate survey ( Arnot et al ., 2024c ), one responded ‘ nope, but you sure asked a lot of dumbass questions’ . Just as with interview-based studies, there must be processes built into the research for debriefing—particularly for students and early career researchers—as well as clear decisions about whether to include or exclude these types of responses when preparing the dataset for analysis and in writing up the results from the survey.

The importance of piloting the survey

Because of the lack of ability to explain and clarify concepts, piloting is particularly important ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al. , 2021 ) to ensure that: (i) the technical aspects of the survey work as intended; (ii) the survey is eliciting quality responses (with limited ‘nonsensical’ responses such as random characters); (iii) the survey responses indicate comprehension of the survey questions; and (vi) there is not a substantial number of people who ‘drop-out’ of the study. Typically, we pilot our survey with 10% of the intended sample size. After piloting, we often change question wording, particularly to address questions that elicit very small text responses, the length of the survey and sometimes refine definitions or language to ensure increased comprehension. Researchers should remember that changes to the survey questions may need to be reviewed by ethics committees before launching the full survey. It is important to build in time for piloting and the revision of the survey to ensure you get this right as once you launch the full survey, there is no going back!

Survey analysis and write-up

Preparing the dataset

Once launching the full survey, the quality of data and types of responses you receive in these types of surveys can vary. There is very limited transparency around how the dataset was prepared (more familiar to some as ‘data cleaning’) in published papers, including the decisions about which (if any) participants (or indeed responses) were excluded from the dataset and why. Nonsensical responses can be common—and can take a range of forms ( Figure 3 ). These can include random numbers or letters, a chunk of text that has been copied and pasted from elsewhere, predictive text or even repeat emojis. In one study, we had a participant quote the script of The Bee Movie in response to questions.

: Visual examples of nonsensical responses in online qualitative surveys.

Part of our familiarization with the dataset [Phase One in Braun and Clarke’s reflexive approach to thematic analysis ( Braun and Clarke, 2013 ; Braun et al ., 2021 )] includes preparing the dataset for analysis. We use this phase to help make decisions about what to include and exclude from the final dataset. While a row of emojis in the data file can easily be spotted and removed from the dataset, sometimes responses can look robust until you read, become familiar and engage with the data. For example, when asked about what they thought about collective climate action ( Arnot et al ., 2023a , 2024c ), some participants entered random yet related terms such as ‘ plastic ’, or repeated similar phrases across multiple questions:

“ why do we need paper straws ”, “ paper straws are terrible ”, “ papers straws are bad for you ”, “ paper straws are gross .”

Participants can also provide comprehensive answers for the first few questions and then nonsensical responses for the rest, which may also be due to question fatigue [( Braun and Clarke, 2013 ), p. 138]. Therefore, it is important to closely go through each participant’s response to ensure they have attempted to provide bone-fide responses. For example, in one of our young people and climate surveys ( Arnot et al ., 2023a , 2024c ), one participant responded genuinely to the first half of the survey before their quality dropped dramatically:

“I can’t even be bothered to read that question ”, “ why so many questions ”, “ bro too many sections. ”

Some market research panel providers may complete an initial quality screen of data. However, this does not replace the need for the research teams’ own data preparation processes. Researchers should ensure they are checking that responses are coherent—for example, not giving information that contradicts or is not credible. In our more recent studies, we have increasingly seen responses cut and pasted from ChatGPT and other AI tools—providing a new challenge in assessing the quality of responses. If you are seeing these types of responses, it might be an opportunity to think about the style and suitability of the questions being asked. For example, the use of AI tools might suggest that people are finding it difficult to answer questions or may feel that they have to present a ‘correct’ answer. We would also note that because of the volume of data in these surveys, the preparation of data involves multiple members of the team. In many cases, decisions need to be made about participants who may not have provided authentic responses across the survey. The research team should make clear in any paper their decisions about their choices to include or exclude participants from the study. There is a careful balancing act that can require assessing the quality of the participants’ responses across the whole dataset to determine if the overall quality of responses contributes to the research.

Navigating the volume of data and writing up results

Finally, discussions about how to navigate the volume of data that these types of studies produce could be a standalone paper. In general, principles of reflexive practices apply to the analysis of data from these studies. However, as a starting point, here are a few considerations when approaching these datasets.

We would argue that online qualitative surveys lend themselves to some types of analytical approaches over others—for example, reflexive thematic analysis, as compared to grounded theory or interpretive phenomenological analysis (though it can be used with these) ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ).

While initial familiarization, coding and analysis can focus on specific questions and associated responses, it is important to analyse the dataset as a whole (or as clusters associated with particular topics) as participants may provide relevant data to a topic under multiple questions ( Terry and Braun, 2017 ). We initially focus our coding on specific questions or a group of survey questions under a topic of investigation. Once we have developed and constructed preliminary themes from the data associated with these clusters of questions, we then move to looking at responses across the dataset as we review themes further.

Researchers should think carefully about how to manage the data—which may not be available as ‘individual participant transcripts’ but rather as a ‘whole’ dataset in an Excel spreadsheet. Some may prefer qualitative data analysis software (QDAS) to manage and navigate data. However, many of us find that Excel (and particularly the use of labelled Tabs) is useful in grouping data and moving from codes to constructing themes.

As with all rigorous qualitative research, coding and theme development should be guided by the research questions. A clear record of decision-making about analytical choices (and being reflexive about these) should be kept. In any write-up, we would recommend that researchers are clear about which survey questions they used in the analysis [researchers could consider providing a supplementary file of some or all of the survey questions—see, for example Hennessy and O’Donoghue (2024) ].

In writing up the results, researchers should still seek to present a rich description of the data, as demonstrated in the presentation of results in the following papers ( Marko et al ., 2022a , 2022b ; McCarthy et al ., 2023 ; Pitt et al ., 2023 ; Hennessy and O’Donoghue, 2024 ). We have found the use of tables with additional examples of quotes as they relate to themes and subthemes can be a practical way of providing the reader with further examples of the data, particularly when constrained by journal word count limits [see, for example, Table 2 in Arnot et al ., (2024c) ]. However, these tables do not replace a full and complete presentation of the interpretation of the data.

This article offers methodological reflections and practical guidance around online qualitative survey design, implementation and analysis. While online qualitative surveys engage participants in a different type of conversation, they have design features that enable the collection of rich data. We recognize that we have much to learn and that while no survey of ours has been perfect, each new experience with developing and conducting online qualitative surveys has brought new understandings and lessons for future studies. In recognizing that we are learning, we also feel that our experience to date could be valuable for progressing the conversation about the rigour of online qualitative surveys and maximizing this method for public health gains.

H.P. is funded through a VicHealth Postdoctoral Research Fellowship. S.M. is funded through a Deakin University Faculty of Health Deans Postdoctoral Fellowship. G.A. is funded by an Australian Government Research Training Program Scholarship. M.H. is funded through an Irish Research Council Government of Ireland Postdoctoral Fellowship Award [GOIPD/2023/1168].

The pregnancy loss study was funded by the Irish Research Council through its New Foundations Awards and in partnership with the Irish Hospice Foundation as civil society partner [NF/2021/27123063].

S.T. is Editor in Chief of Health Promotion International, H.P. is a member of the Editorial Board of Health Promotion International, S.M. and G.A. are Social Media Coordinators for Health Promotion International, M.H. is an Associate Editor for Health Promotion International. They were not involved in the review process or in any decision-making on the manuscript.

The data used in this study are not available.

Ethical approval for studies conducted by Deakin University include the climate crisis (HEAG-H 55_2020, HEAG-H 162_2021); parents perceptions of harmful industries on young people (HEAG-H 158_2022); women and alcohol marketing (HEAG-H 123_2022) and gambling (HEAG 227_2020).

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Sule S , DaCosta MC , DeCou E , Gilson C , Wallace K , Goff SL. Communication of COVID-19 Misinformation on Social Media by Physicians in the US. JAMA Netw Open. 2023;6(8):e2328928. doi:10.1001/jamanetworkopen.2023.28928

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Communication of COVID-19 Misinformation on Social Media by Physicians in the US

• 1 Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts, Amherst
• Correction Errors in Quotes and Dates JAMA Network Open

Question   What types of COVID-19 misinformation have been propagated online by US physicians and through what channels?

Findings   In this mixed-methods study of high-use social media platforms, physicians from across the US and representing a range of medical specialties were found to propagate COVID-19 misinformation about vaccines, treatments, and masks on large social media and other online platforms and that many had a wide reach based on number of followers.

Meaning   This study’s findings suggest a need for rigorous evaluation of harm that may be caused by physicians, who hold a uniquely trusted position in society, propagating misinformation; ethical and legal guidelines for propagation of misinformation are needed.

Importance   Approximately one-third of the more than 1 100 000 confirmed COVID-19–related deaths as of January 18, 2023, were considered preventable if public health recommendations had been followed. Physicians’ propagation of misinformation about COVID-19 on social media and other internet-based platforms has raised professional, public health, and ethical concerns.

Objective   To characterize (1) the types of COVID-19 misinformation propagated by US physicians after vaccines became available, (2) the online platforms used, and (3) the characteristics of the physicians spreading misinformation.

Design, Setting, and Participants   Using US Centers for Disease Control and Prevention guidelines for the prevention and treatment of COVID-19 infection during the study window to define misinformation, structured searches of high-use social media platforms (Twitter, Facebook, Instagram, Parler, and YouTube) and news sources ( The New York Times , National Public Radio) were conducted to identify COVID-19 misinformation communicated by US-based physicians between January 2021 and December 2022. Physicians’ state of licensure and medical specialty were identified. The number of followers for each physician on 4 major platforms was extracted to estimate reach and qualitative content analysis of the messages was performed.

Main Outcomes and Measures   Outcome measures included categories of COVID-19 misinformation propagated, the number and traits of physicians engaged in misinformation propagation, and the type of online media channels used to propagate misinformation and potential reach.

Results   The propagation of COVID-19 misinformation was attributed to 52 physicians in 28 different specialties across all regions of the country. General misinformation categories included vaccines, medication, masks, and other (ie, conspiracy theories). Forty-two physicians (80.8%) posted vaccine misinformation, 40 (76.9%) propagated information in more than 1 category, and 20 (38.5%) posted misinformation on 5 or more platforms. Major themes identified included (1) disputing vaccine safety and effectiveness, (2) promoting medical treatments lacking scientific evidence and/or US Food and Drug Administration approval, (3) disputing mask-wearing effectiveness, and (4) other (unsubstantiated claims, eg, virus origin, government lies, and other conspiracy theories).

Conclusions and Relevance   In this mixed-methods study of US physician propagation of COVID-19 misinformation on social media, results suggest widespread, inaccurate, and potentially harmful assertions made by physicians across the country who represented a range of subspecialties. Further research is needed to assess the extent of the potential harms associated with physician propagation of misinformation, the motivations for these behaviors, and potential legal and professional recourse to improve accountability for misinformation propagation.

As of May 11, 2023, an estimated 1 128 000 COVID-19 deaths had occurred in the US, 1 and nearly 14% of people infected by the COVID-19 virus have experienced the post–COVID-19 condition. 2 , 3 As of December 2022, estimated death rates for unvaccinated persons in the US were 271 per 100 000 compared with 82 per 100 000 for those fully vaccinated, yet only 69.2% of eligible people had received the full primary vaccine series, and 15.5% had received the bivalent booster. 1 Vaccination rates have varied by region throughout the pandemic despite widespread availability, with southeastern states having lower full primary series rates (52%) compared with northeastern states (80%). 1 Other preventive behaviors, such as mask wearing and social distancing, have varied similarly by geographic region. 4 , 5

Individual health behaviors related to COVID-19 have been attributed to complex social phenomena, including inconsistent recommendations by government entities early in the pandemic, mistrust of the scientific community, political polarization, and unclear or incorrect guidance from other sources. 6 - 8 COVID-19 misinformation, defined as false, inaccurate, or misleading information according to the best evidence available at the time, and disinformation, defined as having an intentionally malicious purpose, have been ubiquitous on social media, despite major platforms’ COVID-19 misinformation policies. 9 Medical misinformation was propagated long before the COVID-19 pandemic, 10 but the internet increases reach and speed of dissemination, potentially exacerbating misinformation consequences during an unparalleled public health threat that has killed more than 7 million people across the globe. 11 - 13

COVID-19 misinformation has been spread by many people on social medial platforms, 14 but misinformation spread by physicians may be particularly pernicious. 15 Physicians are often considered credible sources of medical and public health information, increasing the potential negative impact of physician-initiated misinformation. The US Food and Drug Administration (FDA) and others have called for action to limit the potential harm of physician-propagated COVID-19 misinformation. 15 , 16 Despite the rising concerns voiced in news articles and opinion pieces, physician-propagated COVID-19 misinformation and its associated outcomes remain understudied.

This study aimed to address this gap in knowledge by examining COVID-19 misinformation communicated on social media platforms and other online sources by US physicians after vaccines were made available. Understanding the extent of this phenomenon, its potential impact, and associated professional, ethical, and legal ramifications may help to better understand the role that physician-propagated COVID-19 misinformation may have played in preventable COVID-19 deaths and mistrust in institutions.

This mixed-methods study sought to characterize the (1) type of COVID-19 misinformation physicians communicated online between January 1, 2021, and May 1, 2022; (2) social media and other online platforms where misinformation appeared; and (3) characteristics of the physicians. Physician age, sex, and race and ethnicity were not available on social media or other online postings. A decision was made to not infer these data from pictures or other means to avoid potential bias and misclassification. We defined COVID-19 misinformation as assertions unsupported by or contradicting US Centers for Disease Control and Prevention (CDC) guidance on COVID-19 prevention and treatment during the period assessed or contradicting the existing state of scientific evidence for any topics not covered by the CDC (eTable in Supplement 1 ). We conservatively classified inaccurate information as misinformation rather than disinformation because the intent of the propagator cannot be objectively assessed. The University of Massachusetts Institutional Review Board determined that this study did not meet criteria for human participant research. This study followed the Standards for Reporting Qualitative Research ( SRQR ) reporting guidelines.

First, we conducted structured searches of social media platforms and general web searches in late spring of 2022 to identify media containing COVID-19 misinformation attributed to US-based physicians, defined as using doctor of medicine (MD) or doctor of osteopathic medicine (DO) after their name and being licensed to practice medicine in the US at some time or never licensed but working in the US. The start date was selected in relation to the availability of the COVID-19 vaccines. Search terms included the following: “COVID,” “vaccine,” “doctor” or “physician,” “ineffective,” “pharmaceutical,” “medication,” “ivermectin,” “hydroxychloroquine,” and “purchase.” Search terms were refined based on initial searches to include “COVID misinformation,” “doctor” or “physician,” and/or “conspiracy theory.” Conspiracy theories were defined as communicating skepticism of all information that does not fit the theory, overinterpreting evidence that fits the theory, and/or evidence of internal inconsistency. 17 The platforms searched were selected based on the volume of news articles, popularity, and searchability (Instagram, Twitter, YouTube, Facebook, Parler, TikTok, The New York Times , National Public Radio) 18 ; if the findings on one platform indicated that another platform could have additional new data, it was added to the search list. Due to the large volume and repetitiveness of Tweets, Twitter searches focused initially on America’s Frontline Doctors’ Twitter profile because of the volume of COVID-19 misinformation in its Tweets, 19 its large following, and the potential for physicians propagating misinformation to follow the page. Followers of the America’s Frontline Doctors’ page with an MD or DO in their header were traced on Twitter and other platforms as well. General internet searches using Google’s search engine were conducted to identify misinformation attributed to physicians in third party platforms, such as local news articles.

The following information was collected from each source: physician’s name, medical specialty, the state(s) in which they were currently or had been licensed, whether their license to practice was active, had lapsed, or been revoked based on state medical board site searches, when the misinformation was posted (if available), from what source it was found, and the number of followers the physician had (if the source was a social media platform). Misinformation was classified into the following categories: medication, vaccine, mask/distancing, and other unsubstantiated or false claims. After the initial searches were completed, the physicians’ names were searched on the social media platforms and through general online searches to identify misinformation they posted that may have been missed in the initial searches and extended through December 2022.

Descriptive statistics were used to quantify the types of misinformation, the frequency in which they appeared, the platforms on which they were found, and characteristics of the physicians identified (eg, specialty and state[s] in which the physician was licensed). We calculated the total, median, and IQR for the number of followers on platforms with the highest volume of users (Twitter, Facebook, YouTube, Instagram) using Stata software, version 17 (StataCorp).

We performed directed qualitative content analysis 20 of the misinformation using a validated rapid qualitative analysis approach. 21 The analytic team (S.S. and M.D.) populated a templated summary table with misinformation text extracted from each media platform. The team divided the physician list and generated a summary of the misinformation associated with each of the physicians. In the second step of this analytic process, each team member individually identified pertinent and common themes, subthemes, and supporting quotes for each. After this was done individually, the team met to discuss their findings and combine the findings into a final list of themes and subthemes. Considerations regarding reflexivity included that S.G. is a public health professor and physician, and M.D. and S.S. are aspiring physicians, which may have increased sensitivity to potential harms.

A total of 52 US physicians were identified as having communicated COVID-19 misinformation in the period assessed. All but 2 were or had been licensed to practice medicine in the US; the others were researchers. The 50 physicians who currently were or had been licensed represented 28 distinct medical specialties (3 of 50 had 2 different specialties; primary care was the most common overall [18 (36.0%)]) and they were licensed or working in 29 states across the US ( Figure and Table 1 ). Forty-four of the 50 physicians (88.0%) held an active license in at least 1 state; 3 (6.0%) did not have an active license, 4 (8.0%) had had a license suspended or revoked, and 1 (2.0%) had active licenses in 2 states and revoked/suspended licenses in 2 other states. Nearly one-third (16 of 52) were affiliated with groups with a history of propagating medical misinformation, such as America’s Frontline Doctors. Specific types of misinformation included the following: (1) vaccines were unsafe and/or ineffective, (2) masks and/or social distancing did not decrease risk for contracting COVID-19, (3) medications for prevention or treatment were effective despite not having completed clinical trials or having been FDA approved, and (4) other (eg, conspiracy theories).

Most of the 52 physicians (40 [76.9%]) who posted misinformation did so in more than 1 of the 4 categories identified. Vaccine misinformation was posted by the majority (42 [80.8%]), followed by other misinformation (28 [53.8%]; eg, government and public health officials deliberately falsified COVID-19 statistics) and medication misinformation (27 [51.9%]).

Of these 52 physicians, 20 (38.5%) posted COVID-19 misinformation on 5 or more different social media platforms and 40 (76.9%) appeared on 5 or more third-party online platforms such as news outlets. Twitter was the most used platform, with 37 of the 52 physicians (71.2%) posting misinformation and a median of 67 400 followers (IQR, 12 900-204 000). Additional details of physicians’ reach by platforms and followers are in Table 2 and Table 3 .

Major themes identified included the following: (1) claiming vaccines were unsafe and/or ineffective, (2) promoting unapproved medications for prevention or treatment, (3) disputing mask-wearing effectiveness, and (4) other misinformation, including unsubstantiated claims, eg, virus origin, government lies, and other conspiracy theories. Supportive quotes are listed in Table 4 .

The most common theme identified was physicians discouraging the public from receiving COVID-19 vaccines. Promoting fear and distrust of the vaccine and reliance on “natural” immunity were common subthemes.

Some of the misinformation propagated by physicians claimed that COVID-19 vaccines were ineffective at preventing COVID-19 spread. A common approach included circulating counts of positive case rates by vaccination status, claiming that most positive cases were among vaccinated individuals. This claim is technically true but misleading, as many more people are vaccinated, and the proportion of unvaccinated people who are infected is much higher. 22 Some stated that the significant increase in case rates after the initial vaccine rollout was evidence for ineffectiveness.

Assertions that COVID-19 vaccines were harmful was not supported by scientific evidence at the time. Unfounded claims included that the vaccines caused infertility, irreparable damage to one’s immune system, increased risk of developing a chronic illness for children, and a higher risk of cancer and death. Claims that myocarditis was common in children who received the vaccine and that the risks of myocarditis outweighed the risk of vaccination were also unfounded. 23 Several physicians redistributed news articles with stories of individuals suddenly or mysteriously dying from the vaccine, despite evidence from the CDC confirming that deaths caused by a COVID vaccine were extremely rare (9 deaths for over 600 million doses administered in the US as of January 2023) and could be attributed only to the Johnson and Johnson COVID-19 vaccine, which was used much less frequently than other manufacturers’ vaccines in many countries. 24

Many of the identified physicians promoted the use of treatments that had not been tested or FDA approved for use in relation to COVID-19. The 2 most prominent medications promoted were ivermectin and hydroxychloroquine, which have been found to not be effective at treating COVID-19 infections in randomized clinical trials. 25 , 26

Anecdotal personal experiences of successfully treating patients with untested medications were commonly used to support claims about safety and effectiveness, such as patients’ conditions were not improving before receiving the untested medication, but the patient recovered after starting the treatment.

Many physicians posted links or screenshots to articles claiming that ivermectin decreased mortality and hospitalization and increased time to recovery and viral clearance. Although some of the articles appeared to be peer-reviewed, none were in high-quality peer-reviewed biomedical journals, and the FDA had not approved the use of these medications for treating COVID-19. At least 1 of the cited articles has been retracted due to misinterpretation of the data. 27

Many of the physicians propagating misinformation about masking effectiveness portrayed masks in a negative light. Claims centered on ineffectiveness, harm, or both.

Most of the misinformation propagated about wearing protective masks asserted that studies conducted before the pandemic definitively concluded that masks do not prevent the spread of respiratory viral infections. Additionally, data showing rising cases in areas enforcing mask mandates were interpreted to mean that the mandates did nothing to slow the spread of infection.

Allegations of consequences of mask wearing included medical and social or developmental effects, all of which were unfounded. 28 Alleged medical consequences included claims that wearing a face mask restricts one’s oxygen, increases the amount of carbon dioxide being inhaled, and causes mask wearers to inhale bacteria that gets trapped. Many physicians focused on negative consequences related to children and mask mandates in schools, claiming that masks interfered with social development despite lack of evidence and that requiring children to wear masks was a form of child abuse.

This misinformation category included conspiracy theories related to domestic and foreign governments and pharmaceutical companies. Theories related to the government included the following: (1) the COVID-19 pandemic was planned by government officials—the “plandemic”; (2) government and public health officials withheld key information regarding COVID-19 from the public, such as hydroxychloroquine effectiveness, falsified statistics to make the virus appear more severe, and censored information that challenged government messaging; (3) the virus originated in a laboratory in China, which contradicted scientific evidence at the time; and (4) the virus was part of a National Institutes of Health–funded study, was leaked, and that the leak was covered up by government and public health officials. Theories related to pharmaceutical companies included that they played a role in discouraging the use of ivermectin and hydroxychloroquine because these medications were inexpensive and easily accessible, and pharmaceutical companies benefited from the promotion of more novel and expensive treatments.

This study was the first, to our knowledge, to identify the types of COVID-19 misinformation propagated by US physicians on social media and the platforms they used, as well as characterize the physicians who spread the misinformation. The content of misinformation physicians spread was similar to the misinformation spread by others; this study contributes new information about the range of specialties and regions of the country the physicians represented. The widely varying number of followers on social media for each physician suggested that the impact of any individual physician’s social media postings also may vary.

Some of the physicians identified belonged to organizations that have been propagating medical misinformation for decades, 10 but these organizations became more vocal and visible in the context of the pandemic’s public health crisis, political divisiveness, and social isolation. Understanding the motivation for misinformation propagation is beyond the scope of this study, but it has become an increasingly profitable industry within and outside of medicine. For example, America’s Frontline Doctors implemented a telemedicine service that charged $90 per consult, primarily to prescribe hydroxychloroquine and ivermectin for COVID-19 to patients across the country, profiting at least $15 million from the endeavor. 29 Twitter’s elimination of safeguards against misinformation 30 and the absence of federal laws regulating medical misinformation on social media platforms suggest that misinformation about COVID-19 and other medical misinformation is likely to persist and may increase. Deregulation of COVID-19 misinformation on social media platforms may have far-reaching implications because consumers may struggle to evaluate the accuracy of the assertions made. 31

National physicians’ organizations, such as the American Medical Association, have called for disciplinary action for physicians propagating COVID-19 misinformation, 32 but stopping physicians from propagating COVID-19 misinformation outside of the patient encounter may be challenging. 33 Although professional speech may be regulated by courts 34 and the FDA has been called on to address medical misinformation, 16 few physicians appear to have faced disciplinary action. Factors such as licensing boards’ lack of resources available to dedicate toward monitoring the internet 35 and state government officials’ challenges to medical boards’ authority to discipline physicians propagating misinformation 36 may limit action.

Scientific evidence depends on a body of accumulated research to inform practice and guidelines and the evidence depends on the best quality research available at any given time. A recent Cochrane Review has been misinterpreted to have definitively shown that wearing masks does not reduce transmission of respiratory viruses and has been used to support assertions that masks definitively “do not work.” 37 Although the Federal Bureau of Investigation and Department of Energy presented a theory to Congress that the COVID-19 virus was the result of a laboratory leak, 38 scientific evidence and a more recent report from the Office of the Director of National Intelligence demonstrate lack of evidence for a laboratory leak and favor a zoonotic origin of the virus. 39 , 40 These recent challenges to prior understandings illuminate the importance of transparency and reproducibility of the process by which conclusions are drawn.

This study had some limitations. We conducted the study in the spring of 2022, after many major social media platforms had begun to establish policies to combat the propagation of COVID-19 misinformation, which means that the current study may underrepresent the extent of misinformation present before these policies were put in place. On some platforms (eg, Twitter), we were unable to analyze all posts by individuals due to the high volume of Tweets and degree of repetition. This study focused on online platforms whose content was readily accessible to the public; different approaches to identifying misinformation and searches of less used platforms might identify other physicians and include other topics. Misinformation disseminated in other ways, such as during clinical care, was not captured. Vaccines had been approved at the start of the period studied, but accessibility may have varied in the early days of the initial rollout. Finally, the state of scientific evidence for COVID-19 guidelines has evolved rapidly over the course of the pandemic, and this study represents a cross-section of time. The current evidence base for preventive and treatment practices, such as duration of vaccine effectiveness, may differ from the evidence base during the study time frame.

Results of this mixed-methods study of the propagation of COVID-19 misinformation by US physicians on social media suggest that physician-propagated misinformation has reached many people during the pandemic and that physicians from a range of specialties and geographic regions have contributed to the “infodemic.” High-quality, ethical health care depends on inviolable trust between health care professionals, their patients, and society. Understanding the degree to which the misinformation about vaccines, medications, masks, and conspiracy theories spread by physicians on social media influences behaviors that put patients at risk for preventable harm, such as illness or death, will help to guide actions to regulate content or discipline physicians who participate in misinformation propagation related to COVID-19 or other conditions. A coordinated response by federal and state governments and the profession that takes free speech carefully into account is needed.

Accepted for Publication: July 6, 2023.

Published: August 15, 2023. doi:10.1001/jamanetworkopen.2023.28928

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Sule S et al. JAMA Network Open .

Correction: This article was corrected on October 25, 2023, to fix dates in several of the quotes in Table 4 due to coding errors and to correct minor wording inaccuracies in several of the quotes. In addition, the date range of the initial social media searches was clarified in the Methods.

Corresponding Author: Sarah L. Goff, MD, PhD, Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts, 715 N Pleasant St, Amherst, MA 01002 ( [email protected] ).

Author Contributions: Dr Goff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Mss Sule and DaCosta are considered co–first authors.

Concept and design: Sule, Gilson, Goff.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Sule, DaCosta.

Statistical analysis: Sule, DaCosta, Gilson.

Administrative, technical, or material support: DaCosta, DeCou, Gilson, Goff.

Supervision: DaCosta, Goff.

Conflict of Interest Disclosures: Dr Wallace reported contributing to this work while she was a student at University of Massachusetts Amherst, before and outside of her official capacity as a government employee. No other disclosures were reported.

Funding/Support: The study was funded via internal support by the University of Massachusetts (Dr Goff).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed here are those of the authors and do not represent the official policy or position of the US Department of Veteran Affairs or the US government.

Data Sharing Statement: See Supplement 2 .

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This paper is in the following e-collection/theme issue:

Published on 2.7.2024 in Vol 26 (2024)

Issues Related to the Use of Visual Social Networks and Perceived Usefulness of Social Media Literacy During the Recovery Phase: Qualitative Research Among Girls With Eating Disorders

Authors of this article:

Original Paper

• Elena Faccio 1 , Prof Dr   ; 
• Margherita Reggiani 2 , Dr   ; 
• Michele Rocelli 1 , PhD, Dr   ; 
• Sabrina Cipolletta 3 , PhD, Prof Dr  

1 Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova, Padua, Italy

2 Psychologist-Operator at Vivere Verde Onlus, Roma, Italy

3 Department of General Psychology, Padova, Italy

Corresponding Author:

Elena Faccio, Prof Dr

Department of Philosophy, Sociology, Education and Applied Psychology

University of Padova

Via Venezia 14

Padua, 35131

Phone: 39 3479607182

Email: [email protected]

Background: The patient-centered approach is essential for quality health care and patient safety. Understanding the service user’s perspective on the factors maintaining the health problem is crucial for successful treatment, especially for patients who do not recognize their condition as clinically relevant or concerning. Despite the association between intensive use of visual social media and body dissatisfaction and eating disorders, little is known about the meanings users assign to posting or searching for edited photos and the strategies they use to protect themselves from digital risks.

Objective: This study aims to examine how young women recovering from eating disorders in Northern Italy perceive the health risks and potential benefits associated with visual social networks (ie, Instagram and Snapchat). The literature has found these platforms to be detrimental to online body comparisons. It also explores the perceived usefulness, willingness, and personal interest in coconstructing social media literacy programs with girls recovering from eating disorders.

Methods: A total of 30 semistructured interviews were conducted with adolescent girls aged 14-17 years at the end of their treatment for eating disorders. The following areas of research were addressed: (1) the meanings associated with the use of Instagram and Snapchat; (2) the investment in the photographic dimension and feedback; (3) the impact of visual social networks on body experiences; (4) the potential and risks perceived in their use; (5) the importance of supporting girls undergoing treatment for eating disorders in using social networks; and (6) the usefulness and willingness to co-design social network literacy programs. Content analysis was applied.

Results: A total of 7 main contents emerged: active or passive role in using social networks, the impact of online interactions on body image, investment in the photographic dimension, effects on self-representation, perceived risks, self-protective strategies, and potential benefits. The findings highlight a strong awareness of the processes that trigger body comparisons in the virtual context, creating insecurity and worsening the relationship with oneself. The self-protective behaviors identified are the development of critical thinking, the avoidance of sensitive content, increased control over social networking site use, and a certain skepticism toward developing antagonistic ideologies. All these topics were considered fundamental.

Conclusions: The findings provide important insights for health professionals working with youth in preparing media literacy programs. These programs aim to reduce potential risks and amplify the positive effects of online resources. They underscore the importance of addressing this issue during hospitalization to develop skills and critical thinking aimed at changing small habits that perpetuate the problem in everyday life. The inherent limitations in current service practices, which may not adequately address individual needs or impact posttreatment life, must also be considered.

Introduction

Although intensive use of visual social media and online body comparisons have been strongly linked to body dissatisfaction and eating disorders (EDs) [ 1 , 2 ], the literature has only partially explored the potential impact of competence development in the mindful use of social media during hospitalization for EDs [ 3 ].

Recent research on the topic has primarily been divided into 2 main strands: one focusing on the specific ways social media is used by individuals with EDs [ 4 , 5 ], and the other exploring the online environment as a potential “place” for therapy [ 6 , 7 ]. There are no examples of collaborative projects involving mental health professionals and service users during recovery from EDs that aim to jointly examine visual social media in new ways and co-construct new awareness about its use.

The concept that the process of care is a collaborative journey involving various stakeholders—researchers, health care providers, and service users—is a principle prominently featured in official health care documents [ 8 ] but less frequently implemented in practice [ 9 ]. This principle suggests that patients are “real experts” and that their embodied knowledge can form the foundation for coproducing the care pathway. This approach presupposes that care program design occurs within the context of people’s lived experiences, including their discourses around the body, how they perceive it, and the environments in which they socialize about ideals of desirable bodies (eg, social media). It emphasizes the importance of engaging with users in their own worlds and languages, rather than being confined to the perspectives of health care professionals [ 9 ].

During hospitalization for ED treatment, girls are usually either not allowed to use mobile phones or only permitted to use them during restricted time slots. If the use of social networking sites (SNSs) is not discussed and explicitly addressed, returning home may lead patients to revert to their previous SNS usage and interpretations, potentially undermining the long-term effectiveness of the treatment. Social media literacy programs aimed at improving body image–related outcomes should be implemented not only in the context of ED prevention but also in rehabilitation [ 3 ]. According to Fitzsimmons-Craft et al [ 10 ], only 20% of therapists have asked patients with ED about the perceived impact of social media on their body image experiences. Understanding the meanings and ways in which girls use SNSs is essential for designing educational and rehabilitation pathways that help build self- and body perception based on criteria different from those that contributed to the development of the ED [ 11 , 12 ].

Our research represents the first step in drafting a collaborative project involving researchers, health professionals, and service users. The goal is to identify the most salient and relevant issues related to social media use from the perspective of girls undergoing treatment.

SN Use and Body Image Concern: What Psychological Processes Come Into Play?

Social media is a significant source of sociocultural pressure regarding appearance and influences adolescents’ relationships with others as well as their perceptions of their own bodies. Active engagement in activities related to the photographic dimension on social networks (SNs) has been shown to contribute significantly to the development and perpetuation of concerns related to body image and food intake [ 13 , 14 ]. Such activities include publishing photographs, viewing others’ photographs, commenting or liking posts, and receiving feedback. Compared with the passive use of SN platforms, these active behaviors are more insidious in fostering dynamics of comparison and competition between bodies, thereby exposing individuals to the scrutiny of social judgment [ 15 - 17 ].

A clear and direct connection between posting edited photos and risk factors for EDs has been consistently confirmed by various studies [ 18 ]. Indeed, social media usage is a plausible risk factor for the development of EDs, a finding supported by research from Asia, indicating that this association is not limited to traditionally Western cultures [ 19 ].

Intensive use of SNSs has been linked to the internalization of the thinness ideal, self-objectification, and body dissatisfaction [ 20 - 22 ]. The literature defines the internalization of the thinness ideal as the degree to which an individual cognitively adopts socially defined standards of attractiveness and engages in behaviors aimed at approximating these ideals [ 20 ]. This process of striving for an ideal physique through the intensive use of social media can lead to body dissatisfaction and subsequently to disordered eating behaviors. Individuals may pursue an idealized body image that is often unattainable, which can persist even during recovery from EDs and increase the risk of relapse. Moreover, the habit of viewing bodies as objects on social media can socialize girls into self-objectification, as they internalize an external spectator’s perspective of their own bodies. This encourages habitual monitoring of one’s physical appearance, a phenomenon known as self-surveillance. It can lead to feelings of anxiety, reduced awareness of one’s own internal states, body shame, and a fear of internalized judgment from others. Another factor that could influence the relationship between exposure to SNSs and the development of EDs is the significance placed on feedback received through social media. Research has shown that the extent of one’s SN, as measured by the number of “friends” [ 23 ], may predict a stronger inclination toward pursuing thinness. Facebook (Meta Platforms, Inc.) use has been identified as a prospective predictor of increased symptoms related to EDs [ 13 ]. Moreover, research indicates that high “appearance exposure” specifically through Facebook, rather than overall Facebook use, is positively correlated with increased body image issues among adolescent girls [ 14 ].

Visual SNs and the Risk of Developing EDs

Regular sharing of self-images on social media platforms such as Facebook, Instagram (Meta Platforms, Inc.), or Snapchat (Snap Inc.), along with actively manipulating these images before sharing, seems to be linked to heightened perceptions of body shape and weight, increased body dissatisfaction, and tendencies toward dietary restriction [ 24 ]. Facebook users tend to be older compared with Instagram users, and this age difference may contribute to younger Instagram users being at higher risk of developing EDs and expressing greater concerns about the impacts of sharing their images on SNs [ 4 ]. Analyzing fitness content on Instagram, particularly posts tagged with hashtags such as #fitspiration, #fitspo, and #thinspiration, reveals that the majority of images depict women with 2 prominent characteristics: thin bodies that are also visibly toned and muscular. This portrayal reinforces the notion that only a thin body can be considered fit [ 25 ]. The pairing of thinness with muscularity appears in as many as two-thirds of the photos posted by influencers [ 20 ], and these images have a more significant impact on body image concerns compared with photos posted by celebrities or models [ 25 ].

Another SNS that emphasizes the visual dimension and has experienced rapid growth is Snapchat. Currently, there is limited research dedicated to investigating the effects of this platform. One of its distinctive features is that users can apply filters to alter their appearance before sharing photos. Additionally, Snapchat is known for its privacy settings and the ephemerality of content, which is typically automatically deleted shortly after being viewed [ 26 ].

Comparative research indicates that the correlation between photo manipulation using specific editing tools (filters) and body image concerns appears to be stronger on Snapchat than on Instagram [ 27 ]. Those who frequently use Snapchat’s lenses to enhance their photos appear to experience higher levels of dissatisfaction with their appearance, leading them to seek out environments that are highly appearance-oriented and focused on enhancing their appearance. Posts on Instagram tend to be more curated, with teenagers often spending considerable time and effort choosing the “right” content before taking a photo, rather than editing it after it has been taken [ 28 ]. This investment of time and energy before capturing the photo may strongly correlate with concerns about body image compared with postphoto retouching [ 29 , 30 ]. Moreover, while Snapchat is often used to connect with close contacts, users may be less focused on their physical appearance when taking pictures. By contrast, the larger audience on Instagram may have a more significant influence on body image concerns.

Research Aims

In light of these considerations, one might inquire about how adolescent girls undergoing treatment for EDs utilize SNs. What significance do they attribute to their SN usage? Do they differentiate between manipulated and unedited images? What strategies do they use to shield themselves from the impact of the content they post or view? Are they cognizant of which modes of SN use could potentially influence clinically significant outcomes?

Our focus is on exploring the usage of purely photographic platforms such as Instagram and Snapchat, which are particularly insidious in terms of fostering comparisons between bodies on the network [ 27 - 30 ]. We are interested in investigating the different emotions and experiences participants have when sharing their own photos in a private and intimate network among friends, such as Snapchat [ 27 ], versus sharing them in front of a larger audience, as is the case with Instagram [ 30 ].

Another area of interest for our investigation involves understanding the meanings associated with the permanence or short duration of content created and received on social media platforms. Specifically, while content published or shared on Instagram is permanent, on Snapchat, users determine the lifespan of their content, after which it is automatically deleted [ 27 ].

Additionally, we are interested in understanding whether girls use strategies to mitigate the potential influence of exposure to certain images, whether they can differentiate between edited and unedited photos, and whether they protect themselves from uncritically accepting messages from SNs. The literature [ 29 ] has demonstrated that visual social media can also be utilized during the recovery process from an ED to promote health messages and well-being. Paradoxically, the use of SNs that involve transforming one’s own photos has also been identified as an important tool, albeit in a positive sense [ 26 ]. Therefore, it is not merely the photo itself but how it is used that determines whether it serves as an “exit” or “entry” point in managing eating behaviors.

The ability to alter one’s images has both positive and negative implications. It allows individuals to transform their appearance inexpensively and democratically, fostering a sense of personal empowerment. However, the ease of digitally altering one’s appearance also leads to an increase in the number of manipulated images that people view and are confronted with. This phenomenon may subsequently heighten dissatisfaction with one’s physical appearance and intensify the pressure to alter it.

In conclusion, we also sought participants’ opinions on the relevance of the proposed topics and what other subjects they would consider important in a collaboratively designed program focused on the responsible use of SNs, intended for potential users in the recovery process.

Sampling and Recruitment

After sharing the objectives and content of the research with health care staff, we informed users of the local health unit for the treatment of EDs within the National Health Service in Eastern Veneto (specifically, the Casa delle Farfalle Residential Protected Therapeutic Community for Children).

The health care staff presented the research to the girls, obtained their consent, requested authorization from their parents, and provided information about the study. They also organized the schedule for appointments. All the girls who were invited agreed to participate; none declined the invitation. The participants and their families were informed of their right to withdraw from the study at any time. They signed a written informed consent form regarding their participation in the research and its potential publication.

Thirty adolescent girls, with a mean age of 15 (range 14-17) years, expressed interest in participating. The inclusion criteria were as follows: a diagnosis of an ED, being in the early stages of treatment with at least 15 days of hospitalization, having an active Instagram and Snapchat profile for at least six months before admission, and willingness to participate in interviews.

We extended the invitation to participants who were at the beginning of their treatment journey because we preferred individuals who had not yet been significantly influenced by the discussions occurring between users and health care providers during their hospitalization period.

The interviews were conducted by MRe, one of the authors of this study. After confirming their availability, she held several preliminary meetings to establish rapport and further explain the study’s objectives and implications. The interviews were conducted individually in a room on the ward where each participant met with the research assistant.

Ethical Considerations

The research protocol was approved by the Ethical Committee of the School of Padova, University of Padova (approval number 2018/2745-10/7). Before commencing the interviews, participants and their parents were informed that participation in the research was voluntary and without any compensation, and their consent was obtained. The original informed consent that participants signed included permission to conduct secondary analysis without additional consent. The final data set is anonymized, ensuring that no identifiable private information linked to participants is included.

Data Collection and Analysis

A semistructured interview consisting of 9 open-ended questions was designed specifically for this research ( Table 1 ). It covered the following areas: (1) the meanings attributed to the use of Instagram and Snapchat; (2) the level of engagement with the photographic aspect and the interactivity generated around it, particularly in terms of feedback; (3) the perceived impact of Instagram and Snapchat usage on body experiences; (4) the potential benefits and risks associated with the use of SNs; (5) the importance of providing support and guidance to girls undergoing treatment for EDs in their use of SNs; and (6) the willingness to participate in and contribute to the co-design of SN literacy programs.

The researchers formulated the questions based on the research objectives. Initially, there were twice as many questions, but they were later streamlined to focus on the most comprehensible ones. The first interviews helped refine these questions further, addressing any areas that appeared unclear or prone to misunderstanding.

Finally, the girls were asked to provide feedback on the relevance of the suggested themes for developing programs on critical thinking regarding SN use during hospitalization. They were also encouraged to add any additional topics they considered important. The interviews took place between June and July 2021. Each interview lasted approximately 45 minutes and was audio-recorded and transcribed verbatim.

Content analysis was conducted following the guidelines outlined by Creswell [ 31 ]. The responses from participants were read and coded, creating meaning units that were categorized accordingly. This process resulted in the development of a codebook, which was then systematically applied to analyze all responses. A triangulation of analyses involving 3 researchers (MRe, EF, and SC) was conducted. This process included sharing one researcher’s initial coding to critically discuss the initial coding patterns and subsequently reach a consensus on the overall interpretation of the data. This approach allowed for interpretations to be challenged, refined, and ultimately agreed upon through collaborative discussion among the researchers.

As the analysis moved from macrocategories (general) to microcategories (specific), there was a progressive refinement and detailed coding of the responses. Initially, responses were categorized at a broader and more anonymous level, providing a general commentary. As the analysis proceeded, categories became more specific, focusing on individual experiences and emotional impacts on personal lives. For instance, the macrocategory “virtual world configuration (VW)” is subdivided into 2 categories: “VW as an extension of reality” and “VW as a world distinct from real life.” These categories represent opposite ends of a continuum that delineates how participants perceive the relationship between the virtual world and the real world. The category “virtual world as an extension of reality” is further detailed in the subcategory (self-reference) “the virtual world significantly influences self-perception.” Participants who hold this view consider the virtual world relevant, viewing it as a source of inspiration for their real-life decisions (microcategory, fourth level of analysis). Conversely, individuals who perceive the virtual world as “separate and distinct from the real world” (category—second level of analysis) specify that the virtual world “has no impact on their self-concept” (subcategory—third level of analysis) and they “regard it as transient” (microcategory, fourth level of analysis). Another example of the categorization system and codebook created can be seen in describing the use of SNSs: we classified as “active use” everything related to actively seeking contacts and interactions, engaging in discussions, sharing personal information, and editing photos and stories. By contrast, we classified as “passive use” those actions oriented toward reading and viewing content made available by others, without active personal involvement. This position entails observing rather than actively participating in the virtual scene.

The second step was quantitative: each category was assigned a code of 1 or 0 based on its presence or absence. We focused on the number of respondents who mentioned a particular category, rather than the frequency of mentions for that category. This approach allowed us to provide an overview of the girls’ attitudes toward the investigated issue. It was particularly important for us to gain a general understanding of the impact and prevalence of specific types of experiences, as well as to explore the personal meanings the girls attributed to the topic in a more qualitative manner.

After completing the analysis, all authors of the paper convened to review the results and make any required adjustments. The draft summary of the main results paper was also shared and discussed during the collaborative analysis and writing phases.

Virtual Word’s Configuration

An overview of the results and the codebook developed during the analysis can be found in Multimedia Appendix 1 .

The thematic coding of the text collected in reference to the first answer revealed 2 main categories: the first, mentioned 28 times, portrays the virtual world as an extension of everyday reality, where online activities have a tangible impact on how respondents perceive themselves. The second category, mentioned only twice, contrasts with the first by viewing the virtual world as an ephemeral and transient realm where an idealized self-image is projected. In this perspective, the impact of online activities is perceived as less significant compared with activities in “real” life, which are seen as separate and more concrete.

SNs’ Active or Passive Ways of Use

Regarding the mode of SN use, 2 main polarities emerged: one characterized by more active engagement and the other by more passive interaction. The proactive category included initiating relationships with others (5 mentions), sharing personal narratives (11 mentions), posting personal photos or stories (3 mentions), and searching for information (23 mentions). By contrast, the passive end of the spectrum included consulting content posted by others (21 mentions). Regarding proactive use, Instagram was noted for fostering positive emotional experiences through contact and exchange with other users (3 mentions), whereas Snapchat was valued for its utility in sharing daily life and disclosing personal information (2 mentions). The most frequently mentioned activity, active information seeking through SNs, was primarily described as a source of stimulation and inspiration, driven by curiosity (13 mentions), to reinforce and update interests (2 mentions), and also as focused information seeking on body-related issues (16 mentions).

As for the eating disorder, I used it a lot to watch food videos, videos of people cooking or even people doing particular sports, gym, like, I don’t know, all those fitness posts. That was the main use. [Participant 2]

Finally, the use of photo editing functions was noted. Passive use of Instagram and Snapchat refers to the reception of content generated by other users for entertainment purposes.

Online Interactions’ Impact

The impact attributed to SNS use is expressed in terms of “social confirmation,” as they are viewed as significant for providing a channel of self-recognition (20 mentions) that includes both approval and disapproval (12 mentions). This results in emotions of personal gratification (7 mentions), support (3 mentions), and encouragement (5 mentions), but also anxiety related to the fear of judgment (5 mentions) and feelings of disconfirmation when few likes are received (10 mentions).

Back then, I thought that if more people commented on my content, that meant more people liked me. The more likes I received, the more others liked me [...]. [Participant 6]

The impact of online interactions varied depending on the specific use of Instagram or Snapchat (20 mentions): Instagram is perceived as having a more tangible and “real” impact compared with Snapchat (18 mentions). Feedback received on Instagram is deemed more significant, to the extent that some respondents consider it a metric for determining their personal worth (8 mentions). There was also a notable sense of distrust toward feedback gathered through SNSs (10 mentions). Consequently, receiving likes and comments was perceived as unimportant due to skepticism about the authenticity of posts. Some respondents rarely received likes and comments, feeling unpopular (6 mentions) and disregarded both on social media and in everyday life.

Regarding Snapchat, the automatic deletion of content and the narrow composition of the network seem to foster a playful, humorous atmosphere (5 mentions) and encourage creativity. This moderates the impact of feedback received (11 mentions).

Investment in the Photographic Dimension

The use of photographs on social media platforms shifts from total involvement (24 mentions) to complete disengagement (6 mentions). Photographs serve not only for self-promotion (20 mentions), fulfilling the desire to be seen (11 mentions), and presenting the best version of oneself (7 mentions), but also for gaining a deeper understanding of oneself (9 mentions) and celebrating specific events (4 mentions). Active involvement in the photographic dimension was specifically associated with Instagram, attributed to its high degree of self-image exposure (16 mentions). SNSs are portrayed as platforms where users consistently share only the best aspects of themselves to appear perfect (7 mentions). The use of Instagram, in particular, fosters second thoughts and inhibitions regarding photo publication (10 mentions). The high degree of exposure on Instagram promotes a tendency to hyper-control the quality of photographs, induces concerns about the perfection of one’s images, and encourages individuals to scrutinize and edit their photos extensively.

When I was going to use Instagram, I never published photos [...] because many more people can see it there, even two hundred, three hundred people can see it [...] [Participant 3]

The “disinvestment” contents (6 mentions) were primarily attributed to feelings of embarrassment (3 mentions) and discomfort (4 mentions). By contrast, Snapchat’s emphasis on ephemerality (3 mentions) and frivolity (2 mentions) in its content contributes to a platform dominated by carefree attitudes toward self-image. This reflects a disengagement from the photographic dimension.

Self-Representation

The collected texts appear polarized: they describe a correlation between the body presented online and the body perceived in the real world (17 mentions), but also refute this congruence (10 mentions) in favor of emphasizing the dominance of the real. Users primarily discussed self-representation on Instagram due to Snapchat’s ephemeral nature. Sharing photographs of themselves is viewed as a means to express their ways of being and interacting with others and the world (5 mentions), as well as a method to foster deeper personal understanding (3 mentions). There was considerable emphasis on portraying a “true” image of themselves (8 mentions). In some cases, it seems feasible to accept photos from the past, particularly those depicting a thinner body, alongside acceptance of the current body image (2 mentions). However, in other cases, confronting images of oneself from a thinner period can be agonizing (3 mentions), often evoking a sense of regret. Ten responses conveyed a sense of discrepancy between the real-life body and the online representation, attributed to efforts to present oneself in a more favorable light, sometimes accentuating flaws or concealing them (2 mentions). This can lead to a perception of projecting a false self-image (8 mentions) compared with one’s subjective self-image. The existence of photos that diverge so significantly from each other also contributes to a sense of fragmentation in one’s self-image (1 mention).

SNs’ Risks

All the collected texts addressed the risks associated with SNSs’ use, especially activities involving the photographic dimension (30 mentions). Content on Instagram, along with related interactive activities, is perceived as significantly influential in shaping ideas about the body and self-representation (21 mentions). This influence is evident in the promotion of a singular body prototype characterized by thinness, perfection, and muscularity (17 mentions). Viewing photos of others is seen as the initial step toward attaining this ideal, although it is perceived subjectively as deceptive (8 mentions). Unrealistic content shared on Instagram aims to bolster this ideal through maladaptive behaviors (11 mentions), sometimes progressing toward images that align with the “Pro-Ana” direction (5 mentions).

Many responses (24 mentions) emphasized the risk of deteriorating one’s relationship with their body due to a heightened focus on physical appearance and an increased attention to the body dimension. Participants acknowledged the role played by Instagram in exacerbating concerns about weight and body shape (11 mentions), particularly through pages where individuals provide tips related to EDs (10 mentions). The heightened concerns are perceived to induce feelings of being “wrong” (2 mentions) and body dissatisfaction (8 mentions). Comparison with images posted online is a dominant theme (19 mentions), where physical attributes, particularly thinness, are frequently cited as comparison criteria, often accompanied by feelings of envy (4 mentions) and inferiority (9 mentions).

A sort of “vicious circle” of negative influence through imitation has been described:

A famous girl puts up a picture then maybe she sees that the picture has many comments from girls who say, “You’re so thin, you’re so beautiful”, and all this, and then she continues to put up pictures of that type, and the girls obsess more and more. [Participant 4]

In relation to the interactive dimension, risks are linked to social judgment and the pressure toward conformity (2 mentions). Finally, another risk identified is the underestimation and casual approach with which users engage with SNs, not fully recognizing the impact and influence that published content can have on people’s lives (5 mentions).

Regarding Snapchat, the texts indicated a more self-deprecating attitude toward sharing content and less anxiety about posting images. This makes Snapchat perceived as a platform where users feel free from concerns about their physical appearance and comparison with others.

Self-Protective Strategies While Using SNSs

Regarding self-protective strategies, the primary defense that empowers the use of SNs without negative impacts on one’s body image is subjective critical capacity (17 mentions). This includes the ability to recognize and distinguish true content from edited ones (4 mentions) and an awareness that each person has about their own unique body (11 mentions). Useful strategies to promote this critical capacity could be implemented by the Instagram platform itself (4 mentions). One form of defense involves actively avoiding sensitive content (7 mentions), self-exposure (2 mentions), or excessive SN use (1 mention). However, some participants noted the challenge of implementing this strategy due to their strong curiosity to view certain content. The Instagram platform itself should develop protective measures regarding the generation of certain content, which could include content control (2 mentions) or content removal (2 mentions).

From the text analysis, skepticism (8 mentions) and a sense of helplessness (4 mentions) emerged regarding the lack of control over online content, as well as a feeling of inescapability (5 mentions) due to the unavoidable accessibility of certain content on Instagram’s home page, even when not intentionally sought. Additionally, other defensive strategies should involve parental controls (1 mention) and the sharing of experiences and content (3 mentions).

SNs’ Potentials

Several potentials were identified regarding the use of SNs, especially concerning the photographic dimension. These potentials are linked to the possibility of improving one’s relationship with their body by emphasizing spontaneity and naturalness in content creation (4 mentions), which is also perceived as a protective measure against the potential for negative comments (2 mentions). The act of searching for content is perceived as supportive during difficult times (3 mentions), providing an opportunity to follow individuals who have faced similar challenges and who, having overcome them, serve as sources of support (2 mentions) and encouragement (1 mention). Platforms such as Instagram also facilitate personal expression (9 mentions) and allow individuals to take an external perspective on their experiences (3 mentions). Exploring profiles of influencers and artists who promote diverse ideas about the body offers an opportunity to discover perspectives that might not be encountered otherwise. These individuals can inspire the exploration of values that challenge prevailing trends.

Another potential lies in actively creating content that emphasizes authenticity (6 mentions) and carefreeness (5 mentions) rather than solely focusing on physical appearance or presenting oneself in an idealized manner. By promoting authentic content, individuals can contribute to limiting the proliferation of unrealistic body ideals and reducing the circulation of idealized and unrealistic representations of the body (3 mentions). However, this aspiration is tempered by skepticism regarding the actual impact of sharing “realistic” content and finding nondeceptive body ideals. Finally, some texts emphasize the potential offered by the opportunity to connect with other people (6 mentions).

With regard to the importance of guiding girls undergoing treatment for EDs to reflect on the topic, there was unanimous agreement (30 mentions), confirming all proposed topics as relevant. If the project had been implemented, the girls would have enthusiastically participated in the group, viewing it as a safe space to find the courage and express themselves (28 mentions) and being inspired by individual choices (20 mentions). To advocate for content that goes beyond the pursuit of bodily perfection, one needs to observe behaviors in others (15 mentions). Expressing oneself with humor and levity is considered the best antidote (15 mentions), but it necessitates self-confidence and a willingness to reject the sanctity often placed on one’s image (15 mentions).

The interest and willingness were confirmed for both participating in person to listen to other girls undergoing rehabilitation (30 mentions) and discussing these issues on an equal footing with peers in similar situations. Additionally, after completing the therapy course, there is interest in potentially serving as a testimonial to set a positive example of the conscious use of social media based on personal life experiences (28 mentions). This opportunity could enable several outcomes: providing support to others (15 mentions), creating a space for personal reflection (7 mentions), hearing about the challenges others have faced in overcoming EDs (8 mentions), and connecting with peers who share similar experiences (7 mentions).

Principal Findings and Comparison With Prior Studies

This research investigated how young women recovering from EDs perceive both the health risks and potential benefits of visual SNs, specifically Instagram and Snapchat, which have been identified in the literature as platforms where harmful body comparisons can occur. Additionally, the study explored the participants’ willingness and interest in collaboratively developing social media literacy programs aimed at supporting individuals recovering from EDs.

The study’s findings underscore a keen awareness among participants of the mechanisms that trigger body comparisons in the online realm, which contribute to feelings of insecurity and detrimentally impact self-relationships. However, the girls do not consistently harness this awareness to their benefit. The identified self-protective behaviors include the development of critical thinking, avoidance of sensitive content, increased control over SNSs, and a degree of skepticism toward the propagation of conflicting ideologies. All these topics were deemed fundamental by the participants.

For the young people participating in the study, 3 primary modes of using Instagram and Snapchat emerged. The first mode was characterized by the relational dimension, involving affective experiences of contact and exchange, which reduced feelings of loneliness and enhanced perceptions of social support. The second mode of use focused on self-presentation and self-disclosure, particularly evident in relation to Instagram. The third mode of use involved active information seeking, specifically the search for stimuli, inspiration, curiosity, and updates related to one’s passions, interests, appearance, and eating behaviors.

The topics emerging from the data confirm findings in the literature regarding the problematic use of SNs and the development of EDs among preclinical samples. Following appearance-focused accounts on Instagram and engaging in photo-based activities, such as posting selfies or liking and commenting on photos, were associated with poorer body image outcomes [ 14 , 15 , 28 , 31 , 32 ]. Passive use characterized by role passivity, which involves the passive reception of content generated by other users for entertainment or spectatorship purposes, has been linked to a decrease in subjective well-being through social comparison [ 2 ]. Among our participants, even the passive mode of social media use—simply opening food- and body-related videos—was acknowledged by the girls as reinforcing problematic behaviors from a symptomological point of view, such as dieting and exercise obsession.

One of the most alarming findings from our research was the significant disparity between perspectives regarding the online environment either as a continuation of reality or as distinct from it (28 vs 2). Participants who viewed the virtual world as an extension of reality tended to perceive the feedback received as highly impactful on their self-perception and sense of self-worth. The significance of online feedback was closely tied to the validation it provided, through either approval or disapproval. However, some participants expressed skepticism about the authenticity of SNs, viewing the images and content as misleading. As a result, they perceived the impact of online feedback as less meaningful compared with feedback received in real life [ 33 , 34 ].

This finding could be pivotal for a project focused on training, discussing, and reflecting on the subject: Highlighting the distinction between individuals who trust the authenticity of the online environment and those who approach it with skepticism is an initial step toward fostering distance and increasing awareness of one’s online presence and behavior.

Self-promotion emerged as a significant motivator for engaging in photographic activities on SNs. Users aimed to portray their best selves and sought positive recognition from others, aligning with existing findings in the literature [ 35 , 36 ]. The study also identified other motivations such as celebrating moments or events and seeking visibility among others [ 2 ], which are enhanced by Instagram’s exposure and amplification features. Conversely, users’ disengagement was primarily driven by feelings of embarrassment and discomfort associated with self-exposure, as well as the ephemeral and light-hearted nature of content shared on Snapchat [ 37 ].

All participants reported using criteria to select photographs for publication, particularly on Instagram. Those who noted a gap between their online self-presentation and their real selves emphasized an awareness that the virtual world perpetuates a sense of falsity by showcasing only the most desirable image of oneself. Regarding risks associated with photo-related activities, Instagram was seen as a highly visual platform centered around photos, with a strong focus on aesthetic content and a prevalence of edited photos that promote unhealthy, unrealistic, and deceptive body ideals [ 38 ]. These body ideals are perceived as highly influential in promoting and striving for perfection and the thin ideal [ 29 ]. Despite often being perceived as unattainable, media portrayal of this ideal leads women to view it as normative and central to attractiveness, thereby internalizing socially constructed appearance ideals [ 39 , 40 ]. This internalization and subsequent comparison lead to decreased satisfaction with one’s own body, efforts to manage one’s appearance to reach this ideal, and increased concerns about body image [ 41 ]. Social comparisons upward tend to evoke envy and feelings of inferiority, in terms of not only physical appearance but also the personality and lifestyle of individuals within one’s SN. Moreover, participants emphasized the risks associated with the interactivity facilitated by SNs. This phenomenon is referred to in the literature as “body talk,” which involves interpersonal interactions focused on bodies and physical appearance [ 42 ]. Body talk reinforces the value and significance of appearance and contributes to the construction of appearance ideals [ 43 ]. Previous research has demonstrated that body talk is positively correlated with body surveillance, body shame, and perceived pressure to conform to thinness ideals [ 42 ].

In terms of the potential of SNSs, participants emphasized the significance of being able to create, choose, and share content freely. They viewed promoting active sharing of naturalistic and unedited content, characterized by authenticity and spontaneity, as a potential means to enhance their relationship with their own bodies and for personal self-expression [ 44 ]. Improving the relationship with their own bodies was also seen as potentially helpful in finding support from people who have had a similar experience. Finally, users highlighted the potential of SNs to stabilize and enhance peer relationships with previously inaccessible groups, as well as the possibility of discovering things that might be difficult to encounter in everyday offline life. Our participants also highlighted the challenge of self-discipline and avoiding potentially harmful online content. Therefore, in the context of social media literacy programs, it could be beneficial to create spaces where girls can cultivate the courage to block the use of social media in such situations, as they suggested.

Regarding defense strategies against the influence of content published on SNSs, users primarily proposed empowering subjective critical capacity. They suggested developing and enhancing social media awareness and adopting a critical approach to viewing and scrutinizing images and posts, including considerations about the realism of the images and the intentions of the posters. They also suggested enhancing the control that platforms themselves could exercise over the type and quality of images and content posted online, even advocating for automatic deletion of content that could pose risks to users’ body image. However, some users expressed skepticism and uncertainty about the feasibility and legitimacy of such controls. They believed that the best strategy was to avoid content perceived as subjectively risky for their body image and that could potentially expose their image in an undesirable way.

It should be noted, however, that recent literature suggests enhancing critical thinking about the media may not be the sole or primary mechanism of change in effective media literacy interventions. There is uncertainty about whether literacy programs aimed at reducing the risk of EDs also effectively address critical thinking about the media. Future research will need to clarify this ambiguity [ 45 ].

What emerged from our research as a whole is that girls often have an awareness of risks but struggle to use this awareness to their advantage. They can recognize edited photos but still perceive them as authentic. Only a few responses indicated that “distrust” can serve as a strategy to mitigate perceived influence. These findings suggest that enhancing critical thinking about the media may not be the sole or primary mechanism of change for effective media literacy interventions.

However, we did not explore the influence of context, particularly the role of parents and the school environment, in moderating social media use and coping with body dissatisfaction. Among the limited qualitative research available on the meanings associated with social media use, Burnette et al’s [ 46 ] study sheds light on this topic. The authors found that among adolescent girls in general (not necessarily those in treatment for EDs), parental control devices for social media and school environments may be particularly effective in helping adolescents enhance their strategies for filtering out the most harmful messages and developing a broader conception of beauty. These factors act as protective measures against the risks associated with social media use.

Practical Implications

Given the intricate connection between SN usage and its effects on mental health [ 47 ], it is crucial to investigate this phenomenon by valuing the personal perspectives of individuals who directly experience discomfort and pain related to SN use. Health professionals should integrate discussions about SN use into their treatment of body dissatisfaction and disordered eating [ 2 ]. Much of the content emerging from the research explores new dimensions of SNS use beyond existing literature. These include identifying 3 primary modes of use, understanding the challenge of distinguishing between real and online environments and the resulting behaviors, addressing emotional detachment strategies, and considering the implications of interacting with apps that feature permanent visual content and large followings. Additionally, the study discusses platforms with temporary photo availability and intimate networks, strategies to enhance positive social media use through peer support, and methods to mitigate risks shared between users and platform providers.

Considering the ineffectiveness of prohibiting adolescents from using SNs, it could be beneficial to focus on teaching them how to navigate these environments safely instead. Rather than restricting access [ 48 ], leveraging existing SN platforms for targeted interventions is possible. This approach can utilize anonymous access to health information available on the internet, which is appealing to young people seeking such resources [ 49 ]. This strategy aims to empower youth with the knowledge and skills needed to use SNs responsibly and effectively manage their online experiences.

We believe that every problem has its solution. In other words, starting from where young people are—specifically, their desire to engage and immerse themselves in the methods and meanings of SN use—we can empower credible and interested role models (such as girls with EDs) to influence others toward more mindful use of self-protective strategies on SNs. The most impactful approach to wield this influence is to engage these individuals as influencers and collaborate with them to develop literacy programs within treatment frameworks. This research introduces fresh insights and underscores the necessity of addressing sensitive issues to design and implement more effective and tailored educational programs tailored to individual health care recipients [ 47 ].

Limitations

Several study limitations should be noted, including the small sample size and the fact that all participants had undergone treatment at a specialized center for EDs, indicating they already had awareness of the issue. Future research could broaden the survey to include a wider range of participants, including those in the preclinical phase of EDs. This approach would enable professionals to enhance their understanding of potential histories, distress forms, and health promotion strategies, thereby guiding the management of early signs of distress. Another limitation is self-selection, as participants were invited by health care staff and chose to participate voluntarily rather than being randomly selected. This may result in a biased and unrepresentative sample of the population, as those who choose to participate may possess specific characteristics that distinguish them from the broader population. However, it is important to note that qualitative research such as this does not aim to generalize findings to the entire population. Instead, its focus is on exploring the lived experiences and meanings ascribed to those experiences by the participants themselves.

Another limitation arises from the context of ED treatment services where participants were restricted from using phones, which meant their responses relied on memory rather than current experiences. A third limitation that could be addressed in future research involves assessing the long-term retention and application of knowledge about the risks and potentials of social media use over time.

Conclusions

While previous literature extensively covers studies on the risks of using SNs and prevention programs, our study contributes numerous ideas on addressing this topic with young people undergoing therapy for EDs by involving them as experts by experience. It allows the identification of the most significant themes that may arise, enabling health professionals to incorporate them into discussions and share the self-protection strategies identified. There is a call to leverage the potential of SNSs, such as user-generated content and interactivity, to promote beauty ideals divergent from the prevailing model, alongside content that emphasizes humor rather than appearance-centric narratives. However, the crux of the research lies not only in what to propose but also in how to propose it. Enrolling girls as coparticipants in the programs represents, in our view, the real breakthrough.

Being able to share their experiences and offer their stories as a potential source of inspiration and influence among peers allows individuals to transform from passive recipients of life, influenced by others, into conscious leaders who guide and inspire others. This involves coconstructing care pathways, creating space, and negotiating ideas with those willing to take on the new role, such as that of a patient who, after completing their treatment journey, makes themselves available to assist others at the beginning of their own journey. Co-design indeed necessitates flexibility and a strong willingness from all participants. It is not about predefined content but rather entails collaborative decision-making where meetings and individuals together determine the objectives to pursue.

Acknowledgments

We express our gratitude to all the mental health workers who contributed to the research, actively participating in every stage of it, and to all the girls with whom the research project was collaboratively constructed. They gave their time to reflect and share their experiences sincerely and showed a genuine and generous interest in this work. We are also very grateful to our young colleagues Ludovica Aquili (PhD student in Social Sciences) and Lia Bitetti (psychologist, psychotherapist in training, graduated from the University of Padua) for their support and expertise in editing this work.

Data Availability

The data sets generated or analyzed during this study are not publicly available due to privacy restrictions. Indeed, they contain information that could compromise the privacy of research participants. They are available from the corresponding author upon reasonable request.

Authors' Contributions

EF contributed substantially to the conception and design of the work. MRe created the structure and collected the data. Together, both drafted the work and revised it critically for important intellectual content. All authors participated in the analysis and interpretation of the data.

Conflicts of Interest

None declared.

Overview of the results and the codebook of analysis. The 4 categories are indicated from the general (macrocategories and categories) to the particular (subcategories and microcategories). The number in brackets refers to the number of respondents who evoked the relevant category upon the 30 involved. The categories were not always subdivided further; in some cases, in fact, no details were added during the interview. Interviews with young women in recovery from eating disorders (EDs) were held in North Italy in 2021.

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Abbreviations

Edited by A Mavragani; submitted 04.10.23; peer-reviewed by L Aquili, Y Wang, R Vitelli, A Nerini, A Mentasti, R von Brachel; comments to author 02.02.24; revised version received 29.03.24; accepted 20.05.24; published 02.07.24.

©Elena Faccio, Margherita Reggiani, Michele Rocelli, Sabrina Cipolletta. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 02.07.2024.

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