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in their sexual health intervention. After recruiting
seedindividuals into FacebookGroups, they used respondent-
Fro(Cobb, Graham), American Legacy Foundation; Division of
Pulmonaryand Critical Care, Department of Medicine (Cobb),
Department of Oncol-ogytowHePub
Fou172nco
2driven sampling to essentially disseminate the interven-tion
through the social networks of the seeds. Theydescribea large
difference in the success of their recruitment strat-egy by
conditionan average of an additional 1.04 vs 1.79participants
(resulting in over-recruitment in the inter-vention arm). This
difference would appear to be due to
, Lombardi Comprehensive Cancer Center (Cobb, Graham), George-n
University Medical Center, Washington, DC; and Department ofalth,
Behavior and Society (Cobb), Johns Hopkins Bloomberg School oflic
Health, Baltimore, MarylandAddress correspondence to: Nathan K.
Cobb, MD, American Legacyndation, Schroeder Institute for Tobacco
Research and Policy Studies,4 Massachusetts Avenue, NW, Washington
DC 20036. E-mail:[email protected]/$36.00Health
Behavior InAge of Fa
Nathan K. Cobb, MD, A
ehavioral interventions leveraging online net-works have the
potential to affect populationhealth dramatically, given their
capacity to dis-
inate programs virally while simultaneously facilitat-social
support and modifying norms.1 Historically,
ervention design has prioritized effect over reach, as-ming that
dissemination can be achieved post hoc.e papers from Bull2 and
Cavallo3 in this issue poten-lly point us in a different direction
by using Face-ok as an intervention approach for preventing sex-lly
transmitted infection and promoting physicaltivity,
respectively.The scale of Facebooks online network is immense:
animated 149 million Americans use it every month,ch one connected
to an average of 214 people.4 Brandsch as Starbucks have millions
of people engage withir Pages; the social game (App)WordsWith
Friendss 16 million active players every month.5 For healthhavior
change intervention designers, Facebook offersmething
unprecedenteddirect access to an individu-s social network, in real
time, and without the need forious network enumeration by
participants. In theory,s kind of access could support an optimal
networkervention model where diffusion and social supportlinked and
synergistic. For example, an interventionsmoking cessation could
spread from a target to theirends, inducing cessation while
simultaneously aug-nting social support and reinforcing abstinence.
Face-ok provides tools for precisely these network effects:ges and
Groups (as used by Bull2 and Cavallo,3 respec-ely) allow
self-affliation and transmission of informa-n through groups, while
Apps provide direct access toindividuals personal information,
their friends, andtribution channels for diffusion.
m the Schroeder Institute for Tobacco Research and Policy
Studiesthehttp://dx.doi.org/10.1016/j.amepre.2012.08.001
012 American Journal of Preventive Medicine Published by
Elsevierventions in theebookda L. Graham, PhD
Despite these advantages, both papers demonstrate theallenge in
selecting and implementing methods fortwork-based intervention. The
advantages of Groupsd Pages are the low barrier for affliation
(e.g., clickingLike button) and the ability to immediately form adc
networks. However, these approaches are limited byfact they do not
allow access to an individuals per-
nal information or his or her network data. Apps
haveoadermechanisms for social interaction, but are signif-ntly
more diffcult to develop and require formal con-t. The literature
on the use of ad hoc or createdline networks for social support is
well established,6
th roots in traditional support groups. Individuals arecouraged
to subscribe to a site, forum, page, or groupere they interact
primarily with people they do noterwise know and are exposed to
information, norms,d support not previously available. Still, ad
hoc net-rk interventionslike the use of Facebook Groups orgesare
hampered by two issues: (1) the need to haveexisting, functional,
scaled support network prior torticipant enrollment (to avoid an
empty room phe-menon) and (2) the hesitancy of people to
activelygage with strangers.These two issues may explain why
Cavallo and col-gues3 found no beneft from adding a Facebook
groupwhat appears to have been a well-designed web inter-ntion.
Described as a feasibility study, they enrolledly 67 people in the
intervention armless than half thember of friends of the typical
Facebook user. For thiservention to have yielded signifcant
results, it mayve required farmore people in theGroupwith a
greatergree of behavioral heterogeneity. Future research willed to
clarify whether their negative results stem fromory and methods or
merely from lack of scale in thecial network.Bull and colleagues2
used Facebook in a different wayintervention itselfimplemented by a
professional
r Inc. Am J Prev Med 2012;43(5):571572 571
social mediaDiffusion usu(R)a metricthe number oattributable
toaggregate number at about 0intervention. Tfor an intervecompounds
exexceeding 1 insion throughoseeds. Game cgious producintervention
wination probleBoth paper
social influenction impact, thdesign. The imneed to focuslarge
supportorbequcanicreqsppaing
e poten-llo, Bull,r leading
rs of this
rams DB,smoking
ternet Res
li J. Socialr random-474., Ammer-rvention: a012;43(5):
natomy of:1111.4503
5.
6.
7.
knop heng Mwe
nline
572 Cobb and Graham / Am J Prev Med 2012;43(5):571572Groups with
thousands of active participants acrosshavioral stages of change)
or developers need to ac-ire the capacity and infrastructure to
develop Appspable of tapping into an individuals network,
commu-ating across it, and spreading virally. Both approachesuire
multidisciplinary teams that include social mediaecialists,
marketers, and software developers as equalrtners in design and
intervention development. Build-such teams undoubtedly will require
changes to tra-
Did youYou can search over 500 to
online, includivia the AJPM
Visit www.ajpmo2011. arxiv.org/abs/1111.4503.Words with
friendsFacebook application metrics from
AppData.www.appdata.com/apps/facebook/168378113211268-words-with-friends.Archived
at:www.webcitation.org/69XkpIB1a.Eysenbach G, Powell J, Englesakis
M, Rizo C, Stern A. Healthrelated virtual communities and
electronic support groups: sys-tematic review of the effects of
online peer to peer interactions.Br Med J
2004;328(7449):1166.Heffernan JM, Smith RJ, Wahl LM. Perspectives
on the basicreproductive ratio. J R Soc Interface
2005;2(4):28193.
w?alth sciences journalsEDLINE,bsite..org
today!organizationbeing simply more viral.ally is quantifed by the
reproductive ratioderived from epidemiology that refers tof new
respondents (infections) directlya single seed recruit.7 From the
three-wavebers provided, we can estimate this num-.55 for the
control and 0.75 for the activehis difference may appear to be
small, butntion with the capacity to propagate, itponentially. More
importantly, an R valuedicates a tipping point and potential
diffu-ut a population without requiring newompanies repeatedly have
created conta-ts; a health behavior team that built such anould
have cracked the thorniest of dissem-ms.s suggest that if the use
of existing ties fore and diffusion are important to interven-ey
need to be included at the inception ofplications are daunting:
Either designerson the development and maintenance ofnetwork
populations (e.g., Facebook Pages
ditional funding and developmentmodels, but thtial is too large
to be ignored or minimized. Cavaand their collaborators are to be
commended fothe way.
No fnancial disclosures were reported by the authopaper.
References1. Cobb NK, Graham AL, Byron MJ, Niaura RS, Ab
Workshop Participants. Online social networks andcessation: a
scientifc research agenda. J Med In2011;13(4):e119.
2. Bull SS, Levine DL, Black SR, Schmiege S,
Santelmediadelivered sexual health intervention: a clusteized
controlled trial. Am J Prev Med 2012;43(5):467
3. CavalloDN,TateDF, RiesAV, Brown JD,DeVellis RFman AS. A
social mediabased physical activity interandomized controlled
trial. Am J Prev Med 2527532.
4. Ugander J, Karrer B, Backstrom L, Marlow C. The athe Facebook
social graph. Arxiv Preprint ArXivwww.ajpmonline.org
Health Behavior Interventions in the Age of
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