**5. Application**

meetings, physical contact, or face-to-face interactions full of embarrassment for confessing in the middle of a circle of peers one more missed section at the gym, or devouring a big bowl of ice cream each night [19]. Nowadays, encounters take place online, using the advances of digital technology like Facebook groups, which allow meeting peers who share similar values and goals, and who have joined the digital communities to receive the much-needed social

Individuals who use online communities can chat on the website, write about their healthrelated problems, and support each other with specific advice. In certain communities, members can update their health information and receive tailored suggestions, such as daily calorie intake and customized exercise plans, as well as motivational messages from their friends to help them adhere to their goals, or receive encouragement when they are ready to re-start their exercise routine after a relapse; with the advantage of remaining anonymous or using nicknames that will protect them from embarrassing moments and hard critics [20, 21]. One of the advantages of online communities is that they are customized for specific needs. Usually, they are characterized according to the activity they provide (e.g., social support, health advice), the people whom they serve (e.g., breast cancer survivors), or the technology that supports them (e.g., linked to a wearable device). In these communities, individuals can find and provide four types of support: (1) emotional (e.g., friendship, trust, empathy); (2) instrumental (tangible aid); (3) informational (e.g., advice or suggestions); and (4) constructive feedback; which

Even though, SNSs allow different types of interactions and relationships, what distinguishes social support from other interactions are some specific characteristics: social support is always intended to be helpful, is consciously provided in an interpersonal context of caring and respect, and in the case of informational support, it can attempt to influence the behaviors

According to standard economic theory, individuals are fully rational when making decisions, they try to maximize utility and when given information, they are able to make optimal decisions. But behavioral economics (BE) suggests otherwise: consumer behavior is complex, people sometimes make irrational choices, and their behavior does not follow the predictions of economic models. Most people are risk averse and prefer to make decisions based on heuristics or mental shortcuts to reduce efforts and avoid hassles [22]. They also are motivated by rewards and respond easily to incentives and nudges. A nudge is any factor that significantly alters people's behavior in a predictable way. The nudge can be designed by a choice architect, who has the responsibility for organizing the context in which people makes decisions. The nudge can be as simple as the use of specific colors. Most drivers know that they have to stop when they see a red light, and keep driving their cars if the light turns to green. This common knowledge —and way of nudging—has then moved to another areas of people's life, for example, with the use of traffic lights, food labels, and graphics to indicate the energy

in sum become a form of social capital of high value for individuals [3].

and decisions of the receiver [3].

**4. How individuals make decisions**

support.

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In their quest for health and wellbeing, people are turning to technology to reach and maintain their health-related goals and improve their lifestyle. It seems that nowadays, the Internet, the Smartphones, and even jewelry and clothing apparel play an important role in managing specific health conditions. In this section, we describe how digital platforms and technology provide advantages to individuals who need support to reach and maintain their health goals. First, we illustrate how SNS have become commonplace for individuals who seek physical wellbeing and address their need for social support. Second, we describe how patients are using mobile messaging applications to receive instrumental and informational support. And third, we explore the motives to use wearable devices and health monitoring apps.

### **5.1. Facebook communities**

Worldwide there are over 1.79 billion people using Facebook each month. On average, each individual spends around 20 minutes in each visit, and almost 93% of Facebook users reach the SNS from their mobile phones. With more than 650 million of groups available on Facebook, nowadays, individuals have a vast offer of communities where they can meet with virtual friends who share common interests and causes [24]. Online support groups like Weight Watchers, Alcoholic Anonymous, and numerous others provide an adequate environment for voluntary affiliations and facilitate the pursuit of wellbeing with different tools and features that allow individuals to share their fears, doubts, and struggles while trying to achieve a healthier lifestyle.

#### *5.1.1. The method*

To shed more light on how individuals are using SNS to provide and receive the four types of support, we conducted a participant netnography in two different Facebook communities. The first one related with dieting (Weight Watchers), and the second one regarding physical activity (Rapport Runners). The selected communities are highly interactive, heterogeneous, and provide rich data for analysis, as suggested by experts on this qualitative methodology [4]. Members of the two communities are active, constantly posting questions and answers, as well as uploading photos and videos.

To begin the netnography, one of the authors became a participant-observer, interacting as full participant in the local culture, contributing with comments and receiving feedback, always ensuring the ethical treatment of the data posted by the members of the community [4]. The unit of analysis consisted of two random discussion threads containing one initial post by a support seeker and several subsequent response posts published by support providers. As the study evolved, we selected other discussion threads. Online data were captured using word-processing software for further content analysis, and photos and other images were captured as visual images to be also analyzed. A qualitative content analysis was then conducted to identify potential themes, form categories, and classify participants into different segments.

#### *5.1.2. The findings*

The content analysis reveals that the SNSs under study offer a virtual community, where individuals can find encouragement, answers to specific health-related questions, and applause from virtual friends who cheer them up when they attain their goals. Members of the community were classified into two main categories: support providers and support seekers. Each category was then divided into subcategories based on specific traits and characteristics of participants.

Support providers were subclassified into three categories: (1) experts (e.g., doctor, health coach, nutritionist); (2) ordinary members of the community (i.e., virtual friends and acquaintances); and (3) opportunistic (i.e., individuals offering different products for sale, such as vitamins, diet pills).

While support seekers were divided into six categories: (1) anxious and fearful (i.e., individuals afraid of diseases); (2) careless and free (i.e., those individuals who expressed interest for feeling good, avoid stress, and have fun); (3) body conscious (i.e., centered in their looks and physical appearance); (4) techies (i.e., individuals who use specific apps to monitor their health and physical activity, and post their achievements in the SNS); (5) eternal dieters (i.e., individuals who seem to be stuck in their weight loss program and express their failures online); and (6) the window shoppers: the passive individuals that barely post any question or comment but take advantage of the "Like" feature of Facebook. They benefit by reading the posts published by other members of the community and show their interest and agreement by "Liking" those comments that are meaningful for them.

In the majority of posts, the initial conversation was phrased as a question or as a request for advice. Participants usually referred to the difficulty to stick to their goals (e.g., "I want to eat healthy, but I do not like vegetables, do you have any healthy recipes."); their lack of knowledge regarding a health issue (e.g., "Can I reverse my diabetes if I lose some weight?"), or their fears (e.g., "Will I hurt my knees if I start running? I am really overweight.").

Given that the SNSs studied have a specific target, the online environment makes it easier for participants to receive advice and encouragement from peers who are going through similar experiences, providing a frame of trust and empathy for most members of the community. While the presence of experts allows for the provision of reliable information, the advice becomes more meaningful and the support seeker feels listened to and appreciated.

activity (Rapport Runners). The selected communities are highly interactive, heterogeneous, and provide rich data for analysis, as suggested by experts on this qualitative methodology [4]. Members of the two communities are active, constantly posting questions and answers, as

To begin the netnography, one of the authors became a participant-observer, interacting as full participant in the local culture, contributing with comments and receiving feedback, always ensuring the ethical treatment of the data posted by the members of the community [4]. The unit of analysis consisted of two random discussion threads containing one initial post by a support seeker and several subsequent response posts published by support providers. As the study evolved, we selected other discussion threads. Online data were captured using word-processing software for further content analysis, and photos and other images were captured as visual images to be also analyzed. A qualitative content analysis was then conducted to identify potential themes, form categories, and classify participants into differ-

The content analysis reveals that the SNSs under study offer a virtual community, where individuals can find encouragement, answers to specific health-related questions, and applause from virtual friends who cheer them up when they attain their goals. Members of the community were classified into two main categories: support providers and support seekers. Each category was then divided into subcategories based on specific traits and characteristics of

Support providers were subclassified into three categories: (1) experts (e.g., doctor, health coach, nutritionist); (2) ordinary members of the community (i.e., virtual friends and acquaintances); and (3) opportunistic (i.e., individuals offering different products for sale, such as

While support seekers were divided into six categories: (1) anxious and fearful (i.e., individuals afraid of diseases); (2) careless and free (i.e., those individuals who expressed interest for feeling good, avoid stress, and have fun); (3) body conscious (i.e., centered in their looks and physical appearance); (4) techies (i.e., individuals who use specific apps to monitor their health and physical activity, and post their achievements in the SNS); (5) eternal dieters (i.e., individuals who seem to be stuck in their weight loss program and express their failures online); and (6) the window shoppers: the passive individuals that barely post any question or comment but take advantage of the "Like" feature of Facebook. They benefit by reading the posts published by other members of the community and show their interest and agreement

In the majority of posts, the initial conversation was phrased as a question or as a request for advice. Participants usually referred to the difficulty to stick to their goals (e.g., "I want to eat healthy, but I do not like vegetables, do you have any healthy recipes."); their lack of knowledge regarding a health issue (e.g., "Can I reverse my diabetes if I lose some weight?"), or

their fears (e.g., "Will I hurt my knees if I start running? I am really overweight.").

by "Liking" those comments that are meaningful for them.

well as uploading photos and videos.

118 Advances in Health Management

ent segments.

participants.

vitamins, diet pills).

*5.1.2. The findings*

In both the communities, we found the four basic forms of social support and an additional one that we called "network support." Informational support was provided when answering questions with new facts and suggesting recipes for cooking healthy food; emotional support and constructive feedback were demonstrated with messages of encouragement and emoticons showing smiley faces, clapping hands, and thumbs up icons; while tangible assistance was provided by recommending apps, diets, pills, or running shoes, among other products. Finally, the network support is an inherent characteristic of the both communities. When people join the virtual community, they get access to new people facing similar situations or similar goals, who are able to listen with more empathy and to provide specific advice.

We observed a sense of connectedness among the members of the communities, who provide psychological gratification, help individuals to release stress and guilty feelings, and in sum achieve higher levels of wellbeing. In both the cases, the studied communities offer the best of two worlds: the virtual and the face-to-face interactions. Even though we studied the online communities by reading the posts, we learned that both Weight Watchers and Rapport offer their members the opportunity to interact in face-to-face encounters. In fact, Weight Watchers was born in 1963 as a traditional support group for people willing to lose weight, and moved to Facebook just recently to take advantage of the digital technologies and provide different tools for members of the community. While Rapport was created in 2009, people achieved physical and mental goals using neurolinguistic programming and physical activity training. Members of the Rapport community meet weekly for physical training and share questions, photos, and other messages on Facebook.

Members of the studied communities are motivated by common interests and goals. They present certain levels of altruism by offering specific advice and nutritional tips to other members of the community. By choosing when and what to post, members of the virtual communities receive the support when they fail to reach their health-related goals, and the appraisal and recognition for their achievements. At the same time, we identified the presence of social trust. Individuals disclose personal topics, like the low self-esteem derived from being overweight, the struggle to find nice clothes to wear to be physically attractive, and even the criticism they receive from friends and family for not being able to achieve their health-related goals.

#### **5.2. Nudging people toward a better lifestyle with Telegram and Whatsapp**

Bariatric surgery has become an option for adults who need to lose weight for medical reasons. Among other benefits, the surgery reduces the incidence of diabetes and hypertension, but in order to be effective, patients need to make important changes in their eating habits and exercise behaviors. In sum, a new lifestyle comes in order and education, advice, and help are needed to be successful and prevent old habits from resurfacing [25].

When dealing with bariatric surgery as a resource to lose weight, previous research has found positive associations between postoperatory support and weight loss. It seems that to make significant lifestyle adjustments, education and face-to-face support are needed to cope with stress and prevent relapses [26]. But what happens with those patients that have no time to attend the meetings or are too shy to join a support group? Can digital technology provide a solution for them?

With the advent of instant mobile messaging applications such as Telegram and Whatsapp, people have adopted a new way to communicate with each other and to manage their health. Nowadays, individuals are comfortable addressing a health concern with a doctor or sharing a photo related to a personal health problem using their mobile phones. These facts have been considered as an advantage by physicians, health coaches, and psychologists who use the mobile phones and the apps to deliver specific interventions, advice, and counseling to enhance their patients' health. At the same time, apps such as Whatsapp and Telegram provide patients with free tools to have private conversations to share their most personal concerns and build a community of think-alike supporters.

#### *5.2.1. The method*

To shed more light on the use of instant mobile messaging applications in-depth interviews were conducted with five adult women who decided to go into bariatric surgery to lose weight and improve their health. A semistructured questionnaire was used to identify their behaviors and motivations related with health issues and social support. They were also asked about the benefits they receive from using Telegram and/or Whatsapp to be in touch with their doctors and peers. In-depth interviews were recorded, transcribed, and analyzed [27], and the findings are presented in the following section.

#### *5.2.2. The findings*

The in-depth interviews allowed us an understanding of the facts that motivate bariatric surgery patients to use instant messaging applications. The five subjects of our study are patients of a bariatric surgeon in the North of Mexico. In fact, it was the doctor who suggested the patients to join a Whatsapp group in order to provide them—along with 340 more patients consistent and standardized psychological and nutritional advice, designed specifically for bariatric patients.

Our findings suggest that this Whatsapp group offers several advantages, as well as some limitations. The first, and most important, reason to use the group is the presence of three health specialists that conform the bariatric team: the surgeon, a psychologist, and a nutritionist. Having a bariatric team present allows participants to receive supervised support from licensed health providers, who are familiar with each patient case and have the knowledge and experience to provide instrumental and informational support.

Since most persons obtained information for bariatric surgery from friends, there is a need to educate them in several topics, such as grocery shopping, meal preparation, and how to deal with meal times, among other issues. In this group, participants find specific advice on the process of acquiring—and maintaining—a new lifestyle. The nutritionist shares food recipes and provides tips on how to get all the nutritional requirements with less food and even suggests which restaurants to visit and what meals to order when dining out.

When dealing with bariatric surgery as a resource to lose weight, previous research has found positive associations between postoperatory support and weight loss. It seems that to make significant lifestyle adjustments, education and face-to-face support are needed to cope with stress and prevent relapses [26]. But what happens with those patients that have no time to attend the meetings or are too shy to join a support group? Can digital technology provide a

With the advent of instant mobile messaging applications such as Telegram and Whatsapp, people have adopted a new way to communicate with each other and to manage their health. Nowadays, individuals are comfortable addressing a health concern with a doctor or sharing a photo related to a personal health problem using their mobile phones. These facts have been considered as an advantage by physicians, health coaches, and psychologists who use the mobile phones and the apps to deliver specific interventions, advice, and counseling to enhance their patients' health. At the same time, apps such as Whatsapp and Telegram provide patients with free tools to have private conversations to share their most personal con-

To shed more light on the use of instant mobile messaging applications in-depth interviews were conducted with five adult women who decided to go into bariatric surgery to lose weight and improve their health. A semistructured questionnaire was used to identify their behaviors and motivations related with health issues and social support. They were also asked about the benefits they receive from using Telegram and/or Whatsapp to be in touch with their doctors and peers. In-depth interviews were recorded, transcribed, and analyzed [27],

The in-depth interviews allowed us an understanding of the facts that motivate bariatric surgery patients to use instant messaging applications. The five subjects of our study are patients of a bariatric surgeon in the North of Mexico. In fact, it was the doctor who suggested the patients to join a Whatsapp group in order to provide them—along with 340 more patients consistent and standardized psychological and nutritional advice, designed specifically for

Our findings suggest that this Whatsapp group offers several advantages, as well as some limitations. The first, and most important, reason to use the group is the presence of three health specialists that conform the bariatric team: the surgeon, a psychologist, and a nutritionist. Having a bariatric team present allows participants to receive supervised support from licensed health providers, who are familiar with each patient case and have the knowledge

Since most persons obtained information for bariatric surgery from friends, there is a need to educate them in several topics, such as grocery shopping, meal preparation, and how to deal with meal times, among other issues. In this group, participants find specific advice on the

cerns and build a community of think-alike supporters.

and the findings are presented in the following section.

and experience to provide instrumental and informational support.

solution for them?

120 Advances in Health Management

*5.2.1. The method*

*5.2.2. The findings*

bariatric patients.

The common person believes that bariatric surgery is a magical solution for obesity. But the surgery is only the first step in achieving a long-term change. A bariatric surgery patient has to deal with several considerations, therefore, the need to have professional support before and after the procedure. Before the surgery, most patients have mixed feelings: they want the surgery to improve their quality of life and look better, but at the same time, they are scared and fear operative and postoperative complications.

Our findings suggest that being a member of the Whatsapp group before the surgery allows patients to reduce preoperatory stress and feel confident that the surgery will be a successful event. It seems that being in touch with individuals who already went into the surgery provides new patients with a sense of security and provides enough motivation to continue with the procedure.

After the surgery, other concerns arise. In the first days, some individuals feel ill, have nausea, and are afraid to eat to avoid having an upset stomach. Besides, bariatric surgery patients have to stick to a new diet, which includes limitations on what or how much to eat. In the first weeks, the technical advice and support of the nutritionist is very important. Our sample reported being anxious for not having enough knowledge about food and its nutritional value. While most of them were concerned about food calories before the surgery to avoid gaining weight, now their main concern is if they are having enough nutrients to nourish their bodies and have a healthy lifestyle.

The presence of other patients in the group is valuable in this stage. More experienced patients have already acquired the knowledge and experience to deal with food issues. They have tested several recipes, have a selection of restaurants that serve half portions or small portions, and are willing to share their findings with new patients.

The five interviewed women use the Whatsapp group more than three times a week. They find the support useful and want to be in touch with the bariatric team in a constant way. But they find some limitations: the group is very large (more than 340 patients, plus the health care team); therefore, some conversation threads get lost, there is confusion with some answers, and some members of the group make irrelevant comments or include jokes, photos, or messages that do not support the main goal of the group.

The surgeon also created a Facebook group to provide patients with new forms of support. Videos, food recipes, and photos are published on a daily base, allowing members of the community to easily find specific and useful content for their needs. Additionally in this Facebook group, the surgeon publishes photos of patients who have reached a milestone (i.e., a weight goal). These posts serve as motivators for new patients and provide an environment to receive applause and recognition when a milestone is accomplished. We found that positive comments and words of encouragement are important for bariatric surgery patients, especially for those who suffered from low self-esteem before the surgery or were victims of criticism and isolation for being overweight.

Even though the patients we interviewed affirm that the main reason for going into bariatric surgery was to improve their health, they acknowledge the psychological benefits of losing weight as well. They now feel more confident and attractive; feel free to use more fashionable clothes and lead an active social life.

Given the limitations of the large Whatsapp group, 15 female bariatric surgery patients living in the same city in the North of Mexico created a new and smaller group using Telegram, which allows them to encrypt their comments and have a more personal conversation with women who live in the same area and have access to similar gyms, restaurants, and other service facilities.

The five subjects of our study are active participants in this Telegram group. They join the conversation on a daily base to share advice, exchange recipes, encourage each other, and even setting dates to meet at the gym and exercise together. Participants in the study affirm that Telegram is easy to use, is very appealing because it allows private messages within the group, and is reliable and affordable.

In sum, the five bariatric surgery patients believe Telegram and Whatsapp offer them a window of opportunities to be in touch with a team of experts, that provide constant counseling that includes education, coping strategies, and adjustment advice to achieve and maintain a new lifestyle. In these groups, they feel cared and understood by their virtual friends—who in many cases, become real friends—the comments they receive are always positive and encouraging and allow them to face the anxiety and even the depression of being overweight.

#### **5.3. There is an app for that**

The market has a wide offer of technological devices that mounted on the wrist, ankle, or belt of the user track their physical activities, including sleep hours, steps taken, and stairs climbed. Other devices accurately monitor pulse, blood glucose, and stress levels. These wearable devices allow individuals to monitor their health and fitness on a daily basis and have the benefit of creating a dashboard that allows comparison, goal tracking, and even sharing the information with friends and health experts. Some of these devices can be used with specific apps to help users achieve specific health-related goals. There are apps designed for those who want to quit smoking, exercise more, eat healthy or monitor their sleep patterns and stressful moments, and many of them are were built following BE principles, allowing the provision of feedback, triggers, nudges, and rewards [15].

#### *5.3.1. The method*

To explore how individuals use wearable devices, smartphones, and apps we conducted five in-depth interviews with graduate students who are interested in doing physical activity and eating a healthy diet to achieve overall physical wellbeing. A semistructured questionnaire was designed to identify their behaviors, and we also asked them to share with us the information provided by the apps' dashboards and explain us the advantages of using those specific apps and wearable devices.

#### *5.3.2. The findings*

Even though the patients we interviewed affirm that the main reason for going into bariatric surgery was to improve their health, they acknowledge the psychological benefits of losing weight as well. They now feel more confident and attractive; feel free to use more fashionable

Given the limitations of the large Whatsapp group, 15 female bariatric surgery patients living in the same city in the North of Mexico created a new and smaller group using Telegram, which allows them to encrypt their comments and have a more personal conversation with women who live in the same area and have access to similar gyms, restaurants, and other

The five subjects of our study are active participants in this Telegram group. They join the conversation on a daily base to share advice, exchange recipes, encourage each other, and even setting dates to meet at the gym and exercise together. Participants in the study affirm that Telegram is easy to use, is very appealing because it allows private messages within the

In sum, the five bariatric surgery patients believe Telegram and Whatsapp offer them a window of opportunities to be in touch with a team of experts, that provide constant counseling that includes education, coping strategies, and adjustment advice to achieve and maintain a new lifestyle. In these groups, they feel cared and understood by their virtual friends—who in many cases, become real friends—the comments they receive are always positive and encouraging and allow them to face the anxiety and even the depression of

The market has a wide offer of technological devices that mounted on the wrist, ankle, or belt of the user track their physical activities, including sleep hours, steps taken, and stairs climbed. Other devices accurately monitor pulse, blood glucose, and stress levels. These wearable devices allow individuals to monitor their health and fitness on a daily basis and have the benefit of creating a dashboard that allows comparison, goal tracking, and even sharing the information with friends and health experts. Some of these devices can be used with specific apps to help users achieve specific health-related goals. There are apps designed for those who want to quit smoking, exercise more, eat healthy or monitor their sleep patterns and stressful moments, and many of them are were built following BE principles, allowing

To explore how individuals use wearable devices, smartphones, and apps we conducted five in-depth interviews with graduate students who are interested in doing physical activity and eating a healthy diet to achieve overall physical wellbeing. A semistructured questionnaire was designed to identify their behaviors, and we also asked them to share with us the information provided by the apps' dashboards and explain us the advantages of using those spe-

the provision of feedback, triggers, nudges, and rewards [15].

clothes and lead an active social life.

group, and is reliable and affordable.

service facilities.

122 Advances in Health Management

being overweight.

*5.3.1. The method*

cific apps and wearable devices.

**5.3. There is an app for that**

Participants in the study use branded apps (e.g., Nike running) and apps designed by private developers that are offered in the Android and Apple stores. It seems that the subjects of our study prefer apps built with specific scientific knowledge basis like the Transtheoretical Model of Change, which states that behavior change unfold through six different stages: precontemplation, contemplation, preparation, action, maintenance, and termination [28]. These types of apps were designed to acknowledge the typical problems an individual faces when trying to quit smoking or engaging into a healthy diet; therefore, as seen by users as a complete set of tools that will help them achieve and maintain the desired behavior.

The most preferred apps offer tools to create social groups, initiate challenges, provide virtual badges when the user reaches a milestone, and offer real-world rewards (such as cash and points to exchange for merchandise at selected stores) to increase engagement and provide external motivation. The apps offer clear dashboards that allow the users to visualize their goals, their achievements, and compare their results with other individuals, creating a friendly competition among users.

Our participants perceive that wearable devices and health-monitoring apps increase their self-efficacy to attain their goals. They appreciate the accurate feedback and the reminders and nudges that help them keep on track. Wearable devices have become an important item of their wardrobe and help them present a distinctive image in their social groups, letting them show their interests and hobbies with specific products such as a watch, a pair of sneakers, or a bracelet.

At the same time, most of the apps can be synchronized with SNS to share the dashboards' data with virtual friends. Sharing exercise information and earned badges affects feelings of connectedness among members of the SNS. This specific feature allows users to receive feedback from their peers, encouragement when they are running a race, and applause when they reach a milestone. For others, the posts serve as a reminder of their own goals and act as a form of pressure to keep going. App users believe the benefit of sharing information on SNS is mutual: they feel not only challenged by peers to achieve their goals but also perceive themselves as influencers setting a good example for their virtual friends to embrace healthier behaviors. We found that the interaction between apps, SNS, and members of a community provides psychological gratification in the form of network support and social incentives.
