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

Medicine 2.0: Social Media, Open, Participatory, Collaborative Medicine (1641) Participatory Medicine & E-Patients (773)

Published on in Vol 17, No 4 (2015): April

Exploring Women’s Beliefs and Perceptions About Healthy Eating Blogs: A Qualitative Study

Exploring Women’s Beliefs and Perceptions About Healthy Eating Blogs: A Qualitative Study

Exploring Women’s Beliefs and Perceptions About Healthy Eating Blogs: A Qualitative Study

Authors of this article:

Véronique Bissonnette-Maheux1 Author Orcid Image ;   Veronique Provencher1 Author Orcid Image ;   Annie Lapointe1 Author Orcid Image ;   Marilyn Dugrenier1 Author Orcid Image ;   Audrée-Anne Dumas1 Author Orcid Image ;   Pierre Pluye2 Author Orcid Image ;   Sharon Straus3, 4 Author Orcid Image ;   Marie-Pierre Gagnon5, 6 Author Orcid Image ;   Sophie Desroches1, 5 Author Orcid Image
Article Authors Cited by (47) Tweetations (61) Metrics

    Original Paper

    1Institute of Nutrition and Functional Foods, Laval University, Quebec, QC, Canada

    2Department of Family Medicine, McGill University, Montreal, QC, Canada

    3Department of Geriatric Medicine, Toronto University, Toronto, ON, Canada

    4Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

    5CHU de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Quebec, QC, Canada

    6Faculty of Nursing, Laval University, Quebec, QC, Canada

    Corresponding Author:

    Sophie Desroches, RD, PhD

    Institute of Nutrition and Functional Foods

    Laval University

    2440, Hochelaga boulevard

    Pavillon des services, office 2729-P

    Quebec, QC, G1V 0A6

    Canada

    Phone: 1 418 656 2131 ext 5564

    Fax:1 418 656 2131

    Email: sophie.desroches@fsaa.ulaval.ca


    Background: Chronic diseases are the leading cause of death (63%) worldwide. A key behavioral risk factor is unhealthy eating. New strategies must be identified and evaluated to improve dietary habits. Social media, such as blogs, represent a unique opportunity for improving knowledge translation in health care through interactive communication between health consumers and health professionals. Despite the proliferation of food and lifestyle blogs, no research has been devoted to understanding potential blog readers’ perceptions of healthy eating blogs written by dietitians.

    Objective: To identify women’s salient beliefs and perceptions regarding the use of healthy eating blogs written by dietitians promoting the improvement of their dietary habits.

    Methods: We conducted a qualitative study with female Internet users living in the Quebec City, QC, area with suboptimal dietary habits. First, the women explored 4 existing healthy eating blogs written in French by qualified dietitians. At a focus group 2-4 weeks later, they were asked to discuss their experience and perceptions. Focus group participants were grouped by age (18-34, 35-54, and 55-75 years) and by their use of social media (users/nonusers). Using a questionnaire based on the Theory of Planned Behavior, participants were asked to identify salient beliefs underlying their attitudes (advantages/disadvantages), subjective norms (what people important to them would think), and perceptions of control (facilitators/barriers) regarding the use of a healthy eating blog written by a dietitian to improve dietary habits. Discussion groups were audiotaped, transcribed verbatim, coded, and a deductive content analysis was performed independently by 2 individuals using the NVivo software (version 10).

    Results: All participants (N=33) were Caucasian women aged between 22 to 73 year. Main advantages perceived of using healthy eating blogs written by a dietitian were that they provided useful recipe ideas, improved lifestyle, were a credible source of information, and allowed interaction with a dietitian. Disadvantages included increased time spent on the Internet and guilt if recommendations were not followed. Important people who would approve were family, colleagues, and friends. Important people who could disapprove were family and doctors. Main facilitators were visually attractive blogs, receiving an email notification about new posts, and finding new information on the blog. Main barriers were too much text, advertising on the blog, and lack of time.

    Conclusions: The women in this study valued the credibility of healthy eating blogs written by dietitians and the contact with dietitians they provided. Identifying salient beliefs underlying women’s perceptions of using such blogs provides an empirically supported basis for the design of knowledge translation interventions to help prevent chronic diseases.

    J Med Internet Res 2015;17(4):e87

    doi:10.2196/jmir.3504

    Keywords

    blog; health behavior; nutrition; qualitative research; social media; knowledge translation 


    Background

    Chronic diseases are long-lasting diseases that can be controlled but not cured [1]. They are the leading cause of death (63%) worldwide [2]. In Canada, the proportion of people dying from chronic conditions in 2010 was 89% [2]. The World Health Organization has projected that chronic disease deaths will have increased by 15% globally between 2010 and 2020 [3]. Most countries cannot combat chronic disease with medical care alone: prevention is essential [4]. Healthy eating is recognized as a critical factor in preventing many chronic health conditions, including hypertension, diabetes, cardiovascular diseases, and obesity [5,6]. Food skills, including nutrition knowledge and cooking skills [7], appear to be key to improving eating habits [8] and can help reduce the prevalence of obesity and other chronic diseases in the population [9]. Health communication is an effective strategy for changing norms and beliefs about dietary behaviors, especially by promoting knowledge about appropriate dietary choices [10]. Registered dietitians (RDs) are health care professionals who are trained to transfer this knowledge.

    With the advent of Web 2.0, the Web has evolved toward greater simplicity and interactivity. Social media tools are increasingly being used for health communication [11-13], including to deliver health behavior change interventions [14-18], because they reach a large Internet population with diverse sociodemographic characteristics, independently of education, race/ethnicity, or health care access [19]. In the field of physical activity and nutrition, studies have shown promising results [20-26]. A recent literature review published in 2014 that included 22 randomized controlled trials found a significant decrease in dietary fat consumption with the use of social media promoting healthy diet and exercise in the general population [20]. Neuenschwander et al [27] and Bensley et al [28] found that Web-based nutrition education interventions can lead to favorable and effective changes in eating habits when compared with in-person nutrition education interventions. Although these studies show great potential for interventions that use the Internet, none of them included blogs. Blogs are discussion or information sites published by individuals or organizations on the Internet consisting of discrete entries, or posts, displayed in reverse chronological order (the most recent post appears first). Most blogs allow visitors to leave comments and message one another [29].

    Studies conducted on health blogs [30-36] and food blogs [37-40] have focused primarily on identifying why bloggers write the blogs and on their information content rather than on blog readers’ health behaviors and outcomes. In addition, the majority of these studies refer to food blogs written by lay people and not by RDs. Discerning users have to sift through thousands of blogs to find credible information because noncredible, erroneous, or even harmful health information is widely available and may be increasing eating disorder behaviors [35,36].

    To the best of our knowledge, no studies have examined users’ perceptions of healthy eating blogs written by RDs. They represent a unique opportunity for improving knowledge translation in nutrition through interactive communication between consumers and dietitians. However, to make use of blog technology to communicate healthy eating information, RDs must better understand how Internet users perceive healthy eating blogs written by qualified nutrition professionals.

    Healthy living blogs have been defined as personal webpages devoted to sharing an individual’s healthy lifestyle for the purpose of providing an example of “healthy living” to others [35]. There is no standard definition of a healthy eating blog written by an RD; therefore, for the purpose of this study, we defined it as an interactive webpage written by a dietitian promoting the overall improvement of dietary habits (not focused on a specific diet-related disease).

    The majority of food bloggers are women [37,39] and their readership is also mostly women who use blogs as an information source about food in general, recipes, or food preparation [41]. Although men also participate in meal preparation, women remain primarily responsible for food purchase and preparation in most households [42,43]. Consequently, health promotion strategies targeting women have the potential to impact not only women blog readers, but also their families.

    Purpose

    The objective of this qualitative study was to identify the salient beliefs and perceptions of female users/potential users of blogs with suboptimal dietary habits regarding their intention to use a healthy eating blog written by an RD promoting the overall improvement of dietary habits.

    Theoretical Framework

    A recent systematic review showed that Internet-based interventions developed using a theoretical foundation were more likely to predict behavior than atheoretical interventions [44]. Thus, to maximize the identification of beliefs related to the use of a healthy eating blog written by an RD, we based our focus group moderator’s guide and our qualitative analysis on the Theory of Planned Behavior (TPB), which identifies determinants of intention and behavior [45]. We chose this theory because several meta-analytic studies and systematic reviews have shown the strength of its constructs in predicting behavior in a wide variety of contexts [46,47], including healthy eating [48] and, more recently, the use of new Web 2.0 technologies [49-51]. In addition, studies on the adoption of new technologies have suggested a positive correlation between the perception of a blog’s usefulness and ease of use and the perceived attitude toward it [52,53].

    According to the TPB, intention to use a healthy eating blog written by an RD to improve dietary habits is determined by 3 factors (Figure 1): (1) behavioral beliefs, or underlying attitudes (advantages/disadvantages), toward the use of the blog; (2) normative beliefs, or underlying perceptions of whether important people in one’s life would approve or disapprove of the behavior; and (3) control beliefs, or underlying perception of facilitators and barriers to adopting the behavior. Thus, someone will be more inclined to use a healthy eating blog written by an RD to improve his/her dietary habits if he/she perceives more advantages and facilitators than disadvantages and barriers for doing so, and if people who are important to him/her would approve rather than disapprove of the behavior. Developing this knowledge base of beliefs underlying Internet users’ attitudes, subjective norms, and perceptions of control regarding healthy eating blogs written by an RD as a means to improve dietary habits will contribute to a better understanding of factors related to the intentions to use and use of these blogs that can contribute to the development of nutritional interventions.

    ‎
    Figure 1. Ajzen’s Theory of Planned Behavior [45].
    View this figure

    Participants and Recruitment

    We sought female participants with suboptimal dietary habits who were users or potential users of healthy eating blogs. Participants were recruited using the mailing list of the Institute on Nutrition and Functional Foods at Laval University, Quebec, QC, and ads in local newspapers. A total of 57 women responded to our recruitment call, among whom 5 did not meet our inclusion criteria and 19 were no longer interested after they received full information about the nature of their participation. Inclusion criteria were (1) to be a woman living in the Quebec City metropolitan area aged ≥18 years, (2) to have access to the Internet, (3) to use the Internet more than once a week, and (4) to consume 5 or less portions of fruit or vegetables per day (an RD assessed participant’s fruit and vegetable consumption over the past 24 hours). Fruit and vegetable consumption is considered a good predictor of overall diet quality [54]. Participants received no honorarium and all gave written informed consent. This project was approved by the Ethics Committee of Laval University (2012-204 A-1/18-03-2013).

    Data Collection Procedure

    Participants were first interviewed individually and then invited to participate in 1 of 6 focus groups. The focus groups included 4 to 6 women each and were conducted between April and June 2013, 2 to 4 weeks following the individual interview. All focus groups were audiotaped and transcribed verbatim.

    During the individual interview, the 33 women were first invited to complete an online sociodemographic questionnaire including 29 questions about their Internet use; the frequency with which they surfed the Internet, read, or commented on blogs; and if they ever looked for nutritional information online. Questionnaires were validated with 8 women to confirm the clarity of the questions prior to this study. Then, semistructured individual interviews were conducted face-to-face with a research coordinator and scheduled to last approximately 1 hour. This face-to-face interview was devoted to the exploration of 4 popular blogs written in French by RDs that promoted healthy eating. The 4 blogs were the same for all the participants and were chosen before the interview. To identify the 4 blogs, we used the Google search engine and typed the following French keywords: blog, blogue and nutritionniste or diététiste (dietitian). Blogs were included if they met the following criteria: (1) written in French by a Canadian RD, (2) targeted human nutrition as the unique topic, (3) had as its main objective the overall promotion of a healthy diet (ie, did not focus on a specific diet-related disease), and (4) was proactive (ie, had published a new post at least once a month since the creation of the blog and had published a minimum of 12 posts). During the interview, participants were asked their perceptions about design features and nutritional content of those 4 blogs to explore different facets characterizing existent healthy eating blogs written by dietitians. Because some women were not frequent users of blogs or other social media, the primary goal of the interview was to prepare the women to discuss their perceptions of healthy eating blogs written by an RD at the subsequent focus group.

    Between 2 and 4 weeks after the individual interviews, the 33 women were invited to participate in a focus group of 90 minutes moderated by a trained research coordinator and an assistant (VBM). The moderator used a semistructured interview to ask participants questions about their perceptions of consulting healthy eating blogs written by RDs to promote improvement of dietary habits, and the assistant took notes during the discussion. The procedure and interview guide were based on Patton’s recommendations [55]. The standardized open-ended interview questionnaire was developed according to the 3 constructs of the TPB. Questions aimed to identify the salient beliefs underlying their attitudes (advantages/disadvantages), subjective norms (approval or disapproval of important others), and perception of control (facilitators/barriers) with regard to the use of blogs written by RDs promoting improvement of dietary habits, such as those they had encountered during the individual interviews. All women in each focus group were asked the same questions in the same order to increase comparability of responses. The interview guide was validated with a focus group of 6 women before conducting the experimental focus groups [55].

    Six focus groups (4 to 6 women in each focus group) were needed to achieve theoretical saturation [56]. To determine saturation, we calculated the extent to which different focus groups mentioned the same themes. By the end of the fifth focus group, 98.6% of themes had been mentioned at least once; the remaining 1.4% of themes were only mentioned in the sixth focus group. Participants were grouped by age and by their use of social media (Facebook, Twitter, or blogs) to increase homogeneity and better describe population subgroups as per recommendations by Patton and collaborators [55]. Two focus groups included women aged between 18 and 34 years who used social media, 2 focus groups included women between 35 and 54 years who used social media, and 2 focus groups included women older than 55 years who did not use social media on a regular basis.

    Data Analysis

    Descriptive statistics and mean ± SD were used to analyze all quantitative data from the online sociodemographic questionnaire using the SAS version 9.3 (SAS Institute, Inc, Cary, NC, USA). The steps of the deductive content analysis described by Elo et al [57] inspired the content analysis of the focus groups, which were transcribed verbatim. Quotes were coded line by line to bring out the main salient beliefs according to the construct of the TPB: behavioral beliefs, normative beliefs, and control beliefs (Figure 1). Two coders (VBM and MD) performed the coding with NVivo version 10 (QSR International, Cambridge, MA, USA) independently and then compared themes to reach consensus on the terminology to be used for each. A third person (AAD) validated the resulting categories and was available to resolve any discrepancies. For the purpose of our study, all beliefs that emerged in at least 2 groups of 6 (33%) were considered salient beliefs [58]. If the same belief was named by several participants in the same group, it was considered a single belief. Finally, categories obtained for groups according to participants’ age were compared to see if any age-related differences in salient beliefs emerged.


    Of the 33 women who participated in the individual interviews, 29 also participated in 1 of the focus groups. The 4 women who did not complete the project mentioned lack of time or unforeseen personal circumstances on the date scheduled for the focus group. All participants were Caucasian females between 22 and 73 years of age, most were fairly highly educated and of above-average income (Table 1). Of the 33 women, 25 (76%) had consulted a blog before, but only 3 spent more than 10 hours a week on the Internet (Table 2). Yet the majority identified the Internet as their principal source of information about health, nutrition, and recipes (Figure 2).

    Results of the analysis of the 6 focus groups are presented in Table 3, showing the women’s salient beliefs reported in each category and the frequency of mentions according to age group. Select quotes presented subsequently illustrate our key findings. Quotes were originally in French and have been translated by a professional translator.

    Table 1. Sociodemographic characteristics of the 33 participants.
    CharacteristicsParticipants
    Age (years), mean (SD)44 (17)
    Ethnicity, n (%)

    		Caucasian33 (100)
    Highest level of education completed, n (%)

    		Primary1 (3)

    		High school3 (9)

    		College13 (39)

    		University16 (48)
    Family income (Can $), n (%)

    		0-19,9994 (12)

    		20,000-49,99910 (30)

    		50,000-99,9998 (24)

    		100,000-149,9994 (12)

    		150,000-199,9995 (15)

    		≥200,0000 (0)

    		Unknown2 (6)
    Table 2. Internet use characteristics of the 33 participants.
    Internet characteristicsn (%)
    Time spent on Internet for leisure

    		1-3 hours/week13 (39)

    		3-5 hours/week6 (18)

    		5-10 hours/week11 (33)

    		≥10 hours/week3 (9)
    Read a blog before25 (76)
    Read a blog on nutrition beforea16 (64)
    Read comments on a blog beforea18 (72)
    Commented on a blog beforea2 (8)

    aOnly among participants who had already read a blog before (n=25).

    Table 3. Salient beliefs associated with the use of a healthy eating blog.
    Salient beliefsFrequency of groups, n (n=6)Frequency of mentions by age (years), n


    		18-34 (n=2)35-54 (n=2)55-75 (n=2)
    Behavioral beliefs-perceived advantage




    		Gives recipe ideas5221

    		Helps improve diet-related lifestyle4112

    		Promotes interaction with the dietitian4202

    		Interesting to have the opinion of fellow blog readers3120

    		Introduces to new foods3102

    		Introduces to new trends in nutrition3111

    		Allows to learn more about nutrition in general3021

    		Credible information3102

    		Allows to have the opinion of a dietitian2011
    Behavioral beliefs-perceived disadvantages




    		Opinion of only 1 blogger (if only 1 blogger is followed)2200

    		Increases time spent on the Internet2110

    		Nonrelevant comments from blog readers2110

    		Feeling of guilt if one does not follow dietary advice given on the blog2110
    Normative beliefs-approval




    		Family5212

    		Colleagues5221

    		Friends4211

    		Physicians2002

    		Neighbors2011
    Normative beliefs-disapproval




    		Family4220

    		Physicians3012

    		Friends2101

    		Colleagues2110
    Control beliefs-facilitators




    		Visually attractive blog6222

    		Email to inform of a newly published posts5122

    		New information weekly (updated weekly)5122

    		Well-designed for quick access to desired information4022

    		Interesting and entertaining posts4220

    		Quick access to the blog3201

    		Well written, concise info3111

    		Written by a personality3111

    		Notification through Facebook to inform of a newly published posts3210

    		Presence of recipes3120

    		Contains complete information3120

    		Popular blog, referred by someone3111

    		Text well-structured in paragraphs with subtitles3021

    		Availability of nutritional value of the recipes2110

    		Opportunity to read other readers’ comments and to link with them2110

    		Possibility to ask questions, interactivity2011

    		Easy to understand, not too scientific2011

    		Narrative approach2020

    		Posts about novel foods, trends2110
    Control beliefs-barriers




    		Posts too long to read5122

    		Presence of advertising5122

    		Smaller font size4121

    		Conflict of interests, promotion of commercial products by blogger4121

    		Lack of new information, too repetitive4112

    		Lack of time4112

    		Poorly structured, complicated site4121

    		Notifications too frequent4211

    		More negative than positive posts3111

    		Visually unattractive3021

    		Computer issues (eg, slow)2101

    		Information not available, not accessible2011

    		Credibility: can be written by anyone, not always true2110

    		If it is not professional, poor writing2020
    ‎
    Figure 2. Information sources for information on health, nutrition, and recipes.
    View this figure

    Behavioral Beliefs: Perceived Advantages and Disadvantages

    The most frequently cited advantages women perceived to consulting a healthy eating blog by an RD were that it gives recipe ideas (5/6 groups, 83%), helps improve diet-related lifestyle (4/6 groups, 67%), and promotes interaction with a dietitian (4/6 groups, 67%):

    What’s useful with following a blog is if you can comment, you create a link with the nutritionist and you can follow her, and so there’s a connection that builds up.
    [group #3, participant 21]

    Numerous participants aged 35 years and older considered healthy eating blogs as a tool for learning more about nutrition in general (3/4 groups, 75%):

    I mean food is such a huge topic, it’s impossible to know everything about it, so you can go and look at what you like [on the blog] and that leads you on to new ideas for trying new things out. (group #1, participant 3)

    The 4 most cited disadvantages were having the opinion of only 1 dietitian-blogger (if only 1 blog was followed) (2/6 groups, 33%), increased time spent on the Internet (2/6 groups, 33%), irrelevant comments from other readers on the blog (2/6 groups, 33%), and guilt arising from not complying with the dietary recommendations on the blog (2/6 groups, 33%):

    If you’re working...sometimes, I don’t even have time to stop and eat at work, or whatever. So then, I go look at it [the blog], and there are some great recipes. I don’t have time to go grocery shopping, I don’t have time to make them. And then, ah, I’m so discouraged
    [group #3, participant 20]

    Although groups comprised of women ≥55 years mentioned few disadvantages (n=2) of consulting a healthy eating blog by an RD, each was only mentioned in 1 group.

    Normative Beliefs: Approval and Disapproval

    Participants identified many individuals they believed would approve of them reading a blog to improve their dietary habits. Among them, family (5/6 groups, 83%), colleagues (5/6 groups, 83%), and friends (4/6 groups, 67%) were most frequently mentioned as normative referents. Interestingly, most participants (4/6 groups, 67%) considered reading and interacting with a blog as a personal or a private action, so it was unclear to them (and perhaps irrelevant) whether people would approve or disapprove:

    The things I go and look at on the Internet, they’re also personal. I’m not the type to go talking about everything I do. So it’s not likely that I’ll know if people around me are against it—I keep it to myself. If I’m interested in nutrition, in going on blogs, that’s my business, it’s not anyone else’s.
    [group #5, participant 33]

    Almost all groups (5/6 groups, 83%) reported that it was difficult to be against healthy eating considering that it is an inoffensive subject. However, some participants identified their family (4/6 groups, 67%) and physicians (3/6 groups, 50%) as the persons most likely to disapprove of their use of blogs to improve dietary behaviors, perhaps because of erroneous or harmful information that can be found on health blogs:

    My doctor already warned me, because I’ve told her twice that I go on it. She said for sure there are some good things, but she said to be careful. She meant that not everything out there is good.
    [group #2, participant 2]

    Control Beliefs: Facilitators and Barriers

    All groups mentioned that visual characteristics of the blog were important facilitators:

    An attractive site, that helps too. When it’s just text with no pictures, it’s heavy. I’m very...I like it when it’s simple, very visual, that makes me want to go look at it.
    [group #3, participant 29]

    Most women said that facilitators were receiving an email notifying them of a new post published on the blog (5/6 groups, 83%) and having new content or new information each week (5/6 groups, 83%):

    It shouldn’t always repeat the same thing. You can get tired of it, you know. It has to be a little different ... for example, every week something new that will make us want to go check it out
    [group #2, participant 2]

    Interesting and entertaining posts as well as well-designed blogs allowing quick access to the desired information were also identified frequently as facilitators (4/6 groups, 67%).

    In contrast, the most often reported barriers to consulting a healthy eating blog by an RD were posts being too long (5/6 groups, 83%), presence of advertising (5/6 groups, 83%), bloggers being in conflict of interest by promoting products on their blog (4/6 groups, 67%), and lack of time (4/6 groups, 67%).

    Lack of new information, repetitive posts, small font sizes, or badly structured sites were also considered barriers to using a blog by most women (4/6 groups, 67%). Finally, receiving notifications of new posts too often was also identified as a barrier (4/6 groups, 67%):

    If it’s irritating, if someone or something doesn’t stop bugging me, I’m gonna go, like, ok, this is junk mail.
    [group #3, participant 8]

    Principal Findings

    Our objective in conducting this qualitative study was to better understand women’s perceptions toward healthy eating blogs written by RDs as a tool to improve their dietary habits. Identifying the salient beliefs underlying women’s attitudes, subjective norms, and perceptions of control have important implications for developing interventions to prevent diet-related chronic diseases, including helping dietitians to design user-friendly and relevant healthy eating blogs to improve dietary habits and to assess their efficacy. Many of our results can be read as clear design guidelines regarding details such as blog length, website structure, email notifications, and visual attractiveness. In addition, we believe the following 5 points are worthy of further discussion.

    First, results of our study show that healthy eating blogs written by RDs may be an important nutritional knowledge translation tool for preventing chronic disease. The women perceived numerous advantages, including increased knowledge about new foods, nutrition trends, healthy recipes, and knowledge about nutrition in general, and they identified few disadvantages. This is coherent with findings by Edwards et al [59] who reported that among chronic disease patients, the most important constructs related to interest in use of technology to provide health care remotely were (1) confidence in using it and (2) perceiving greater advantages and fewer disadvantages.

    Second, the credibility of the blogger and the information found on blogs were not barriers mentioned frequently by participants in our study. Given that many studies have found that credibility is a concern frequently mentioned by users searching for health information on social media [60,61], this suggests that the fact that the blogs in our study were written by RDs made a difference to the participants’ confidence in them. This suggestion is upheld by Greenberg et al [57] who reported that blogs written by experts are perceived as being more credible than personal blogs. However, the extent to which food blogs not written by accredited health care professionals such as dietitians contain erroneous information remains to be studied. In a recent survey of 679 food bloggers, 87% said they were writing a blog primarily because of their passion for food and only 22% had a work history relating to food (not necessarily dietitians) [62]. The credibility of information found on blogs is thus an important concern not only for health care providers, but also for consumers of healthy eating blogs and suggests that there might be an important role for dietitians in designing interventions that will be of interest to consumers.

    Third, an interesting feature of blogs as potential tools for promoting better health is their interactive nature [63]. Many women in our study perceived that interacting with others, including the other blog users but especially with an expert dietitian-blogger, was one of the chief advantages of consulting healthy eating blogs written by RDs. Recent studies have shown that increased interaction, shared information, and peer support are key benefits to using social media for health communication [52,53]. In contexts where the health care system provides limited access to live health care professionals, this feature may be especially attractive to potential users.

    Fourth, our results show that healthy eating blogs written by a dietitian may not yet be the media of choice for translating nutritional knowledge to older women. First, although they cited few disadvantages (determinant of attitude), they mentioned several barriers (determinant of perceived control), suggesting that their issues with blogs were more in the domain of perceived capacity. Also, the features they appreciated, such as email notifications about new posts rather than a notification through Facebook for instance, suggest that these women may be more comfortable with email than with more recent interactive communication technologies (eg, Facebook). In our study, the nutrition-related content of the post (eg, recipes, quality of information) seemed more important for young women, whereas the site design (structure of the blog and the posts) seemed more important for older women. According to Chou and collaborators [19], age is the greatest predictor of the use of social media, with a lower penetration in the older population aged 55 years and older. However, studies also suggest that this phenomenon is changing. According to a recent Pew Internet survey, 50% of respondents aged 50-64 years reported using social media in 2012 compared to approximately 15% in 2008 [64]. Designers should include users of all ages in the process of developing different knowledge translation strategies.

    Finally, our results raise the theoretical question of the use of the unmodified TPB for examining predictors of intention for using social media, particularly the relevance of the subjective norm construct. Women in our study considered that consulting a healthy eating blog by an RD to improve their dietary habits was a personal and individual action that did not necessarily require approval from others. Several cognitive behavior models that account for technology acceptance have been explored in the quest for a “unified theory” that may provide fruitful avenues for modifying or adding to the TPB in future studies of the experiences of potential users of healthy eating blogs written by RDs with a view to developing effective interventions for chronic disease prevention [51,52].

    Limitations

    Godin et al [58] suggest that a sample of 25-30 participants is appropriate to highlight salient beliefs of a population, the participants in our study were all Caucasians, mostly educated above high school level (college and university), and had a relatively high family salary income; therefore, they are not fully representative of the general population. Second, this was an experimental and not a natural setting. However, as we wished to reach potential users as well as users, we were obliged to introduce potential users to blogs. In addition, we exercised control over the setting because we were exploring blogs specifically written by dietitians.

    Conclusion and Implications for Health Care

    As the interest for the use of social media, such as blogs, in the population is growing, there is an urgent need to assess their impact on health outcomes. Research in blogging as a potential tool for knowledge translation in health is in its infancy and much work remains to be done before we can determine its effectiveness for improving healthy eating. Our study identified the perceptions of female Internet users with regard to their use of healthy eating blogs written by RDs. Our results can help design interventions that address attitudes, facilitators, and barriers in developing theory-based dietary behavior change interventions with a view to preventing diet-related chronic diseases.

    Acknowledgments

    We would like to thank the participants of this study for their time, Mylène Turcotte for moderating the focus groups and for her guidance during the qualitative analysis of the results, and Louisa Blair for editing this paper. We also want to express our gratitude to Knowledge Translation Canada for their financial support.

    Authors' Contributions

    VBM wrote a first draft of this paper. SD, PP, VP, MPG, and SS designed the study. AL, MD, and AAD contributed to the transcriptions and content analysis of the focus groups with VBM. All authors have reviewed and accepted the manuscript. VBM and AL performed the individual interviews and took field notes during the focus groups.

    Conflicts of Interest

    None declared.

    1. The Center for Managing Chronic Disease. What is chronic disease?   URL: http://cmcd.sph.umich.edu/what-is-chronic-disease.html [accessed 2015-03-23] [WebCite Cache]
    2. World Health Organization. Noncommunicable diseases country profiles 2011. Geneva: World Health Organization; 2011.   URL: http://whqlibdoc.who.int/publications/2011/9789241502283_eng.pdf [accessed 2014-04-22] [WebCite Cache]
    3. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: World Health Organization; 2011.   URL: http://www.who.int/nmh/publications/ncd_report_full_en.pdf [accessed 2014-04-22] [WebCite Cache]
    4. Elmslie K. Against the Growing Burden of Disease. Ottawa, ON: Public Health Agency of Canada; 2012.   URL: http://www.ccgh-csih.ca/assets/Elmslie.pdf [WebCite Cache]
    5. Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008 Jan;31 Suppl 1:S61-S78. [CrossRef] [Medline]
    6. Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases. Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser 2003;916:i-viii, 1. [Medline]
    7. Region of Waterloo Public Health. Food Skills of Waterloo Region Adults. 2010 Jan.   URL: http://chd.region.waterloo.on.ca/en/researchresourcespublications/resources/foodskills.Pdf [accessed 2014-11-12] [WebCite Cache]
    8. Shaikh AR, Yaroch AL, Nebeling L, Yeh MC, Resnicow K. Psychosocial predictors of fruit and vegetable consumption in adults a review of the literature. Am J Prev Med 2008 Jun;34(6):535-543. [CrossRef] [Medline]
    9. Public Health Agency of Canada. 2012. Curbing childhood obesity: A federal, provincial and territorial framework for action to promote healthy weights   URL: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/framework-cadre/ [accessed 2014-11-12] [WebCite Cache]
    10. Viswanath K, Bond K. Social determinants and nutrition: reflections on the role of communication. J Nutr Educ Behav 2007;39(2 Suppl):S20-S24. [CrossRef] [Medline]
    11. Smith A. Older adults and technology use. Washington, DC: Pew Internet & American Life Project; 2014 Apr 03.   URL: http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use/ [accessed 2014-04-23] [WebCite Cache]
    12. Fox S, Duggan M. Health Online 2013. Washington, DC: Pew Internet & American Life Project; 2013 Jan 15.   URL: http://www.pewinternet.org/2013/01/15/health-online-2013/ [WebCite Cache]
    13. Fox S. The Social Life of Health Information, 2011. Washington, DC: Pew Internet & American Life Project; 2011 May 12.   URL: http://www.pewinternet.org/2011/05/12/the-social-life-of-health-information-2011/ [accessed 2014-04-22] [WebCite Cache]
    14. Rosser BA, Vowles KE, Keogh E, Eccleston C, Mountain GA. Technologically-assisted behaviour change: a systematic review of studies of novel technologies for the management of chronic illness. J Telemed Telecare 2009;15(7):327-338. [CrossRef] [Medline]
    15. Kerr C, Murray E, Noble L, Morris R, Bottomley C, Stevenson F, et al. The potential of Web-based interventions for heart disease self-management: a mixed methods investigation. J Med Internet Res 2010;12(4):e56 [FREE Full text] [CrossRef] [Medline]
    16. Wantland DJ, Portillo CJ, Holzemer WL, Slaughter R, McGhee EM. The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes. J Med Internet Res 2004 Nov 10;6(4):e40 [FREE Full text] [CrossRef] [Medline]
    17. Springvloet L, Lechner L, Oenema A. Planned development and evaluation protocol of two versions of a web-based computer-tailored nutrition education intervention aimed at adults, including cognitive and environmental feedback. BMC Public Health 2014;14:47 [FREE Full text] [CrossRef] [Medline]
    18. Laranjo L, Arguel A, Neves AL, Gallagher AM, Kaplan R, Mortimer N, et al. The influence of social networking sites on health behavior change: a systematic review and meta-analysis. J Am Med Inform Assoc 2015 Jan;22(1):243-256. [CrossRef] [Medline]
    19. Chou WS, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the United States: implications for health communication. J Med Internet Res 2009;11(4):e48 [FREE Full text] [CrossRef] [Medline]
    20. Williams G, Hamm MP, Shulhan J, Vandermeer B, Hartling L. Social media interventions for diet and exercise behaviours: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2014;4(2):e003926 [FREE Full text] [CrossRef] [Medline]
    21. Maher CA, Lewis LK, Ferrar K, Marshall S, De BI, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res 2014;16(2):e40 [FREE Full text] [CrossRef] [Medline]
    22. Anderson-Bill ES, Winett RA, Wojcik JR, Winett SG. Web-based guide to health: relationship of theoretical variables to change in physical activity, nutrition and weight at 16-months. J Med Internet Res 2011;13(1):e27 [FREE Full text] [CrossRef] [Medline]
    23. Neville LM, O'Hara B, Milat AJ. Computer-tailored dietary behaviour change interventions: a systematic review. Health Educ Res 2009 Aug;24(4):699-720 [FREE Full text] [CrossRef] [Medline]
    24. Norman GJ, Zabinski MF, Adams MA, Rosenberg DE, Yaroch AL, Atienza AA. A review of eHealth interventions for physical activity and dietary behavior change. Am J Prev Med 2007 Oct;33(4):336-345 [FREE Full text] [CrossRef] [Medline]
    25. Kroeze W, Werkman A, Brug J. A systematic review of randomized trials on the effectiveness of computer-tailored education on physical activity and dietary behaviors. Ann Behav Med 2006 Jun;31(3):205-223. [CrossRef] [Medline]
    26. Broekhuizen K, Kroeze W, van Poppel MNM, Oenema A, Brug J. A systematic review of randomized controlled trials on the effectiveness of computer-tailored physical activity and dietary behavior promotion programs: an update. Ann Behav Med 2012 Oct;44(2):259-286 [FREE Full text] [CrossRef] [Medline]
    27. Neuenschwander LM, Abbott A, Mobley AR. Comparison of a web-based vs in-person nutrition education program for low-income adults. J Acad Nutr Diet 2013 Jan;113(1):120-126. [CrossRef] [Medline]
    28. Bensley RJ, Anderson JV, Brusk JJ, Mercer N, Rivas J. Impact of internet vs traditional Special Supplemental Nutrition Program for Women, Infants, and Children nutrition education on fruit and vegetable intake. J Am Diet Assoc 2011 May;111(5):749-755. [CrossRef] [Medline]
    29. Wikipedia. Blog   URL: http://en.wikipedia.org/wiki/Blog [accessed 2015-03-23] [WebCite Cache]
    30. Lagu T, Kaufman EJ, Asch DA, Armstrong K. Content of weblogs written by health professionals. J Gen Intern Med 2008 Oct;23(10):1642-1646 [FREE Full text] [CrossRef] [Medline]
    31. Buis LR, Carpenter S. Health and medical blog content and its relationships with blogger credentials and blog host. Health Commun 2009 Dec;24(8):703-710. [CrossRef] [Medline]
    32. Denecke K, Nejdl W. How valuable is medical social media data? Content analysis of the medical web. Information Sciences 2009 May 30;179(12):1870-1880. [CrossRef]
    33. Miller EA, Pole A. Diagnosis blog: checking up on health blogs in the blogosphere. Am J Public Health 2010 Aug;100(8):1514-1519. [CrossRef] [Medline]
    34. Della LJ, Griffin DB, Eroğlu D, Bernhardt JM, Wells RR. Is there health out there in the afrosphere? An analysis of health-related content posted by black bloggers. Health Mark Q 2013;30(1):1-18. [CrossRef] [Medline]
    35. Boepple L, Thompson JK. A content analysis of healthy living blogs: evidence of content thematically consistent with dysfunctional eating attitudes and behaviors. Int J Eat Disord 2014 May;47(4):362-367. [CrossRef] [Medline]
    36. Gies J, Martino S. Uncovering ED: a qualitative analysis of personal blogs managed by individuals with eating disorders. The Qualitative Report 2014;19(57):1-15.
    37. Lynch M. Healthy habits or damaging diets: an exploratory study of a food blogging community. Ecol Food Nutr 2010;49(4):316-335. [CrossRef] [Medline]
    38. Cox AM, Blake MK. Information and food blogging as serious leisure. Aslib Proceedings 2011 Mar 22;63(2/3):204-220. [CrossRef]
    39. Simunaniemi AM, Sandberg H, Andersson A, Nydahl M. Laypeople blog about fruit and vegetables for self-expression and dietary influence. Health Commun 2011 Oct;26(7):621-630. [CrossRef] [Medline]
    40. Lynch M. From food to fuel: perceptions of exercise and food in a community of food bloggers. Health Education Journal 2010 Nov 18;71(1):72-79. [CrossRef]
    41. Wright S, Camahort E. slideshare. 2009. 2009 Women and Social Media Study, by BlogHer, iVillage and Compass Partners   URL: http:/​/fr.​slideshare.net/​LisaStone/​2009-women-and-social-media-study-by-blogher-ivillage-and-compass-partners [accessed 2014-04-23] [WebCite Cache]
    42. Lake AA, Hyland RM, Mathers JC, Rugg‐Gunn AJ, Wood CE, Adamson AJ. Food shopping and preparation among the 30‐somethings: whose job is it? (The ASH30 study). British Food Journal 2006 Jun;108(6):475-486. [CrossRef]
    43. Flagg LA, Sen B, Kilgore M, Locher JL. The influence of gender, age, education and household size on meal preparation and food shopping responsibilities. Public Health Nutr 2014 Sep;17(9):2061-2070 [FREE Full text] [CrossRef] [Medline]
    44. Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12(1):e4 [FREE Full text] [CrossRef] [Medline]
    45. Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes 1991 Dec;50(2):179-211. [CrossRef]
    46. Kim M, Hunter JE. Relationships among attitudes, behavioral intentions, and behavior: a meta-analysis of past research, part 2. Communication Research 1993 Jun 01;20(3):331-364 [FREE Full text] [CrossRef]
    47. Webb TL, Sheeran P. Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychol Bull 2006 Mar;132(2):249-268. [CrossRef] [Medline]
    48. Conner M, Norman P, Bell R. The theory of planned behavior and healthy eating. Health Psychol 2002 Mar;21(2):194-201. [Medline]
    49. Lau ASM. Hospital-based nurses' perceptions of the adoption of Web 2.0 tools for knowledge sharing, learning, social interaction and the production of collective intelligence. J Med Internet Res 2011;13(4):e92 [FREE Full text] [CrossRef] [Medline]
    50. Fleming ML, Barner JC, Brown CM, Shepherd MD, Strassels S, Novak S. Using the theory of planned behavior to examine pharmacists' intention to utilize a prescription drug monitoring program database. Res Social Adm Pharm 2014;10(2):285-296. [CrossRef] [Medline]
    51. Pelling EL, White KM. The theory of planned behavior applied to young people's use of social networking Web sites. Cyberpsychol Behav 2009 Dec;12(6):755-759. [CrossRef] [Medline]
    52. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: Toward a unified view. MIS Quarterly 2003;27(3):425-478.
    53. Cohen S. Social relationships and health. Am Psychol 2004 Nov;59(8):676-684. [CrossRef] [Medline]
    54. Garriguet D. Statistics Canada. 2009. Diet quality in Canada   URL: http://www.statcan.gc.ca/pub/82-003-x/2009003/article/10914-eng.pdf [accessed 2015-03-23] [WebCite Cache]
    55. Patton MQ. Qualitative Research and Evaluation Methods, 3rd ed. Thousand Oaks, CA: Sage Publications; 2002.
    56. Morse JM. The significance of saturation. Qualitative Health Research 1995 May 01;5(2):147-149. [CrossRef]
    57. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs 2008 Apr;62(1):107-115. [CrossRef] [Medline]
    58. Godin G. Les comportements dans le domaine de la santé, first ed. Montreal, QC: Les presses de l'Université de Montréal; 2012.
    59. Edwards L, Thomas C, Gregory A, Yardley L, O'Cathain A, Montgomery AA, et al. Are people with chronic diseases interested in using telehealth? A cross-sectional postal survey. J Med Internet Res 2014;16(5):e123 [FREE Full text] [CrossRef] [Medline]
    60. Antheunis ML, Tates K, Nieboer TE. Patients' and health professionals' use of social media in health care: motives, barriers and expectations. Patient Educ Couns 2013 Sep;92(3):426-431. [CrossRef] [Medline]
    61. Greenberg S, Yaari E, Bar‐Ilan J. Perceived credibility of blogs on the internet – the influence of age on the extent of criticism. Aslib Proceedings 2013 Jan;65(1):4-18. [CrossRef]
    62. Wetherell S. Foodista. 2013 May 29. Results of the 2013 State of Food Blogging Survey   URL: http://www.foodista.com/blog/2013/05/29/results-of-the-2013-state-of-food-blogging-survey [accessed 2014-11-12] [WebCite Cache]
    63. Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res 2013;15(4):e85. [Medline]
    64. Zickuhr K, Madden M. Older adults and internet use. Washington, DC: Pew Internet & American Life Project; 2012 Jun 06.   URL: http://www.pewinternet.org/2012/06/06/older-adults-and-internet-use/ [accessed 2014-04-23] [WebCite Cache]

    ‎
    RD: registered dietitian
    TPB: Theory of Planned Behavior

    Edited by G Eysenbach; submitted 30.04.14; peer-reviewed by M Lynch, B Walters; comments to author 23.09.14; revised version received 15.12.14; accepted 03.02.15; published 08.04.15

    Copyright

    ©Véronique Bissonnette-Maheux, Veronique Provencher, Annie Lapointe, Marilyn Dugrenier, Audrée-Anne Dumas, Pierre Pluye, Sharon Straus, Marie-Pierre Gagnon, Sophie Desroches. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.04.2015.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.