Computers in Human Behavior 29 (2013) 559562

Contents lists available at SciVerse ScienceDirect

Computers in Human Behavior

journal homepage: www.elsevier.com/locate/comphumbeh

Facebook-based stress management resources for rst-year medical students: A multi-method evaluation
Daniel R. George a,, Cheryl Dellasega b, Megan M. Whitehead a, Alan Bordon c
a

Department of Humanities, Penn State Hershey College of Medicine, USA Humanities and Womens Health, Penn State Hershey College of Medicine, USA c MS II, Penn State Hershey College of Medicine, USA
b

a r t i c l e

i n f o

a b s t r a c t
Student anxiety and doubt about academic performance in the early years of medical school have been well documented. Stress management programs can be helpful but are challenged by shortages of time, personnel, and resources. Therefore, popular online social networks such as Facebook may offer an innovative strategy for addressing student stress and supporting coping. This pilot study explored whether rst-year medical students could benet from a stress management intervention based exclusively on Facebook. During orientation week at Penn State College of Medicine, participants were randomly assigned to a Facebook stress management group that addressed problematic issues during the rst semester. The intervention took place during the rst eleven weeks of medical school. A multi-method evaluation of the intervention was completed using descriptive statistics for demographics and frequencies and qualitative procedures for focus group data. The accessibility and ease of use of a Facebook-based stress management program proved valuable for medical students, particularly early in the semester when engagement was greatest. These preliminary results suggest that medical schools might consider adding an online social networking component to existing stress management programming. This online strategy may also be of benet to other health professionals and students from other health disciplines. 2012 Elsevier Ltd. All rights reserved.

Article history: Available online 16 January 2013 Keywords: Medical education Social media Stress management Social network Communication Technology

1. Introduction Stress and depression are major problems for medical students (Aktekin et al., 2001; Inam, Saqib, & Alam, 2003; Lubitz & Nguyen, 1996) and can adversely impact learning (Elnicki, 2010), coping (i.e., alcoholism and drugs) (Delnevo, Abatemarco, & Gotsch, 1996; Dunn, Iglewicz, & Moutier, 2008), self-care habits (Hull, DiLalla, & Dorsey, 2008), and later, professional mental health (Dahlin, Joneborg, & Runeson, 2005; Dyrbye et al., 2008, 2010; Frank, Biola, & Burnett, 2000; Goebert et al., 2009; Hays, Cheever, & Patel, 1996; Schwenk, Davis, & Wimsatt, 2010; Tjia, Givens, & Shea, 2005; Tyssen, Vaglum, Grnvold, & Ekeberg, 2001). Challenges intrinsic to the rst year of medical school have been documented (Brennan, McGrady, Lynch, & Whearty, 2010). Most students must transition to new living arrangements and social settings without familiar supports (i.e., friends and family). Additionally, new learning skills are required by the curriculum often in competitive and adversarial environments that can also deter students from seeking mental health care (Chew-Graham, Rogers, & Yassin, 2003; Givens
Corresponding author. Address: Department of Humanities, Penn State Hershey College of Medicine, 500 University Drive, Hershey, PA 17033, USA. Tel.: +1 717 531 8778; fax: +1 717 531 3894. E-mail address: drg21@psu.edu (D.R. George).
0747-5632/$ - see front matter 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.chb.2012.12.008

& Tjia, 2002; Link & Phelan, 2001). Recent studies have shown that M1M2 students are more likely than M3M4 peers to stigmatize depressed classmates (Schwenk et al., 2010), while others have found that younger students (2224 years) are less likely to seek treatment than older students (Tjia et al., 2005). Mitigating stress and enhancing coping skills should be a priority for medical educators, especially during early professionalization experiences. However, despite benecial outcomes of previous interventions (Brennan et al., 2010; Frank et al., 2000; Shapiro, Schwartz, & Bonner, 1998; Shapiro, Shapiro, & Schwartz, 2000), programs have been challenged by shortages of time, personnel, and resources (Cox, Cambre, Wolf, Webster, & Hooper, 2001; Shapiro et al., 2000). These barriers beg the question of whether there are alternative means including increasingly popular online social networks (OSNs) of addressing student stress and depression (Brennan et al., 2010). Recent surveys have shown that over 90% of medical students participate in OSNs (Bosslet, Torke, Hickman, Terry, & Helft, 2011), with rates having risen signicantly in just a few years (Chretien, Goldman, Beckman, & Kind, 2010; Moubarak, Guiot, Benhamou, Benhamou, & Hariri, 2011; Thompson et al., 2008). A previous study on college students has suggested that OSNs can reduce stigma surrounding mental health conditions (Moreno et al., 2011). The intent of this pilot study was to explore whether a

560

D.R. George et al. / Computers in Human Behavior 29 (2013) 559562

Facebook stress management group could reduce anxiety, enhance academic condence, and facilitate social connectedness during the rst semester of medical school. This report describes the descriptive statistical and qualitative analysis of the intervention. 2. Methods 2.1. Intervention After receiving IRB approval, a secure Facebook group was designed for rst-year students at Penn State College of Medicine (PSCOM). The framework blended cognitive behavioral theory and concepts from Lazarus & Folkmans model of stress and coping (Folkman & Lazarus, 1980). Specically, content provided problemfocused coping strategies such as changing the environment through reframing or relaxation, and emotion-focused strategies that addressed feelings and responses to stress (Folkman & Lazarus, 1988). Under the supervision of experts in counseling and information technology, second-year medical students helped create Facebook group content consisting of three streams of material: (1) personal narratives, (2) education/information, and (3) stress-management resources. Every day, new content was posted in the form of: 55 original YouTube video-narratives of older medical students and faculty describing stress coping strategies and study tips; prompts that provoked discussion (e.g., What music lowers your stress?), information about campus support resources; links to supportive content (i.e., relaxing music, breathing and meditation techniques, healthy eating tips); and prompts to fun light questions with incentives for participation (i.e., coupons for local activities/ events). The site was monitored daily by a mental health professional throughout implementation to ensure appropriate usage. 2.2. Study design During orientation week, all rst-year students (n = 145) were offered the opportunity to participate in the study. Of those, 66% (n = 95) consented (see Table 1). Participants were randomized into either the in-person stress management group (n = 48) or the Facebook group (n = 47) using simple randomization (see Fig. 1). 2.3. Main outcome measures Upon completion of the intervention, a second-year medical student performed an independent evaluation of Facebook group usage patterns using Microsoft Excel. Simple counts and analyses were generated where appropriate, and postings and replies were summarized. To evoke richer explanations of benets/drawbacks of the Facebook group, a 6-person focus group was conducted. The group, led by an experienced facilitator not privy to the FaceTable 1 Participant characteristics. Characteristics Women, number Men, number Age, mean Unmarried Married Previously employed Not previously employed Student housing Non-student housing Highest degree (a) Bachelors (b) Masters Facebook (n = 47) 27 20 23 39 8 28 19 31 16 43 4 Percentage (%) 57 43 49 83 17 60 40 66 34 91 9

Number of Students Approached n=145

Number declined n=50

Facebook Group n=47

In-Person Group n=48

Reached at Follow-Up n=26

Reached at Follow-Up n=18

Fig. 1. Recruitment ow chart.

book intervention, began with the inquiry: What was it like for you to be part of Facebook stress management group? Followup questions explored helpful/unhelpful aspects of the intervention, suggestions for improvement, and discussion about admitting need for support. The focus group was recorded digitally, transcribed, cleaned, and analyzed using qualitative methods. Specically, three researchers independently conducted line-by-line analysis of participant responses using open coding. Initial coding involved assigning key phrases or words to each unit and collapsing codes that addressed the same concept. The resulting coding groups were compared between researchers using iterative analysis to create common themes. Axial coding was then used to discover relationships between themes and create a tentative model of response to the intervention that would be conrmed by independent analysis and quantitative data. 3. Results 3.1. Evaluation of site content The 55 YouTube video-narratives were viewed a total of 369 times. The following videos represented the most-viewed content: Faculty perspectives on handling failure (27); The rst few days of medical school (21); Best advice for medical school (20); and Taking the rst Gross Anatomy test (19). Videos were watched more in the beginning of the semester, with a downward trend as Gross Anatomy progressed, peaking slightly during the week of the rst exam (see Fig. 2). 3.2. Focus group analysis Data from the focus group revealed the following emergent themes: 3.2.1. User-friendly strategies for coping with stress Students found certain Facebook content to be most helpful to their coping. Specically, the video-narratives with advice from older students and faculty as well as links to online resources were identied as most useful. One participant said: I looked at most of

D.R. George et al. / Computers in Human Behavior 29 (2013) 559562

561

ticipants also found value in YouTube video-narratives that addressed failure. One student said, I liked hearing the horror stories it was nice to hear that people were failing; Id say Yes! Im doing better! Another stated that they enjoyed listening to faculty members reect on Gross Anatomy failures: My favorite video on Facebook was a doctor who had failed an exam. He didnt lose his [position] so I guess it wasnt that bad. Norming failure early in the semester helped students brace for potential underachievement in Gross Anatomy and reframe their concept of and reaction to failure. 6. Identifying limitations
Fig. 2. Number of YouTube video viewings by week.

the links and videos it was a nice break from studying. There was consensus that offering stress-management resources on a familiar OSN accessible at any time was helpful, per this comment: I like the fact that a Facebook group is always there, and there were constantly things being posted . . . stress-related content was always there for me. Since all participants were already highly facile with Facebook, having stress management content on this platform was a logical t in their lives. As one student explained: I would just pop on and it is on my home screen, and I would see something posted so I would peek at it. Generally, students appreciated receiving content via Facebook rather than email, which was described as onerous. Further, Facebook allowed users to access stress management content while remaining anonymous (as long as they did not respond to a post), thereby avoiding stigmatization by classmates. Five out of six participants preferred Facebook to an in-person stress management intervention, and one was resolute about not using in-person resources, stating: I would do a Facebook group before I would go to a group [session], hands down. Students generally agreed that an important aspect of receiving support was condentiality. 4. Peer support While participants despaired about aggression in medical school (i.e., competing for time of teaching assistants, dealing with gunner classmates) the Facebook group created an environment conducive to peer dialog and support. No student posted personal information or expressed any mental health issues online (nor did they mention them during the focus group), but the opportunity to have non-academic light-hearted exchanges with their classmates was valued. In one instance, a student who won a gift-card during one of the fun contests offered to treat a losing student to coffee. This exchange was liked by multiple classmates, and ultimately engendered a friendship. Participants also enjoyed the humorous video-narratives and felt this content which pointed out the quirks of medical school and offered insider advice from colleagues might have been even more valuable before orientation. Although most students had a Big (i.e., an MS2 assigned at the beginning of the school year who served as a mentor and guide), the opportunity to engage with multiple peers in a non-invasive way was perceived as possibly more effective. 5. Norming failure and reducing stigma Half of the focus group indicated that they enjoyed hearing personal narratives about student and faculty success. However, as evidenced both by site analytics and focus group transcripts, par-

Students said the Facebook group might have been more effective if older medical students managed the group instead of faculty. The intervention was time-sensitive, with greater benets accruing at the beginning of Gross Anatomy. One student commented: It was nice in the beginning . . . but as I kind of found my own way in anatomy I think it was less needed. Participants would have liked to see videos before arriving at school, although they cautioned that watching too many could become overwhelming. 7. Discussion First-year medical students engaged with and improved coping strategies through the Facebook group, particularly early in the semester. Specically, video-narratives with stress management tips and advice emerging from students and colleagues supported benecial coping strategies. Practical content and advice from peers in OSN format was preferred to in-person stress management resources. It is likely that with nearly all contemporary medical students using OSNs such as Facebook, the online format is an intuitive, effective, and efcient medium for the dissemination of stress management resources. Therefore, online social networking interventions may be a practical means through which medical schools can help build relationships, socialize students around healthier norms of stress, reduce stigma associated with help-seeking behaviors, connect students to resources, and serve as a venue for role-modeling and seeking professional guidance. Indeed, this pilot study builds on a previous study that found OSNs reduced stigma surrounding mental health conditions for undergraduates (Moreno et al., 2011), and strongly suggests that social media can augment existing stress management programming for medical students who stand to benet from a modernized, online approach. However, our small study population was representative of only a fraction of motivated medical students. Developing, posting, and monitoring the site requires personnel, and contingency plans for misuse or mental health crises must be in place. Future replication might benet from enlisting advanced students to administer the Facebook group, which would reduce burden on faculty and/or administration while providing unique opportunities for peer mentoring. Such efforts must keep apprised of privacy setting alterations and other functionality changes of OSNs. Ultimately, given the preliminary results of our pilot study as well as the nearly uniform presence of medical students on OSNs, medical schools should strongly consider integrating social media into existing stress management programming. In addition to offering coping benets for students, the institutional embrace of social media might also create pedagogical opportunities to explore the unique professional and ethical dilemmas posed by emerging technology, as well as inform conversations about the potential of OSNs to contribute to the delivery of more effective health care in an era of increasing social media usage for both medical professionals and patients (George, 2011; George & Green, 2012).

562

D.R. George et al. / Computers in Human Behavior 29 (2013) 559562 Elnicki, D. (2010). Learning with emotion: Which emotions and learning what? Academic Medicine, 85, 1110. Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-aged community sample. Journal of Health and Social Behavior, 2, 219239. Folkman, S., & Lazarus, R. S. (1988). Ways of Coping Questionnaire (Research edition). Palo Alto, CA: Consulting Psychologists Press. Frank, E., Biola, H., & Burnett, C. (2000). Mortality rates and causes among US physicians. American Journal of Preventative Medicine, 19, 155159. George, D. R. (2011). Friending Facebook?: A mini-course explores what the Social Media era means for the health professions. Journal for Continuing Education in the Health Professions, 31(3), 216220. George, D. R., & Green, M. J. (2012). Beyond good and evil: Exploring medical trainee use of social media. Teaching and Learning in Medicine, 24(2), 155157. Givens, J. L., & Tjia, J. (2002). Depressed medical students use of mental health services and barriers to use. Academic Medicine, 77, 918921. Goebert, D., Thompson, D., Takeshita, J., Beach, C., Vryson, P., Ephgrave, K., et al. (2009). Depressive symptoms in medical students and residents: A multischool study. Academic Medicine, 84, 236241. Hays, L. R., Cheever, T., & Patel, P. (1996). Medical student suicide, 19891994. American Journal of Psychiatry, 153, 553555. Hull, S. K., DiLalla, L. F., & Dorsey, J. K. (2008). Prevalence of health-related behaviors among physicians and medical trainees. Academic Psychiatry, 32, 3138. Inam, S., Saqib, A., & Alam, E. (2003). Prevalence of anxiety and depression among medical students of private university. Journal of Pakistan Medical Association, 53, 4447. Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363385. Lubitz, R., & Nguyen, D. (1996). Medical student abuse during third-year clerkships. Journal of American Medical Association, 275, 414416. Moreno, M. A., Jelenchick, L. A., Egan, K. G., Cox, E., Young, H., Gannon, K. E., et al. (2011). Feeling bad on Facebook: Depression disclosures by college students on a social networking site. Depression and Anxiety, 28, 447455. Moubarak, G., Guiot, A., Benhamou, Y., Benhamou, A., & Hariri, S. (2011). Facebook activity of residents and fellows and its impact on the doctorpatient relationship. Journal of Medical Ethics, 37, 101104. Schwenk, T. L., Davis, L., & Wimsatt, L. A. (2010). Depression, stigma, and suicidal ideation in medical students. Journal of American Medical Association, 304, 11811190. Shapiro, S. L., Schwartz, G. E., & Bonner, G. (1998). Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine, 21, 581599. Shapiro, S. L., Shapiro, D. E., & Schwartz, G. E. (2000). Stress management in medical education: A review of the literature. Academic Medicine, 75, 748759. Thompson, L. A., Dawson, K., Ferdig, R., Black, E. W., Boyer, J., Coutts, J., et al. (2008). The intersection of online social networking with medical professionalism. Journal of General Internal Medicine, 23, 954957. Tjia, J., Givens, J. L., & Shea, J. A. (2005). Factors associated with undertreatment of medical student depression. Journal of American College Health, 53, 219224. Tyssen, R., Vaglum, P., Grnvold, N. T., & Ekeberg, O. (2001). Suicidal ideation among medical students and young physicians: A nationwide and prospective study of prevalence and predictors. Journal of Affective Disorders, 64, 6979.

Acknowledgments The Woodward Endowment for Medical Science Education funded this work but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Ethical approval for the project was received through the Internal Review Board at Penn State College of Medicine. All authors had a substantial role in conceptualizing and writing the manuscript, and all authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. We report no conicts of interest. References
Aktekin, M., Karaman, T., Senol, Y., Erdem, S., Erengin, H., & Akaydin, M. (2001). Anxiety, depression and stressful life events among medical students: A prospective study in Antalya, Turkey. Medical Education, 35, 67. Bosslet, G., Torke, A., Hickman, S., Terry, C., & Helft, P. (2011). The patientdoctor relationship and online social networks: Results of a national survey. Journal of General Internal Medicine, 26, 11681174. Brennan, J., McGrady, A., Lynch, D., & Whearty, K. (2010). Stress management intervention for rst year medical students. Annals of Behavioral Science and Medical Education, 16, 10751211. Chew-Graham, C. A., Rogers, A., & Yassin, N. (2003). I wouldnt want it on my CV or their records: Medical students experiences of help-seeking for mental health problems. Medical Education, 37, 873880. Chretien, K. C., Goldman, E. F., Beckman, L., & Kind, T. (2010). Its your own risk: Medical students perspectives on online professionalism. Academic Medicine, 85, S68S71. Cox, C. C., Cambre, K. M., Wolf, T. M., Webster, M. G., & Hooper, J. (2001). Trends in the number and administrative characteristics of medical school health promotion programs. Medical Education, 35, 173174. Dahlin, M., Joneborg, N., & Runeson, B. (2005). Stress and depression among medical students: A cross-sectional study. Medical Education, 39, 594604. Delnevo, C. D., Abatemarco, D. J., & Gotsch, A. R. (1996). Health behaviors and health promotion/disease prevention perceptions of medical students. American Journal of Preventative Medicine, 12, 3843. Dunn, L. B., Iglewicz, A., & Moutier, C. (2008). A conceptual model of medical student well-being: Promoting resilience and preventing burnout. Academic Psychiatry, 32, 4453. Dyrbye, L. N., Massie, F. S., Eacker, A., Harper, W., Power, D., Durning, S. J., et al. (2010). Relationship between burnout and profession conduct and attitudes among US medical students. Journal of American Medical Association, 304, 11731180. Dyrbye, L. N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, A., Harper, W., et al. (2008). Burnout and suicidal ideation among US medical students. Annals of Internal Medicine, 149, 334341.