Preferences of young adults regarding dissemination of online vitamin D information.
Vitamin D plays a key role in bone health by increasing calcium absorption, helping to prevent rickets in children and osteomalacia in adults . Vitamin D may increase innate immune function  and deficiency has been associated with various types of cancer [3-6] and a host of other disease states [7, 8]. Adequate vitamin D intake is therefore important at all ages, and particularly during the period from 18 to 25 years, referred to as "emerging adulthood" . This is a time of increased independence and autonomy that is considered crucial for developing patterns of long-term health behaviours, and it has been cited as an often overlooked, yet important, window for dietary behaviour change .
Emerging adulthood is also a critical period for the development of peak bone mass (PBM). In females, PBM reaches about 90% of its potential during late adolescence and cannot be increased significantly after the late 20s . The age at which PBM occurs varies by sex and body site; lumbar spine PBM occurs between ages 33-40 years in females and 19-33 years in males; whereas, total hip PBM occurs between ages 16-19 years in females and 19-21 years in males . Given that bone mass cannot be increased after this time point, adequate consumption of calcium and vitamin D during young adulthood is essential for the maintenance of optimal health .
The current recommended dietary allowance (RDA) for vitamin D (1-70 years of age) is 600 IU per day , and several researchers recommend serum vitamin D3 levels of [greater than or equal to] 75 nmol/L for optimal health [13-15]. However, national data indicate that Canadian adults aged 19-30 years consume only 236 IU vitamin D per day, on average from food sources , and less than a quarter (24.1%) (1) of those aged 18-25 years have plasma levels [greater than or equal to] 75 nmol/L .
Despite the importance of adequate vitamin D intake to long-term health, targeting health behaviour change among emerging adults can be difficult. The term "young invincibles" has been used to describe this life stage , which is often associated with feelings of invincibility and a disregard for future health consequences. Vitamin D poses an additional challenge because the most well-documented outcomes of deficiency (i.e., osteomalacia, osteoporosis) occur in old age , perhaps decreasing the perceived importance of meeting recommendations during the younger years.
The Internet is a promising mode of delivery for health-behaviour change directed to young adults , and online interventions focusing on dietary behaviours such as nutrition , weight maintenance , and alcohol consumption [23, 24] are emerging. However, few researchers have conducted online interventions related to vitamin D  or examined vitamin D knowledge among young adults . Thus, little is known about how to effectively communicate with or engage this population regarding the importance of vitamin D to health and disease prevention. The current study therefore aimed to explore strategies for disseminating online vitamin D information among a young adult population. A qualitative approach was taken to gain an in-depth understanding of young adults' views and to elicit feedback on 5 communication strategies.
A post-positivist approach guided the data collection and analysis . In this approach the participants' views of reality are the primary focus and the researchers aim for objectivity while acknowledging their assumptions and biases (i.e., interest in health, nutrition, and vitamin D) . The participants' own words were used to support the themes that "emerged" from the data, and they formed a descriptive narrative with little interpretation by the researchers. This technique is what Strauss and Corbin  term "accurate description."
Participants and recruitment
Research participants (n = 50) for this exploratory study were recruited using convenience sampling from the Guelph, Ontario, area using online and poster advertisements in the community and the University of Guelph campus. Advertisements recruited participants for a 1-hour informal discussion relating to vitamin D and health; participants expressed their interest by email. Participants were required to be 18-25 years of age and fluent in English. The University of Guelph Research Ethics Board granted approval for this study.
Participants were asked to provide feedback on a series of strategies relating to communicating information about vitamin D and its health outcomes. Following a review of the literature on health behaviour change in adolescents and young adults including a systematic review , 5 main strategies were proposed: (i) educational messages presented in a text-based format, (ii) statistics, (iii) educational messages delivered by a health professional, (iv) video testimonials from young adults, and (v) an interactive survey. Participants were also asked about their preference for positive versus negative messaging and short versus long-term health effects of vitamin D. Questions were pilot-tested with a group of
6 participants, leading to the revision of 1 item. All participants also completed a short demographic survey to collect data on age, sex, ethnicity, education level, employment, and student status (see Supplementary Appendix A (2)).
Eight focus groups were conducted at the University of Guelph in August 2012 (4 each with males and females, separately). Males and females were studied independently (i) to ensure that participants felt comfortable expressing their opinions and (ii) to examine whether responses differed by sex. After providing written informed consent, 2 trained female facilitators each led 4 semi-structured focus groups (see interview guide in Supplementary Appendix A (2)). A series of open-ended questions were asked; participants answered freely and were occasionally prompted for elaboration. Participant responses were audio recorded; trained volunteer notetakers also recorded participant responses in abbreviated type. Responses were linked to unique ID numbers rather than names for confidentiality. The researchers concluded that theoretical saturation was reached once similarities between discussions emerged and few new ideas were introduced. Participants each received a $50 gift card as compensation for their time, effort, and parking expenses.
Audio files were transcribed verbatim using ExpressScribe (ExpressScribe Software, NCH Software, Boston, MA, 2002). These words, along with observations (in this case, notes taken during the focus group interviews), were coded to reduce and categorize the data into themes and subthemes following the procedures for thematic analysis outlined by Braun and Clarke . After becoming familiar with the data, the first author developed a coding scheme to identify key ideas and concepts (see Supplementary Appendix A (2)). A list of key themes was generated from the initial codes. Eight themes were initially identified; further refinement resulted in 5 final themes. All coding was done manually using hard copies of transcripts and coloured pens. An external coder independently analyzed all 8 transcripts to identify major themes and subthemes, as a check on the validity of the interpretation. Agreement on any discrepancies was reached through verbal discussion. This process led to minor refinement of the final themes, including alteration of 2 theme names and the promotion of 1 code to a subtheme. Demographic statistics were analyzed using SPSS software (IBM SPSS Statistics for Windows version 20.0, IBM Corp., Armonk, NY, 2011). Chi-squared tests were used to test for significant differences between males and females on demographic variables.
Fifty participants (22 males; 28 females) participated in the focus groups; sample characteristics are listed in Table 1. Groups consisted of 3-8 participants (mean = 6). Participants ranged in age from 18 to 25 years (mean = 21.9 years) and the majority were Caucasian (78%). Ninety-four percent had at least "some" university education. Chi-squared tests indicated that males and females did not differ significantly on any socio-demographic variables; however, more women (n = 18) had taken a nutrition course than men (n = 8), P = 0.05.
Analysis of focus group transcripts revealed that while personal preferences for receiving vitamin D information varied widely, 5 key themes emerged (Table 2).
Theme 1: Time is of the essence
In regards to almost every proposed methodology, it was apparent that young adults valued their time. Text and video messages related to vitamin D information would therefore be well received only if they were short and concise. A few individuals also commented that they would prefer text to video, because it would allow them to quickly skim for important points. As explained by this female:
Well I would be more into reading something, yeah something short, just because I'd like, skim through it and pick out the things that I want to learn. But things like videos, I never watch them, no, 'cause like I'd have to sit there for like the 5 minutes to watch it, whereas if I'm reading I'll just be like finished, and then I can go on if I want to.
Similarly, while several females liked the idea of an interactive quiz, the likelihood of participation depended on the amount of free time available to them. In contrast, most males stated that they would not take the time to participate in a vitamin D quiz. One male admitted,
Um ... if I got to a point where it said, "Now take this fun quiz about vitamin D, " I'd go back to playing Free Cell [a solitaire card game played on the computer] or something.
Clearly, free time is valuable to these young adults, who would rather spend their time engaging in leisure activities than learning about vitamin D through a lengthy video or quiz. Effective materials must be concise to engage youth, who might rather spend their leisure time on other activities.
A subtheme that emerged was "stress simplicity." When asked "what could we do that would get you to make changes to your diet?" several participants responded that the message should focus on simple, specific changes that emphasize how easy it is to meet the RDA. One male pointed out that taking a daily supplement is an easy way to prevent vitamin D deficiency, and is a good example of a message that would be short and simple to communicate.
Well even just in the winter, as you say, it's like, it's just one pill to make sure you [reach the recommendations] or supplement, or even your multivitamin. If it's just one pill, that's pretty easy as well.
Theme 2: Information materials require a "hook"
Comments by both males and females indicated that materials would be engaging if they were: visually appealing (including images, animations, or infographics), interactive, attention-grabbing, surprising, shocking, scary, touching, or memorable. One female suggested using shock-value to engage viewers:
What about those old--you know those old smoking commercials? Like it's extreme but like you know that one where ... I think it was the husband of the lady who worked in the diner who died from, from lung cancer who 'd never smoked a day--something like that. Like it's a big shock factor, but we all remember that commercial and we know exactly what it was for, so something like that might help it click.
In discussions of positive versus negative messaging, although individual preferences varied, several males and females mentioned that they were more likely to remember a fear-provoking message. As stated by this young male:
I think fear works so much better, 'cause you've been hearing like your entire life, you know, "Insert X is good for building strong bones. " Like everything is good for building strong bones. But like tell 'em something that'll actually scare them and something that you're actually going to remember, you know?
Similarly, several females discussed viral videos that focused on melanoma and were described as "powerful," "touching," or "frightening." As one female recalled,
That one cancer video on melanoma, it was like a variety of people, so it was mostly like teenagers or older people who had suffered from skin cancer, that was really like touching, and I think if people, like it matters to them--that subject, it might draw their attention more, too.
Finally, a subtheme that emerged in relation to materials requiring "a hook" was that incentives would increase engagement. Several males and females indicated that they would participate in an interactive quiz or survey if they were offered an incentive such as coupons for supplements, grocery store gift cards, or the chance to win a prize.
Theme 3: It's all about me: personal relevance and feedback
Text, statistics, and videos were perceived as being more valuable if they were specific and personally relevant. One educational tool that participants viewed favourably was personal feedback--presumably because this strategy increases the relevance of the information presented. Participants felt that individual feedback regarding their vitamin D status might motivate them to increase their intake or to seek more information. Further, personal feedback would help individuals differentiate themselves from others when reading facts or statistics. For instance, without any information about their personal vitamin D status, many participants admitted that they would assume that a given statistic did not apply to them. One male stated,
I'd probably be like ... I'll just throw [the statistic] away and [assume] I'm probably not in that 25%, you know what I mean?
However, several participants acknowledged that if they had access to information regarding their personal vitamin D status, they might pay more attention to their intake. The idea of a web-based or handheld (i.e., mobile) calculator that could estimate your vitamin D status was raised during 1 focus group, and was a well-received idea in subsequent groups.
A subtheme that emerged was that immediate health outcomes are more relatable than long-term effects. There was an overall consensus among both males and females that it would be most effective to focus on the immediate health benefits of vitamin D. Long-term consequences such as developing osteoporosis or breaking a hip were considered irrelevant and not particularly motivating.
Theme 4: Credibility is essential
The credibility of information was very important among this sample of young adults. Statistics and study results were deemed to be useful only if the date and source were identified; further, information should come from a reputable source and not be endorsed by a company with a financial conflict of interest. When asked what they perceive to be a credible information source, 1 male stated,
Well if it's like a doctor writing it or someone who knows what they're talking about. Not just like a random person blogging about it.
Similarly, video information was also perceived as more motivating if was produced by a credible source. Both sexes indicated that they would prefer to receive health information from a health professional, whereas video testimonials delivered by an individual of their own age were widely considered to be phony or scripted.
Theme 5: A combination of strategies would appeal to a wider audience
With the exception of a video testimonial by a young adult actor, which was disliked by the majority of participants, findings regarding the effectiveness of any particular strategy were mixed. Several individuals appreciated statistics; others felt that too many numbers were overwhelming or dismissed them as irrelevant. These differences in opinion were apparent in discussions on positive versus negative messaging, interactive quizzes, and text versus video messaging. As a result, several participants suggested combining strategies to appeal to a wider range of users and personal preferences.
Both sexes also mentioned "TED Talks" ; these lecture-style videos are informative, credible, and entertaining. A female participant explains:
And you had mentioned TED Talks, I think if you did something like that people would be into it as well. Because it's all there, it's like 5-10 minutes and then [Facilitator: yeah] it also gives you stats, um and in that presentation you can incorporate foods you would need and well levels you would need to reach, because they have like Power Points behind them as well, so it's auditory and [another participant: it's like a lecture kind of], ya it's like a lecture. And you get the varying lengths too and you get um specific talks for specific things ...
Evidently, the right blend of facts, interest, and entertainment is essential for educational materials to be effective among this audience, whose individual preferences vary widely.
Overall, findings revealed that individuals preferred different learning strategies, and no one strategy (text-based format, statistics, messages delivered by health professionals, video testimonials from young adults, or interactive survey) appealed to the majority of participants. This is an important challenge to be considered when planning educational interventions for young adults, as the reach of informational materials may vary widely depending upon individual preferences and learning styles. Other age groups and audiences may have less diverse preferences for learning strategies. However, there was general consensus that an effective educational intervention should be short, simple, interesting, personally relevant, credible, and include incentives.
Combining multiple strategies could appeal to a wider range of individual tastes, preferences, and learning styles, leading to increased reach. These findings align with those reported in the literature; a systematic review of online intervention programs targeted towards adolescents and young adults found that the combination of several strategies increased intervention exposure . Although the authors of this review were unable to distinguish the effects of each strategy individually, they noted that the combination of personal feedback, reminders, and incentives led to higher exposure of Internet intervention programs .
Unlike other online programs developed for this age group that are reported in the literature (such as responsible alcohol consumption or preventing weight gain in college) promoting vitamin D has unique challenges because the health consequences of insufficiency are perceived as being too distant to be a present concern. There was an overall consensus among both males and females that it would be most effective to focus on the immediate health benefits of vitamin D, which may challenge educators to think differently about this nutrient. Emerging roles of vitamin D in relation to immune function, cancer, some autoimmune diseases, diabetes mellitus, and insulin resistance [7, 8] may be perceived as more relevant to young people. In some focus groups, participants indicated they had heard about research examining possible relationships between vitamin D and seasonal affective disorder, and this caught their interest.
One of the unique contributions of this study is the idea of a hand-held calculator that provides an estimate of individual vitamin D intake. This concept includes a combination of qualities deemed important by this sample of young adults--including visual components, numeric results, immediate feedback, and personally relevant information, and would allow for individual self-monitoring of vitamin D intake. Given that self-monitoring has been associated with increased effectiveness of healthy eating interventions , this idea holds promise as a tool with which to enhance intervention programs that aim to increase intake of vitamin D or other nutrients.
Participants in this sample were primarily Caucasian and well educated. Although a group of 50 participants shared their lived experiences with various learning strategies, the views of this sample may not resonate with a more ethnically diverse group or a less educated group of young adults. This study was exploratory in nature, and focused on views about various learning strategies among a sample of young adults. A behavioural model/theory was not used in this study, but would be useful to examine the behavioural, environmental, and social factors that facilitate or hinder adequate intakes of vitamin D.
RELEVANCE TO PRACTICE
The findings of this research have practical implications. Researchers, dietitians, clinicians, and health associations can draw upon the themes generated by these focus groups when designing online materials or programs that aim to deliver dietary information to young adults. The strategies identified herein will be especially useful for disseminating information related to vitamin D or other nutrients that affect long-term health, for instance, calcium, which has similar implications for future bone health . Tools that enable young adults to calculate and monitor their dietary intakes, such as handheld calculators or phone apps designed to track vitamin D intakes, would provide personalized feedback. Short online quizzes with catchy facts for this age group would be another strategy for giving instant feedback to those who enjoy interactive learning. Providing incentives such as coupons for free products and draws for prizes would increase the interest in participating in online programs.
Finally, other researchers have suggested drawing from findings related to different health behaviours when designing online behaviour change interventions for young adults . Similarly, many of the themes identified herein could be extended to other health behaviours, especially those with potential health outcomes that occur later in life, such as alcohol, tobacco use, and sedentary behaviour.
The authors would like to acknowledge Robyn Manwell for her contributions as second coder.
Financial support: Financial support for this project was provided by a Canadian Institutes of Health Research (CIHR) Frederick Banting Doctoral Scholarship awarded to Samantha Goodman.
Conflict of interest: the authors have no conflicts of interest to report.
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SAMANTHA ERIN GOODMAN,PhD (a) JUDY SHEESHKA, PhD, RD (b)
(a) Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, ON; (b) Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON
(1) 95% CI: 15.0-36.5; Use with caution; coefficient of variation is between 16.6% and 33.3%.
(2) Supplementary data are available with the article through the journal Web site at http://dcjournal.ca.www.nrcresearchpress.com/doi/suppl/10.3148/ cjdpr-2016-011.
Table 1. Sample characteristics of participants in focus group study (n = 50). Variable No. (%) Sex Female 28 (56) Male 22 (44) Age (y) 18-19 7 (14) 20-21 15 (30) 22-23 16 (32) 24-25 12 (24) Ethnicity White/Caucasian 39 (78) Japanese, Chinese, Korean 4 (8) South East Asian 3 (6) European 3 (6) Middle-Eastern or Arab 1 (2) Highest level of education High school, apprenticeship, or professional 3 (6) certificate Some university or undergraduate degree 41 (82) Some graduate school, graduate degree, or 6 (12) certificate Student status Currently a student 37 (74) Employment status Unemployed 15 (30) Part-time 20 (40) Full-time 15 (30) Table 2. Final themes and explanations from focus group (n = 50). No. Theme name Explanation 1 Time is of the essence Messages must be short Subtheme: Stress and concise, whether they simplicity are in text or videos, because time is valuable. Explicitly outlining the desired behaviour change makes the message simpler. 2 Intervention materials To be effective and require "a hook" engaging, information must Subtheme: Incentives be catchy and interesting increase motivation Participation in interactive surveys or quizzes will increase if incentives (e.g., prizes, coupons) are provided. 3 It's all about me: Text, statistics, and videos personal relevance and should provide information feedback that is personally relevant. Subtheme: Immediate Feedback on vitamin D health outcomes are more status could be motivating. relatable than long-term Long-term health issues are effects not relatable to these young adults, who are focused on the here and now. 4 Credibility is essential Information should come from a reputable source and not be endorsed by a company with a possible financial conflict of interest. 5 Two strategies are There were wide differences better than one! in opinions about the 5 strategies. Therefore, combining 2 or more strategies might reach and appeal to more young people.
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|Author:||Goodman, Samantha Erin; Sheeshka, Judy|
|Publication:||Canadian Journal of Dietetic Practice and Research|
|Date:||Dec 1, 2016|
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