Computer-Mediated Communication

Title: Using Computer Mediated Communication to Explore Eating Behaviour and Adjustment Post Weight Loss Surgery

Author: Tetley, D.(1), Dexter, S.(2) and Hill, A. J.(1)

Affiliation: (1) Academic Unit of Psychiatry and Behavioural Sciences, Leeds University School of Medicine, UK.
(2) Leeds Teaching Hospitals NHS Trust, UK.

 

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The results of weight loss surgery are not equal for all. This study aimed to explore patients’ ‘real lived’ accounts of their eating behaviours following restrictive weight loss surgery (WLS), and any psychological consequences that impacted on their ability to adjust to new eating styles required for post-operative success, and on their ability to sustain weight loss post-operatively. The research was patient-led by a researcher with personal experience of WLS.

 

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Computer Mediated Communication was used throughout the research process. Stage 1 adopted a descriptive phenomenological approach examining the nature and veracity of reported post-surgical eating behaviours and related psychological constructs. Documentary analysis was undertaken of over 300 messages posted asynchronously to topic specific forums on a WLS support website retrospectively over twelve months. Stage 2 adopted an Interpretive Phenomenological Approach (IPA) gaining a deeper understanding of behaviours/constructs observed, considering contextual features that might have a direct bearing on their nature and existence. Online semi-structured text-based synchronous interviews were undertaken with 12 women and 4 men.

Stage 1 was exploratory. No attempt was made to define a guiding framework. Experiences were not linked to context (e.g. types of surgery, stage of post operative recovery) and there was no attempt to identify patterns in the data. The findings were used primarily to understand what needed to be considered when exploring further the constructs of eating behaviour, adjustment, related psychological issues and the ways they are managed post-surgery via semi-structured online interviews (Stage 2).

The use of IPA in Stage 2 of the research aimed to elicit a deeper understanding of the constructs observed at Stage 1. IPA is a distinctive approach widely used in the conduct of qualitative work in psychology and it was an ideal tool for the focus within this study; the exploration of patients' experience, understandings, perceptions and views (Reid, Flowers and Larkin, 2005; Smith, 1996). The successful use of IPA has previously been demonstrated in fields of enquiry related to WLS (see Ogden et al, 2006). Knowing and understanding the topic under investigation is a pre-requisite for the use of IPA as it involves a detailed examination of participants’ lived experience rather than just an objective account of what is experienced. It provided an active role for me as a researcher/participant; enabling me to make sense of participants’ personal world through a process of interpretive activity. Having this ‘insider perspective’ was advantageous, giving me a unique understanding, enabling me to understand from their point of view what it is like to have had WLS, and to ‘take their side’ (Smith, 2008).

The use of online research methods was fundamental to both stages of the research. The primary source of social support for WLS patients in the UK is through a virtual online support group. Whilst there are a number of physical WLS support group meetings across the UK these are not easily accessed by all patients due to their geographical locations. Marginal groups of patients such as these have been shown to be difficult to reach using conventional research approaches especially where they are widely geographically distributed (O’Lear, 1996; O’Connor and Madge, 2001). Moreover, WLS may be viewed as a sensitive topic for some and the use of an online approach is especially useful when researching sensitive topics or health related issues (King, 1994; Finn & Lavitt, 1994) as participants do not have to face an interviewer in an interview situation. Participants including myself (as researcher) were already members of the WLS online support community with experience of virtual communication in this forum. I was hopeful that the use of the WLS web-site would permit me to interface with individuals who had undergone restrictive WLS. I also hoped that members’ existing relationships with myself, their support of this research and their knowledge of my own WLS would give added value to the research, permitting an ‘insider perspective’ to be gained as well as establishing trust, confidence and reassurance to the members who participated.

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Stage 1 of the research enabled the identification of themes and constructs in relation to eating behaviours, adjustment and psychological impact post WLS. Along with a comprehensive literature review these provided the building blocks necessary to inform the development of a qualitative interview schedule for pilot and use in Stage 2.

Advantages in using documentary analysis as an approach to undertaking Stage 1 of the research were numerous. There was the ease of access to the archived data and the ‘non-reactive’ nature of this material i.e. the text was naturally occurring. As a researcher I was ‘invisible’ to the participants and could view what may be considered ‘private’ accounts i.e. accounts given to people like themselves of experiences without contamination from my own personal values and opinions and presence (Cornwell, 1984). There is some evidence to suggest that disclosures of personal experiences is encouraged on the internet (Rheingold, 1994) making these ‘postings’ a rich source of information. Finally, and most importantly, I was able to understand the experiences of people I would not otherwise be able to capture, mainly because of access, time and geographical constraints (Fleitas, 1982). Documentary analysis made the research possible whereas it would not be using other more conventional methods.

However, there were implications in using this approach and these were considered in the formulation and design of this stage of the research. It was important to take care not to bias the selection of material in any way e.g. to support my own ideas or ones already acquired from the literature. Researcher reflexivity was important here as well as meticulous reporting and measures to ensure the reliability of my interpretation of material gathered (Murray & Sixsmith, 2002). There were also some ethical considerations that needed to be taken into account before conducting the study.

Using a descriptive phenomenological approach to documentary analysis it was important to remain unbiased in the selection of the lived experiences of those I was studying. To ensure that the potential for bias was minimised a full literature review was not undertaken prior to initiating the study nor was there any attempt to shape the research questions at this stage other than to explore the issues generally (Natanson, 1973). A technique called ‘bracketing’ (following the guidance of Ahern, 1999) was employed to ensure that reflexivity was used to identify potential areas of bias and to ensure their impact on the research process was minimal. This involved holding in abeyance my ideas, any preconceptions, and personal knowledge when selecting documentary evidence, undertaking textual analysis and when reflecting on the lived experiences of WLS Individuals (Drew, 1999). Bracketing was a useful way of demonstrating the validity of both the data collection and the analytic process (Ahern, 1999).

Although British Psychological Society Guidelines in Psychological Research online (2007) provided a minimum standard of good practice in overcoming ethical issues they did not deal with key dilemmas relating to documentary analysis. The BPS general ethical guidelines (Code of Ethics and Conduct, 2006: 13) note that unless consent has been sought any observation of behaviour can only take place ‘where people would reasonably expect to be observed by strangers’. Undertaking documentary analysis of archived content of the websites discussion forums meant that participants could be invisibly observed without their knowledge and individuals may not have been aware of the research activity or its purpose – e.g. at the time of accessing the content many individuals may have ceased to be contributors to the website making gaining consent difficult. It was also important to acknowledge that the WLS website operated as an online support group, therefore members’ perceptions of privacy may have been different with some members believing their publicly accessible internet activity to be private.

Privacy was of paramount importance especially as the material available on the WLS website is ultimately in the public domain. Using words without members consent could have been potentially damaging to the research process and to the WLS community and have led to a distrust of researchers (Sixsmith and Murray, 2001). It was therefore important to assure participant anonymity by removing any identifying information contained within ‘posts’ collected, including names and pseudonyms. Additional safeguards were taken to ensure there was no potential for traceability of the material gathered by entering participants’ quotations into two internet search engines. Difficulty in protecting an individuals’ anonymity can arise from citing the name of the online community (Eysenbach and Wyatt, 2002) for this reason the name of the online community used was withheld when reporting the findings.

In Stage 2 of the research, online semi-structured text-based synchronous interviews were undertaken. Participants (volunteers) were recruited via a ‘posting’, a request for volunteers to talk about their post-surgical eating behaviours made on the WLS web site by me. At this stage having information relating to context was important. Demographic data for each participant, e.g. age, location, type and date of surgery, etc was initially collected from each persons ‘profile’ available on the WLS website. Any incomplete information was requested at the time of interview. The semi-structured interview is an exemplary method for IPA (Smith and Osborn, 2008). It enabled me and the participants to engage in a dialogue whereby I could modify questions in light of participants’ responses probing interesting and important areas as they arose. This is in contrast to the structured interview which deliberately limits what the participant can talk about.

One-to-one interviews were preferred to focus group interviews because of the personal nature of the interviews and concern regarding patients’ unwillingness to disclosure of sensitive information. The practical drawbacks in the undertaking of focus group interviews on-line was also a consideration (see, Stewart et al, 1998) e.g. the possible challenges facing me as a researcher in the facilitation of an on-line focus group, including speed of interaction and my ability to guide conversation to address the topics necessary. Participants’ speed of interaction in particular, may have given rise to those with greater typing skill being able to say the most resulting in inequitable contributions. There were also significant ethical considerations to be considered in undertaking the interviews online. These included the need to verify participant identity, informed consent, withdrawal and data protection (BPS, 2007).

Although the online WLS support website hosted a ‘chat room’ facility this was not used to undertake interviews even though it was available and accessible to all its members. Whilst this ‘chat’ facility could have been configured to provide private access only, the website’s moderators had access to the content and history of all conversations taking place – use of this would have threatened the participant anonymity and confidentiality. In order to safeguard participants’ privacy an independent on-line meeting room was used to undertake the interviews utilising Adobe ConnectNow BETA © web conferencing facility. This virtual space permitted real-time text-based communication. The meeting room had a conversation flow area where participants could read all contributions as well as a separate composition area for writing their own messages. Using this medium had the additional advantage of permitting automatic transcription of the interview, thereby avoiding traditional limitations of recording and transcription of face-to-face interviews (see Hammer and Wildavsky, 1989: 70-1).

The meeting room facility was secure and could be ‘locked’. Access to this meeting room was via a web link emailed to each participant prior to interview. There was no requirement for participants to download additional software onto their computers. It was important to authenticate participant identity before proceeding with any online interview especially as the participant and my self had never met physically. This security was enforced through the use of a unique password emailed to each participant prior to the interview proper. This password enabled them to enter the locked meeting room and ensured a level of participant verification regarding identity. This way, the online environment provided security, confidentiality and privacy.

Sensitive handling of the research process was important for the success of the online synchronous interviews (O’Connor and Madge, 2001). Generating data in the qualitative interviews depended on developing rapport (Fontana and Frey, 1994). It was therefore important to rely heavily on my own identity as a fellow patient who had undergone restrictive WLS. However, it was not my intention to be perceived as an ‘expert’, rather as an individual who understood what participants had to say. Strategies were employed to overcome the loss of face-to face interaction and to build rapport with participants. Building rapport was critical for ensuring there was, reciprocity, trust between participants and myself and to ensure that participants felt a sense of being in a safe environment (Murphy and Collins, 1997; Cutler, 1995; Parks and Floyd, 1996). Some of the strategies adopted were generic i.e. they were not only important for the online interview but related to establishing rapport in all kinds of interviews (Mann and Stewart, 2000).

In overcoming the core methodological difficulties information was disclosed about myself to each participant prior to the onset of each interview. This was undertaken in an attempt to establish trust and to bridge the geographical distance that may characterise online interviewing (Moore, 1993). Participants were sent a brief biography of me; that explained my reasons for conducting the research and informed them that I was also a member and participant of the WLS website. This personal disclosure was posted to volunteers and included photographs of me pre and post surgery, as well as information about the research project. A written explanation of the interview procedure was also given. A consent form was also enclosed for participants to sign and return in a stamp addressed envelope provided. Participants were invited to contact me via email or telephone if they had any further questions they would like to ask.

Gaining consent for this online research was particularly important as there was no way of knowing whether material about the research sent to volunteers prior to the onset of the online interview had been read or understood – this approach would not have constituted informed consent. Having written consent prior to the interview avoided the possible situation where a participant may leave the interview before consent has been obtained leaving the problem of tracing the participant before any material can be included. Volunteers under the age of 16 were not eligible to participate without parental consent. However, verifying online identity including age is fraught with difficulty consequently the interview schedule used was reviewed for its content to ensure that it was appropriate for all individuals (including young people) and appropriate for use online. This was established through an online ‘pilot’.

Interviews online provided some challenges as both verbal and non-verbal cues were missing. The online interview method can be problematic due to the loss of paralinguistic cues (Chen and Hilton, 1999). This non-verbal communication is additional information which aids interpretation in the face-to-face interview. To overcome the absence of these cues the use of internet language (‘netlingo’) was encouraged throughout the interviews e.g. LOL meaning ‘Laugh (ing) Out Loud’ or ROFL meaning ‘Rolling On the Floor Laughing’. Use of this language enabled participants to convey the mood of the communication and to make social and emotional connections (Mann and Stewart, 2000). The use of ‘emoticons’ (used to convey emotion in a written message) were also permitted. Emoticons offered another textual means to show feelings and added humour or whimsicality (Murphy and Collins, 1997). Emotions were represented by icons e.g. :-) representing smiles, :-( sadness or disappointment. To further put participants at ease with the process they were instructed not to worry about errors or spelling mistakes during the interview, not to attempt to correct them and to continue with the conversation ignoring them if they occurred.

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Text-based communication provided through the use of asynchronous documentary analysis (Stage 1) and synchronous online interviews (Stage 2) provided rich data about individual experiences in relation to eating behaviours and psychological constructs experienced post WLS. The data collected at both stages revealed very ‘private’ detailed accounts of individual experiences. Generally, participants reported enjoying the online interview and the use of the online meeting room. Participant access to it and use of its technology was reliable throughout. Interviews took longer to conduct compared to the traditional face-to-face interview due to the additional time required to type responses. However, participants commented that they enjoyed the experience and many suggested that they felt that in typing their responses they had to focus directly on the question asked – others suggested that this made them give a much more considered response than they would have done in a verbal response. Some participants also revealed that they spoke much more openly giving information that they would not have done if the interview had been undertaken taken face-to-face. Many claimed my ‘invisibility’ enabled them to say what they felt with ease.

Whilst the WLS support website presented a potentially rich resource to strengthen knowledge of the impact of restrictive WLS on eating behaviour and adjustment post surgery, the study and its conclusions may have been limited by additional factors. Participants only included volunteers who were members of the online community and may have only appealed to those who were more computer literate or those who had a high level of interest in or focus on their WLS experience. Nevertheless, the aim was to understand the ‘real lived experiences’ of patients who have had restrictive WLS. In this sense the findings from this research provided ‘… a valuable source of indicative as opposed to easily generalisable data’ (Coomber, 1997:1). Further research will be necessary to confirm the generalisability of the findings. This will be undertaken quantitatively at a later stage.

 

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