A Qualitative Analysis of an Online Forum to Understand How Young People Use This Platform for Mental Health Support

Learning Outcomes

By the end of this case, students should be able to

• Understand methodological issues associated with collecting qualitative data via online forums
• Understand the advantages and disadvantages of this methodological approach
• Consider some of the ethical issues associated with using real-world data from an online setting
• Gain an understanding of thematic analysis as undertaken in this research
• Gain an insight into the “ups and downs” of being a qualitative researcher
• Discuss benefits and challenges associated with external organizations providing real-world data for research

Project Overview and Context

This methods case study is based on one phase of a research project that formed a much larger body of work aimed at understanding support online. This phase of the project was funded by the University of Bolton’s Jenkinson Award, a relatively modest award of approximately £5,000. The project involved three streams of data collection. These three streams included a systematic review of the literature, online focus groups conducted on the live forums and facilitated by a Kooth project worker, and the data under discussion in this case study, focusing upon online static forum data.

The research team consisted of three individuals and was a collaboration between two universities. The lead researcher (J.P.) organized and managed the project. A PhD student (K.U.) was employed as a research assistant from the same university who carried out the data analysis using NVivo software. A third researcher (T.H.) from the collaborating university had a well-established relationship with an online counseling service—Kooth, which provided the data for the study. Within the collaboration, the authors have a track record of work around online therapy (T.H.) and using online methods for data collection (J.P.).

Kooth is an online counseling service for young people aged 11-25 experiencing emotional and mental health problems. It is based in the United Kingdom and provides support that is anonymous, confidential, and free at the point of delivery. The service offers young people a number of services including a themed moderated message forum (the themes at the time of writing were relationships, bullying, eating disorders, depression, self-harm, health, friends, family, and ideas for Kooth). Kooth provided the research team with all the online forum posts between a 2-year period from December 12, 2013, to December 31, 2015. This resulted in a data set of 622 initial posts and 3,657 initial posts with responses. Thematic analysis was employed to elicit key themes from the data set.

Rationale for the Study: Background Literature

Young people are commonly highlighted as a group that are potentially at risk of psychological distress (Coleman & Brooks, 2009; Green, McGinnity, Meltzer, Ford, & Goodman, 2005). Although it has recently been acknowledged that data on young people’s mental health in the United Kingdom are outdated (Mental Health Foundation, 2015), figures suggest that 10% of young people aged 5-16 have a clinically diagnosable mental health problem (Green et al., 2005). According to the Office for National Statistics (ONS) surveys 1999-2004, the rates of mental health problems rise steeply in mid to late adolescence (Green et al., 2005). In a 2005 U.S. study, it was found that 75% of mental health problems are established by age 24 and 50% by age 14 (Kessler et al., 2005). According to the Children’s Society (2008), 70% of young people who experience mental health problems do not receive sufficient intervention early enough. The evidence suggests that although young people may need to access mental health services, they tend not to (Rickwood, Deane, Wilson, & Ciarrochi, 2005), and this lack of engagement is viewed as a challenge by health service providers working with, or trying to reach, young people (Turner, Hammond, Gilchrist, & Barlow, 2007).

The Internet has become a primary source for general information and health information to young people (Fox & Duggan, 2013; Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005). In regard to mental health, the anonymity of online mental health forums has been found to be an important feature and can lead to increased self-disclosure of forum users (Kummervold et al., 2002). When we think about the difference between online and offline support, we need to consider how the affordances of the Internet provide opportunities for young people to reach out to services online they may otherwise not engage with offline. For instance, research has found that young people view online counseling to be more confidential and therefore more appropriate than offline services (Evans, 2014; Hanley, 2012).

The features of anonymity, accessibility, and control (what and how much people disclose about themselves) enable some people to feel safe online. The Internet has the ability to provide a potentially safe place for people to seek support. Caution is required when seeking support and posting personal information online. Young people (and people generally) need to be aware that although they may feel anonymous online and perhaps safe due to this anonymity, their online activity does indeed leave a digital footprint. This digital footprint means what you post online stays online and can be associated back to you. Despite the caution required, the Internet can provide a space for young people to connect with others at a similar age and in a similar situation or people who are experiencing similar difficulties with no geographical boundaries. Due to the removal of geographical boundaries and accessibility issues, the Internet can offer young people both professional and peer support (Prescott, Hanley, & Ujhelyi, 2017), as well as referral to appropriate services (Horgan, McCarthy, & Sweeney, 2013).

There is a growing interest in the area of online counseling and how social media such as blogs can support mental health. However, much of this research has focused on an adult population. The research that has considered young people has tended to be conducted with university-based counseling sites (Hogan et al., 2013; Richards, 2009; Turner et al., 2007) or sites set up specifically for certain conditions such as self-harm or depression (Barak & Dolev-Cohen, 2006; Greidanus & Everall, 2010; Owens et al., 2012). A major contribution of the study discussed here is that the data set is first a large data set and second real-world data.

More About the Study

The overall aim of the study was to gain an understanding of how young people use an online forum for emotional and mental health issues. The study had two main objectives. The first objective was to gain an understanding of the issues young people wanted to discuss or seek support for, as well as to understand how young people started conversations/posts on this site. This objective was addressed through the analysis of the 622 initial posts. The second objective aimed to gain an insight into how the young people provided each other with peer-to-peer support. This objective was achieved through analysis of the 3,657 initial posts and the responses to those posts.

Although the forum provides themes to help guide young people into relevant topic areas, the data were analyzed afresh. This was done to allow the data to lead the theming, an approach that might be considered as an inductive approach to thematic analysis (Braun & Clarke, 2006; Clarke, Braun, & Hayfield, 2015). Thematic analysis and how we analyzed the data will be discussed next.

About Thematic Analysis and How It Was Undertaken in This Project

Qualitative research is concerned with participants’ own experience of life events. The aim is to interpret what participants have said to gain some insight or understanding of their lived experience or to explore in-depth a topic area of interest. To achieve this, qualitative researchers need to use data collection methods which enable participants to express themselves openly and without constraint.

Traditional data collection methods for qualitative research would include face-to-face interviews and face-to-face focus groups. However, the Internet offers qualitative researchers another avenue to collect data. Online qualitative data collection can include email interviews, blogs, forum data (as used in this study), and information posted on social media such as Facebook or Twitter. In this research, we used data from online forums to gain a real insight into how young people support each other on this forum. We will discuss online forums and blogs in more depth shortly, but first we want to tell you more about how we analyzed the forum data.

Data analysis can be challenging in qualitative research. There are no universally accepted rules for analyzing and ensuring quality in qualitative data (Twining, Heller, Nussbaum, & Tsai, 2017). At its simplest, it involves clustering together related types of narrative into coherent themes. According to Braun and Clarke (2006), “Thematic analysis is a method for identifying, analysing and reporting patterns (themes) within data” (p. 79). This is the approach we took to analyze this large qualitative data set.

Analysis can be facilitated with the use of computer software, with one popular program being NVivo, the software we used for the analysis of these data. NVivo is a useful package that allows researchers to manage their data efficiently, allowing the researcher to move easily between the original data and the themed data. It is important to note that the package does not interpret the data and that the researcher still needs to make sense of the information they are examining. We found NVivo to be a very useful tool that is easy to use and is very helpful in organizing your qualitative data which then helps you in your interpretation of the material.

NVivo involves the dragging and dropping of relevant text into relevant nodes (themes) so that the researcher (you) can organize large amounts of text. It can then help you to find and extract quotations from the data when producing a report. To effectively use the software, however, you still need to follow the six-step process as described by Braun and Clarke (2006) and familiarize yourself with the data to know the data and generate themes from it. The six-step approach is as follows:

• Phase 1: familiarizing yourself with your data;
• Phase 2: generating initial codes;
• Phase 3: searching for themes;
• Phase 4: reviewing themes;
• Phase 5: defining and naming themes;
• Phase 6: producing the report.

To analyze these data, we needed to read all the forum posts to get a feel for the data and so we were familiar with the content. The data were really interesting, and once we had all read through and familiarized ourselves with it, we were able to discuss as a team what we had each taken from the data. This discussion enabled us to generate the themes and really think about how young people were using the forum for support. It is during this theming process that the analysis of data moves from description to interpretation. Theming is best described in the following quote: “A theme captures something important about the data in relation to the research question, and represents some level of patterned response or meaning within the data set” (Braun & Clarke, 2006, p. 82). We recommend doing phases 1-3 before starting to use NVivo, and that is how we approached the data in this research. This is a useful approach that enables you to set up NVivo with the themes and subthemes already established. You can then code your data based on the themes. This adds another level to the coding process so the data are coded thoroughly.

The quality of the data and its trustworthiness may be an issue when conducting qualitative research. This issue of trustworthiness may be overcome through the collaboration of the authors by refining the process (Shenton, 2004). When analyzing the posts on the forum for the study, J.P., T.H., and K.U. reviewed the themes and discussed them at length. This enabled us to refine the previously defined themes and subthemes, as well as their hierarchy. In addition, it was important for us all to read the raw data to be able to develop the coding framework. This helped achieve as well as increase inter-coder reliability and ensured the reliability of the results. Once the coding framework was established, K.U. coded the data sets in accordance on NVivo. Thematic analysis involves reading the data a number of times to fully immerse yourself in it and to be able to analyze it. This large data set took time to read and theme. We ended up with the themes of emotional and informational support each with the subtheme of directive and nondirective support to put forward an interpretation of how young people support each other on the forum.

It is also worth mentioning that there are two distinct types of conducting thematic analysis: inductive and deductive. As previously mentioned, in this research, we used an inductive thematic analysis approach. Inductive, or bottom-up thematic analysis, is driven by the data. This means that themes are pulled out of the data without direct consideration of pre-existing coding frames or the researcher’s preconceptions. So, in this research, we read the forum data to decide what themes were emerging from the data, hence inductive approach.

In contrast, deductive or top-down analysis is theory-driven. This means that the analysis is driven by the researcher’s theoretical interests and is more analyst-driven. The process might therefore involve coding for a specific research question. Other considerations involve semantic or explicit analysis, as compared with latent or interpretative analysis. In semantic analysis, themes are identified within the explicit or surface meaning of the data; that is, what the participant has said/written, whereas latent analysis involves the researcher going beyond the semantic content to examine the underlying ideas and assumptions. We used a more latent analysis to gain an understanding of what we termed the directive and nondirective support we viewed as an important finding from these data (more on this later).

Using Forums for Research Purposes: Benefits and Challenges

There are two types of gathering data online via forums: (1) the forum is being purposely set up for research purposes so it would be an active tool where participants are recruited and asked to engage and (2) the forum (or blog) already exists where researchers can observe the already established input (often referred to as blog mining). Analyzing data from social media, such as Facebook, would also constitute as this type of data collection.

Both forms of data collection mentioned above use asynchronous techniques, where the researcher and the participant do not need to be online at the same time, and there is often a time delay between what is written and when it is read. Asynchronous approaches allow researchers to tap into considered and reflective responses, compared with “off the top of the head” synchronous responses such as face-to-face interviews (Hanley, 2011). We will discuss both forms of data collection in more detail next.

Ethical Considerations

All research using human participants need to consider any ethical issues that may arise from the study. Informed consent, anonymity, and confidentiality are basic ethical considerations for any researcher. The ethical issues for the set up for research purposes online data collection is very similar to more traditional ethical considerations. For instance, participants would be able to provide informed consent in the same way. However, when the data are used for research which was not the intended use, a number of different ethical considerations arise. Remaining mindful of the four main ethical principles, as outlined by the British Psychological Society (BPS) code of human research ethics (2010), is therefore essential. These are as follows:

• 1.
  Respect for the autonomy and dignity of persons;
• 2.
  Scientific value;
• 3.
  Social responsibility;
• 4.
  Maximizing benefits and minimizing harm.

The issue of public versus private domain is an essential consideration when conducting research online (BPS, 2013). This distinction is important because if the communication is considered private, informed consent is required. However, if the communication is in the public domain, this information is often considered available for research purposes if treated with due respect of the individuals involved. When considering if information available online is public or private, it is advisable to consider the ethical principles of distance and perceived privacy (Lomborg, 2012). The distance principle enables the researcher to consider the conceptual distance (the closeness) between the data that the researcher is interested in using in their study and the person who produced it. For this research, the distance between the data and the person may be viewed quite small because the data involve personal accounts from young people about their mental health, their personal experiences, and concerns about their mental health and emotional issues. In contrast, a large distance might involve, for example, the number of times the young people discussed depression on the forum.

Perceived privacy is concerned with how the participant may view their information online as private or not. Perceived privacy blurs the boundaries of private and public domains. Just because information is public, does that mean the producer of that information is aware that it is public? As noted, these data are real-world data so we need to consider a number of questions: Did the young people know we would use their accounts and discussions for this research? Did they presume that their posts were private and for Kooth staff only? Kooth do indeed explain to young people at sign up that some data may be used for research and evaluation as will be used in reports and publications. It is also an ethical consideration for researchers using data from companies that have stated in their terms and conditions that the data may be used for research purposes. Flick (2016) provides a very interesting case study through the Facebook emotional manipulation study, arguing that any information about the data being used for research purposes should not be buried deep within a lengthy terms and conditions statement and should instead be very clear in order for people to provide informed consent.

There is controversy around researchers using online communities for research purposes. In some instances, researchers can destroy the community due to their presence (Eysenbach & Till, 2001). Utilizing open access data from the Internet including social media is an important issue for researchers. Individual projects need to consider the ethical issues of collecting data via online sources. The Association of Internet Researchers (AoIR, 2012) states that there is not a one-size-fits-all approach that can be taken when considering Internet research. The AoIR (2012) suggests that researchers need to consider the ethics on a case-by-case basis (Markham & Buchanan, 2012).

Despite ethical considerations, which we considered at every level within this research, we are in agreement with Golder, Amed, Norman, and Booth’s (2017) recently stated viewpoint that “we cannot afford to miss the considerable potential of social media research and its unique contribution to knowledge” (p. 14).

This research was in partnership with the mental health service Kooth. Before Kooth provided us with the data, a data agreement was provided by Kooth and signed by T.H. and J.P. The data agreement states how we can use the data in terms of the agreed research that will be conducted on the data provided. This type of agreement is often required due to the potentially sensitive nature of the information being shared, and we followed the terms within this data agreement.

Anonymity is an important consideration in any research and the Internet can afford people anonymity relatively easily. For instance, the information required to join Kooth is limited to ensure that young people remain anonymous (this includes their location in the United Kingdom, gender, ethnicity, and the year and month they were born). The young person then sets up a username and password to post on the forum and use the services offered by Kooth. Although we decided to use full quotations from the forums in publications to give a transparent flavor of the communication, the only identifiable material related to the young people in the data set was their username. Because the young people are posting on the forum for genuine rather than research purposes, we decided not to include any username details and changed any specific information so that quotes are unidentifiable. It is important to highlight that direct quotes can be traced back to an individual and this can violate the individual’s anonymity, confidentiality, perceived privacy, and security (Rooke, 2013). Due to the end-to-end encryption on the website, Kooth content cannot be searched for in search engines. Despite this knowledge, to make sure that the anonymity of the participants was maintained to satisfy our ethical concerns, we copied the quotes that are used in publications and tried to search for them online ourselves. Although we acknowledge that we may not be the most proficient online searchers, we do, however, feel that this method enabled us to see whether the quotes are easily traceable to the individual poster. Ultimately, in reflecting upon the ethical decisions made while conducting this research, we feel we have treated the data and the individuals who generated the data with respect and as securely as possible. All publications resulted from the study have been shared with the organization research lead, as stated in the shared data agreement document, prior to publication adding another layer of ethical consideration to the data.

Results of the Study

The research brought a wealth of interesting findings. The young people felt comfortable discussing and disclosing issues related to their mental health and emotional well-being via the moderated forums. It is perhaps due to the anonymous nature of online communication that enables this environment to feel safe to discuss and disclose, as Kummervold et al. (2002) have previously suggested. What was notable, and a principal finding from the research, was that the young people provided each other with both informational and emotional support, from what the authors termed a nondirective and directive way (Prescott et al., 2017). The nondirective approach refers to young people providing support by sharing their own experiences. These posts do not include explicit advice to act in a particular way, but the sharing process is hoped to be of use to the poster. In contrast, the directive approach involves individuals making an explicit suggestion of what they believe the poster should do.

Overall, we found that the findings from the study tended to support previous findings related to the affordances of the Internet benefiting young people seeking support online (Evans, 2014; Hanley, 2012; Horgan et al., 2012; Walther, 2004; Webb, Burns, & Collin, 2008).

Reflections

Working on this project has been interesting but not without its challenges. Qualitative analysis is often more time-consuming than quantitative methods, and this is often the reason why students decide not to approach qualitative methodologies. For this study, we had a lot of information to process; thus, reading and theming took time. A challenge we encountered was managing the large amount of data we had to analyze, a factor that meant that NVivo often struggled and would frequently crash. We liaised with both the University IT team and often with NVivo support services to rectify the problems we encountered with the software. This took perseverance and time away from the analysis and was very frustrating at times, especially for K.U. The main reason for why we had issues with the software was because the university had not installed it as a main program and we were using it by remote access. This was eventually resolved by the package being installed on the computers of J.P. and K.U. Working with an external organization is a great way to access information that you may otherwise not have access to, but relying on an external organization needs a good strong collaboration to receive the data in a timely fashion. We were lucky in that one of the research members (T.H.) had a well-established relationship with the organization. Despite the established relationship, the organization, whose staff are incredibly busy supporting young people with mental health issues, did need to be asked on a number of occasions for the data they had agreed to supply. Persistence was therefore required. We were, however, lucky to be working with a supportive partner, but, as previously mentioned, external organizations may delay a project due to their own needs and wants (e.g., providing information while they have a busy agenda or reviewing papers). With this in mind, it is advisable to consider the implications of an external organization to the research at the start of the project. Specifically, you might consider their role, how communication will be arranged, and having a data agreement at the outset of a project is highly recommended.

As a PhD student, K.U. posits that it is crucial to be able to work and learn independently. Becoming a research assistant helps learning through real-life practice of research skills and by having the opportunity to work in collaboration with experienced researchers. This gives students first-hand experience in the ups and downs of the life span of a research project. Building on previous knowledge, it enables students to put theory into practice. Students have the opportunity to improve numerous skills that will be useful in their career, such as teamwork, communication skills, computer skills, research methodology, and report writing skills. The practical knowledge that can be gained through such projects is invaluable and makes students more resilient in their future endeavors.

Conclusion

Using real-life data is valuable for researchers interested in understanding human experience. The Internet provides qualitative researchers with a wealth of social interaction and behavior that is not necessarily obtained in an artificial setting. The online forum data used in this research is one such data set. This case study highlights a number of the benefits and challenges of using online forum data for qualitative research. The case study has discussed some of the practicalities of conducting research and the considerations that need to be borne in mind when using the Internet as a source of data collection, especially the widely debated ethical considerations of Internet-based research.

Exercises and Discussion Questions

• 1.
  What do you view as the advantages of using real-world data, such as forum or blog data, in research?
• 2.
  What are the disadvantages or potential challenges of using real-world data?
• 3.
  Thinking of your own social media use, how do you view this as being in the public or the private space? Describe how you might react to information about yourself that is available online in the public domain being used for research.
• 4.
  This methodological approach has been used in this case study with young people. Discuss how this approach could both potentially reach and also potentially exclude other demographics.