Preliminary Findings
This review has synthesized the findings from 8 studies focusing on the role and value of online forums for patients undergoing bariatric surgery. These early qualitative studies have shown how online forums can assist in supporting patients’ emotional and informational needs [37]. The value of peer-to-peer connectedness has been well documented in previous settings, with authors acknowledging benefits in quality of life and care satisfaction [38-40]. Not only does connectedness with peers allow for informational support, but it also provides emotional support and reassurance [41]. Online forums offer the opportunity to engage with a vast community of peers, which can be particularly beneficial for anyone who feels socially isolated [22].
Preoperatively and postoperatively, patients acknowledged the benefits and value of peer support in helping to maintain their own responsibility and motivation. This is not a new theme in the literature, where social connectedness and peer support have been linked to enhanced postoperative weight loss [14,42]. Atwood et al. [25] discussed that the frequency of informational peer support was higher in postoperative forums. They reported that posters readily shared their personal strategies as topics of information, such as ways to manage physical side effects or symptoms following surgery, and posting nutritional advice for adhering to lifestyle adjustments. The authors hypothesized that this information was likely to be reiterated from information provided at bariatric specialist appointments [25]. Given that a previous work has found that patients struggle with retaining information provided at specialist appointments [43], online forums could help to reinforce the ongoing educational messages throughout the surgical pathway.
It is well-evidenced that attendance at postoperative bariatric follow-up assessments is poor, with contributing factors relating to travel burden, geographical isolation, and time commitments [44-46]. Furthermore, patients have reported not seeing the value in postoperative clinics because the surgery had already been completed [47-50], and some preferred not to share sensitive information about their surgical journey in front of others [49]. Online forums can play a role in complementing traditional care and providing ongoing postoperative support, while helping to overcome these challenges. Studies have demonstrated that the content of online forums closely matched that of face-to-face clinics, meaning that patients are seeking support in the same subject areas [13]. Perhaps delivering this support via an online forum could be a way of overcoming these barriers, providing patients with the peer-support exposure they would be given if it were face-to-face, but ensuring anonymity for information sharing.
Internet-based forums, involving both health care professionals and patients, also existed in the wider literature, previously termed online health communities [31]. Patients have reported the benefits of utilizing these online forums for many health-related conditions, as well as for bariatric surgery [25,36,51,52]. In their review into the empowerment effects of online forums and support groups, Bartlett and Coulson [30] discussed the benefits of promoting active collaboration between the patient and their personal doctor [30]. The authors concluded that online forums increase patient empowerment and positively affect patient–provider encounters, leading to beneficial impacts on health-related outcomes and behavior change. Patients reported increased feelings of accountability and responsibility to adhere to healthier lifestyles and treatment plans as a result of digitally enabled connectivity with health care professionals [30]. These findings are also echoed in the wider health-related literature [37,53,54]. This receptivity toward positive health behaviors has also been associated with the concept of teachable moments [55,56]. A teachable moment is defined as “an event that creates an opportunity for positive behavioural change” [57]. Perhaps digital technologies and online forums hold value in this, where engagement with providers can opportunistically exploit patient insight to encourage healthy behaviors and empower to improved postoperative outcomes.
Despite the advantages of online forums, and digitally enabled health care, there are notable challenges too, particularly in understanding the digital divide and ensuring the accuracy of content and information being shared [51,58]. The digital divide refers to a gap in the access and use of technology [59,60], but with recent statistics supporting regular internet use by over 90% of the UK population, perhaps it could be better interpreted as “inequalities in understanding and interpreting the information” [1,61]. The digital divide has been acknowledged as a threat specifically to disadvantaged, minority, and older patients, as well as to those with lower sociodemographics and educational attainment [60,62,63]. In their review concerning the digital divide in health care, López et al. [62] call for the careful design and implementation of digital health interventions with the potential to eliminate disparities and bridge the digital divide, “we should ensure that disparities are not simply an afterthought for digitally enabled health care.” Despite increases in the integration of digital and online interventions, the digital divide is important to acknowledge in order to best support patients [61,64,65].
Sanders et al. [66] identified barriers to using online forums, reporting the main factors to be low health literacy, disinterest, and increased costs. Findings from a related study reiterate similar barriers as recognized challenges when it comes to the role of online forums for patients undergoing bariatric surgery [32]. We must not forget that there continues to be a population who prefer to use face-to-face contact with health care professionals or forms of traditional media (such as leaflets or books) as their primary source of health information [3,38,67]. Understanding the reasons behind this could be a pivotal finding in overcoming barriers to usability and uptake. This cohort should not be forgotten when it comes to introducing technology-delivered health care solutions; there is a risk of minorities falling further behind and widening the gap. Perhaps this supports the argument for implementing digital technologies (such as online forums) to complement traditional care, instead of replacing it.
Given the high acceptability (and engagement) of online forums, it would be prudent to consider the nature of the information shared, and the credibility and accuracy of the posts [31,33,35,68]. Many bariatric surgical forums are dominated by peer-to-peer communication without professional supervision or involvement. In their review, Li and Suh [69] reported that users associated credibility of posts with certain factors; increased presence of particular users (mainly how often they interact with posts) and posts that share anecdotes of personal experiences are perceived to be of higher credibility [69]. In another study, the content and accuracy of nutrition posts in a bariatric surgery Facebook group were evaluated [35]. The authors of that study raised concerns about the fidelity of the information posted, and encouraged health care professionals to caution patients when interpreting forum discussions [35]. They recognized benefits that may come from a greater presence of health care professionals in online groups, referring to potential roles in moderation of posts and provision of evidence-based recommendations [35]. Further to this, Lindsay et al. [70] reported that having a moderator in an online support group for heart disease meant patients were more likely to adhere to advice, and thus more readily maintaining healthy behaviors. Similar findings were reported by Graham et al. [9], but this time from the perspective of a bariatric surgical health care professional [9]. Members of the surgical team specifically acknowledged that information shared which originates from other countries may conflict with the advice from UK recommendations, and that discussions about dietary intake may not be adequately tailored for those recovering from bariatric surgery [9].
It is clear that online forum content is an area that would benefit from further research in order to systematically review the data and better appreciate the place of digital support in a modern health care system. Surgical team members should consider the availability of digital support, and the possibilities or detriments this could have on patients before and after surgery.