A Structured Social Media Health Support Program after Bariatric Surgery

Abstract

Background Social media networks have been found to provide emotional, instrumental, and social support, which may contribute to improved adherence to postbariatric surgery care recommendations.

Objectives This study aimed to evaluate the impact of an online social media-based, health care professional-led, educational and support program on patients' long-term engagement with and adherence to follow-up guidelines, self-care recommendations, and weight management after bariatric surgery.

Methods An observational cohort study, employing mixed methods, accompanied a 12-week interactive, structured, social media psychoeducational intervention program delivered on Facebook. Program participants, who had undergone one bariatric surgery within the past 1 to 7 years and were at least 18 years old at the time of surgery, were invited to join the program via posts online. Interested individuals were provided information about the program and the accompanying evaluation study, and those who met requirements completed study questionnaires before and after the program. Questionnaires included demographic and anthropometric information; postoperative recommendations received and their clarity and implementation; attitudes toward recommendation adherence; and well-being. Daily system data on program engagement were collected from the Facebook website.

Results Of the 214 participants enrolled in the program, 101 (80.2% female, mean age 43.8 ± 9.1 years and mean body mass index 30.2 ± 6.8 kg/m², 1–7 years after bariatric surgery) completed both baseline and end-of-program questionnaires and were included in the analysis. Following the program, improvements were observed in most aspects of participants' adherence to postoperative recommendations and well-being. Close to half of the participants (44.6%) reported reaching their postoperative target weight at the end of the program or maintaining it throughout the program. Video posts drew higher participant engagement than other media, and content about proteins received the highest number of reactions. However, participants' active engagement gradually declined over time.

Conclusion Interactive health support on social media can positively enhance patient engagement, adherence to treatment recommendations, health outcomes, and overall well-being.

Keywords

social media - customer health informatics - continuity of care - patients with chronic illness - social networking - internet-based program - bariatric surgery - obesity

Background and Significance

Adherence to postbariatric surgery follow-up appointments is correlated with improved health outcomes.[1] [2] [3] [4] A systematic review and meta-analysis of studies on adherence to follow-up after bariatric surgery found that patients who meet routine postoperative follow-up care for 6 months to 3 years lose more excess weight than patients who do not adhere to the scheduled visits.[5] Furthermore, patients who fail to adhere to the recommended medical follow-up regimen are at higher risk for postoperative complications, including weight regain and obesity-associated morbidity, such as diabetes (∼50%); cardiovascular diseases, specifically hypertension (60–70%); and airway-related diseases (e.g., obstructive sleep apnea).[1] [6] [7] These complications may be due to eating behaviors, such as uncontrolled eating or grazing (17–47%), not following dietary advice, and lack of physical activity; as well as physical responses, such as hormonal changes that boost appetite and cravings, resulting in higher calorie intake. In a study of 1,406 patients following bariatric surgery, the average weight regain (from the lowest postoperative weight) steadily increased over time, from 5.7% at 1 year to 15% at 5 years. Further, the percentage of patients who experienced at least 10% weight regain increased from 23% at 1 year to 72% at 5 years postsurgery.[8]

In keeping with postbariatric guidelines around the world,[9] [10] the Israeli Ministry of Health recommends that in the first year after surgery, at least three follow-up visits should be conducted at the multidisciplinary bariatric center where the surgery took place. Thereafter, follow-up should be conducted by a family physician in the community, based on recommendations the patient received at the bariatric center. Patients should also be referred for follow-up by a dietician, physiotherapist, and social worker/psychologist; and patient weight, hemoglobin A1c (among patients with diabetes), mood, malnutrition/sarcopenia, bone density, and other measures should be monitored as needed.[11]

The rate of adherence to follow-up among bariatric patients widely varies and ranges between 3 and 63%[1] [12]; however, since many patients do not undergo postoperative monitoring, adherence rates may be overestimated.[13] These low rates arise from the challenges that patients often face after bariatric surgery, including socioeconomic, social, geographic, and transportation issues that prevent them from seeking further assistance or support to improve and maintain weight loss outcomes.[13] [14] [15]

A growing body of evidence shows that group meetings (in-person, via video conferencing, or in virtual environments) can increase adherence to postbariatric surgery care. Group meetings provide social support by allowing for experiences to be shared.[16] [17] [18] [19] Online social media networks (SMNs) often serve as platforms for health support groups.[20] [21] [22] [23] Such groups, managed on SMNs via Facebook and similar platforms, have been reported to enhance self-care among patients with chronic diseases.[24] Moreover, SMNs have been found to provide emotional, instrumental, and social support to patients in general[25] [26] and to be effective communication platforms for weight loss interventions in obesity medicine.[24] [27] [28] Conversely, in the context of public health and medicine, the effectiveness of social media has not been fully demonstrated.[29]

SMNs are used for advice and support on bariatric surgery-related health care concerns among patients who underwent bariatric surgery.[30] [31] [32] In addition, studies have shown that using internet-based health interventions can positively affect participants' health.[33] [34] [35] [36] In one study, frequent users of Facebook groups for patients after bariatric surgery, operated by a bariatric center, achieved greater weight loss levels than others during the first 2 years after surgery.[19] However, despite patients' use of SMNs, to the best of our knowledge, health care professionals do not use these platforms beyond providing access to prepublished resources, responding to patients' queries, and supervising sharing of experience. Therefore, our program was designed to narrow the gap in psychoeducational interventions after bariatric surgery.

Objectives

In this study, we aimed to evaluate the impact of an online social media-based, health care professional-led, support program on patients' long-term engagement (1–7 years' postsurgery) with and adherence to follow-up guidelines, self-care recommendations, and weight management after bariatric surgery.

Methods

We conducted an observational cohort study that accompanied an SMN health support program aimed at increasing adherence to long-term, health-related follow-up recommendations among patients 1 to 7 years after bariatric surgery.

Social Media Networks Health Support Program Description

A 12-week internet-based program was delivered in Hebrew via a private Facebook group created for this purpose, from April 1, 2021, to June 24, 2021. After enrollment, participants were granted access to the group. To ensure confidentiality, the group was given a generic name, entitled “Bariactcare.” Further, upon joining the group, participants were required to agree to the group rules, including not to share personal content and member information beyond the group. The group became inactive at the end of the program but remained open to allow members access to program content.

The program was divided into two 6-week phases. The first phase comprised intensive content delivery (posts) twice a day on weekdays and once a day on weekends. During the second phase of the program, the content provided in the first phase was expanded upon with additional highlights and delivered in the same manner and timing as before ([Fig. 1]).

Fig. 1 Flowchart of program and study components. This figure presents an overview of the intervention program and the study components. Top row: Participant recruitment was conducted 2 months prior to the intervention among people enrolled in the program. The intervention was divided into two 6-week phases: (1) intensive content delivery and (2) the content was expanded upon with additional highlights. Bottom row (arrows): Participants completed the study questionnaire prior to and at the end of the intervention. Two weeks after the intervention began, 10 participants were individually interviewed to gather feedback on the content and its delivery; at the end of the intervention, another 10 participants were interviewed on their overall experience of the program.

The program focused on three main topics: nutrition, physical activity, and emotional support. The content was written by experts in nutrition, psychology, nursing, physiology, and physical activity, who are experienced in bariatric medicine and employed by accredited health care organizations. The content was later refined based on feedback from a patient panel composed of three representatives of the program's target population, who were active in relevant social media groups at the time of the study. To ensure the suitability of the program content and its delivery methods, a random sample of 10 program participants was individually interviewed by telephone 2 weeks after the program began. Interviews followed a brief interview guide of 12 closed-ended questions and one open-ended question on post topics, types, timing, and frequency. As participants' responses indicated no significant issues or unmet needs, the program was not modified after these interviews.

The content was delivered to the Facebook group in posts of various forms, including information pages, infographics, educational lectures, participant videos about their postbariatric surgery process to inspire and empower others, and live sessions with experts and web “influencers.” Some posts also included activities related to nutrition and mental and physical health. Delivery methods were determined based on consultations with a group of experts and end-users and aimed to cater to different learning preferences, to make content relatable and engaging, and to offer opportunities for participant interaction and direct engagement with experts and peers. Overall, decisions on delivery forms were driven by the desire to maximize intervention effectiveness and accessibility for the intended audience.

The influencers were identified in a preliminary search of SMNs and appeared to be very active in the area. They had at least 5 years of postsurgery experience and had previously shared their stories on several SMNs. The influencers did not receive payment for their contribution to the program.

In the first week, participants received an overview of the program, including the themes that would be discussed each week. Weekly subthemes were posted at the beginning of the week. Each week was dedicated to specific health-related topics. Summary and highlights of the week's content were posted on Friday, and the topic of the upcoming week was posted on Saturday evening. Participants could also choose to receive notifications about new posts by joining a voluntary WhatsApp group.

The content was delivered in the following order during the program: acquaintance with the program leaders and the program; active lifestyle; proteins and nutrition (in general); feelings; building muscles; choosing healthy oils; carbohydrates; emotional eating and aerobics; ongoing behavioral support (“We are here for you”); vitamins and minerals; common symptoms after bariatric surgery and symptom management; body image; family and marital relationships; summary, closure, and end of the program ([Supplementary Appendices 1], [2]; available in the online version). Program content was developed by experts in the field and based on well-established guidelines and research evidence.[10] [37]

In addition to the program content, participants were regularly invited to respond to knowledge and opinion questions and to watch health-related Zoom lectures by experts. These invitations were added to scheduled posts by the program team. Participants' responses could be viewed by all group members. Participants could privately message the program administrator, if they preferred to respond privately. It is important to note that engagement in the “Bariactcare” group could not be anonymous nor anonymized using Facebook platform features at the time of the program.

Study Design

Study Population and Recruitment

Study participants were recruited among participants enrolled in the program and met the programs' inclusion criteria. All program participants had undergone bariatric surgery (i.e., laparoscopy gastrectomy sleeve, one-anastomosis gastric bypass [OAGB], laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or biliopancreatic diversion with duodenal switch) 1 to 7 years prior to enrolling in the program and were 18 years of age or older at the time of the bariatric surgery. Country of surgery or residence after surgery was not limited to Israel since the principles of postoperative bariatric recommendations are comparable across the world. Body mass index (BMI) was not considered a requirement in order to allow interested postsurgery patients to refresh their knowledge and not necessarily to attempt to lose weight.

Individuals who had undergone more than one bariatric procedure in their lifetime, who were not proficient in Hebrew (as the program was in Hebrew), and who did not have access to a regular internet connection were excluded from the program. Participants who expressed persistent discomfort with the program or withdrew from the program during its first month were excluded from the study. Only participants who completed data collection at two time points—prior to the program and at program completion—were included in the study analysis.

Participant enrollment in the program and recruitment to the accompanying study were conducted via online posts on Facebook in groups whose target audience was bariatric patients and on an online bariatric patient forum, with an invitation in Hebrew to contact the study team. These channels were selected to reach potential participants in the similar virtual environment to the one in which the program was delivered. To ensure participants' anonymity, the list of the Facebook groups and forums used to recruit the participants is not disclosed herein but is available from the lead researcher upon reasonable request. The study coordinator provided interested individuals with information about the program and the accompanying evaluation study by e-mail. Individuals interested in participating in the program were asked to complete an online questionnaire. They were notified that by completing the questionnaire, they agreed to participate in the accompanying study and would be asked to complete an additional questionnaire at the end of the program. Participants were also notified that choosing not to be included in the study would not affect their participation in the program.

Data Collection

Participants were asked to complete an online questionnaire before and at the end of the program on their perceptions of the recommendations they received for long-term postoperative care, long-term treatment guidelines and adherence, and well-being. Questions about participant satisfaction with the program were included in the postprogram questionnaire. The questionnaire, which was delivered via e-mail, WhatsApp, and Facebook, included five sections:

1. Basic demographic (sex, age, and education) and anthropometric (weight and height) information; expected postoperative weight loss; weight loss status (achievement/maintenance) at program enrollment (preprogram questionnaire); and weight loss status at the end of the program (postprogram questionnaire).

2. Instructions received on postoperative care: level of instruction implementation on a 5-point Likert scale (1 = very low, 2 = low, 3 = moderate, 4 = high, 5 = very high). Cronbach's alpha was 0.83 in the preprogram questionnaire and 0.77 in the postprogram questionnaire, indicating high internal consistency.[38] An additional question appeared in the postprogram questionnaire regarding consultations with health care providers about postoperative care due to the program.

3. Perceptions on adherence to long-term postoperative guidelines and recommendations: 19 items were drafted according to the Health Belief Model, which predicts health-related behavior based on health beliefs.[39] [40] The items included: (a) perceived risk of nonadherence to guidelines, three items (e.g., “If you do not adhere to the guidelines, there is a chance that your weight will return to the previous state”); (b) perceived barriers to guideline implementation, five items (e.g., “I do not have time to go to the clinic for clarification and follow-up”); (c) perceived benefits of adhering to the guidelines, four items (e.g., “if you follow the guidelines, you will feel more energized”); (d) perceived self-efficacy in following guidelines after bariatric surgery, seven items (e.g., “I have the ability to do whatever it takes according to the guidelines”). Participants rated each item on a 5-point Likert scale (1 = “strongly disagree,” 2 = “disagree,” 3 = “undecided,” 4 = “agree,” 5 = “strongly agree”). Cronbach's alpha was 0.84 in the preprogram questionnaire and 0.76 in the postprogram questionnaire, indicating high internal consistency.[38]

4. Subjective psychological general well-being: the five-item World Health Organization Well-Being Index (WHO-5) questionnaire,[41] which measures positive mood, vitality, and general interest in the 2 weeks prior to completing the questionnaire. Items are rated on a 6-point Likert scale (0 = “never,” 1 = “some of the time,” 2 = “less than half of the time,” 3 = “more than half of the time,” 4 = “most of the time,” 5 = “all of the time”). A validated version in Hebrew—available on the website of the Psychiatric Research Unit, Mental Health Centre North Zealand, Hillerød, Denmark, developers of the WHO-5 questionnaire—was used.[42]

5. Expectations from the “Bariactcare” program: expectations prior to the program appeared at the preprogram time point and fulfillment of expectations appeared at the end-of-program time point. Participants were asked to choose one or more of the following aspects: acquiring knowledge, improving the ability to adhere to postoperative recommendations, increasing health habits, emotional support, improving health, and improving mood. Space was left for participants to add other aspects.

Quantitative data on participant engagement in the program (i.e., automated system data) were collected from Facebook in aggregate. In addition, at the end of the program, 10 participants were randomly selected to participate in a telephone interview on their overall experience of the program, with an emphasis on the topics covered and the delivery methods. These interviewees were not the same participants who were interviewed at the beginning of the program. These interviews were conducted by the senior researcher of the study. Pre- and postprogram questionnaires were anonymized by assigning a code number to each participant in the program. These codes allowed the researchers to match participants' pre- and postprogram questionnaire responses. Interview data were anonymized prior to analysis.

Data Analysis

Statistical analysis included descriptive statistics of central indices, dispersion indices, and proportions and segmentation according to demographic and anthropometric variables, well-being scores, program engagement levels, and Facebook group activity obtained from Facebook system data. Results are presented as mean and standard deviations for continuous variables (by considering Gaussian distributions) and as frequency and percentages for categorical variables. Chi-square tests and t-tests were used to compare variable distribution or means before and after the program. The significance threshold (p) was set at 0.05. Quantitative data were analyzed using IBM SPSS Statistics for Windows, version 26. Qualitative data were categorized by two researchers into topics. Results may be biased as the study accompanied a program that was implemented independently of this research. Limitations are discussed further in the Discussion and Conclusion sections.

Results

A total of 214 participants met the inclusion criteria, enrolled in the program, and completed the preprogram questionnaire. Two participants withdrew from the study during the first month due to unmet expectations from the program. Of the remaining 212 participants who completed the program, 101 (47.2%) completed both the pre- and postprogram questionnaires and were included in the study ([Fig. 2]).

Fig. 2 Flowchart of study population inclusion process. The program included 214 participants who met the inclusion criteria and completed the first questionnaire, of whom 2 did not complete the program. At the end of the intervention, 101 participants completed the second questionnaire and were included in the study analysis.

Participants' Demographic and Anthropometric Characteristics

Among the 101 participants who completed the study, 81 (80.2%) were female. Participants' mean age was 43.8 ± 9.1 years and mean BMI was 30.2 kg/m² (20.6 kg/m² minimum and 77.0 kg/m² maximum) at the beginning of the program. Most participants (74.3%) had postsecondary education (nonacademic or academic). The most common bariatric surgery that participants had undergone was OAGB (78.2%). Prior to the program most participants used Facebook more than once a day (91.9%) and 61.3% more than three times a day. There were no significant differences in baseline characteristics between all enrolled program participants (n = 214) and the participants who were included in the final analysis (n = 101; [Table 1]).

Table 1 Demographic and anthropometric characteristics: program and study participants

	Program participants n = 214	Study participants, n = 101	p-Value
Sex, %
Female	86.9	80.2	0.123
Male	13.1	19.8	0.123
Age, y, mean ± SD	42.7 ± 9.0	43.8 ± 9.1	0.314
Education, %
High school	29.9	25.7	0.441
Higher nonacademic education	27.1	30.7	0.508
Academic education	43.0	43.6	0.920
Body mass index, kg/m2, mean ± SD	29.7 ± 5.8	30.2 ± 6.8	0.500
Bariatric surgery
One anastomosis gastric bypass	80.8	78.2	0.591
Sleeve gastrectomy	10.7	11.9	0.752
Roux-en-Y-gastric bypass	5.1%	5.9%	0.769
Laparoscopic adjustable gastric banding	2.8%	3.0%	0.921
Biliopancreatic diversion with duodenal switch	0.5%	1.0%	0.610

Abbreviation: SD, standard deviation.

Adherence to Long-Term Health Recommendations following Bariatric Surgery before and after the Program

The participants were asked to report on their level of adherence to various components of long-term postoperative care instructions ([Fig. 3]). Following the program, more participants agreed that they follow postoperative recommendations compared with the preprogram period. A statistically significant increase was found in participant adherence to a healthy diet, physical activity, periodic blood tests, and follow-up meetings with a physician. In addition, 24.8% reported that participating in the program prompted them to interact with a health care provider regarding long-term postoperative follow-up.

Fig. 3 Likert plot of levels of adherence to long-term postoperative care recommendations. *p < 0.05, **p < 0.01.

Perceptions Regarding Adherence to Long-Term Postoperative Recommendations

Study participants were asked about their perceptions regarding adherence to clinical and health-related long-term postoperative recommendations. At the end of the program, the number of participants who perceived nonadherence as risky ([Fig. 4A]) and adherence as doable ([Fig. 4D]), more difficult ([Fig. 4B]), and beneficial to maintaining outcomes ([Fig. 4C]) increased.

Fig. 4 (A–D) Likert plots of perceptions on adherence to long-term postoperative care recommendations. (A) Perceived risk of nonadherence to postoperative recommendations. (B) Perceived barriers to adherence to postoperative care recommendations. (C) Perceived benefits of adhering to postoperative care recommendations. (D) Perceived self-efficacy in following postoperative care recommendations. *p < 0.05, **p < 0.01

Psychological Well-Being

The mean WHO-5 well-being score significantly increased after the program (16.55 ± 5.49 before the program vs. 18.29 ± 5.35 at its end, p < 0.01), representing improvement in psychological well-being of the study participants.

Desired Weight after Bariatric Surgery at Pre- and Postprogram Time Points

Prior to the program, 32.7% of the study participants reported that their weight was their postoperative target weight. After the program, close to half (44.6%) of the participants reported that their weight was their postoperative target weight.

Expectations from and Satisfaction with the Program

Seventy percent of the participants reported being satisfied to highly satisfied with the program. Only 9.50% reported that the program failed to meet their expectations due to no (or insufficient) new knowledge in program content regarding postoperative care. Before the program, most participants (80.7%) expected to acquire knowledge during the program; after the program, 79.3% reported that their expectations were fulfilled. However, while most participants (79.2%) expected the program to improve their ability to adhere to postoperative recommendations, only 44.8% reported that these expectations were fulfilled. Further, while most (78.8%) expected to improve their health habits, only 55.2% reported that these expectations were fulfilled. Over half (56.4%) expected emotional support, but only 37.1% reported that these expectations were fulfilled. Less than half (39.8%) expected to improve their health and a similar percentage 38.8% reported that expectations were fulfilled. On the other hand, while only 24.6% expected the program to improve their mood, 31.9% reported that their expectations in this regard were fulfilled.

Participant Engagement with the Program on Facebook

We tracked participant engagement in the Facebook group by post type and content. The mean number of engagements (i.e., views, likes, and comments) per post gradually declined over time in the program ([Fig. 5]). Video posts drew a higher mean number of engagements than text posts. Excluding the posts in which participants became acquainted with the program and the program leaders, posts on proteins garnered the most engagements on average, followed by physical activity, general nutrition issues, and emotional support ([Table 2]).

Table 2 Engagement in the Facebook group by type of post and content topic

	Number of posts	Views (mean)	Likes (mean)	Comments (mean)
Type of post	137
Text	115	119	18	11
Video	22	126	27	25
Topic
Acquaintance	7	219	66	42
Physical activity	29	130	20	8
Nutrition	38	114	15	7
Proteins	6	180	31	16
Nutrition and emotional support	2	82	12	2
Emotional support	24	99	13	4
Other	31	104	16	7
Total	137	120	19	10

Fig. 5 Participant engagement per type of post. Graph representation of the mean number of SMN post engagements during the program. The number of participants' post views, by post date is represented by the blue line. The drops in views correspond with two national holidays (Memorial Day and the Shavuot holiday), when there were no posts, and a 10-day national safety-related event. The green line which represents the number of likes and the light-blue line the number of comments demonstrates the gradual declined of active engagement, mainly after the first month.

Participant Feedback on the Program

Analysis of participant feedback from the postprogram questionnaire and from the telephone interviews revealed that the participants wanted more live, face-to-face video sessions with different health specialists; direct contact with specialists via WhatsApp, e-mail, and telephone; the flexibility to ask unsolicited questions, unrelated to the topic of the week, and to write their own posts rather than being limited to comments on posts; and additional content not covered in the program, including physiology, sexuality, and skin excess as they relate to bariatric surgery. All participants reported difficulties finding old posts, as they appeared by date in the group on Facebook. In addition, they asked for fewer informational posts and more practical “to-do” items, advice, and inspiration.

Discussion

To the best of our knowledge, this is the first study to evaluate a structured, social media health support program for patients after bariatric surgery that was led by health care professionals, with full involvement of representatives of the target population as advisors on program content and modes of delivery. Results show that most participants were satisfied with the program, and improvements were found in most aspects of their adherence to postoperative guidelines and in their psychological and physical well-being following the program. Giustini et al's systematic review also found that social media improves patients' psychosocial support.[29] Similar results were found in a video conferencing-based study that delivered psychoeducational messages to participants.[17]

A substantial number of participants either kept their original target weight throughout the program period or reached it by the end of the program. Previous studies have similarly demonstrated weight management improvements in obese patients through a Facebook intervention program.[24] [43]

The participants reported that adherence to postoperative recommendations and their health-related behavior improved following the program. Although not all adherence aspects were statistically significant, behavioral aspects (i.e. healthy diet and eating, physical activity, and periodic clinic visits) improved significantly and over half of the participants (and up to 90% of them) either agreed or strongly agreed that they feel capable of adhering to the recommendations. Although these improvements cannot be directly attributed to the program, results suggest that following the program, participants had increased clarity regarding postoperative recommendations and recognized the importance of following recommendations to improve outcomes. Further, a quarter of the participants reported that they initiated a follow-up meeting with a health care provider as a result of taking part in the program. It is important to note that participants expressed interest in having more opportunities to meet and consult with various health care professionals during the program, which may point to availability or accessibility issues in the health care system, a gap that may be more easily addressed through an SMN program.

Several studies have reported on the growing role of Facebook groups in providing social support to patients after bariatric surgery. Such support has been found to be most influential when experienced bariatric personnel monitor the Facebook group activity.[19] [30] [44] Professional support prevents patient exposure to inconsistent health-related content and unreliable information.[30] Further, patients have been shown to perceive greater safety and privacy in a monitored Facebook support group after bariatric surgery than in unprotected social groups.[44] Our program was monitored by the group administrator, and upon joining the group, all group members agreed to maintain participants' privacy, thus reducing potential concerns about behavior or weight judgment.

Most of the participants (70.0%) were satisfied with the online program. Representatives of the target population were fully involved in its design, including topics covered, content, and delivery methods. Their involvement may have contributed to participant satisfaction, as their input was based on their own experience. The fixed schedule of content provision was created to allow regular and predictable participant engagement, as Pagoto et al[45] suggest actively encouraging commitment is more effective than waiting for spontaneous, unguided content. However, participant engagement in the program declined over time. National-level events did not seem to trigger or accelerate this decline. Rather, use of the Facebook platform may have influenced participants' engagement levels, as Facebook may not be the preferred SMN for all ages[46] and participants' ages widely varied (from 18 to 73 years). Further, participation in the program was free of charge, which may have influenced participants' commitment to program completion. Future programs should consider charging a minimal fee.

Video posts received more Facebook engagement than text posts and posts about protein received more engagement than other health topics. After the program, participants asked for fewer informational posts and more encouraging and inspirational posts focused on practical activities. This preference may be influenced by their high levels of prior knowledge or previous exposure to unfiltered posts that deal with health care after bariatric surgery.[47] Alternatively, it may reflect participants' fatigue from education per se. Further, their interest in more opportunities to meet health care professionals may point to the need for a “human and personal touch” in the form of more options for questions and answers with an expert in real-time online, which cannot be replaced by an automated virtual medium.

Strengths and Limitations

Many bariatric patients struggle to maintain the positive outcomes of their surgery over time. Adherence to clinical recommendations is key to postsurgical success, mainly in the long term. However, support programs after the first year's “honeymoon period” are limited as are suitable curricula.[48] One of the main strengths of the “Bariactcare” program is that it was developed and implemented by a multiprofessional team (including a bariatric surgeon), providing a multidimensional approach to the topics and to participants' queries. In addition, the program was digitally accessible (e.g., via smartphone), making it easy for participants to engage wherever they were and at any time, thus increasing possibilities for engagement. Finally, and most importantly, participants were at least 12 months' postsurgery, and despite the length of time after surgery, they found the program beneficial.

This study had a number of limitations that reduce the representativeness of the sample and limit the generalizability of the results. First, the study did not include a reference group, thus limiting the implications of the findings and the ability to draw definitive conclusions about the effectiveness of the intervention. Without a reference group, it is challenging to ascertain whether any observed changes are attributable to the intervention or to external factors. Second, the study sample largely comprised female participants (86.9%), as such, the applicability of the results to both sexes may be limited. Sex, and by extension gender, can influence various aspects of health behavior and outcomes; so, the overrepresentation of female participants may have biased the results toward their perspectives and experiences. Third, the questionnaires were self-reported; therefore, social desirability bias may have affected the results. Participants may have provided responses that align with social norms or expectations rather than their authentic behaviors or experiences. This bias could distort the accuracy of the collected data, particularly regarding sensitive topics, such as weight management. Fourth, participation in the program was voluntary, which may have biased the sample due to self-selection. Volunteer participants may share psychological traits and abilities (e.g. motivation) that differ from nonvolunteers. Fifth, conducting the intervention exclusively in Hebrew excluded potential participants who are not proficient in the language. This limitation may have resulted in a less diverse sample, potentially overlooking important perspectives and experiences of individuals who speak other languages. Finally, the inclusion of participants spanning a wide age range (18–73 years) may have introduced variability in program engagement and responsiveness. Different age groups may have distinct preferences, needs, and levels of familiarity with the intervention platform, impacting their participation and outcomes in different ways.

Future Perspectives

In the 3 years since the study was conducted, new and effective prescription medications to treat overweight and obesity are continuously being introduced to the market. These medications may potentially become the ultimate therapy for many bariatric surgery candidates. However, they are not suitable for all patients for various reasons.[49] [50] As such, bariatric surgery will remain relevant for many people, especially due to the high number of adults classified as obese. In 2021, on average across 38 OECD (Organisation for Economic Co-operation and Development) countries, 18% of adults were obese[51]; in Israel, the obesity rate was 25% among adults.[52] Future research should consider using Facebook or similar online SMNs to improve postoperative outcomes, with an emphasis on providing a space for participants to connect and open a forum for communication with experts. Patient involvement in program design may increase their satisfaction with the program, and their input should be used to fine-tune the content and modes of delivery to better suit their needs and preferences. Moreover, the diversity of the bariatric surgery candidates highlights the importance of providing targeted coaching and support programs tailored to different ages and backgrounds, such as education level, language proficiency, and culture, as well as SMN preferences. Delivering engaging personalized programs via SMNs can increase recommended postbariatric surgery behaviors among patients and improve their health outcomes.

Conclusion

Interactive health support interventions on social media can positively enhance postoperative bariatric patient engagement, adherence to treatment recommendations, health outcomes, and overall well-being. Further research is warranted to explore the full potential of social media interventions to improve health and to increase our understanding of how such interventions can benefit diverse patient populations.

Clinical Relevance Statement

• Social media-based programs are a favorable means of psychoeducational health support in the long-term after bariatric surgery, and health care providers should consider incorporating validated programs in their arsenal of tools to enhance patient engagement and adherence to postoperative treatment recommendations.

• Incorporating video posts can increase participant engagement in social media-based health support programs.

• Integrating opportunities for active participant engagement, such as sharing content of interest, may increase their engagement in social media-based health support programs.

Multiple-Choice Questions

1. Social media programs can enhance bariatric surgery results over time. In this study, how did participants' outcomes improve?

   • Significant weight loss

   • Improvements in adherence to postoperative recommendations

   • Ensuring continuous sleep

   • Taking medication according to instructions

   Correct Answer: The correct answer is option b. Individuals who undergo bariatric surgery are advised to adhere to clinical instructions that encompass dietary adjustments, regular exercise, supplements, and ongoing medical monitoring. Research indicates that adherence to these directives can be challenging over time. Our social media program supported adherence to most of these guidelines.

2. Which of the following features would improve the program according to study participants?

   • Adding ability for participants to post content

   • Incorporating physical meetings

   • Increasing the number of daily posts

   • Adding more recipes for low-calorie meals

   Correct Answer: The correct answer is option a. Patients involvement in constructing the intervention plan and soliciting feedback from them throughout and at the conclusion of the intervention is crucial for ensuring content relevance; participant satisfaction; and, potentially, treatment outcomes. In our study, content was generated by a multidisciplinary team of health care professionals, with patients unable to directly respond to the material or raise concerns on their behalf. This absence was noted as a deficiency, and future initiatives should address this important issue.

Conflict of Interest

None declared.

Acknowledgments

The authors thank Sharon Furman-Assaf, PhD, and Fadwa Dabbah-Assadi, PhD (Bioforum, Israel) for assisting in the preparation of the manuscript. The authors would also like to thank Sara Promislow, PhD, for her helpful edits and comments on the manuscript.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was approved by the Sheba Medical Center Ethics Committee (approval number: 202019582, dated December 20, 2020). All data were anonymized prior to analysis. Completed questionnaires were stored in an encrypted folder on a secure server with restricted access at the institution of one of the researchers.

^* Equal contribution.

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Publication History

Received: 26 March 2024

Accepted: 17 August 2024

Accepted Manuscript online:
20 August 2024

Article published online:
13 November 2024