{'fraction_non_alphanumeric': 0.02497058063775437, 'fraction_numerical': 0.008954966849401566, 'mean_word_length': 5.345292296485158, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 5, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Navigating the Online World of Lifestyle Health Information: Qualitative Study With Adolescents

Background Adolescence is a critical life stage characterized by an interplay of biological, social, and environmental factors. Such factors influence lifestyle health-related trajectories, including dietary behaviors, physical activity levels, body weight, and sleep. Generation Z (born 1995-2015) is the most internet-dependent and technologically savvy generation in history with increasing rates of smartphone ownership across high- and low-income countries. Gaps exist in understanding what online platforms adolescents are using and barriers and facilitators of these platforms to seek lifestyle health information. Objective We evaluated adolescents’ perceptions on the use of contemporary digital platforms (websites, social media platforms, smartphone apps) to seek lifestyle heath information or advice. Methods Virtual focus groups were held via Zoom teleconference between July 2021 and August 2021. Eligible participants were 13 years to 18 years old, were living in Australia, and had searched for online lifestyle health information in the previous 3 months. For this study, lifestyle health information referred to key behaviors and risk factors for chronic disease, namely, diet, physical activity, weight management, and sleep. Participants were recruited through an existing database of research participants and networks of the research team. Focus groups were analyzed using the framework approach, in which data are systematically searched to recognize patterns in the data and manage, analyze, and identify themes. Focus group audio files were transcribed verbatim and independently coded by 2 researchers (RR, SSJ). Through an iterative, reflexive process, a final coding matrix was agreed on by all researchers and used to thematically analyze the data. Results We held 5 focus groups (n=32; mean age: 16.3 [SD 1.4] years; 18/32, 56% female; 13/32, 41% spoke language other than English at home). Thematic analysis revealed participants searched for information both actively (eg, on Google or YouTube) and passively (eg, scrolling social media and using existing apps preloaded to their smartphone such as Apple Health, Samsung Health, or Google Fit apps). Participants identified that the most helpful information was well-presented in terms of aesthetic appeal and layout and came from a credible and reliable source (eg, any sponsorships disclosed), and they expressed the need for the information to be relatable. Mixed views were reported for the application of lifestyle health information found online. Some participants reported behavior change, while others noted that certain advice was hard to maintain and incorporate into their lifestyle. Conclusions This study highlights the abundance and complexity of lifestyle health information online for adolescents. Adolescents in the digital age seek access to information that is appealing, credible, relevant, and actionable for lifestyle health behaviors. To appeal to needs of adolescents, future interventions for adolescents relating to lifestyle health must consider co-design methodological approaches. Furthermore, the regulation of lifestyle health information available online warrants further investigation.


Introduction
Today's adolescents, defined by the World Health Organization (WHO) as aged 10 years to 19 years, make up 16% of the global population [1]. Adolescence is a critical life stage during which a complex interplay of biological, social, and environmental factors determines the trajectory of lifestyle health behaviors into adulthood [2]. Lifestyle health behaviors and risk factors that are of great importance during adolescence are diet, physical activity, weight management, mental health, and sleep hygiene, as they are predictors of adverse health outcomes in adulthood, such as obesity and cardiovascular disease [3]. Globally, most adolescents do not meet diet or physical activity guidelines [4,5], and there has been a dramatic increase in the prevalence of overweight and obesity, jumping from 4% to over 18% in the last 40 years [6]. In Australia, very few adolescents meet guidelines for diet and physical activity [7,8], and adolescents do not get enough sleep on school nights [9]. Adolescence is an opportunistic window for establishing good lifestyle health behaviors [10]. Despite this, research priorities during adolescence are often focused on reducing other high-risk behaviors such as suicides, substance use, and sexual activity, with limited attention given to research that effectively harnesses digital technologies to target prevention of chronic diseases through lifestyle risk factor management [11,12].
Adolescents are known as "digital natives" as they have been born into a ubiquitous digital environment [13], which has grown exponentially in the last 20 years. In Australia, 94% of adolescents own a mobile phone, 95% are accessing the internet daily, and they use an average of 4 different social media platforms [14]. Previous research has shown that adolescents frequently turn to online sources such as internet websites and social media for lifestyle health information [15]. A national US survey found that adolescents are primarily looking at diet and fitness information online, with more trust placed on the internet than social media [16]. Furthermore, studies have explored how adolescents search for and appraise online health information and the extent to which they trust this information [17,18]. Furthermore, there is a constant expansion in the variety of digital platforms, including the uprise of contemporary platforms such as TikTok and Discord. As such, the current evidence base exploring the use of digital platforms to obtain information on lifestyle health behaviors is outdated. Contemporary digital platforms are a highly appealing and easily accessible way for adolescents to obtain lifestyle health information, given the increasing rates of smartphone ownership and their widespread use among adolescents for the pursuit of lifestyle health information.
As the digital health space is growing, gaps exist in our understanding of what contemporary digital platforms adolescents are using to seek this information and the barriers and facilitators of obtaining lifestyle health information on these platforms. Understanding the barriers and facilitators is crucial for governments, health organizations, researchers, and policy makers to be able to deliver appealing and effective lifestyle health promotion and support adolescents with management of chronic disease risk factors. Therefore, the aim of this study was to explore adolescent perceptions of obtaining information or advice related to lifestyle health from contemporary digital platforms.

Methods
This study adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines for reporting qualitative research (Multimedia Appendix 1) [19]. The study protocol was approved by the University of Sydney Human Research Ethics Committee (approval number 2020/613), and participants gave informed e-consent prior to participation.

Participants
Participants who were eligible to take part in the focus groups were aged 13 years to 18 years (inclusive). The WHO defines adolescents as 10 years to 19 years old; however, the range of 13 years to 18 years was selected to coincide with the age range of secondary education in Australia, which is a common setting for health promotion interventions by governments. Further eligibility criteria included living in Australia and having had accessed lifestyle health information online at least once in the previous 3 months. For this study, lifestyle health information referred to key behaviors and risk factors for chronic disease, namely, diet, physical activity, weight management, and sleep.

Recruitment
Participants were recruited through an existing database from a previous cross-sectional survey (Digitalize Study) [20] and known networks to the research team. The Digitalize Study was a cross-sectional survey to find out how young people (13-18 years old) search for lifestyle health information online including which digital platforms were most used, perceived helpfulness of information on digital platforms, helpfulness for positive behavior changes, and the quality of platforms' health information. Email invitations were sent with a link to the participant information sheet. All prospective participants read the participant information sheet online, provided informed e-consent, and were directed to an online survey to indicate demographic characteristics (age, gender, postcode, and language spoken at home) and how often they searched for lifestyle health information online in the previous 3 months. A 3-month time frame was chosen so that participants had up-to-date knowledge of lifestyle health information on these digital platforms. If participants had not accessed lifestyle health information in the previous 3 months, they were not able to complete the survey and therefore were not contacted to take part in the focus groups. All eligible participants were contacted via text message to confirm date and time of focus group and were emailed the secure teleconference link.

Data Collection
A semistructured discussion guide was developed by the research team based on the outcomes of the Digitalize study [20] to further explore the perceptions of obtaining and using lifestyle health information online. To assess whether the focus group questions were easy to understand and acceptable, the interview guide was piloted with 2 youth advisors who currently work with the research team. The discussion guide is provided as supplementary material (Multimedia Appendix 2).
One researcher (RR) gave a brief overview of the discussion at the commencement of the focus groups. Participants were asked about where they accessed health information online (internet websites, social media platforms, and smartphone apps), why they used online sources, what type of content they found most engaging, and any potential changes to their lifestyle behaviors as a result of applying the information they obtained online. Based off their responses, the 2 platforms of most interest to the group were discussed in more detail. Questions explored how they searched for information on these online sources, what made these sources most and least appealing, and how they judged the reliability and usefulness of the information they found.

Data Analysis
The framework approach was used to analyze qualitative data [21], where data are systematically searched to recognize patterns in the data and manage, analyze, and identify themes. On completion of focus groups, RR and SSJ familiarized themselves with the data and undertook thematic analysis independently. RR and SSJ developed coding labels relevant to the research question and identified emergent themes. After systematically coding all the transcripts, the research team (RR, SSJ, and SRP) discussed themes that were further developed through an iterative and reflexive process. Consensus on final themes were developed and agreed on by all researchers. Qualitative data analysis was performed using NVivo 12 (12.2.0).

Participant Characteristics
Focus group attendance was confirmed by 37 participants; 5 participants did not attend the focus groups without providing a reason, leaving a total sample of 32. Participant characteristics are reported in Table 1. Participants had a mean age of 16.3 years. From the study sample, 56% (18/32) of participants identified as female, with most participants residing in New South Wales (22/32, 69%). Two-fifths (13/32, 41%) spoke a language other than English at home. Participants varied in their frequency of accessing health information online with over one-third accessing health information online 1 to 2 times a month (12/32, 38%).

Overall Findings
Thematic analysis identified a complex interplay of 5 main themes relating to obtaining lifestyle health information across contemporary digital platforms ( Figure 1). These 5 themes included the processes of accessing lifestyle health information online, the presentation of lifestyle health information online, the importance of credible and reliable information, having information relevant to adolescents, and perceived behavior changes from application of lifestyle health information found online. These themes emerged across the 3 digital platforms that were discussed in-depth (internet websites, social media platforms, and smartphone applications). Across different digital platforms, there were distinct similarities and differences, which are explored in detail in each theme in the next sections. Despite attempting to ascertain which type of lifestyle health content (ie, diet, physical activity, weight management, or sleep) would be most engaging to adolescents, all 5 focus groups did not have a clear emerging theme, with all aspects of lifestyle health discussed. The 5 emergent themes are discussed in detail in the following sections.

Theme 1: Processes for Accessing Lifestyle Health Information Online
Adolescents identified internet websites and social media platforms as the top 2 sources for lifestyle health information online. However, they described the process for accessing information from these 2 sources differently. On digital platforms such as Google and YouTube, participants described actively searching for information of interest to them. Google searching for information was reported by most participants, who stated that they would only visit the first few websites that appeared in the search results. Websites that were commonly frequented by participants for health information were government-based websites and blogs. Some participants searched on YouTube for health information, especially relating to exercise and recipes. Accessing health information on social media platforms was described differently as participants would passively receive information that appeared in their feed (from people who they chose to follow) or by scrolling through explore pages. Participants also identified that the information that they came across on social media platforms may have been targeted to them due to algorithms used by these platforms. Smartphone applications were also identified by some participants as being used to access lifestyle health information. Similarly, for smartphone applications, participants mostly reported using applications that were already available on their smartphone (eg, Apple Health, Samsung Health, Google Fit) rather than searching app stores for new applications. When exploring reasons behind app usage, cost was a major factor, which supports this finding of using apps that are readily available to them.

Theme 2: Presentation of Lifestyle Health Information Online
Participants placed a large emphasis on the importance of how lifestyle health information is presented and organized for them online to be able to easily read and to interpret the information. This included the importance of white space and the use of dot points and subheadings on websites that would make them "easy to navigate" [FG4, 17F]. They reported that, if websites were not laid out logically or in an aesthetically appealing manner, they would often look elsewhere for the same information. Another subtheme that emerged was the importance of the quality of the content. This was reported both in terms of the actual information that was being presented and the production quality of videos or posts on social media. When information was presented in a way that appeared to be high quality and aesthetically appealing, most participants reported that they found it more credible. On social media, the production of posts or videos needed to be of good quality for them to follow that person and to "dig deeper" [FG5, 13F] into the account.

Theme 3: Credible and Reliable Lifestyle Health Information Online
Nearly all participants identified that they assessed whether the health information online was credible or reliable and this was achieved differently depending on the online source. For websites, participants reported looking if the information was referenced or included a bibliography. It was also recognized that participants mostly trusted government websites and well-known health organizations, but when it came to other websites, that they would "cross check" [FG1, 18F] to see whether there was a scientific backing to the information presented. By verifying this information with other sources, this demonstrates an awareness of where credible information originates. On social media platforms, participants identified multiple ways they assessed whether what they saw was credible or reliable. First, participants emphasized the importance of having a person behind the account with their credentials clearly stated. Many participants also stated that if they had a blue tick, meaning that the account was verified, this would also increase their credibility. Furthermore, the follower count of the social media account was also seen to increase reliability, with more followers making them more reliable.
I think knowing more about the person behind it is useful because sometimes you will find information and you can tell that it is like really biased. It Nearly all participants were acutely aware of sponsorships and advertising online. On social media, influencers are often paid to promote certain products or services. For most participants, if an account was constantly promoting one product, this would be a deterrent to trusting the information that they portrayed and was seen to be "off putting" [FG2, 18F]. Participants also understood that this was a way in which these accounts generated income.
I was just going to say that I think the content really matters and whether or not they're putting it out for the right reasons. I see, like sometimes, influencers, is that they are just kind of putting up information because they're getting paid to, you know, to advertise for those things. Regarding advertising on websites, participants reported the type of advertisements were important. If the advertisement was unrelated to the website itself, then the website would be seen to be unreliable. However, having advertisements in general was seen to be acceptable, and when the information was referenced correctly, they would still consider the website to be reliable. Another subtheme that was identified was that some participants assessed other people's comments on social media posts to see other opinions about whether the information that was presented was reliable. Likewise, when assessing mobile applications that they would potentially download, some participants looked at reviews on app stores to see whether other people thought the app was helpful for them. I would also definitely look at the reviews and not just what the reviews say but the amount of the reviews, how many people access the app, how many people say this or that, that kind of thing. [FG4, 16F]

Theme 4: Lifestyle Health Information Relevant to Adolescents
Most participants reported that searching for health information online was convenient. Participants reported online information as being easy to access, readily available, and regularly updated. Also, many participants reported that they accessed lifestyle health information from a variety of sources to compare the information themselves rather than seeing a health professional, which takes time and money and they may not provide the extent of information that can be found online.

I definitely think it's easier to look it up online because then you just get a bigger range of answers as well like if you go to a doctor, they normally just give you one straight answer. [FG2, 18F]
When referring to social media specifically, many participants reported following accounts that were relatable. For an account to be relatable, they had to engage frequently with their followers in terms of posts or stories and have lifestyle health information and advice that would be easy to implement into their own lives. Also, it was recognized that the person behind the account was important in terms of relatability, due to a sense of familiarity. This did depend on the size of their existing following, with smaller accounts being favored as they were more likely to respond and engage with followers, whereas larger accounts were viewed as more reliable. Websites were often reported by participants as being too generalized and therefore were sometimes viewed as unrelatable and unhelpful for obtaining health information. Some participants identified that the information may not be specifically directed toward young people or in line with what they were wanting to achieve in terms of their personal goals. It was also identified that they had visited websites that provided a large variety of information but not enough detail; therefore, they were unable to make a judgement of whether that information would be relevant to them.

Theme 5: Perceived Behavior Changes Based on Online Lifestyle Health Information
When regarding behavior change from online health information, participants reported a mixed variety of personal effectiveness. Some participants reported making changes based on information that they had seen online, including dietary changes such as restricting calories and physical activity changes including trying specific workouts that were not effective for them and subsequently viewed these behavioral changes negatively. As the behavioral changes were viewed undesirably, the changes were not sustained long term. Contrary to this, other participants reported making changes such as intermittent fasting and increasing total sleep time, which were viewed by participants as positive changes. It is important to note that, for some lifestyle changes, some of the participants viewed these positively, and others viewed them negatively, demonstrating the complexities of lifestyle health information and how individual preference also plays an important role. Furthermore, some participants outlined desire to make changes; however, the information that they found was "too hard to integrate" [FG4,17F]  • "I really like the pages that just kind of just sum all the points up like when they speak really, you know, sophisticated, it like, it allows you to trust what they are saying. I also like it when they sum it up at the end in just real simple English so it's straight to the point." [FG2, 16F] • "If there's like...subheadings within the website or like the answer to it is straightforward rather than in like big paragraphs, because like I wouldn't be likely to read that and in dot points would be even easier." [FG3, 17M] • "Yeah sorry, like headings and it being like scientific, so it is reliable but not um too scientific that we don't understand what is going on." [FG3, 18F] • "A lot of the people who I'm like friends with, they would follow the person as well. And then like, just seeing their content, I kind of go through it, like if they're professional, you can [kind of] tell, and like they have it in their bios." [FG5, 14F] • "The, um, production has to be eye catching for me to actually sort of dig a bit deeper into their account, but otherwise if the content is good, then I'll follow them." [FG5, 13F] • "It's quite hard to sift through things that are unbiased, especially on the internet, especially with influencers as well when they are paid." [FG2, 18F] • "I also agree with the sponsorship thing because when I found out some of the sponsorships, that's when I realized that some of this information it wasn't...like true, it was just because they were being paid to say that." [FG2, 14F] • "Another thing that I do sometimes is before I download it, some people leave comments on App Store, which can actually end up being pretty helpful...and then if I think I don't want it anymore, I just don't download it." [FG5, 14F]

Theme 4. Lifestyle health information relevant to adolescents
• "I do it because a lot of the times, I feel like the health advice I'm trying to find is when a problem isn't that big of a deal, so I don't think it's worth going to someone like important." [FG2, 14F] • "And it's also like having to see a person in real life is more daunting than actually searching up information for yourself." [FG3, 17M] "I would often go to an influencer even knowing that their information may not be as trustworthy just for the convenience aspect." [FG5, 15M] • • "I say when you talk about the engaging part, social media really takes the lead there because the type of video they make is captivating and the target audience can always be found." [FG3, 17M] • "When it comes to diet information, I don't really find it helpful because um, because often the diet information is only helpful for like one specific type of group and it's like, it's hard to find something that is directed towards me." [FG2, 14F] • "So, maybe if there's a government or some other organization released like a bunch of websites that they think would be really useful and then you could check them out and like maybe get feedback from young people to see which websites they like and things like that, that would definitely help." [FG4, 16F]

Principal Findings
Overall, this qualitative study provides strong insight from adolescents into the barriers and facilitators of accessing and using lifestyle health information on contemporary digital platforms. To our knowledge, this study is among the first to explore adolescents' perceptions on their use of these contemporary digital platforms to obtain information and advice about lifestyle health. The results demonstrate that adolescents' methods for searching for lifestyle health information differ across online platforms, with active searching for information across platforms such as Google and YouTube and passive receiving of information across other social media including Facebook, Instagram, TikTok, and Twitter. Furthermore, adolescents desired information to be well-presented, credible, and relevant to them. The findings from this study can be used to inform future research into the development of effective online lifestyle health promotion strategies and interventions for adolescents.

Comparison With Prior Work
Previous research has shown that nearly 63% of adolescents use online information broadly to maintain a healthy lifestyle [22]. Many previous studies assessed online information as a whole, without differentiating between online platforms (eg, websites, social media). Our findings from this study appear consistent with previous research regarding the processes that adolescents use to search for health information online; however, this study elicited new findings across the different contemporary digital platforms. From an adolescent perspective, it is apparent why social media is favored over websites when it comes to lifestyle health information. Social media is a common feature in many adolescents' everyday lives, with mobile devices making access to social media more frequent and personalized [23]. Features available on social media platforms, such as Instagram stories and turning on notification features for favorite accounts, allow content to be highly engaging and of higher production quality. These features increased the perceived credibility of the account by adolescents and allow adolescents to curate who they follow on social media and thereby ensure that the information that they are digesting is relevant to them.
Processes used to search for lifestyle health information by adolescents included searching for information on websites and both actively and passively using social media platforms [17,22]. The passive nature of information exchange on social media is potentially increasing due to the increasing amount of targeted advertising across different social media platforms. In 2021, social media advertising was projected to reach Aus $199 million (US $21.7 million), which is a growth of 4.9% [24]. Users now have less control over the information content within their social media feeds [25]. A study by Hausmann et al [15] suggested only 25% of adolescents agreed that social media could help them obtain useful health information, despite almost ubiquitous use of social media among adolescents. In this study, participants identified several barriers to ascertain whether information on social media was useful. Such barriers included the use of sponsorships and advertising by companies and influencers on social media and the targeted nature of information due to algorithms employed on these platforms. eHealth literacy is the ability to seek, find, evaluate and appraise, integrate, and apply information to solve a health problem in an electronic environment [26]. eHealth literacy was not assessed as part of this study; however, adolescents demonstrated awareness of broad social media advertising and sponsorship strategies. Evaluations of eHealth literacy in the context of contemporary digital platforms warrant further investigation.
Co-design is widely used in the development of eHealth interventions to increase their acceptability and effectiveness among adolescent populations, as they are particularly hard to engage [27,28]. This same methodology can be applied to the development of online health information to increase its appeal in terms of organization of information and relevance to adolescents. A previous systematic review of Australian websites found that very few websites were written specifically for adolescents and none were found to be excellent quality, interactive, and written in plain English [29]. This finding was also demonstrated in our study, with adolescents reporting that information found on websites was often too hard to understand, too difficult navigate, or not relevant to them. To ensure that information is presented in a format that adolescents understand and is relevant to them, co-design of online health information with adolescents could be utilized to increase its acceptability and effectiveness in management of chronic disease risk factors.
The digital space is highly unregulated, and this challenges the credibility of online health information. Due to the rise in user-generated content on digital platforms and popularity of using social media to access lifestyle health information, it is becoming increasingly difficult to regulate digital content, with authors often unidentifiable [30]. As explored in this study, participants reported a preference for "a face behind the account" and being clearly able to see their qualifications in the biography section of their profile to increase credibility and trust in the account. Furthermore, adolescents are acutely aware of advertising and sponsorships within content across social media platforms. The WHO has recognized the influence of food marketing as detrimental to children in many countries. Although regulations have been put in place surrounding advertising to children in Australia (aged 0-14 years) [31], regulations around the world rarely address adolescents [32]. This is despite an increase of more than US $400 million spend on advertising between 2012 and 2019 by the fast food industry targeting children and adolescents [33]. Social media platforms are commercial companies with advertising as their sole generation of income [34]. Currently, there are minimal laws surrounding advertising on social media in Australia, particularly sponsored posts [35]. For example, advertising of weight loss products in Australia must be truthful, accurate, and not mislead consumers [36], but this does not apply to sponsorships. It is important to note that adolescents currently have access to what they perceive as both helpful and harmful lifestyle health information online. Through the addition of regulation and legislation around these areas, there is the capability to make information more useful and credible and potentially lead to behavior change that is helpful for the prevention of chronic disease while also causing minimal harm. Therefore, the regulation of advertising toward adolescents is a challenging space, and further research is required to explore the influence of advertising on contemporary digital platforms toward lifestyle health behaviors of adolescents.

Strengths and Limitations
This qualitative study has several strengths as well as limitations.
We were able to recruit a diverse sample of adolescents to take part in this study, including 41% of participants who spoke a language other than English at home and from different states throughout Australia. Also, this qualitative study is among the first to provide insights into perceived barriers and facilitators of lifestyle health information on contemporary digital platforms, allowing opinions and thoughts to be gathered from the target population. However, it should be emphasized that, as this study was advertised and took place virtually, it may limit the generalizability of the findings to adolescents with higher eHealth literacy skills. For this study, we did not capture data on the eHealth literacy skills of participants. It is possible that groups with lower eHealth literacy may also offer useful insights into their perceptions of online lifestyle health information.

Recommendations for Development of Online Lifestyle Health Information
Considering the findings from this qualitative study and previous research, a series of recommendations has been developed regarding the development of online lifestyle health information to ensure relevancy, appeal, and engagement for adolescents: • Employ co-design of lifestyle health information with adolescents for contemporary digital platforms.
• Conduct further research into the regulation of online lifestyle health information for adolescents.

•
Consider the eHealth literacy level of adolescents in the development of online lifestyle health information for contemporary digital platforms.

Conclusions
In summary, this study highlights the abundance and complexity of online lifestyle health information available to adolescents, which is exponentially growing across contemporary digital platforms. Adolescents in this study reported wanting access to information that was credible, appealing, and relevant to them. To develop effective online lifestyle health promotion strategies and interventions, future research should include co-design of information with adolescents and consider their eHealth literacy levels. Furthermore, the influence of advertising on contemporary digital platforms and regulations around this warrants further investigation.