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Santer, M., Chandler, D., Lown, M., Francis, Nicholas A. and Muller, I. 2017. Views of oral
antibiotics and advice seeking about acne: a qualitative study of online discussion forums. British
Journal of Dermatology 177 (3) , 751 -757. 10.1111/bjd.15398 file
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1
Viewsoforalantibioticsandadviceseekingaboutacne:a
qualitativestudyofonlinediscussionforums
Runninghead:Onlinediscussionforumsforacne
Words:3574(previously2912)
Tables:1
Figures:2(1figureand1box)
MSanter1,DChandler
1,MLown
1,NAFrancis
2,IMuller
1
1. UniversityofSouthampton
2. CardiffUniversity
Correspondingauthor:
MiriamSanter
PrimaryCareandPopulationSciences
UniversityofSouthampton
AldermoorHealthCentre
AldermoorClose
SouthamptonSO165ST
02380241019
Fundingsources:none
Conflictofinterest:nonedeclared
2
What’salreadyknownaboutthistopic?(70words,currently66)
• Acnevulgarisisverycommonandcanhaveconsiderableimpactonqualityoflife.
• Althoughsomeinformationisavailableaboutpatients’viewsoforalisotretinoin,littleis
knownaboutviewsandexperiencesofthemostcommontreatmentsforacne,including
oralantibiotics.
• Onlinediscussionforumsareanincreasinglycommonsourceofinformationabout
healthconditions,yetweknowlittleabouttheadviceexchangedaboutacneonline.
Whatdoesthisstudyadd?(70words,currently67)
• Wefoundverydiverseviewsaboutoraltreatmentsingeneralandoralantibioticsin
particular.
• Sourcesoffrustrationincludedthedelayedonsetofactionofantibioticsforacne,
perceptionsofonlytemporaryeffectivenessandadverseeffects.
• Adviceonsomediscussionthreadsseemedinappropriatebecausetheseverityofacne
wasnottakenintoaccount;advisingsunshineforsevereacneordermatologyreferral
for‘somespots’forexample.
Whataretheclinicalimplicationsofthework?(70words,currently60)
• Peopleseekinginformationaboutacneinonlineforumsarelikelytofindbewildering
advicewithpotentiallynegativeaswellaspositiveimpacts.
• Cliniciansprescribingoraltreatmentsforacneneedtoprovideinformationandsupport
aroundthedelayedonsetofaction.
• Healthprofessionalscanhelpavoidconfusionbysignpostingpeoplewithacnetowards
reliable,evidence-basedresourcestoaccessoutsidetheconsultation.
3
ABSTRACT
Background
Acnevulgarisiscommonandcansignificantlyimpairqualityoflife,yetlittleisknownaboutpatients’
understandingofacneanditstreatments.Oralantibioticsarewidelyusedforacne,despiteconcerns
aboutantibioticresistance.Peopleareincreasinglyturningtoonlinediscussionforumsforadvice
andinformationonthesesitesmayinfluencehealthbeliefsandtreatmentadherence.
Objective
Toexploreunderstandingsabouttheuseoforalantibioticsforacneandadvicesharedamongst
messagespostedononlineforums.
Methods
Wesystematicallysearchedforonlineforumsandidentifiedfourwhereacnewasfrequently
discussed.Discussionthreadsrelatingtooralantibioticswereanalysedthematically.NVivo11
facilitateddatahandling.
Results
Weextracted136pagesofdata;65discussionsamongst294participants.Wefoundawiderangeof
perceptionsaroundeffectivenessofantibioticsforacneandconcernsaboutadverseeffects.The
delayedonsetofactionofantibioticswasasourceoffrustrationandcompoundeddissatisfaction
withhealthcareproviders,whopeopleperceivedas‘fobbingthemoff’withprolongedcoursesof
ineffectivetreatment.Advicerangedfromcostlycleanserstowhentoaskfor,orinsiston,referral.
Postsrelatedtoawiderangeofseverities,from‘spots’tosevereacne,whichmaymakeitconfusing
foruserstoassessappropriatenessofinformation.
Conclusions
Onlineforumsofferopinionsthatcouldbeconfusingorleadtoearlyabandonmentoftreatments,
challengingconsultationsandpatientdissatisfaction.Usersexpressedfrustrationaboutthedelayed
onsetofactionofantibioticsforacne,perceptionsofonlytemporaryeffectivenessandadverse
effects.
4
BACKGROUND
Acnevulgarisisaverycommoncondition.Somedegreeofacneaffectsalmostallteenagersandis
moderatetoseverein15to20%,oftenpersistingtoadulthood.1Itisestimatedthat30%of
teenagershaveacnethatmayrequiremedicaltreatment.2Themainimpactofacneispsychological,
withincreasedriskofdepressionandsuicide1,2andpsychosocialdisabilitysimilartothatseenin
conditionssuchasasthmaanddiabetes.2
Over3%ofpeopleaged13to25yearsconsultforacneinprimarycareintheUKeachyear.3
Guidelinessuggeststep-wisetreatmentinvolving(i)singleagenttopical,(ii)combinationtopical,(iii)
oralantibioticsplustopicaltreatment.2However,oralantibioticsarewidelyprescribedforacnein
theUK,4despiteconcernsaboutthedevelopmentofantibioticresistance.
5,6Itisnotclearwhether
thisover-useoforalantibioticsisduetopatientpressureordoctorpreference.
Qualitativeresearchhasexploredtheimpactonadultsandyoungpeopleoflivingwithacne7,8and
onpeople’sviewsoforalisotretinoin9,yetlittleisknownaboutpeople’sviewsofotheracne
treatments.Thismattersbecausehealthbeliefshaveastronginfluenceontreatmentadherence,10
whichisacommonbarriertoeffectivetreatmentinacne.1
In2015,78%ofadultsinGreatBritainusedtheinterneteverydayoralmosteveryday.11Almost
50%ofadultscurrentlyusetheinternettoaccesshealthinformation,afigurewhichcontinuesto
rise.11Onlineforumsarediscussionsitesthatallowuserstocommunicatetheirpersonalexperiences
throughasynchronouswrittencommunicationandareincreasinglybeingusedtoseekinformation
fromotherswithsimilarhealthissues.12Onlinediscussionforumsareoftenmorepopularthanstatic
websitesbecausepeoplevaluefirst-personaccountsandfeelsupportedbyothersintheonline
community.12Onlineforumsprovidequalitativeresearcherswitharichandvaluablesourceofdata
aboutusers’perspectivesandexperiencesandtherehasbeenanincreaseinqualitativeresearch
exploringonlineexchangesrelatingtoarangeofhealth-relatedconditions.13-15
Onlineforumsappeartoimpactbothpositivelyandnegativelyonhealthbehaviours,forinstance
throughhelpingpeoplefindinformationandfeelsupported,influencingbehaviour(throughreading
others’experiences)andinforminghowtonavigatehealthservices(includingaskingquestionsof
healthprofessionals).12Exchangesinonlineforumsgenerallyhaveapermanence,providing
searchableinformationavailabletofutureforumuserswithapotentialforimpactonmanyusers.16
ArecentBMJeditorialcommentedthat,‘Theconversationspatientshaveintheironline
communitiesmustbebroughtclosertotheconversationscurrentlyconductedamonghealth
professionals.’17Onewayofworkingtowardsthisisforhealthprofessionalstogainabetter
understandingoftheconcernsandviewssharedinonlinecommunities.
Qualitativeexplorationofdiscussionsaboutacneinonlineforumscanallowinsightintoforumusers’
viewpointsandanappreciationofadvicethattheymayhavereceivedpriortoconsulting.Thisstudy
focussesonperceptionsoforalantibioticsasthesearewidelyusedforacneandthereareconcerns
abouttheimpactofthisonrisingantibioticresistance.5Wethereforeaimedtoinvestigate
understandingsandconcernsabouttheuseoforalantibioticsforacneandexplorethenatureof
adviceseekingforacneamongstpeoplewhohavepostedmessagesononlineforums.
5
METHODS
Thisqualitativestudysoughttoexploremessages(andtheirresultantdiscussions)aboutoral
antibioticspostedbypeoplewithacne,andtheircarers,inUK-baseddiscussionforums.
Dataretrieval
InitialscopingreviewofonlineresourceswascarriedoutinJune-July2016byenteringtheterms
‘acne’,‘acneantibiotics’,‘teenageacneantibiotics’and‘acneforum’intothreedifferentcommonly-
usedsearchengines,usingthe‘UKresultsonly’option,andlookingatthefirst100hits.Wefound
discussionoforalantibioticsforacnewithinacne-specificforums,forumsforothermedical
conditionsandgeneralmedicalforums,parentingforums,andgeneraldiscussionforums.Only
activeforumsconsideredtobeinthepublicdomainwereincludedinthisstudy.Forumswere
excludediftheyrequiredregistrationtoviewposts,containedfewerthanthreerelevantthreadsor
hadnothadanypostswithinthelastsixmonths.Therewere12remainingforums,ofwhichwe
selectedfourinordertoyieldamanageableamountofdata.Wechosefourforumsofferingdiverse
perspectives,choosingoneacne-specificforum,onegeneralforum,onegeneralmedicalforumand
oneparenting-focusedforum,selectingtheonewiththegreatestofnumberofacne-relatedposts
fromeachcategory.AllfourlistedaUKaddress.
Duetovariationintheavailabilityandcapabilitiesoftheinternalsearchfunctionsoftheselected
forums,auniformsearchstrategycouldnotbeapplied.Theresearcher(DC)familiarisedhimself
witheachforumtotailoranappropriatesearchstrategy(Box1).
Postsweredefinedasrelevantiftheyincludedviewsorexperiencesoforalantibiotics,orwerepart
ofaconversationthatincludedthese.Threadswereinitiallyonlyincludediftheyhadbeenposted
duringorafter2010,butwithinthesethreadsallrelevantpostswereincludedregardlessofdate,in
ordertoretaincontextforthelaterposts.InJuly2016,90pagesofdatawerecollectedfromthe
fourselectedforums,butreviewofthesesuggestedthatmoredatawereneededtosaturatethe
mainthemes.Anadditional46pageswerethereforecollectedinearlyAugust2016(Figure1).
Onceextracted,threadswereanonymisedanduniqueidentifierswereassignedtoeachthreadand
toeachusername.TheanonymiseddataweretransferredtoNVivo11tofacilitatedatahandling.
Dataanalysis
Aninductivethematicanalysis18identifiedcommonthemesrunningthroughthediscussions.Coding
beganfollowingreadingandre-readingofthedata.Asampleofthediscussionswerecodedlineby
line(DC)inordertoproduceaninitialcodingframe.Thiswasdiscussedamongsttheresearchteam,
initialthemesandsubthemeswereidentifiedandadraftcodingmanualwasproduced.Thismanual
wasiterativelydeveloped(DC,IM,ML,MS),andthenusedtointerrogatethedataforthemesand
subthemesandtosearchfordisconfirmingcases.Asanalysisprogresseditbecameclearthat
consideringthreadsinthecontextoftheinitialpostwasnecessarytocontextualisecommentsand
datawasre-readandcodedinthisway.
6
Ethicalissues
ApprovalwasgrantedbyUniversityofSouthamptonFacultyofMedicineEthicsCommittee
(reference22431).Thisstudyconsidersonlineforummessagesthatcanbeviewedwithout
registrationtobelocatedwithinthepublicdomain,inlinewithguidelinesfromtheBritish
PsychologicalSociety19andinlinewiththeapproachusedinotherstudies.
13-15Discussionspostedin
theonlineforumsexaminedforthisstudyareaccessiblebyanyoneandsoseekinginformedconsent
isnotapplicable.Stepshavebeentakentomaximisetheanonymityofparticipants:forumsarenot
identifiedbyname,threadtitlesandusernameshavebeenreplacedwithuniqueidentifiersand
quoteshavebeenparaphrasedtofurtherprotectparticipants’identities.Allauthorsagreedthe
adaptedparaphrasedquotationspriortosubmission.
RESULTS
Forumsearchesyielded136pagesoftextcomprising65discussionscontainingpostsrelatingtothe
useoforalantibioticsforacne(Table1).Thesediscussionsdatedfrom2007to2016andappeared
tohavebeenpostedby294differentusers,althoughitispossiblethatsomeusersusedmorethan
oneusername.Thediscussionsweregenerallysupportive,sometimesconversational,oftentaking
theformthatoneuserstartedathreadwithaquestionorrequestforadvice,followedbyanumber
ofresponses.Theacne-specificforumincludedpostsfromuserswhoappearedtobebasedoutside
theUK(asjudgedfromtheircomments),whereastheotherforumsmainlyappearedtobeusedby
UKresidents.Theacne-specificforumcontainedmorepoststhatappearedtocomefromindividuals
withcommercialinterests,forinstancedirectingotherstowardsprivatenutritionists.Theparenting
forumappearedtohavegreatersitemoderation(i.e.anemployeeorforumuserwhorespondedto
someofthecommentsorremovedspam),whosometimesdirectedthread-starterstorelevant
pagesonNHSChoices.
Inductivethematicanalysisofdatafromthefourforumsrevealedthemesrelatingtoantibioticsand
othertreatments,navigationofservicesandtheimpactoflivingwithacne.Thispaperwillfocuson
themesrelatingtoviewsandconcernsaboutoralantibiotics(effectiveness,adverseeffectsand
frustrationsarounddelayedonsetofaction)andthenatureoftheadviceonofferinthediscussion
forums.
Perceptionsaroundeffectivenessandappropriatenessoforalantibioticsforacne
Onlineforumusersexpressedarangeofviewsrelatingtotheuseoforaltreatmentsingeneraland
oralantibioticsinparticular.Reasonsgivenfornotwantingtouseoraltreatmentsincludedageneral
preferencefor‘natural’remedies,whereasothersfeltthat‘treatmentfromtheinside’wasessential
forsuccessfultreatmentofacne,orthattopicaltreatmentswere“mild”whileoraltreatmentswere
“strong”.
I’mconstantlytakingmydaughtertothedoctors,asheracnehasspreadsomuch.Weeven
sawsomeoneatthehospital,butnothingwehavebeengivensofarhasbeenanyhelp.They
7
saidshemightendupontablets,butIdon’tlikethesoundofthat–she’sonlyakid!Before
shetriesthatI’mgoingtolookin[cosmeticsshop]andseewhattheyhave.
Parentingforumuser193
Igavebenzoylperoxideago,butIdon’tthinkitdoesanygoodtotreatacneontheoutside
unlessyoufightitontheinsideaswell.
Generalforumuser79
Manyusersreportedsuccesswithantibioticsbutmanyalsoreportedthattheyreceivedtemporary
successwithoralantibiotics,butthatsymptomsreappearedorworsenedwhentheystopped.There
wasageneralperceptionoforalantibioticsbecomingineffective,oftenpresentedintermsofthe
personthemselvesbecoming‘resistant’or‘immune’tothemedication.
Someuserswerepostingwithindaysofstartingtreatmentwithoralantibiotics,seekingadvice
abouthowlongtheywouldtaketowork.Afewusers,ratherthanexpressingabeliefthatantibiotics
eitherwouldorwouldn’thelp,simplyexpressedtheirhopeordesperation,whileafewseemed
confusedaboutwhethertheiroraltreatmentwasanantibioticornot.
Iwenttothedoctorbecausemyskinwasupsettingmesomuch.I’mjustprayingthe
antibioticsthey’vegivenmewillfixit.
Generalmedicalforumuser37
Ihopetheroaccutaneantibioticthey’vegivenmewillmakethingsbetter.
Generalforumuser112
Whilemanyforumusersregardedoralantibioticsaseffective,orpartiallyeffective,therewerealso
manywhoperceivedthemasineffective.Oralantibioticsweresometimesonlymentionedbriefly
amidwiderpostslistingtreatmentsthathadbeentriedpriortoeventualresolutionofacnewithoral
isotretinoin.Thelatterwasoftencontrastedwithantibiotics(andothertreatments)asahighly
effectiveandlong-lastingtreatment,althoughtherewaswidespreadawarenessofcommonside
effects(e.g.dryskin/lips)andconcernsaboutpossiblementalhealthsideeffects.
Afterseveralappointmentswiththedoctormysonhasendeduponatopicallotionand
someantibiotics,butIknowtheywon’tdoanygood.Ithinkroaccutanewouldbemuch
betterforhim,soI’mtakinghimtoseeadermatologistprivately.
Parentingforumuser140
Adverseeffectswithantibiotics
Perceivednegativeeffectsassociatedwithtakingoralantibioticswerecommonlyreported,
sometimeslastingbeyondcessationoftreatment,particularlygastro-intestinalsideeffectsor
8
‘weakenedimmunesystem’.Thereweresomereportofpeoplestoppingtheirantibioticsduetothe
negativeeffectstheyassociatedwiththem,mainlynauseaorothergastrointestinalsideeffects.
ThetetracyclinesItrieddidhelpquiteabitintheend,buttakingthemwassoterribleandit
wastakingsolongtogetbetterthatIgaveuponthem.Onegavemeanitchyrash,whilethe
othermademefeelreallysick.
Acneforumuser8
Theparentingforumincludedathreadofdiscussionaroundthenegativeeffectsoftaking
lymecyclinewhilepregnant,inwhichseveralusersmentionedstrugglingtoaccessdetailed
informationontheimpactthiswouldhaveontheirunbornchild.
Delayinonsetofactionoforalantibiotics
Peoplefrequentlydiscussedthedelayinonsetofactionoforalantibioticsandthatwaitingforeffect
wasadifficulttime.Manyseemedtohavebeenadvisedtoexpectthisdelay,althoughafewusers
appearedtothinktheywouldactwithindays.
Well,4daysinandstillnotlookinganybetter…
Parentingforumuser150
Thedelayinonsetofactionwasasourceoffrustrationtomany(“Ihateallthiswaiting”),particularly
thosewhoweredesperatetoseeimprovementintheiracne.Someperceivedthedelayinonsetof
actionandneedforseveralmonths’useinordertojudgeeffectivenessaspartofbeing“fobbedoff”
bytheirGP.Peoplewhowishedfororalisotretinoinastheirtreatmentofchoicefeltthatbeing
askedtotryantibioticsforsomemonthsfirstwasanunwelcomedelayandthiswasasourceof
dissatisfactionwithhealthcareprovidersinsomeinstances.
I’monantibioticstoo.MydoctorsaidIhavetotakethenfullcoursebeforeIcantry
somethingelse.Threemonthsissolongtowait–IfeellikeI’llbedealingwiththisforever.
Generalforumuser61
Antibioticsdon’tdoanythingforacne,thedoctorjustgivesyouthemtofobyouoff.
Generalforumuser281
Variableadviceandexperiencesinacneseverity
Aswithmanyonlinediscussionforums,thequalityoftheadviceusersofferedeachotherwashighly
variablebut,addedtothat,peopleappeartobediscussingverydifferentsortsof‘acne’,varying
from‘somespots’toseverenodulocysticacne.Manyusersappearedtoassumethattheywere
9
talkingtosomeonewithacnesimilartotheirown,forinstance,peoplewithexperienceofsevere
acnesometimesadvisedothersthattheymustseeaDermatologistregardlessofseverity.
MyskinissobadandnothingItryhelps–I’vetrieddifferentskincareroutines,mydietis
healthyandIdrinkplentyofwater.It’sjustgetsmedowntoseeeveryonewithgreatskin
aroundmewhenminelookslikethis.
Generalforumuser277
YoushouldDEFINATELYgotoadoctor,andbeadamantaboutareferraltodermatology.I
havebeenseeingadermatologistandtheyarereallyhelping.Don’twait,asyourskinwill
getworseifyouleaveit.
Generalforumuser279
Otherswereadvisingcosmeticorlifestyleadvicewhereadvicetoconsultseemedmoreappropriate.
Well,I’mspendingyetanotherhotsunnydaysittinginmybedroom.Ihavenodularacne–
worsethanthenormalteenagething.Ican’tshowmyfaceoutsidewhenIlooklikethis.I
usedtobesohappy,andnowIthinkaboutkillingmyself.Ihaven’tseensomeofmyfriends
inatleastayear.Ihavetriedeverythingtotreatitbutnothinghelps.
Generalforumuser284
YoucouldgiveNeemoilorTeaTreeOilago.
Generalforumuser285
Ithasmajorsideeffects,butasyouracneisaffectingyousomuchyoushouldconsider
Roaccutane.YouwouldneedadermatologyreferralfromyourGPtogetit.
Generalforumuser286
Sunlightisgreatfortheskin,soyoushouldgooutasmuchasyoucan!
Generalforumuser287
Goseeadoctor?
Generalforumuser288
Manypeoplestronglyrecommendedthatpeoplewhoweresufferingfromacneseekhelpfroma
doctor,eitherformedicationtheGPcouldprescribe,orforareferraltodermatology.Itwasstriking
howfrequentlyuserswereurgedtopressurisetheirGPforareferraltoaDermatologist.Thismaybe
relatedtoinputfrompeoplewithahistoryofsevereacne,orbecauseofinputfromusersbased
outsidetheUK(particularlyintheacne-specificforum).Sometimespeopleadvisedseekinga
10
dermatologyreferralfortreatmentsthataGPcanprescribe,oradvisedpeoplewithrelativelymild
skinproblemstoseekreferral,whichmayhaveledtodifficultconsultations.
Onlyoneusercommentedthatno-onekneweachother’sseverityandreflectedthattheirdoctor
mightbewell-placedtojudgeacneseverity.
There’sloadsofinformationavailableontheinternet…butultimatelyonlyyourdoctorwill
reallybeabletodecidehowsevereyouracneisandwhetheritisgettingbetter.No-onehere
canhelpyouwiththat.It’dbeareallygoodideatogobacktoseeyourGP…
Generalforumuser275
DISCUSSION
Wefoundabroadrangeofviewsandexperiencesrelatingtooralantibioticsexpressedinonline
discussionforumsandamixofpotentiallyhelpfulaswellasunhelpfuladvice.Reportedexperiences
withoralantibioticsrangedfromrapidandtotalsuccesstomakingtheacneworseandcausing
intolerablesideeffects.Assuch,itisdifficulttopredictwhatattitudemaybefosteredinforumusers
whoseekadviceaboutoralantibiotics,otherthanalikelihoodthattheywouldfindthisa
bewilderingexperience.Dissatisfactionwithoralantibioticsrelatedtoavarietyoffactors:a
perceptionthattheantibioticsdidn’tworkorstoppedworkingwithtime,experiencesofside
effects,andageneralreluctancetotakeantibiotics.
Findingsinthecontextofexistingliterature
Forumusersreferredtoantibioticresistancebothinrelationtobothtopicalandoralantibioticsbut,
ashasbeenfoundinotherstudies,20antibioticresistancewasgenerallyinterpretedasapropertyof
thehumanbodyratherthanbacterialcells.‘Resistance’wasgenerallyonlymentionedasareason
fortreatmenttostopworking;neitherthelongtermimplicationsfortheusernorthewider
implicationsofoveruseofantibioticsforhealthcarewerediscussed,thoughitisunclearwhetherthis
isbecauseofalackofawarenessorbecauseitwasn’trelevanttothediscussionthread.Thisis
concordantwithfindingsfromotherstudies,whichhavefoundthatparticipantsoftenview
antibioticresistanceasbeingoflowrisktothemselvesandmoreatopicforconcernforcliniciansor
otherpeople.21
Wefoundthatforumusersfrequentlydiscussedexperienceswithconsultingdoctors,generally
frustration,andoftenadvisedeachothertopressuriseGPsforreferraltoaDermatologist.This
echoesqualitativeresearchcarriedoutamongstpatientswithotherdermatologicalconditions
suggestingthattheymayfaceparticularchallengesinthedoctor-patientrelationship;including
feelingsof‘notbeingtakenseriously’andthatbothGPsandDermatologistscanbeperceivedasnot
engagingwiththepsychologicaldistressassociatedwithskindisease.22-24
Qualitativeresearchon
eczemahashighlighteda‘mismatch’ofviewsbetweenpatients/carersandhealthprofessionalsthat
canaddtofrustrations.25,26
11
Thefindingthatpeopleoftenobtainadviceonlineabouthowtonavigatehealthservices,aswellas
thepotentialforbothpositiveandnegativeimpacts(inthiscase,bothusefuladviceandpotentially
confusingorinappropriateadvice)havebeenfoundinotherstudiesofonlinediscussionforums.12
Limitations
Thisresearchhaslimitations,someofwhichareinherenttocarryingoutqualitativeresearchin
onlinediscussionforums.Whilethisallowsaccesstorichnaturalisticdata,littleinformation
availableaboutparticipants’demographics,whichprecludespurposivesampling.Thispresentsa
particulardifficultywithacne,whichissocommonlyexperiencedandsovariedinseverity.
Contextualinformationonseverityandimpactwouldbehighlyrelevanttounderstandingattitudes
totreatments.However,tofindthemesincommonwithinthisheterogeneoussamplesuggeststhat
thesearehighlyrelevanttounderstandingtheconcernsofpeoplewithacne.Itmaybethatpeople
whouseonlinediscussionforumsdifferinimportantwaysfromthosewhodonotanditwouldbe
usefultocarryoutfurtherresearchtoexplorethis.
Researchimplications
Althoughwehavefoundsignalspointingtowardsexplainingthepopularityoforalantibiotics(e.g.
theperceptionthattopicalsare‘mild’andoraltreatmentsare‘strong’),furtherexplorationofover-
useofantibioticsforacnecouldfocusonqualitativeinterviewswithbothhealthprofessionalsand
peoplewitharangeofacneseveritiesandtreatmentexperiences.Insomenon-dermatological
conditionsitisthoughtthatpatientsplacepressureonhealthprofessionalstoprescribeantibiotics
duetoaperceptionthattheyforma‘magicbullet’,27yetwedonotknowwhetherthisisthecasein
acne.
Furtherresearchisneededtofindeffectivewaysofcommunicatingwithpeoplewithacne(for
instancethroughonlineresources),includingprovidingsupportduringdelayedonsetofactionof
treatments,supportwithadherenceandaddressingquestionsarisingoutsidetheconsultation.
Clinicalimplications
Thesefindingscanhelpclinicianstounderstandtheperspectivesofpatientswithacne,andgainan
insightintothehighlyvariableinformationthattheymayaccesspriortoconsulting.Assessing
informationneedsandhealthbeliefsisanimportantpartofthedermatologyconsultation28anda
keyroleofhealthprofessionalsistosignpostpeopletowardshighqualityevidence-based
informationfreefromcommercialbias,1particularlyasitisknownthatpatientsdonotrecalla
substantialproportionofinformationgiventothemduringtheconsultation.29Aquantitativestudy
ofonlineforumpostsforAcnerosaceafoundextensiveinformationneedsandtheauthors
concludedthatifdoctorsofferedpatientsreliablesourcesofinformationthenthismayprevent
patientstreatmentnon-adherenceandfollowingpotentiallyerroneousadvicefromtheinternet.30
12
CONCLUSIONS
Thisstudyshowsthatonlineforumspresentreaderswithdiverseadviceandviewsonoral
antibiotics,whichcouldatbestbeconfusingandatworstleadtoearlyabandonmentoftreatments,
requestsforinappropriatereferrals,challengingconsultationsandpatientdissatisfaction.Someof
themorepotentiallyhelpfulpostsdirectedreaderstowardsreliablesourcesofinformation,suchas
NHSChoices.Ifpatientswithacneweredirectedtothisinformationthentheymayexperience
bettertreatmentoutcomes.
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14
Figure1
Onlineforumsearchstrategy
Forumsidentifiedthroughsearchengines:n=33
Exclusions:
Forumswithnopostsinthepast6months:n=4
Forumswithfewerthan3relevantthreads:n=17
Forumseligibleforstudy:n=12
Forumsforotherspecifichealthconditionsnot
consideredfurther:n=3
Remainingforums:n=9
Acnespecific:n=1
Generalmedical:n=2
General:n=4
Parenting:n=2
Selectedforstudy:n=4
Acnespecific:n=1;Threads:n=5,Participants:n=31
General:n=1;Threads:n=26,Participants:n=121
Generalmedical:n=1;Threads:n=11,Participants:n=21
Parenting:n=1;Threadsn=23,Participants:n=121
Forumselectionbasedonnumber
ofrelevantaccessiblethreads
15
Box1
Table1
Datasources
Numberof
pagesoftext
(point11)
Numberof
relevant
discussion
threads
Numberofforum
userscontributing
tothreads
Datesof
discussion
threads
Acne-specific
forum
16 5 31 2009–2016
Generalforum 57 26 121 2007–2016
Generalmedical
forum
9 11 21 2008–2015
Parentingforum 54 23 121 2011–2016
All4discussion
forums
136 65 294 2007–2016
- Fortheacnespecificforum,wherenoviablesearchenginewaspresent,the
forumsweresearchedmanuallyforrelevantthreadsuntilasufficient
volumeofdatawasobtainedorallrelevantthreadshadbeenextracted.
- Forthegeneralandthegeneralmedicalforums,whereachronological
searchfunctionwaspresent,theresearchersearchedfor“acneantibiotics”,
then“acne”,then“acnetreatment”.Ineachcase,relevantthreadswere
identifiedfromnewesttooldest,andrelevantpostsextracted.Postswere
extractedfromthegeneralforumuntilasufficientvolumeofdatawas
obtained;thegeneralmedicalforumhadfewerrelevantthreads,soall
relevantthreadswereextracted.
- Fortheparentingforum,whereasearchfunctionwaspresentbutresults
werenotreturnedchronologically,theresearchersearchedfortheterms
describedabove,andthenthefirst10pagesofeachsearchwereexamined
forrelevantthreads.Onceallrelevantthreadswereidentified,thesewere
examinedchronologically,fromnewesttooldest,andrelevantposts
extracteduntilasufficientvolumeofdatawasobtained.
