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Journal of Health Communication
International Perspectives
ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20
Communicating About Cancer Through Facebook:
A Qualitative Analysis of a Breast Cancer
Awareness Page
Karley Abramson, Brian Keefe & Wen-Ying Sylvia Chou
To cite this article: Karley Abramson, Brian Keefe & Wen-Ying Sylvia Chou (2015)
Communicating About Cancer Through Facebook: A Qualitative Analysis of a Breast
Cancer Awareness Page, Journal of Health Communication, 20:2, 237-243, DOI:
10.1080/10810730.2014.927034
To link to this article: http://dx.doi.org/10.1080/10810730.2014.927034
Published online: 13 Dec 2014.
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Communicating About Cancer Through Facebook:
A Qualitative Analysis of a Breast Cancer Awareness Page
KARLEY ABRAMSON1, BRIAN KEEFE2, and WEN-YING SYLVIA CHOU3
1University of Michigan Law School, University of Michigan, Ann Arbor, Michigan, USA
2ICF International, Rockville, Maryland, USA
3Behavioral Research Program, National Cancer Institute, Rockville, Maryland, USA
Social media channels are increasingly being used for health communication and promotion. Social networking sites such as
Facebook have become popular platforms for organizations to communicate health messages and encourage user participation
around health topics. While the evaluation of social media’s effectiveness in health promotion is beginning to emerge in the litera-
ture, few studies have examined actual interactions and user behaviors on Facebook Pages hosted by health organizations. Theauthors present a qualitative case study of a popular Facebook Page from a nonprofit organization devoted to raising awareness
about breast cancer. With the goal of identifying the functions and uses of the Page, our study analyzes the content of Wall posts
during Breast Cancer Awareness Month, October 2010. Common themes and characteristics are identified, including open miccommunication, scarcity of health information, the commodification of breast cancer, unpredictable locations of conversation,
and the use of gendered images and language. The findings have potential implications for health promotion efforts using social
media platforms.
In recent years, social media, characterized by its interactive
and participatory nature, has become a popular tool for
health communication. Nonprofit and government health
organizations have increasingly used social networking sites(SNSs) to reach and engage their audiences (Thackeray,Keller, Heilbronner, & Dellinger, 2011). For example, dur-
ing the H1N1 health scare, the Centers for Disease Controland Prevention used Twitter and Facebook to communicateflu symptoms and promote vaccinations (Fox News, 2009).
The National Cancer Institute’s Smokefree Women initiativeuses Facebook as an online support group for sharinginformation (women.smokefree.gov, n.d.). Such SNSs arethought to hold significant health communication potentialbecause they allow consumers to engage in the creative pro-
cess of content promotion and facilitate viral marketing
(Korda & Itani, 2011). While we are witnessing a rapid
growth of social media in health promotion practices, littleis known concerning how real-world organizations and usersuse the ‘‘participative Internet’’ for health-related discus-sions (Hesse et al., 2011; Jones & Fox, 2009). To address this
question, this case study examines the functions, uses, andcontent of a popular Facebook Page devoted to breast can-cer awareness. Through a qualitative descriptive analysis ofthe dialogue between user and organization, the analysis willshed light on the interactions and behaviors surroundinghealth promotion efforts.
Facebook is currently the most popular SNS in the world,
attracting more than 1.15 billion active monthly users(Facebook, 2013). One of the key features on Facebook—
Facebook Pages—is distinct from other online communitiesin that it is at once a community of users and the public faceof a figure or organization, enabling that person or group todirectly communicate with users (Facebook, 2012a ). For this
reason, the number of nonprofit organizations with Face-book Pages is growing rapidly. Unlike traditional Facebookprofiles, which are accessible only to individual friends selec-ted by the owner of the profile, Facebook Pages are visible toall Facebook users (Facebook, 2012b ). This means that any
user can choose to follow status updates from a Page (byclicking a ‘‘like’’ button on the Page), post content, or com-ment on content found on the Page, and any interactions thatoccur on a Page are visible to all Facebook users (Facebook,2012b ). The main place on a Page for such interactions is the
Wall, a public discussion board, where users can exploit the‘‘combined intelligence’’ of the Internet to ask questionsand initiate discussions (Hesse et al., 2011). Because of the
public nature of this communication, these Pages providesocial science researchers the opportunity to analyze andunderstand interactions among individual users and organi-
zations. For a detailed examination of the features found
on a typical Facebook Page, please see the Appendix.
1Address correspondence to Brian Keefe, ICF International, 530
Gaither Road, Rockville, MD 20850, USA. E-mail: brian.
keefe@icfi.com
Color versions of one or more of the figures in the article
can be found online at www.tandfonline.com/uhcm .1The Facebook Page format continues to evolve and change.Journal of Health Communication , 20:237–243, 2015
Copyright #Taylor & Francis Group, LLC
ISSN: 1081-0730 print/1087-0415 online
DOI: 10.1080/10810730.2014.927034

With the goal to evaluate health communication on
Facebook, recent studies have identified some key uses of
Facebook for specific health conditions. SNSs are found tofacilitate communication among health stakeholders, includ-ing patients, caregivers, and health care professionals(Farmer, Holt, Cook, & Hearing, 2009). There are currently
hundreds of user-initiated Facebook Groups that addresscommon medical conditions, and most are patient =peer
groups, followed by general support groups, and fundraisinggroups. A study reviewing breast cancer Facebook Groupsfound that fundraising and awareness, as opposed to socialsupport, were the most common Group functions (Bender,Jimenez-Marroquin, & Jadad, 2011). In addition, despite
the large number of users that these Groups attract, therewere relatively little explicit user contributions overall.
To date, studies on the health communication on Face-
book have mainly focused on Facebook Groups, rather thanFacebook Pages (Gajaria et al., 2011; Thoren et al., 2013;
Zhang, He, & Sang, 2013). Facebook Groups differ distinctly
from Pages: Groups are predominately created by individualFacebook users for the purposes of small group discussionaround a common interest, whereas Pages act as the officialvoice of an organization on Facebook (Facebook, 2012b ).
While both have the capacity to create content and facilitatediscussion, Pages generally reach more users, with contentopen for public consumption and comment, and are mana-ged by official representatives for a business or organization(Facebook, 2012b ). In-depth analysis is needed to examine
the posted content on health-related Facebook Pages.
Our study expands upon previous research by presenting
a case study of an authentic Facebook Page of a popularbreast cancer awareness organization. We chose to focuson breast cancer because it remains one the most commoncancers in the United States; close to 1 in 8 women are esti-mated to develop invasive breast cancer in their lifetime(American Cancer Society, 2010). This prevalence rate
makes breast cancer one of the most highly visible healthtopics in all forms of media, including Facebook. Whilethere are numerous breast cancer organizations on Face-book, we chose the organization with most popular Page(based on the number of fans or ‘‘likes’’ of the page) in order
to provide an in-depth qualitative analysis. We refer to this
page with a pseudonym, Breast Cancer Organization (BCO),for this study. The study describes interactions between BCOand its users on the Wall (the most popular feature of thePage), identifies common types of exchanges, and determinesthe functions of each type of exchange. While not readilygeneralizable to other social media platforms, this in-depthanalysis highlights key features and functions of social mediaas related to health, therefore the findings have implicationson SNS-based health communication efforts.
Method
Our analysis used a grounded theory approach. We collectedand analyzed Facebook interaction data without a pre-defined theory, allowing concepts and ideas to emerge nat-urally (Ferrante, Shaw, & Scott, 2011; Glaser, 1967). A
strength of this approach is that it allows the researcher tostudy human interaction and behavior within its social con-text (Schreiber & Stern, 2001). In this study, it can be said
that the Facebook community serves as the larger socialcontext, and the conversations and interactions on theFacebook Page’s Wall are the studied behavior.
With the goal of focusing on how organizations leveraged
Facebook Pages for breast cancer outreach, we used theFacebook search engine to find a pool of potential Pages
for analysis. We used the search phrase ‘‘breast cancer’’
and limited the search results to ‘‘Pages’’ only (as opposedto Groups or People). We selected two groups with the high-est number of likes for initial analysis. After examining theinformation sections of these pages, we determined eachPage’s affiliation with or connection to an outside organiza-tion. The Page with the highest number of likes (1,737,216 asof February 1, 2011), BCO, identified itself as a nonprofitorganization with a stated mission of helping fund freemammograms for women and ‘‘spreading awareness.’’
In particular, we extracted interactions on the Wall sec-
tion of the page during the month of October of 2010, BreastCancer Awareness Month. A Wall section is where theorganization and users post wide range of messages andinformation. Facebook wall posts are publically accessibleand therefore consent to analyze the posts was neitherrequired nor obtained from either Page owners or users.During our study period, BCO posted 84 messages to itsWall and received more than 2,500 user responses to thesemessages, ranging from just a few comments to more than600 comments per post. In addition, there were nearly 500posts initiated by Facebook users. It is worth noting that
even though the organization sponsoring BCO is not gener-
ally the most nationally known one (e.g., a Google searchidentifies other organizations before this one), it has by farthe widest reach in its social marketing campaign on Face-book (based on overall number of likes in February 2011).
We retrospectively analyzed Wall posts during Breast
Cancer Awareness Month in 2010 (October 1, 2010, toOctober 31, 2010). The content was categorized accordingto its source (i.e., who initiated the post; Page-host generatedvs. user generated). The content was then analyzed for dis-tinct themes and concepts, and their primary functions.
One researcher began this process by reading through each
post on the wall and the responses that the post received.Each post was copied and pasted into a spreadsheet withthe corresponding responses. After this initial read-through,the same researcher examined the posts a second time andbegan creating a list of common themes, phrases, and con-cepts that emerged. The process was repeated with a secondresearcher. The two researchers then contrasted their find-ings and discussed common concepts and functions. A thirdresearcher participated in the discussion to help reconciledifferences in interpretation. As a result of this collabor-
ation, five primary themes emerged.
Results
Five main themes emerged in our analysis of the Wall posts.
Each theme is subsequently illustrated with example texts.238 K. Abramson et al.

To protect the participants’ privacy and confidentiality, all
potentially identifiable names, products, websites, andcompanies have been altered or replaced with ‘‘XX’’ in theselected excerpts.
Theme 1: Open Mic Night: Facebook as an Open Space for
Self-Expression
We found that the BCO Page functions primarily as an open
gathering place for users to share information and ideas. The
Wall section in particular provides the most visible stage for
these interactions to occur. Likened to an open mic event,the Page host from BCO acts as the emcee, guiding dis-cussion topics and highlighting themes =content with daily
Wall posts. The audience (users) can respond to a commentor steer the content away in an entirely different direction.
The intent of user posts varies from information seek-
ing and giving, support seeking and giving, promotionof products, events, and services, and sharing of personalstories and opinions. Furthermore, user-generated ques-tions vary substantially in tone and content. For example,
users may post questions and express a need for specific
advice:
My friend has just found out she has breast cancer and I
am so upset and I don’t know what to say to her. I just
keep saying sorry. What is the right thing to say?
—Carla
User posts also address topics that are not related to
breast cancer:
Where can I buy the pink light bulbs? I looked at XX andthey didn’t have them. Thanks.
—Eileen
The aforementioned question has little to do with breast
cancer, but because of the pink theme commonly seen
throughout communication channels related to breastcancer, this poster brings up such a question on the Page.Moreover, a large proportion of user posts can be classified
as shoutouts, where users briefly discuss a personal story or
anecdote, and then reference a particular friend or relativethat has faced breast cancer. These posts often do not out-wardly suggest that they are seeking a response, as is the casewith the following example:
My Mom was diagnosed in 1994 …she beat it. Never give
up and always keep a positive attitude.
—Tiffany
In addition to sharing personal stories, users use the
Facebook mic to express personal opinions regardingbreast cancer prevention, symptoms, treatment, and relatedtopics:
Don’t only get checked regularly, stop eating crappy foods.
Don’t eat out, go vegetarian and start working out regu-
larly, your children and family depend on it.
—MichaelNote this example is typical in the sharing of health infor-
mation that is not accurate or based on evidence. The open
mic forum allows for individuals’ opinions and stories to befreely shared and we didn’t notice much attempt from BCO’spart to intervene, correct, or contradict posts. Note, though,that obviously we do not have data on what may have beentaken down. Open mic posts also include promotional con-tent from users, as they advertise various products, services,
and events connected to breast cancer:
I am an author =editor who is putting together an
anthology of art, short stories …about breast cancer.
Anyone who would like to submit their work for this
project can visit my website …Proceeds from this project
will go toward breast cancer research.
—Elaine
In these promotional posts, the author most commonly
includes a URL link or promotional pictures or videos to
lead their interested audience away from the current space.
Theme 2: Promoting Awareness With Scarce Health
Information
The BCO posts help communicate the goals of the Page,
namely supporting breast cancer screening and promotingawareness. Our analysis found that while BCO encouragesusers to participate in their ‘‘Click the Pink Button’’ cam-paign, they rarely supplement their goals with relevanthealth= cancer information. Rather, BCO encourages partici-
pation through imperative statements (‘‘Help us fund mam-
mograms!’’) or questions (‘‘Where are you clicking from?’’).
The following are two examples:
Click, Pass, Repeat! We need your help if we’re going to
hit our goal of funding 500 mammograms this Octoberwith FREE clicks @ XX. Click Now—And Pass the Pink
Ribbon on! Help us fund 500 Mammograms this October!
—BCO
Where are you clicking from? Comment below with your
location and show the world that we’re in this together!Click to fund FREE mammograms!
—BCO
In a few rare occasions, health information or statistics
are included to motivate and supplement the call to
participation:
While breast cancer in men is rare (of 100 women diag-
nosed only 1.1 men are diagnosed) why take the chance?
If you find a lump, just get it checked out ASAP!
—BCO
All in all, there is little breast cancer–related information
or education on the Page. Of the 84 messages that BCO
posted during October 2010, only 3 contained healthinformation. This may be related to the purported goal ofthe site to raise breast cancer awareness and fundCommunicating About Cancer Through Facebook 239

screening tests. In this way, awareness raising is not through
provision of health information or consumer education, butrather persuasive techniques to encourage donation andcamaraderie.
Theme 3: Commodification of Breast Cancer
One central feature of the BCO Facebook Page is the
emphasis on online purchasing as a way to support breast
cancer research. These posts tend to make a connection
between BCO products and positive emotions or admirablecharacteristics:
Faith. Hope. Love. Joy. What do you wish for? Get $1
standard shipping on $20 țUS orders! Ends 10= 6
11:59 pm PT
—BCO
Remind yourself or another woman in your life of the
immeasurable strength that’s within each of us. Leave
your comments below! ‘‘XX’’ Bracelet – 20% Off! Everyitem sold helps fund free mammograms for women in
need. Shop where it matters!’’
—BCO
BCO also demonstrates the theme of commodification
through their promotional efforts on behalf of other compa-
nies or organizations. In addition, other third party compa-
nies use the BCO space specifically, and breast cancer ingeneral, to create, promote, and market various products:
Come in and celebrate X with our exclusive Pink XX! 25
cents of every sale will go to Breast Cancer Research
—Company A
Theme 4: Unpredictable Location and Evolution of
Conversation
In general, conversation occurs through comments or
responses to Wall posts, but often times the content of theconversation has little to do with the content of the originalpost. For example, in response to the BCO post about a pairof Pink Pants, the following conversation occurred:
How does one get a mammogram that cannot afford it? I
click every day but I am in need for one but cannot find
out how?
—Valerie
Valerie, I would call your human service department. Shouldbe listed in the government pages in your phone book.
—Margaret
Call the local news, here in Indy they had it where you
could go free, ask the desk to find out …Get yours. It’s
so important.
—Karen
As shown in the aforementioned example, the conversations
that occur and the topics that they address are often notconsistently related to the content of the original post =ques-
tion. In this case, the original question about pink ribbonswas ignored, but the following posts present a conversationabout another topic, namely, access to mammographyscreenings. Note that we found it very rare that a coherentconversation on a common topic continues for more thanthree or four turns.
The type of community occurring on the BCO Page seem-
ingly then occurs organically and completely separate fromthe stated goal of the BCO Page. Users may have beendrawn to the Page because it was generally about BreastCancer, but appropriated it for their own needs once theyarrived on the Page. While this may be useful for supportpurposes, there could be a danger in users engaging in seem-ingly nonmoderated conversations about health topics andadvice.
Theme 5: Gendered Images and Language
Breast cancer images in the media are found to be highly
feminized and gendered (Haines, 2010). Our analysis con-
firms the observation that BCO used feminine imagery andlanguage to engage users. Furthermore, the types of pro-ducts being sold tended to be stereotypically feminine items.The following represents a typical product post from BCO:
Click Like if you need to be pampered! Today only, get a
free XX Scarf with all orders! Ends 10= 1 11:59 pm PT. I
want this Super Cozy XX!
In addition, because one of the stated goals of the Page is
to fund free mammograms for women, BCO expressly refers
to women in posts. Looking at all interactions within themonth of October, men were only expressly referenced byBCO twice:
Thank you to all the fathers, brothers, sons, husbands,
and friends who click at The Breast Cancer Site inOctober and throughout the year. Keep yourself safe
too! Reminder from a male breast cancer survivor.
Discussion
While BCO primarily focused the content of their posts on
women, it appears that men and women used and contribu-ted to the Page. However, from the self-identified namesappearing on the site, women are much more frequent part-icipants on the Page than men. This is unsurprising given thetopic of the Page and social media usage patterns withregard to gender. Women are more avid users of socialmedia channels, including Facebook, a trend that has held
true from the date of data collection for this study to present
day (Pew Internet and American Life Project, 2013). Unfor-
tunately, because in many cases we cannot ascertain the gen-der of the posters, the distinct ways in which men andwomen contributed to and used the Page is beyond the scopeof our analysis.240 K. Abramson et al.

Implications for Health Communication Practice
Based on the content of the BCO Facebook Page, several con-
siderations emerge as we consider health communication onSNSs. Most important, the objective of raising awareness (ofa health topic) can be realized in distinctly different ways andin many ways, it does not entail communicating health infor-mation. In this case, BCO’s stated goal was to raise moneyfor and awareness of breast cancer screening, and this is donemainly through ‘‘Click to Fund Mammogram’’ programs.Posts focus on shopping, product promotion, and fundraising;they contain little health information. While this may be unsur-prising, as one of their stated main goals was to fund mammo-
grams for women in need, the extent to which BCO successfully
spread awareness is a central question to ponder.
In analyzing the BCO’s Facebook Page, key questions
remain to be answered regarding the impact of health-relatedFacebook pages on awareness of and attitudes towards spe-cific health conditions and behaviors. Specific questions thatshould be analyzed in future research include: Does havingthe active interactions on its Facebook Page and the mostnumber of fans improve awareness? Is this awareness aboutscreening mammography and general breast cancer preven-tion? Do the interactions on the Page bring awareness to other
health-related attitudes and perceptions? To what extent is
health information necessary to truly increase public aware-ness of the value of screening mammography and equitableaccess to such preventive care? It is possible that absent ofany health education effort, SNSs potentially still have abroader reach and efficacy than mass communication mediaby stimulating community participation and a dialogue abouta particular health issue (e.g., breast cancer, mammography).
Moreover, because users evidently use the SNS space for
their own purposes and for spreading their ideas, healthorganizations might need to consider their role in moderat-
ing and monitoring their Page’s content and activity. In
our case study, BCO does not appear to censor user postsfor content accuracy, possibly due to the organization’soverall focus on awareness rather than education. Further-more, the analysis indicates that the ‘‘Wisdom of theCrowd’’ effect was not pervasive on this Page. Specifically,the current literature on crowdsourcing suggests that withenough volume of opinions (e.g., posts or evaluation abouta topic on a Facebook page) a crowd will self-correct toreach a more unbiased viewpoint, (Surowiecki, 2005). While
a small number of arguments or debates did arise over a spe-
cific comment, much of the inaccurate information shared
on the page went unchallenged. For example, one BCO Pagefollower named Michael implored other users to ‘‘Don’t eatout, go vegetarian and start working out regularly’’ to pre-vent cancer. While there may be validity to the effects ofworking out and eating right to lower cancer risk, the state-ment as a whole could be seen as being inaccurate or notinformed by scientific evidence. However, this statementwent unchallenged on the Page and was not addressed byBCO. It is worth noting that because our analysis took placein February 2011, we cannot account for the fact that some
comments may have been deleted or altered before we
viewed the data, so some monitoring could have occurred.Regardless, evidence-based health promotion efforts withexplicit educational aims should consider the risks andresponsibility of user-generated content, as well as the effortneeded to monitor user posts for inaccuracies.
The study is limited as it represents only one Facebook
Page on a singular health topic, and thus cannot begeneralized to all health-related Facebook Pages. Inaddition, we are unable to examine or predict how users par-
ticipating in other health-related Facebook Pages may inter-
act or respond to various health messages. Given thatcontent continues to evolve and change, the analysis is notdirectly replicable, though the themes emerged should begenerally representative of similar Facebook Groups cur-rently publically accessible. As previously stated, we cannotaccount for any user comments that may have been deletedor altered prior to our review. Therefore, it is possible thatBCO had engaged in monitoring activities, specifically thedeletion of inaccurate or inappropriate posts.
Looking forward, it is important to recognize that social
media–based health promotion efforts are challenging toevaluate. In addition to ascertaining impact on health atti-tudes, beliefs and behaviors, descriptive research on theinteraction dynamics and content can be difficult. In parti-cular, our findings show that much of the content servesmultiple and overlapping functions; for this reason codingchunks of discussion into mutually exclusive categories isnot feasible or useful. It is a key research priority in thisera of participative media to develop innovative and appro-priate methodologies for observational studies, as well asimpact evaluation for social media-based communication
efforts. Further research is needed to understand how wider
ranges of Facebook Pages are used for health promotion.Experimental studies to assess the effectiveness of healthcommunication strategies that use social media in generalare also warranted. A recent study reviewed current evidenceregarding the effectiveness of social media and the impact onhealth knowledge, behavior, and outcomes (Korda & Itani,2011). This study recognized the challenges for social media
use in health promotion, emphasizing the need for theory-based evaluation methods and metrics, a deeper understand-ing of behavior change in the Web 2.0 world, and more
information on the costs and benefits of social media as a
health communication strategy (Korda & Itani, 2011). More
of these types of studies—along with deeper qualitativeanalyses that can illuminate the intricacies of social mediaactivity—are essential for realizing the full potential of socialmedia for health communication.
Acknowledgment
Conclusions drawn in this article belong to the authors andnot to the National Cancer Institute, University ofMichigan, or ICF International.
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Appendix: Layout and Functions of a Facebook Page
Facebook Page [Screenshot] (2012). Retrieved from https://www.facebook.com/facebook?ref=tsCommunicating About Cancer Through Facebook 243