The Science of Diabetes Self-Management and Care 2025, Vol. 51(6) 602–614 © The Author(s) 2025 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/26350106251374238 journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of this study was to collect qualitative feedback from key stakeholders as to their recommendations for developing a behavior-change-focused social media toolkit for American Indian and Alaska Native (AI/AN) female youth who are at risk for gestational diabetes mellitus (GDM). AI/AN women experience a higher rate of GDM than women from most other racial and ethnic groups. The Stopping Gestational Diabetes in Daughters and Mothers (SGDM) program is designed to reduce GDM risk for AI/AN females.
Methods: Individual interviews were conducted with content experts (health care providers/educators, researchers, and social media experts) who serve AI/AN communities (n = 20), and focus group interviews were conducted with female AI/AN youth ages 12 to 21 (n = 20) and AI/AN mothers (n = 20). Interviews were conducted via teleconference by an experienced AI/AN moderator, and transcripts were analyzed using thematic analysis. Participants completed a survey assessing personal characteristics and technology use.
Results: All youth and mothers (100%) reported using social media daily; 60% of content experts reported daily social media use. Overarching themes included (1) negative aspects of social media use should be balanced with health-promoting messaging; (2) female AI/AN youth need positive AI/AN female role models, support, and connection to be healthy; (3) engage female AI/AN youth on social media through use of videos, humor, strengths-based messaging, and codevelopment of content.
Conclusion: Understanding the perspectives of content experts and members of the priority audience is a key first step in developing an AI/AN culturally relevant and community-engaged social media toolkit.
Gestational diabetes mellitus (GDM) is the most common complication of pregnancy, affecting >10% of US pregnancies.1 Defined as glucose intolerance with onset in pregnancy, GDM leads to complications for women and their offspring.1 Women with GDM have increased rates of type 2 diabetes (T2D) postpregnancy, and their children have increased rates of obesity and T2D.2 American Indian and Alaska Native (AI/AN) women are twice as likely to develop GDM as non-Hispanic White women.2
The Stopping Gestational Diabetes in Daughters and Mothers (SGDM) program is a developmentally appropriate, evidence-based preconception counseling intervention that presents science-based content specific to GDM and encourages behaviors that can reduce GDM risk (eg, family planning, healthful body weight).3,4 The SGDM program consists of an online eBook4 and a ≈45 minute video3 for AI/AN female youth and their mothers, a communication resource booklet for mothers,5 and recommended supporting resources.6 SGDM was adapted for AI/AN female adolescent youth and young adults (hereafter referred to as “AI/AN female youth”) who are at risk for diabetes from the American Diabetes Association (ADA)-endorsed, evidence-based, theory-driven Reproductive-Health Education and Awareness of Diabetes in Youth for Girls (READY-Girls) program. The READY-Girls program is distributed at no charge by the ADA as their endorsed preconception counseling standard of care to prevent unplanned pregnancy and pregnancy complications in adolescent females living with type 1 diabetes or T2D.7,8
The SGDM program was adapted for AI/AN audiences based on in-depth interviews with AI/AN female youth, their mothers, and AI/AN women who had experienced GDM; AI/AN-serving health care providers; and tribal leaders.9-11 Given the central role of family in AI/AN communities,12 SGDM includes educational content for mothers, such as guidance on how they can support the female youth in their lives in the pursuit of reproductive health. AI/AN adult women have important roles culturally in caring for AI/AN female youth in their communities, and this includes mothers, grandmothers, and aunts.13,14 Hereafter, authors will use the term “mothers” as inclusive of grandmothers and aunts who play an important role in AI/AN female youths’ lives.
Research suggests that mobile health technology may provide an effective avenue for developing interventions that can overcome barriers to health care access while promoting engagement and peer support.15-18 Social media may be a particularly valuable platform for SGDM for AI/AN female youth. A recent survey indicated that 95% of AI/AN youth have access to a smartphone, with 65% reporting 3 to 7 hours of social media use per day and the vast majority checking ≥1 platform at least weekly (eg, 94% for Instagram).19
To support widespread dissemination of key behavioral recommendations supported by the SGDM program in AI/AN communities, the research team secured funding to develop a social media toolkit to expand SGDM reach and access. The toolkit will contain a library of social media posts designed to disseminate key behavioral recommendations for reducing GDM risk and guidance for how content can be shared using social media platforms preferred by AI/AN female youth and mothers. To ensure the social media toolkit will be well tailored to the priority audience, the research team has conducted a multiple-methods inquiry to understand the social media preferences of AI/AN female youth, AI/AN mothers, and AI/AN-serving content experts. Because SGDM aims to reduce GDM risk among AI/AN female youth—in part, by engaging mothers in support of their daughters’ reproductive health—understanding the social media preferences of AI/AN female youth and their mothers is critical. The purpose of this study was to collect qualitative feedback from key stakeholders as to their recommendations for developing a behavior-change-focused social media toolkit for AI/AN female youth who are at risk for GDM.
Research Question: How can social media be a vehicle for GDM risk reduction among AI/AN female youth?
This project employs an adapted version of the integrated theory of mHealth as a foundational theoretical framework,20 which was developed by a study team member (SB) in recognition that mHealth interventions require conceptual models that include factors unique to mHealth as well as traditional health behavior theory. The model highlights the importance of access and engagement as critical determinants of the success of mHealth interventions. Understanding social media preferences and access is a key element of the integrated theory of mHealth. To be effective with technology-based health education, interventions must reach people where they are, which means being informed on what technology people access, whether access is widespread or universal, and if there are barriers to access. The theory also emphasizes user engagement in technology-based interventions, which requires understanding the target population’s preferences around what types of content and formats they find engaging and salient.20 Consistent with work to develop the READY-Girls and SGDM programs, the adapted model also includes the expanded health belief model,21 which posits that health beliefs impact health behavior.
This study was framed by a constructivist epistemological approach to data collection and analysis, which allowed themes to emerge that researchers might not have anticipated.22 The research team used a multiple-methods approach to this study, including both individual key informant and focus group interviews and a survey assessing personal characteristics and technology use to contextualize findings and describe the sample.
To understand the perceptions and preferences of the priority audience, the research team conducted interviews with AIAN female youth and mothers and experts, specifically, AI/AN-serving health care providers and health educators, researchers who use social media to connect with AI/AN audiences, and others who have expertise in using social media to communicate health information to AI/AN audiences. Individual interviews were used for the content expert interviews—largely because of the difficulty of scheduling for these experts. The research team used focus group interview methods to facilitate discussions with the AI/AN female youth and mothers. The focus group method of interviewing was intentionally chosen to offset the power dynamic between interviewer and participant by “outnumbering” the researchers with more than 1 participant.23 This practice is especially important when discussing sensitive topics or interviewing children or adolescents.24,25
The University of Colorado Multiple Institutional Review Board (No. 23-2122), the Indian Health Service National Institutional Review Board (No. N24-N-02), and the Akwesasne Task Force on the Environment’s Research Advisory Committee all approved this protocol as exempt; therefore, an information sheet was used in lieu of a signed informed consent document.
Focus group interviews with AI/AN female youth and mothers. The research team conducted semistructured focus groups with 20 female youth and 20 mothers. Participants were recruited and screened for eligibility by 3 American Indian female recruiters. One recruited from a northeast rural tribal reservation, 1 from the southwest part of the United States in a rural but not tribe-specific geography, and 1 from an urban community in the Pacific Northwest. The recruitment strategy was meant to employ maximum purposive sampling methods26 by recruiting from these 3 communities to produce a diverse sample, including youth and women from urban and rural areas, living on and off tribal lands, and having a variety of tribal affiliations. To be eligible to participate, female youth needed to be English-speaking, ages 12 to 21 years, and to self-identify as AI/AN. Female youth with a prior diagnosis of diabetes, including GDM, were excluded. To be eligible, mothers needed to be English-speaking, ages ≥18 years, to self-identify as AI/AN, and/or be the mother of an AI/AN female youth ages 12 to 21 years residing in the same household. Although some of the mothers recruited were the mothers of participating AI/AN female youth, this was not a requirement to participate.
Individual interviews with content experts. The research team conducted individual key informant interviews with 20 AI/AN-serving health care providers and health educators and researchers and others who have expertise using social media to connect with AI/AN audiences. Participants were recruited through the research team’s robust professional and social networks and through snowball sampling.26 To be eligible, these key experts had to have been English-speaking, be ages ≥18 years, have experience as a health care provider or health educator for AI/AN female youth, and/or have experience communicating with this audience via social media.
Focus group interviews with AI/AN female youth and mothers. Although we aimed for focus groups to include 5 to 8 participants, most included only 2 to 3 participants because of challenges related to timing and scheduling of the groups. All focus groups were conducted by teleconference (eg, Zoom) and were moderated by a skilled American Indian female interviewer (SM). Prior to the start of each focus group, the moderator reviewed an information sheet about the study with participants, who then had a chance to ask questions and provide verbal consent. For participants ages 12 to 17 years, a parent or legal guardian also provided consent, and the female youth provided her own assent. At the end of each interview or focus group, participants completed a brief online survey assessing sociodemographic informatio (age, gender, race, ethnicity, state of residence), health literacy and electronic health literacy,27 and technology access and use.19
Focus groups with AI/AN female youth were conducted separately from those for mothers but followed the same semistructured moderator guide. The semistructured moderator guide was developed by the team’s qualitative lead (SS) and was finalized based on input from the project team, including American Indian qualitative experts (KG, KB, SM), social media content developers (SB, NR, SM, JL), diabetes and preconception counseling expert (DSP), additional American Indian collaborators (NR, HG, MA, MC), and the principal investigator (PI; AB). The guide focused on soliciting input regarding participants’ perspectives on promoting health for AI/AN female youth, preferred sources of health information, preferences for social media platforms, recommendations for format, and suggestions for ensuring active social media engagement of female youth and mothers. Table 1 displays the moderator guide questions used for this study. All focus group participants received a $50 gift card for their time.
Individual interviews with content experts. Individual interviews with health care providers, health educators, researchers, and other social media experts were conducted via videoconference (eg, Zoom) by an experienced American Indian qualitative researcher (SM). Prior to the start of each interview, the moderator provided participants with an information sheet about the study and reviewed it with them. Participants had the opportunity to ask questions and provided verbal consent. At the end of the interviews, participants completed a brief online questionnaire assessing sociodemographic characteristics and professional background (eg, educational background and degrees, job title and organization, years of experience, social media habits).
Interviews with content experts followed a moderator guide developed by the lead qualitative researcher and revised based on input from the whole research team, including qualitative experts, the diabetes and preconception counseling expert, the social media content developers, American Indian collaborators, and the PI (AB). The moderator guide solicited information about participants’ experience providing care to AI/AN female youth and adults, expertise related to GDM and family planning, experience using social media to connect with AI/AN female youth, recommended platforms and formats, and suggestions for ensuring engagement. Eligible providers (ie, federal employees were not eligible to accept payment) received a $50 gift card for their participation.
All interviews were recorded and transcribed verbatim by a professional transcription company. Transcripts were checked for accuracy in their entirety and de-identified. The research team utilized Atlas.ti (Mac version 8.1.1) to digitize and increase transparency in the analytic process.28 Two researchers independently double-coded 100% the transcripts.29 The first round of coding included inductive free coding of 2 transcripts, where no predetermined codebook was utilized.29 At this point, deductive (a priori) codes were applied to these same 2 transcripts. These deductive codes were based on the moderator guide, supporting literature, and research questions. During the second comprehensive round of coding, the lead qualitative researcher coded all transcripts with the codebook, including inductive and deductive codes. The lead researcher then met with the study PI and social media content developers to provide preliminary findings, which were used to inform development of social media content. A second coder then independently coded all transcripts using the same codebook and refined code definitions where clarification was warranted. After all transcripts were double-coded, the 2 primary coders summarized and collapsed codes into categories. For example, the codes “social media not healthy,” “social media not safe,” and “limit social media” were grouped together under category “negative aspects of social media.”29 Ultimately, the categories revealed 3 overarching themes from this thematic analysis.30 The 2 primary coders then met with the research team, including American Indian consultants and the social media content developers, to review preliminary themes and supporting categories as a means to triangulate preliminary findings with American Indian members of the research team.31 The analysis and description of findings follow the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines, a 32-item checklist designed to ensure rigorous and systematic reporting of qualitative research.32
The research team conducted individual key informant interviews with content experts (ie, AI/AN-serving health care providers, health educators, researchers, and social media experts; n = 20) and focus groups with AI/AN female youth (n = 8 focus groups; n = 20 participants) and AI/AN mothers (n = 9 focus groups; n = 20 participants). For details on the data collected, see Table 2. For details on the personal characteristics of the focus group and individual interview participants, see Table 3.
All youth (100%) identified as AI/AN. The mean age for AI/AN female youth participants was 17.6 years (SD = 2.82). All youth reported using social media daily. Half (50%) of the youth participants reported less than a high school education, and 40% were high school graduates. Although self-identifying as AI/AN was an eligibility criterion for mothers, 1 mother did not; the remaining 95% of mothers identified as AI/AN. The non-AIAN mother was retained because she is the mother of an AI/AN female youth. Most mothers reported having a high school diploma (40%) or technical/vocational/associate’s degree (40%), and all (100%) reported using social media daily. All (100%) of the content experts had a graduate degree, with 60% using social media daily. Although 70% self-identified as White, nearly half (40%) identified as AI/AN alone or in combination with another race. The majority (60%) of content experts identified their professional role as researcher (35% researcher alone and 25% as researcher plus another role, ie, health care provider, health educator, and/or public health professional). Other responses included health care provider (20%), health educator (10%), and public health professional (10%). Most content experts (55%) worked at a school or university, 20% worked at an AI/AN-serving health care facility, 10% worked at a nonprofit organization, and 15% worked at a different type of organization. The mean number of years of experience working with AI/AN female youth was 17.45 (SD = 9.36). Nearly half (45%) of content experts indicated they share content on social media at least weekly with the AI/AN female youth with whom they work.
Three salient themes emerged across individual interviews and focus groups. First, there are negative aspects of social media that need to be considered and balanced in health-promoting messaging (eg, promotion of unrealistic body image), and social media can be unsafe for female youth. Second, female AI/AN youth need positive AI/AN female role models, support (eg, mental health), and connection (eg, to others, to culture) to be healthy. Third, key recommendations to engage AI/AN female youth on social media to promote healthful behaviors include using videos, humor, empowering and strengths-based messaging, and codevelopment of content (eg, youth and social media experts developing content together). Although these were overarching themes across all 3 groups of participants, it is noteworthy that “safety” was a prominent topic of discussion in the content expert interviews and was not mentioned as directly in the mother and youth focus groups.
Theme 1: Negative aspects of social media need to be considered and balanced with health-promoting messaging, and social media can be unsafe for female youth. Across most interviews and focus groups, participants discussed the negative aspects of social media use. Some of these topics were not specific to female youth, such as social media being “addictive” and “mindless” and participants suggesting they used it “way too much.” Most participants indicated that using social media “less” was a goal, and often adults (eg, mothers, content experts) indicated that they advise female youth to limit their social media use, limit how much they share about their personal life on social media, and “unplug” more often to promote health, wellness, and balance. One AI/AN female youth noted the irony of how “toxic” social media is and the (eg, research team) efforts to develop a health-promoting social media toolkit. Additionally, one mother shared:
I feel like we’re so drawn to social media sometimes, especially our youth. And I’ll tell my daughter, “Don’t spend too much time, don’t get sucked in or drawn into that.” Because even my 10-year-old is sometimes scrolling and there’s [advertising] information that’s fed to her.
One social media content expert shared:
We are, on one hand, meeting youth where they are. On the other hand, we are also summoning youth into a space where we know it’s healthy to step away from social media, to put our phones down and be engaged in the real world with actual human beings. There’s always 2 sides to the coin. In some ways you could argue we contribute to getting youth on social media. But, that’s where they are, and can we be a force of good in that space that has so many risks we are only beginning to understand the dangers of social media on youth in particular.
Participants also shared concerns about widespread “misinformation” on social media and that it is easy to lose track of “what is accurate information and what is not,” especially for female youth. One health care provider shared:
Kids spend an inordinate amount of time engaging with social media. I think that is where they’re getting most of their information. . . . So, absolutely, it’s important that we reach them that way.
Participants shared concerns about unhealthy and unrealistic images of women on social media, which can be very detrimental for female youths’ confidence. Another health care provider said:
I think a lot of the nutrition stuff on TikTok is fad diets and bad nutrition advice that can be damaging to young women not to mention all the images of unrealistic body types. They’re just being bombarded with unrealistic expectations and their real life is completely different. What they have access to, what they’re able to eat and exercise and that sort of thing, especially living out on the res, it’s a really hard reality to deal with, especially as a young woman.
Of note, some of the younger youth in the focus groups shared that they did not have any social media because they were not “allowed” to (by their parents), and some of the adult females mentioned they did not let their younger children use social media other than “just to message with me [the parent] and their siblings.” Although participants shared concerns about social media use in health promotion among AI/AN female youth, almost all indicated that social media is a large part of most people’s live and that it can be a good way to reach this priority audience.
Theme 2: Female AI/AN youth need positive AI/AN female role models, support (eg, mental health), and connection (eg, to others, to culture) to be healthy. When asked what AI/AN female youth need to be healthy and how social media could promote healthful behaviors for this priority audience, participants said that healthy AI/AN female role models, support, and connection are key. Specific to the importance of role models, one health care provider shared:
Some people are lucky and have a great older sister or strong female example in their life, but I think that’s part of the intergenerational trauma and challenges that face the community is their mom had diabetes, their grandma has diabetes, and it’s almost like, well of course [I’ll have] diabetes. Seeing women that lift weights and run marathons . . . I’m like, “You’re badass. Please keep this up because our little girls need to see you doing this.” If we can really highlight those women that are taking care of themselves and having strong bodies, that’s the most valuable thing.
Participants indicated that support is also key to promoting health, including support from adults, friends, health care providers, and community. One youth participant shared her experience with community support when asked what AI/AN female youth need to be healthy:
I would say a good family or a good support system and good friends. I find that, here, it’s a lot of women supporting women. I’m in a big friend group and our families treat each other like we’re all sisters. Me and my friends, we’re sisters and their moms are my mom, and my dad’s their dad, families looking after other kids. I find it really helps, although my parents are divorced and my mother wasn’t really around for my upbringing, I never felt that absence because I always had some female figure, whether it was my friend’s mother or my aunties. The families say, “Okay, she’s missing this part and let’s step up and fill that gap.”
In response to the same question in another focus group, one AI/AN female youth shared:
Having supportive families and friends plays a huge part in being healthy as well as just being in an environment where you’re able to thrive . . . somewhere where you’re being validated of your dreams and your goals and the things you want to do in life, and just feeling that support as well as having access to the essentials such as food and clean water.
Participants also shared the importance of connection and broadly used this term to include connection to each other (eg, peers), family, community, and culture. For the female youth who had left home for college or work, they suggested these connections are often bolstered through social media. One health educator who uses social media in her work shared:
I think, overall, it just took a lot of innovation and thinking about, how do we reach our youth? How do we talk about healthy food? How do we talk about diabetes? How do we talk about taking care of yourself and how do we talk about spirituality? Because that was really important as well, getting connected with their culture, with their aunties, and grandmas. Then having that relationship, a 3-generation relationship in many times, or 4 generations. So, we’re always thinking about that matrilineal and matriarchal connection that comes from our tribe, but also the meaning behind that.
Further conversation was about the importance of connection to culture centered around traditional AI/AN cultural values of relationality, storytelling, intergenerational relationships, holistic health, resilience, and connection with nature. Regarding how to operationalize “connection to culture,” topics such as traditional foods and healthful cooking were discussed frequently. Participants indicated that indeed social media has a lot of potential to foster these healthful behaviors by promoting healthy role models, sources of support, and connection.
Theme 3: Key recommendations to engage AI/AN female youth on social media to promote healthful behaviors included using videos, humor, empowering and strengths-based messaging, and codevelopment of content (eg, youth and social media experts developing content together). Regarding recommendations to develop health-promoting social media content for AI/AN female youth, participants shared recommendations and mentioned many existing social media platforms as exemplars. Participants discussed humor, relatability, and positive messaging as the primary reason they “share” or “like” content on social media. One youth participant shared:
For the purpose of creating media to promote women’s wellness and exercise, I feel like it needs to be relatable. I don’t follow stuff . . . that has a sterile approach to their production. When I want to follow Native-specific fitness people, they’re relatable in some way, like their humor or they have a challenge where they just move 30 minutes a day. Humor is a big portion about why I keep following people and I don’t want this clean aesthetic if it were to be a Native-related fitness channel.
Participants indicated short video-based messaging, showing physical activity as outdoor activity (vs in a gym setting), and showing youth doing activities together (eg, being physically active) as important to ensure engaging content. A mother shared:
Using creative platforms through social media. . . . Youth, they do not want to read 5, 6 pages of information. They’re not interested in a lecture or a PowerPoint anymore. They’re just interested in something that’s quick and interactive, and that’s it. And I think that’s why they’re engaged in the TikTok platform. It’s like 2 or 3 minutes and that’s it. It’s someone that’s talking to them with images, interactive videos, stuff that’s engaging rather than just giving them a lecture for an hour.
Participants also discussed the need for a “hook” to engage female youth and that strength-based approaches using a cocreative design process with youth and social media experts would be a promising strategy. Participants suggested framing healthful behaviors in terms of what is important to the audience instead of “disease prevention,” which often does not resonate with this age group. A health educator who develops social media content recommended:
In terms of having the program sustained and have successful outcomes, the main thing is to involve the youth and key community members in the design, implementation, and keep them involved. Especially right now, if we’re using digital platforms, they’re changing day by day. Facebook was the “It” platform 10 years ago. Then Instagram. And Tiktok is ruling over everything right now. So, it keeps on changing year by year, it’s important to keep involving [youth and community members] and understand their perspectives, especially if you see that, at one point, there was a dip in the reach or engagement, to address that gap early on.
They also discussed sharing cooking and nutrition information (eg, recipes) as common topics they “like” and “share” on social media and to promote healthful dietary behaviors rooted in culture (eg, traditional foods). Considering aforementioned concerns about misinformation on social media, participants also explained how building “trust” with the priority audience was important. Key recommendations to foster trust and confidence in quality information included featuring AI/AN health care providers and role models and grounding healthful behavior recommendations in cultural practices. They also suggested that social media can be used as a tool to promote in-person connection, such as announcements about group physical activity or cultural activity opportunities in the community. Additionally, participants noted that because the research team was developing a social media toolkit for national use, it could be tricky to build trust and important to include community and culturally specific content. Another health educator shared:
I have to say the most important thing is establishing trust. . . . And you’re dealing with not a homogenous population. If you’re hoping to apply this across the entire continent, you’re talking about a lot of different cultural backgrounds. So, gaining trust in all those different situations will probably require a little bit of work.
Generally, participants suggested prioritizing platforms such as TikTok, Instagram, and Facebook, although they noted that each is used for different things. For example, Facebook is more to communicate with friends and family and share/monitor community events, whereas Instagram can have great images and positive messaging. Some model programs mentioned include Healthy Native Youth,33 Native WYSE Choices,34 and We R Native.35
The topic of “safety” was discussed largely during interviews with the social media content expert interviewees and notably not discussed during mother or youth focus groups. When asked about recommended social media resources to promote health and “what AI/AN female youth need to be healthy,” many of the content expert interviewees mentioned “safety” in terms of safe social media exposure and safe environments and relationships. Although mothers did not specifically use the term “safety,” many did share that they follow or monitor their daughters’ social media use and are able to access their social media accounts for the purpose of ensuring that their daughters are safe in the social media environment.
Social media is an accessible way to reach and engage with large numbers of people to improve health behaviors among individuals with limited access to quality health care.15-18 Many AI/AN people receive their health care through the Indian Health Service (IHS), which provides health care to members of federally recognized tribes. However IHS is perpetually underfunded, and based on 2023 data, per capita health care expenditures were $4078 for IHS users compared to $13 493 nationally.36 Furthermore, AI/AN people who do not have access to IHS resources may also not have access to culturally relevant health education or health care.37-40 Having health education resources, such as SGDM, available through social media may allow us to reach more members of the priority audience, many of whom may lack access to other health education programs and positive health messaging. A recent survey reported that 95% of AI/AN youth have access to a smartphone, with 65% reporting using social media 3 to 7 hours per day.19 Nascent, largely observational literature on health messaging social media interventions and adolescent behavior changes primarily focuses on how youth use social media and resulting associations with their health.41 Nutrition-related interventions delivered through social media may be promising in improving outcomes such as weight and waist circumference, dietary outcomes, and physical activity among adolescents.41,42
Overall, the most common social media channels utilized by AI/AN individuals in the current study and other studies were similar and included Facebook, Instagram, Snapchat (now Snap, Inc), and Twitter.43,44 These channels were often utilized to share inspirational or humorous messages and to communicate with family and friends. AI/AN youth shared the need for “support” through AI/AN-specific cultural resources through social media.43 These findings reveal that members of the priority audience want to get health and wellness information from AI/AN female role models, female family members, or trusted health professionals. These key messages were similar to qualitative findings from the original SGDM program development study, during which researchers incorporated similar input from AI/AN youth and mothers, AI/AN women with a history of GDM, and health professionals who cared for these populations.9-11,45 SGDM has an AI/AN female physician narrating the video,3 and both the eBook and video incorporated original images of real-life multigenerational AI/AN females.3,4
Social media is one way for AI/AN youth to connect with others who are involved with healthy AI/AN traditions (eg, connecting with nature, crafts, and traditional foods), which can improve adolescents’ mental health.46 The need for trusted adults and third-party responders to be present on social media channels to mitigate misinformation and increase safety was also mentioned in both the current study and in the literature.43 In addition to the benefits of reaching a large audience through social media, there are also risks for female youth who utilize social media. The findings from this study regarding “safety” reveal that only the health care content experts interviewed discussed this topic, but mothers often discussed “monitoring” their children’s social media and/or using a particular social media platform only because their children did. Without mentioning “safety” explicitly, it may be that this is the parents’ strategy for ensuring safety. As supported by the literature, parents report monitoring their children’s online presence through checking youths’ social media profile or websites they visit, posting a comment on youths’ social media profile, and searching for their children’s names online.47 Parents reported that these monitoring strategies felt necessary due to concerns of private information getting into the wrong hands, depression, and effects on health.47,48
The literature suggests that exposure to body-positive images, body satisfaction, and body appreciation via social media can be valuable for improving their own body image and reducing social comparison.49,50 Yet critics of the movement argue that it reasserts the importance of physical appearance. An alternative includes nonappearance-focused media that does not have images of people as effective for supporting positive body image49 because social comparison to unrealistic images and activities can be harmful to female youths’ body image and self-esteem.50 A study focusing on the positive and negative influence on youths’ affective well-being suggests that positive experiences with social media use, such as self-expression, self-reflection, validating feedback, interestdriven learning, and online peer communication, can lead to a sense of belonging. The study also reported positive and negative attributes of social media use among youth. Positive feelings of closeness, affirmation, acceptance, inspiration, and entertainment were some of the positive attributes.51 Negative attributes were feelings of disconnection, peer judgments, inferiority, boredom, and wasted time.51
Despite documented risks, when used appropriately, social media can be successfully used as a tool to disseminate health-related information to adolescents. Useful strategies that other social media-based AI/AN health education resources utilize are engaging viewers in polls to prioritize the content, tailoring posts to images of AI/AN people, posting new content about every 2 days, tagging viewers to increase participation, and prompting new members to introduce themselves.18 Introducing the social media intervention to the priority audience and adapting based on feedback is helpful to enhance engagement and relevance.52 In the current study, participants had useful suggestions to aid in the creation of the content, such as showing both group-based and individual physical activities and use of realistic photos of AI/AN youth. Additionally, posting body-positive content as a strengthsbased approach is useful when tailoring content for female youth.50,53 Finally, sharing the curriculum through channels where AI/AN youth are already present has also been useful, such as in school, during community events, and at youth gatherings.33
A key limitation from this data set is low engagement with the female youth in the focus group interviews. In some focus groups, only 1 or 2 of the youth spoke at all, and in most focus groups, it was difficult for the moderator to get youth to expand on their responses to the moderator guide questions. Given this, it is challenging to extrapolate their perspectives to a larger audience of their peers. To mitigate this in the future, the research team may consider training a youth researcher to collect data from youth or find another means to more fully engage youth (eg, focus group conversations at gatherings where something else is taking place, such as sewing circle or cooking).
Understanding the perspectives of content experts and members of the priority audience as to the potential of social media as a platform to promote healthful behavior for GDM risk reduction is a key first step in developing such a resource. Findings from this study will be used to inform the social media toolkit for the SGDM program and can be used to inform other social-media-based strategies to improve health of other groups of youth.
The authors thank all of the participants involved in the key informant interviews and focus group interviews for their time and shared experience and expertise.
SAS analyzed qualitative data and drafted all versions of the manuscript; SP analyzed qualitative data and contributed to writing the discussion; SM collected all data; SJM contributed to data collection and writing the methods; KB, HG, MA, and MC recruited participants and reviewed all quotations; DCP and KG provided senior mentorship; AB provided leadership and original writing of all versions of the manuscript. All authors have reviewed, edited, and approved the final version of this manuscript.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: American Diabetes Association Grant No. 7-23-ICTSWH-08 (PI: Brega) and National Institute for Diabetes and Digestive and Kidney Disease Grant No. P30DK092923 (MPIs: Manson and Brega) and Grant No. K01DK128023 (PI: Stotz).
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From Department of Food Science and Human Nutrition, Colorado State University, Fort Collins, Colorado (Dr Stotz, Ms Palmer); Independent consultant, Ada, Oklahoma (Dr McCage); Independent consultant, Portland, Oregon (Ms Charley); Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado (Ms Mumby, Ms Aspaas, Dr Bull, Ms Leon, Ms Reed, Dr Brega); Maven Collective Consulting, LLC, Edmond, Oklahoma (Ms Begay); Saint Regis Mohawk Let’s Get Healthy, Akwesasne, New York (Ms Garrow); University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (Dr Charron-Prochownik); and Portland State University, Portland, Oregon (Dr Gonzales).
Corresponding Author: Angela G. Brega, Department of Community and Behavioral Health, Centers for American Indian & Alaska Native Health, Colorado School of Public Health, 13055 East 17th Avenue, Mail Stop F800, Aurora, CO 80045, USA. Email: angela.brega@cuanschutz.edu
