Adults’ experiences of using journalling to reflect on suicide and self-harm related online use: indications of a potential area for intervention development to reduce online harm

Adults’ experiences of using journalling to reflect on suicide and self-harm related online use: indications of a potential area for intervention development to reduce online harm | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adults’ experiences of using journalling to reflect on suicide and self-harm related online use: indications of a potential area for intervention development to reduce online harm Lucy Biddle, Laura Kennedy, Lydia Grace, Jane Derges, Zoë Haime This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4869852/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: It is well-established that self-harm and suicide-related online use can bring harms and benefits for users. Research suggests a need to upskill users and improve metacognition around online engagement to manage these conflicting effects but there is currently a lack of behavioural interventions to achieve this. We explored incidental data from a longitudinal qualitative study, which indicated that self-completing a research diary about online engagements could impact participants’ online behaviour. Methods: Participants (n=9) were enrolled in a 6-month longitudinal qualitative study exploring self-harm and suicide-related online activity. They were interviewed at three timepoints and between these intervals completed a daily reflective diary of online activity. Experiences of completing the diary were explored qualitatively during mid and end-point interviews, and through free-text diary entries. Results: All participants derived benefits from journalling about their online use with respect to self-harm and suicide-related content. These included increased insight about time spent online, the motivations behind engagement, and the nature and impact of use. Some participants reported resultant behaviour change. However, daily completion was burdensome and there were potential costs for some participants, such as increased attention or exposure to self-harm content. Conclusion: Journalling about online activity should be explored more deliberately as a possible method for addressing the existing gap in individual-level interventions to tackle online harms. Well-designed research and co-design work with lived-experience users will be essential to evaluating the potential for this to function safely as an intervention both within and outside of clinical settings. Suicide Self-harm Internet Self-monitoring Journaling Intervention. Introduction Self-harm and suicide-related online use is common among individuals experiencing suicidal thoughts and self-harm behaviours[ 1 – 3 ], including those who go on to die by suicide[ 4 ]. Significant empirical literature has sought to explore the impact of such engagement[ 5 , 6 ], especially in adolescents and young people[ 7 ], reporting both associated harms and benefits. While individuals may receive encouragement to self-harm, obtain information about high lethality or novel suicide methods, and join suicide pacts online[ 8 , 9 ], they may also derive hope and support from recovery content and peer communities, or obtain online help[ 10 – 12 ]. Crucially, research has revealed online content cannot easily be defined as either helpful or harmful since impact varies across and within individuals over time, depending on mental wellness[ 13 , 14 ]. Helpful and harmful content coexist and are searched for within the same online spaces, rendering individuals persistently negotiating an online environment where they are vulnerable to harm[ 14 ]. Online engagement is thus dynamic and individualised. This nuance makes it difficult to effectively regulate content, despite such an approach being the mainstay of online harm prevention. A complementary approach to intervention is to recognise the agency of online users and equip them with behavioural strategies and tools to manage the online environment. Such an approach fits well with users’ requests to be empowered online rather than banned from use, so that benefits can still be realised[ 15 ], but requires self-awareness and the ability to reflect on one’s online behaviour[ 14 ]. While population-level digital literacy is promoted (for instance in schools), targeted, individual-level interventions for those presenting with harmful online use have received little attention[ 16 – 18 ] despite potential to reduce morbidity and mortality. We report incidental findings from a longitudinal qualitative research (LQR) study exploring individuals’ experiences of engaging with online self-harm and suicide content, in which self-completed daily diaries of online activity were used as an ethnographic research tool. Data capturing participants’ experiences of diary use indicated that self-monitoring could alter online behaviour. We sought to analyse data pertaining to this unintended finding. Method Data for this study was collected as part of the DELVE study (full description in Haime et al, 2024[14]). Informed by an interpretivist perspective, DELVE explored individuals’ engagement with online suicide and self-harm content over a six-month period. Using a semi-structured approach, participants were interviewed at baseline, three-months and six-months. Additionally, to collect quasi-ethnographic data, they were asked to complete research diaries throughout the intervening periods in which they logged and were prompted to reflect upon their online use. Participants were asked about their experiences of diary completion during interviews and could also add comments to a relevant free-text box within the diary. Recruitment Participants were English-speaking, 16 years or over, and described on-going engagement with online self-harm and/ or suicide content. Recruitment was carried out through various channels (including, social media platforms, a mental health app for young people and charity networks), and evolved in an attempt to access underrepresented groups, such as men and participants who create as well as view self-harm content. Potential participants completed a short screening questionnaire and purposive sampling was used to invite a diversity final sample according to demographic characteristics and the nature of online use reported, such as the platforms accessed. Sample size was guided by the concept of information power, considering the specificity of participants recruited and the depth of data obtained in relation to the original DELVE study aims, which were to explore changing patterns of engagement with suicide and self-harm online content over time. The diary The diary (Supplementary file 1) was developed based on knowledge from previous qualitative research about self-harm and suicide-related online use[8] and by drawing on general worksheet templates for Cognitive Behavioural Therapy. Participants were asked to complete five diaries, each covering a one-month period and provided as a structured Microsoft Word document with questions and space to type answers. Paper copies were also offered, but only requested by one participant for one month. Blank diaries were sent via email and completed diaries were returned via a secure encrypted link. Each diary consisted of: Daily entries (Mon – Fri): logging details of all suicide and self-harm related activity including frequency, timing, type (e.g. browsing, interacting with others, creating content, searching, help-seeking), search behaviour, perceived impact of use, and whether the participant witnessed any specific content, or took part in any online events they experienced as particularly salient. This captured of routines, dips, peaks and ‘key moments’. Daily mood rating (Mon – Fri): on a five-point emotion picture scale (0 – very low to 5 - very happy). End of Week summaries – questions asking participants to reflect on i) self-harm and suicidal thoughts or behaviours over the week; ii) any changes in related online activity; iii) if specific content had a particular impact; iv) any strategies employed to stay safe online; v) discussion about online engagement with others’ offline (e.g. health practitioners, family); and vi) experiences of diary completion. The diary included help signposting and participants were informed that their entries would not be actively monitored. Data collection and analysis Acceptability of completing the diaries was explored qualitatively with each participant through open-ended questioning and probing during 3 and 6-month interviews. These discussions included participants’ feelings about completing the diary, how they managed completion, whether they thought it influenced their online behaviour and suggestions for improving the diary. Interviews took place online. Verbatim transcripts were produced. All data about diary completion were extracted by ZH, then coded and arranged into thematic categories by LB using a reflexive thematic approach. Themes were finalised collaboratively by LB and ZH. Relevant diary free-text was also extracted and coded using the same coding frame. Results Fourteen participants were enrolled in DELVE (see [ 14 ]). Four dropped out after baseline interview, and one declined to complete diaries. The remaining nine participants returned at least one diary and were included in this sub-study. These participants were men and women, representing a range of ages and ethnicities and reported engaging with self-harm and suicide content on a wide variety of online platforms. All had self-harmed; most within the past year. There were no observable differences between participants who did and did not return diaries (Table 1 ). Table 1 Demographic characteristics of participants who completed at least one diary entry vs. participants who did not complete a diary entry. Completed Diaries N = 9 N (%) No Completed Diaries N = 5 N (%) Gender Female 6 (66.7) 4 (80.0) Male 3 (33.3) 1 (20.0) Ethnicity Asian British 2 (22.2) 0 (0.0) Black British 1 (11.1) 0 (0.0) White British 4 (44.4) 3 (60.0) Asian Other 1 (11.1) 1 (20.0) Black Other 0 (0.0) 0 (0.0) White Other 1 (11.1) 0 (0.0) Mixed Race 0 (0.0) 1 (20.0) Age (years) 16–24 5 (55.6) 3 (60.0) 25–45 3 (33.3) 1 (20.0) 46–54 1 (11.1) 1 (20.0) Last episode of self-harm More than a year ago 3 (33.3) 0 (0.0) In the last year 3 (33.3) 2 (40.0) In the last month 0 (0.0) 3 (60.0) In the last week 3 (33.3) 0 (0.0) Social media sites/apps or internet forums used to access self-harm or suicide related content a Instagram 2 (22.2) 2 (40.0) Facebook 3 (33.3) 1 (20.0) TikTok 0 (0.0) 1 (20.0) Tumblr 1 (11.1) 2 (40.0) Twitter 2 (22.2) 5 (100.0) Discord 0 (0.0) 1 (20.0) WhatsApp 1 (11.1) 0 (0.0) YouTube 2 (22.2) 2 (40.0) Google 1 (11.1) 2 (40.0) Other (Weibo) 0 (0.0) 1 (20.0) Pro-choice suicide Forum 1 (11.1) 1 (11.1) a Participants could select more than one platform Of the 9 participants, 4 (44.4%) completed all 5 diaries, 4 (44.4%) completed 3 or 4, and 1 (11.1%) completed 2 diaries. While some fields were left blank, between 77.4% and 100% of end of week summary questions were completed across the diaries. Positive impacts All participants reported deriving personal benefit from completing the diary and stated this outweighed any burden of completion. Benefits included valuing the responsibility of having to fill out a diary (ID84), feeling accomplished once this was completed (ID10) and finding it useful to track moods and experiences (ID3, ID4, ID84) and be reminded to ‘check in with yourself’ (ID10). In this way, completion could promote ‘interesting’ insight (ID24) about patterns in one’s mental health and coping. Specific benefits were also discussed relating to individuals’ online use. Three participants stated that logging activities had drawn attention to how long they spent online, allowing them to monitor and potentially modify their usage: The first questions about ‘when have you been online?’, that made me realise that at the beginning I went online far too much basically (ID4) Similar awareness could be prompted around types of content accessed, motivations for engaging with self-harm content and how or when this may be unhelpful: Keeping this diary has made me reflect on my online behaviour and I guess that (online use) could probably count as self-harming - seeking out something I know will make me feel worse because I feel bad about myself and I have urges to harm myself. Even though I didn’t cut, I still felt a lot of the same emotions like guilt and shame for looking (ID11). I find reflection very helpful and I found it really helpful for me to reflect on how I use the internet and whether I’m doing it always for the best reasons (ID4). Two participants indicated that keeping a record of content viewed also provided a route for discussing difficult content with others – in this case, the study interviewer: It also helps me to talk about what I have seen online which is also good for my mental health (ID84) If I saw something which I felt uncomfortable with or I thought that was worth talking about then I took a photo of it and uploaded it. So, I think overall it was a good experience… I probably wouldn’t have talked about them [self-harm images]… I think there’s tangible benefits [to completing the diary]. The tangible ones are reflecting. The tangible ones are talking to you (ID10) When asked, ID84 also recognised potential benefits of sharing the diary with a mental health professional: It would be really good because generally, it would lead to more help, and some kind of conclusion and solutions. (ID84) Behaviour change In view of reported benefits, participants were asked if completing the diary had altered their online behaviour. While one (ID2) stated it had not, another presented the opposite viewpoint: I’m one of the very lucky ones who spends less time online as a result of the work you do… Even though I’ve only done [diary] for six months… I think I’ve learned more about [the internet] as a result and I’m a bit more streetwise (ID10). The remaining participants presented more nuanced accounts, implying that habitual patterns of use had been disrupted and that they exercised more agency as a result of completing the diary, or now had an intention to change: Towards the start of the study, I think I was blindly interacting with just about everything, whereas now I won’t just like a post because it’s on my feed. I’ll like it if I want to (ID24). This shit is complex… I think moving forward I need to be a LOT more aware of my own urges online (diary free-text) (ID11). It was evident that for another participant, the impact of diary completion had evolved during the study period: Midpoint interview - Int: Did you find completing the diary changed the way that you interacted with any of the self-harm or suicidal content? ID4: No, I don’t think so. No. I wondered about that. Final interview It’s [diary] helped me understand more about how social media impacts upon me...I think you need to recognise that sometimes you need a break and the writing down, going in a diary and that has helped me understand more about that. Final diary entry I’ve learnt a lot about myself and it’s a good reflection on how things have changed… the growing list of what I do to distract etcetera [from online content] and changes around self-harm. I feel really proud of it. Some participants said they would consider continuing a diary after the study having appreciated the reflective space it provided. Acceptability and adherence All participants found the diary acceptable and felt willing to disclose their online activities and associated feelings, though it should be noted that these comments were collected about the diary as a research tool rather than an intervention. They described themselves as ‘really honest’ (ID3) and not editing responses: ‘I included everything, there wasn’t anything missed out’ (ID2). One participant related this openness to a belief that the audience - mental health researchers - were likely to understand the content: As long as you can understand everything I don’t mind sharing because it’s a safe space… I think a lot of the stuff you either know about, or because of the work you do you … you’ve got a good understanding of (ID10). Some participants were used to journalling about their mental health so found the diary a familiar activity, but lengthy compared to other diaries. Daily completion was problematic for most participants for reasons such as forgetting (ID2), finding the structure repetitive (ID2, ID10), or finding it tiring (ID10, ID84) or ‘overwhelming’ (ID3, ID10). Two explicitly stated that mood impacted on their ability to complete: I didn’t think, ‘I don’t feel like doing it,’ or ‘I don’t want to do it.’ It was in terms of where I was at with my mental health and I thought, ‘I will do stuff that has to be done to make it through.’ The diary wasn’t one of those things (ID11). Completion was more difficult for high-volume online users: I thought, ‘this is going to be really easy. Five minutes sitting down and doing a diary, really easy.’ But then you realise that actually there’s a lot more to it. I mean I spend most of my time on the phone. You look at your phone 7, 10, 15 times a day and I think I spent three hours in one day on Twitter... then you realise that actually you have to write about it and suddenly you can write a lot about it. You know, you can write an essay (ID10). Completion barriers led to missing entries or adaptations in how the diary was completed. Several participants completed it in retrospective blocks, rather than daily, with an acknowledged effect on recall and three took screenshots to make recording their activities manageable: I would just screenshot stuff and then at the end of the week maybe go in and do the whole diary of whatever days that I’d got these screenshots for and fill it out retrospectively rather than doing it daily (ID3). Commitment to the study led three participants to experience feelings of anxiety or guilt about whether they were completing their diaries satisfactorily. Negative impacts and ethical considerations Only one participant criticised the diary, explaining that completing it could interfere with benefits they perceived from online engagement and implying that readiness to change was key to acceptability: I can barely put my phone down for ten minutes, so I’m already very aware that it’s a bit of an issue... and it’s just not something that I want to deal with right now. [Online use] is a distraction. Sometimes reading about somebody else’s story takes you away from thinking about your own for five minutes… then having to stop and think, ‘Oh no, I’m doing this in the real world. I’m filling out this diary, so I must now make a note of this,’ which breaks that. It stops that from working so well. (ID3) Unintended consequences also emerged. Two participants indicated logging engagements could increase attention to, or even consumption of, self-harm/ suicide content due to curiosity or desire to return an ‘interesting’ diary, though the impact of this was not clear. When you’re keeping a diary, this sounds strange, but you want to see what’s really out there. You’re more inquisitive… I think I would have still looked at those things. I still would have done those things, but I think there’s more thought there (ID10) I felt that perhaps my input into this study was a little useless as I wasn’t seeing any posts noteworthy for my diary. Then, towards the end of the week, I slowly started seeing more posts and then felt bad that I’d perhaps willed the posts onto my feed! (ID24, Diary free-text) I think maybe I just am more aware when I’m looking at it, whereas before, I’d look at a post and scroll past. Now, sometimes I’ll read it and actually pay attention to what I’m looking at. So, I think it’s actually made me more conscious (ID24). Similarly, revisiting content in order to log it, or the practice of screenshotting (above) increased exposure and created a record of content on the participants’ devices unless this was deleted. I’m scrolling through [social media] all day long and then I forget that I’ve read something. I’ll then go back looking for it. Like I say, I tried the screenshotting for a while because that was a bit easier… That felt very much like ‘Oh god, I’ve got to go back through and relook at stuff now (ID3). Two participants included online images of self-harm within their first diary but not in later diaries despite reporting increased engagement with such images. One (ID84) explained choosing to exclude these “to avoid that pressure of downloading them”. In a research context, one participant (ID3) raised the issue of possible repercussions of disclosing online activity in a diary, expressing fears this could create a negative impression or necessitate action. Such concerns could also be relevant if used in clinical practice, though this was not explored. Because I’ve been really honest in my diary… there were some times that I was a little bit anxious about whether or not you were going to do something because, like I say, I’ve got this real fear of being sectioned (ID3) Suggestions for improvement Four participants suggested the diary should be made electronic and ‘phone friendly’, for instance as an online form or app. One participant (ID11) specifically stated they would continue completing the diary for their personal benefit if it were delivered in this format. It was also suggested that the diary should prioritise weekly reflection, particularly around triggers and impacts resulting from online engagement (rather than logging daily content), to make completion more manageable, less repetitive and more useful – particularly for communicating online experiences with others. Discussion We report incidental findings which allow us to hypothesise that keeping a reflective diary of online activity could promote safer online behaviour. Although our diary was intended as a research tool for capturing ‘in the moment’ data and not an intervention, it became apparent that participants were susceptible to a Hawthorne Effect[ 19 ] as a result of knowing their online behaviour was being observed, and that diary completion could change the behaviour under observation. This effect was magnified because, as the diary completers, participants were prompted to become the observers of their own behaviour. Participants spontaneously described benefits associated with completion. Most notable was increased awareness of the extent, nature and impact of their engagements with online self-harm content, which prompted individuals to begin critiquing their use by considering their motivations for accessing content, how they engaged with this and whether it was detrimental to them. Two participants also implied the diary could become a communication tool by helping them to pinpoint difficult content and record negative online experiences to bring for discussion with a healthcare practitioner or others who may support them. Several participants stated they had made, or were intending to make, changes to their online behaviour such as monitoring time spent online, becoming more discerning about how they interacted with content, or recognising the need for self-enforced breaks from some online spaces. However, most participants did find daily completion burdensome. This led to missing entries, retrospective reporting and could increase exposure to negative online content where actions were taken to enable diary completion, such as taking screenshots of significant engagements and retracing browsing sessions in order to log content. Also, for some participants, completing a diary appeared to increase attention to self-harm content. Our findings suggest the process of observing one’s online behaviour via a diary resulted in learning, insight and reflection, which could increase participants’ metacognition when engaging online. Increased awareness of their thought processes prompted decision-making, allowing some to make positive adjustments to their online behaviour. This speaks to an emerging dialogue within online safety research which advocates for intervention approaches which recognise the potential agency of users and focus on upskilling and empowering them to assert control online and manage online safety[ 14 , 15 ]. Our hypothesis that journalling could be an effective approach is compatible with existing therapeutic approaches and tools, such as the use of mood monitoring in CBT-based interventions. It is also in keeping with other studies that have explored diaries and expressive writing as potential mental health interventions and found improvements in psychological[ 20 , 21 ], though it is noted that more evidence about the efficacy of journalling in the treatment of mental illness is required[ 22 ]. Our findings warrant further research into the value of obtaining insight into one’s own behaviour in the context of engaging with online self-harm suicide content and how this can impact on behaviour. Suggestion that a diary could serve as a tool for facilitating conversations about online use and negative online experiences with trusted others is relevant to increased expectation that such discussion is incorporated into mental health consultations[ 15 , 23 ] and may serve as an area for suicide prevention[ 24 ]. Previous research has noted that asking about suicide-related online behaviour can assist clinicians to arrive at a more holistic view of a patient and contribute to perception of risk[ 3 ]. Other examples of self-monitoring data being shared within consultations to enable quick exchange of suicide risk information lend support to this assertion[ 25 ]. However, it should also be noted that some participants referenced how declining mental health could negatively impact their ability to complete the diary, which would be an important consideration if designing such an intervention targeted at a clinical population. Also, our findings hint that willingness to openly disclose online activity in a diary may be contingent upon the perceived knowledge and understanding of the diary’s audience. Research with young people shows that fear of negative judgement and misunderstanding from mental health practitioners in relation to their online usage hinders reporting[ 26 ] and that there is a practitioner training gap in this area[ 27 ]. Actions to address this would therefore be necessary. Strengths and Limitations Our findings were gathered in the context of an in-depth qualitative study based on a small sample of participants and not initially intended to explore the interventional potential of a diary. The reflections gathered centred around participants’ experiences of using the diary as a research tool. Views about acceptability and willingness to openly disclose in the diary may not fully extrapolate to a clinical or intervention context. Similarly, the potential impact of therapeutic input from a clinician as part of the journalling process is not known. Participants reduced to nine after attrition. It is possible that being asked to complete the diary contributed to study dropout and that those remaining in the study were disposed more favourably towards diary completion, but our less than 50% attrition rate is favourable compared to similar LQR studies without a diary component, (e.g. 55% reported by Vogl and Zartler, 2020[ 28 ]). Our study focused on adults aged 16 years or older and most participants were female, limiting our ability to draw conclusions about the acceptability of journalling to males and adolescents. Also, data were not collected on other participant characteristics such as neurodiversity. Nevertheless, given the absence of studies exploring individual-level interventions for addressing online harms, our preliminary findings are novel and provide insights, which may provide a foundation for future work to address this acknowledged gap. Further work should be expanded to incorporate children and adolescents given their high usage of digital technologies. Our study design allowed for diaries to be used over a period of six-months and for longitudinal data collection over this period. This enabled us to capture qualitative narratives, which were also naturalistic since they emerged spontaneously as part of an unplanned natural experiment. However, the unplanned nature also meant that no quantitative before and after measures of problematic online use were included to assess change. Implications Although only formative, our study indicates that journalling about online activity could be explored as a potential means to enhance online safety amongst those who engage with self-harm or suicide-related content. Research could also explore whether such an approach might similarly be applied to other specific areas of online harm (such as, disordered eating), or individuals exhibiting Problematic Internet Use (PIU)/ ‘internet addiction’[ 29 ] more generally. Some participants drew parallels with journalling they used in other contexts to support their mental health, either as part of treatment or through their own decision, thus indicating the study diary as a familiar approach for addressing online activity. Further research is needed to investigate the acceptability and usefulness of integrating this within clinical practice from both a patient and clinician perspective. Such an approach could support conversations in clinic about online use. Recent survey data focused on young adults’ mental health suggest only 40% of young people experiencing mental distress are asked by a mental health practitioner about their online experiences[ 30 ]. Practitioners similarly report that such conversations can occur infrequently due to low practitioner confidence, among other issues[ 27 ]. Training and resources to support mental health practitioners in this area are currently limited and practitioners have expressed a wish for interventions to use with patients[ 27 ]. Our diary approach could facilitate clinicians to engage with patients about their online use and provide the foundation for such an intervention, if adequately supported by training. Equally, many DELVE participants had begun engaging with online content due to difficulties accessing mental health care[ 14 ], suggesting it is also relevant to explore the potential for journalling about online activity to be used as a self-help tool, or supported outside of clinical services, for instance by parents or school nurses. While promising, clear limitations were also identified with the diary’s current format, which require careful consideration if adapting this from a research tool into an intervention. In particular, these concerned the burden of daily reporting and potential for iatrogenic effects; namely, increased exposure or attention to online self-harm/ suicide content where individuals are encouraged to keep a daily log of this. Any research building on this work must therefore address the potential for adverse outcomes and seek means to mitigate. Similarly, it is necessary to consider how emotions such as guilt and self-depreciation associated with poor completion can be overcome in this population group, particularly in a clinical setting where feedback or reassurance may be more difficult to impart due to time constraints. Participants indicated they would prefer to complete the diary in an electronic format, such as an app. With this in mind, further research could explore the potential for automating some aspects of the diary, such as capture of search history, in order to reduce burden and exposure. Conclusions There is a need for individual-level intervention to address harmful online behaviour relating to self-harm/ suicide and mental ill-health more generally. Our incidental findings offer hypotheses about where advances in knowledge could be made. In line with theory around metacognition, our research diary showed promise by allowing participants space to reflect on their online use and encouraging discussion and thinking around ways to disengage from harmful content or resist the determinism of algorithms and other technological features. Well-designed research is now required to explore whether this research tool could be adapted therapeutically to function as an intervention and communication tool. It will be essential that this considers mechanisms of change, most appropriate settings for delivery, how to ensure feasibility and safety of completion, and involves potential users in co-creation of any intervention going forward, both in terms of content and mode of delivery. Statements and Declarations Author Contributions LB conceived the study and all authors contributed to study design. LB and JD designed the study and diary template. LB, ZH and LK collected and analysed study data. ZH ran the DELVE study. All authors contributed to participant recruitment, topic guide creation and provided intellectual input. The first draft of the manuscript was written by LB and all authors commented on versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank Dr Rachel Cohen and Esther Kissane-Webb for their assistance in creating the diary template and all the study participants who completed diaries and took part in study interviews. Data Availability The data that support the findings of this study are available from the corresponding author (LB) upon reasonable request. Competing interests The authors have no relevant financial or non-financial interests to disclose. Funding The research leading to these results received funding from Samaritans UK Online Excellence Programme. LB is partly funded by National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation Trust. ZH is partly funded by Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Ethics approval All procedures in this study were approved by the University of Bristol Faculty of Health Sciences Ethics Committee (Ref: 117491) and therefore were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish Participants signed informed consent regarding publishing their data. 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Psychiatry 61(8):842-54 https://doi.org/10.1111/jcpp.13245 Robinson J, Rodrigues M, Fisher S, Bailey E, Herrman H (2015) Social media and suicide prevention: findings from a stakeholder survey. Shanghai Arch. Psychiatry 2;27(1):27 doi: 10.11919/j.issn.1002-0829.214133 Brennan C, Saraiva S, Mitchell E, Melia R, Campbell L, King N, House A (2022) Self-harm and suicidal content online, harmful or helpful? A systematic review of the recent evidence. J. Public Ment. Health 5;21(1):57-69. https://doi.org/10.1108/JPMH-09-2021-0118 Haime Z, Kennedy L, Grace L, Cohen R, Derges J, Biddle L (2024) The journey of engaging with web-based self-harm and suicide content: longitudinal qualitative study. JMIR infodemiology 4:e47699 doi: 10.2196/47699 Biddle L, Rifkin-Zybutz R, Derges J, Turner N, Bould H, Sedgewick F, Gooberman-Hill R, Moran P, Linton MJ (2022) Developing good practice indicators to assist mental health practitioners to converse with young people about their online activities and impact on mental health: a two-panel mixed-methods Delphi study. BMC psychiatry 19;22(1):485 https://doi.org/10.1186/s12888-022-04093-w Augner C, Vlasak T, Aichhorn W, Barth A (2022) Tackling the ‘digital pandemic’: The effectiveness of psychological intervention strategies in problematic Internet and smartphone use—A meta-analysis. Aust N Z J Psychiatry 56(3):219-29 https://doi.org/10.1177/00048674211042793 El Asam A, Samara M, Terry P (2019) Problematic internet use and mental health among British children and adolescents. Addict. Behav. 1;90:428-36 https://doi.org/10.1016/j.addbeh.2018.09.007 Lam LT, Lam MK (2016) eHealth intervention for problematic internet use (PIU). Curr. Psychiatry Rep. 18:1-7 https://doi.org/10.1007/s11920-016-0747-5 Sedgwick P, & Greenwood N (2015) Understanding the Hawthorne effect. BMJ 351. https://doi.org/10.1136/bmj.h4672 Baikie K, & Wilhelm K (2005). Emotional and physical health benefits of expressive writing. Adv. Psychiatr. Treat. 11(5), 338-346. doi:10.1192/apt.11.5.338 Hiemstra R (2001). Uses and benefits of journal writing. In: English LM Gillen MA (eds) Promoting journal writing in adult education (New Directions for Adult and Continuing Education) San Francisco, Jossey-Bass, 90 pp 19-26 Sohal M, Singh P, Dhillon BS, Gill HS (2022) Efficacy of journaling in the management of mental illness: a systematic review and meta-analysis. Fam Med Community Health 10(1) doi: 10.1136/fmch-2021-001154 Moreno MA, Dixon LB, Jankowski S, Adler DA, Berlant J, Brunette MF, Castillo EG, Edwards ML, Erlich MD, First MB, Kozloff N (2024) The Need to Adapt the Psychiatric Clinical Assessment to the Digital Age: A Practical Approach. Psychiatr. Serv. 2024 https://doi.org/10.1176/appi.ps.20230399 Cohen R, Biddle L (2021) The Influence of Social Media on Suicidal Behaviour among Students. In: Smith J & Mallon S (eds) Preventing and responding to student suicide: A practical guide for FE and HE settings. Jessica Kingsley Publishers, London, pp94-107 Hetrick SE, Goodall J, Yuen HP, Davey CG, Parker AG, Robinson J, Rickwood DJ, McRoberts A, Sanci L, Gunn J, Rice S, & Simmons MB (2017) Comprehensive Online Self-Monitoring to Support Clinicians Manage Risk of Suicide in Youth Depression. Crisis 38 (3), 147–157. https://doi.org/10.1027/0227-5910/a000422 Derges J, Bould H, Gooberman-Hill R, Moran P, Linton MJ, Rifkin-Zybutz R, Biddle L (2023) Mental health practitioners’ and young people’s experiences of talking about social media during mental health consultations: qualitative focus group and interview study. JMIR Form. Res. 7:e43115 doi: 10.2196/43115 Haime Z, Griffiths G, Linton M-J, Bould H, Biddle L (2024) Mental Health Practitioners’ Training Needs and Preferences for Addressing Online Use with Children and Young People. Evid.-Based Pract. Child Adolesc. Ment. Health (In press). Vogl S, & Zartler U (2021) Interviewing adolescents through time: balancing continuity and flexibility in a qualitative longitudinal study. Longitud. Life Course Stud. 12 (1), 83-97 https://doi.org/10.1332/175795920X15986464938219 Spada MM (2014) An overview of problematic Internet use. Addict. Behav. 1;39(1):3-6 https://doi.org/10.1016/j.addbeh.2013.09.007 Rifkin-Zybutz R, Turner N, Derges J, Bould H, Sedgewick F, Gooberman-Hill R, Linton MJ, Moran P, Biddle L (2023) Digital technology use and mental health consultations: survey of the views and experiences of clinicians and young people. JMIR Ment.Health. 10(1):e44064 doi: 10.2196/44064 Additional Declarations No competing interests reported. Supplementary Files Supplementaryfilediarytemplateextract.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4869852","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":341030183,"identity":"074b7b84-392b-4cfb-b3ea-f584887dce6a","order_by":0,"name":"Lucy Biddle","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBACPhDB2CDB2HCcgfExA4MEkMvcAJaSwKGFDa7lMAOzMUgdD5BLjBYGkBY2aRCHsBaJ5GcSjDssZPsOMx+rLtxjYW/P3tjA8KOGIXFmAy4taWYSjGckjGceZku7PeOZRGIPz8EGxp5jDImzcdqSwybB2CaRuOEwj9ltngMSCTwSiQ0MvA0MifMIa+H/VgzUYg/SwviXOC08bMxALYw9QC3MIFtwOoznmbFFIsQvxtIzDgD9cuZgw2GZY0ARHN7nZ09+eOPjjjrZvuPNDz8XHKizZ29vPvjwTY2N7IwDOKxhYGCRSEAXOoA7VsCA+QM+2VEwCkbBKBgFDAA1PFUgS/XjWAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Bristol","correspondingAuthor":true,"prefix":"","firstName":"Lucy","middleName":"","lastName":"Biddle","suffix":""},{"id":341030186,"identity":"b67d0ae1-fe55-481a-99a4-09fc51a00292","order_by":1,"name":"Laura Kennedy","email":"","orcid":"","institution":"King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Kennedy","suffix":""},{"id":341030190,"identity":"340b51b7-47a9-4b37-9c52-e2102b943106","order_by":2,"name":"Lydia Grace","email":"","orcid":"","institution":"Samaritans UK","correspondingAuthor":false,"prefix":"","firstName":"Lydia","middleName":"","lastName":"Grace","suffix":""},{"id":341030192,"identity":"66e4632f-3898-40f8-9838-2a7c5ccb6572","order_by":3,"name":"Jane Derges","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Derges","suffix":""},{"id":341030193,"identity":"ca7d587d-31b8-4287-a2f3-29db423205af","order_by":4,"name":"Zoë Haime","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Zoë","middleName":"","lastName":"Haime","suffix":""}],"badges":[],"createdAt":"2024-08-06 16:17:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4869852/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4869852/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":65289681,"identity":"a97ba53e-d0c1-45bb-8758-393a890ee4b7","added_by":"auto","created_at":"2024-09-25 16:53:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":547709,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4869852/v1/2b8be375-c389-4c7f-925a-f5a06ee7db83.pdf"},{"id":63851658,"identity":"e90e23b2-106c-496f-a2c9-6d202ffc5de8","added_by":"auto","created_at":"2024-09-03 04:17:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":168182,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfilediarytemplateextract.docx","url":"https://assets-eu.researchsquare.com/files/rs-4869852/v1/a3e5d7d8f3d5b29812342f5c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adults’ experiences of using journalling to reflect on suicide and self-harm related online use: indications of a potential area for intervention development to reduce online harm","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSelf-harm and suicide-related online use is common among individuals experiencing suicidal thoughts and self-harm behaviours[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], including those who go on to die by suicide[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Significant empirical literature has sought to explore the impact of such engagement[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], especially in adolescents and young people[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], reporting both associated harms and benefits. While individuals may receive encouragement to self-harm, obtain information about high lethality or novel suicide methods, and join suicide pacts online[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], they may also derive hope and support from recovery content and peer communities, or obtain online help[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Crucially, research has revealed online content cannot easily be defined as either helpful or harmful since impact varies across and within individuals over time, depending on mental wellness[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Helpful and harmful content coexist and are searched for within the same online spaces, rendering individuals persistently negotiating an online environment where they are vulnerable to harm[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Online engagement is thus dynamic and individualised. This nuance makes it difficult to effectively regulate content, despite such an approach being the mainstay of online harm prevention.\u003c/p\u003e \u003cp\u003eA complementary approach to intervention is to recognise the agency of online users and equip them with behavioural strategies and tools to manage the online environment. Such an approach fits well with users\u0026rsquo; requests to be empowered online rather than banned from use, so that benefits can still be realised[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], but requires self-awareness and the ability to reflect on one\u0026rsquo;s online behaviour[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. While population-level digital literacy is promoted (for instance in schools), targeted, individual-level interventions for those presenting with harmful online use have received little attention[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] despite potential to reduce morbidity and mortality.\u003c/p\u003e \u003cp\u003eWe report incidental findings from a longitudinal qualitative research (LQR) study exploring individuals\u0026rsquo; experiences of engaging with online self-harm and suicide content, in which self-completed daily diaries of online activity were used as an ethnographic research tool. Data capturing participants\u0026rsquo; experiences of diary use indicated that self-monitoring could alter online behaviour. We sought to analyse data pertaining to this unintended finding.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eData for this study was collected as part of the DELVE study (full description in Haime et al, 2024[14]). Informed by an interpretivist perspective, DELVE explored individuals’ engagement with online suicide and self-harm content over a six-month period. Using a semi-structured approach, participants were interviewed at baseline, three-months and six-months. Additionally, to collect quasi-ethnographic data, they were asked to complete research diaries throughout the intervening periods in which they logged and were prompted to reflect upon their online use. Participants were asked about their experiences of diary completion during interviews and could also add comments to a relevant free-text box within the diary. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were English-speaking, 16 years or over, and described on-going engagement with online self-harm and/ or suicide content. Recruitment was carried out through various channels (including, social media platforms, a mental health app for young people and charity networks), and evolved in an attempt to access underrepresented groups, such as men and participants who create as well as view self-harm content. Potential participants completed a short screening questionnaire and purposive sampling was used to invite a diversity final sample according to demographic characteristics and the nature of online use reported, such as the platforms accessed. \u0026nbsp;Sample size was guided by the concept of information power, considering the specificity of participants recruited and the depth of data obtained in relation to the original DELVE study aims, which were to explore changing patterns of engagement with suicide and self-harm online content over time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe diary\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe diary (Supplementary file 1) was developed based on knowledge from previous qualitative research about self-harm and suicide-related online use[8] and by drawing on general worksheet templates for Cognitive Behavioural Therapy. Participants were asked to complete five diaries, each covering a one-month period and provided as a structured Microsoft Word document with questions and space to type answers. Paper copies were also offered, but only requested by one participant for one month. Blank diaries were sent via email and completed diaries were returned via a secure encrypted link. Each diary consisted of:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cem\u003eDaily entries (Mon – Fri):\u003c/em\u003e logging details of all suicide and self-harm related activity including frequency, timing, type (e.g. browsing, interacting with others, creating content, searching, help-seeking), search behaviour, perceived impact of use, and whether the participant witnessed any specific content, or took part in any online events they experienced as particularly salient. This captured of routines, dips, peaks and ‘key moments’.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eDaily mood rating (Mon – Fri):\u003c/em\u003e on a five-point emotion picture scale (0 – very low to 5 - very happy).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eEnd of Week summaries\u003c/em\u003e – questions asking participants to reflect on i) self-harm and suicidal thoughts or behaviours over the week; ii) any changes in related online activity; iii) if specific content had a particular impact; iv) any strategies employed to stay safe online; v) discussion about online engagement with others’ offline (e.g. health practitioners, family); and vi) experiences of diary completion.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe diary included help signposting and participants were informed that their entries would not be actively monitored.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection and analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcceptability of completing the diaries was explored qualitatively with each participant through open-ended questioning and probing during 3 and 6-month interviews. These discussions included participants’ feelings about completing the diary, how they managed completion, whether they thought it influenced their online behaviour and suggestions for improving the diary. Interviews took place online. Verbatim transcripts were produced. All data about diary completion were extracted by ZH, then coded and arranged into thematic categories by LB using a reflexive thematic approach. Themes were finalised collaboratively by LB and ZH. Relevant diary free-text was also extracted and coded using the same coding frame.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFourteen participants were enrolled in DELVE (see [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]). Four dropped out after baseline interview, and one declined to complete diaries. The remaining nine participants returned at least one diary and were included in this sub-study. These participants were men and women, representing a range of ages and ethnicities and reported engaging with self-harm and suicide content on a wide variety of online platforms. All had self-harmed; most within the past year. There were no observable differences between participants who did and did not return diaries (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographic characteristics of participants who completed at least one diary entry vs. participants who did not complete a diary entry.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompleted Diaries N\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo Completed Diaries N\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (80.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed Race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLast episode of self-harm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than a year ago\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the last year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the last month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn the last week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial media sites/apps or internet forums used to access self-harm or suicide related content\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstagram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacebook\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTikTok\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumblr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwitter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscord\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhatsApp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYouTube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoogle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (Weibo)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePro-choice suicide Forum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e Participants could select more than one platform\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 9 participants, 4 (44.4%) completed all 5 diaries, 4 (44.4%) completed 3 or 4, and 1 (11.1%) completed 2 diaries. While some fields were left blank, between 77.4% and 100% of end of week summary questions were completed across the diaries.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePositive impacts\u003c/h2\u003e \u003cp\u003eAll participants reported deriving personal benefit from completing the diary and stated this outweighed any burden of completion. Benefits included valuing the responsibility of having to fill out a diary (ID84), feeling accomplished once this was completed (ID10) and finding it useful to track moods and experiences (ID3, ID4, ID84) and be reminded to \u003cem\u003e\u0026lsquo;check in with yourself\u0026rsquo;\u003c/em\u003e (ID10). In this way, completion could promote \u003cem\u003e\u0026lsquo;interesting\u0026rsquo;\u003c/em\u003e insight (ID24) about patterns in one\u0026rsquo;s mental health and coping.\u003c/p\u003e \u003cp\u003eSpecific benefits were also discussed relating to individuals\u0026rsquo; online use. Three participants stated that logging activities had drawn attention to how long they spent online, allowing them to monitor and potentially modify their usage:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe first questions about \u0026lsquo;when have you been online?\u0026rsquo;, that made me realise that at the beginning I went online far too much basically (ID4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilar awareness could be prompted around types of content accessed, motivations for engaging with self-harm content and how or when this may be unhelpful:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eKeeping this diary has made me reflect on my online behaviour and I guess that (online use) could probably count as self-harming - seeking out something I know will make me feel worse because I feel bad about myself and I have urges to harm myself. Even though I didn\u0026rsquo;t cut, I still felt a lot of the same emotions like guilt and shame for looking (ID11).\u003c/p\u003e\u003cp\u003eI find reflection very helpful and I found it really helpful for me to reflect on how I use the internet and whether I\u0026rsquo;m doing it always for the best reasons (ID4).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTwo participants indicated that keeping a record of content viewed also provided a route for discussing difficult content with others \u0026ndash; in this case, the study interviewer:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt also helps me to talk about what I have seen online which is also good for my mental health (ID84)\u003c/p\u003e\u003cp\u003eIf I saw something which I felt uncomfortable with or I thought that was worth talking about then I took a photo of it and uploaded it. So, I think overall it was a good experience\u0026hellip; I probably wouldn\u0026rsquo;t have talked about them [self-harm images]\u0026hellip; I think there\u0026rsquo;s tangible benefits [to completing the diary]. The tangible ones are reflecting. The tangible ones are talking to you (ID10)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen asked, ID84 also recognised potential benefits of sharing the diary with a mental health professional:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt would be really good because generally, it would lead to more help, and some kind of conclusion and solutions. (ID84)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBehaviour change\u003c/h2\u003e \u003cp\u003eIn view of reported benefits, participants were asked if completing the diary had altered their online behaviour. While one (ID2) stated it had not, another presented the opposite viewpoint:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI\u0026rsquo;m one of the very lucky ones who spends less time online as a result of the work you do\u0026hellip; Even though I\u0026rsquo;ve only done [diary] for six months\u0026hellip; I think I\u0026rsquo;ve learned more about [the internet] as a result and I\u0026rsquo;m a bit more streetwise (ID10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe remaining participants presented more nuanced accounts, implying that habitual patterns of use had been disrupted and that they exercised more agency as a result of completing the diary, or now had an intention to change:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTowards the start of the study, I think I was blindly interacting with just about everything, whereas now I won\u0026rsquo;t just like a post because it\u0026rsquo;s on my feed. I\u0026rsquo;ll like it if I want to (ID24).\u003c/p\u003e\u003cp\u003eThis shit is complex\u0026hellip; I think moving forward I need to be a LOT more aware of my own urges online (diary free-text) (ID11).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt was evident that for another participant, the impact of diary completion had evolved during the study period:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eMidpoint interview\u003c/em\u003e - Int: Did you find completing the diary changed the way that you interacted with any of the self-harm or suicidal content? ID4: No, I don\u0026rsquo;t think so. No. I wondered about that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFinal interview\u003c/strong\u003e \u003cp\u003eIt\u0026rsquo;s [diary] helped me understand more about how social media impacts upon me...I think you need to recognise that sometimes you need a break and the writing down, going in a diary and that has helped me understand more about that.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFinal diary entry\u003c/strong\u003e \u003cp\u003eI\u0026rsquo;ve learnt a lot about myself and it\u0026rsquo;s a good reflection on how things have changed\u0026hellip; the growing list of what I do to distract etcetera [from online content] and changes around self-harm. I feel really proud of it.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eSome participants said they would consider continuing a diary after the study having appreciated the reflective space it provided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAcceptability and adherence\u003c/h2\u003e \u003cp\u003eAll participants found the diary acceptable and felt willing to disclose their online activities and associated feelings, though it should be noted that these comments were collected about the diary as a research tool rather than an intervention. They described themselves as \u003cem\u003e\u0026lsquo;really honest\u0026rsquo;\u003c/em\u003e (ID3) and not editing responses: \u003cem\u003e\u0026lsquo;I included everything, there wasn\u0026rsquo;t anything missed out\u0026rsquo;\u003c/em\u003e (ID2). One participant related this openness to a belief that the audience - mental health researchers - were likely to understand the content:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAs long as you can understand everything I don\u0026rsquo;t mind sharing because it\u0026rsquo;s a safe space\u0026hellip; I think a lot of the stuff you either know about, or because of the work you do you \u0026hellip; you\u0026rsquo;ve got a good understanding of (ID10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants were used to journalling about their mental health so found the diary a familiar activity, but lengthy compared to other diaries. Daily completion was problematic for most participants for reasons such as forgetting (ID2), finding the structure repetitive (ID2, ID10), or finding it tiring (ID10, ID84) or \u0026lsquo;overwhelming\u0026rsquo; (ID3, ID10). Two explicitly stated that mood impacted on their ability to complete:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI didn\u0026rsquo;t think, \u0026lsquo;I don\u0026rsquo;t feel like doing it,\u0026rsquo; or \u0026lsquo;I don\u0026rsquo;t want to do it.\u0026rsquo; It was in terms of where I was at with my mental health and I thought, \u0026lsquo;I will do stuff that has to be done to make it through.\u0026rsquo; The diary wasn\u0026rsquo;t one of those things (ID11).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCompletion was more difficult for high-volume online users:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI thought, \u0026lsquo;this is going to be really easy. Five minutes sitting down and doing a diary, really easy.\u0026rsquo; But then you realise that actually there\u0026rsquo;s a lot more to it. I mean I spend most of my time on the phone. You look at your phone 7, 10, 15 times a day and I think I spent three hours in one day on Twitter... then you realise that actually you have to write about it and suddenly you can write a lot about it. You know, you can write an essay (ID10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCompletion barriers led to missing entries or adaptations in how the diary was completed. Several participants completed it in retrospective blocks, rather than daily, with an acknowledged effect on recall and three took screenshots to make recording their activities manageable:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI would just screenshot stuff and then at the end of the week maybe go in and do the whole diary of whatever days that I\u0026rsquo;d got these screenshots for and fill it out retrospectively rather than doing it daily (ID3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCommitment to the study led three participants to experience feelings of anxiety or guilt about whether they were completing their diaries satisfactorily.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eNegative impacts and ethical considerations\u003c/h2\u003e \u003cp\u003eOnly one participant criticised the diary, explaining that completing it could interfere with benefits they perceived from online engagement and implying that readiness to change was key to acceptability:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI can barely put my phone down for ten minutes, so I\u0026rsquo;m already very aware that it\u0026rsquo;s a bit of an issue... and it\u0026rsquo;s just not something that I want to deal with right now. [Online use] is a distraction. Sometimes reading about somebody else\u0026rsquo;s story takes you away from thinking about your own for five minutes\u0026hellip; then having to stop and think, \u0026lsquo;Oh no, I\u0026rsquo;m doing this in the real world. I\u0026rsquo;m filling out this diary, so I must now make a note of this,\u0026rsquo; which breaks that. It stops that from working so well. (ID3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnintended consequences also emerged. Two participants indicated logging engagements could increase attention to, or even consumption of, self-harm/ suicide content due to curiosity or desire to return an \u0026lsquo;interesting\u0026rsquo; diary, though the impact of this was not clear.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen you\u0026rsquo;re keeping a diary, this sounds strange, but you want to see what\u0026rsquo;s really out there. You\u0026rsquo;re more inquisitive\u0026hellip; I think I would have still looked at those things. I still would have done those things, but I think there\u0026rsquo;s more thought there (ID10)\u003c/p\u003e\u003cp\u003eI felt that perhaps my input into this study was a little useless as I wasn\u0026rsquo;t seeing any posts noteworthy for my diary. Then, towards the end of the week, I slowly started seeing more posts and then felt bad that I\u0026rsquo;d perhaps willed the posts onto my feed! (ID24, Diary free-text)\u003c/p\u003e\u003cp\u003eI think maybe I just am more aware when I\u0026rsquo;m looking at it, whereas before, I\u0026rsquo;d look at a post and scroll past. Now, sometimes I\u0026rsquo;ll read it and actually pay attention to what I\u0026rsquo;m looking at. So, I think it\u0026rsquo;s actually made me more conscious (ID24).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, revisiting content in order to log it, or the practice of screenshotting (above) increased exposure and created a record of content on the participants\u0026rsquo; devices unless this was deleted.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI\u0026rsquo;m scrolling through [social media] all day long and then I forget that I\u0026rsquo;ve read something. I\u0026rsquo;ll then go back looking for it. Like I say, I tried the screenshotting for a while because that was a bit easier\u0026hellip; That felt very much like \u0026lsquo;Oh god, I\u0026rsquo;ve got to go back through and relook at stuff now (ID3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTwo participants included online images of self-harm within their first diary but not in later diaries despite reporting increased engagement with such images. One (ID84) explained choosing to exclude these \u003cem\u003e\u0026ldquo;to avoid that pressure of downloading them\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn a research context, one participant (ID3) raised the issue of possible repercussions of disclosing online activity in a diary, expressing fears this could create a negative impression or necessitate action. Such concerns could also be relevant if used in clinical practice, though this was not explored.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause I\u0026rsquo;ve been really honest in my diary\u0026hellip; there were some times that I was a little bit anxious about whether or not you were going to do something because, like I say, I\u0026rsquo;ve got this real fear of being sectioned (ID3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSuggestions for improvement\u003c/h2\u003e \u003cp\u003eFour participants suggested the diary should be made electronic and \u0026lsquo;phone friendly\u0026rsquo;, for instance as an online form or app. One participant (ID11) specifically stated they would continue completing the diary for their personal benefit if it were delivered in this format. It was also suggested that the diary should prioritise weekly reflection, particularly around triggers and impacts resulting from online engagement (rather than logging daily content), to make completion more manageable, less repetitive and more useful \u0026ndash; particularly for communicating online experiences with others.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe report incidental findings which allow us to hypothesise that keeping a reflective diary of online activity could promote safer online behaviour. Although our diary was intended as a research tool for capturing \u0026lsquo;in the moment\u0026rsquo; data and not an intervention, it became apparent that participants were susceptible to a Hawthorne Effect[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] as a result of knowing their online behaviour was being observed, and that diary completion could change the behaviour under observation. This effect was magnified because, as the diary completers, participants were prompted to become the observers of their own behaviour.\u003c/p\u003e \u003cp\u003eParticipants spontaneously described benefits associated with completion. Most notable was increased awareness of the extent, nature and impact of their engagements with online self-harm content, which prompted individuals to begin critiquing their use by considering their motivations for accessing content, how they engaged with this and whether it was detrimental to them. Two participants also implied the diary could become a communication tool by helping them to pinpoint difficult content and record negative online experiences to bring for discussion with a healthcare practitioner or others who may support them. Several participants stated they had made, or were intending to make, changes to their online behaviour such as monitoring time spent online, becoming more discerning about how they interacted with content, or recognising the need for self-enforced breaks from some online spaces. However, most participants did find daily completion burdensome. This led to missing entries, retrospective reporting and could increase exposure to negative online content where actions were taken to enable diary completion, such as taking screenshots of significant engagements and retracing browsing sessions in order to log content. Also, for some participants, completing a diary appeared to increase attention to self-harm content.\u003c/p\u003e \u003cp\u003eOur findings suggest the process of observing one\u0026rsquo;s online behaviour via a diary resulted in learning, insight and reflection, which could increase participants\u0026rsquo; metacognition when engaging online. Increased awareness of their thought processes prompted decision-making, allowing some to make positive adjustments to their online behaviour. This speaks to an emerging dialogue within online safety research which advocates for intervention approaches which recognise the potential agency of users and focus on upskilling and empowering them to assert control online and manage online safety[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our hypothesis that journalling could be an effective approach is compatible with existing therapeutic approaches and tools, such as the use of mood monitoring in CBT-based interventions. It is also in keeping with other studies that have explored diaries and expressive writing as potential mental health interventions and found improvements in psychological[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], though it is noted that more evidence about the efficacy of journalling in the treatment of mental illness is required[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our findings warrant further research into the value of obtaining insight into one\u0026rsquo;s own behaviour in the context of engaging with online self-harm suicide content and how this can impact on behaviour.\u003c/p\u003e \u003cp\u003eSuggestion that a diary could serve as a tool for facilitating conversations about online use and negative online experiences with trusted others is relevant to increased expectation that such discussion is incorporated into mental health consultations[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and may serve as an area for suicide prevention[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Previous research has noted that asking about suicide-related online behaviour can assist clinicians to arrive at a more holistic view of a patient and contribute to perception of risk[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Other examples of self-monitoring data being shared within consultations to enable quick exchange of suicide risk information lend support to this assertion[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, it should also be noted that some participants referenced how declining mental health could negatively impact their ability to complete the diary, which would be an important consideration if designing such an intervention targeted at a clinical population. Also, our findings hint that willingness to openly disclose online activity in a diary may be contingent upon the perceived knowledge and understanding of the diary\u0026rsquo;s audience. Research with young people shows that fear of negative judgement and misunderstanding from mental health practitioners in relation to their online usage hinders reporting[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and that there is a practitioner training gap in this area[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Actions to address this would therefore be necessary.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eOur findings were gathered in the context of an in-depth qualitative study based on a small sample of participants and not initially intended to explore the interventional potential of a diary. The reflections gathered centred around participants\u0026rsquo; experiences of using the diary as a research tool. Views about acceptability and willingness to openly disclose in the diary may not fully extrapolate to a clinical or intervention context. Similarly, the potential impact of therapeutic input from a clinician as part of the journalling process is not known.\u003c/p\u003e \u003cp\u003eParticipants reduced to nine after attrition. It is possible that being asked to complete the diary contributed to study dropout and that those remaining in the study were disposed more favourably towards diary completion, but our less than 50% attrition rate is favourable compared to similar LQR studies without a diary component, (e.g. 55% reported by Vogl and Zartler, 2020[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]). Our study focused on adults aged 16 years or older and most participants were female, limiting our ability to draw conclusions about the acceptability of journalling to males and adolescents. Also, data were not collected on other participant characteristics such as neurodiversity. Nevertheless, given the absence of studies exploring individual-level interventions for addressing online harms, our preliminary findings are novel and provide insights, which may provide a foundation for future work to address this acknowledged gap. Further work should be expanded to incorporate children and adolescents given their high usage of digital technologies. Our study design allowed for diaries to be used over a period of six-months and for longitudinal data collection over this period. This enabled us to capture qualitative narratives, which were also naturalistic since they emerged spontaneously as part of an unplanned natural experiment. However, the unplanned nature also meant that no quantitative before and after measures of problematic online use were included to assess change.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eAlthough only formative, our study indicates that journalling about online activity could be explored as a potential means to enhance online safety amongst those who engage with self-harm or suicide-related content. Research could also explore whether such an approach might similarly be applied to other specific areas of online harm (such as, disordered eating), or individuals exhibiting Problematic Internet Use (PIU)/ \u0026lsquo;internet addiction\u0026rsquo;[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] more generally.\u003c/p\u003e \u003cp\u003eSome participants drew parallels with journalling they used in other contexts to support their mental health, either as part of treatment or through their own decision, thus indicating the study diary as a familiar approach for addressing online activity. Further research is needed to investigate the acceptability and usefulness of integrating this within clinical practice from both a patient and clinician perspective. Such an approach could support conversations in clinic about online use. Recent survey data focused on young adults\u0026rsquo; mental health suggest only 40% of young people experiencing mental distress are asked by a mental health practitioner about their online experiences[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Practitioners similarly report that such conversations can occur infrequently due to low practitioner confidence, among other issues[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Training and resources to support mental health practitioners in this area are currently limited and practitioners have expressed a wish for interventions to use with patients[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Our diary approach could facilitate clinicians to engage with patients about their online use and provide the foundation for such an intervention, if adequately supported by training. Equally, many DELVE participants had begun engaging with online content due to difficulties accessing mental health care[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], suggesting it is also relevant to explore the potential for journalling about online activity to be used as a self-help tool, or supported outside of clinical services, for instance by parents or school nurses.\u003c/p\u003e \u003cp\u003eWhile promising, clear limitations were also identified with the diary\u0026rsquo;s current format, which require careful consideration if adapting this from a research tool into an intervention. In particular, these concerned the burden of daily reporting and potential for iatrogenic effects; namely, increased exposure or attention to online self-harm/ suicide content where individuals are encouraged to keep a daily log of this. Any research building on this work must therefore address the potential for adverse outcomes and seek means to mitigate. Similarly, it is necessary to consider how emotions such as guilt and self-depreciation associated with poor completion can be overcome in this population group, particularly in a clinical setting where feedback or reassurance may be more difficult to impart due to time constraints. Participants indicated they would prefer to complete the diary in an electronic format, such as an app. With this in mind, further research could explore the potential for automating some aspects of the diary, such as capture of search history, in order to reduce burden and exposure.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is a need for individual-level intervention to address harmful online behaviour relating to self-harm/ suicide and mental ill-health more generally. Our incidental findings offer hypotheses about where advances in knowledge could be made. In line with theory around metacognition, our research diary showed promise by allowing participants space to reflect on their online use and encouraging discussion and thinking around ways to disengage from harmful content or resist the determinism of algorithms and other technological features. Well-designed research is now required to explore whether this research tool could be adapted therapeutically to function as an intervention and communication tool. It will be essential that this considers mechanisms of change, most appropriate settings for delivery, how to ensure feasibility and safety of completion, and involves potential users in co-creation of any intervention going forward, both in terms of content and mode of delivery.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLB conceived the study and all authors contributed to study design. LB and JD designed the study and diary template. LB, ZH and LK collected and analysed study data. ZH ran the DELVE study. All authors contributed to participant recruitment, topic guide creation and provided intellectual input. The first draft of the manuscript was written by LB and all authors commented on versions of the manuscript. All authors read and approved the final manuscript. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr Rachel Cohen and Esther Kissane-Webb for their assistance in creating the diary template and all the study participants who completed diaries and took part in study interviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author (LB) upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research leading to these results received funding from Samaritans UK Online Excellence Programme.\u0026nbsp;LB is partly funded by National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation Trust. ZH is partly funded by\u0026nbsp;Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK. The views expressed are those of the authors\u0026nbsp;and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll procedures in this study were approved by\u0026nbsp;\u003c/em\u003ethe University of Bristol Faculty of Health Sciences Ethics Committee (Ref: 117491) and therefore were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to publish\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants signed informed consent regarding publishing their data.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMars B, Heron J, Biddle L, Donovan JL, Holley R, Piper M, Potokar J, Wyllie C, Gunnell D (2015) Exposure to, and searching for, information about suicide and self-harm on the Internet: Prevalence and predictors in a population-based cohort of young adults. 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Behav. 1;90:428-36 https://doi.org/10.1016/j.addbeh.2018.09.007\u003c/li\u003e\n\u003cli\u003eLam LT, Lam MK (2016) eHealth intervention for problematic internet use (PIU). Curr. Psychiatry Rep. 18:1-7 https://doi.org/10.1007/s11920-016-0747-5\u003c/li\u003e\n\u003cli\u003eSedgwick P, \u0026amp; Greenwood N (2015) Understanding the Hawthorne effect. BMJ 351. https://doi.org/10.1136/bmj.h4672\u003c/li\u003e\n\u003cli\u003eBaikie K, \u0026amp; Wilhelm K (2005). Emotional and physical health benefits of expressive writing. Adv. Psychiatr. Treat. 11(5), 338-346. doi:10.1192/apt.11.5.338\u003c/li\u003e\n\u003cli\u003eHiemstra R (2001). Uses and benefits of journal writing. In: English LM Gillen MA (eds) Promoting journal writing in adult education (New Directions for Adult and Continuing Education) San Francisco, Jossey-Bass, 90 pp 19-26\u003c/li\u003e\n\u003cli\u003eSohal M, Singh P, Dhillon BS, Gill HS (2022) Efficacy of journaling in the management of mental illness: a systematic review and meta-analysis. Fam Med Community Health 10(1) doi: 10.1136/fmch-2021-001154\u003c/li\u003e\n\u003cli\u003eMoreno MA, Dixon LB, Jankowski S, Adler DA, Berlant J, Brunette MF, Castillo EG, Edwards ML, Erlich MD, First MB, Kozloff N (2024) The Need to Adapt the Psychiatric Clinical Assessment to the Digital Age: A Practical Approach. Psychiatr. Serv. 2024 https://doi.org/10.1176/appi.ps.20230399\u003c/li\u003e\n\u003cli\u003eCohen R, Biddle L (2021) The Influence of Social Media on Suicidal Behaviour among Students. In: Smith J \u0026amp; Mallon S (eds) Preventing and responding to student suicide: A practical guide for FE and HE settings. Jessica Kingsley Publishers, London, pp94-107\u003c/li\u003e\n\u003cli\u003eHetrick SE, Goodall J, Yuen HP, Davey CG, Parker AG, Robinson J, Rickwood DJ, McRoberts A, Sanci L, Gunn J, Rice S, \u0026amp; Simmons MB (2017) Comprehensive Online Self-Monitoring to Support Clinicians Manage Risk of Suicide in Youth Depression. Crisis\u003cem\u003e 38\u003c/em\u003e(3), 147\u0026ndash;157. https://doi.org/10.1027/0227-5910/a000422\u003c/li\u003e\n\u003cli\u003eDerges J, Bould H, Gooberman-Hill R, Moran P, Linton MJ, Rifkin-Zybutz R, Biddle L (2023) Mental health practitioners\u0026rsquo; and young people\u0026rsquo;s experiences of talking about social media during mental health consultations: qualitative focus group and interview study. JMIR Form. Res. 7:e43115 doi: 10.2196/43115\u003c/li\u003e\n\u003cli\u003eHaime Z, Griffiths G, Linton M-J, Bould H, Biddle L (2024) Mental Health Practitioners\u0026rsquo; Training Needs and Preferences for Addressing Online Use with Children and Young People. Evid.-Based Pract. Child Adolesc. Ment. Health (In press).\u003c/li\u003e\n\u003cli\u003eVogl S, \u0026amp; Zartler U (2021) Interviewing adolescents through time: balancing continuity and flexibility in a qualitative longitudinal study. Longitud. Life Course Stud. \u003cem\u003e12\u003c/em\u003e(1), 83-97 https://doi.org/10.1332/175795920X15986464938219\u003c/li\u003e\n\u003cli\u003eSpada MM (2014) An overview of problematic Internet use. Addict. Behav. 1;39(1):3-6 https://doi.org/10.1016/j.addbeh.2013.09.007\u003c/li\u003e\n\u003cli\u003eRifkin-Zybutz R, Turner N, Derges J, Bould H, Sedgewick F, Gooberman-Hill R, Linton MJ, Moran P, Biddle L (2023) Digital technology use and mental health consultations: survey of the views and experiences of clinicians and young people. JMIR Ment.Health. 10(1):e44064 doi: 10.2196/44064\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Suicide, Self-harm, Internet, Self-monitoring, Journaling, Intervention. ","lastPublishedDoi":"10.21203/rs.3.rs-4869852/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4869852/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eIt is well-established that self-harm and suicide-related online use can bring harms and benefits for users. Research suggests a need to upskill users and improve metacognition around online engagement to manage these conflicting effects but there is currently a lack of behavioural interventions to achieve this. We explored incidental data from a longitudinal qualitative study, which indicated that self-completing a research diary about online engagements could impact participants’ online behaviour.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eParticipants (n=9) were enrolled in a 6-month longitudinal qualitative study exploring self-harm and suicide-related online activity. They were interviewed at three timepoints and between these intervals completed a daily reflective diary of online activity. Experiences of completing the diary were explored qualitatively during mid and end-point interviews, and through free-text diary entries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAll participants derived benefits from journalling about their online use with respect to self-harm and suicide-related content. These included increased insight about time spent online, the motivations behind engagement, and the nature and impact of use. Some participants reported resultant behaviour change. However, daily completion was burdensome and there were potential costs for some participants, such as increased attention or exposure to self-harm content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eJournalling about online activity should be explored more deliberately as a possible method for addressing the existing gap in individual-level interventions to tackle online harms. Well-designed research and co-design work with lived-experience users will be essential to evaluating the potential for this to function safely as an intervention both within and outside of clinical settings.\u003c/p\u003e","manuscriptTitle":"Adults’ experiences of using journalling to reflect on suicide and self-harm related online use: indications of a potential area for intervention development to reduce online harm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-03 04:09:14","doi":"10.21203/rs.3.rs-4869852/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4f9a8d1-68c0-4456-b114-e8a3c4bc2f10","owner":[],"postedDate":"September 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-25T16:53:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-03 04:09:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4869852","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4869852","identity":"rs-4869852","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}