Anonymous : the problems , dilemmas and desires of Slovenian adolescents in online counselling

Introduction: Online counselling represents a new medium for finding health information. The aim of the research is to determine the importance of analysis of adolescents' issues in order to understand their problems, needs and desires. Methods: In 2012 the system for the classification of questions by the type of problem was introduced. In relation to the contents the questions were first sorted to the parent category then followed by the categorization according to the subject matter. The calculation comprised the portions, averages and quartiles, and in some cases even Cramer's V coefficients. The analysis covered the entire defined population (3,257 coded questions). Results: Most of the users are girls (76 %), the most representative group encompasses adolescents aged between 14 and 17 years (57 %). Most questions were grouped into the categories Sexuality and sexual health (24 %), Relationships (23 %) and Body (20 %). The length of posts increases with the age of the user (Cr's V = 0.18), but differs by the gender (a higher proportion of longer questions (Cr's V = 0.15) were posted by girls) and the themes (Cr's V = 0.31). Discussion and conclusion: The categorizing of questions is suitable for the identification and analysis of adolescents' problems, needs and desires. Regular categorisation of questions with analysis will serve as a useful research tool for youth work.


Introduction
The Web is increasingly gaining importance as a source of information about the issues that interest adolescents.Additional light on the use of online technologies and everyday practices on the Internet was shed by the study on Slovenian adolescents Youths and the Net.The use of Internet was greatest in adolescents between 15 and 19, of which more than 80 % used the Internet every day (Lobe & Muha, 2011;Rapuš Pavel, 2012).The findings of similar recent research projects in Slovenia also show that the use of Internet does not supplant the direct communication of young people in real environments, while the use of Internet social networks offers psychologically less stable young people more secure environment (Rapuš Pavel, 2012).
The use of the internet is recently also a part of the broader context of health information resources.More recent studies of adolescent health information sources have also included the internet and the results show that the use of this medium by adolescents is increasing rapidly (Borzekowski & Vaughn, 2001b;Hansen, et al., 2003;Skinner, et al., 2003;Gray, et al., 2005;Ybarra & Suman, 2006;Mishna, et al., 2008).For adolescents, the Internet can serve as an important tool in acquiring health information for several reasons: first, adolescents can easily access this medium; second, the Internet offers adolescents a confidential and less threatening way to get information that might otherwise be difficult or compromising to obtain; third, the interactive nature of the Internet can provide adolescents 'personalized' information (Borzekowski & Vaughn, 2001a, pp. 813-814).

Online counselling
Over the past decade when millions of people worldwide gained access to the Internet, online counselling has arisen as a new counselling modality.Since its inception, the demand for online counselling is increasingly growing, since it enables healthcare available to anyone who receives care without the physical presence of a counsellor.As the numbers of individuals, including children and youth, who seek online counselling escalates, mental health professionals and organizations are increasingly offering online counselling and other online services (Mishna, et al., 2008).
The online counselling is an ideal medium through which to reach adolescents not only because many of them have access to the Internet and are not restricted by geographical or physical constraints, but also because many youth feel comfortable with the Internet, and may be embarrassed to seek therapy or support in a face-to-face situation (Suler, 2004;Young, 2005;Chester & Glass, 2006;Bambling, et al., 2008;Mishna, et al., 2008;Burns, et al., 2010).Anonymity within online counselling -in addition to protecting their personal data -is also a mental category, which can be described as a psychological anonymity, which enables to maintain client's self-assurance, personal dignity, and also the projection of an 'ideal counsellor' (Schultze, 2006).The study on changes in behaviours related to adolescent health in Slovenia between 2002 and 2010 found that the share of adolescents who find it easy to talk about the things of their interest with their parents, was in decline (Jeriček Klanšček, et al., 2013).As the adolescents keep their anonymity, the online counselling space is viewed as a safe environment to discuss personal issues.Slovenian adolescents often say they would not be able to discuss many of the issues revealed anonymously on our website face-toface or would be dissuaded from seeking help at all by the feelings of doubt and shame (Lekić, et al., 2009a).Gender differences amongst adolescents may occur in using a clinical service when it comes to mental health issues (Burns, et al., 2010).There are also gender differences in using online counselling: Adolescent boys seek online help less often than girls (Glasheen & Campbell, 2009).

'Most wanted' topics
Slovenian adolescents use the Internet to obtain information especially on topics such as romantic relationships, sexuality and health (Lobe & Muha, 2011).These are the topics that are of interest to adolescents worldwide (Subrahmanyam, et al., 2004;Suzuki & Calzo, 2004;Trompetter, 2004;Valkenburg & Peter, 2011).
An especially sensitive area for online counselling is comprised of questions related to self-harm and suicidality (Ekman & Söderberg, 2009;Fiedorowicz & Chigurupati, 2009;Murray & Osborne, 2009; Online counselling skills Within the context of online counselling we cannot ignore certain sceptical views of the Web as a place to seek counsel and the many pitfalls of online counselling practice.In online counselling, we keep in view both the positive and the negative aspects of such approach (Lekić, et al., 2009b).What is missing are clearly defined methods of providing Internet counselling that have been evaluated for effectiveness and that form the basis of empirically-based approaches in this new medium (Mallen, et al., 2005).Certainly there is a difference between synchronous communication that occurs in real time and require direct responses and social interactions, and asynchronous communication, where there is a significant amount of time between responses and may be more task-oriented (Trepal, et al., 2007).
The counsellor needs to compensate face-toface communication by entering the client's mental constructs via the written word (The Nature of the therapeutic relationship within online counselling, 2011, p. 12), therefore the examination of this area is very important.

Online counselling service 'To sem jaz / This is Me'
The online counselling service was one of our responses to the life-style and communication needs in today's adolescents.The online counselling service was founded by the National Institute of Public Health in Celje in 2001 ('To sem jaz' / 'This is Me ', 2014).It was the first Web-based counselling service in the field of public health in Slovenia that gave adolescents online access to various experts without waiting times and referrals.Online communication and counselling within the 'This is Me' programme is one of the two key areas of proactive prevention work with adolescents.The second area comprises prevention workshops based on the concept of 10 steps to a better self-esteem, intended for classroom implementation in the school environment (Tacol, 2010).The basic mission of the programme is to raise the level of organized mental-health care for adolescents.It aims to promote a positive and realistic self-perception, social communication, useful life skills and other elements of mental health (Lekić, et al., 2010).The 'This is Me' programme has received six national and international awards.It has been noted as an example of good practice in publications by the European Commission (Braddick, et al., 2009) and the World Health Organization (Stengard & Appelqvist-Schmidlechner, 2010).
During thirteen years of continued operation the 'This is Me' portal has grown into a popular online counselling service.It provides an anonymous, free and simple public access to expert advice.The online counselling team consists of 60 professionals from the field of medicine, psychology, social care and education.They include medical specialists in different fields (school physician, paediatrician, family physician, gynaecologist, epidemiologist ...), psychologists, psychotherapists and other experts (social and sports counsellors, social workers etc.).They are all volunteers from various institutions.Up to now, they have answered 31,700 questions about varied dilemmas and distresses encountered while growing up.
In order for the online counselling service to develop, we need to study and understand the content of online communication between the adolescents and experts.The online counselling service has proven its value as a convenient platform for adolescents to seek advice and open up without fear.However, we need to listen to their voices systematically and closely to understand them better.

Aims and objectives
The editors of the 'This is Me' service sought a deeper insight into the issues brought forward by the adolescent's question.This goal became attainable through introduction of daily, real-time categorisation of incoming questions.Classification according to issue typology was seen as a promising development in the online counselling activity that would provide a comprehensive overview of the question content and improve the understanding of counsel seekers.The typology and analysis of the issues will enable a more transparent documentation of questions and a more relevant display of the counselling website content.By regularly categorising the questions we build a powerful research tool to be used in the field of youth work.We expect our investment into a real-time and consistent categorisation of incoming questions, presented in the form of a systematic online catalogue, to contribute towards improved understanding of the lives of adolescents, an especially vulnerable population in the context of health promotion.
With this research we would like to prove or find out, if the categorising of the questions and systematic online catalogue in the hereinafter gives relevant adolescents' data to identify and analyse their problems, needs and desires.

Methods
First, we used a qualitative method, which was performed by using descriptive and non-experimental likelihood research methods.In this context, classification method according to issue typology was made with the assistance of descriptive method and non-experimental causal research method using the catalogue to categorise issues.The data were collected using coding technique: First, the method of analysis of data was made and second, method of synthesis to categorise questions was used.
Second, we used quantitative method to process some data automatically recorded in the database at the questions' posts and which are essential for its proper functioning.Such are, for example, the time and date of publication issue of the user and the time and date of the first response of the editorial board (usually the reply of the counsellor).Some data were calculated from the questions themselves: the number of characters and issues of the first publication of the editorial board without spaces (the length of questions and the length of response).
In the programming language R we have passed the basic descriptive analysis: we calculated proportions, averages and quartiles.When it was applicable, we also calculated the coefficient of associations namely Cramer's V coefficient (also Cramer's alpha coefficient or Cr's V), which can take the values between 0 and 1, where 1 means a perfect correlation.We decided to use Cramer's alpha coefficient due to highly asymmetric distribution of phenomena under examination (the length of questions and answers and response times) as well as the possibility of simple and understandable interpretations.All calculated coefficients are comparable to each other, since the Cr's V is not sensitive to the number of units and the size of the contingency tables (Cramér, 1946).Since the analysis is performed at the population level (questions online counseling 'This is Me'), there was no statistical test.

Description of the instrument
Drawing from the editors' experience and knowledge of the issues, the online counselling service 'This is Me' developed a detailed online catalogue used to categorise questions.Each new forum topic created by an adolescent seeking expert counsel is entered into the catalogue under its respective category.
The online catalogue (code table) is a tree-structured file defining several research categories such as (toplevel) category, (general) topic, subtopic, gender, age and other.The descriptions are accompanied by category codes.The code table defines 11 top-level categories as follows: (1) Body, (2) Sexuality, (3) Sexual health, (4) Mental health, (5) Drugs and addiction, (6) Relationships, (7) Physical health, (8) Problems at school, (9) Attitude towards society, (10) Opinions, (11) Forwarded questions.These 11 categories are further divided into subcategories.The code table contains 90 subcategories (topics).For example, the top-level category Body contains the following subcategories: Physical maturation; Nutrition; Sports, physical activity and body shaping; Weight; Negative body-image; Body decorations; Other.The content of each forum topic is thus assigned a code from the treestructured code table.One forum topic (i.e. one online post for the attention of the experts) can contain several questions from more than one field.Therefore each post (forum topic) is first assigned a general topic and linked to any related topics.The general topic identifies the main focus of the adolescent's post.The general topics are re-coded into parent (top-level) categories.

Description of the sample / population
In 2012, adolescents have addressed 3,888 questions to our experts (online counsellors), of which 3,257 have been assigned codes that represent the whole population -posts by the adolescents received within one year between 1 st January 2012 and 31 st December 2012.It was not possible to count the number of adolescents, as their questions have been anonymously posted.
The difference between the number of all questions submitted and the number of codes -631 in our case -stems from the sub-questions submitted by the adolescent after receiving a reply.Namely, only the original post/question is assigned codes while subsequent ones are not as the subsequent questions are usually a continuation of the original post.The codes were assigned by qualified personnel, usually the editor or her assistant in her absence.This way, a consistent encoding was achieved.
For the purpose of our research, we analysed all coded posts.It would not have been enough to analyse only a sample as every question submitted in the given time period needed to be considered to make sure we recorded the most severe issues that are usually implied only in a fraction of all posts.When all questions in a given time period are classified no implied issue can be missed.
A technical analysis of the 'This is Me' website by the Google Analytics tool shows that the website was viewed almost 500,000 times in 2012.The Web address of 'This is Me' was visited by more than 110,000 users.Almost 40 % of visitors have visited the website before (repeated visits).The most visited section of the website was the online counselling service itself (a third of the total traffic).
Anyway, our target population of counselling service users was adolescents aged between 14 and 17.

Data analysis
The study took place in 2012 and was supported by the National Institute of Public Health in Celje, Slovenia.Data were collected anonymously and processed by qualitative and quantitative methods.An example of a forum topic and its codes is shown on Figure 1.
The example (Figure 1) was categorised into the top-level category Relationships and its subcategory Friendship.The post was further categorised according to related topics implied by the adolescent as her relationship issues are also connected to peer relations (category Relationships), feelings of anxiety (category Mental health) and problems at school (category Problems at school).The poster's gender could be determined from the post too.The exact age was not given, however, an age group could be assigned.

Results
The coding -analysis by problem typology -included 3,257 forum topics (questions by adolescents).In continuation we present some of the key findings providing insight into the This is Me online counselling service and its users.
Girls account for the majority of active counselling service users.In 2012, girls submitted 76 % of all questions and the rest (24 %) were submitted by boys.The best represented age group was 14 to 17 years (58 %). 25 % of users belong to the youngest age group (10 -13 years).Users submit most questions in the afternoon, evening and at night; boys between 8 pm and 10 pm while the girls are more active in the afternoon.
Figure 2 shows the distribution of questions by toplevel category.The category Sexual health contains the topics on contraception, sexually-transmitted diseases, gynaecological examination, genitals, etc.The category Sexuality contains the topics on sexual  An analysis of general topics (subcategories) reveals that the most commonly appearing questions on the This is Me online counselling service are related to the following content: Infatuation and love (12 %) and Physical maturation (11 %).Different age groups are typically concerned with different general topics.The topics Low self-esteem and Infatuation are among the top ten topics in all age groups except in the >21 age group.In 2012, the questions submitted by the youngest users -children aged between 10 and 11 -dealt predominantly with topics of physical maturation, body weight, infatuation, masturbation, poor body image, relationships and emotions.
In 2012, 148 questions submitted by users were found to reflect the most severe distress.In the complete database of 3,257 questions, the topics dealing with the most difficult issues account for 4.5 % of all questions.The 148 examples of severe issues were assigned 183 topic codes as shown in Table 1.These topics are treated as a special subset of the most difficult questions.The largest share of the most difficult issues has appeared in a group of users between the ages of 18 and 21 years (8.9 % of all issues in this age group).24 % of the hardest questions deal with self-harming behaviour.The length of posts by adolescents and experts (characters without spaces) was also analysed.75 % of posts by adolescents contain 585 or less characters without spaces.The posts by our experts exceeded the posts by users in length, 75 % of experts' responses contains 807 characters without spaces or less.The longest question contained 7,189 characters without spaces.The longest reply by our expert contained 7,267 characters without spaces.Both longest posts deal with the most difficult topics.
The likelihood of a post exceeding 500 characters increases with age (Cr's V = 0.18).The post length is also related to the type of problem described by the adolescent (Cr's V = 0.31).The largest share of posts exceeding 500 characters without spaces appears in the category Mental health (53 %).The shortest posts appear under the category Sexuality (14 %).
Differences in shares of posts longer than 500 characters without spaces also exist according to gender (Cr's V = 0.15).Girls have announced 36 % of posts longer than 500 characters without spaces, and boys 20 %.
The length of expert posts is most strongly associated with content issues (parent category) (Cr's V = 0.56), and the length of questions (Cr's V = 0.39).
The longer answers are characterized in particular for the categories related to Mental health, Relationships and Problems at school, and shorter responses for the categories related to physical health, such as Sexual health, Body and Physical health.With the length of the response gender (Cr's V = 0.08) and age (Cr's V = 0.06) are negligible weak associated.
We examined the time required for the adolescent to receive a reply to their question as an important indicator of our online counselling activity.25 % of users received a reply within two days or less, 50 % in three days or less.The majority of users (75 %) received an expert's reply within five days or less.Some even received the reply on the same day.

Discussion
As the Web is increasingly gaining importance as a source of information about the issues that interest adolescents, the use of the internet is recently also a part of the broader context of health information resources for them.As the adolescents keep their anonymity, the online counselling space is viewed as a safe environment to discuss personal issues.The analysis of the This is Me website shows that in 2012 the website was viewed almost 500,000 times and the Web address ('To sem jaz' / 'This is Me', 2014) was visited by more than 110,000 users.The most visited section of the website was the online counselling service itself.
Classification according to the issue typology was seen as a promising development in the online counselling activity that would provide a comprehensive overview of the question content and improve the understanding of counsel seekers.The typology and analysis of issues will enable a more transparent documentation of questions and a more relevant display of the counselling website content.By regularly categorising the questions we build a powerful research tool to be used in the field of youth work.
The research project on Slovenia's largest and oldest online counselling service for adolescents included more than 3,000 questions posted by adolescents and categorised by issue typology.The new findings are relevant because of both, the extent of our investigative efforts and the nature of data obtained in a unique setting of a virtual counselling community characterised by a great level of trust and sincerity in describing the issues concerning adolescents.The relevance of our research is furthered by the fact it provides an insight into the Slovenian adolescent population from its own perspective; its curiosity, desires, needs, dilemmas, hopes and life situations.As the virtual space gains prominence in the lives of today's adolescents, their transition into adulthood and problem solving become increasingly reflected there.
As the use of Internet in Slovenia is greatest in adolescents between 15 and 19, of which more than 80 % used the Internet every day (Lobe & Muha, 2011;Rapuš Pavel, 2012;Pirnat & Skela Savič, 2013), our programme succeeded in reaching out to our target population as more than half of counselling service users are aged between 14 and 17. 25 % of users are between 10 and 13 years of age.We find the number of younger users has been increasing over the years.We are aware of the dilemma regarding the suitability of these topics and the age group concerned.The discussions that develop in the online counselling setting are mostly generated by older adolescents.
An analysis of top-level categories shows that the questions are distributed almost equally among three best represented areas: Relationships, Sexuality and sexual health, Body (each category accounts for about a fifth of all questions) -very similar note to other Slovenian as well as authors around the world (Subrahmanyam, et al. , 2004;Suzuki & Calzo, 2004;Trompetter, 2004;Lobe & Muha, 2011, Valkenburg & Peter, 2011).Top-level topics are followed by the categories of physical and mental health.The adolescents report most issues in the area of mental health; they are related to communication problems, self-expression, emotional management and low self-esteem.
Girls speak about their issues and dilemmas more often than boys (76 % of questions are posted by girls), which coincides with the findings about gender differences in seeking or using the help when it comes to mental issues (Glasheen & Campbell, 2009;Burns, et al., 2010).Still, it is possible that boys, while posting fewer questions, still read the website content.Girls have announced 36 % posts longer than 500 characters without spaces, and boys 20 %.
The post length is also influenced by the type of problem described by the adolescent.In addition to the post gender and type of a problem, the likelihood of a post's length increases with age.The largest share of posts exceeding 500 characters (53 %) appears in the category Mental health.The shortest posts appear under the category Sexuality (14 %).The likelihood of a longer reply increases when an expert is responding to a question from the field of mental health, relationships and problems at school.The question length also associates the length of expert posts.
An especially sensitive area for online counselling (a critical point) is comprised of questions related to the most severe issues.The major part of the most difficult questions deals with self-harm and suicidality.An analysis of post length reveals that certain topics require an in-depth counselling dialogue between the adolescent and the expert.The most serious issues and questions of mental health also coincide with post length.In many cases, cyber counselling is offered without key issues adequately addressed, such as counsellor-client boundaries, confidentiality and duty-to-warn in situations of abuse (Mallen, et al., 2005).
The online counselling activity is characterised by a good average response time of editors and counsellors as most users (75 %) receive their reply within five days or less.As this is asynchronous communication, where there is a significant amount of time between responses, according to Trepal et al. (2007) our service should be more task-oriented.The response times are mostly influenced by the availability of online counsellors and are as such defined by the size of the counselling team and the number of questions submitted.The number of counsellors grew from 7 experts in 2001 to 60 experts in 2014.While the counselling team is strong both in numbers and knowledge, the number of questions submitted has seen a significant rise.
While developing the programme, we have learnt from our experience that the Web can serve as a useful counselling tool and a supplementary form of help, if it is used carefully and with a keen sense for the adolescents.With a strong network of expert counsellors, the Web can be used creatively and gain prominence as a measure to support and protect the adolescents.We found that the role of an e-counsellor is mostly preventive.Online counselling is successful each time a counsellor succeeds in guiding an adolescent towards positive change (Lekić, et al., 2011).In the context of our online counselling service, while we are interested in the empirical impact of online counselling, it is not available to us.Our personal experience confirms that online counselling in its diverse forms is evolving into an important part of the current and future counselling practices and prevention efforts.
The developers of the 'This is Me' programme believe that the image of today's adolescents, as reflected online in the context of an emphatic and thoughtful counselling service, accurately portrays the characteristics of contemporary adolescents and their perception of reality.The only 'virtual' aspect is the platform through which expert counsel is obtained.

Conclusion
The research work of the This is Me e-counselling service has demonstrated the importance of our online database that has grown to include 31,700 questions and expert replies over its 13 years of operation.It is both extraordinary and unique as a source of learning more about our adolescents growing up.
The value of the database will continue to increase with the years.At the current stage we succeeded in investigating a tenth of the complete database (limited to 2012).A full insight into the changes undergone by the adolescent population from 2001 could be gained by an extensive analysis of the complete database compiled over more than a decade of operation.Such a project would, however, require significant resources in terms of funds, time and personnel.A more accessible option is a regular yearly analysis of questions, which would evolve to serve as a convenient, useful and relevant research tool for learning more about the spirit of the modern adolescent.
Figure 1: Example of coding the question by type of problem Slika 1: Primer kodiranja vprašanja glede na tipologijo problema