Impact of an intervention through Facebook to strengthen Self-esteem in nursing students

Objective: to evaluate the impact of the “Strengthening Self-Esteem” intervention proposed by the Nursing Interventions Classification, conducted through the use of Facebook, on the self-esteem and self-efficacy levels of nursing undergraduates. Method: quasi-experimental study carried out in two Higher Education Institutions. The sample consisted of 74 students. Two data collection tools were applied before and after the intervention: Rosenberg Self-Esteem Scale and General and Perceived Self-Efficacy Scale. The students were submitted to the intervention for ten sessions. Posts were made in private profile created on Facebook and consisted of positive messages, reflective texts and pictures, all supported by the persuasive resources of Bandura’s theoretical framework. Results: of the 264 students who answered the pretest, 74 (28.03%) participated in the interventions and the post-test. Rosenberg self-esteem (p=0.026) and self-efficacy (p=0.001) scores after the intervention were significantly higher than those obtained before, confirming the effectiveness of the intervention. Conclusion: the “Strengthening Self-Esteem” intervention was effective for improving students’ self-esteem and self-efficacy levels. Such interventions help spread knowledge and build mentally healthier individuals.

This scenario warns us that these students are part of a population vulnerable to mental imbalance or crisis arising from stressors related to the undergraduate course.
Low self-esteem is an important risk factor for several mental illnesses, especially anxiety and depression (9)(10) . Self-esteem is the basis for an individual's psychic construction. Liking yourself, feeling appreciation and valuing yourself is a condition associated with the development of mentally healthier young people and adults (11) .
A recent research has shown an association between self-esteem and self-efficacy (5, 12) , identified as essential emotional support for stress relief and the adoption of satisfactory coping measures in nurses and nursing students (12)(13)(14) .

Self-efficacy is a key construct of Bandura's Social
Cognitive Theory and can be defined as one's belief about one's own competence and ability to perform and organize tasks with desired effect (15) , being associated with social skills (16) , emotional intelligence (16) and learning processes in university students (17) .

Robust scientific evidence on interventions to
promote self-esteem in university students is scarce in the literature (6,18) , especially with the advent of the Internet and in the Brazilian context. In general, these studies guided their interventions in group and face-to-face sessions, using many strategies such as cognitive behavioral therapy (19)(20) , interpersonal relationship training (21) , positive self-esteem (22) and self-esteem education assertiveness (23) .
In addition, there is little clinical research on mental health promotion using Facebook as a social network within the Internet or another technological resource. In addition, we consider this social network a favorable and prosperous strategy for positive outcomes, as studies have shown that shy people with relationship problems, lonely or with low self-esteem consider it a comfortable place to connect with others (24) .
This study addresses these gaps in the literature, proposing to test the Nursing Interventions Classification (NIC) (25) , "Strengthening Self-Esteem", applied through the social network Facebook. The choice to work with the Internet was due to the students' lack of time to participate in person of the activities. Among the choice of online modalities, Facebook is a popular tool widely used by young adults, has reduced cost and accessibility at any time, and produces scientific evidence, with the possibility of expansion and practical implementation.
Moreover, a randomized clinical trial that used the Internet to promote the improvement of depression pointed to the need and importance of extending investigations with online therapeutic approaches to promote psychological well-being and resilience in adults (26) .
Considering the above, the objective of our study was to evaluate the impact of the "Strengthening Self-Esteem" intervention, proposed by NIC and conducted through Facebook, on self-esteem and self-efficacy levels among nursing students.  Figure 1 demonstrates the process of selection and sampling of participants.

Method
Three data collection tools were applied: Sociodemographic Characterization, Rosenberg Self-Esteem Scale (EAR) (11,27) and General and Perceived Self-Efficacy Scale (28) . The sociodemographic characterization consisted of personal, family and undergraduate course data.
EAR (11) is a four-point Likert type; 1 means "strongly agree" and 4 "strongly disagrees". It consists of 10 items that measure a single dimension: five that assess the individual's positive feelings about him/herself and five negative feelings (27) . The self-esteem measure is obtained by summing the values of the answers to Ribeiro RM, Bragiola JVB, Eid LP, Ribeiro RCHM, Sequeira CAC, Pompeo DA. the items and can vary from 10 to 40. The self-esteem is classified as high or satisfactory (greater than 30 points), average (from 20 to 30 points) and low or unsatisfactory (less than 20 points) (27) . This scale was validated for Portuguese in 2001 (27) , has high internal consistency values (Cronbach's alpha: 0.90) and has been one of the most widely used tools in the national and international literature to assess self-esteem (29) .

POPULATION (N=404): UNDERGRADUATE NURSING STUDENTS
140 students excluded because they did not meet the inclusion criteria: age under 18 years (n=3); no show on data collection days (n=58); did not have a Facebook profile (n=6); did not accept to participate in the survey (n=73) N=254 students -Intervention "Strenghtening Self-Esteem" (10 students were discontiued for not accepting the friend request on the Self-Esteem Strenghting Facebook Profile) N=74 students -Post-test (180 students were discontinued: report of non-access of at least 70% of the proposed interventions (n=138) and no show on post-test days (n=42)

N=264 students -Pre-test
Educational institution 1=148 Educational institution 2=256 The General and Perceived Self-Efficacy Scale (28) is Likert type, consisting of 10 items, with answers ranging from one to five. These items outline the achievement of goals and the individual's perception of a successful situation. The scale value ranges from 10 to 50. Higher score points to greater perception of self-efficacy.
The psychometric properties of the General and performed among university students (28) .
Data collection and intervention were carried out by researchers from February to June 2017. The intervention applied was the "Strengthening of Self-Esteem" (patient care to increase personal judgment of self-worth) (25) , using psychoeducation as a therapeutic strategy to promote higher levels of self-esteem, based This profile "Strengthening Self-Esteem" was created as a scenario for dissemination of the proposed nursing activities. Thus, after filling out the tools, the researchers searched the student profiles on Facebook and invited them to join the intervention group.
Then, on the scheduled date, the postings about the interventions began, through the "Strengthening Self-Esteem" profile on Facebook. The content of this therapy was organized into 10 sessions, held in 10 weeks (one approach per week). The number of sessions was established from other studies (20)(21) and the NIC nursing activities were allocated to specific themes, as shown in Figure 2.
By accessing Facebook, participants would see the content of the intervention, which was preceded by a sentence that motivated them to read, such as the following example: "We have reached our 4 th meeting! Certainly, some changes must have already taken place within you, as you have been reading and reflecting weekly on strengthening such important social skills as self-awareness, self-esteem, self-confidence and certainty. The results will appear! This week you will be the protagonist of your life! In intervention 4, we will encourage you to accept new challenges. Challenge yourself, you are able to win. Have a great reading." Then the students accessed the content of nursing activities.
These activities to strengthen self-esteem were offered in a text form, with positive messages, reflective texts and pictures, all supported by the persuasive resources of Bandura's theoretical framework (15) . As a way to influence students, the material provided  Figure 3 illustrates the data collection steps.

Demographic Characterization
Self-Esteem Scale

Post-test (3)
Self-Esteem Scale The t-test for paired samples was used to verify the differences between Rosenberg self-esteem and selfefficacy scores in the pre-and post-intervention periods.
Data followed normality and homogeneity, verified by the Anderson-Darling and Levene test, respectively.
A significance level of 5% or (p <0.05) was established.

Results
The results showed that most undergraduate

Self-knowledge and self-esteem
To encourage self-knowledge, identifying strengths and weaknesses, verbalizing positive self-affirmations, and monitoring feelings of self-negativity.

Overcoming self-criticism, guilt and insecurity
To assist in finding self-acceptance, avoiding criticism, and identifying the group's impact on their feelings of self-worth. To explore the reasons of self-criticism.
3. Self-confidence and self-esteem To assist in determining your self-confidence. Reinforce positive points and avoid criticism.

You as protagonist of your own life
To encourage greater responsibility for yourself. To assist in assessing own behavior and monitoring the lack of follow-up in achieving goals. To encourage accepting new challenges.

Goal Planning
To assist in setting realistic goals. Encourage assessing own behavior, accepting new challenges, and taking greater responsibility for themselves and their goals.
6. Little challenges To encourage acceptance of new challenges and recall successful experiences that increase autonomy.
7. See yourself in a good way To assist in reevaluating negative self-perception and self-acceptance. To teach the strategy of rewarding and complimenting progress towards the goals achieved. To encourage identification of strengths and locus of control.

Do something cool
To pass on confidence in the ability to handle situations. To encourage new challenges and avoid selfcriticism.

Avoid comparisons
To assist in overcoming bullying or teasing and assessing own behavior. To pass on confidence in the ability to handle situations.

Positive thinking is essential
To help identifying positive responses from others. Explore goals achieved and to pass on confidence in the ability to handle situations.
were significantly higher than pre-intervention scores.
This assumes that Facebook's "Strengthening Self-Esteem" intervention had a positive effect on the selfesteem and self-efficacy levels of the students evaluated in the study.

Discussion
Of the 264 participants in our study, 74 completed the intervention. When comparing our findings with the literature, we found that, in fact, there is greater adherence to face-to-face therapies (19)(20)(21)(22)(30)(31) and that most studies that tested interventions to improve mental health over the Internet presented significant losses during the process, ranging from 44.1% to 81.63% (32)(33)(34)(35) .
It is considered that the low adherence to as well as increased well-being (34) .
Scientific evidence points to the effectiveness of digital media interventions, but a caution is needed, as most of these researches have been conducted with adults, many with anxiety and depression. Therefore, the results cannot be generalized to a specific population, such as our research. Thus, we also sought to compare our findings with investigations that used other resources to promote self-esteem in nursing undergraduates.
Several studies using face-to-face intervention methods that were effective in improving psychic parameters, especially self-esteem, were identified in nursing students (19)(20)(21)(22)30) and university students from other courses (31) . This shows that different strategies can be used to promote mental health in young people with positive results.
One of these methods was cognitive behavioral therapy, applied with the objective of promoting improvement of students' self-esteem and self-efficacy levels (20) , stress, self-efficacy and coping strategies (19) and self-esteem and resilience (31) . The results were effective; However, this is a specific intervention by a qualified psychologist or physician.
In the field of nursing, face-to-face strategies such as positive psychotherapy, positive self-esteem promotion and interpersonal relationships program, selfesteem and depression were tested and obtained positive results in the mental health of nursing students (21)(22)30) . It is also noted that most interventions to promote mental health deal with anxiety and depression (21,(34)(35)(37)(38) . This fact may be related to the high prevalence of these diseases in the world population, with the prospect of elevation (39) , a condition that encourages scientific research.
The literature has solid and consistent evidence of the association of self-esteem with emotional variables, especially depression (9)(10) . There are several theoretical models that describe this relationship, however the most robust evidence falls on the vulnerability model, that is, low self-esteem contributes to depression (9) .
Our study did not assess anxiety and depression, however, theoretical research emphasized that selfesteem has a long-term impact on an individual's life.
In addition, the authors suggest that depression may be prevented or reduced by interventions that strengthen self-esteem (9) , data that increase the relevance of programs to strengthen this construct.
The satisfactory results achieved in this research can be explained by man's ability to intentionally intervene in his environment. People not only react to the external environment, but have the ability to reflect on it in order to glimpse and choose action that they find most convenient or necessary (15) . These psychoemotional interventions can offer individuals favoring environmental conditions, as well as promote personal judgment of capacity, use cognitive and metacognitive and self-reinforcing strategies (15) .
Face-to-face therapeutic proposals represent the majority of studies; however, resources from the Internet have been promising and effective opportunities for psychosocial interventions, either in the treatment and/ or prevention of mental health conditions (33,(35)(36) .
A study using the Web to reduce depression in adults showed that, overall, participants reported a high level of confidence in online intervention to improve a person's understanding of depression. However, reliability that a website could help people learn skills to prevent depression was lower (36) .
A recent research on an intervention based entirely on cognitive behavioral theory called myCompass aimed at the improvement of depression, anxiety and stress revealed that most users found the interactive elements of the program useful, especially the tasks to be developed. and self-monitoring of their progress (33) .

Conclusion
We conclude that the "Self-Esteem Strengthening" intervention, proposed by the NIC and applied through Facebook, was effective in raising the self-esteem and self-efficacy levels of undergraduate nursing students.
Interventions such as these provide expanded access to information and can help build mentally healthier individuals.
We expect that, with the advent of new technologies, higher education schools in nursing can establish guidelines and implement actions that promote the mental health and well-being of their students.