“Falsehood flies, and the truth comes limping after it”: social media and public health

Abstract

Purpose of review

To highlight the various uses of social media by public health practitioners and organizations, with special emphasis on how social media has been successfully applied and where applications have struggled to achieve the desired effects.

Recent findings

Social media has been used effectively in improving the timeliness and accuracy of public health surveillance. Social media has also been used to communicate information between public health organizations and reinforce consistent messaging about enduring threats to public health. It has been applied with some success to coordinate of disaster response and for keeping the public informed during other emergency situations. However, social media has also been weaponized against the public health community to spread disinformation and misinformation, and the public health community has yet to devise a successful strategy to mitigate this destructive use of social media.

Summary

Social media can be an effective tool for public health practitioners and organizations who seek to disseminate information on a daily basis, rapidly convey information in emergent situations, and battle misinformation. Social media has been uniquely valuable and distinctly destructive when it comes to protecting and improving public health.

Introduction

When Jonathan Swift wrote [1], “falsehood flies, and the truth comes limping after it,” in 1710 he could easily have been describing the state of social media use for public health in 2021. The spread of misinformation is a major threat to public health with social media being a uniquely useful tool to speed up and amplify this spread. Fortunately, there are also examples of social media improving public health in uniquely efficient and effective ways and there is an emerging literature on effective ways to combat misinformation.

Among the factors that make social media important to public health is its widespread use. Facebook alone had over 2.7 billion users globally as of 2020 [2] with estimates of over 4 billion users for all social media platforms in early 2021 [3]. By 2019, 72% of U.S. adults were using at least one social media site [4]. The widespread use of social media, however, presents a double-edged sword for public health. In this review, we explore how social media can be leveraged to effectively improve human health and ways it is currently a threat to public health, with suggestions for future research and practice.

Current uses of social media for public health

There is enormous potential to improve human health using social media for conducting surveillance to efficiently identify and address public health problems [5], communicating public health information in widespread public health campaigns [6] and targeted health interventions [7], and effective crisis and risk communication during public health emergencies [8*,9]. However, social media has also been uniquely effective at spreading misinformation which worsens human health.

Surveillance

A promising area for social media to promote health is in improving the timeliness and accuracy of public health surveillance. Traditional methods of identifying public health threats can be costly and slow [10,11]. Evidence demonstrates that social media can address both these problems by identifying infectious disease outbreaks in real-time [12], allowing public health officials to take swift action to control the spread. A 2014 study adding Twitter data to forecasting of influenza-like illness in the U.S. improved the accuracy of prediction by reducing modeling error 17–30% and improved the speed of prediction by two to four weeks [13]. Similarly, using Twitter and HealthMap to aid in assessing a cholera outbreak in Haiti reduced the time to accurately assess the outbreak by two weeks [14].

Infectious disease outbreak detection is not the only place where social media can speed up surveillance efforts. Health departments have used social media to identify potential food safety concerns in real-time by monitoring Twitter and following up with Twitter users who post about their foodborne illness symptoms [15]. On study found that Twitter users who tweeted about foodborne illness symptoms and then filled out a form about recent meals allowed inspectors to identify more serious food safety violations compared to regularly scheduled inspections [5].

Unfortunately, there are challenges integrating data from social media into underfunded public health systems [16]. A 2014 study of 13 event-based surveillance systems including several using social media data sources found that none were being used in national surveillance programs [10]. Another review suggested that, while pairing traditional surveillance methods with social media and crowdsourcing could provide improved data integration and validation [17*], this pairing may also bring challenging ethical considerations to public health surveillance.

Communicating public health information

In addition to improving surveillance, social media can support effective communication between public health professionals, organizations, and the general public. Prior research has shown that social media has been used for sharing and increasing accessibility of health information, facilitating dialogue around health topics, health promotion or education, and intervention delivery [18] and can promote increases in knowledge, positive health behaviors, and social capital [7,19–22], but content matters. A 2015 study of tweets about diabetes found that tweets about health problems were positively associated with engagement, but tweets about nonmedical resources, diabetes statistics, and diabetes related jokes or sarcasm were negatively associated with engagement [23]. In another example, a study of Facebook fan pages about autism spectrum disorders found positive emotions were expressed more often than negative emotions in posts and comments [24]. Autism-related posts with more emotional words resulted in emotional reactions to the post. There was more overall engagement with autism-related posts for organizations with more followers, posts containing audiovisual content, and posts with emotional language had more engagement overall. Another study found that a skin cancer social media campaign had different types of engagement with skin cancer messages with shocking content (most views), humorous content (most overall engagement via clicks, likes, comments, shares, or retweets), and informative messages (most retweets) [25].

A systematic review of 24 publications about social media use by governmental public health organizations across six countries found that social media was mostly used to communicate with citizens with a focus on transparency and accountability [26]. In the U.S. 60% of state health departments had at least one social media page by 2012 [27], although the accounts had little public interaction. Local health departments representing larger populations, those in western states, and those employing a public information specialist were more likely to adopt [28] and use [29] social media but, like state health departments, had little engagement with individuals [30]. One possible reason for the limited interaction was lack of relevance of social media posts to local residents. For example, U.S. public health organization tweets about Ebola were not associated with geographic distribution of Ebola cases [31] and frequency of the U.S. Centers for Disease Control and Prevention (CDC) tweets about Zika were negatively associated with actual Zika prevalence [32]. Another reason is that the followership of local governmental public health, at least in the U.S., tends to be other organizations rather than individuals [30].

Evidence suggests that social media is also a useful tool for keeping the public informed during storms, fires, terrorist attacks, and other emergency situations [33–35*]. A survey in Germany found that nearly half of people have used social media during an emergency to share or find information and think it is a faster channel that is particularly useful for spreading information [34]. Likewise, an examination of Twitter use for emergency management in the UK during two emergency events, weather and riots, demonstrated effective spread of information from officials to the public [36]. A study of social media for communication during Hurricane Sandy in the U.S. found that accounts posting relevant news and updates gained followers [8*].

Social media can also make it easier to spread messages challenging public health policy. After the adoption of a new e-cigarette policy in Chicago, the local health department found themselves to be a target of a Twitter bombing by e-cigarette advocates [24]. Most of the tweets (89.2%) were anti-policy with many (58.8%) focusing on the safety of e-cigarettes vs. traditional cigarettes. A large proportion of the tweets (36.8%) accused the health department of lying/propaganda, potentially eroding trust in local public health officials. A small percent (14.1%) of the Twitter users involved in the Twitter bombing were considered “astroturfers” or fake grass-roots accounts.

These findings are especially important, given there has been little guidance available to public health organizations seeking to develop, grow, and maintain their social media presence [37*,38*] despite evidence that social media is a simple and low-cost tool to inform people about health topics, communicate during emergencies, and drive traffic to public health intervention sites [39].

Public health misinformation and disinformation

A 2019 systematic review of health-related misinformation found increasing numbers of studies on the role of social media in the proliferation of misinformation with infectious disease being the most common topic of misinformation research [40*]. Pagoto and friends [38*] found that social media misinformation spans numerous public health topics including vaccines, antibiotics, cancer, electronic cigarettes, eating disorders, and nutrition. This was likely no surprise to Waszak, Kasprzycka-Waszak, and Kubanek [41], who found that 40% of the links about medical topics most frequently shared on Polish language social media led to “fake news.” A recent systematic review found Twitter had the most misinformation of the platforms and that drugs, smoking products, and vaccines were the topics most prone to misinformation [42*]. The misinformation on social media was often started by people but spread by automated twitter accounts known as bots. Bots on social media often spread anti-vaccination messages by pretending to be regular users who create false equivalency anti-vaccine messaging [43]. The anti-vaccination rhetoric increased following the election of President Trump who supported vaccine skeptics and made appointments of high-profile people believing in vaccines-autism link [44]. Trump’s stances were reinforced on Twitter where anti-vax tweets were tagging the Trump Twitter account and mentioning his anti-vax policy stances.

Misleading information on social media is a threat to public health because it tends to attract more engagement than credible information. For example, during the Zika pandemic, 81% of social media posts contained useful or credible news information about Zika, with most of these coming from news agencies. However, 12% of Zika-related posts contained misleading information and the most popular misleading post was viewed 10x more than most popular factual post [45]. Likewise, anti- and pro- vaccine Facebook pages attract about the same number of users, but anti-vax Facebook pages have more engagement with five times as many posts per week by the page authors and 33 times as many posts per week by page members compared to pages with a pro-vaccine or neutral stance [46]. Similarly, a study of tweets containing “yellow fever” and “treatment” or “cure” after outbreaks of yellow fever in several countries in 2015–2016 found 61.3% of the tweets contained misleading content [47]. A study of Twitter use during the Ebola pandemic found that 55.5% of tweets about Ebola contained medical misinformation and tweets with misinformation had wider reach than those with correct information [48]. This spread of misinformation online has real-life consequences for human health. Dunn and friends [49] found that misleading information about the Human Papilloma Virus (HPV) vaccine on Twitter was correlated with lower vaccine coverage in the U.S. A prescient article by Larson [50] described the anti-vaccine misinformation spreading on social media as a major global health threat with targeted strategies necessary to combat misinformation.

Indeed, misinformation spread via social media has been a major factor during the COVID-19 pandemic, with one study finding that 42.2% of tweets about COVID-19 contained misinformation or unverifiable information [51*] and another finding a daily average of 46,000 misleading Twitter posts in Italy [52]. Misleading information about COVID-19 has consequences. Allington and colleagues [53] found a negative relationship between social media use and adoption of COVID-19 protective behaviors and a positive relationship between social media use and COVID-19 conspiracy beliefs [53]. Of 117 videos reviewed on TikTok, 14.5% were by the WHO, 14.5% discussed anxiety, 10.5% discussed quarantine, less than 10% shared information about covid symptoms, transmission, or prevention, and 4.3% shared misinformation [54*]. Lack of adoption of protective behaviors is not the only result of misinformation spread on social media. An examination of infodemics, or epidemics of bad information, during COVID-19 found 89% of posts were rumors, 7.8% were conspiracy theories, and 3.5% were stigma [55]. The rumors ranged from relatively harmless, like stop eating spicy food, to deadly like a rumor about drinking methanol to kill COVID-19 resulting in hundreds of poisoning deaths in Iran [56].

How has social media use by the public health community proven effective or ineffective?

As presented earlier, social media has been used with some success for surveillance, communication and knowledge translation, and mobilizing and informing the public in emergent situations. Clearly, the literature is inconclusive in these areas, but the data suggest potential for social media as a tool for public health. Social media has, so far, been largely ineffective in combating misinformation and disinformation. One of the challenges in addressing misinformation on social media is the lack of detail on the circumstances supporting spread of misinformation [38*]. In addition to knowing where misinformation is likely to arise, there is the question of how to respond. Bode and Vraga [57] compared an algorithm that posts correction stories following a Zika story that featured misinformation on a Facebook timeline with people posting the same correction stories as commenters on the misinformation. They found that the two strategies were equally good at combatting misinformation and recommended refuting misinformation with clear, simple, evidence-based information from appropriate sources [57]. Another study found that people who received factual elaboration about the misinformation were more likely to take preventive actions compared to those who received just a simple rebuttal [58*]. Another study found that the source of information is important in debunking, with government health agencies and news media more successful than peers at debunking misinformation [58*]. Sharing positive or accurate health information could combat the spread of misinformation [42*]. Public health can learn from successful social media campaigns: use simple and familiar language to encourage participation and collect data; build online communities by accessing existing networks, develop engaging content, actively drive traffic, make people feel like part of a community, and expect to spend time creating a social media presence [59]. As stated by Naeem, Bhatti, and Khan, the public health community should ensure that accurate information is disseminated [52].

What are the future opportunities to utilize social media by the public health community?

A glass half full perspective would contend that opportunities abound for research and practice regarding the utilization of social media by public health professionals. Very little is known regarding effective strategies for mobilizing this pervasive technology for the public good, which presents a plethora of opportunities for research. A more pessimistic perspective might assert that social media represents a Pandora’s Box of blights, as social media’s ability to spread misinformation and disinformation is difficult to challenge. Regardless of one’s perspective, there are opportunities for research to be explored. A recent article by Pagoto et. al [38*] outlines future opportunities and challenges for research in the use of social media by the public health community. As presented by the authors, public health needs a social media agenda that answers three questions: “(1) How much social media use is unhealthy and what individual and contextual factors shape that relationship; (2) What are ways social media can be used to improve physical and mental well-being; and (3) How does health (mis)information spread, how does it shape attitudes, beliefs and behavior, and what policies or public health strategies are effective in disseminating legitimate health information while curbing the spread of health misinformation?” [38*]. While social media has potential for health promotion, more research is needed to evaluate effectiveness of social media interventions [60].

Conclusion

Social media is a relatively recent medium, and research in its effectiveness to advance the goals of public health is still in its infancy. Social media can be an effective tool for public health practitioners who seek to disseminate information on a daily basis, rapidly convey information in emergent situations, and battle misinformation. Social media has been uniquely valuable and distinctly destructive when it comes to protecting and improving public health.

Key Points.

• Social media can be an effective way to establish communication channels between public health professionals, organizations, and the general public, but establishing these channels can be difficult to establish and maintain within the resource constraints faced by professionals and organizations.

• Social media shows promise as a tool for public health surveillance.

• The response by health professionals is no proportionate to the threat posed by mis- and dis-information and existing efforts are largely ineffective.