Parent Support for Social Media Standards Combatting Vaccine Misinformation

Abstract

We sought to assess parental support for varying standards that social media sites can employ to combat vaccine misinformation. Between July-August 2019, we conducted a web-based survey with a national sample of 1,073 parents of adolescents and who use social media. The survey assessed support for ten standards about vaccine misinformation. Multivariable logistic regression assessed correlates of support. Overall, 61% of parents supported at least one standard. Support for each standard varied greatly (12%−51%), with higher support for less restrictive standards. Parents more often supported standards if their child had already initiated human papillomavirus (HPV) vaccination, if they were non-Hispanic black or Hispanic, if they agreed that vaccine misinformation is harmful, or if they saw information on social media in favor of HPV vaccine (all p<.05). Our findings suggest favorable support for standards that social media sites can implement to combat vaccine misinformation.

1. INTRODUCTION

Parental vaccine hesitancy reflects concerns about the decision to vaccinate one’s children and manifests on a continuum of decisions, ranging from a cautious acceptance of vaccines to delay of vaccines according to some alternative schedule to refusal of some or all vaccines (1). Of concern, a growing number of U.S. parents are refusing vaccination for their children due to concerns about adverse events (2, 3), even though safety misconceptions have been debunked by strong scientific data (4). Vaccine misinformation posted on social media contributes to these negative opinions and deters guideline-concordant vaccination (5, 6). For example, Margolis et al. reported that parents who heard harmful stories about human papillomavirus (HPV) vaccine, especially on social media, were less likely to initiate vaccination compared to those who did not hear any stories (7).

A range of pro-vaccination marketing and educational campaigns have been launched to counteract vaccine misinformation on social media, including efforts to use the same social media sites where misinformation proliferates; however, they have not succeeded in increasing vaccine uptake (8, 9). Unfortunately, parents who are exposed to both positive and negative stories about vaccines are as likely to decline vaccination as those who only see negative stories (7). A potential approach that social media sites can put in place to limit vaccine misinformation posted to their sites is through the implementation of standards (users’ policies or guidelines that regulate vaccine content). The American Academy of Pediatrics (AAP) (10) and the World Health Organization (WHO) (11) are urging social media sites to join in combatting vaccine misinformation by implementing such standards. In the United States, for example, Twitter prompts users to reliable information from the U.S. Department of Health and Human Services when anyone searchers for vaccine-related content (12), and YouTube demonetized anti-vaccine channels by removing ads from their videos (13).

Level of support among the general public for social media standards for vaccine information is unknown, including among parents of vaccine-eligible adolescents. This group of parents deserves special attention because adolescent vaccines, particularly HPV vaccine, are common targets for misinformation on social media sites (14), potentially putting many of today’s U.S. adolescents at unnecessary risk of vaccine-preventable diseases including HPV-related cancers. Further, the standards social media sites could put in place vary along a spectrum of least to most restrictive, and it is likely that different levels of restriction yield different levels of support from social media users. Understanding acceptable social media standards can help guide social media sites on this public health issue. The aims of our study were to 1) assess parents’ support for varying social media standards to combat vaccine misinformation and 2) identify correlates of overall parental support for such standards.

2. METHODS

2.1. Participants and Procedures

Participants were members of an existing market research panel of U.S. adults maintained by Qualtrics, a commercial software and survey research company. The panel was constructed from suppliers with a diverse set of recruitment methodologies, so the overall sampling frame is not overly reliant or dependent on any particular demographic group (15). Survey invitations were emailed to a random sample of 11,000 panel members, and 6,470 responded by visiting the survey and completing the eligibility screener. Eligible participants were parents of at least one 11- to 17-year-old child living primarily in their household. A total of 1,109 parents were eligible, provided informed consent, and completed the survey between July and August 2019. After accounting for ineligible panel members (n=5,270) and excluding respondents who failed to complete at least two-thirds of the survey (n=91), the survey response rate was 58%, calculated using American Association for Public Opinion Research Response Rate 5 (16). The survey was programmed to stop recruiting when it reached 1,200 enrolled participants (both complete and partial surveys). The survey instructed participants with more than one eligible child to respond with regard to the child with the most recent birthday. For this analysis, we excluded 36 parents who reported not using social media, to produce our final sample of 1,073 parents. The present study was part of a larger survey research project on vaccine communication with a focus on HPV vaccination. The Penn State College of Medicine Institutional Review Board approved the study protocol.

2.2. Measures

The questionnaire introduced respondents to social media standards with the prompt, “Some social media platforms are now proposing standards to monitor anti-vaccine content.” It then assessed parents’ support for social media standards with one item, “What social media standards to monitor anti-vaccine information would you support?” Ten response options were provided, each with a varying level of control over vaccine misinformation (Figure 1). We developed these item responses by assessing current standards outlined by social media sites’ user guidelines (12, 17, 18) and public health and medical organizations’ recommendations to sites (10, 11). Social media standards assessed in the study ranged from “assessing anti-vaccine information before it is posted” to “disabling user or group accounts promoting anti-vaccine information,” as well as an option for “no standards should be used.” Parents could check multiple options except when choosing “no standards.” We created the dichotomous outcome variable of support as follows: parents who checked one or more standards were coded as “support” (1) and those who checked “no standards” were coded as “no support” (0).

Fig. 1.

Social media standards response options.

The questionnaire also asked parents to rate their level of agreement on a five-point scale (ranging from “strongly disagree” to “strongly agree”) with the following statement about perceived harm of vaccine misinformation: “Anti-vaccine information posted on social media is harmful.” Parents were also asked how much they agree or disagree (five-point scale) with seven statements regarding vaccine conspiracy beliefs, including vaccine data fabrication, industry and government cover ups, and deception practices (19). We created a vaccine conspiracy score by calculating their mean response values and creating two categories: low (<4) and high (4−5). The questionnaire also assessed exposure to vaccine information on social media with the item: “Have you seen information about the HPV vaccine on social media even when you were not looking for it?” For parents who answered yes, the questionnaire asked whether the information they saw was “completely in favor of the vaccine,” “mostly in favor,” “mostly against,” “completely against” or “a mix of both.” We then created a four-level categorical variable of exposure that captured whether parents had seen: 1) information in favor of HPV vaccine only (“completely” or “mostly”); 2) information against HPV vaccine only (“completely” or “mostly”); 3) both in favor and against; or 4) neither (parents who answered no).

Sociodemographic variables included parents’ sex, race/ethnicity, educational attainment, annual household income, and state of residence (categorized in four U.S. regions). The survey also assessed the sex, age, and HPV vaccination status (dichotomized as “≥1 doses” or “0 doses”) of the index child. Content and face validity were established for the survey instrument by having it reviewed by four researchers experienced in survey research and vaccine communication studies. We did not pilot test the survey with the sample population.

2.3. Data Analysis

Descriptive statistics characterize level of support for each of the ten social media standards. We used bivariate logistic regression to identify variables associated with parents’ support for standards using the dichotomous outcome variable of support. We then entered statistically-significant covariates into a multivariable logistic regression model. Statistical tests were two-tailed with a critical α of 0.05. We calculated odds ratios (OR) and 95% confidence intervals (CI). Analyses were conducted using Stata version 13.1.

3. RESULTS

3.1. Participant Characteristics

Parents were evenly split between reporting on a daughter (51%) or a son (49%) (Table 1). The average child age was 14 years (standard deviation, 1.9 years) and most had received at least one dose of HPV vaccine (61%). The majority of parents were female (75%) and non-Hispanic white (71%), with approximately nationally-representative numbers of minority participants (e.g., non-Hispanic blacks=12%; Hispanics=11%). More than one-fifth (23%) of parents had a high school degree or less education, and almost one-third (30%) reported an annual household income of $40,000 or less. Parents reported from all regions of the United States.

Table 1.

Sample characteristics (n=1,073)

	N	(%)
Child characteristics
Female	547	(51)
Age, years
11–14	642	(60)
15–17	431	(40)
HPV vaccine doses received
0 doses	414	(39)
≥1 doses	659	(61)
Parent and household characteristics
Female	809	(75)
Race/Ethnicity
Non-Hispanic White	764	(71)
Non-Hispanic Black	130	(12)
Hispanic	121	(11)
Other	58	(5)
Education
High school degree or less	243	(23)
Some college	444	(41)
College degree or higher	386	(36)
Household Income
<$40,000	327	(30)
$40,000 – $79,999	348	(32)
≥$80,000	363	(34)
Not reported	35	(3)
Region
Northeast	147	(14)
Midwest	214	(20)
South	327	(30)
West	385	(36)
Vaccine conspiracy beliefs score, mean (SD)	2.84	(1.03)

3.2. Support for Social Media Standards

Overall, 61% of parents support social media standards (Table 2). Support for individual standards varied greatly. Support was highest for less restrictive standards, such as assessing anti-vaccine information (51%), making information less common on newsfeeds (32%), and moving pages with misinformation down on search results (26%) (Figure 2). Conversely, support was lower for more restrictive standards, including barring searches for anti-vaccine information (12%), disabling anti-vaccine users or groups (16%), and restricting use of anti-vaccine hashtags (18%).

Table 2.

Correlates of parents’ support for social media standards to combat vaccine misinformation (n=1,073)

	# of parents who supported social media standards/Total in category (%)	Bivariate OR (95% CI)	Multivariable OR (95% CI)
Overall	650/1,073 (61)	NA	NA
Child characteristics
Sex
Male	325/526 (62)	Ref	-
Female	325/547 (59)	0.91 (0.71, 1.16)	-
Age, years
11–14	398/642 (62)	Ref	-
15–17	252/431 (58)	0.86 (0.67, 1.11)	-
HPV vaccine doses received
0 doses	218/414 (53)	Ref	Ref
≥1 doses	432/659 (66)	1.71 (1.33, 2.20)**	1.50 (1.14, 1.96)**
Parent and household characteristics
Sex
Male	170/264 (64)	Ref	-
Female	480/809 (59)	0.81 (0.60, 1.08)	-
Race/Ethnicity
Non-Hispanic White	432/764 (57)	Ref	Ref
Non-Hispanic Black	94/130 (72)	2.01 (1.33, 3.02)**	2.76 (1.79, 4.28)**
Hispanic	85/121 (70)	1.81 (1.20, 2.75)**	2.05 (1.32, 3.19)**
Other	39/58 (67)	1.58 (0.90, 2.78)	1.55 (0.85, 2.82)
Education
High school degree or less	141/243 (58)	Ref	-
Some college	270/444 (61)	1.12 (0.82, 1.54)	-
College degree or higher	239/386 (62)	1.18 (0.85, 1.63)
Income
<$40,000	194/327 (59)	Ref	-
$40,000 – $79,999	203/348 (58)	0.96 (0.71, 1.30)	-
≥$80,000	236/363 (65)	1.27 (0.94, 1.73)	-
Not reported	17/35 (49)	0.65 (0.32, 1.30)
Region
Northeast	93/147 (63)	Ref	-
Midwest	130/214 (61)	0.90 (0.58, 1.39)	-
South	195/327 (60)	0.86 (0.57, 1.28)	-
West	232/385 (60)	0.88 (0.59, 1.30)	-
Vaccine attitudes
Vaccine conspiracy beliefs score
Low (<4)	561/904 (62)	Ref	Ref
High (4–5)	89/169 (53)	0.68 (0.49, 0.95)*	0.78 (0.54, 1.13)
Vaccine misinformation posted on social media is harmful
Disagree/neither	300/615 (49)	Ref	Ref
Agree	350/458 (76)	3.40 (2.60, 4.45)**	3.57 (2.70, 4.73)**
HPV vaccine information seen on social media
Neither	396/678 (58)	Ref	Ref
In favor only	159/217 (73)	1.95 (1.39, 2.74)**	1.82 (1.28, 2.61)**
Against only	28/52 (54)	0.83 (0.47, 1.46)	0.93 (0.51, 1.72)
Both in favor and against	67/126 (53)	0.81 (0.55, 1.18)	0.84 (0.56, 1.26)

NOTE. HPV = Human papillomavirus; OR = Odds ratio; CI = confidence interval; Ref = Referent group; NA = Not applicable. Dashes (−) indicate the variable was not included in the multivariable model because it was not statistically significant in bivariate analysis.

^*p<.05;

^**p<.01

Fig. 2.

Parents’ support for individual social media standards (n = 650).

3.3. Correlates

In multivariable analysis, parents more often supported standards if their child had already initiated HPV vaccination (OR=1.50, 95% CI:1.14, 1.96) (Table 2). Non-Hispanic black (OR=2.76, 95% CI:1.79, 4.28) and Hispanic (OR=2.05, 95% CI:1.32, 3.19) parents were more likely to support standards compared to non-Hispanic whites. Also, parents who agreed that vaccine misinformation posted on social media is harmful (OR=3.57, 95% CI:2.70, 4.73) and those who reported seeing information on social media in favor of HPV vaccine (OR=1.82, 95% CI:1.28, 2.61) were more likely to support standards. In bivariate but not multivariate analyses, vaccine conspiracy beliefs score was inversely associated (p<.05) with support for social media standards, meaning those who scored high for vaccine conspiracy beliefs were less likely to support standards.

4. DISCUSSION

This study fills an important gap in the literature in understanding parental support for standards that social media sites can employ to address vaccine misinformation. We found a majority of parents (61%) support the implementation of at least one standard, aligning with the urgent call public health and medical organizations have made to combat vaccine misinformation on social media (9, 10). Stopping the spread of vaccine misinformation is becoming more relevant than ever as the COVID-19 pandemic has also propelled a “misinformation pandemic” (20).

We identified wide variability in support for each of the standards, ranging from 12% to 51%. Overall, the least restrictive standards had the most support, while more restrictive standards had the least support. Social media sites are already implementing many of these standards, for example, Pinterest is barring searches for anti-vaccine information (17), a standard that gained less support in our study (12%). On the other hand, Facebook’s standards include not recommending anti-vaccine pages or content (18) and, more recently, removing posts with misinformation (21); these two standards had 38% and 32% support, respectively. Consistent with our finding that 51% of participants supported social media sites to assess vaccine information before it is posted, a recent study conducted with a nationally-representative sample of U.S. adults found that 54% of respondents agreed that social media sites should fact check social media posts (22). It is possible that most people agreed with this type of standard because it is more passive compared with others that involve actions to move down, restrict access to, or delete content posted online. However, simply assessing and flagging vaccine misinformation seem insufficient because many users will still engaging with and trusting that content even if it is labelled as inappropriate (23).

We also found that non-Hispanic black and Hispanic parents were more likely to support social media standards compared to non-Hispanic whites. This finding is important because a recent Pew Research Center survey found that Blacks and Hispanics see lower health benefits and higher risk of side effects from childhood vaccines (24), so minimizing their exposure to anti-vaccine messaging would be important for vaccine promotion efforts. We also found that parents who vaccinated their child against HPV expressed high levels of support for standards. It is possible that vaccine-compliant parents have overall positive attitudes toward vaccination, thereby contributing to their support of standards against vaccine misinformation. In addition, we found that exposure to information in favor of HPV vaccination on social media was positively associated with reporting support for standards. Our finding can be explained by the “echo chamber” phenomenon, in which people select for social networks and information that aligns with their own vaccine views, a common practice on social media (25). Parents may be seeing social media content in favor of HPV vaccination because they generally accept vaccines, making them more likely to support standards regulating anti-vaccine information. Interestingly, another study with U.S. parents of adolescents reported that exposure to stories about vaccination harms may be more strongly associated with HPV vaccination non-adherence than positive stories about HPV vaccine preventable diseases (7). The latter study asked parents about stories in social media, traditional media, and conversations while our study asked about stories in social media only. More research is needed to continue exploring how social media information about vaccines, especially misinformation, influences overall parental vaccination attitudes (e.g., support for standards) and behaviors.

There are considerable challenges to implement social media standards. First, demand from the public and organizations is needed to encourage social media companies to ramp up standards against vaccine misinformation. For example, when large companies pulled millions of dollars in advertising from Facebook demanding that the platform monitored hate speech more aggressively, Facebook acted accordingly (26). The campaign, #StopHateForProfit, was led by a coalition of civil rights activists and other advocacy groups. Similarly, social media sites have implemented a range of standards after the AAP and WHO called them to combat vaccine misinformation. Defining vaccine misinformation and applying standards equally to all users and content are also persistent challenges faced by social media sites. For example, Facebook uses a combination of users’ feedback and third-party fact-checkers to identify potential health misinformation including vaccination (27). Fact-checkers then rate content as false, altered, partly false, or missing context, and apply standards based on these ratings. YouTube uses a combination of people and machine learning to “detect problematic content at scale.” (28) Despite these strict processes, the Centre for Countering Digital Hate (29) have found that 95% of posts containing vaccine misinformation were not acted on by social media sites after the Centre notified companies about the issue. The Centre also noted that the 147 most popular anti-vaccine accounts in social media had gained at least 7.8 million followers from 2019 to 2020, an increase of 19% from last year. In addition to implementation challenges, “de-platforming” or limiting posted content deemed vaccine misinformation raises concern about censorship (23). However, U.S. social media sites can restrict online content without violating the right of free speech because they are not government entities. Future research should explore how to meet these challenges to ensure the successful implementation of standards, as well as how anti-vaccine advocates adjust their communication tactics (e.g., migrating to social media platforms with less restrictions, modifying wording to go undetected as misinformation) in response to different social media standards.

4.1. Strengths and Limitations

Study strengths include using a large, national sample of parents and having an adequate response rate. This study had several limitations. Our covariates regarding vaccine uptake and exposure to vaccine information on social media were limited to HPV vaccine; the degree to which these relationships may generalize to other vaccines is unknown. Also, we provided participants a list of standards but experiencing them on social media sites (e.g., seeing banners promoting public health websites, interacting with content flagged as misinformation) may produce varying levels of support. Studies exploring how social media users react to these standards in real-world scenarios are needed. We asked standards that can apply to any of the most commonly used social media sites but some of these standards are more relevant to particular sites based on their main functionalities (e.g., social networking, microblogging, social blogging, video sharing, photo sharing) so this may have impacted participants’ responses. Also, we did not provide further definitions or explanations on how sites implement standards, so those participants unfamiliar with the standards assessed in the study could have had varying interpretations of them. Finally, although our study focused on parents of adolescents, we acknowledge that levels of support may differ for other social media user groups (e.g., parents of young children, adults in general). The generalizability of our study findings to other groups remains to be established.

4.2. Conclusion

Since major medical and public health organizations urged social media platforms to combat vaccine misinformation, many of these companies have been working diligently on that direction. Our study found high levels of parental support for these standards, which suggests that it is important and acceptable for social media platforms to continue to implement mechanisms for limiting the spread of vaccine misinformation.