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Aim Using an integrated model of health literacy, we discuss the importance of health literacy among foreign domestic workers in the provision of informal caregiving during outbreaks of communicable diseases. COVID-19 pandemic is used as an example. Background Adequate health literacy in the population is known to be important for the prevention of communicable diseases. Foreign domestic workers, a group of marginalized caregivers in private households, are generally presumed to have limited health literacy because of numerous socio-cultural disadvantages. To date, there is limited evidence that these informal health care providers receive support from community-based nurses. Design A discursive paper. Conclusion Foreign domestic workers, with varying levels of health literacy, may be viewed either as a resource to break the chain of infection or as a potential reservoir of communicable diseases in the community. Meanwhile, restrictions imposed in response to diseases transmissions (e.g., stay-at-home measures for COVID-19) may directly exacerbate the social support received by these foreign domestic works and their ability to access health-related information. There are also concerns about their ability to appraise and evaluate information related to communicable diseases at a time when fake news and misinformation is being disseminated through social media. Language and cultural barriers are important issues that need to be addressed to ensure that foreign domestic workers are in a position to follow public health recommendations. Relevance to clinical practice Nurses hold an important position in empowering foreign domestic workers with adequate health literacy, by engaging groups of foreign domestic workers in the community and their consulates in planning educational programmes and effectively disseminating information. At a time of global pandemic, an assessment of the health literacy levels of foreign domestic workers in places like Hong Kong is urgently required.

Material hardship and stress, associated with poor infant outcomes, increased during the Coronavirus Disease 2019 pandemic. Chinese American families were vulnerable to racism-driven disparities. Little is known about maternal perceptions of pandemic impacts on their infants, family, and community. Purposive sampling of low-income Chinese American mothers (n = 25) with infants (1-15 months). Semi-structured qualitative interviews conducted in Mandarin, Cantonese, or English were audio-recorded, transcribed, and translated. Transcripts coded using applied thematic analysis in an iterative process of textual analysis until thematic saturation. Three themes emerged: (1) Heightened family hardship included financial strain, disruption of transnational childcare, experiences of racism; (2) Altered infant routines/developmental consequences included using protective equipment on infants, concerns about infant socio-emotional development; (3) Coping strategies included stockpiling essentials, adapting family diets. Strategies to mitigate disparities include expanding social needs screening, correcting misinformation, strengthening support networks, and including low-income Chinese Americans in these efforts.

Controversies surrounding the handling of corpses have been amplified during the present COVID-19 pandemic. According to Indonesian scholars, certain perspectives driving these controversies inhibit the implementation of health protocols issued by the government. This study comprehensively explores the diverse perceptions and responses of religious leaders regarding COVID-19 funeral management. Participants comprised six scholars from major Islamic religious organizations, two community leaders, and two families representing COVID-19 patients. Furthermore, content analysis was used to analyze the data. The results showed that the religious leaders, all men aged over 50 years, supported the health directives designed to reduce high transmission risk. However, there were substantial disparities in corpse preparation processes, potentially due to organizational beliefs around burial rites. Some religious leaders aligned their protocols with their religious beliefs. Conversely, families of the deceased insisted that the approved protocol for handling corpses went against their religious and cultural values. Therefore, promotion of protocols and coordination among the government, religious leaders, and the community are needed to decrease the misperceptions and misinformation surrounding the new COVID-19 funeral protocols.

Background Human papillomavirus (HPV) vaccination rates among adolescents are increasing in Minnesota (MN) but remain below the Healthy People 2020 goal of 80% completion of the series. The goal of this study was to identify messaging and interventions impacting HPV vaccine uptake in MN through interviews with clinicians and key stakeholders. Methods We conducted semi-structured key participant interviews with providers and stakeholders involved in HPV vaccination efforts in MN between 2018 and 2019. Provider interview questions focused on messaging around the HPV vaccine and clinic-based strategies to impact HPV vaccine uptake. Stakeholder interview questions focused on barriers and facilitators at the organizational or state level, as well as initiatives and collaborations to increase HPV vaccination. Responses to interviews were recorded and transcribed. Thematic content analysis was used to identify themes from interviews. Results 14 clinicians and 13 stakeholders were interviewed. Identified themes were grouped into 2 major categories that dealt with messaging around the HPV vaccine, direct patient–clinician interactions and external messaging, and a third thematic category involving healthcare system-related factors and interventions. The messaging strategy identified as most useful was promoting the HPV vaccine for cancer prevention. The need for stakeholders to prioritize HPV vaccination uptake was identified as a key factor to increasing HPV vaccination rates. Multiple providers and stakeholders identified misinformation spread through social media as a barrier to HPV vaccine uptake. Conclusion Emphasizing the HPV vaccine’s cancer prevention benefits and prioritizing it among healthcare stakeholders were the most consistently cited strategies for promoting HPV vaccine uptake. Methods to combat the negative influence of misinformation about HPV vaccines in social media are an urgent priority.

Decreasing COVID-19 vaccine hesitancy is an urgent challenge in the US. This study aimed to examine COVID-19 vaccine hesitancy among U.S. adults with a history of using tobacco products or marijuana. Data were collected online in 2020–2021 including respondents’ willingness to accept a COVID-19 vaccine, factors that may promote vaccine acceptance, and prior history of influenza vaccination. Logistic regression models were conducted to estimate the associations between vaccine hesitancy and demographic characteristics, substance use, the impact of the COVID-19 pandemic, and prior influenza vaccination. Among 387 respondents, 49.1% were willing to receive a COVID-19 vaccine, 26.0% were unwilling, and 24.9% were “not sure.” Blacks, suburban or rural residents, those who lived by themselves or with a family with five members or above, those who were not stressed because of the COVID-19 pandemic were more likely to say “no” to a COVID-19 vaccine. Respondents who never, only once, or during some years received an influenza vaccine were 7.0, 6.2, and 5.2 times more likely to say “no” to a COVID-19 vaccine than respondents who received an influenza vaccination every year or almost every year. The use of cigarettes, e-cigarettes, and marijuana, as well as heavy drinking of alcohol, were not associated with COVID-19 hesitancy. The associations between demographic factors and vaccine hesitancy were roughly similar for COVID-19 and influenza vaccines. Although various demographic groups have different levels of vaccine hesitancy and also have different factors to increase their acceptance, addressing misinformation related to COVID-19 vaccines, particularly concern about the safety of the vaccines is crucial in general.

Introduction While cigarette use has decreased, adolescents' overall use of tobacco (e.g. e-cigarettes, cigars, and hookah) has increased. The purpose of this qualitative study is to highlight the decision-making process of adolescents to use certain products over others and why certain tobacco products appeal to them. Methods Twenty-five participants were recruited from a larger study surveying adolescents' perceptions and tobacco use (772 high school students). The participants were involved in one-on-one semi-structured phone interviews on the appeal of different tobacco products. Interviews were recorded, transcribed verbatim, and analyzed by identifying relevant codes and themes. Results Participants for this study had a mean age of 16.4 (SD=1.2) years; over half (14/25) were female. Three major themes emerged from the interviews: 1) social context and circumstances to use, including using and sharing with peers, and reducing boredom; 2) importance of flavors, smell, taste, smoke tricks, and accessibility of products; and 3) misperceptions and misinformation of product risks. Conclusions The findings that emerged showed why participants favored certain tobacco products, especially e-cigarettes, over others. The results support areas for future research and practice, and inform how interventions can better address the appeal of different tobacco products to ultimately prevent adolescent use.

The emergence of SARS-CoV-2 in the end of 2019, an aetiologic agent responsible for the 1SARS plunged the world into an unprecedented sanitary crisis. Papers on COVID-19 have been fast-tracked since then.2–5 Accelerated time from submission to publication6–8 and qualitative changes in peer review,9 associated with empirical evidence that duplicate and implausible clinical trials have been carried out during the pandemic,10–12 could perhaps imply lower quality of peer review in COVID-19 research. Accumulating empirical evidence has also been indicating the pandemic era output to be less reliable than its prepandemic counterpart.2 10–14 A systematic review to evaluate the methodological quality of COVID-19 peer-reviewed clinical studies compared with historical controls found methodological quality scores to be lower in COVID-19 articles across all study designs.12 Meanwhile, data sharing practices remained largely unchanged during the first year of the pandemic.13 14 With no mandates of data sharing in place for COVID-19 studies, the reproducibility of these data on COVID-19 is yet to be independently verified as well.2 However, more efficiency in scientific publication did manifest in accelerated publication,6–8 journals tearing down their paywalls for their COVID-19 output,14 an increased usage of life and medical sciences preprint servers to increase speed and transparency,15 not to mention the intense international collaboration that resulted in the development of multiple high-efficacy vaccines within the first year of the pandemic.16 On the other hand, some pratices that reduce the reliability of clinical trials may have gained some traction during 2020, such as executing underpowered studies with small samples, multiplicity of trials testing ideas with low prior probability of being true, forgoing blinding to test interventions10 11 14 17–20 and incomplete reporting of findings, which was already an issue before the pandemic.12 21 To …

Introduction: Vaccinations are referred to as one of the greatest achievements of modern medicine. However, their effectiveness is also constantly denied by certain groups in society. This results in an ongoing dispute that has been gradually moving online in the last few years due to the development of technology. Our study aimed to utilize social media to identify and analyze vaccine-deniers’ arguments against child vaccinations. Method: All public comments posted to a leading Polish vaccination opponents’ Facebook page posted between 01/05/2019 and 31/07/2019 were collected and analyzed quantitatively in terms of their content according to the modified method developed by Kata (Kata, 2010). Sentiment analysis was also performed. Results: Out of 18,685 comments analyzed, 4,042 contained content covered by the adopted criteria: conspiracy theories (28.2%), misinformation and unreliable premises (19.9%), content related to the safety and effectiveness of vaccinations (14.0%), noncompliance with civil rights (13.2%), own experience (10.9%), morality, religion, and belief (8.5%), and alternative medicine (5.4%). There were also 1,223 pro-vaccine comments, of which 15.2% were offensive, mocking, or non-substantive. Sentiment analysis showed that comments without any arguments as well as those containing statements about alternative medicine or misinformation were more positive and less angry than comments in other topic categories. Conclusions: The large amount of content in the conspiracy theory and misinformation categories may indicate that authors of such comments may be characterized by a lack of trust in the scientific achievements of medicine. These findings should be adequately addressed in vaccination campaigns.

HPV vaccination rates have improved in recent years, but remain suboptimal in the United States. Physician recommendation is associated with increased uptake; however, specific strategies used by physicians to recommend the vaccine and address hesitancy are underexplored. We iteratively conducted qualitative in-depth interviews with family medicine and pediatrics/adolescent medicine physicians recruited from four primary care settings (federally qualified health centers and hospital-affiliated practices) within a large academic-hospital system in New Jersey. Interviews aimed to understand factors influencing physician recommendations. Transcripts were analyzed iteratively using a team-based, thematic content analysis approach. All physicians reported strong support for HPV vaccination, intention to recommend for target age groups, and providing factsheets to parents. Many physicians used electronic medical records and/or the state immunization registry for monitoring vaccinations, but few were able to report their own clinic-level rates. The majority said they needed to overcome both hesitancy for at least 10–30% of parents and misinformation from the internet. Most cited having their own children vaccinated for HPV as a first-line strategy for addressing parental hesitancy. Other strategies included using data or professional authority to address safety concerns, linking HPV to cervical cancer, highlighting only needing two doses if vaccinated younger, and normalizing the vaccine. While our findings indicate physicians are knowledgeable about HPV vaccination and recommend it to parents, strategies to overcome parental hesitancy varied. Physician, clinic, and health-system-based strategies need to be adopted to overcome parental hesitancy for HPV vaccination.

Background vaccination uptake in the UK and increased care home testing are likely affecting care home visitation. With scant scientific evidence to date, the aim of this longitudinal qualitative study was to explore the impact of both (vaccination and testing) on the conduct and experiences of care home visits. Methods family carers of care home residents with dementia and care home staff from across the UK took part in baseline (October/November 2020) and follow-up interviews (March 2021). Public advisers were involved in all elements of the research. Data were analysed using thematic analysis. Results across 62 baseline and follow-up interviews with family carers (n = 26; 11) and care home staff (n = 16; 9), five core themes were developed: delayed and inconsistent offers of face-to-face visits; procedures and facilitation of visits; variable uptake of the COVID-19 vaccine; misinformation, education and free choice; frustration and anger among family carers. The variable uptake in staff, compared to family carers, was a key factor seemingly influencing visitation, with a lack of clear guidance leading care homes to implement infection control measures and visitation rights differently. Conclusions we make five recommendations in this paper to enable improved care home visitation in the ongoing, and in future, pandemics. Visits need to be enabled and any changes to visiting rights must be used as a last resort, reviewed regularly in consultation with residents and carers and restored as soon as possible as a top priority, whilst more education needs to be provided surrounding vaccination for care home staff.

Background Nurses are at the forefront of the COVID-19 pandemic. During the pandemic, nurses have faced an elevated risk of exposure and have experienced the hazards related to a novel virus. While being heralded as lifesaving heroes on the front lines of the pandemic, nurses have experienced more physical, mental, and psychosocial problems as a consequence of the COVID-19 outbreak. Social media discussions by nursing professionals participating in publicly formed Facebook groups constitute a valuable resource that offers longitudinal insights. Objective This study aimed to explore how COVID-19 impacted nurses through capturing public sentiments expressed by nurses on a social media discussion platform and how these sentiments changed over time. Methods We collected over 110,993 Facebook discussion posts and comments in an open COVID-19 group for nurses from March 2020 until the end of November 2020. Scraping of deidentified offline HTML tags on social media posts and comments was performed. Using subject-matter expert opinions and social media analytics (ie, topic modeling, information retrieval, and sentiment analysis), we performed a human-in-a-loop analysis of nursing professionals’ key perspectives to identify trends of the COVID-19 impact among at-risk nursing communities. We further investigated the key insights of the trends of the nursing professionals’ perspectives by detecting temporal changes of comments related to emotional effects, feelings of frustration, impacts of isolation, shortage of safety equipment, and frequency of safety equipment uses. Anonymous quotes were highlighted to add context to the data. Results We determined that COVID-19 impacted nurses’ physical, mental, and psychosocial health as expressed in the form of emotional distress, anger, anxiety, frustration, loneliness, and isolation. Major topics discussed by nurses were related to work during a pandemic, misinformation spread by the media, improper personal protective equipment (PPE), PPE side effects, the effects of testing positive for COVID-19, and lost days of work related to illness. Conclusions Public Facebook nursing groups are venues for nurses to express their experiences, opinions, and concerns and can offer researchers an important insight into understanding the COVID-19 impact on health care workers.

Background: The response of populations to public health measures may rely on the degree to which the population trusts sources of information and institutions. There has been little research in this area in the Caribbean. This exploratory study aimed to evaluate public trust in information sources, confidence in institutions and COVID-19 vaccine willingness in Trinidad and Tobago. Methods: An exploratory online survey was conducted in Trinidad and Tobago from November 10th to December 7th 2020. The survey instrument was a validated questionnaire developed by the World Health Organisation (WHO) and adapted to the local setting. Descriptive statistics and regression analyses were used to analyse the data. Findings: The most trusted sources of information included health workers (32.5%) and the ministry of health (23.6 %). Increasing levels of trust in the medical sector were associated with decreasing levels of believing misinformation. Overall, 62.8 % of participants said they would take the COVID-19 vaccine if available. Regression analyses showed those who agreed that everyone should adhere to the national immunization schedule and those who would take the flu vaccine, were 2.77 (95% CI 1.77-4.35) and 4.60 (95% CI 3.11-6.84) timesmore likely to take the vaccine, respectively. Interpretation: Our study found increasing trust in health sources, confidence in medical sector, adherence to the national immunisation schedule and acceptance of the flu vaccine may increase COVID-19 vaccine willingness rates. Although the generalisability of the findings is limited, the results of this exploratory survey may be used to identify areas for prioritisation and improvement in future research.

Background Despite the public health importance of vaping and the widespread use of TikTok by adolescents and young adults, research is lacking on the nature and scope of vaping content on this networking service. Objective The purpose of this study is to describe the content of TikTok videos related to vaping. Methods By searching the hashtag #vaping in the discover feature, ~478.4 million views were seen during the time of data collection. The first 100 relevant videos under that hashtag were used in this study. Relevance was determined by simply noting if the video was related in any way to vaping. Coding consisted of several categories directly related to vaping and additional categories, including the number of likes, comments, and views, and if the video involved music, humor, or dance. Results The 100 videos included in the sample garnered 156,331,347 views; 20,335,800 likes; and 296,460 comments. The majority of the videos (n=59) used music and over one-third (n=37) used humor. The only content category observed in the majority of the videos sampled was the promotion of vaping, which was included in 57 videos that garnered over 74 million views (47.5% of cumulative views). A total of 42% (n=42) of the 100 videos sampled featured someone vaping or in the presence of vape pens, and these videos garnered over 22% (>35 million) of the total views. Conclusions It is necessary for public health agencies to improve understanding of the nature and content of videos that attract viewers’ attention and harness the strength of this communication channel to promote informed decision-making about vaping.

Background: The vaccination uptake rates of the human papillomavirus (HPV) vaccine remain low despite the fact that the effectiveness of HPV vaccines has been established for more than a decade. Vaccine hesitancy is in part due to false information about HPV vaccines on social media. Combating false HPV vaccine information is a reasonable step to addressing vaccine hesitancy. Objective: Given the substantial harm of false HPV vaccine information, there is an urgent need to identify false social media messages before it goes viral. The goal of the study is to develop a systematic and generalizable approach to identifying false HPV vaccine information on social media. Methods: This study used machine learning and natural language processing to develop a series of classification models and causality mining methods to identify and examine true and false HPV vaccine-related information on Twitter. Results: We found that the convolutional neural network model outperformed all other models in identifying tweets containing false HPV vaccine-related information (F score=91.95). We also developed completely unsupervised causality mining models to identify HPV vaccine candidate effects for capturing risk perceptions of HPV vaccines. Furthermore, we found that false information contained mostly loss-framed messages focusing on the potential risk of vaccines covering a variety of topics using more diverse vocabulary, while true information contained both gain- and loss-framed messages focusing on the effectiveness of vaccines covering fewer topics using relatively limited vocabulary. Conclusions: Our research demonstrated the feasibility and effectiveness of using predictive models to identify false HPV vaccine information and its risk perceptions on social media. Technology Services and the Cancer Center at Illinois at the University of Illinois at Urbana-Champaign; National Institutes of HealthUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA [1R21CA237483] Published version We thank Chieh-Li (Julian) Chin and Wen-Yuh Su for their assistance in the data collection and preparation for this study. We also thank the Technology Services and the Cancer Center at Illinois at the University of Illinois at Urbana-Champaign for their support of our study. This study was supported by a grant from the National Institutes of Health (#1R21CA237483). Any opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the National Institutes of Health.

Background An infodemic is an overflow of information of varying quality that surges across digital and physical environments during an acute public health event. It leads to confusion, risk-taking, and behaviors that can harm health and lead to erosion of trust in health authorities and public health responses. Owing to the global scale and high stakes of the health emergency, responding to the infodemic related to the pandemic is particularly urgent. Building on diverse research disciplines and expanding the discipline of infodemiology, more evidence-based interventions are needed to design infodemic management interventions and tools and implement them by health emergency responders. Objective The World Health Organization organized the first global infodemiology conference, entirely online, during June and July 2020, with a follow-up process from August to October 2020, to review current multidisciplinary evidence, interventions, and practices that can be applied to the COVID-19 infodemic response. This resulted in the creation of a public health research agenda for managing infodemics. Methods As part of the conference, a structured expert judgment synthesis method was used to formulate a public health research agenda. A total of 110 participants represented diverse scientific disciplines from over 35 countries and global public health implementing partners. The conference used a laddered discussion sprint methodology by rotating participant teams, and a managed follow-up process was used to assemble a research agenda based on the discussion and structured expert feedback. This resulted in a five-workstream frame of the research agenda for infodemic management and 166 suggested research questions. The participants then ranked the questions for feasibility and expected public health impact. The expert consensus was summarized in a public health research agenda that included a list of priority research questions. Results The public health research agenda for infodemic management has five workstreams: (1) measuring and continuously monitoring the impact of infodemics during health emergencies; (2) detecting signals and understanding the spread and risk of infodemics; (3) responding and deploying interventions that mitigate and protect against infodemics and their harmful effects; (4) evaluating infodemic interventions and strengthening the resilience of individuals and communities to infodemics; and (5) promoting the development, adaptation, and application of interventions and toolkits for infodemic management. Each workstream identifies research questions and highlights 49 high priority research questions. Conclusions Public health authorities need to develop, validate, implement, and adapt tools and interventions for managing infodemics in acute public health events in ways that are appropriate for their countries and contexts. Infodemiology provides a scientific foundation to make this possible. This research agenda proposes a structured framework for targeted investment for the scientific community, policy makers, implementing organizations, and other stakeholders to consider.

Lay Summary Vaccine hesitancy, the rejection or delay to get vaccinated even if there is an effective vaccine available, may be instrumental in the resurgence of vaccine-preventable disease. Studies have shown that the rise in nonmedical exemptions for vaccination increases rates of childhood vaccine-preventable disease. One factor that influences vaccine hesitancy is online misinformation. False or misleading information online regarding vaccines can be found in independent news outlets, websites, and social media. The spread of vaccine misinformation is especially important during the COVID-19 pandemic as false information can decrease pro-vaccine opinions. The recent announcement of an effective COVID-19 vaccine became a hot topic online, with many adults hesitant to take the vaccine. Public health experts, medical professionals, and pro-vaccine individuals can help curb the spread of misinformation by correcting false statements online. Social media companies can also aid in stopping misinformation by implementing and enforcing policy that limits misinformation on their platforms., Although rates of vaccination have increased worldwide, the rise in nonmedical exemptions for vaccination may have caused a resurgence of childhood vaccine-preventable diseases. Vaccine hesitancy plays an important role in the decreasing rates of vaccination and is considered by the World Health Organization as a top ten global threat to public health. Online vaccine misinformation is present in news outlets, websites, and social media, and its rapid and extensive dissemination is aided by artificial intelligence (AI). In combating online misinformation, public health experts, the medical community, and lay vaccination advocates can correct false statements using language that appeal to those who are undecided about vaccination. As the gatekeepers to online information, they can implement and enforce policy that limits or bans vaccine misinformation on their platforms. AI tools might also be used to address misinformation, but more research is needed before implementing this approach more broadly in health policy. This commentary examines the role that different online platforms appear to be playing in the spread of misinformation about vaccines. We also discuss the implications of online misinformation on attitudes about COVID-19 vaccine uptake and provide suggestions for ways to combat online misinformation.

Background Immunizing children throughout their early years prevents the spread of communicable disease and decreases the morbidity and mortality associated with many vaccine-preventable diseases. Searching online allows individuals rapid access to health information. Objective The purpose of this review was to develop an understanding of the existing literature of parents’ online health information-seeking behaviors to inform their vaccination choices for their children and to identify gaps in the literature around parents’ use of online health information and their vaccination choices. Methods A scoping review of peer-reviewed literature from Canada and the United States was performed. The following databases were utilized to perform the search: PubMed, CINAHL, Nursing & Allied Health Database, Scopus, and PsycINFO. The purpose of this review was to examine parents’ use of online information seeking related to vaccine information and to understand how parents utilize this information to inform decisions about vaccinating their children. Of the 34 papers included in the review, 4 relevant themes and subthemes were identified: information seeking, online information resources, online vaccine content, and trust in health care providers. Results Examination of the literature revealed conflicting information regarding parents’ use of social media and online resources to inform decisions around vaccinating their children. There is evidence of significant misinformation regarding vaccine risks online. Parents’ digital health literacy levels are unknown and may affect their ability to appraise online vaccination information. Conclusions Parents are seeking vaccine information from online sources. However, the influence of online vaccine information on parental vaccine practices remains uncertain.

Background In recent years, medical journals have emphasized the increasingly critical role that social media plays in the dissemination of public health information and disease prevention guidelines. However, platforms such as Facebook and Twitter continue to pose unique challenges for clinical health care providers and public health officials alike. In order to effectively communicate during public health emergencies, such as the COVID-19 pandemic, it is increasingly critical for health care providers and public health officials to understand how patients gather health-related information on the internet and adjudicate the merits of such information. Objective With that goal in mind, we conducted a survey of 1003 US-based adults to better understand how health consumers have used social media to learn and stay informed about the COVID-19 pandemic, the extent to which they have relied on credible scientific information sources, and how they have gone about fact-checking pandemic-related information. Methods A web-based survey was conducted with a sample that was purchased through an industry-leading market research provider. The results were reported with a 95% confidence level and a margin of error of 3. Participants included 1003 US-based adults (aged ≥18 years). Participants were selected via a stratified quota sampling approach to ensure that the sample was representative of the US population. Balanced quotas were determined (by region of the country) for gender, age, race, and ethnicity. Results The results showed a heavy reliance on social media during the COVID-19 pandemic; more than three-quarters of respondents (762/1003, 76%) reported that they have relied on social media at least “a little,” and 59.2% (594/1003) of respondents indicated that they read information about COVID-19 on social media at least once per week. According to the findings, most social media users (638/1003, 63.6%) were unlikely to fact-check what they see on the internet with a health professional, despite the high levels of mistrust in the accuracy of COVID-19–related information on social media. We also found a greater likelihood of undergoing vaccination among those following more credible scientific sources on social media during the pandemic (χ216=50.790; φ=0.258; P Conclusions The findings suggest that health professionals will need to be both strategic and proactive when engaging with health consumers on social media if they hope to counteract the deleterious effects of misinformation and disinformation. Effective training, institutional support, and proactive collaboration can help health professionals adapt to the evolving patterns of health information seeking.

Background Cultural trends in the United States, the nicotine consumer marketplace, and tobacco policies are changing. Objective The goal of this study was to identify and describe nicotine-related topics of conversation authored by the public and social bots on Twitter, including any misinformation or misconceptions that health education campaigns could potentially correct. Methods Twitter posts containing the term “nicotine” were obtained from September 30, 2018 to October 1, 2019. Methods were used to distinguish between posts from social bots and nonbots. Text classifiers were used to identify topics in posts (n=300,360). Results Prevalent topics of posts included vaping, smoking, addiction, withdrawal, nicotine health risks, and quit nicotine, with mentions of going “cold turkey” and needing help in quitting. Cessation was a common topic, with mentions of quitting and stopping smoking. Social bots discussed unsubstantiated health claims including how hypnotherapy, acupuncture, magnets worn on the ears, and time spent in the sauna can help in smoking cessation. Conclusions Health education efforts are needed to correct unsubstantiated health claims on Twitter and ultimately direct individuals who want to quit smoking to evidence-based cessation strategies. Future interventions could be designed to follow these topics of discussions on Twitter and engage with members of the public about evidence-based cessation methods in near real time when people are contemplating cessation.

Control of the COVID-19 pandemic relies heavily on behavioral mitigation strategies such as physical distancing, hand washing and mask wearing. Even with the availability of SARS-CoV-2 vaccines, the extraordinary effort to distribute the vaccines must be paired with continued adherence to behavioral recommendations as well as vaccine confidence. To facilitate rapid and equitable uptake of the vaccines, there is a need for responsive, trustworthy, and evidence-informed communication about vaccination, enhanced trust in science, and engaging populations disproportionately affected by the pandemic. Efforts to address vaccine hesitancy and increase vaccine confidence will address the emerging gaps between vaccine availability and actual vaccination. Although these gaps are attributable, in part, to challenges with logistics and access, social and behavioral drivers of vaccination decision making also have a significant role in vaccination uptake. As federal, state, and local health and public health agencies coordinate vaccine dissemination, there will be a continuous need to adapt to an evolving landscape of SARS-CoV-2 vaccines, new scientific information, and the spread of COVID-19- and vaccine-related misinformation. Facilitating widespread vaccination and maintaining a focus on equity requires thoughtful and compassionate approaches to reach and address the needs of those who are disproportionately affected by the pandemic such as underserved, vulnerable, and racial/ethnic minority populations. This commentary focuses on several National Institutes of Health initiatives that are supporting behavioral and social science research to address SARS-CoV-2 vaccine communication and increase the uptake of vaccination. We conclude with implications for future research.

Background As several COVID-19 vaccines are rolled-out globally, it has become important to develop an effective strategy for vaccine acceptance, especially in high-risk groups, such as elderly. Vaccine misconception was declared by WHO as one of the top 10 health issues in 2019. Here we test the effectiveness of applying debunking to combat vaccine misinformation, and reduce vaccine hesitancy. Methods Participants were recruited via a daily news show on Dutch Television, targeted to elderly viewers. The study was conducted in 980 elderly citizens during the October 2020 National Influenza Vaccination Campaign. Borrowing from the recent literature in behavioural science and psychology we conducted a two-arm randomized blinded parallel study, in which participants were allocated to exposure to a video containing social norms, vaccine information plus debunking of vaccination myths (intervention group, n = 505) or a video only containing vaccine information plus social norm (control group, n = 475). Participants who viewed either of the video's and completed both a pre- and post-intervention survey on vaccination trust and knowledge, were included in the analysis. The main outcomes of this study were improvement on vaccine knowledge and awareness. Findings Participants were recruited from the 13th of October 2020 till the 16th of October 2020 and could immediately participate in the pre-intervention survey. Subsequently, eligible participants were randomly assigned to an interventional video and the follow-up survey, distributed through email on the 18th of October 2020, and available for participation till the 24th of October 2020. We found that exposure to the video with addition of debunking strategies on top of social norm modelling and information resulted in substantially stronger rejection of vaccination misconceptions, including the belief that: (1) vaccinations can cause Autism Spectrum Disorders; (2) vaccinations weaken the immune system; (3) influenza vaccination would hamper the COVID-19 vaccine efficacy. Additionally, we observed that exposure to debunking in the intervention resulted in enhanced trust in government. Interpretation Utilizing debunking in media campaigns on top of vaccine information and social norm modeling is an effective means to combat misinformation and distrust associated with vaccination in elderly, and could help maximize grounds for the acceptance of vaccines, including the COVID-19 vaccines. Funding Dutch Influenza Foundation.

Background Vaccination against COVID-19 is an important public health strategy to address the ongoing pandemic. Examination of online search behavior related to COVID-19 vaccines can provide insights into the public's awareness, concerns, and interest regarding COVID-19 vaccination. Objective The aim of this study is to describe online search behavior related to COVID-19 vaccines during the start of public vaccination efforts in the United States. Methods We examined Google Trends data from January 1, 2021, through March 16, 2021, to determine the relative search volume for vaccine-related searches on the internet. We also examined search query log data for COVID-19 vaccine-related searches and identified 5 categories of searches: (1) general or other information, (2) vaccine availability, (3) vaccine manufacturer, (4) vaccine side-effects and safety, and (5) vaccine myths and conspiracy beliefs. In this paper, we report on the proportion and trends for these different categories of vaccine-related searches. Results In the first quarter of 2021, the proportion of all web-based search queries related to COVID-19 vaccines increased from approximately 10% to nearly 50% of all COVID-19–related queries (P Conclusions This study demonstrates an increase in online search behavior related to COVID-19 vaccination in early 2021 along with an increase in the proportion of searches related to vaccine availability at pharmacies. These findings are consistent with an increase in public interest and intention to get vaccinated during the initial phase of public COVID-19 vaccination efforts.

Background Although “infodemiological” methods have been used in research on coronavirus disease (COVID-19), an examination of the extent of infodemic moniker (misinformation) use on the internet remains limited. Objective The aim of this paper is to investigate internet search behaviors related to COVID-19 and examine the circulation of infodemic monikers through two platforms—Google and Instagram—during the current global pandemic. Methods We have defined infodemic moniker as a term, query, hashtag, or phrase that generates or feeds fake news, misinterpretations, or discriminatory phenomena. Using Google Trends and Instagram hashtags, we explored internet search activities and behaviors related to the COVID-19 pandemic from February 20, 2020, to May 6, 2020. We investigated the names used to identify the virus, health and risk perception, life during the lockdown, and information related to the adoption of COVID-19 infodemic monikers. We computed the average peak volume with a 95% CI for the monikers. Results The top six COVID-19–related terms searched in Google were “coronavirus,” “corona,” “COVID,” “virus,” “corona virus,” and “COVID-19.” Countries with a higher number of COVID-19 cases had a higher number of COVID-19 queries on Google. The monikers “coronavirus ozone,” “coronavirus laboratory,” “coronavirus 5G,” “coronavirus conspiracy,” and “coronavirus bill gates” were widely circulated on the internet. Searches on “tips and cures” for COVID-19 spiked in relation to the US president speculating about a “miracle cure” and suggesting an injection of disinfectant to treat the virus. Around two thirds (n=48,700,000, 66.1%) of Instagram users used the hashtags “COVID-19” and “coronavirus” to disperse virus-related information. Conclusions Globally, there is a growing interest in COVID-19, and numerous infodemic monikers continue to circulate on the internet. Based on our findings, we hope to encourage mass media regulators and health organizers to be vigilant and diminish the use and circulation of these infodemic monikers to decrease the spread of misinformation.

Background As part of the response plans for the current outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), authorities are drafting and implementing containment measures across jurisdictions worldwide in the effort to slow down transmission and reduce the infection rate. A solid communication strategy is needed to increase the reach of valid information to health professionals, reduce misinformation, and efficiently implement recommended measures. Objective The aim of this paper is to describe the utilization of a dedicated mobile health (mHealth) platform to disseminate up-to-date and validated information about SARS-CoV-2 to all medical staff of the Children’s Hospital at the University Hospitals of Geneva. Methods Three documents containing institutional information concerning screening, local containment procedures, and frequently asked questions and answers for parents were made available to the staff through a mobile app developed in the University of Geneva, Switzerland. Using a third-party statistics tool, we anonymously monitored user activity as well as content utilization patterns since the diagnosis of the first case of SARS-CoV-2 in Switzerland on February 25, 2020. Results From February 25, 2020, to March 13, 2020 (18 days), information documents on SARS-CoV-2 were viewed 859 times, which accounted for 35.6% of the total content views (total views=332). User activity increased significantly with 50.8 (SD 14.4) users per day in this period as compared to the previous weeks (mean 26.4, SD 9.8; P Conclusions The use of an mHealth solution to disseminate novel coronavirus–related information seemed to be an effective and time-saving communication channel within our institution during the SARS-CoV-2 outbreak. Medical staff felt reassured and informed in daily practice. More research should be done on the clinical impact and outcomes of the integration of mHealth solutions as a communication channel of validated information within health institutions.

Health behavior of nursing students is often inadequate in terms of dietary, physical activity, smoking and alcohol drinking habits. The main aim of this position paper is to explore dietary habits, obesity and university life on nurse undergraduates. This critical review covers three distinct dimensions of student life as related to nursing studies, i.e. the eating and lifestyle behaviors of nursing students; the transitional period and risk of gain weight; students’ national origin and eating behaviors.Obesity is increasing not only in the western world but in developing countries as well. University life is a transitional period where risk of weight gain is increased. Often, stress may lead students to ‘binge’ eating and weight problems. In terms of students’ national origin and eating behavior, dietary choices for nurse students are multifaceted, as their cultural backgrounds may be. Nurses, amongst other healthcare professionals, encounter barriers to positive lifestyles and healthy eating just as many of their patients do. Moreover, as healthcare professionals are regarded as potential health promoters, their own health behavior represents an important key clinical and educational function.Yet, nutritional knowledge is not easy to apply as there is so much misinformation readily available both online and elsewhere.Given the highly stressful conditions associated with their profession, nurses also need to care for their own health. Thus there is a need for designing educational programs for current nursing curricula to encourage healthy lifestyles which include coping with stress, increased physical activity, healthy food and drink choices.

Background The current opioid crisis in the United States impacts broad population groups, including pregnant women. Opioid use during pregnancy can affect the health and wellness of both mothers and their infants. Understanding women’s efforts to self-manage opioid use or misuse in pregnancy is needed to identify intervention points for improving maternal outcomes. Objective This study aims to identify the characteristics of women in an online health community (OHC) with opioid use or misuse during pregnancy and the self-management support needs of these mothers. Methods A total of 200 web posts by pregnant women with opioid use participating in an OHC were double coded. Concepts and their thematic connections were identified through an inductive process until theoretical saturation was reached. Statistical tests were performed to identify patterns. Results The majority of pregnant women (150/200, 75.0%) in the OHC exhibited signs of misuse, and 62.5% (125/200) of the participants were either contemplating or pursuing dosage reduction. Self-managed withdrawal was more common (P Conclusions OHCs provide vital self-management support for pregnant women with opioid use or misuse. Women pursuing self-managed dosage reduction are prone to misinformation and repeated relapses, which can result in extreme measures to avoid testing positive for drug use at labor. The study findings provide evidence for public policy considerations, including universal screening of substance use for pregnant women, emphasis on treatment rather than legal punishment, and further expansion of the Drug Addiction Treatment Act waiver training program. The improvement of web-based platforms that can organize geo-relevant information, dispense clinically validated withdrawal schedules, and offer structured peer support is envisioned for harm reduction among pregnant women who opt for self-management of opioid misuse.

Background The COVID-19 infodemic has been disseminating rapidly on social media and posing a significant threat to people’s health and governance systems. Objective This study aimed to investigate and analyze posts related to COVID-19 misinformation on major Chinese social media platforms in order to characterize the COVID-19 infodemic. Methods We collected posts related to COVID-19 misinformation published on major Chinese social media platforms from January 20 to May 28, 2020, by using PythonToolkit. We used content analysis to identify the quantity and source of prevalent posts and topic modeling to cluster themes related to the COVID-19 infodemic. Furthermore, we explored the quantity, sources, and theme characteristics of the COVID-19 infodemic over time. Results The daily number of social media posts related to the COVID-19 infodemic was positively correlated with the daily number of newly confirmed (r=0.672, P Conclusions Our study found that the COVID-19 infodemic on Chinese social media was characterized by gradual progress, videoization, and repeated fluctuations. Furthermore, our findings suggest that the COVID-19 infodemic is paralleled to the propagation of the COVID-19 epidemic. We have tracked the COVID-19 infodemic across Chinese social media, providing critical new insights into the characteristics of the infodemic and pointing out opportunities for preventing and controlling the COVID-19 infodemic.

Background The World Health Organization named the phenomenon of misinformation spread through social media as an “infodemic” and recognized the need to curb it. Misinformation infodemics undermine not only population safety but also compliance to the suggestions and prophylactic measures recommended during pandemics. Objective The aim of this pilot study is to review the impact of social media on general population fear in “infoveillance” studies during the COVID-19 pandemic. Methods The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol was followed, and 6 out of 20 studies were retrieved, meta-analyzed, and had their findings presented in the form of a forest plot. Results The summary random and significant event rate was 0.298 (95% CI 0.213-0.400), suggesting that social media–circulated misinformation related to COVID-19 triggered public fear and other psychological manifestations. These findings merit special attention by public health authorities. Conclusions Infodemiology and infoveillance are valid tools in the hands of epidemiologists to help prevent dissemination of false information, which has potentially damaging effects.

BackgroundAn unproven “nicotine hypothesis” that indicates nicotine’s therapeutic potential for COVID-19 has been proposed in recent literature. This study is about Twitter posts that misinterpret this hypothesis to make baseless claims about benefits of smoking and vaping in the context of COVID-19. We quantify the presence of such misinformation and characterize the tweeters who post such messages.MethodsTwitter premium API was used to download tweets (n = 17,533) that match terms indicating (a) nicotine or vaping themes, (b) a prophylactic or therapeutic effect, and (c) COVID-19 (January-July 2020) as a conjunctive query. A constraint on the length of the span of text containing the terms in the tweets allowed us to focus on those that convey the therapeutic intent. We hand-annotated these filtered tweets and built a classifier that identifies tweets that extrapolate the nicotine hypothesis to smoking/vaping with a positive predictive value of 85%. We analyzed the frequently used terms in author bios, top Web links, and hashtags of such tweets.Results21% of our filtered COVID-19 tweets indicate a vaping or smoking-based prevention/treatment narrative. Qualitative analyses show a variety of ways therapeutic claims are being made and tweeter bios reveal pre-existing notions of positive stances toward vaping.ConclusionThe social media landscape is a double-edged sword in tobacco communication. Although it increases information reach, consumers can also be subject to confirmation bias when exposed to inadvertent or deliberate framing of scientific discourse that may border on misinformation. This calls for circumspection and additional planning in countering such narratives as the COVID-19 pandemic continues to ravage our world. Our results also serve as a cautionary tale in how social media can be leveraged to spread misleading information about tobacco products in the wake of pandemics.

Healthcare providers (HCPs) are at the frontline to curb the spread of vaccine hesitancy in the community. However, HCPs themselves may delay or refuse vaccines. In light of the emerging vaccine hesitancy in the United Arab Emirates (UAE), we aimed to explore HCPs doubts and concerns regarding vaccination. We conducted face-to-face interviews with 33 HCPs from 7 ambulatory healthcare services in the Al Ain region, UAE. An interview guide was developed based on the European Center for Disease Prevention and Control guide for vaccine hesitancy among HCPs. An inductive thematic framework was employed to explore the main and emerging themes conceptualizing the predisposing, reinforcing, and enabling factors that influence HCPs' hesitancy regarding vaccinations for themselves and while recommending, prescribing, or discussing vaccines with their patients. The sample included general practitioners, family physicians, nurses, pharmacists, and other administrative staff. The major themes included positive predisposing factors such as trust in the system and the government, previous education, and social responsibility. Positive enabling factors included affordability and availability of vaccination services. Many participants were hesitant to receive the mandatory influenza vaccination. Misinformation regarding vaccines on social media was a major concern. However, HCPs showed little interest in being active on social media. Most participants reported never receiving any training on how to address vaccine hesitancy among patients. Because HCPs play an important role in influencing patients' decisions regarding undergoing vaccination, their confidence in addressing vaccine hesitancy must be improved.

Background In the face of the COVID-19 pandemic, the UK National Health Service (NHS) extended eligibility for influenza vaccination this season to approximately 32.4 million people (48.8% of the population). Knowing the intended uptake of the vaccine will inform supply and public health messaging to maximize vaccination. Objective The objective of this study was to measure the impact of the COVID-19 pandemic on the acceptance of influenza vaccination in the 2020-2021 season, specifically focusing on people who were previously eligible but routinely declined vaccination and newly eligible people. Methods Intention to receive the influenza vaccine in 2020-2021 was asked of all registrants of the largest electronic personal health record in the NHS by a web-based questionnaire on July 31, 2020. Of those who were either newly or previously eligible but had not previously received an influenza vaccination, multivariable logistic regression and network diagrams were used to examine their reasons to undergo or decline vaccination. Results Among 6641 respondents, 945 (14.2%) were previously eligible but were not vaccinated; of these, 536 (56.7%) intended to receive an influenza vaccination in 2020-2021, as did 466 (68.6%) of the newly eligible respondents. Intention to receive the influenza vaccine was associated with increased age, index of multiple deprivation quintile, and considering oneself to be at high risk from COVID-19. Among those who were eligible but not intending to be vaccinated in 2020-2021, 164/543 (30.2%) gave reasons based on misinformation. Of the previously unvaccinated health care workers, 47/96 (49%) stated they would decline vaccination in 2020-2021. Conclusions In this sample, COVID-19 has increased acceptance of influenza vaccination in previously eligible but unvaccinated people and has motivated substantial uptake in newly eligible people. This study is essential for informing resource planning and the need for effective messaging campaigns to address negative misconceptions, which is also necessary for COVID-19 vaccination programs.

Background The COVID-19 outbreak has left many people isolated within their homes; these people are turning to social media for news and social connection, which leaves them vulnerable to believing and sharing misinformation. Health-related misinformation threatens adherence to public health messaging, and monitoring its spread on social media is critical to understanding the evolution of ideas that have potentially negative public health impacts. Objective The aim of this study is to use Twitter data to explore methods to characterize and classify four COVID-19 conspiracy theories and to provide context for each of these conspiracy theories through the first 5 months of the pandemic. Methods We began with a corpus of COVID-19 tweets (approximately 120 million) spanning late January to early May 2020. We first filtered tweets using regular expressions (n=1.8 million) and used random forest classification models to identify tweets related to four conspiracy theories. Our classified data sets were then used in downstream sentiment analysis and dynamic topic modeling to characterize the linguistic features of COVID-19 conspiracy theories as they evolve over time. Results Analysis using model-labeled data was beneficial for increasing the proportion of data matching misinformation indicators. Random forest classifier metrics varied across the four conspiracy theories considered (F1 scores between 0.347 and 0.857); this performance increased as the given conspiracy theory was more narrowly defined. We showed that misinformation tweets demonstrate more negative sentiment when compared to nonmisinformation tweets and that theories evolve over time, incorporating details from unrelated conspiracy theories as well as real-world events. Conclusions Although we focus here on health-related misinformation, this combination of approaches is not specific to public health and is valuable for characterizing misinformation in general, which is an important first step in creating targeted messaging to counteract its spread. Initial messaging should aim to preempt generalized misinformation before it becomes widespread, while later messaging will need to target evolving conspiracy theories and the new facets of each as they become incorporated.

Background It is expected that COVID-19 vaccines will become available in China by the end of 2020. Vaccinating children against COVID-19 would contribute to the control of the pandemic and the recovery of the global economy. For children under the age of 18 years, parents are usually the decision makers regarding their children’s vaccination. Objective The goal of this study was to investigate parental acceptability of free COVID-19 vaccination for children under the age of 18 years in China. Methods This is a secondary analysis of a cross-sectional, closed online survey among 2053 factory workers in Shenzhen, China, implemented from September 1 to 7, 2020. Participants of the online survey were full-time employees aged 18 years or over who had resumed work in factories in Shenzhen. Factory workers in Shenzhen are required to receive physical examinations once a year. Eligible workers attending six designated physical examination sites were invited to complete an online survey. This study was based on a subsample of those who had at least one child under the age of 18 years (N=1052). After being briefed that COVID-19 vaccines developed by China are likely to be available by the end of 2020, participants were asked about their likelihood of having their children under the age of 18 years take up free COVID-19 vaccination provided by the government, if it existed. Multivariate logistic regression models were fitted to examine the associations of perceptions related to COVID-19 vaccination based on the theory of planned behavior (TPB) and exposure to information related to COVID-19 through social media with parental acceptability, after controlling for significant background characteristics. Results The prevalence of parents’ acceptability of COVID-19 vaccination for their children was 72.6% (764/1052). After adjusting for significant background characteristics, positive attitudes toward COVID-19 vaccination (adjusted odds ratio [AOR] 1.70, 95% CI 1.50-1.91), the perception that a family member would support them in having their children take up COVID-19 vaccination (ie, perceived subjective norm) (AOR 4.18, 95% CI 3.21-5.43), and perceived behavioral control to have the children take up COVID-19 vaccination (AOR 1.84, 95% CI 1.49-2.26) were associated with higher parental acceptability of COVID-19 vaccination. Regarding social media influence, higher exposure to positive information related to COVID-19 vaccination was associated with higher parental acceptability of COVID-19 vaccination (AOR 1.35, 95% CI 1.17-1.56). Higher exposure to negative information related to COVID-19 vaccination was negatively associated with the dependent variable (AOR 0.85, 95% CI 0.74-0.99). Conclusions Parents’ acceptability of COVID-19 vaccination for their children under 18 years of age was high in China. The TPB is a useful framework to guide the development of future campaigns promoting COVID-19 vaccination targeting parents. Transparency in communicating about the vaccine development process and vaccine safety testing is important. Public health authorities should also address misinformation in a timely manner.

Background Online misinformation proliferation during the COVID-19 pandemic has become a major public health concern. Objective We aimed to assess the prevalence of COVID-19 misinformation exposure and beliefs, associated factors including psychological distress with misinformation exposure, and the associations between COVID-19 knowledge and number of preventive behaviors. Methods A cross-sectional online survey was conducted with 1049 South Korean adults in April 2020. Respondents were asked about receiving COVID-19 misinformation using 12 items identified by the World Health Organization. Logistic regression was used to compute adjusted odds ratios (aORs) for the association of receiving misinformation with sociodemographic characteristics, source of information, COVID-19 misinformation belief, and psychological distress, as well as the associations of COVID-19 misinformation belief with COVID-19 knowledge and the number of COVID-19 preventive behaviors among those who received the misinformation. All data were weighted according to the Korea census data in 2018. Results Overall, 67.78% (n=711) of respondents reported exposure to at least one COVID-19 misinformation item. Misinformation exposure was associated with younger age, higher education levels, and lower income. Sources of information associated with misinformation exposure were social networking services (aOR 1.67, 95% CI 1.20-2.32) and instant messaging (aOR 1.79, 1.27-2.51). Misinformation exposure was also associated with psychological distress including anxiety (aOR 1.80, 1.24-2.61), depressive (aOR 1.47, 1.09-2.00), and posttraumatic stress disorder symptoms (aOR 1.97, 1.42-2.73), as well as misinformation belief (aOR 7.33, 5.17-10.38). Misinformation belief was associated with poorer COVID-19 knowledge (high: aOR 0.62, 0.45-0.84) and fewer preventive behaviors (≥7 behaviors: aOR 0.54, 0.39-0.74). Conclusions COVID-19 misinformation exposure was associated with misinformation belief, while misinformation belief was associated with fewer preventive behaviors. Given the potential of misinformation to undermine global efforts in COVID-19 disease control, up-to-date public health strategies are required to counter the proliferation of misinformation.

Background Information disclosure is a top priority for official responses to the COVID-19 pandemic. The timely and standardized information published by authorities as a response to the crisis can better inform the public and enable better preparations for the pandemic; however, there is limited evidence of any systematic analyses of the disclosed epidemic information. This in turn has important implications for risk communication. Objective This study aimed to describe and compare the officially released content regarding local epidemic situations as well as analyze the characteristics of information disclosure through local communication in major cities in China. Methods The 31 capital cities in mainland China were included in this city-level observational study. Data were retrieved from local municipalities and health commission websites as of March 18, 2020. A checklist was employed as a rapid qualitative assessment tool to analyze the information disclosure performance of each city. Descriptive analyses and data visualizations were produced to present and compare the comparative performances of the cities. Results In total, 29 of 31 cities (93.5%) established specific COVID-19 webpages to disclose information. Among them, 12 of the city webpages were added to their corresponding municipal websites. A majority of the cities (21/31, 67.7%) published their first cases of infection in a timely manner on the actual day of confirmation. Regarding the information disclosures highlighted on the websites, news updates from local media or press briefings were the most prevalent (28/29, 96.6%), followed by epidemic surveillance (25/29, 86.2%), and advice for the public (25/29, 86.2%). Clarifications of misinformation and frequently asked questions were largely overlooked as only 2 cities provided this valuable information. The median daily update frequency of epidemic surveillance summaries was 1.2 times per day (IQR 1.0-1.3 times), and the majority of these summaries (18/25, 72.0%) also provided detailed information regarding confirmed cases. The reporting of key indicators in the epidemic surveillance summaries, as well as critical facts included in the confirmed case reports, varied substantially between cities. In general, the best performance in terms of timely reporting and the transparency of information disclosures were observed in the municipalities directly administered by the central government compared to the other cities. Conclusions Timely and effective efforts to disclose information related to the COVID-19 epidemic have been made in major cities in China. Continued improvements to local authority reporting will contribute to more effective public communication and efficient public health research responses. The development of protocols and the standardization of epidemic message templates—as well as the use of uniform operating procedures to provide regular information updates—should be prioritized to ensure a coordinated national response.

Background The COVID-19 pandemic and countries’ response measures have had a globally significant mental health impact. This mental health burden has also been fueled by an infodemic: an information overload that includes misinformation and disinformation. Suicide, the worst mental health outcome, is a serious public health problem that can be prevented with timely, evidence-based, and often low-cost interventions. Suicide ideation, one important risk factor for suicide, is thus important to measure and monitor, as are the factors that may impact on it. Objective This investigation had 2 primary aims: (1) to estimate and compare country-specific prevalence of suicide ideation at 2 different time points, overall and by gender and age groups, and (2) to investigate the influence of sociodemographic and infodemic variables on suicide ideation. Methods A repeated, online, 8-country (Canada, the United States, England, Switzerland, Belgium, Hong Kong, Philippines, and New Zealand), cross-sectional study was undertaken with adults aged ≥18 years, with measurement wave 1 conducted from May 29, 2020 to June 12, 2020 and measurement wave 2 conducted November 6-18, 2021. Self-reported suicide ideation was derived from item 9 of the Patient Health Questionnaire-9 (PHQ-9). Age-standardized suicide ideation rates were reported, a binomial regression model was used to estimate suicide ideation indication rates for each country and measurement wave, and logistic regression models were then employed to relate sociodemographic, pandemic, and infodemic variables to suicide ideation. Results The final sample totaled 17,833 adults: 8806 (49.4%) from measurement wave 1 and 9027 (50.6%) from wave 2. Overall, 24.2% (2131/8806) and 27.5% (2486/9027) of participants reported suicide ideation at measurement waves 1 and 2, respectively, a difference that was significant (P Conclusions Suicide ideation is prevalent and significantly increasing over time in this COVID-19 pandemic era, with considerable variability between countries. Younger adults and those residing in Hong Kong carried disproportionately higher rates. Social media appears to have an increasingly detrimental association with suicide ideation, although having a stronger SOC had a larger protective effect. Policies and promotion of SOC, together with disseminating health information that explicitly tackles the infodemic’s misinformation and disinformation, may importantly reduce the rising mental health morbidity and mortality triggered by this pandemic.

Background Human papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making. Objective This study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI. Methods We conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network. Results The 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience. Conclusions Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child’s pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents.

Background The human papillomavirus (HPV) vaccine is a major advancement in cancer prevention and this primary prevention tool has the potential to reduce and eliminate HPV-associated cancers; however, the safety and efficacy of vaccines in general and the HPV vaccine specifically have come under attack, particularly through the spread of misinformation on social media. The popular social media platform Instagram represents a significant source of exposure to health (mis)information; 1 in 3 US adults use Instagram. Objective The objective of this analysis was to characterize pro- and anti-HPV vaccine networks on Instagram, and to describe misinformation within the anti-HPV vaccine network. Methods From April 2018 to December 2018, we collected publicly available English-language Instagram posts containing hashtags #HPV, #HPVVaccine, or #Gardasil using Netlytic software (n=16,607). We randomly selected 10% of the sample and content analyzed relevant posts (n=580) for text, image, and social media features as well as holistic attributes (eg, sentiments, personal stories). Among antivaccine posts, we organized elements of misinformation within four broad dimensions: 1) misinformation theoretical domains, 2) vaccine debate topics, 3) evidence base, and 4) health beliefs. We conducted univariate, bivariate, and network analyses on the subsample of posts to quantify the role and position of individual posts in the network. Results Compared to provaccine posts (324/580, 55.9%), antivaccine posts (256/580, 44.1%) were more likely to originate from individuals (64.1% antivaccine vs 25.0% provaccine; P Conclusions Identifying characteristics of misinformation related to HPV vaccine on social media will inform targeted interventions (eg, network opinion leaders) and help sow corrective information and stories tailored to different falsehoods.

Background Understanding public behavioral responses to the coronavirus disease (COVID-19) epidemic and the accompanying infodemic is crucial to controlling the epidemic. Objective The aim of this study was to assess real-time public awareness and behavioral responses to the COVID-19 epidemic across 12 selected countries. Methods Internet surveillance was used to collect real-time data from the general public to assess public awareness and rumors (China: Baidu; worldwide: Google Trends) and behavior responses (China: Ali Index; worldwide: Google Shopping). These indices measured the daily number of searches or purchases and were compared with the numbers of daily COVID-19 cases. The trend comparisons across selected countries were observed from December 1, 2019 (prepandemic baseline) to April 11, 2020 (at least one month after the governments of selected countries took actions for the pandemic). Results We identified missed windows of opportunity for early epidemic control in 12 countries, when public awareness was very low despite the emerging epidemic. China's epidemic and the declaration of a public health emergency of international concern did not prompt a worldwide public reaction to adopt health-protective measures; instead, most countries and regions only responded to the epidemic after their own case counts increased. Rumors and misinformation led to a surge of sales in herbal remedies in China and antimalarial drugs worldwide, and timely clarification of rumors mitigated the rush to purchase unproven remedies. Conclusions Our comparative study highlights the urgent need for international coordination to promote mutual learning about epidemic characteristics and effective control measures as well as to trigger early and timely responses in individual countries. Early release of official guidelines and timely clarification of rumors led by governments are necessary to guide the public to take rational action.

Background In case of a population-wide infectious disease outbreak, such as the novel coronavirus disease (COVID-19), people’s online activities could significantly affect public concerns and health behaviors due to difficulty in accessing credible information from reliable sources, which in turn causes people to seek necessary information on the web. Therefore, measuring and analyzing online health communication and public sentiment is essential for establishing effective and efficient disease control policies, especially in the early stage of an outbreak. Objective This study aimed to investigate the trends of online health communication, analyze the focus of people’s anxiety in the early stages of COVID-19, and evaluate the appropriateness of online information. Methods We collected 13,148 questions and 29,040 answers related to COVID-19 from Naver, the most popular Korean web portal (January 20, 2020, to March 2, 2020). Three main methods were used in this study: (1) the structural topic model was used to examine the topics in the online questions; (2) word network analysis was conducted to analyze the focus of people’s anxiety and worry in the questions; and (3) two medical doctors assessed the appropriateness of the answers to the questions, which were primarily related to people’s anxiety. Results A total of 50 topics and 6 cohesive topic communities were identified from the questions. Among them, topic community 4 (suspecting COVID-19 infection after developing a particular symptom) accounted for the largest portion of the questions. As the number of confirmed patients increased, the proportion of topics belonging to topic community 4 also increased. Additionally, the prolonged situation led to a slight increase in the proportion of topics related to job issues. People’s anxieties and worries were closely related with physical symptoms and self-protection methods. Although relatively appropriate to suspect physical symptoms, a high proportion of answers related to self-protection methods were assessed as misinformation or advertisements. Conclusions Search activity for online information regarding the COVID-19 outbreak has been active. Many of the online questions were related to people’s anxieties and worries. A considerable portion of corresponding answers had false information or were advertisements. The study results could contribute reference information to various countries that need to monitor public anxiety and provide appropriate information in the early stage of an infectious disease outbreak, including COVID-19. Our research also contributes to developing methods for measuring public opinion and sentiment in an epidemic situation based on natural language data on the internet.

BackgroundSince the beginning of the novel coronavirus disease (COVID-19) outbreak, fake news and misleading information have circulated worldwide, which can profoundly affect public health communication.ObjectiveWe investigated online search behavior related to the COVID-19 outbreak and the attitudes of “infodemic monikers” (ie, erroneous information that gives rise to interpretative mistakes, fake news, episodes of racism, etc) circulating in Italy.MethodsBy using Google Trends to explore the internet search activity related to COVID-19 from January to March 2020, article titles from the most read newspapers and government websites were mined to investigate the attitudes of infodemic monikers circulating across various regions and cities in Italy. Search volume values and average peak comparison (APC) values were used to analyze the results.ResultsKeywords such as “novel coronavirus,” “China coronavirus,” “COVID-19,” “2019-nCOV,” and “SARS-COV-2” were the top infodemic and scientific COVID-19 terms trending in Italy. The top five searches related to health were “face masks,” “amuchina” (disinfectant), “symptoms of the novel coronavirus,” “health bulletin,” and “vaccines for coronavirus.” The regions of Umbria and Basilicata recorded a high number of infodemic monikers (APC weighted total >140). Misinformation was widely circulated in the Campania region, and racism-related information was widespread in Umbria and Basilicata. These monikers were frequently searched (APC weighted total >100) in more than 10 major cities in Italy, including Rome.ConclusionsWe identified a growing regional and population-level interest in COVID-19 in Italy. The majority of searches were related to amuchina, face masks, health bulletins, and COVID-19 symptoms. Since a large number of infodemic monikers were observed across Italy, we recommend that health agencies use Google Trends to predict human behavior as well as to manage misinformation circulation in Italy.

The transplantation of organs is one of the most successful medical advances in recent decades, and transplantation is the treatment of choice for severe organ failure worldwide. Despite this situation and the general acknowledgment of organ donation (OD) as a global priority, the demand for organs outstrips the supply in virtually every country in the world. The study aims to elucidate whether age, gender and religion influence decision-making about organ donation in religious Muslims living in Sweden Data were collected through three group interviews using open-ended questions and qualitative content analysis. Twenty-seven participants, 15 males and 12 females from four countries, participated in the focus group interviews. The analysis of the collected data resulted in three main categories: “Information and knowledge about organ donation,” “The priorities when deciding about organ donation” and “The religious aspects of organ donation,” including a number of subcategories. Good information about and knowledge of OD, priorities in OD, importance of the fact that religion must be studied and taught daily and religious education were only a few of the factors informants emphasized as predictors of the total and successful donation of organs. Age, gender or religion did not have an impact on organ donation. High levels of education through religious education and good information via various media, as well as a good knowledge of the Swedish language, are predictors of improved OD. In order to overcome religious ideology as a source of misinformation relating to OD and to promote increased OD in the future, specific intervention studies and the improved involvement of religious communities and education in schools and the healthcare system are vital and must be a starting point for improved OD.

Background School-based alcohol, tobacco, and other drug use (ATOD) surveys are a common epidemiological means of understanding youth risk behaviors. They can be used to monitor national trends and provide data, in aggregate, to schools, communities, and states for the purposes of funding allocation, prevention programming, and other supportive infrastructure. However, such surveys sometimes are targeted by public criticism, and even legal action, often in response to a lack of perceived appropriateness. The ubiquity of social media has added the risk of potential online firestorms, or digital outrage events, to the hazards to be considered when administering such a survey. Little research has investigated the influence of online firestorms on public health survey administration, and no research has analyzed the content of such an occurrence. Analyzing this content will facilitate insights as to how practitioners can minimize the risk of generating outrage when conducting such surveys. Objective This study aimed to identify common themes within social media comments comprising an online firestorm that erupted in response to a school-based ATOD survey in order to inform risk-reduction strategies. Methods Data were collected by archiving all public comments made in response to a news study about a school-based ATOD survey that was featured on a common social networking platform. Using the general inductive approach and elements of thematic analysis, two researchers followed a multi-step protocol to clean, categorize, and consolidate data, generating codes for all 207 responses. Results In total, 133 comments were coded as oppositional to the survey and 74 were coded as supportive. Among the former, comments tended to reflect government-related concerns, conspiratorial or irrational thinking, issues of parental autonomy and privacy, fear of child protective services or police, issues with survey mechanisms, and reasoned disagreement. Among the latter, responses showed that posters perceived the ability to prevent abuse and neglect and support holistic health, surmised that opponents were hiding something, expressed reasoned support, or made factual statements about the survey. Consistent with research on moral outrage and digital firestorms, few comments ( Conclusions The components of even a small online firestorm targeting a school-based ATOD survey are nuanced and complex. It is likely impossible to be fully insulated against the risk of outrage in response to this type of public health work; however, careful articulation of procedures, anticipating specific concerns, and two-way community-based interaction may reduce risk.

Squalene-based adjuvants have been included in influenza vaccines since 1997. Despite several advantages of adjuvanted seasonal and pandemic influenza vaccines, laypeople's perception of such formulations may be hesitant or even negative under certain circumstances. Moreover, in Italian, the term “squalene” has the same root as such common words as “shark” (squalo), “squalid” and “squalidness” that tend to have negative connotations. This study aimed to quantitatively and qualitatively analyze a representative sample of Italian web pages mentioning squalene-based adjuvants used in influenza vaccines. Every effort was made to limit the subjectivity of judgments. Eighty-four unique web pages were assessed. A high prevalence (47.6%) of pages with negative or ambiguous attitudes toward squalene-based adjuvants was established. Compared with web pages reporting balanced information on squalene-based adjuvants, those categorized as negative/ambiguous had significantly lower odds of belonging to a professional institution [adjusted odds ratio (aOR) = 0.12, p = .004], and significantly higher odds of containing pictures (aOR = 1.91, p = .034) and being more readable (aOR = 1.34, p = .006). Some differences in wording between positive/neutral and negative/ambiguous web pages were also observed. The most common scientifically unsound claims concerned safety issues and, in particular, claims linking squalene-based adjuvants to the Gulf War Syndrome and autoimmune disorders. Italian users searching the web for information on vaccine adjuvants have a high likelihood of finding unbalanced and misleading material. Information provided by institutional websites should be not only evidence-based but also carefully targeted towards laypeople. Conversely, authors writing for non-institutional websites should avoid sensationalism and provide their readers with more balanced information.

BackgroundOver 60% of military personnel in the United States currently use dietary supplements. Two types of dietary supplements, weight loss and sports performance (WLSP) supplements, are commonly used by military personnel despite the associated serious adverse effects such as dehydration and stroke.ObjectiveTo understand peer-to-peer communication about WLSP supplements among military personnel, we conducted a pilot study using the social media website, Reddit.MethodsA total of 64 relevant posts and 243 comments from 2009 to 2019 were collected from 6 military subreddits. The posts were coded for year of posting, subreddit, and content consistent with the following themes: resources about supplement safety and regulation, discernability of supplement use through drug testing, serious adverse effects, brand names or identifiers, and reasons for supplement use.ResultsA primary concern posted by personnel who used supplements was uncertainty about the supplements that were not detectable on a drug test. Supplements to improve workout performance were the most frequently used.ConclusionsOur pilot study suggests that military personnel may seek out peer advice about WLSP supplements on Reddit and spread misinformation about the safety and effectiveness of these products through this platform. Future directions for the monitoring of WLSP supplement use in military personnel are discussed.

Background Health misinformation is a public health concern. Various stakeholders have called on health care professionals, such as nurses and physicians, to be more proactive in correcting health misinformation on social media. Objective This study aims to identify US physicians’ and nurses’ motivations for correcting health misinformation on social media, the barriers they face in doing so, and their recommendations for overcoming such barriers. Methods In-depth interviews were conducted with 30 participants, which comprised 15 (50%) registered nurses and 15 (50%) physicians. Qualitative data were analyzed by using thematic analysis. Results Participants were personally (eg, personal choice) and professionally (eg, to fulfill the responsibility of a health care professional) motivated to correct health misinformation on social media. However, they also faced intrapersonal (eg, a lack of positive outcomes and time), interpersonal (eg, harassment and bullying), and institutional (eg, a lack of institutional support and social media training) barriers to correcting health misinformation on social media. To overcome these barriers, participants recommended that health care professionals should receive misinformation and social media training, including building their social media presence. Conclusions US physicians and nurses are willing to correct health misinformation on social media despite several barriers. Nonetheless, this study provides recommendations that can be used to overcome such barriers. Overall, the findings can be used by health authorities and organizations to guide policies and activities aimed at encouraging more health care professionals to be present on social media to counteract health misinformation.

Background In late March 2020, South Africa implemented a 5-stage COVID-19 Risk Adjusted Strategy, which included a lockdown that required all residents to remain home to prevent the spread of COVID-19. Due to this lockdown, individuals have been forced to find and use alternatives for accomplishing tasks including shopping, socializing, working, and finding information, and many have turned to the internet and their mobile devices. Objective This study aimed to describe how South Africans consume and internalize information surrounding the COVID-19 outbreak in order to determine whether the COVID-19 lockdown and social isolation have influenced technology behavior, particularly in terms of health communication and information. Methods From June 24 to August 24, 2020, people in South Africa were invited to complete a survey through the Upinion mobile app, an online data collection resource. The survey collected information on demographics, and technology use during the lockdown, and COVID-19 knowledge. Results There were 405 participants, of which 296 (73.06%) were female. A total of 320 (79.01%) participants had a tertiary school education, 242 (59.75%) were single, and 173 (42.72%) had full-time employment. The lockdown forced 363 (89.63%) participants to use more technology, especially for work (n=140, 24.05%) and social media/communication (n=133, 22.85%). Security or privacy issues (n=46, 38.98%) and unfamiliarity with technology (n=32, 27.12%) were identified as the most common issues faced by the 127 (31.36%) participants who were unsure about using technology prior to the lockdown. Almost all participants (n=392, 96.79%) stated that they would continue using technology after the lockdown. Multimedia (n=215, 53.09%), mobile phone content (n=99, 24.44%), and health organizations and professionals (n=91, 22.47%) were the main sources of COVID-19 information. Most participants (n=282, 69.63%) felt that they had enough information. Two-thirds (n=275, 67.90%) of participants stated that they had used their mobile phones for health information before the lockdown, with web searches (n=109, 26.91%), social media (n=58, 14.32%), and government and institutional websites (n=52; 12.84%) serving as their main sources of information. Overall, the mean COVID-19 knowledge score was 8.8 (out of 10), and 335 (82.72%) had adequate knowledge (scored ≥8). Males were less likely to identify the correct transmission routes, and single participants were less likely to identify the signs and symptoms of the coronavirus. Tertiary school graduates were 4 times more likely to correctly identify the routes and 2 times more likely to identify how to stop the spread of the virus. People aged 43-56 years were 4 times more likely to identify how the coronavirus can be prevented, and participants ≥57 years were 2.6 times more likely to obtain a knowledge score of 10 when compared to those under 29 years of age. Conclusions This study has shown that the COVID-19 lockdown has forced people to increase technology use, and people plan to continue using technology after the lockdown is lifted. Increased technology use was seen across a variety of fields; however, barriers including privacy, unfamiliarity, and data costs were identified. This population showed high COVID-19 knowledge, although the use of web searches and social media, instead of government and institutional websites, increases the potential for health misinformation to be spread.

Background Holding conspiracy beliefs regarding the COVID-19 pandemic in the United States has been associated with reductions in both actions to prevent the spread of the infection (eg, mask wearing) and intentions to accept a vaccine when one becomes available. Patterns of media use have also been associated with acceptance of COVID-19 conspiracy beliefs. Here we ask whether the type of media on which a person relies increased, decreased, or had no additional effect on that person’s COVID-19 conspiracy beliefs over a 4-month period. Objective We used panel data to explore whether use of conservative and social media in the United States, which were previously found to be positively related to holding conspiracy beliefs about the origins and prevention of COVID-19, were associated with a net increase in the strength of those beliefs from March to July of 2020. We also asked whether mainstream news sources, which were previously found to be negatively related to belief in pandemic-related conspiracies, were associated with a net decrease in the strength of such beliefs over the study period. Additionally, we asked whether subsequent changes in pandemic conspiracy beliefs related to the use of media were also related to subsequent mask wearing and vaccination intentions. Methods A survey that we conducted with a national US probability sample in March of 2020 and again in July with the same 840 respondents assessed belief in pandemic-related conspiracies, use of various types of media information sources, actions taken to prevent the spread of the disease and intentions to vaccinate, and various demographic characteristics. Change across the two waves was analyzed using path analytic techniques. Results We found that conservative media use predicted an increase in conspiracy beliefs (β=.17, 99% CI .10-.25) and that reliance on mainstream print predicted a decrease in their belief (β=–.08, 99% CI –.14 to –.02). Although many social media platforms reported downgrading or removing false or misleading content, ongoing use of such platforms by respondents predicted growth in conspiracy beliefs as well (β=.072, 99% CI .018-.123). Importantly, conspiracy belief changes related to media use between the two waves of the study were associated with the uptake of mask wearing and changes in vaccination intentions in July. Unlike other media, use of mainstream broadcast television predicted greater mask wearing (β=.17, 99% CI .09-.26) and vaccination intention (β=.08, 95% CI .02-.14), independent of conspiracy beliefs. Conclusions The findings point to the need for greater efforts on the part of commentators, reporters, and guests on conservative media to report verifiable information about the pandemic. The results also suggest that social media platforms need to be more aggressive in downgrading, blocking, and counteracting claims about COVID-19 vaccines, claims about mask wearing, and conspiracy beliefs that have been judged problematic by public health authorities.