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Benefits of CPD

CPD is an investment in yourself, linking formal and informal learning directly to your professional practice. A systematic approach to CPD will ensure that you maintain and enhance your skills and competencies supporting your career development aspirations. It can also build confidence, strengthen your professional credibility and employability prospects.

Professional competency is also a key part of our Code of Ethics and Conduct , which all members agree to abide by when joining or renewing their SET membership. The Code clearly states that members should aintain professional knowledge and competence through continuing professional development in both teaching and subject specialism' .

SET's approach to CPD

We expect members to illustrate their commitment to their own professional development and to uphold the Code of Ethics and Conduct. There is no mandatory requirement to formally record or submit CPD undertaken and SET will not audit its members CPD activity. However, we may undertake a group analysis of completed CPD logs to ascertain what types of CPD members are undertaking, how much and how often, to inform our future planning and further development of our CPD policy.

We firmly believe that CPD is a very personal journey which should focus on your own professional development needs and the results i.e. the outputs and outcomes of the activity undertaken and, most importantly, the difference it has had or is likely to have on your professional practice and ultimately your learners. SET does not therefore stipulate that a minimum number of CPD points or hours must be achieved each year; we are not looking for evidence of how much time has been spent on CPD.

Our full CPD policy and requirements can be read here .

The CPD Cycle

The CPD cycle breaks down the process of completing CPD into four key areas - identify, plan, act, reflect/evaluate. The four stages of the CPD cycle will be driven by you and will help you set your own development goals and objectives which should include both formal and informal leaning.

Identify: use the Professional Standards and Self-Assessment tool to identify areas and opportunities for professional development. Understand where you are now and where you want to be.

Plan: once you understand where you want to be the next step is to plan how you get there. Your plan should include anticipated outcomes and milestones so that progress can be tracked. Good practice is to plan on a 12-month cycle.

Act: once the plan is in place, then act upon it. Members are encouraged to undertake a mix of formal and informal CPD activities.

Reflect (evaluate): at the end of each CPD activity, members would be expected to reflect and evaluate the difference the CPD has made and how they will implement their learnings, including where appropriate, sharing insights within their own professional networks.

CPD resources

SET members have access to a range of member only CPD resources including live webinars and areas of special interest.

In addition, the Education and Foundation has a comprehensive range of workforce development programmes and activities. View courses. You may also wish to use the CPD mapping tool on the ETF website, which links the various CPD resources from ETF and SET to the Professional Standards.

As a benefit of membership, SET members also have access to an online CPD recording tool to help you plan and track your CPD. Members may have their own way to track CPD or may also have access to a CPD recording tool provided by their employer. We don't prescribe what tool should be used. The SET recording tool is a benefit of membership which enables you to link your CPD activity to the Professional Standards.

Questions/support

If you have a question about CPD or need further guidance or support please see our FAQs in the first instance or contact us.

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Benefits of CPD CPD is an investment in yourself, linking formal and informal learning directly to your professional practice. A systematic approach to CPD will ensure that you maintain and enhance your skills and competencies supporting your career development aspirations. It can also build confidence, strengthen your professional credibility and employability prospects.

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Transphobia statement is a milestone for the profession - CSP

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Transphobia statement is a milestone for the profession - CSP

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The statement

reaffirms the CSP commitment to challenging transphobia

directs members to their professional obligations as HCPC registrants

sets out a number of definitions of transphobia to inform members

commits the CSP to eight actions including developing safe spaces for learning about trans issues, providing advice on trans healthcare and challenging transphobia in the healthcare system.

Ishmael Beckford, chair of the CSP Council has called on members to educate themselves about transphobia, and drew attention to the CSP commitments in the document. He said:

'Publishing this statement is a significant milestone in our profession's journey in recognising and challenging transphobia and its negative impacts. This collaborative piece of work is a first step which will be supported by the delivery of the actions that the CSP has committed to.

'There is more we all need to do to ensure our physiotherapy community is inclusive and free from discrimination, so I'd encourage all members to review the statement and do whatever you can to educate yourselves around the experience of our transgender colleagues. I'd like to thank everyone that has been involved for their commitment and patience.'

Stephanie Land, chair of the CSP LGBTQIA+ network thanked all those who contributed to developing the statement, she said:

'As the chair of the LGBTQIA+ network, I would like to thank the CSP staff and members who have worked tirelessly towards this document and for the efforts and emotional labour put into this pivotal piece of work.

'This position statement on transphobia from the CSP is the first of its kind and is a vital first step as part of the CSP Equity, Diversity and Belonging strategy. I encourage all members of the CSP to read this, to reflect on the statement and the commitments set by the CSP to tackle transphobia in the profession and in wider society.

It is imperative that all CSP members, in their own day to day practice, ensure they are in line with the new HCPC Standards of Practice that relate to equity, diversity and belonging.

Sarine Baz, chair of the CSP Equity, Diversity and Belonging committee reiterated that transphobia is never acceptable.

She said: 'Expressing negative attitudes or feelings towards transgender individuals, or other transphobic actions, can't be tolerated. The CSP has worked in partnership to co-create this position statement pledging to challenge transphobia and change behaviours. I encourage all members to review, reflect and to take action to actively be trans allies in your practice.'

The CSP recognises that understanding of the manifestations of transphobia will evolve. We will need to update our position in light of experience and learning. The statement will therefore be reviewed and updated as the law or HCPC requirements change or when the CSP Equity, Diversity and Belonging committee recommends changes in light of evolving understanding.
We have now closed the comments section of this news item one week after its publication date as we are unable to continue monitoring and responding to questions from members here. We advise members to please contact CSP enquiries if you have any further questions - we will continue to add to the member FAQs where appropriate.

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Transphobia statement is a milestone for the profession

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Following dialogue involving our LGBTQIA+ Network and Equity, Diversity and Belonging committee, the CSP has adopted our first definitive position statement on transphobia.

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Strengths and weaknesses of affective touch studies over the lifetime: A systematic review

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Strengths and weaknesses of affective touch studies over the lifetime: A systematic review

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ScienceDaily discussing  'A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions'

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ScienceDaily discussing  'A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions'

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Through a large-scale analysis, researchers at the Netherlands Institute for Neuroscience have uncovered the ways in which consensual touch can benefit a person's physical and mental wellbeing.

You might recognize the comforting feeling when someone offers you a hug at the end of a stressful day or strokes your shoulder when you're feeling down. But the question remains: can touch really help you feel better, and does it matter who it's from or how they touch you? To explore these questions, researchers from the Social Brain Lab at the Netherlands Institute for Neuroscience and the University Hospital Essen conducted a large-scale analysis of studies exploring touch interventions.
The benefits of touch on mental and physical health
Does touch truly improve someone's wellbeing? It is an easy question to ask but more complicated to answer. Individual studies often only focus on specific instances and may contradict each other. Combining all these studies together for a large-scale analysis offers a clearer answer: yes, touch substantially improves both physical and mental wellbeing, for example via reduction of pain, anxiety, depression, and stress in adults. But in fact, those with physical or mental health problems (and therefore most in need of support) benefit even more from touch than healthy adults. "This is especially relevant considering how often touch interventions are overlooked" Packheiser, first author, adds.

"A key question of our study is to leverage the hundreds of individual studies out there to identify what type of touch works best," adds professor Keysers, director of the Social Brain Lab. "What if you don't have a friend or partner close by to hug you? Would touch from a stranger or even a machine also help? And how often? The study clearly shows that touch can indeed be optimized, but the most important factors are not necessarily those we suspect."

Interestingly, the person touching you, how they touch you, and the duration of their touch doesn't make a difference in terms of impact. A long-lasting massage by a therapist could therefore be just as effective as a quick hug offered by a friend. That is, until the frequency of the intervention is considered. The more often a touch intervention is offered, the greater the impact. A quick hug could therefore be even more impactful than a massage if it is offered more frequently.
Human or non-human touch?
The next question was whether touch intervention needs to be human at all. As it turns out, object or robot interventions can be equally effective at improving physical wellbeing. "There are lots of people in need of wellbeing improvements, perhaps because they're lonely but also because they may be inflicted by clinical conditions. These results indicate that a touch-robot, or even a simple weighted blanket has the potential to help those people," last author Frédéric Michon explains. However, the benefits of robot and object interventions are less effective for mental wellbeing. Mental health disorders like anxiety or depression might therefore require human touch after all, "perhaps suggestive of the importance for an emotional component associated with the touch," Michon point out.

While the researchers were equally curious about human-to-animal contact, studies exploring this question are still lacking. "It would be useful to see whether an animal's or pet's touch could improve wellbeing, and inversely if they also benefit from it, but unfortunately there simply aren't enough studies, or properly controlled ones, for us to draw any general conclusions on these topics," Michon clarifies.
Touch interventions across ages
When the team looked into the impact of touch on newborns, they found out that newborns also benefited significantly from touch. However, the person conducting the touch intervention was more important: the benefits of touch are higher when done by a parent instead of a healthcare worker. "This finding could be impactful," Packheiser adds. "Death rates due to premature births are high in some countries and the knowledge that a baby benefits more from the touch of their own parent offers another easily implementable form of support for the baby's health."

Due to a lack of studies, it proved difficult to draw conclusions about children and teenagers. "Large scale studies like this help us draw more general conclusions but they also help us identify where research is lacking," Michon explains. "We hope that our findings can steer future research to explore lesser-known questions. This includes animal touch, but also touch across ages, and in specific clinical settings like autistic patients, another category that has not been explored extensively."

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alternative medicine; mental health research; chronic illness; fitness; perception; mental health; depression; disorders and syndromes

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New study highlights the benefit of touch on mental and physical health

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Through a large-scale analysis, researchers have uncovered the ways in which consensual touch can benefit a person's physical and mental wellbeing.

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Credible or Questionable? Assessing Quality of Evidence Presented on Social Media

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Credible or Questionable? Assessing Quality of Evidence Presented on Social Media

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Digital professionalism on social media: A narrative review of the medical, nursing, and allied health education literature

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Digital professionalism on social media: A narrative review of the medical, nursing, and allied health education literature

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Identifying Credible Sources of Health Information in Social Media: Principles and Attributes

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Identifying Credible Sources of Health Information in Social Media: Principles and Attributes

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Helen Burstin, MD, MPH, MACP, Susan Curry, PhD, Megan L. Ranney, MD, MPH, Vineet Arora, MD, MAPP, Brian Boxer Wachler, MD, Wen-Ying Sylvia Chou, PhD, MPH, Ricardo Correa, MD, EdD, Donna Cryer, JD, Don Dizon, MD, FACP, FASCO, Efrén J. Flores, MD, Gerald Harmon, MD, Anjali Jain, MD, Kevin Johnson, MD, MS, FAAP, FAMIA, FACMI, Christine Laine, MD, MPH, Lindsey Leininger, PhD, Graham McMahon, MD, MMSc, Laura Michaelis, MD, Ripudaman Minhas, MD, MPH, FRCPC, FAAP, Richard Mularski, MD, MSHS, MCR, ATSF, FCCP, FACP, John Oldham, MD, MS, Rema Padman, PhD, FAMIA, Claude Pinnock, MD, MPH, Jessica Rivera, MS, Brian Southwell, PhD, Antonia Villarruel, PhD, RN, FAAN, and Katrine Wallace, PhD, CPH

Introduction

A recent review suggests that 5.03 billion individuals use the Internet worldwide, with approximately 4.70 billion, or 59% of the global population, using some form of social media ( Kemp, 2022). While it is challenging to determine overlap across platforms, it has been reported that worldwide exposure to information on either Facebook or YouTube1 is in excess of 2 billion people each ( Meta, 2022; YouTube, 2022). The Pew Research Center reported that approximately 72% of adults in the United States use at least one social media outlet ( Pew Research Center, 2021). It is estimated that some 90% of Americans use social media sources for health information, including searches related to serious conditions, general information searches, and searches for minor health problems ( Bishop, 2019). Research demonstrates that online information can influence health beliefs, health behaviors, and decisions about seeking health care ( Chen et al., 2018; Tan and Goonawardene, 2017).

In the context of so much of the public using the Internet and social media to inform health decisions, stakeholders-including medical and public health professionals-have raised serious concerns about the quality and reliability of health information on social media due to the lack of standards or regulations around what is posted and how content is monitored ( Wang et al., 2019; Broniatowski et al., 2018). These concerns were heightened during the COVID-19 pandemic, and recent reports have found an increased volume of health mis- and disinformation online during the pandemic ( Borges do Nascimento et al., 2022; Khullar, 2022; OSG, 2021). While mis- and disinformation about health care topics are neither new nor unique to social media, the viral nature of some posts, the presence of platform algorithms that elevate popular content, and limited resources to vet every item posted to social media amplifies the volume of misinformation that readers are exposed to on all social media channels.

In response to these concerns and the proliferation of mis- and disinformation online, Google/YouTube2 has supported efforts, conducted in two phases by independent groups, to develop principles and attributes to guide social media and other digital platforms to rigorously identify credible sources of health information. Through such identification, consumers could be directed to credible sources first when they search for health information online. However, the authors of this paper recognize that identification of credible sources may not be sufficient to ensure that consumers are accessing high-quality information, and social media companies may need to employ parallel strategies such as content assessment, management of misinformation, addressing health literacy and culturally competent communication, and developing avenues for sources to self-regulate in order to truly address this complex issue.

The first phase of this work (Phase 1) was completed in 2021 by an expert advisory group convened by the National Academy of Medicine (NAM), which yielded foundational principles and attributes for determining credibility of health information sources3. The scope of Phase 1 was limited to U.S.-based entities and concentrated on identifying credibility among nonprofit and government entities with established vetting or accrediting procedures. In Phase 1, described below, the expert advisory group proposed three foundational principles to support assessment of source credibility and developed attributes for assessing a source's alignment with the principles ( Kington et al., 2021).

Phase 1: Foundational Principles, Attributes, and Additional Findings

In Phase 1, an expert advisory group proposed three foundational principles to support the assessment of credibility of online sources of health information: 1) science-based; 2) objective; and 3) transparent and accountable. The members of the expert advisory group also provided a selection of material attributes that can be used by social media companies and others, including consumers, to assess a source's alignment with the three principles ( Kington et al., 2021). See Table 1 for an overview of these principles and attributes.

TABLE 1

Principle

Attributes (Phase 1)

Science-based: Sources should provide information that is consistent with the best scientific evidence available at the time and should meet standards for the creation, review, and presentation of scientific content.

Acknowledges the limitations and evolution of knowledge

Clearly labels information with the date it was last updated and strives to reassess and update content

Demonstrates subject-specific expertise

Links to and is linked to by other credible sources [ a]

Provides citations for information shared and evidence to justify claims

Synthesizes information from multiple sources, rather than a single source

Uses a consensus process to develop the information shared [ b]

Uses peer review or another form of content review to vet information before sharing [ c]

Objective: Sources should take steps to reduce the influence of financial and other forms of conflict of interest or bias that might compromise or be perceived to compromise the quality of the information they provide.

Keeps health information separate from financial, political, or ideological messages

Maintains independence from funders [ d]

Separates lobbying activities from health information (or does not engage in lobbying)

Does not include advertisements with relevant health information (or does not host advertisements at all) [ e]

Transparent and accountable: Sources should disclose the limitations of the information they provide, as well as conflicts of interest, content errors, or procedural missteps.

Discloses financial and nonfinancial conflicts

Discloses relevant policy positions and lobbying activities

Follows FACA regulations or similar transparency policies [ f]

Posts public corrections or retractions

Prioritizes accessibility and equitable access to information

Provides a mechanism for public feedback

Shares data, methods, or draft recommendations

As noted by Kington and colleagues in a flowchart for credibility of sources of health information (see Figure 1 ) in Phase 1, organizational sources could be afforded a preliminary assumption of credibility if they were subject to pre-existing, standardized vetting mechanisms, including government accountability, accreditation, and academic journal indexing. Entities considered by the Phase 1 process included nonprofit and government sources like government organizations, academic journals, accredited health care organizations, educational institutions, and public health departments in the U.S.

In addition to identifying factors to assist in determining credibility, the Phase 1 expert advisory group also identified three key areas to be considered in the ongoing mission to elevate credible content.

The Phase 1 expert advisory group limited their deliberations to principles and attributes that could be applied to U.S.-based organizations. The World Health Organization (WHO), after the release of the Phase 1 paper, convened an expert panel to assess this initial guidance from a global perspective, and recommended that further work be done to extend the principles to make them more generalizable to international audiences. Globalization then became one of the charges to the authors of this paper (Phase 2).

The Phase 1 expert advisory group also identified health equity, diversity, and inclusion as critical components to be included in any system used to elevate credible sources.

Finally, while outside of the scope of work for both Phase 1 and 2, the Phase 1 expert advisory group highlighted the importance of content review, implementation, and research on the impact of credibility designations as important future directions for this work.

Phase 2: Advisory Committee Charge and Scope

Phase 2 was carried out by a multidisciplinary, independent advisory committee convened by the Council of Medical Specialty Societies (CMSS), in collaboration with NAM and WHO. The committee was charged with adapting the principles and attributes established in Phase 1 to allow for the evaluation of the credibility of other health information sources, including other nonprofit entities, for-profit entities, and individuals, with an eye towards global applicability (see Box 1).

Box 1

Construct a globally relevant, expanded set of principles, attributes, and definitions applicable to a wider group of potential sources of credible information

Building upon the seminal work completed in Phase 1, the Phase 2 advisory committee was charged with considering three additional potential sources for health information found on various social media platforms:

1.

Nonprofit organizations without pre-existing standardized vetting mechanisms, including foundations, patient disease organizations, community health organizations, and think tanks;

2.

For-profit entities, including drug or device manufacturers; and

3.

Individuals, including scientists and clinicians, other professionals, and patients.

This wide-ranging group of sources presented a variety of potential issues around feasibility of credibility assessment and varying levels of transparency into how health information was collected and content was generated.

Methods

For consistency and transparency, the methods and processes employed during Phase 2 were substantively similar to those employed during Phase 1 ( Kington et al., 2021). Additionally, the Phase 2 advisory committee adopted the definitions of 'credible' and 'high-quality information' established during Phase 1 (see Box 2) and began their deliberations with the foundational principles and attributes proposed in Phase 1 and reaffirmed by the WHO ( WHO, 2022; Kington et al., 2021).

Box 2

The following are definitions and discussions of the key terms established in Phase 1 and used in the present paper (refer to Kington et al., 2021, for full discussion).

Credible

For the purposes of this paper, the authors present their own definition of credible in the context of sources of online health information: "offering information that is consistent with the best scientific evidence available at the time and employing processes to reduce conflict of interest and promote transparency and accountability."

High-Quality Information

High-quality information is that which is "science-based," or consistent with the best scientific evidence available at the time. Science and knowledge are always evolving, so the marker of time is an important component of this definition. The evolution of knowledge is also the reason that more absolute terms, such as accurate, are less appropriate. Although this paper does not consider information quality directly, increasing access to high-quality information is the goal of the approach under discussion.

Composition and Selection of the Advisory Committee

The advisory committee is composed of independent volunteers who were nominated by CMSS, WHO, and NAM based on their subject matter expertise. Individuals were not eligible to participate on the committee if they were currently employed by social media companies. The committee included authors of the Phase 1 paper and new members from multiple disciplines including information governance, health information development, public health and health equity, social media and misinformation, and science communication.

Managing Conflict of Interest

Similar to Phase 1, in order to minimize conflicts of interest, CMSS, WHO, and NAM took steps to ensure the independence and objectivity of the advisory committee and this paper, in that authors were required to disclose financial and non-financial conflicts of interest ( Kington et al., 2021). This paper represents the opinions of the authors and does not reflect a consensus position of CMSS; NAM; the National Academies of Sciences, Engineering, and Medicine; WHO; or the authors' organizations. The advisory committee did not receive payment for their contributions to this paper.

Deliberative Sessions

The authors of this paper participated in one recorded orientation session, which was asynchronously viewed by the group, and three virtual, interactive, closed deliberative sessions between July and October 2022. Representatives from Google/YouTube attended the first live virtual session to explain the company's current policies, initial experiences with implementing Phase 1, and future goals regarding elevating high-quality health information from different sources, as well as answer questions from the authors. Representatives from Google/YouTube did not attend any part of the subsequent deliberative sessions, and were not involved in committee discussions, in drafting the principles and attributes, or in drafting or reviewing this paper.

Approach and Timeline

The Phase 2 advisory committee examined and deliberated on the three principles established during Phase 1 and their defining attributes in individual breakout groups that each focused on one of three potential sources of credible health information: for-profit organizations, non-accredited nonprofit organizations, and individuals. Each breakout group outlined attributes of each principle that were relevant to the assigned Phase 2 source. Each breakout group aimed to identify the key attributes for that source, focusing on those that were important to credibility, were identifiable, and were practical to implement.

Next, the entire committee virtually discussed and prioritized the suggested attributes from each breakout group, stating whether they agreed or disagreed with each revision and rating the attribute as Very Important, Important, or Not Very Important for each source. Items ranked as Not Very Important for a source were deleted, and items ranked as Important or Very Important would potentially be incorporated. At the next meeting, the breakout groups reconvened separately to discuss and critically assess the attributes suggested and prioritized by the entire committee for each source of information.

Public Comment Period

A draft of the proposed new attributes, a related questionnaire, and a preliminary draft of this paper were posted for public comment by CMSS from 12:00 PM CST on September 9, 2022, to 11:59 PM CST on September 19, 2022. Comments were specifically solicited from interested parties, including researchers, medical specialty society leadership, clinicians, creators of online health information, for-profit and non-profit organizations, health care providers, and members of the public. The committee reviewed all comments received. The comments were analyzed, sorted into themes, and summarized by program staff and the authors of this paper (see Box 3 for key themes from the public comment period and the committee's response).

Box 3

The feedback generally supported requiring all sources to meet all principles and to meet a preponderance of prioritized attributes.

Committee: The committee agreed with commenters that a preponderance of attributes was appropriate. However, the committee determined that compliance with all attributes would be unrealistic, especially for the global community. The committee suggests that discussions about this approach continue beyond the publication of this paper.

There was strong support for the importance of science-based and objective attributes, especially regarding use of citations that have undergone peer review.

Commenters indicated strong support for disclosure of any sponsored and paid partnerships. Some commenters noted that this area needed more consistency across all sources. Commenters also noted the variability across social media platforms, including the inability to provide standardized bios or link to sources on some platforms (e.g., Twitter, TikTok).

Committee: Consider disclosure of "financial relationships" regardless of whether those financial relationships present a conflict of interest or not.

There were many comments related to advertising revenue received by creators from social media platforms. Commenters referred to existing guidelines and guardrails in place to protect consumers (e.g., FTC regulations). Commenters recommended referencing existing guidelines and regulations.

Committee: While the committee believes that advertising revenue is not necessarily something that requires disclosure (unlike paid partnerships), focus on regulations alone (e.g., FTC regs) would only be applicable in the U.S. (not globally).

Some commenters raised concerns around highlighting "does not engage in lobbying" for non-profit organizations since some may lobby on issues unrelated to the health information.

Committee: The current attribute allows for lobbying if it is "separate from health information," but the wording of this attribute was updated and clarified.

There was strong support for a testing or trial period on the accuracy of source attestation to the principles and attributes.

Commenters also noted concerns about sources that are deemed credible that post misinformation. Potential solutions included on and off ramps for credibility assessment or regular attestation by social media platforms.

Most commenters considered the principles and attributes appropriate from a global perspective and noted several non-U.S.-centric platforms for consideration (e.g., WeChat, WhatsApp, LINK Social).

The feedback generally supported the new principle of inclusiveness and equitability. Some comments noted the need for further enhancement of the new principle and attributes, providing clarity around "diversity of voices" across a channel, and more information on how this principle might be operationalized.

Committee: Important aspirational call for improvement that may provide a future path to increase diverse voices.

Committee: Appreciated focus on targeted audiences.

Committee: Provides a cross-cutting theme for other criteria.

The final virtual meeting was then convened so the entire committee could discuss and incorporate feedback from the public comment process.

Phase 2 Principles

The Phase 2 advisory committee accepted the foundational principles developed during Phase 1 and discussed the relevance and applicability of the original attributes to the sources of information prioritized for examination during Phase 2. The Phase 2 advisory committee unilaterally agreed that all information, independent of source, should be held to the principles of being science-based, objective, and transparent and accountable. Although there is overlap between the principles of science-based and objective, the Phase 2 advisory committee distinguished between them by noting that objective focuses more on avoiding potential conflict of interest. Discussion of incorporating values of diversity, equity, and inclusion (DEI) arose throughout all principles and across all information sources. As a result, a new principle targeting inclusiveness was drafted and included in the Phase 2 final principles.

To address some of the challenges of implementing the proposed principles and attributes, the Phase 2 advisory committee suggested modifications to the Phase 1 attributes to make them more applicable to the information sources prioritized during Phase 2 (see Table 2 ) and discussed how to ensure, within all the principles and attributes, that credibility is actually achievable (see Table 2 for all proposed modifications to the attributes).

Principle: Inclusive and Equitable

The Phase 2 advisory committee identified DEI as a cross-cutting theme of sufficient importance to elevate it as a new principle. The Phase 2 advisory committee then drafted attributes that could help in the evaluation of adherence to DEI standards for all potential sources of credible information in a global context, including those considered in Phase 1. The Phase 2 advisory committee believes this principle is necessary to ensure that the suggested attributes included with the other three principles do not inadvertently suppress credible information from diverse sources and voices (see Box 4 for more details about the new principle and Table 2 for a complete list of all principles and attributes). The Phase 2 advisory committee recognizes that the new principle includes attributes that apply to both content and source and therefore exceed the scope of work for this paper. Still, the Phase 2 advisory committee agreed that this new principle and accompanying attributes are an important aspirational call for improvement in the credibility of online health information and must be included.

Box 4

Principle

Inclusive and Equitable: Sources should prioritize inclusion of diverse, equitable, and trusted voices for health information that reflect the demographics of the audience

Attributes

Use accessible and culturally appropriate language for intended population

Avoid stigmatizing language about specific groups of people

Prioritize equitable access to health information

Contextualize and make research relevant for the intended population

Credibility Factors

While the overarching principles from Phase 1 were retained into the Phase 2 work, it became apparent through discussion that the individual attributes for each principle may differ across the sources prioritized in Phase 2. Each of the potential sources of health information considered in Phase 2 brings different challenges to both establishing credibility and avoiding inadvertently diminishing the reach of diverse voices.

For example, when considering information developed by for-profit organizations, such as a pharmaceutical manufacturer, the underlying motive is often to drive customers to the business. However, for-profit businesses may provide highly useful and credible information for patients, including education and resources. Regarding the reach of diverse voices, there is a concern about the risk of setting the bar of credibility at a level where it is never attainable by a given source. If credibility is not attainable, then diverse voices may be inadvertently or indirectly silenced. Conversely, while nonprofit organizations may be perceived as having a higher level of transparency and credibility than for profit organizations, nonprofits are often motivated to increase brand awareness and fundraising, which can raise similar concerns to those regarding for-profit motivations and potential conflicts of interest. Therefore, credibility needs to be uniquely assessed for nonprofits and for-profits, and an iterative process is needed to off-ramp or on-ramp entities based on how well they meet the criteria necessary to be deemed credible. Edits to these attributes across the sources of information prioritized in Phase 2 can be found in Table 2 .

The advisory committee proposed that the attributes within each principle could be prioritized to allow social media platforms to focus on the most essential attributes necessary to identify credible sources of health information. Pragmatically, the Phase 2 advisory committee determined that the sources of information could be required to meet only a preponderance of the attributes, rather than demonstrating adherence to each and every attribute. Understanding that it may seem like a loophole to allow sources to meet only a preponderance of the attributes, the Phase 2 advisory committee worked to balance an ideal set of attributes with the inability of most sources, even those with significant resources, to realistically meet all the attributes necessary to be deemed credible. The advisory committee believes that meeting a preponderance of the attributes will allow for an effective deployment of this framework into actual practice.

Source-Specific Considerations

The Phase 2 advisory committee outlines below some of the important points raised during discussion of each source of information prioritized in Phase 2 and some suggestions to address concerns in assessing each individual source's level of credibility.

Non-Accredited Nonprofit Organizations

There was some discussion around the special nature of non-accredited nonprofit organizations. For example, accreditation can be a fluid state, whereby an organization may enter into and fall out of accredited status. If, for example, an accredited nonprofit loses its accreditation, it should be further vetted against the principles and attributes developed in Phase 2 and listed in Table 2 . Alternatively, a non-profit that achieves new accreditation could then be solely considered against the principles and attributes outlined in Phase 1. Due to the fluid state of accreditation, it will be necessary to re-vet an organization periodically to determine its status and where it falls within the scope of defined attributes. Because there is no pre-existing vetting mechanism for the sources prioritized in Phase 2, social media companies should develop a standardized process and reassessment intervals for evaluating source alignment with the principles and attributes outlined in Table 2 .

Organizations with nonprofit status tend to be viewed with a halo of credibility, impartiality, or in a positive light due to the nature of their mission. However, it should be recognized that nonprofit organizations, which are typically mission-driven, can still be sources of mis- or disinformation. While one of the important attributes underpinning the principle of science-based is providing citations and a synthesis of information from multiple sources, the Phase 2 advisory committee was concerned with the potential for citing pseudoscience or selectively choosing references that support a particular viewpoint without identifying and discussing conflicting evidence. The Phase 2 advisory committee also suggested that social media companies examine the currency of citations, where older information may be cited and newer citations demonstrating the progression of knowledge on a particular subjected may be ignored or not updated in a timely manner.

In terms of transparency, many nonprofits create information to facilitate fundraising efforts, which raises the question of whether content used for fundraising is less legitimate than other types of content. The Phase 2 advisory committee believes that delegitimizing such content could be needlessly punitive. Another consideration regarding transparency is that many nonprofits are beholden to very few or even a single funder. Therefore, even if a nonprofit attempts to maintain independence, it may not be possible to completely remove the bias of what the funder would want or not want represented. Finally, some nonprofits obtain most of their funding from revenue streams such as subscriptions (to journals or products), membership dues, or from annual society meetings, which can include income from vendors renting booths or advertising in journals. A potential approach a nonprofit in this situation could take to abide by the principle of transparency would be to clearly describe their process for segregating their funding sources from the health information presented.

For-Profit Organizations

Several themes arose during discussion of for-profit organizations, with the Phase 2 advisory committee expressing many similar points to the discussion of non-accredited nonprofit organizations. In many cases the overlap between these two sources of content was so broad that there is potential for the attributes for the different sources to be condensed and applied across both source types. The Phase 2 advisory committee discussed the tension between completeness of information for each potentially credible source and the pragmatic need for ensuring that implementation of the criteria is practical on a global scale across a variety of social media platforms.

The Phase 2 advisory committee recognized that all groups presenting health information, inclusive of nonprofits and individuals, would potentially realize financial or non-financial gains should they be deemed a credible source and elevated as such. Additionally, the Phase 2 advisory committee recognized that deeming one source as credible may potentially confer a commercial advantage over another source that was not deemed credible. However, determining the credibility of for-profit organizations is even more challenging in that they are, by definition, seeking financial gain through the dissemination of health information. This motive, on its own, establishes an explicit conflict of interest as the dissemination of health information cannot be uncoupled from pursuing financial gain. With that understood, for-profit organizations can mitigate concerns about this and other conflicts of interest by demonstrating adherence to the principles of being science-based, objective, transparent, and inclusive and equitable; not promoting their own product in health information posts; and meeting the attributes that support the principles outlined in Table 2 . The Phase 2 advisory committee also acknowledged that for-profit entities (and individuals and non-profits supported by these for-profit entities) may be subject to U.S. Federal Trade Commission (FTC) and U.S. Food and Drug Administration regulations regarding allowable promotion of products.

Individuals

Identifying credibility attributes of individuals was identified by the Phase 2 advisory committee as their most challenging task.

Consideration of this group covers both individuals on their own and individuals within the context of an organization. One of the complex issues considered by the Phase 2 advisory committee is the relationship of an individual to their organization. For example, if an individual is the chief medical officer of a health system, how is their individual credibility related to the credibility of the organization? The relationship of the individual's credibility to the credibility of the organization would, necessarily, be informed by the status and attributes for credibility of the organization as a whole. Individual sources may not represent the consensus view of their organization and organizations may have a limited oversight role of the social media presence of individuals within the organization. There was agreement within the Phase 2 advisory committee that it may not be possible to hold individual sources to the same attributes as nonprofit or for-profit organizations with large staffs-particularly regarding attributes such as the use of a consensus process to develop the information that the individual is sharing (which would be untenable for a true individual). However, the Phase 2 advisory committee believes that, in order to be compliant with the principles listed in Table 2 , individuals should consult experts and evidence-based sources on a topic prior to sharing information on social media.

Another attribute that posed a potential untenable burden on individuals was the criterion of updating content as science and knowledge evolves. The Phase 2 advisory committee felt it was unrealistic to expect individual creators to continue to update their posts constantly or frequently, but it was agreed that having an initial date accompany the posting was an important criterion to keep. The Phase 2 advisory committee also thought that it was reasonable for individuals to link out to other high-quality sources, but that it did not seem practical to expect that an individual would need to have other organizations or individuals linking to them as a marker of credibility.

The Phase 2 advisory committee believes that documentation of funding, advertising, and paid partnerships is particularly important for individuals to disclose. Additionally, it is important to delineate between content for which an individual is paid versus content that is strictly advertising, sponsored content, or lobbying. Some, but not all, social media platforms have requirements for clearly labeling advertising, so in the absence of this requirement, creators should disclose this themselves. Moreover, in some countries, local guidelines and regulations require these disclosures on social media posts, including the FTC ( CFR, 2009). From a practical standpoint, it might be sufficient for individuals to provide attestations about independence of funding, but this is an issue to be considered in implementation.

Another challenge is establishing the credibility of an individual and their lived experience, and distinguishing "health stories" from "health information." More specifically, information about various facets of the health care system and health care delivery from patients with lived experience is considered important for peer support and essential for clinical guideline development and patient-centered research. Online peer support in self-management of health concerns is a valued and valuable source of information for individuals living with illness, especially when clinical information is lacking. However, anecdotal health stories may or may not be based on scientifically reliable information, and although stories matter, they do not necessarily meet foundational principles of credibility regarding science-based information.

The Phase 2 advisory committee discussed various mechanisms to identify the scientific or medical credentials of individuals, as these could be considered important attributes for credibility. However, trying to find a single credential that is used across nations and the world is a significant barrier, as a single credential does not exist. While U.S. health care professionals may carry board certification and other credentials, these are not universally available in the global community. Relatedly, credible lay individual sources may not have such credentials, and ultimately, possession of such credentials does not necessarily ensure credibility ( Rubin, 2022). The Phase 2 advisory committee suggested that individuals could provide disclosures of regionally appropriate licensure, education, training, and scientific expertise to social media platforms while recognizing that at present, not all social media platforms provide the means for an individual to disclose such information.

However, it is important to underscore that the Phase 2 advisory committee believes that individuals should be held accountable to the same principles as the other sources described in Phases 1 and 2, although the specific attributes may need to be modified to make credibility more achievable for an individual.

Implementation

Establishing a set of principles and attributes by which sources can be deemed credible is a vital first step, but the proof of its effectiveness will be in the implementation of these criteria. The use of these principles and attributes in elevating credible sources needs to be evaluated with a critical eye both towards applicability for the global community and across multiple social media platforms. The Phase 2 advisory committee agreed that attestation alone, while a first step, would be insufficient for establishing source credibility. The Phase 2 advisory committee therefore supported creating a standardized biographical statement or attestation for individual sources to use to consistently link to key attributes like licensure, expertise, and conflicts of interest across social media platforms. Ideally, these attributes should be able to be verified independently. Moreover, the Phase 2 advisory committee believes that source credibility must be reviewed regularly to both allow new sources to become credible and to remove sources that no longer meet credibility criteria. Specific criteria to be evaluated within each attribute should be considered within the context of local regulations (e.g., FTC regulations in the U.S. regarding advertisements). From an end-user standpoint, the Phase 2 advisory committee believes it is valuable for the consumer to understand the factors used to define the credibility of a source. The Phase 2 advisory committee also encouraged as much consistency as is feasible in the application of attributes across social media platforms. Finally, beyond the present goal of identifying credible sources, the Phase 2 advisory committee emphasized the need to further explore pragmatic and effective means of managing the larger issue of health-related mis- and disinformation online.

Assessment and Testing of the Processes

The first paper in this series extensively outlined a series of steps to be undertaken when assessing sources of information that cannot be afforded a preliminary assumption of credibility ( Kington et al., 2021). Those sources are the focus of this paper. Social media platforms will need to develop standardized processes to assess how well a given source aligns with the principles and attributes that would allow for a judgement of credibility. These standardized processes might rely on primary data collected by the platforms themselves or could rely on secondary data provided by the source.

Recognizing the implementation challenges that are likely to occur, the Phase 2 advisory committee agreed that it is essential to iteratively test how algorithms perform in accurately flagging credible sources of valid health information, and, ultimately, how consumers make use of the results. The Phase 2 advisory committee also emphasized that testing of the assessment process itself will be critical both prior to wide-scale implementation of assessing sources (through use cases and pilot tests), and over time (by following potential credible sources longitudinally) to determine whether the processes are functioning as intended and whether there is evidence of inadvertent harm. The Phase 2 advisory committee believes that this testing should include global social media platforms. The Phase 2 advisory committee encourages social media platforms to develop transparent, standardized, digitally verifiable processes to assess how well a source aligns with the principles and attributes that would allow for a judgment of credibility. Lastly, the Phase 2 advisory committee encourages social media platforms to collaborate with research experts to assess the impact and validity of identifying credible sources and elevating them on their platforms.

Conclusion

Given increasing challenges to accessing high-quality health information on social media, elevating credible sources of health information online will assist consumers in finding information they can trust. The COVID-19 pandemic highlighted how vast amounts of misinformation and disinformation damaged individual and population-level health and even life expectancy. Social media platforms that elevate the most viewed posts, regardless of source credibility, potentially contribute to the viral spread of misinformation. As more people search for health information on social media, it is therefore critical that social media platforms provide indicators that identify and elevate the most credible sources of health information. Ideally, consumers would choose to consider sources deemed most credible in their personal evaluation of health information sources.

The advisory groups convened in both Phase 1 and Phase 2 of this work agree that research undertaken by social media platforms will be most valuable and useful if the research data and processes are shared externally in a transparent manner.

Building on the prior work of the advisory group convened by the NAM in 2021 that yielded the foundational principles and attributes for determining credibility of health information sources, this paper provides guidance for a wider range of potential sources, including the full range of non-profit and for-profit organizations and individual sources. The additional guidance provided in this paper in Phase 2 will further the goal of identifying and elevating credible sources of health information, although the Phase 2 advisory committee acknowledges that more work remains to be done.

In particular, the new principle on the importance of promoting diverse and equitable voices on social media will require support from funders, government agencies, and social media platforms to assist historically marginalized groups, including patient groups and community-based non-profits, to be able to offer social media content that is grounded in evidence and free of bias. Both grant makers and accredited organizations, who are subject to the Phase 1 principles, should support the development of credible health content by authentically representative groups or individuals through their research agendas, grantmaking, and partnerships between accredited organizations and community-based groups. Ideally, all types of groups-including patient organizations, community organizations, and individuals-will see a benefit to attesting to scientific rigor, objectivity, transparency, and inclusivity through greater visibility of their social media content.

While this paper provides principles and attributes on the full array of potential sources for social media platforms, source credibility is likely to be dynamic and periodic reassessment of source credibility may be required. In addition, source credibility may not be an adequate protection against misinformation if sources do not uniformly share credible content. The Phase 2 advisory committee encourages social media platforms to iteratively test how algorithms perform in accurately identifying credible sources of health information.

Ultimately, by applying and evaluating this committee's principles and attributes of credible sources, social media platforms may be able to elevate credible health information sources and potentially break the cycle of misinformation.

Appendix A: Project Team

Council of Medical Specialty Societies (CMSS)

Julia Peterson, CAE, Chief Operating Officer

Suzanne Pope, MBA, Project Manager

National Academy of Medicine (NAM)

Laura DeStefano, Director of Strategic Communications & Engagement

World Health Organization (WHO)

Andrew Pattison, MS, Team Lead, Digital Channels

Monta Reinfelde, MS, Technical Officer, Digital Communications

Sigma Health Consulting, LLC

Kristen E. D'Anci, PhD, Science Writer, Senior Manager

Frances M. Murphy, MD, MPH, Expert Advisor, President & CEO

Acknowledgments

This paper benefitted from the thoughtful input of Lisa Fitzpatrick, Grapevine Health; Tom Hubbard, Network for Excellence in Health Innovation; David Lazer, Northeastern University; and Gül Seçkin, University of North Texas.

The authors would like to thank Julia Peterson and Suzanne Pope at the Council of Medical Specialty Societies, Laura DeStefano at the National Academy of Medicine, Andrew Pattison and Monta Reinfelde at the World Health Organization, and Kristen E. D'Anci and Frances M. Murphy at Sigma Health Consulting, LLC for their assistance with this paper.

Funding Statement

The views expressed in this paper are those of the author and not necessarily of the author's organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies.

Conflict-of-Interest Disclosures: Megan L. Ranney discloses receiving financial compensation from the National Opioid Abatement Trust II. Vineet Arora discloses receiving honoraria from the Journal of Hospital Medicine and UpToDate and receiving royalties from McGraw Hill. Don Dizon discloses receiving financial compensation from AstraZeneca and Clovis and stock options from Midi. Efrén J. Flores discloses receiving honoraria from Medscape and financial compensation from Journal of the American College of Radiology. Anjali Jain discloses sole proprietorship of Anjali Jain Research & Consulting, LLC. Richard Mularski discloses receiving grants from Gilead Sciences, Merck, and Pfizer. Claude Pinnock discloses former employment at Meta/Facebook.

Contributor Information

Helen Burstin, Council of Medical Specialty Societies and George Washington University School of Medicine.

Susan Curry, University of Iowa.

Megan L. Ranney, Yale School of Public Health.

Vineet Arora, The University of Chicago Medicine.

Brian Boxer Wachler, Boxer Wachler Vision Institute.

Wen-Ying Sylvia Chou, National Cancer Institute.

Ricardo Correa, The University of Arizona College of Medicine.

Donna Cryer, Global Liver Institute and Council of Medical Specialty Societies Board of Directors.

Don Dizon, Brown University, Lifespan Cancer Institute, Legorreta Cancer Center, and Rhode Island Hospital.

Efrén J. Flores, Massachusetts General Hospital and Harvard Medical School.

Gerald Harmon, Tidelands Health and American Medical Association.

Anjali Jain, Agency for Healthcare Research and Quality.

Kevin Johnson, University of Pennsylvania.

Christine Laine, Annals of Internal Medicine, Thomas Jefferson University, and American College of Physicians.

Lindsey Leininger, Dartmouth College.

Graham McMahon, Accreditation Council for Continuing Medical Education.

Laura Michaelis, Froedtert Hospital Cancer Center, Medical College of Wisconsin.

Ripudaman Minhas, St. Michael's Hospital and University of Toronto.

Richard Mularski, Kaiser Permanente Center for Health Research.

John Oldham, Baylor College of Medicine.

Rema Padman, Carnegie Mellon University.

Claude Pinnock, Wider Circle.

Jessica Rivera, The Pandemic Tracking Collective, The Rockefeller Foundation.

Brian Southwell, RTI International.

Antonia Villarruel, University of Pennsylvania.

Katrine Wallace, University of Illinois Chicago School of Public Health.

References

7. Kington R, Arnesen W-YS, Chou S, Curry S, Lazer D, Villarruel A. NAM Perspectives. National Academy of Medicine; Washington, DC: 2021. Identifying Credible Sources of Health Information in Social Media: Principles and Attributes. Discussion Paper. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

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Articles from NAM Perspectives are provided here courtesy of National Academy of Medicine

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Identifying Credible Sources of Health Information in Social Media: Phase 2-Considerations for Non-Accredited Nonprofit Organizations, For-Profit Entities, and Individual Sources

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Helen Burstin, MD, MPH, MACP, Susan Curry, PhD, Megan L. Ranney, MD, MPH, Vineet Arora, MD, MAPP, Brian Boxer Wachler, MD, Wen-Ying Sylvia Chou, PhD, MPH, Ricardo Correa, MD, EdD, Donna Cryer, JD, Don Dizon, MD, FACP, FASCO, Efrén J.

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Keep posting and following social media profiles about physical therapy, but be aware! A cross-sectional study of social media posts on Instagram and Twitter

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Keep posting and following social media profiles about physical therapy, but be aware! A cross-sectional study of social media posts on Instagram and Twitter

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Explaining and trusting expert evidence: What is a ‘sufficiently reliable scientific basis’?

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Explaining and trusting expert evidence: What is a ‘sufficiently reliable scientific basis’?

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We Are All Victims: Questionable Content and Collective Victimisation in the Digital Age

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We Are All Victims: Questionable Content and Collective Victimisation in the Digital Age

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We Are All Victims: Questionable Content and Collective Victimisation in the Digital Age

Abstract

Traditionally, the idea of being a victim is associated with a crime, accident, trickery or being duped. With the advent of globalisation and rapid growth in the information technology sector, the world has opened itself to numerous vulnerabilities. These vulnerabilities range from individual-centric privacy issues to collective interests in the form of a nation's political and economic interests. While we have victims who can identify themselves as victims, there are also victims who can barely identify themselves as victims, and there are those who do not realise that they have become victims. Misinformation, disinformation, fake news and other methods of spreading questionable content can be regarded as a new and increasingly widespread type of collective victimisation. This paper, drawing on recent examples from India, examines and analyses the rationale and modus operandi -both methods and types-that lead us to regard questionable content as a new form of collective victimisation.

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Introduction

Web 2.0 is a participatory platform whereby information and the dissemination of information are no longer in the hands of a few. This indiscriminate liberty regarding dissemination of information has led to the circulation of a plethora of content which is authentic, but has also opened the door to 'questionable content' such as fake news, misinformation and disinformation. Over the past few years, there has been a significant rise in the circulation of misinformation, disinformation, fake news and other problematic content through the meteoric rise in social media platforms.

Web 2.0 not only saw the rise of social media, but also of blogs, online news portals and media sharing applications, and it coincided with the widespread availability of cheap SIM cards and low-cost smartphones. This led to a paradigm shift in an individual's role in information dissemination. Individuals, who traditionally primarily played a passive role as consumers of information and not as active producers or circulators of content, can now also play an active role creating and circulating information.

With the paradigm shift, the risk of abuse increased many fold. The indiscriminate access and power brought a significant rise in misinformation, disinformation, propaganda and other problematic content. The Compact Oxford English Dictionary defines misinformation as false or inaccurate information given by someone. Disinformation is defined as "information intended to mislead". Propaganda is defined as "information that is often biased or misleading, used to promote a political cause or point of view", while satire is defined as "use of humour, irony, or exaggeration as a form of mockery or criticism". In this article, all the above-mentioned kinds of information are clubbed together under the umbrella term 'questionable information' or 'questionable content'.

The abuse of technology to create and disseminate questionable information is producing a new form of "collective violence" and "collective victimisation." The World Health Organisation has defined collective violence as "the instrumental use of violence by people who identify themselves as members of a group-whether this group is transitory or has a more permanent identity-against another group or set of individuals, in order to achieve political, economic or social objectives" (Zwi et al. 2002, p. 215) and the group suffering from the collective violence are collective victims (Vollhardt 2012). Current research on collective violence/victimisation is concerned with the experience, denial/recognition of victimisation, victim identity, collective memories and includes violence caused by war, terrorism, state-perpetrated violence and organised violent crime (e.g. Bagci et al. 2018; Littman and Paluck 2015; Vollhardt 2020).

While research has shown that people see fake news as a bigger threat than violent crime, illegal immigration and even terrorism (Mitchell et al. 2019), there is still no research that discusses how the abuse of technology in the form of questionable information is causing a new form of collective victimisation. Although questionable information might seem relatively harmless at the individual level, it can play a significant role in shaping the thought process of a large segment of society and influence decision making. When it comes to political content or sensitive issues, it could cause serious harm to society and then everyone becomes a victim.

This article will focus on the significance of information in a democratic system and the scope and nature of questionable content. This paper proposes that to address successfully questionable information and collective victimisation, we need to consider its rationale and modus operandi (both the methods and types). This paper will also describe approaches undertaken by countries to meet the challenge of questionable information and their efficacy from the perspective of collective victimisation.

Role of Information in a Democratic Society

Democratic rights, which the citizens of a State acquire by virtue of being citizens, are considered to be paramount for any democratic system to survive. A true form of democracy not only ensures that the people are aware of their democratic rights but also are correctly informed about the obligations and duties which democracy entails (Kuklinski et al. 2000). Only when individuals have the tool of information, can they judiciously and appropriately exercise their democratic rights including but not limited to voting rights.

In the nineteenth century and into the twentieth century, citizens consumed political news primarily through newspapers. Politicians and other political actors relied on newspapers to be their medium to propagate their ideologies or defend their actions. With the development of electronic media in the form of radio and television, political news found a faster and more attractive medium to reach most members of society (Lazer et al. 2018). While society was grappling with the challenges televised journalism was posing, the Internet age dawned upon us and this was further enhanced by the introduction of the Web 2.0 platform upon which social media thrived. Online news consumption is reaching new heights due to the analytics and algorithms of social media to the extent that this form of media is well on track to eventually replace television in general (Nguyen and Western 2006). Social media is playing a significant role in the personal, social, economic and political transformation of individuals and can influence the mental health and decision-making capacity of people.

In the recent past, several existing forms of crime have been facilitated through social media, and new forms of crime have been created which are dependent upon technology such as tampering with computer source documents, identity theft, phishing, online lottery scams, illegal access, data interference and child pornography. Many of these crimes are a technological extension of existing crimes such as stealing computer resources, cheating by impersonation, terrorism and sexual crimes (Broadhurst and Chang 2013; Chang 2017). The theory of victimisation which was developed to address the concerns and issues of victims of crimes has remained static in terms of its scope as it limited itself to individuals and dominantly victims of conventional crimes.

Questionable content appearing on web-based platforms differs from content in traditional media in two primary ways: (a) traceability of the source of information and (b) the limit and extension of circulation. For instance, a news piece which is incorrect and falsified, when circulated through traditional media such as a newspaper or telecast, is easily traced and suitable action can be taken directly against the perpetrators. But in the case of similar misinformation on social media, who is the original source of the story often remains unknown. This added protection shields perpetrators and creates a more favourable environment for those wishing to circulate questionable content. Secondly, the reach of content distributed on social media is less certain than the reach of content distributed through traditional media where TV ratings and print circulation are approximately known. Content on social media has the potential to "go viral" and reach many more people than traditional media. Thus, even though the consumption of questionable content on social media is predominantly individualistic, the ultimate impact is on society as a whole and can cause collective victimisation.

Questionable Content

Questionable content in this context can be crystallised as content that is politically or ideologically motivated online disinformation, fake news, hate speech, online misinformation and foreign encroachment in the domestic affairs of the State, misreporting and misconstrued satire (Shin et al. 2018; Tenove et al. 2018). Such content has the potential to impact individuals and the population collectively by changing the attitude of consumers, creating scepticism towards the electoral process, blocking educated political decision-making, causing political unrest, communal riots, and violence, sabotaging free and fair electoral processes, altering the political landscape, marginalising certain classes or communities and damaging the economy (Brown 2018). The threats to the collective are not theoretical, as the world has already witnessed events such as the Pizzagate Incident (Persily 2017), Russian interference with the 2016 U.S. Presidential election (Marvel 2019) and a wave of disinformation originating in China fed onto Taiwanese Internet domains, seeking to interfere in local and national elections (Wong and Wen 2020).

India, although a country with relatively limited Internet penetration, has a significant number of people using social media and the spread of misinformation is extensive. The dissemination of questionable content has caused communal violence, lynching and innumerable incidents of violence against particular groups of people in India, as well as influencing the 2019 election (Arun 2019; Roozenbeek and van Der Linden 2019). Fake news, online misinformation and disinformation regarding COVID-19 (see below) occurred to such an extent that it moved the issue from being just a health pandemic to also being about communal tensions and religious conflict (Ellis-Petersen and Rahman 2020). Some of the questionable content was, on the face of it, absurd and yet many people believed it (Sengupta 2020). The nature of the platform makes it extremely difficult to curb. These forms of victimisation viewed through the prism of standard principles, embodied in constitutional law, human rights law, criminal law, the basic tenets of democracy, the UN Charter and international law, constitute a violation of India's domestic law as well as international law.

In the space of a few months in early 2020 in India, there were a number of cases of questionable content regarding COVID-19, targeting different political parties and religions and which had an impact over the collective even though they were accessed individually1:

1. (a)
An audio clip claimed that a vendor with a certain religious background was spreading COVID-19. The perpetrator produced a 6 min and 42 s audio clip, within which he suggested that a vendor was selling vegetables at a low price with the ulterior objective of spreading COVID-19. The audio clip was examined by the fact-checking organisation 'Boom' and was found to be fake (Alphonso 2020). It is apparent the perpetrator intended to use the audio clip to create communal hatred in the time of the pandemic. Individuals received the message in their personal space, but the insecurity it created within the victims potentially could have given birth to a collective distrust in vendors based on their religious background and even violence if not tackled in time. Many would not be aware of the follow-up fact-checking and would continue to live with the misinformation and the prejudice it fuelled.

2. (b)
During the time of COVID-19, a photo of Switzerland's Matterhorn mountain lit with the Indian flag was tweeted, claiming that it was lit in the name of hope after the leader of the government supplied hydroxychloroquine tablets (HCQ-a drug for the treatment of rheumatoid arthritis and believed by some scientists to lessen the symptoms of COVID-19). The tweet went viral and was shared widely via Twitter and Facebook. A fact-checking organisation in India, altnews.in, found that, although the image of the Indian national flag had been projected on the Matterhorn, the claim shared along with the image that this happened after India supplied HCQ tablets to the country was false. The projection on that day was to express solidarity with Indians in the fight against COVID-19 and was one of a series of flag projections intended to be a sign of hope as the world battled the novel Corona Virus (Kinjal 2020a, b). While the tweet in itself seems harmless, it had the intended effect of encouraging Indians to feel an 'exclusive' and positive emotion about the nation and the performance of the political party in government.

3. (c)
Over twitter, a picture demonstrating social distance practice during COVID-19 at Mizoram, a state in northeastern India, received many likes. However, Boom (India) & Boom Myanmar ran verification of the picture, and it was found that the picture was not of Mizoram but of Kalaw, a hill town in Myanmar's Shan State (Nabodita 2020). While some would argue that by encouraging social distancing, its accuracy was unimportant as it had a positive influence over people. However, it was fake news and it might have had the perverse effect of causing additional COVID-19 cases due to a false sense of security based on a belief that safe practices were protecting the community.

4. (d)
The impact of questionable content is strongly felt when popular individuals, political personalities or individuals circulate and share the information. For example, a video from Bijnor, a district in the Indian state of Uttar Pradesh, depicted an elderly fruit seller belonging to a minority faith, accused of sprinkling urine over bananas to be sold. Eminent political figures and media personnel fuelled the circulation by circulating the video. It did not take much longer for the video to get viral. It was later found, and verified by Bijnor police, that the elderly fruit seller had only washed his hands with water from the bottle and did not sprinkle urine as claimed in the video (Jha 2020).

The above incidents are illustrative of the power of questionable content and the damage it can cause to individuals and societal harmony. This damage can be brought on very quickly by the participation of entertainment or sport celebrities and political leaders as potential 'super spreaders'. The rationale for targeting such individuals is simple, as their re-posting is understood by their supporters as an endorsement and this will give a significant boost to the circulated content, even if it is questionable content.

Gossip and rumours have undoubtedly existed since the invention of languages; however, the invention of the Gutenberg printing press in 1440 enabled precise and rapid reproduction of books, dramatically reducing their cost and increasing their availability, and thereby also increasing the scope for the circulation of misinformation and disinformation (Posetti and Matthews 2018). The advent of the participatory web interface with its indiscriminate access to information has again significantly increased the opportunity for misinformation and disinformation and the speed at which it circulates. To access social media, all that an individual needs is a workable network and a device supporting the social media applications or website and then the individual is good to go. This indiscriminate access has been far more widespread than the understanding amongst the population about the nature of the technology. With no qualification necessary to use and access social media, the perpetrators and victims of questionable content are separated by no more than a click (Chang 2012).

The industry of misinformation and ancillary activities we argue can be regarded as a new type of collective violence and is generating a new form of collective victimisation where individuals are not even aware that they are victimised. We consider here the rationale and motivation behind questionable content, and then the characteristics of questionable content.

Rationale and Motivation Behind Questionable Content

While any individual with a device which supports social media platforms potentially can be a perpetrator, perpetrators tend to be certain entities with particular objectives such as political entities, extra-political entities, extremists (Ben-David and Matamoros Fernández 2016) and individuals or a group of individuals with nefarious motives. There are websites and portals which are entirely dedicated to the production of fabricated and manipulated information that operate under a name which is deceptively similar to that of a legitimate news organisation (Allcott and Gentzkow 2017). India is periodically a victim of such websites, as was evidenced by the website " viralinindia", which was shut down on account of abusing information prior to the 2019 general election. However, such entities are hard to shut down permanently as it is easy to re-emerge in some other form (Usha 2019).

While perpetrators capitalise on the insecurities, prejudices and limited education of the victims and on the channel algorithms, the victims are unaware of and are not alert to the motives of the perpetrators. Unwittingly, they aid and assist the perpetrators to (i) polarise the population for or against a particular cause, (ii) evoke emotions among the population and cloud independent and rational judgement, (iii) spread conspiracy theories and infuse distrust in the existing knowledge base, (iv) troll and infuse an existential crisis in an individual or even a group, (v) deflect blame and target another, create a parallel narrative and (vi) impersonate (Roozenbeek and van Der Linden 2019). The perpetrators engage in all the above-mentioned strategies either for a pecuniary benefit or ideological validation (Allcott and Gentzkow 2017; Silverman and Singer-Vine 2016). Most media attention has focused on the use of these strategies by foreign agencies interested in domestic politics. During the 2020 Taiwanese Presidential election, questionable content was put into circulation. The questionable content did not stop with fake news and sought to manipulate public opinion by spreading misinformation (Kuo 2019; Lee and Blanchard 2019). Having regard to China's claim that Taiwan is a part of China, the interference by an international entity must be viewed as potentially threatening Taiwan's security and the coveted principle of self-determination.

Characteristics of Questionable Content

The modus operandi along with the content of questionable content helps us to determine and identify the actor, the rationale and also the intended target. Various forms of questionable content are crafted to attain different objectives and impact individual behaviours or attitudes differently. Collectively, they are often termed as a semantic attack, as the questionable content tends to adversely impact the semantics of information (Kumar and Geethakumari 2014). The factors which differentiate between legitimate information and questionable information are certainty, accurateness, comprehensiveness and deceptiveness.

A semantic attack is directed towards individual users of social media and is crafted in such manner which awakens the insecurities of individuals or reaffirms their existing belief (Allcott and Gentzkow 2017). In a nation with a heterogeneous and diverse population, the impact of miscommunication and like events could be tremendous. A nation-state with diverse religious practices, cultural heritage, socio-economic standards and educational disparity, and with the substantial reach of social network-enabled devices in the hands of such a diverse population, is prone to be a victim of insecurities. Social media is a platform which provides an insight into the lives of others and individuals who previously had limited knowledge about the lives or thoughts of others can now access them with the click of a button. Social media has led to a significant detrimental effect in the psychological condition due to comparison of self over social media with other participants (Vogel et al. 2014). The comparisons which stem out of insecurities are not limited to lifestyle comparisons but also intellectual comparisons. People engage to influence others by showcasing their intellectual abilities and ideological bent, which often is guided by intolerance and rigidity to accept a diverse outlook leading to extremism and polarisation (Jost et al. 2018). The propagation of questionable content is further aided by the speed of its circulation and uncertain geographical location of the source.

Styling and the text of questionable content are crafted in a particular manner depending on the type of questionable content such as satire, fake news, disinformation, propaganda and misinformation and on its audience. The style of questionable content differs from real news on several counts. Fake news is often crafted with a longer and striking title, or heading, which attracts immediate attention, the vocabulary used is simpler, with limited use of technical words so that even a reader with limited education or intellectual abilities is not discouraged from reading it. Furthermore, the presentation of the content is colourful, capitalised and dramatised to grab the attention of the potential target (Horne and Adali 2017).

When it comes to content, articles are shorter in length compared with real news and there are fewer punctuation marks and quotes which lowers the possibility of tracing the content back to an authoritative figure. There is greater use of adverbs, pronouns and redundancies. The content also prefers using self-referential terms such as 'I', 'We', 'You' and 'Us' (Horne and Adali 2017). Such self-referential terminology behaves as if the content directly speaks to the reader or on behalf of the reader; consequently, the reader feels connected with the message and messenger.

Satirical websites are producing content some of which can cause similar damage as fake news and misinformation when its reception is without a context. The wide range of actors also includes websites engaging in the production of a mixed format of news, with a certain portion being true and other portion fabricated thereby creating a cloud in the judgement of people at large (Allcott and Gentzkow 2017). India has been a victim of delivery of content from a website which engages in the dissemination of satire from eminent political figures leading to a grant of authenticity to the satire, at least in the mind of some. For example, a leading politician resorted to quoting from " fakingnews", a portal which declares itself as a satire and humour website, and he was subsequently re-tweeted by the official political handle of the political party forming government. (Chaudhuri 2020). The device of questionable content is equally exploited by the opposition in the Indian parliament as they use this mechanism to question the credibility of the governing political party. Opposition parties in the Indian parliament have often attempted to malign the image of the Prime Minister by questioning his lifestyle and using visuals which are either wrongly dated or wrongly contextualised (Kinjal 2020a, b).

Collective Victimisation

Questionable content in India frequently has elements such as religious intolerance, people with a certain political affiliation violating the law, photos and news related to celebrities, outrageous claims regarding the performance of government and international accolades received by India. Most of the content is supported with photographs from unconnected events (see examples from BoomLive, https://www.boomlive.in/fake-news). The questionable content capitalises on the strong religious sentiments of the majority, or political sentiment, which itself is connected to religious affinity, or with a little description and an image, which aids people with limited education to interpret or celebrities, who are often revered as a god by a large section of India's population.

It is not that every individual who is accessing social media is bound to fall in the trap laid by questionable content. The most vulnerable are individuals with limited education or awareness about the medium and scope of the medium, those who lack an objective outlook or have had experiences which have had an impact on their psychological condition making them either insecure or prone to seeking validation of existing prejudiced ideology (Allcott and Gentzkow 2017; Silverman and Singer-Vine 2016). Having an education does not guarantee protection from questionable content. However, it can be argued that a limited education (including digital literacy) plays a significant role in the victimisation of individuals as it enables them to access social media but does not enable them to discern or make rationale choices in favour of real information. A lack of awareness and skills to identify fake news from real news enhances the circulation of questionable material. The insecurities upon which the questionable content capitalises were also in evidence in Taiwan during the elections in 2018 and 2020, as well as during the COVID-19 pandemic.

The Individual as Unwitting Perpetrator

To socialise, individuals do not need to leave their homes anymore, they can reach out to anyone and everyone through the algorithms of social networking. An individual sitting in the comfort of their home can spend hours over a social network, reading, watching, writing, contributing content. However, the significant change is that they now also are engaged in sharing the content they consume. While the individual presumes that they are acting on their own in their private domain and are not involving others, the moment their activities involve sharing, the impact goes beyond them individually. With the act of sharing, an individual actively enters the realm of algorithms of the social network, and the shared content has the potential to have an impact beyond the individual, extending to the individual's social network and then beyond to the social networks of the individual's social network growing exponentially until it eventually impacts society collectively, or at least a certain portion of it. When the information circulating is real and genuine, the impact is not necessarily adverse; however, unchecked questionable content undoubtedly has an adverse impact on people collectively. Except for the perpetrators, who introduced the questionable material, all the other individuals who consumed it and actively shared it without verification could be considered collective victims of questionable content.

Often, when questionable content comes from someone in their contact list or from friends and family, the propensity is to believe in the content and it is often misconstrued as authentic and genuine as opposed to content received from an unknown person. Recipients of questionable content often do not undertake a fact-finding exercise or analyse the information from an objective standpoint to ascertain its reliability; they are prone to trust their friends and family over social media unless there exists an ideological difference with the actor. With this trust reposed upon the contact and network, the recipient turns into actor and feels the need to share and inform others in their contact group thus becoming a victim as the recipient and also inflicting injury to others.

Acting Individually, Impacting Collectively

The individual sharing questionable content has an impact on the collective by virtue of changing the attitude of consumers towards a particular issue or by creating general indifference towards an election by generating a certain amount of scepticism and distrust (Persily 2017). Irrespective of the end goal-pecuniary benefit or ideological reach-questionable content creates a "blanket of fog" which conceals and cloaks authentic information and creates confusion over what to believe or to fall prey to the content circulated. The idea of "educated political decision" is subsequently lost leading to a situation where voters have been exposed to incorrect information influencing how they cast their votes or whether they vote at all. When this results in the election of individuals who would not otherwise have been elected, it can be regarded as collective victimisation as it engulfs the majority of the population (Persily 2017).

The experience of the USA in 2016 suggests that social media can play a vital but not decisive role in communicating electoral news and that the average American voter did not just believe any fake news; however, they were likely to believe stories that favoured their preferred candidate (Allcott and Gentzkow 2017). India, the world's largest democracy, has also fallen victim to questionable content circulated over web-based social media platforms. Oxford Internet Institute ( 2019) suggested that "the proportion of polarizing political news and information in circulation over social media in India is worse than all of the other country case studies we have analysed, except the US Presidential election in 2016". And according to Oxford Internet Institute ( 2019), a data collected in February to April 2019, 2 months right before the 2019 general election, showed that both Bharatiya Janta Party (BJP) and Indian National Congress (INS) shared a substantial amount of news on Facebook that they classified as "divisive and conspirational content", i.e., junk news and information. The potential of the questionable content impacting a collective is not only limited to political events as was seen during the COVID-19 pandemic.

Regulating 'Questionable Content' in the Digital Age

Crimes and forms of crimes have been ever-evolving and the Internet age has created both new opportunities for crime and new crimes. The big question that lies before the government of each state is how to regulate information systems, and specifically questionable content. Government-imposed regulations can be a double-edged sword as regulations can eliminate or restrict the flow of questionable content, while at the same time can potentially act as a legally sanctioned mechanism to gag real news and ultimately violate media independence, freedom of information and the right to free speech. It is a difficult issue to balance as India saw when the Indian Government was about to enforce a rigorous law suspending the accreditation of journalists propagating questionable content but soon froze it owing to protests from the media. In India, questionable material (rumours) circulated deliberately over WhatsApp, a popular platform for text and media exchange over a smartphone, has resulted in several incidents of lynching (Arun 2019). The Indian Government felt that the onus was on WhatsApp to stop the acts of lynching. Through notices to WhatsApp, the government put pressure on the company to address the problem by preventing the messages from spreading. WhatsApp responded by installing a "forwarded" label to tell the reader that the individual sharing the content did not create it. While web-based platforms such as WhatsApp are undoubtedly being used to amplify and target hate speech, if the aim is to limit the incitement to violence, then other factors that contribute to the production and promotion of questionable content such as the context, and the roles of leaders and local police, need to be addressed (Arun 2019). A holistic approach is needed for regulation including the identification and application of penal laws against the perpetrators. Equally, those vulnerable to spreading questionable content need to be made cyber security aware to protect themselves from the content and from spreading the content (Chang and Coppel 2020).

In April 2019, the US Law Library of Congress published a report on initiatives taken by a few countries from different regions to counter the menace of fake news. The uniform issue in the study was the role and impact of questionable content in the fair and free election process (The Law Library of Congress 2019). A similar study was done by www.poynter.org, with selected countries representing various regions (see https://www.poynter.org/ifcn/anti-misinformation-actions/). Both studies reveal that countries have undertaken three approaches: (a) steps by government to monitor, assess and assist in the reduction of questionable material over social networking sites; (b) steps closely resembling the sanctions and strict measures against questionable content and (c) steps involving elements of awareness to control collective victimisation. However, there is not a uniform approach by the nation States.

Countries are attempting to address the growing challenge of questionable content through different measures including monitoring, imposing a sanction, conducting awareness programs and demanding accountability. However, regulation is not a simple answer as was seen in Malaysia where legislation in 2018 faced heavy criticism for its broad definition of 'fake news' and was also examined for potentially being oppressive and regressive (The Law Library of Congress 2019). A similar stance was taken in Israel where there has been growing apprehension within the political opposition about excessive governmental control over information systems that could lead to violations of the essential right to information and freedom of speech (The Law Library of Congress 2019).

In both India and Myanmar, the Internet in parts of the country was shut down to stop the dissemination of information, ostensibly for security reasons but also to limit awareness of the situation on the ground. This can be seen as the gagging of the right to speech and an excessive imposition that violates not only human rights but also adversely impacts the economy (Aung and Moon 2020; Kiran 2020). In 2018, the Indian government proposed to penalise journalists for publishing and propagating fake news; however, the proposal was withdrawn amid protest and claims of interference by the Prime Minister's Office (Dutta 2018; Khalid 2018).

Rather than impose a repressive regulatory approach, the Taiwanese Government has adopted a "humour over rumour" strategy to counter questionable content. In order to provide timely and correct information, the government uses humourous memes to provide information. By mocking government officials themselves (e.g. the meme with the Premier showing his rear saying "We only have one butt" (see Image 1) to encourage people not to panic buy toilet paper during the COVID-19 pandemic) or using a "spokesdog" (rather than a spokesperson) to communicate its public messages (see Image 2). These messages successfully attract people's attention in a timely manner and effectively cut back the dissemination of questionable content.

We only have one butt. Source: Ministry of Economic Affairs, Taiwan

Timing to wash hands by the Spokesdog. Source: Ministry of Health and Welfare, Taiwan

In another alternative to government regulation, fact checking organisations, such as altnews.in (India). boomlive.in (India) and mygopen.com (Taiwan), investigate and identify questionable content. However, they are not always perceived as being independent. Furthermore, social media platforms and applications that curb questionable content not only assist governments but also run the risk of becoming-or appearing to be-unaccountable agents of the government in determining what is acceptable content.

In addition to the abovementioned, certain other innovative measures have been developed by the participants of the dotcom world (Chang and Grabosky 2017). One such innovation involves an online game which enables the individual players to play the role of questionable content producer, and through this role-playing, the player gets psychological training to identify techniques used to produce such content (Roozenbeek and van Der Linden 2019). Regulation will never be enough to protect the population from questionable content and there needs to be a focus also on "hardening" the target. Cybersecurity awareness training programs equip an individual with the ability to discriminate between real news and questionable content form part of the armoury. One example of such effort is CyberBaykin (see https://www.facebook.com/CyberBayKin/), which was created to raise awareness about cyber safety and risk in Myanmar (Chang and Coppel 2020).

Conclusion

It is evident that questionable content over social media in the form of fake news, misinformation, disinformation, propaganda and misconstrued satire have become a menace to reckon with. It is also acknowledged that human rights relating to freedom of speech and the right to information are threatened. Effective regulation of the world of questionable content will not be possible unless all measures such as monitoring and sanction are aided by awareness and accountability measures.

One of the key barriers in need of resolution to successfully regulate questionable content in the information system is the lack of an acknowledgment that questionable content is collectively victimising the nation's population. The primary challenge to such an acknowledgement is due to the limited construct of the identification of 'victim'. Traditionally, the subject of a criminal offence is considered to be the victim, and barring a few circumstances like war, genocide and similar acts, it is an 'individual' who forms the subject matter of victimisation. Often, psychological damage is not considered as victimisation as evidencing the criminal act is difficult. The challenge of extending the idea of victimisation to a collective is a notch higher, in terms of difficulty.

A question may arise, even after acknowledging that questionable content is playing an adverse role in the electoral process, why this is not categorised as collective victimisation of the nation's population? The answer might lie in the lack of scope to provide compensatory privilege to a collective, which is the essence in the study of victimology. Besides, there exists another significant rationale for not categorising a nation's population as a collective victim: the authority or the political force shouldering the responsibility of regulating and addressing the collective victimisation may have taken advantage of the menace of questionable content. However, that remains a subject for later study. Nonetheless, to make progress, we as a community need to appreciate and accept at the outset the concept of collective victimisation of a nation's population resulting from questionable content, before we try to make inroads to resolve and address the problem.

Notes

These are just some of the questionable content that was circulated in India and they are used as examples. This is not an exclusive list and we recognise that questionable content in India targets many political and religious groups.

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Authors and Affiliations

1. School of Social Sciences, Monash University, Clayton, Victoria, Australia

Lennon Y. C. Chang

2. CRSGPP, Kolkata, India

Souvik Mukherjee

3. Melbourne, Australia

Nicholas Coppel

Corresponding author

Correspondence to Lennon Y. C. Chang.

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Chang, L.Y.C., Mukherjee, S. & Coppel, N. We Are All Victims: Questionable Content and Collective Victimisation in the Digital Age. Asian J Criminol 16, 37-50 (2021). https://doi.org/10.1007/s11417-020-09331-2
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# data[].attributes.attachment_link.title
We Are All Victims: Questionable Content and Collective Victimisation in the Digital Age - Asian Journal of Criminology

# data[].attributes.attachment_link.description
Traditionally, the idea of being a victim is associated with a crime, accident, trickery or being duped. With the advent of globalisation and rapid growth in the information technology sector, the world has opened itself to numerous vulnerabilities. These vulnerabilities range from individual-centric privacy issues to collective interests in the form of a nation's political and economic interests.

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A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

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A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

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Abstract

Receiving touch is of critical importance, as many studies have shown that touch promotes mental and physical well-being. We conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review ( n = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy. Included studies always featured a touch versus no touch control intervention with diverse health outcomes as dependent variables. Risk of bias was assessed via small study, randomization, sequencing, performance and attrition bias. Touch interventions were especially effective in regulating cortisol levels (Hedges' g  = 0.78, 95% confidence interval (CI) 0.24 to 1.31) and increasing weight (0.65, 95% CI 0.37 to 0.94) in newborns as well as in reducing pain (0.69, 95% CI 0.48 to 0.89), feelings of depression (0.59, 95% CI 0.40 to 0.78) and state (0.64, 95% CI 0.44 to 0.84) or trait anxiety (0.59, 95% CI 0.40 to 0.77) for adults. Comparing touch interventions involving objects or robots resulted in similar physical (0.56, 95% CI 0.24 to 0.88 versus 0.51, 95% CI 0.38 to 0.64) but lower mental health benefits (0.34, 95% CI 0.19 to 0.49 versus 0.58, 95% CI 0.43 to 0.73). Adult clinical cohorts profited more strongly in mental health domains compared with healthy individuals (0.63, 95% CI 0.46 to 0.80 versus 0.37, 95% CI 0.20 to 0.55). We found no difference in health benefits in adults when comparing touch applied by a familiar person or a health care professional (0.51, 95% CI 0.29 to 0.73 versus 0.50, 95% CI 0.38 to 0.61), but parental touch was more beneficial in newborns (0.69, 95% CI 0.50 to 0.88 versus 0.39, 95% CI 0.18 to 0.61). Small but significant small study bias and the impossibility to blind experimental conditions need to be considered. Leveraging factors that influence touch intervention efficacy will help maximize the benefits of future interventions and focus research in this field.

Main

The sense of touch has immense importance for many aspects of our life. It is the first of all the senses to develop in newborns1 and the most direct experience of contact with our physical and social environment2. Complementing our own touch experience, we also regularly receive touch from others around us, for example, through consensual hugs, kisses or massages3.

The recent coronavirus pandemic has raised awareness regarding the need to better understand the effects that touch-and its reduction during social distancing-can have on our mental and physical well-being. The most common touch interventions, for example, massage for adults or kangaroo care for newborns, have been shown to have a wide range of both mental and physical health benefits, from facilitating growth and development to buffering against anxiety and stress, over the lifespan of humans and animals alike4. Despite the substantial weight this literature gives to support the benefits of touch, it is also characterized by a large variability in, for example, studied cohorts (adults, children, newborns and animals), type and duration of applied touch (for example, one-time hug versus repeated 60-min massages), measured health outcomes (ranging from physical health outcomes such as sleep and blood pressure to mental health outcomes such as depression or mood) and who actually applies the touch (for example, partner versus stranger).

A meaningful tool to make sense of this vast amount of research is through meta-analysis. While previous meta-analyses on this topic exist, they were limited in scope, focusing only on particular types of touch, cohorts or specific health outcomes (for example, refs. 5,6). Furthermore, despite best efforts, meaningful variables that moderate the efficacy of touch interventions could not yet be identified. However, understanding these variables is critical to tailor touch interventions and guide future research to navigate this diverse field with the ultimate aim of promoting well-being in the population.

In this Article, we describe a pre-registered, large-scale systematic review and multilevel, multivariate meta-analysis to address this need with quantitative evidence for (1) the effect of touch interventions on physical and mental health and (2) which moderators influence the efficacy of the intervention. In particular, we ask whether and how strongly health outcomes depend on the dynamics of the touching dyad (for example, humans or robots/objects, familiarity and touch directionality), demographics (for example, clinical status, age or sex), delivery means (for example, type of touch intervention or touched body part) and procedure (for example, duration or number of sessions). We did so separately for newborns and for children and adults, as the health outcomes in newborns differed substantially from those in the other age groups. Despite the focus of the analysis being on humans, it is widely known that many animal species benefit from touch interactions and that engaging in touch promotes their well-being as well7. Since animal models are essential for the investigation of the mechanisms underlying biological processes and for the development of therapeutic approaches, we accordingly included health benefits of touch interventions in non-human animals as part of our systematic review. However, this search yielded only a small number of studies, suggesting a lack of research in this domain, and as such, was insufficient to be included in the meta-analysis. We evaluate the identified animal studies and their findings in the discussion.

Results

Touch interventions have a medium-sized effect

The pre-registration can be found at ref. 8. The flowchart for data collection and extraction is depicted in Fig. 1.

Animal outcomes refer to outcomes measured in non-human species that were solely considered as part of a systematic review. Included languages were French, Dutch, German and English, but our search did not identify any articles in French, Dutch or German. MA, meta-analysis.

For adults, a total of n = 2,841 and n = 2,556 individuals in the touch and control groups, respectively, across 85 studies and 103 cohorts were included. The effect of touch overall was medium-sized ( t(102) = 9.74, P < 0.001, Hedges' g = 0.52, 95% confidence interval (CI) 0.42 to 0.63; Fig. 2a). For newborns, we could include 63 cohorts across 52 studies comprising a total of n = 2,134 and n = 2,086 newborns in the touch and control groups, respectively, with an overall effect almost identical to the older age group ( t(62) = 7.53, P < 0.001, Hedges' g = 0.56, 95% CI 0.41 to 0.71; Fig. 2b), suggesting that, despite distinct health outcomes, touch interventions show comparable effects across newborns and adults. Using these overall effect estimates, we conducted a power sensitivity analysis of all the included primary studies to investigate whether such effects could be reliably detected9. Sufficient power to detect such effect sizes was rare in individual studies, as investigated by firepower plots10 (Supplementary Figs. 1 and 2). No individual effect size from either meta-analysis was overly influential (Cook's D < 0.06). The benefits were similar for mental and physical outcomes (mental versus physical; adults: t(101) = 0.79, P = 0.432, Hedges' g difference of −0.05, 95% CI −0.16 to 0.07, Fig. 2c; newborns: t(61) = 1.08, P = 0.284, Hedges' g difference of −0.19, 95% CI −0.53 to 0.16, Fig. 2d).

On the basis of the overall effect of both meta-analyses as well as their median sample sizes, the minimum number of studies necessary for subgroup analyses to achieve 80% power was k = 9 effects for adults and k = 8 effects for newborns (Supplementary Figs. 5 and 6). Assessing specific health outcomes with sufficient power in more detail in adults (Fig. 3a) revealed smaller benefits to sleep and heart rate parameters, moderate benefits to positive and negative affect, diastolic blood and systolic blood pressure, mobility and reductions of the stress hormone cortisol and larger benefits to trait and state anxiety, depression, fatigue and pain. Post hoc tests revealed stronger benefits for pain, state anxiety, depression and trait anxiety compared with respiratory, sleep and heart rate parameters (see Fig. 3 for all post hoc comparisons). Reductions in pain and state anxiety were increased compared with reductions in negative affect ( t(83) = 2.54, P = 0.013, Hedges' g difference of 0.31, 95% CI 0.07 to 0.55; t(83) = 2.31, P = 0.024, Hedges' g difference of 0.27, 95% CI 0.03 to 0.51). Benefits to pain symptoms were higher compared with benefits to positive affect ( t(83) = 2.22, P = 0.030, Hedges' g difference of 0.29, 95% CI 0.04 to 0.54). Finally, touch resulted in larger benefits to cortisol release compared with heart rate parameters ( t(83) = 2.30, P = 0.024, Hedges' g difference of 0.26, 95% CI 0.04-0.48).

a, b, Health outcomes in adults analysed across 405 in part dependent effect sizes from 79 studies and 97 cohorts ( a) and in newborns analysed across 105 in part dependent effect sizes from 46 studies and 56 cohorts ( b). The type of health outcomes measured differed between adults and newborns and were thus analysed separately. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents the heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.
Source data

In newborns, only physical health effects offered sufficient data for further analysis. We found no benefits for digestion and heart rate parameters. All other health outcomes (cortisol, liver enzymes, respiration, temperature regulation and weight gain) showed medium to large effects (Fig. 3b). We found no significant differences among any specific health outcomes.

Non-human touch and skin-to-skin contact

In some situations, a fellow human is not readily available to provide affective touch, raising the question of the efficacy of touch delivered by objects and robots11. Overall, we found humans engaging in touch with other humans or objects to have medium-sized health benefits in adults, without significant differences ( t(99) = 1.05, P = 0.295, Hedges' g difference of 0.12, 95% CI −0.11 to 0.35; Fig. 4a). However, differentiating physical versus mental health benefits revealed similar benefits for human and object touch on physical health outcomes, but larger benefits on mental outcomes when humans were touched by humans ( t(97) = 2.32, P = 0.022, Hedges' g difference of 0.24, 95% CI 0.04 to 0.44; Fig. 4b). It must be noted that touching with an object still showed a significant effect (see Supplementary Fig. 7 for the corresponding orchard plot).

a, Forest plot comparing humans versus objects touching a human on health outcomes overall across 467 in part dependent effect sizes from 85 studies and 101 cohorts. b, The same as a but separately for mental versus physical health outcomes across 467 in part dependent effect sizes from 85 studies and 101 cohorts. c, Results with the removal of all object studies, leaving 406 in part dependent effect sizes from 71 studies and 88 cohorts to identify whether missing skin-to-skin contact is the relevant mediator of higher mental health effects in human-human interactions. Numbers on the right represent the mean effect with its 95% CI in square brackets and the significance level estimating the likelihood that the effect is equal to zero. Overall effects of moderator impact were assessed via an F test, and post hoc comparisons were done using t tests (two-sided test). The F value in the top right represents a test of the hypothesis that all effects within the subpanel are equal. The Q statistic represents the heterogeneity. P values of post hoc tests are depicted whenever significant. P values above the horizontal whiskers indicate whether an effect differed significantly from a zero effect. Vertical lines indicate significant post hoc tests between moderator levels. P values were not corrected for multiple comparisons. Physical outcomes are marked in red. Mental outcomes are marked in blue.
Source data

We considered the possibility that this effect was due to missing skin-to-skin contact in human-object interactions. Thus, we investigated human-human interactions with and without skin-to-skin contact (Fig. 4c). In line with the hypothesis that skin-to-skin contact is highly relevant, we again found stronger mental health benefits in the presence of skin-to-skin contact that however did not achieve nominal significance ( t(69) = 1.95, P = 0.055, Hedges' g difference of 0.41, 95% CI −0.00 to 0.82), possibly because skin-to-skin contact was rarely absent in human-human interactions, leading to a decrease in power of this analysis. Results for skin-to-skin contact as an overall moderator can be found in Supplementary Fig. 8.

Influences of type of touch

The large majority of touch interventions comprised massage therapy in adults and kangaroo care in newborns (see Supplementary Table 1 for a complete list of interventions across studies). However, comparing the different types of touch explored across studies did not reveal significant differences in effect sizes based on touch type, be it on overall health benefits (adults: t(101) = 0.11, P = 0.916, Hedges' g difference of 0.02, 95% CI −0.32 to 0.29; Fig. 5a) or comparing different forms of touch separately for physical (massage therapy versus other forms: t(99) = 0.99, P = 0.325, Hedges' g difference 0.16, 95% CI −0.15 to 0.47) or for mental health benefits (massage therapy versus other forms: t(99) = 0.75, P = 0.458, Hedges' g difference of 0.13, 95% CI −0.22 to 0.48) in adults (Fig. 5c; see Supplementary Fig. 9 for the corresponding orchard plot). A similar picture emerged for physical health effects in newborns (massage therapy versus kangaroo care: t(58) = 0.94, P = 0.353, Hedges' g difference of 0.15, 95% CI −0.17 to 0.47; massage therapy versus other forms: t(58) = 0.56, P = 0.577, Hedges' g difference of 0.13, 95% CI −0.34 to 0.60; kangaroo care versus other forms: t(58) = 0.07, P = 0.947, Hedges' g difference of 0.02, 95% CI −0.46 to 0.50; Fig. 5d; see also Supplementary Fig. 10 for the corresponding orchard plot). This suggests that touch types may be flexibly adapted to the setting of every touch intervention.

The role of clinical status

Most research on touch interventions has focused on clinical samples, but are benefits restricted to clinical cohorts? We found health benefits to be significant in clinical and healthy populations (Fig. 6), whether all outcomes are considered (Fig. 6a,b) or physical and mental health outcomes are separated (Fig. 6c,d, see Supplementary Figs. 11 and 12 for the corresponding orchard plots). In adults, however, we found higher mental health benefits for clinical populations compared with healthy ones (Fig. 6c; t(99) = 2.11, P = 0.037, Hedges' g difference of 0.25, 95% CI 0.01 to 0.49).

A more detailed analysis of specific clinical conditions in adults revealed positive mental and physical health benefits for almost all assessed clinical disorders. Differences between disorders were not found, with the exception of increased effectiveness of touch interventions in neurological disorders (Supplementary Fig. 13).

Familiarity in the touching dyad and intervention location

Touch interventions can be performed either by familiar touchers (partners, family members or friends) or by unfamiliar touchers (health care professionals). In adults, we did not find an impact of familiarity of the toucher ( t(99) = 0.12, P = 0.905, Hedges' g difference of 0.02, 95% CI −0.27 to 0.24; Fig. 7a; see Supplementary Fig. 14 for the corresponding orchard plot). Similarly, investigating the impact on mental and physical health benefits specifically, no significant differences could be detected, suggesting that familiarity is irrelevant in adults. In contrast, touch applied to newborns by their parents (almost all studies only included touch by the mother) was significantly more beneficial compared with unfamiliar touch ( t(60) = 2.09, P = 0.041, Hedges' g difference of 0.30, 95% CI 0.01 to 0.59) (Fig. 7b; see Supplementary Fig. 15 for the corresponding orchard plot). Investigating mental and physical health benefits specifically revealed no significant differences. Familiarity with the location in which the touch was applied (familiar being, for example, the participants' home) did not influence the efficacy of touch interventions (Supplementary Fig. 16).

Frequency and duration of touch interventions

How often and for how long should touch be delivered? For adults, the median touch duration across studies was 20 min and the median number of touch interventions was four sessions with an average time interval of 2.3 days between each session. For newborns, the median touch duration across studies was 17.5 min and the median number of touch interventions was seven sessions with an average time interval of 1.3 days between each session.

Delivering more touch sessions increased benefits in adults, whether overall ( t(101) = 4.90, P < 0.001, Hedges' g = 0.02, 95% CI 0.01 to 0.03), physical ( t(81) = 3.07, P = 0.003, Hedges' g = 0.02, 95% CI 0.01-0.03) or mental benefits ( t(72) = 5.43, P < 0.001, Hedges' g = 0.02, 95% CI 0.01-0.03) were measured (Fig. 8a). A closer look at specific outcomes for which sufficient data were available revealed that positive associations between the number of sessions and outcomes were found for trait anxiety ( t(12) = 7.90, P < 0.001, Hedges' g = 0.03, 95% CI 0.02-0.04), depression ( t(20) = 10.69, P < 0.001, Hedges' g = 0.03, 95% CI 0.03-0.04) and pain ( t(37) = 3.65, P < 0.001, Hedges' g = 0.03, 95% CI 0.02-0.05), indicating a need for repeated sessions to improve these adverse health outcomes. Neither increasing the number of sessions for newborns nor increasing the duration of touch per session in adults or newborns increased health benefits, be they physical or mental (Fig. 8b-d). For continuous moderators in adults, we also looked at specific health outcomes as sufficient data were generally available for further analysis. Surprisingly, we found significant negative associations between touch duration and reductions of cortisol ( t(24) = 2.71, P = 0.012, Hedges' g = −0.01, 95% CI −0.01 to −0.00) and heart rate parameters ( t(21) = 2.35, P = 0.029, Hedges' g  = −0.01, 95% CI −0.02 to −0.00).

Demographic influences of sex and age

We used the ratio between women and men in the single-study samples as a proxy for sex-specific effects. Sex ratios were heavily skewed towards larger numbers of women in each cohort (median 83% women), and we could not find significant associations between sex ratio and overall ( t(62) = 0.08, P = 0.935, Hedges' g = 0.00, 95% CI −0.00 to 0.01), mental ( t(43) = 0.55, P = 0.588, Hedges' g = 0.00, 95% CI −0.00 to 0.01) or physical health benefits ( t(51) = 0.15, P = 0.882, Hedges' g = −0.00, 95% CI −0.01 to 0.01). For specific outcomes that could be further analysed, we found a significant positive association of sex ratio with reductions in cortisol secretion ( t(18) = 2.31, P = 0.033, Hedges' g = 0.01, 95% CI 0.00 to 0.01) suggesting stronger benefits in women. In contrast to adults, sex ratios were balanced in samples of newborns (median 53% girls). For newborns, there was no significant association with overall ( t(36) = 0.77, P = 0.447, Hedges' g = −0.01, 95% CI −0.02 to 0.01) and physical health benefits of touch ( t(35) = 0.93, P = 0.359, Hedges' g  = −0.01, 95% CI −0.02 to 0.01). Mental health benefits did not provide sufficient data for further analysis.

The median age in the adult meta-analysis was 42.6 years (s.d. 21.16 years, range 4.5-88.4 years). There was no association between age and the overall ( t(73) = 0.35, P = 0.727, Hedges' g = 0.00, 95% CI −0.01 to 0.01), mental ( t(53) = 0.94, P = 0.353, Hedges' g = 0.01, 95% CI −0.01 to 0.02) and physical health benefits of touch ( t(60) = 0.16, P = 0.870, Hedges' g = 0.00, 95% CI −0.01 to 0.01). Looking at specific health outcomes, we found significant positive associations between mean age and improved positive affect ( t(10) = 2.54, P = 0.030, Hedges' g = 0.01, 95% CI 0.00 to 0.02) as well as systolic blood pressure ( t(11) = 2.39, P = 0.036, Hedges' g  = 0.02, 95% CI 0.00 to 0.04).

Body part

A list of touched body parts can be found in Supplementary Table 1. For the touched body part, we found significantly higher health benefits for head touch compared with arm touch ( t(40) = 2.14, P = 0.039, Hedges' g difference of 0.78, 95% CI 0.07 to 1.49) and torso touch ( t(40) = 2.23, P = 0.031; Hedges' g difference of 0.84, 95% CI 0.10 to 1.58; Supplementary Fig. 17). Touching the arm resulted in lower mental health compared with physical health benefits ( t(37) = 2.29, P = 0.028, Hedges' g difference of −0.35, 95% CI −0.65 to −0.05). Furthermore, we found a significantly increased physical health benefit when the head was touched as opposed to the torso ( t(37) = 2.10, P = 0.043, Hedges' g difference of 0.96, 95% CI 0.06 to 1.86). Thus, head touch such as a face or scalp massage could be especially beneficial.

Directionality

In adults, we tested whether a uni- or bidirectional application of touch mattered. The large majority of touch was applied unidirectionally ( k = 442 of 469 effects). Unidirectional touch had higher health benefits ( t(101) = 2.17, P = 0.032, Hedges' g difference of 0.30, 95% CI 0.03 to 0.58) than bidirectional touch. Specifically, mental health benefits were higher in unidirectional touch ( t(99) = 2.33, P = 0.022, Hedges' g difference of 0.46, 95% CI 0.06 to 0.66).

Study location

For adults, we found significantly stronger health benefits of touch in South American compared with North American cohorts ( t(95) = 2.03, P = 0.046, Hedges' g difference of 0.37, 95% CI 0.01 to 0.73) and European cohorts ( t(95) = 2.22, P = 0.029, Hedges' g difference of 0.36, 95% CI 0.04 to 0.68). For newborns, we found weaker effects in North American cohorts compared to Asian ( t(55) = 2.28, P = 0.026, Hedges' g difference of −0.37, 95% CI −0.69 to −0.05) and European cohorts ( t(55) = 2.36, P = 0.022, Hedges' g difference of −0.40, 95% CI −0.74 to −0.06). Investigating the interaction with mental and physical health benefits did not reveal any effects of study location in both meta-analyses (Supplementary Fig. 18).

Systematic review of studies without effect sizes

All studies where effect size data could not be obtained or that did not meet the meta-analysis inclusion criteria can be found on the OSF project12 in the file 'Study_lists_final_revised.xlsx' (sheet 'Studies_without_effect_sizes'). Specific reasons for exclusion are furthermore documented in Supplementary Table 2. For human health outcomes assessed across 56 studies and n = 2,438 individuals, interventions mostly comprised massage therapy ( k = 86 health outcomes) and kangaroo care ( k  = 33 health outcomes). For datasets where no effect size could be computed, 90.0% of mental health and 84.3% of physical health parameters were positively impacted by touch. Positive impact of touch did not differ between types of touch interventions. These results match well with the observations of the meta-analysis of a highly positive benefit of touch overall, irrespective of whether a massage or any other intervention is applied.

We also assessed health outcomes in animals across 19 studies and n = 911 subjects. Most research was conducted in rodents. Animals that received touch were rats (ten studies, k = 16 health outcomes), mice (four studies, k = 7 health outcomes), macaques (two studies, k = 3 health outcomes), cats (one study, k = 3 health outcomes), lambs (one study, k = 2 health outcomes) and coral reef fish (one study, k = 1 health outcome). Touch interventions mostly comprised stroking ( k = 13 health outcomes) and tickling ( k  = 10 health outcomes). For animal studies, 71.4% of effects showed benefits to mental health-like parameters and 81.8% showed positive physical health effects. We thus found strong evidence that touch interventions, which were mostly conducted by humans (16 studies with human touch versus 3 studies with object touch), had positive health effects in animal species as well.

Discussion

The key aim of the present study was twofold: (1) to provide an estimate of the effect size of touch interventions and (2) to disambiguate moderating factors to potentially tailor future interventions more precisely. Overall, touch interventions were beneficial for both physical and mental health, with a medium effect size. Our work illustrates that touch interventions are best suited for reducing pain, depression and anxiety in adults and children as well as for increasing weight gain in newborns. These findings are in line with previous meta-analyses on this topic, supporting their conclusions and their robustness to the addition of more datasets. One limitation of previous meta-analyses is that they focused on specific health outcomes or populations, despite primary studies often reporting effects on multiple health parameters simultaneously (for example, ref. 13 focusing on neck and shoulder pain and ref. 14 focusing on massage therapy in preterms). To our knowledge, only ref. 5 provides a multivariate picture for a large number of dependent variables. However, this study analysed their data in separate random effects models that did not account for multivariate reporting nor for the multilevel structure of the data, as such approaches have only become available recently. Thus, in addition to adding a substantial amount of new data, our statistical approach provides a more accurate depiction of effect size estimates. Additionally, our study investigated a variety of moderating effects that did not reach significance (for example, sex ratio, mean age or intervention duration) or were not considered (for example, the benefits of robot or object touch) in previous meta-analyses in relation to touch intervention efficacy5, probably because of the small number of studies with information on these moderators in the past. Owing to our large-scale approach, we reached high statistical power for many moderator analyses. Finally, previous meta-analyses on this topic exclusively focused on massage therapy in adults or kangaroo care in newborns15, leaving out a large number of interventions that are being carried out in research as well as in everyday life to improve well-being. Incorporating these studies into our study, we found that, in general, both massages and other types of touch, such as gentle touch, stroking or kangaroo care, showed similar health benefits.

While it seems to be less critical which touch intervention is applied, the frequency of interventions seems to matter. More sessions were positively associated with the improvement of trait outcomes such as depression and anxiety but also pain reductions in adults. In contrast to session number, increasing the duration of individual sessions did not improve health effects. In fact, we found some indications of negative relationships in adults for cortisol and blood pressure. This could be due to habituating effects of touch on the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, ultimately resulting in diminished effects with longer exposure, or decreased pleasantness ratings of affective touch with increasing duration16. For newborns, we could not support previous notions that the duration of the touch intervention is linked to benefits in weight gain17. Thus, an ideal intervention protocol does not seem to have to be excessively long. It should be noted that very few interventions lasted less than 5 min, and it therefore remains unclear whether very short interventions have the same effect.

A critical issue highlighted in the pandemic was the lack of touch due to social restrictions18. To accommodate the need for touch in individuals with small social networks (for example, institutionalized or isolated individuals), touch interventions using objects/robots have been explored in the past (for a review, see ref. 11). We show here that touch interactions outside of the human-human domain are beneficial for mental and physical health outcomes. Importantly, object/robot touch was not as effective in improving mental health as human-applied touch. A sub-analysis of missing skin-to-skin contact among humans indicated that mental health effects of touch might be mediated by the presence of skin-to-skin contact. Thus, it seems profitable to include skin-to-skin contact in future touch interventions, in line with previous findings in newborns19. In robots, recent advancements in synthetic skin20 should be investigated further in this regard. It should be noted that, although we did not observe significant differences in physical health benefits between human-human and human-object touch, the variability of effect sizes was higher in human-object touch. The conditions enabling object or robot interactions to improve well-being should therefore be explored in more detail in the future.

Touch was beneficial for both healthy and clinical cohorts. These data are critical as most previous meta-analytic research has focused on individuals diagnosed with clinical disorders (for example, ref. 6). For mental health outcomes, we found larger effects in clinical cohorts. A possible reason could relate to increased touch wanting21 in patients. For example, loneliness often co-occurs with chronic illnesses22, which are linked to depressed mood and feelings of anxiety23. Touch can be used to counteract this negative development24,25. In adults and children, knowing the toucher did not influence health benefits. In contrast, familiarity affected overall health benefits in newborns, with parental touch being more beneficial than touch applied by medical staff. Previous studies have suggested that early skin-to-skin contact and exposure to maternal odour is critical for a newborn's ability to adapt to a new environment26, supporting the notion that parental care is difficult to substitute in this time period.

With respect to age-related effects, our data further suggest that increasing age was associated with a higher benefit through touch for systolic blood pressure. These findings could potentially be attributed to higher basal blood pressure27 with increasing age, allowing for a stronger modulation of this parameter. For sex differences, our study provides some evidence that there are differences between women and men with respect to health benefits of touch. Overall, research on sex differences in touch processing is relatively sparse (but see refs. 28,29). Our results suggest that buffering effects against physiological stress are stronger in women. This is in line with increased buffering effects of hugs in women compared with men30. The female-biased primary research in adults, however, begs for more research in men or non-binary individuals. Unfortunately, our study could not dive deeper into this topic as health benefits broken down by sex or gender were almost never provided. Recent research has demonstrated that sensory pleasantness is affected by sex and that this also interacts with the familiarity of the other person in the touching dyad29,31. In general, contextual factors such as sex and gender or the relationship of the touching dyad, differences in cultural background or internal states such as stress have been demonstrated to be highly influential in the perception of affective touch and are thus relevant to maximizing the pleasantness and ultimately the health benefits of touch interactions32,33,34. As a positive personal relationship within the touching dyad is paramount to induce positive health effects, future research applying robot touch to promote well-being should therefore not only explore synthetic skin options but also focus on improving robots as social agents that form a close relationship with the person receiving the touch35.

As part of the systematic review, we also assessed the effects of touch interventions in non-human animals. Mimicking the results of the meta-analysis in humans, beneficial effects of touch in animals were comparably strong for mental health-like and physical health outcomes. This may inform interventions to promote animal welfare in the context of animal experiments36, farming37 and pets38. While most studies investigated effects in rodents, which are mostly used as laboratory animals, these results probably transfer to livestock and common pets as well. Indeed, touch was beneficial in lambs, fish and cats39,40,41. The positive impact of human touch in rodents also allows for future mechanistic studies in animal models to investigate how interventions such as tickling or stroking modulate hormonal and neuronal responses to touch in the brain. Furthermore, the commonly proposed oxytocin hypothesis can be causally investigated in these animal models through, for example, optogenetic or chemogenetic techniques42. We believe that such translational approaches will further help in optimizing future interventions in humans by uncovering the underlying mechanisms and brain circuits involved in touch.

Our results offer many promising avenues to improve future touch interventions, but they also need to be discussed in light of their limitations. While the majority of findings showed robust health benefits of touch interventions across moderators when compared with a null effect, post hoc tests of, for example, familiarity effects in newborns or mental health benefit differences between human and object touch only barely reached significance. Since we computed a large number of statistical tests in the present study, there is a risk that these results are false positives. We hope that researchers in this field are stimulated by these intriguing results and target these questions by primary research through controlled experimental designs within a well-powered study. Furthermore, the presence of small-study bias in both meta-analyses is indicative that the effect size estimates presented here might be overestimated as null results are often unpublished. We want to stress however that this bias is probably reduced by the multivariate reporting of primary studies. Most studies that reported on multiple health outcomes only showed significant findings for one or two among many. Thus, the multivariate nature of primary research in this field allowed us to include many non-significant findings in the present study. Another limitation pertains to the fact that we only included articles in languages mostly spoken in Western countries. As a large body of evidence comes from Asian countries, it could be that primary research was published in languages other than specified in the inclusion criteria. Thus, despite the large and inclusive nature of our study, some studies could have been missed regardless. Another factor that could not be accounted for in our meta-analysis was that an important prerequisite for touch to be beneficial is its perceived pleasantness. The level of pleasantness associated with being touched is modulated by several parameters34 including cultural acceptability43, perceived humanness44 or a need for touch45, which could explain the observed differences for certain moderators, such as human-human versus robot-human interaction. Moreover, the fact that secondary categorical moderators could not be investigated with respect to specific health outcomes, owing to the lack of data points, limits the specificity of our conclusions in this regard. It thus remains unclear whether, for example, a decreased mental health benefit in the absence of skin-to-skin contact is linked mostly to decreased anxiolytic effects, changes in positive/negative affect or something else. Since these health outcomes are however highly correlated46, it is likely that such effects are driven by multiple health outcomes. Similarly, it is important to note that our conclusions mainly refer to outcomes measured close to the touch intervention as we did not include long-term outcomes. Finally, it needs to be noted that blinding towards the experimental condition is essentially impossible in touch interventions. Although we compared the touch intervention with other interventions, such as relaxation therapy, as control whenever possible, contributions of placebo effects cannot be ruled out.

In conclusion, we show clear evidence that touch interventions are beneficial across a large number of both physical and mental health outcomes, for both healthy and clinical cohorts, and for all ages. These benefits, while influenced in their magnitude by study cohorts and intervention characteristics, were robustly present, promoting the conclusion that touch interventions can be systematically employed across the population to preserve and improve our health.

Methods

Open science practices

All data and code are accessible in the corresponding OSF project12. The systematic review was registered on PROSPERO (CRD42022304281) before the start of data collection. We deviated from the pre-registered plan as follows:

Deviation 1: During our initial screening for the systematic review, we were confronted with a large number of potential health outcomes to look at. This observation of multivariate outcomes led us to register an amendment during data collection (but before any effect size or moderator screening). In doing so, we aimed to additionally extract meta-analytic effects for a more quantitative assessment of our review question that can account for multivariate data reporting and dependencies of effects within the same study. Furthermore, as we noted a severe lack of studies with respect to health outcomes for animals during the inclusion assessment for the systematic review, we decided that the meta-analysis would only focus on outcomes that could be meaningfully analysed on the meta-analytic level and therefore only included health outcomes of human participants.

Deviation 2: In the pre-registration, we did not explicitly exclude non-randomized trials. Since an explicit use of non-randomization for group allocation significantly increases the risk of bias, we decided to exclude them a posteriori from data analysis.

Deviation 3: In the pre-registration, we outlined a tertiary moderator level, namely benefits of touch application versus touch reception. This level was ignored since no included study specifically investigated the benefits of touch application by itself.

Deviation 4: In the pre-registration, we suggested using the RoBMA function47 to provide a Bayesian framework that allows for a more accurate assessment of publication bias beyond small-study bias. Unfortunately, neither multilevel nor multivariate data structures are supported by the RoBMA function, to our knowledge. For this reason, we did not further pursue this analysis, as the hierarchical nature of the data would not be accounted for.

Deviation 5: Beyond the pre-registered inclusion and exclusion criteria, we also excluded dissertations owing to their lack of peer review.

Deviation 6: In the pre-registration, we stated to investigate the impact of sex of the person applying the touch. This moderator was not further analysed, as this information was rarely given and the individuals applying the touch were almost exclusively women (7 males, 24 mixed and 85 females in studies on adults/children; 3 males, 17 mixed and 80 females in studied on newborns).

Deviation 7: The time span of the touch intervention as assessed by subtracting the final day of the intervention from the first day was not investigated further owing to its very high correlation with the number of sessions ( r(461) = 0.81 in the adult meta-analysis, r(145) = 0.84 in the newborn meta-analysis).

Inclusion and exclusion criteria

To be included in the systematic review, studies had to investigate the relationship between at least one health outcome (physical and/or mental) in humans or animals and a touch intervention, include explicit physical touch by another human, animal or object as part of an intervention and include an experimental and control condition/group that are differentiated by touch alone. Of note, as a result of this selection process, no animal-to-animal touch intervention study was included, as they never featured a proper no-touch control. Human touch was always explicit touch by a human (that is, no brushes or other tools), either with or without skin-to-skin contact. Regarding the included health outcomes, we aimed to be as broad as possible but excluded parameters such as neurophysiological responses or pleasantness ratings after touch application as they do not reflect health outcomes. All included studies in the meta-analysis and systematic review48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204,205,206,207,208,209,210,211,212,213,214,215,216,217,218,219,220,221,222,223,224,225,226,227,228,229,230,231,232,233,234,235,236,237,238,239,240,241,242,243,244,245,246,247,248,249,250,251,252,253,254,255,256,257,258,259,260,261,262,263 are listed in Supplementary Table 2. All excluded studies are listed in Supplementary Table 3, together with a reason for exclusion. We then applied a two-step process: First, we identified all potential health outcomes and extracted qualitative information on those outcomes (for example, direction of effect). Second, we extracted quantitative information from all possible outcomes (for example, effect sizes). The meta-analysis additionally required a between-subjects design (to clearly distinguish touch from no-touch effects and owing to missing information about the correlation between repeated measurements264). Studies that explicitly did not apply a randomized protocol were excluded before further analysis to reduce risk of bias. The full study lists for excluded and included studies can be found in the OSF project12 in the file 'Study_lists_final_revised.xlsx'. In terms of the time frame, we conducted an open-start search of studies until 2022 and identified studies conducted between 1965 and 2022.

Data collection

We used Google Scholar, PubMed and Web of Science for our literature search, with no limitations regarding the publication date and using pre-specified search queries (see Supplementary Information for the exact keywords used). All procedures were in accordance with the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines265. Articles were assessed in French, Dutch, German or English. The above databases were searched from 2 December 2021 until 1 October 2022. Two independent coders evaluated each paper against the inclusion and exclusion criteria. Inconsistencies between coders were checked and resolved by J.P. and H.H. Studies excluded/included for the review and meta-analysis can be found on the OSF project.

Search queries

We used the following keywords to search the chosen databases. Agents (human versus animal versus object versus robot) and touch outcome (physical versus mental) were searched separately together with keywords searching for touch.

1. 1.
TOUCH: Touch OR Social OR Affective OR Contact OR Tactile interaction OR Hug OR Massage OR Embrace OR Kiss OR Cradling OR Stroking OR Haptic interaction OR tickling

2. 2.
AGENT: Object OR Robot OR human OR animal OR rodent OR primate

3. 3.
MENTAL OUTCOME: Health OR mood OR Depression OR Loneliness OR happiness OR life satisfaction OR Mental Disorder OR well-being OR welfare OR dementia OR psychological OR psychiatric OR anxiety OR Distress

4. 4.
PHYSICAL OUTCOME: Health OR Stress OR Pain OR cardiovascular health OR infection risk OR immune response OR blood pressure OR heart rate

Data extraction and preparation

Data extraction began on 10 October 2022 and was concluded on 25 February 2023. J.P. and H.H. oversaw the data collection process, and checked and resolved all inconsistencies between coders.

Health benefits of touch were always coded by positive summary effects, whereas adverse health effects of touch were represented by negative summary effects. If multiple time points were measured for the same outcome on the same day after a single touch intervention, we extracted the peak effect size (in either the positive or negative direction). If the touch intervention occurred multiple times and health outcomes were assessed for each time point, we extracted data points separately. However, we only extracted immediate effects, as long-term effects not controlled through the experimental conditions could be due to influences other than the initial touch intervention. Measurements assessing long-term effects without explicit touch sessions in the breaks were excluded for the same reason. Common control groups for touch interventions comprised active (for example, relaxation therapy) as well as passive control groups (for example, standard medical care). In the case of multiple control groups, we always contrasted the touch group to the group that most closely matched the touch condition (for example, relaxation therapy was preferred over standard medical care). We extracted information from all moderators listed in the pre-registration (Supplementary Table 4). A list of included and excluded health outcomes is presented in Supplementary Table 5. Authors of studies with possible effects but missing information to calculate those effects were contacted via email and asked to provide the missing data (response rate 35.7%).

After finalizing the list of included studies for the systematic review, we added columns for moderators and the coding schema for our meta-analysis per our updated registration. Then, each study was assessed for its eligibility in the meta-analysis by two independent coders (J.P., H.H., K.F. or F.M.). To this end, all coders followed an a priori specified procedure: First, the PDF was skimmed for possible effects to extract, and the study was excluded if no PDF was available or the study was in a language different from the ones specified in ' Data collection'. Effects from studies that met the inclusion criteria were extracted from all studies listing descriptive values or statistical parameters to calculate effect sizes. A website266 was used to convert descriptive and statistical values available in the included studies (means and standard deviations/standard errors/confidence intervals, sample sizes, F values, t values, t test P values or frequencies) into Cohen's d, which were then converted in Hedges' g. If only P value thresholds were reported (for example, P < 0.01), we used this, most conservative, value as the P value to calculate the effect size (for example, P = 0.01). If only the total sample size was given but that number was even and the participants were randomly assigned to each group, we assumed equal sample sizes for each group. If delta change scores (for example, pre- to post-touch intervention) were reported, we used those over post-touch only scores. In case frequencies were 0 when frequency tables were used to determine effect sizes, we used a value of 0.5 as a substitute to calculate the effect (the default setting in the 'metafor' function267). From these data, Hedges' g and its variance could be derived. Effect sizes were always computed between the experimental and the control group.

Statistical analysis and risk of bias assessment

Owing to the lack of identified studies, health benefits to animals were not included as part of the statistical analysis. One meta-analysis was performed for adults, adolescents and children, as outcomes were highly comparable. We refer to this meta-analysis as the adult meta-analysis, as children/adolescent cohorts were only targeted in a minority of studies. A separate meta-analysis was performed for newborns, as their health outcomes differed substantially from any other age group.

Data were analysed using R (version 4.2.2) with the 'rma.mv' function from the 'metafor' package267 in a multistep, multivariate and multilevel fashion.

We calculated an overall effect of touch interventions across all studies, cohorts and health outcomes. To account for the hierarchical structure of the data, we used a multilevel structure with random effects at the study, cohort and effects level. Furthermore, we calculated the variance-covariance matrix of all data points to account for the dependencies of measured effects within each individual cohort and study. The variance-covariance matrix was calculated by default with an assumed correlation of effect sizes within each cohort of ρ = 0.6. As ρ needed to be assumed, sensitivity analyses for all computed effect estimates were conducted using correlations between effects of 0, 0.2, 0.4 and 0.8. The results of these sensitivity analyses can be found in ref. 12. No conclusion drawn in the present manuscript was altered by changing the level of ρ. The sensitivity analyses, however, showed that higher assumed correlations lead to more conservative effect size estimates (see Supplementary Figs. 19 and 20 for the adult and newborn meta-analyses, respectively), reducing the type I error risk in general268. In addition to these procedures, we used robust variance estimation with cluster-robust inference at the cohort level. This step is recommended to more accurately determine the confidence intervals in complex multivariate models269. The data distribution was assumed to be normal, but this was not formally tested.

To determine whether individual effects had a strong influence on our results, we calculated Cook's distance D. Here, a threshold of D > 0.5 was used to qualify a study as influential270. Heterogeneity in the present study was assessed using Cochran's Q, which determines whether the extracted effect sizes estimate a common population effect size. Although the Q statistic in the 'rma.mv' function accounts for the hierarchical nature of the data, we also quantified the heterogeneity estimator σ² for each random-effects level to provide a comprehensive overview of heterogeneity indicators. These indicators for all models can be found on the OSF project12 in the Table 'Model estimates'. To assess small study bias, we visually inspected the funnel plot and used the standard error as a moderator in the overarching meta-analyses.

Before any sub-group analysis, the overall effect size was used as input for power calculations. While such post hoc power calculations might be limited, we believe that a minimum number of effects to be included in subgroup analyses was necessary to allow for meaningful conclusions. Such medium effect sizes would also probably be the minimum effect sizes of interest for researchers as well as clinical practitioners. Power calculation for random-effects models further requires a sample size for each individual effect as well as an approximation of the expected heterogeneity between studies. For the sample size input, we used the median sample size in each of our studies. For heterogeneity, we assumed a value between medium and high levels of heterogeneity ( I² = 62.5%271), as moderator analyses typically aim at reducing heterogeneity overall. Subgroups were only further investigated if the number of observed effects achieved ~80% power under these circumstances, to allow for a more robust interpretation of the observed effects (see Supplementary Figs. 5 and 6 for the adult and newborn meta-analysis, respectively). In a next step, we investigated all pre-registered moderators for which sufficient power was detected. We first looked at our primary moderators (mental versus physical health) and how the effect sizes systematically varied as a function of our secondary moderators (for example, human-human or human-object touch, duration, skin-to-skin presence, etc.). We always included random slopes to allow for our moderators to vary with the random effects at our clustering variable, which is recommended in multilevel models to reduce false positives272. All statistical tests were performed two-sided. Significance of moderators was determined using omnibus F tests. Effect size differences between moderator levels and their confidence intervals were assessed via t tests.

Post hoc t tests were performed comparing mental and physical health benefits within each interacting moderator (for example, mental versus physical health benefits in cancer patients) and mental or physical health benefits across levels of the interacting moderator (for example, mental health benefits in cancer versus pain patients). The post hoc tests were not pre-registered. Data were visualized using forest plots and orchard plots273 for categorical moderators and scatter plots for continuous moderators.

For a broad overview of prior work and their biases, risk of bias was assessed for all studies included in both meta-analyses and the systematic review. We assessed the risk of bias for the following parameters:

1. (1)
Bias from randomization, including whether a randomization procedure was performed, whether it was a between- or within-participant design and whether there were any baseline differences for demographic or dependent variables.

2. (2)
Sequence bias resulting from a lack of counterbalancing in within-subject designs.

3. (3)
Performance bias resulting from the participants or experiments not being blinded to the experimental conditions.

4. (4)
Attrition bias resulting from different dropout rates between experimental groups.

Note that four studies in the adult meta-analysis did not explicitly mention randomization as part of their protocol. However, since these studies never showed any baseline differences in all relevant variables (see 'Risk of Bias' table on the OSF project), we assumed that randomization was performed but not mentioned. Sequence bias was of no concern for studies for the meta-analysis since cross-over designs were excluded. It was, however, assessed for studies within the scope of the systematic review. Importantly, performance bias was always high in the adult/children meta-analysis, as blinding of the participants and experimenters to the experimental conditions was not possible owing to the nature of the intervention (touch versus no touch). For studies with newborns and animals, we assessed the performance bias as medium since neither newborns or animals are likely to be aware of being part of an experiment or specific group. An overview of the results is presented in Supplementary Fig. 21, and the precise assessment for each study can be found on the OSF project12 in the 'Risk of Bias' table.

Reporting summary

Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article.

# data[].attributes.attachment_link.title
A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions - Nature Human Behaviour

# data[].attributes.attachment_link.description
Receiving touch is of critical importance, as many studies have shown that touch promotes mental and physical well-being. We conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review (n = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy.

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Ruth, could you remove me as admin from the SMTO FB page too please? Thanks Jane