# data[].attributes.attachment_caption
Thanks to Indiania University East for this information.

# data[].attributes.body
Checking sources is crucial. If you cannot find sources related to your article, look for other articles about the same topic, education is key and is vital for judging sources. The more knowledgeable you are you can then be more informed about the topic.

For research purposes use the most updated information you can find.

# data[].attributes.headline
Important for Nurses to give credible information to patients.

# data[].attributes.subject
Important for Nurses to give credible information to patients.

# data[].attributes.body
This article gives important information as to why nurses should help patients and families have access to "credible, (and) trusted health information."

# data[].attributes.attachment_link.readable_text
Editor's note: This is an early release of an article that will appear in the February 2022 issue of American Nurse Journal.
Takeaways:

Nurses have an important role in helping patients, families, and communities access credible, trusted health information.

Nurses should consider the foundational attributes of information sources when engaging on social media platforms where professional, social, and familial identities may converge.

On July 15, 2021, the U.S. Surgeon General issued an urgent plea for all Americans to take part in slowing a serious threat to public health. He wasn't talking about the COVID-19 pandemic but rather the deleterious effects on personal and public health caused by the creation and spread of health misinformation. Nurses, cited as the most trusted profession for their honesty and ethical standards, have a critical responsibility in combating misinformation and in helping patients, families, and communities identify and access credible, trusted health sources.

Misinformation: Then and now

A difference exists between misinformation and disinformation. Misinformation is false, inaccurate, or misleading information. Disinformation is a deliberate intent to deceive for political, personal, and monetary gain. Health misinformation has a long history. A well-known example is an 1802 cartoon depicting people turning into cows after receiving smallpox inoculations. In America, the term "snake oil" refers to ineffective and even poisonous "medications" popularized by traveling salespeople and newspaper advertising.

Although these past incidents echo in the digital age, the high volume and wide array of sources of information and content-all propagated, refined, and disseminated at warp-speed via computing networks and platforms of previously unimaginable power and reach-amplifies the problem. Social media platforms (SMPs), a major source of information dissemination, provide visually appealing content (such as memes or engaging images or tweets) that communicates simplistic messages and evokes suspicion. This stands in contrast to peer-reviewed science publications that provide more accurate information but tend to be densely worded and complex, preventing the same impact or uptake of SMP messages. In addition, studies by Chen and colleagues and Vosoughi and colleagues indicate that false information may more rapidly diffuse and spread further in part because of the strong emotions they may elicit.

The spread of misinformation also may be driven by the commercial interests of SMPs to increase engagement by presenting opinions, statements, and images that reward, affirm, and closely affiliate with a user's real, assumed, or social interests. SMPs use algorithms and prioritize content based on popularity or similarity to a user's previously viewed content. The resulting information creates a bubble composed of narrowly tailored messages based on individual interests, exposing users to more extreme perspectives while insulating them from neutral or opposing ones.

SMPs' high volume of information and lack of quality control can lead to a preponderance of low-quality information, misinformation, or disinformation when patients, families, and communities search for answers to health questions. Misinformation has accelerated during the pandemic, resulting in what the World Health Organization (WHO) calls an "infodemic." The effects include confusion and support for behaviors that can harm health, lead to mistrust in science, and ultimately undermine the public health response to the pandemic.

SMPs must do more to minimize these harms. They must implement policies and technical improvements that evaluate, promote, and imbed information from credible and verifiable sources of health information. Content labeling and transparency also can help reduce misinformation.

Nurses and misinformation

Nurses play an important role in reducing health misinformation harm and helping patients, families, and communities access credible, trusted sources. The Code of Ethics for Nurses with Interpretive Statements includes the duty to respect the inherent dignity of every person, including protecting a patient's right to autonomy. But truly autonomous decision-making and informed consent are possible only when information is accurate, complete, and understandable. Nurses must ensure that patients have access to credible information, which can be defined simply as that which is consistent with the best scientific evidence available at the time.

How do nurses and other health professionals identify credible information? Foundational principles of credible sources of health information proposed by Kington and colleagues include science-based, objective (biases and conflicts are disclosed), and transparent and accountable. (See Credible health information: Foundational principles and attributes.) Librarians, especially those specializing in health and undergraduate education, have developed many rubrics and tools to help consumers navigate the credibility and authority of online information.

Blakeslee's CRAAP (or CRAP) test, one of the most well-known and widely used formal tools for source criticism, encourages users to walk through brief pathways to identify key areas of online source credibility (for example, currency, relevance, authority [author's credentials], and purpose). CRAAP and similar tests can help evaluate traditional websites but may be less helpful in analyzing social media misinformation and disinformation. Kington and colleagues also developed more granular attributes and an algorithm to aid in assessing sites and information. ( See Credibility algorithm.)

Nurses should consider these foundational attributes when interacting on SMPs where their professional, social, and personal identities may converge. In addition, they should integrate them into clinical practice. Health systems concerned with training, accreditation, and patient education can support and sustain health professionals' scientific and statistical literacy beyond undergraduate and graduate education by providing continuing professional education, establishing journal clubs, and promoting awareness of reliable resources (such as Khan Academy and Cochrane's Students 4 Best Evidence).

Patients and families trust nurses to identify, recommend, and affirm credible sources of information. However, recommending a source also must include assessing the appropriateness of how information is presented, how patients navigate complex health information, and whether they trust the sources (even if they're credible). Many credible sources are fact- and text-dense, requiring advanced comprehension skills and vocabulary, and they may present complex findings that patients find difficult to understand. In addition, most credible scholarly research in the health sciences languishes behind subscription paywalls, making it inaccessible to most patients.

Many publishers, particularly those who work with practice guidelines and high-quality reviews (including Cochrane Reviews, the Joanna Briggs Institute, the Patient-Centered Outcomes Research Institute, and journals such as Pediatrics), have started to recommend or require plain-language summaries, infographics, video abstracts, and other comprehensible, openly available, and shareable content alongside the original scholarly document.

Before recommending sources, assess where and why people access health information. Many health professionals and librarians routinely refer patients to government websites, including the Centers for Disease Control and Prevention and National Institutes of Health (NIH). However, many individuals and communities, for historical or political reasons, don't trust the government. Other credible sources, such as MedlinePlus, WHO, and KidsHealth, also rank highly in search results and could be shared as credible sources along with websites such as Snopes ( snopes.com), FactCheck ( Factcheck.org), and PolitiFact ( politifact.org). Health website certification programs, such as Health On the Net ( www.hon.ch), provide review and verification of health-related internet sites. Definitions of credible nonprofit entities can help you identify nongovernmental information sources.

Nurses and consumers must develop skills to evaluate information critically. A study examining the impact of trust in science found that people with a high trust in science were more likely to believe and disseminate misinformation about COVID-19 and genetically modified organisms in the presence of a scientific reference compared to false claims without scientific references. These findings underscore the importance of critically evaluating information, even from trusted sources.
A call to action
The Surgeon General recommends specific healthcare professional and organization actions to combat misinformation. Fundamental to these actions is to create an environment of trust by demonstrating empathy and curiosity, which encourages patients and families to share concerns and ask questions.

Proactively engage with patients and the public about health information.

Acknowledge the barrage of health information available through technology platforms and other sources and the difficulty of "knowing who and what to trust." ("I know there's a great deal of information about COVID and not all of it is the same. Sometimes, it is hard to sort it out and know what to trust.")

Assess where patients and families get their health information and what sources they trust. Frequently, credible sources aren't trusted sources. ("Where do you get most of your information about COVID-19? What makes that a trusted source for you?")

Provide alternate and accurate sources of information. ("I'm not familiar with that website, but I'll look at it and let you know what I think. In the meantime, here's where I get information and why I trust it.")

When correcting misinformation be nonjudgmental. ("I've heard similar information about not getting vaccinated. Here's what I've learned from the science and why I believe getting vaccinated is important and safe.")

Use technology and media platforms to share accurate health information with the public.

In addition to serving as a subject-matter expert and sharing peer-reviewed research, provide broadly accessible information via various platforms. For example, Dear Pandemic (dearpandemic.org) is a team of researchers and clinicians, including nurses, committed to answering questions and concerns with facts about COVID-19. They have platforms on Twitter and Facebook and serve as sources for public and professional media.

Although not all health professionals are comfortable with social media, you and your interprofessional colleagues should consider when and how your voices can be best used to promote credible, evidence-based health information.

Partner with community groups and local organizations to prevent and address health misinformation.

Nurses are important members of many communities beyond their relationships with patients, including in faith organizations, school, work, and social circles. Use opportunities to partner with these to provide and clarify information about COVID-19.

The NIH Community Engagement Alliance (covid19community.nih.gov) provides national and local resources that you can use and share.

Answer the call

COVID-19 has demonstrated the need to prioritize science communication and public engagement at every level of society. Nurses understand that facilitating education and public access to health information provides pre-exposure prophylaxis against misinformation. As we all know, prevention is better than cure. Treating people for the harms of the infodemic is both difficult and uncertain, but nurses have access to a wealth of tools, principles, and approaches for ensuring that patients and communities receive evidence-based, up-to-date, and credible health information. The COVID-19 pandemic and related infodemic are calling us all to act in our professional and personal lives. How will you answer the call?
The authors work at the University of Pennsylvania. Antonia M. Villarruel is a professor, Margaret Bond Simon Dean of the School of Nursing, and senior fellow in the Leonard Davis Institute of Health Economics. Richard James is nursing liaison librarian and clinical outreach coordinator for the University of Pennsylvania libraries. Acknowledgment
Aliza Narva, JD, MSN, RN, HEC-C, director of ethics at the Hospital of the University of Pennsylvania provided assistance by reviewing the article before submission.

References

American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: ANA Enterprise; 2015. nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only

Blakeslee S. The CRAAP Test. LOEX Quarterly. 2004;31(3). commons.emich.edu/loexquarterly/vol31/iss3/4

Center for Countering Digital Hate. Malgorithm: How Instagram's Algorithm Publishes Misinformation and Hate to Millions During a Pandemic. March 9, 2021. counterhate.com/malgorithm

Chen J, Liu Y, Zou M. User emotion for modeling retweeting behaviors. Neural Netw. 2017;96:11-21. doi: 10.1016/j.neunet.2017.08.006

Chou W-YS, Gaysynsky A, Vanderpool RC. The COVID-19 misinfodemic: Moving beyond fact-checking. Health Educ Behav. 2021;48(1):9-13. doi:10.1177/1090198120980675

Kington RS, Arnesen S, Chou W-YS, Curry SJ, Lazer D, and Villarruel AM. Identifying credible sources of health information in social media: Principles and attributes. NAM Perspect. 2021. doi:10.31478/202107a

O'Brien T, Palmer R, Albarracin, D. Misplaced trust: When trust in science fosters belief in pseudoscience and the benefits of critical evaluation. J Exp Soc Psychol. 2021;96:104184. doi:10.1016/j.jesp.2021.104184

Office of Disease Prevention and Health Promotion. Health literacy online: A guide to simplifying the user experience. June 8, 2016. health.gov/healthliteracyonline

Office of the Surgeon General. Confronting Health Misinformation: The U.S. Surgeon General's Advisory on Building a Healthy Information Environment. US Department of Health and Human Services. 2021. hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf

Saad L. U.S. ethics ratings rise for medical workers and teachers. Gallup. December 22, 2020. news.gallup.com/poll/328136/ethics-ratings-rise-medical-workers-teachers.aspx

Swire-Thompson B, Lazer D. Public health and online misinformation: Challenges and recommendations. Annu Rev Public Health. 2020;41:433-51. doi:10.1146/annurev-publhealth-040119-094127

Simpson E, Conner A. Fighting Coronavirus misinformation and disinformation: Preventive product recommendations for social media platforms. Center for American Progress. August 18, 2020. americanprogress.org/issues/technology-policy/reports/2020/08/18/488714/fighting-coronavirus-misinformation-disinformation

Vosoughi S, Roy D, Aral S. The spread of true and false news online. Science. 2018;359(6380):1146-51. doi.org/10.1126/science.aap9559

World Health Organization. Infodemic. 2021. who.int/health-topics/infodemic#tab=tab_1

# data[].attributes.attachment_link.description
American Nurse Journal, the official, clinically and career-focused journal of the American Nurses Association (ANA), is a fresh voice of nursing across America

# data[].attributes.body
The article brings up a great point that misinformation should be addressed in the health field to not only deal with the negative effects that came out with COVID, but also to look forward to future pandemics and being able to find the correct information.

# data[].attributes.attachment_link.readable_text
Michael Stellefson, Academic Editor

Abstract

Low digital health literacy affects large percentages of populations around the world and is a direct contributor to the spread of COVID-19-related online misinformation (together with bots). The ease and 'viral' nature of social media sharing further complicate the situation. This paper provides a quick overview of the magnitude of the problem of COVID-19 misinformation on social media, its devastating effects, and its intricate relation to digital health literacy. The main strategies, methods and services that can be used to detect and prevent the spread of COVID-19 misinformation, including machine learning-based approaches, health literacy guidelines, checklists, mythbusters and fact-checkers, are then briefly reviewed. Given the complexity of the COVID-19 infodemic, it is very unlikely that any of these approaches or tools will be fully effective alone in stopping the spread of COVID-19 misinformation. Instead, a mixed, synergistic approach, combining the best of these strategies, methods, and services together, is highly recommended in tackling online health misinformation, and mitigating its negative effects in COVID-19 and future pandemics. Furthermore, techniques and tools should ideally focus on evaluating both the message (information content) and the messenger (information author/source) and not just rely on assessing the latter as a quick and easy proxy for the trustworthiness and truthfulness of the former. Surveying and improving population digital health literacy levels are also essential for future infodemic preparedness.

Keywords: COVID-19, infodemic, misinformation, disinformation, social media, health literacy, digital health literacy

1. Introduction

The COVID-19 pandemic has been accompanied by an explosion of inaccurate information about the disease, making it difficult for the general public to make informed decisions. The exact scale of spread of the excessive amount of online COVID-19 misinformation is still unknown but is nevertheless a cause of high concern. Misinformation can be broadly defined as "cases in which people's beliefs about factual matters are not supported by clear evidence and expert opinion" [ 1]. It is false information being spread regardless of intent to mislead, while disinformation is false information being spread with bad intent, to deliberately deceive. The Director-General of the World Health Organization (WHO) termed the COVID-19 misinformation situation as an 'infodemic' (i.e., misinformation epidemic or misinformation pandemic) swarming with conspiracy theories, propaganda, and unproven scientific claims regarding the diagnosis, treatment, and prevention of the disease [ 2, 3]. This infodemic has made reliable information harder to find and discern, and allowed rumours to spread more quickly, putting public health at risk by making it difficult to implement effective preventive measures [ 3].

2. COVID-19-Related Misinformation on Social Media

Social media outlets, such as Facebook, Twitter, YouTube, etc., emerged as major information seeking and sharing channels during the pandemic. As a result, the use of social media platforms increased by 20-87% around the world [ 4]. During health crises, access to reliable information sources and services becomes critical to enable the general public to take part in healthcare and preventive decisions. However, the abundance of health information on social media without any comprehensive checks makes it difficult for the general public to identify accurate information, thus impeding effective public health response [ 5].

Fondazione Bruno Kessler analysed 112 million posts shared on social media related to COVID-19, and concluded that more than 40% of posts contained information from unreliable sources, while 42% of posts were circulated on social media platforms through bots [ 4]. Lee et al. reported that 67.78% of adults have been exposed to COVID-19-related misinformation through social networking services or instant messaging [ 6]. In another study, an analysis of 1225 fake news stories about COVID-19 from January to April 2020 showed that social media accounted for spreading half or 50.5% of the stories [ 5]. Content spreading misinformation about vaccines gained 4.5 billion views on social media in just one month (March to April 2020) [ 7]. Several studies indicated that the infodemic of misleading information during COVID-19 is a threat to the COVID-19 vaccination campaign [ 8].

A comprehensive systematic review of studies published before March 2019 on the prevalence of health misinformation on social media reported widespread misinformation in six areas, namely (i) vaccines, (ii) drugs or smoking, (iii) non-communicable diseases, (iv) pandemics, (v) eating disorders, and (vi) medical treatments. Twitter was the leading source spreading health-related misinformation [ 9]. Naeem and colleagues classified the most commonly identified fake news about COVID-19 into three main types: (i) false claims, such as "coronavirus can be transmitted through houseflies or mosquito bites", (ii) conspiracy theories, such as the ones about 5G (fifth generation technology standard for broadband cellular phone networks) and coronavirus, and (iv) pseudoscientific health therapies, such as "colloidal silver solution can help with coronavirus" [ 5]. A content analysis of a sample of 233 tweets identified 81 tweets (34.8%) falsely claiming that COVID-19 and 5G were linked, 75 tweets (32.2%) criticising the conspiracy theory, and 77 general tweets (33%) not giving any personal remarks or opinions. Surprisingly, 152 (65.2%) of tweets were from people who were non-conspiracy-theory supporters [ 10].

Digital communications, particularly on social media platforms, catalyse the rapid spread of misinformation, threatening public health [ 3, 10]. Bridgman et al. examined 0.6 million tweets on COVID-19 and found that the use of social media was positively associated with misperceptions regarding basic COVID-19 facts. The opposite was true for news media. The study also revealed that comparatively more misleading content related to COVID-19 circulated on Twitter as compared to traditional news media [ 11]. In the same vein, Su concluded that social media use is significantly associated with misinformation beliefs related to COVID-19 [ 12].

Evidence from several studies showed that misleading information and conspiracy theories spread more rapidly when the flow of factual information is slow, and when people's trust in the information sources and services available to them is also low, or when credible information is hard to come by [ 13, 14, 15]. Tworek argues that "communications in a public health crisis are as crucial as medical intervention. In fact, communications policies ARE a medical intervention" [ 16]. Effective health communication plays a critical role in speeding up the flow of factual information and building trust among people regarding health information sources and services.

The United Nations Development Programme has directed governments across the world to "step up to lead the fight against a growing tide of false, inflammatory and misleading information that threatens to worsen the already severe impacts of the virus" [ 17]. There is a broad commitment among researchers, healthcare professionals, information professionals, IT experts, policymakers, and social media experts to prevent the spread of misinformation.

3. Health Literacy and Healthcare Outcomes

Health literacy has received significant attention since the year 2000, when the WHO stated that a low level of public health literacy is a serious concern for public health, and stressed the need to improve public health literacy to minimise inequities in health services [ 18]. Health literacy covers "the ability to access, comprehend, evaluate and communicate information to promote, maintain and improve health in a variety of settings across the life course" [ 19]. Health literacy has been defined by WHO as the individual features and societal resources required for the public and individuals to obtain, recognise, and evaluate information and services in order to make appropriate decisions about health. Health literacy allows and encourages the public to contribute to, and improve, their healthcare and well-being. People possessing good health literacy usually have more skills to manage their health in a better way compared to those with low health literacy skills. The WHO considers the level of people's health literacy an indicator that can be used in assessing the health status of the population [ 20].

Health literacy has three main pillars, namely (i) the capacity to obtain health information (where to find help), (ii) the ability to (properly) understand the information gathered, and (iii) the ability to (properly) apply health information [ 21]. The Australian Commission on Safety and Quality in Health Care (ACSQHC) describes two main components of health literacy: (i) individual health literacy, comprising the individual skills and ability to find, understand and use health-related information; for example, to be able to navigate and use health/care systems, and (ii) the health literacy environment, covering components related to a health system, such as policies, materials and procedures that affect the way people engage with the system [ 22].

Significant amounts of health-related information and myths about COVID-19 are not sufficiently simple or clear to easily comprehend or debunk by the average layperson. The pandemic and associated infodemic have brought unprecedented challenges to public health, affecting the public throughout the world in terms of socio-psychological and economic hardships, and stressing international relations (e.g., by originally naming COVID-19 variants after the places or countries where they were first reported; the WHO now recommends using Greek letters to neutrally refer to these variants). Digital technologies have amplified misinformation, but could also hold the solution.

The World Health Organization is a strong promoter of digital health literacy. With 'digital' added to the formula, we can anticipate wider accessibility of reliable health information, improved healthcare quality and reduced healthcare costs [ 23]. Digital health literacy is the ability to seek, find, understand, and appraise health information using information and communication technologies (ICTs) to address or solve a healthcare problem [ 20, 24, 25].

Prevalence of Low Health Literacy

Low health literacy is very common among people across the world. According to a large-scale national survey, more than 1 in every 3 adults in America have low health literacy [ 26]. Only 8.8% of people were health literate in China in 2012, leading the National Health Commission of China to issue a new strategic plan in the year 2014 to increase the health literacy of the population to 20% by 2020 [ 27]. In the UK, 4 in 10 adults struggle to understand health information that is meant for the public, and more than 6 in 10 adults struggle with health-related information that includes numbers and statistics [ 28, 29].

The evidence also shows that people with a low level of health literacy skills are more likely than those people with a greater level of health literacy skills to report poor health [ 30]. COVID-19 impacted people with inadequate health literacy more badly and more frequently as compared to people with proficient health literacy levels, due to the inability of the former to properly understand and follow health-related recommendations. They find it difficult to locate healthcare providers and healthcare services, share their medical condition and history with healthcare providers, seek preventive healthcare, understand directions on medicines (prescriptions), and recognise the connection between risky behaviours and health [ 31].

A large-scale systematic review covering 111 published studies that measured health literacy and its association with health outcomes concluded that low health literacy is a contributor to compromised health outcomes and inadequate use of healthcare services, resulting in greater use of emergency services, increased hospitalisations, lower vaccination rates, improper medication-taking, inadequate ability to interpret prescriptions and health messages, and higher mortality rates among elderly persons. People with poor health literacy skills are at higher risk of poor health outcomes and unhealthy behaviours [ 24].

The literature is abundant with studies covering these negative consequences; for example, research linking low health literacy to a lower engagement with health services [ 32] and healthcare providers [ 33], to inadequate use of preventive health services [ 34], to poor health status and increased hospital re-admission rates [ 35], to a lack of understanding of medication instructions [ 36], to a lower quality of life in specific medical conditions [ 37], and to poor ability to self-manage health [ 38]. Low health literacy is also strongly correlated with health inequalities [ 39].

Health literacy is context-dependent. This means people with generally acceptable health literacy skills can still face health literacy challenges in some contexts, such as when they are not familiar with some complex medical jargon, or in certain health conditions requiring complicated self-care. Abdulai et al. assessed digital literacy levels among lay consumers of online COVID-19 information in Ghana, a low-income country, using a survey based on the eHealth Literacy Scale (eHEALS). Not only did the majority of respondents in their study exhibit poor ability to find COVID-19 information online, but they also demonstrated relatively low skills in differentiating scientific from unscientific information on the Internet. Gender, age, frequency of searching the Internet for COVID-19 information and for educational purposes, and having adequate or poor knowledge of COVID-19 were predictive of digital literacy levels [ 40]. Socioeconomic status, inadequate education, limited English proficiency, older age, and being from a diverse background are among the main factors linked to low health literacy [ 41, 42, 43, 44]. In another survey of South Korean adults in 2020, Lee et al. found that COVID-19 misinformation exposure was associated with misinformation belief, and that misinformation belief was linked to fewer preventive behaviours [ 6].

We live in a highly digitised world where every piece of information available online is potentially subject to authenticity and validity checks. Thus, we must recognise and promote e-health and media literacies as fundamental skills, just as writing and reading are. Digital health and media literacies should also be promoted as lifelong-needed competencies that, once acquired, could be useful in any health-related context. Only then will we be able to empower people to better identify and protect themselves from misinformation and to make correctly informed decisions about their health [ 45]. Many studies recommend developing good digital health literacy skills among the public as a way forward to critically (self-)appraise information and prevent the spread of misinformation during pandemic times [ 40, 46]. Health literacy and numeracy skills are two fundamental skill sets that should be promoted among the public in order to ensure better healthcare outcomes [ 30].

4. Strategies and Methods to Detect and Prevent the Spread of Misinformation

To prevent the spread of COVID-19 misinformation, a number of guidelines, checklists, resources, fact-checking tools, mythbusters, digital health literacy training instructions, and long-term strategies have been proposed, developed and/or implemented. These misinformation mitigation attempts have mainly been made by computer scientists, data science experts, information professionals, researchers, government agencies, and professional associations. Computer scientists developed fact-checking tools, applications and resources using artificial intelligence-based approaches, including machine learning, while information professionals, social and behavioural science researchers, and professional associations created guidelines and checklists to help the general public recognise fake news.

Given the complexity of the infodemic, no approach has yet managed to fully automate the challenge of fake news detection. According to the Fake News Challenge Stance-Detection Task's creators, 'truth labelling' is very difficult in practice. They proposed developing a dedicated tool for that purpose, preferring a reliable semi-automated approach over a fully-automated system in order to achieve a greater percentage of accuracy in detecting fake news [ 47]. Although, fully automated systems have received some success in recognising information validity, their accuracy has not (yet) reached an acceptable level. In one study published in late 2019, the best performing system achieved a FEVER (Fact Extraction and VERification) score of 64.21% [ 48]. The rapidly changing COVID-19 information landscape and the associated relatively "novel" pandemic language make currently used (pre-pandemic) misinformation recognition datasets and models ineffective for debunking COVID-19 misinformation [ 49].

Daniel J. Levitin, a neuroscientist, said that "what looks like (and reads like) the truth may be riddled with lies if you look more closely". He identified "four tricky ways that fake news can fool you". These include (i) "lies are tucked in among truths", (ii) "websites masquerade under misleading names", (iii) "numbers are given without context", and (iv) "claims rest on false sources". He recommended that the task of figuring out the truth and discarding fake news falls on us all, and requires critical thinking and time. It also requires us to keep updating our knowledge as information continues to evolve very rapidly [ 50].

4.1. Machine Learning-Based Approaches

Several tools, approaches, and models have been reported in the literature that can flag COVID-19 related misinformation as false information. For example, Hossain et al. [ 49] introduced COVIDLies, a tweet debunking dataset annotated by experts, containing COVID-19 misinformation accompanied by tweets that 'agree', 'disagree', or express 'no stance' for each piece of misinformation. Abdelminaam and colleagues proposed CoAID-DEEP (COVID-19 heAlthcare mIsinformation Dataset), a machine learning and deep learning system to automate the identification of COVID-19-related fake news [ 51]. Kolluri and Murthy introduced CoVerifi, a Web application that attempts to appraise the credibility of news based on human feedback and the power of a machine learning-based approach. It provides a multi-channel check for news, using user feedback to detect fake news that have failed to be recognised by Web-based fact-checking tools and vice versa [ 52]. Khanday et al. argue that machine learning and deep learning can replace humans in providing accurate results regarding fake news detection [ 53], but it is obvious that such a bold claim cannot be universally applied in every situation.

4.2. Health Literacy Guidelines, Checklists, Mythbusters and Fact-Checkers

The International Federation of Library Associations' (IFLA) guidelines are among the most widely accepted and used fake news detection checklists available today. It comprises eight steps: (i) "consider the source", (ii) "check the author", (iii) "check the date", (iv) "check your biases", (v) "read beyond", (vi) "seek supporting sources", (vii) ask "is it a joke?", and (viii) "ask the experts" [ 54].

CRAAP (Currency, Relevance, Authority, Accuracy, and Purpose) is another useful checklist for evaluating online information resources, created by the Meriam Library, California State University. It focuses on whether an information resource is 'current' and up-to-date, 'relevant', 'accurate', and 'telling the truth', and directs information evaluators to seek answers to questions such as who is the 'author' (who wrote or compiled the resource under investigation), and what is the resource's 'purpose' or why was it created [ 55].

The World Economic Forum's three-step guidance on "how to read the news like a scientist and avoid the COVID-19 infodemic" is quite handy for debunking misinformation. The three steps are: (i) "embracing uncertainty responsibly", (ii) "asking where is the information coming from?" and (iii) "determining who is backing up the claim" [ 56].

Llewellyn proposed a contact-tracing-like technique to identify COVID-19 misinformation. As with coronavirus itself, we should think about "contact tracing" the message and its sender(s): "who sent or shared the information", "what is the original source", and "how do I know it to be true?" [ 57]. Mantas compiled a six-step kit after evaluating various fact-checking organisations. These steps include: (1) "stop, breathe-before sharing" (2) "check the source", (3) "trust scientists before politicians", (4) "beware your emotions", (5) "use (adequate) tools to help verify images and videos", and (6) "know what you don't know" [ 58].

Mheidly and Fares proposed an "infodemic response checklist" to help overcome the challenges posed by the infodemic. Their checklist recommends a number of mitigatory actions, including (i) offering more exposure or 'airtime' for medical professionals and scientists, (ii) verifying the social media accounts of scientists, medical professionals and public health officials, (iii) sharing scientific evidence, (iv) promoting the Web sites of public health organisations via search engines, (v) monitoring engagement on social media platforms, (vi) developing infographics and educational material, (vii) addressing minorities, racial, and ethnic differences, (viii) adopting empathy in social media communication, (ix) promoting dialogue and sharing of personal experiences, (x) improving coping skills against mental health stressors, and (xi) boosting investment in health communication research [ 59].

The United Nations Educational, Scientific and Cultural Organization--UNESCO 'MIL CLICKS' social media initiative for promoting media and information literacy is helping people acquire key skills related to media and information literacy in their normal day-to-day use of the Internet and social media. 'MIL CLICKS' is an acronym that stands for 'Media and Information Literacy: Critical-thinking, Creativity, Literacy, Intercultural, Citizenship, Knowledge and Sustainability' [ 60].

Conard developed a health literacy instructional model combining five domains of literacy (knowledge, numeracy, navigation, communication, and decision making) with three components (emotional, behavioural, and educational) to help build health literacy skills. The model presents a framework for addressing the emotional state of the individual in the first stage, with a second stage offering strategies that aim at strengthening the engagement and commitment of the person using a behavioural approach, and a final phase delivering an educational solution [ 61].

The iHeal.eu project (November 2018-April 2021), co-funded by the European Commission, is another successful programme for up-skilling older EU citizens (aged 50+) in digital health literacy to prevent marginalisation and exclusion. Project outputs included (i) a transnational digital health literacy ecosystem map and methodological framework, (ii) a curriculum, with storyboards and content, (iii) an interactive Web platform, learning environment, applications, and digital learning tools, and (iv) a training adaptation toolkit [ 62].

Besides the roles played by the aforementioned checklists and guidelines in tackling the COVID-19 infodemic, mythbusters have contributed significantly to flagging COVID-19 related misinformation and promoting factual information. iHealthFacts.ie is a Web-based resource where the public can easily and quickly check the authenticity of common health claims circulated on social media [ 63]. It is a useful resource, helping people to think critically about health claims and make informed decisions about their health [ 64]. Other examples of mythbusters are provided in Table 1 .

Table 1

Service Name

Hosting Organisation and Web Address

Several Web-based fact-checking tools are also available that allow people to check the authenticity of a specific claim. The majority of reputable fact-checking sites subscribe to codes of practice and standards that explicitly call for neutrality and transparency, such as the International Fact-Checking Network's (IFCN) code of principles [ 70]. Together with the very closely related online mythbusters, these fact-checkers are helping combat the spread of COVID-19-related misinformation. Examples of these fact-checking tools are provided in Table 2 .

Table 2

Service Name

Hosting Organisation and Web Address

5. Discussion and Recommendations

Low digital health literacy affects large percentages of populations around the world. It is a direct contributor to the spread of COVID-19 misinformation (e.g., via sharing on social media) as result of the affected populations' inability to recognise falsehoods and their high vulnerability to deception by fake news (bots also contribute to the spread of online misinformation). The 'viral' nature of social media sharing further complicates the situation [ 76].

Given the complexity of the COVID-19 infodemic and the high prevalence of low digital health literacy among populations, it is very unlikely that any of the above-mentioned strategies, methods, and services (e.g., machine learning-based approaches, health literacy guidelines, and fact-checkers) will be fully effective alone in stopping the spread of COVID-19 misinformation. Banerjee and Meena offer a useful summary of the different ways in which digital technology and (social) media platforms can be used during health emergencies, such as the COVID-19 pandemic, to aid the general public [ 77].

Interestingly, Zhao et al. found a correlation between people's preferences for particular media outlets when seeking health-related information and their behaviours during the pandemic in the USA. For example, people who considered Fox News a more trustworthy information source compared to CNN (Cable News Network) demonstrated a higher number of risky behaviours and less preventive behaviours in relation to COVID-19 (e.g., not wearing face masks). People's behavioural responses to the pandemic were clearly divided along media bias lines. News outlets should therefore be made accountable, and their unhelpful partisan stance should be minimised during health emergencies [ 78].

Medical/health journalists reporting medical research in mainstream news media often unwittingly contribute to online health misinformation through bad reporting practices and distorted translation of research findings in their news reports, e.g., misinterpreting or exaggerating findings and other forms of inaccurate and/or incomplete reporting, resulting in public confusion. However, well trained, ethical medical/health journalists can play an important role in combatting misinformation.

In fact, in his July 2021 ' Advisory on Building a Healthy Information Environment-Confronting Health Misinformation', the US Surgeon General calls for media, science, digital, data and health literacy programmes and training to be provided for journalists, as well as health practitioners, librarians and others, as part of longer-term efforts to build resilience against health misinformation. He also urges the implementation of product design and policy changes on technology platforms to slow the spread of misinformation, in addition to expanding research that deepens our understanding of health misinformation and the best ways of tackling it [ 79].

Health planners and public health professionals responsible for ensuring future infodemic preparedness should comprehensively survey the digital health literacy levels of their target populations to determine the best strategies for improving these levels, namely well-targeted community outreach and awareness-raising interventions, including well-tailored education and training programmes that closely match the health literacy levels and specific needs of target audiences [ 20]. A number of (mostly complementary) scales and tools exist for measuring (digital) health literacy, e.g., eHEALS [ 40, 80], NVS (Newest Vital Sign) [ 79, 81], eHLA (eHealth Literacy Assessment Toolkit) [ 82], etc. Some (but not all) of these tools are available in multiple languages. Using two or more of these tools in conjunction is often required in order to achieve a more complete and accurate picture of the surveyed population's digital health literacy levels.

Improving people's digital health will enable them to more (pro)actively and effectively participate in the healthcare system. There is a pressing need to raise awareness among the general public that they should only seek information from valid, trusted sources [ 83], or as Charlie Baker, the Governor of Massachusetts, rightly suggested that "Everybody needs to get their news from legitimate places, not from their friend's friend's friend's friend" [ 84].

However, Kamel Boulos argues that it is hard to be objective and to remain so at all times, calling for a comprehensive evaluation of both 'the message' (information content) and 'the messenger' (information author/source), rather than fully relying on the latter as (an-easy-to-establish) proxy for the trustworthiness and truthfulness of an information resource. All systems of peer review and fact-checking are inherently flawed to some extent and prone to subjectivity and influence by conflicting interests and agendas, including political ones. Having information spread or published by a reputable academic belonging to a prestigious institution, or an author with recognised qualifications, or a prestigious-scientific-award winner, or a high-impact-factor scholarly journal does not always guarantee quality (and does not disapprove it either). Consumers of online information should always take 'recognised qualifications', 'prestigious institutions', 'fact-checking sites', 'peer review', 'reputable journals' (and their impact factors), etc., with a grain of salt. These information-source attributes are all relative rather than absolute, and are always more helpful and useful when considered together, combined rather than individually, and when considered alongside other equally, if not more, important information quality criteria that focus on the message rather than the messenger [ 85].

6. Conclusions

Low digital health literacy affects large percentages of populations around the world and is a direct contributor to the spread of COVID-19-related online misinformation and to its devastating effects. The ease and 'viral' nature of social media sharing further complicate the situation. A number of strategies, methods, and services exist that can be used to detect and prevent the spread of COVID-19 misinformation, including machine learning-based approaches, health literacy guidelines, checklists, mythbusters, and fact-checkers. However, given the complexity of the COVID-19 infodemic, it is very unlikely that any of these approaches or tools will be fully successful alone in combatting COVID-19 misinformation. Instead, a mixed, synergistic approach, combining the best of these strategies, methods, and services together, is essential as the most effective way forward to tackle online health misinformation, and mitigate its negative effects in COVID-19 and future pandemics. Furthermore, to achieve the best results possible, techniques, and tools should focus on evaluating both the message (information content) and the messenger (information author/publisher/source), and not just rely on assessing the latter as a quick and easy proxy for the trustworthiness and truthfulness of the former. Surveying and improving population digital health literacy levels is also key to future infodemic preparedness.

Author Contributions

Paper conceptualization and scope, M.N.K.B.; literature review, S.B.N. and M.N.K.B. (equally); manuscript writing, S.B.N. and M.N.K.B. (equally). All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analysed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

45. Dib F., Mayaud P., Chauvin P., Launay O. Online mis/disinformation and vaccine hesitancy in the era of COVID-19: Why we need an eHealth literacy revolution. Hum. Vaccin. Immunother. 2021:1-3. doi: 10.1080/21645515.2021.1874218. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

48. Thorne J., Vlachos A., Cocarascu O., Christodoulopoulos C., Mittal A. The Fact Extraction and VERification (FEVER) Shared Task. arXiv. 20181811.10971 [ Google Scholar]

49. Hossain T., Logan R.L., IV, Ugarte A., Matsubara Y., Young S., Singh S. COVIDLies: Detecting COVID-19 Misinformation on Social Media; Proceedings of the 1st Workshop on NLP for COVID-19 (Part 2) at EMNLP; Online. 20 November 2020; [[ CrossRef] Google Scholar]

50. Levitin D.J. Weaponized Lies: How to Think Critically in the Post-Truth Era. Dutton Books-Penguin Publishing Group; New York, NY, USA: 2017. [ Google Scholar]

64. Zaki M., Devane D., Conway T., Galvin S., Burke N., Finucane E. Battling the COVID-19 infodemic in an Irish context: The role of iHealthFacts. HRB Open Res. 2020:3. doi: 10.12688/hrbopenres.13174.1. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

85. Kamel Boulos M.N. Health literacy 101-Beyond 'lazy proxies of trust': Evaluating the message, not the messenger (Invited Keynote-delivered via Zoom); Proceedings of the International Symposium on 'Infodemic Management'; Bahawalpur, Pakistan. 25-26 June 2021; [[ CrossRef] Google Scholar]

Articles from International Journal of Environmental Research and Public Health are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

# data[].attributes.attachment_link.title
COVID-19 Misinformation Online and Health Literacy: A Brief Overview

# data[].attributes.attachment_link.description
Low digital health literacy affects large percentages of populations around the world and is a direct contributor to the spread of COVID-19-related online misinformation (together with bots). The ease and 'viral' nature of social media ...

# data[].attributes.headline
Use the CRAAP Method for finding credible information.

# data[].attributes.subject
Use the CRAAP Method for finding credible information.

# data[].attributes.body
Thanks to psychologytoday.com for the information.

*Currency
When was the content written.
When was the information published? Has there been any
updates?

*Relevance
Does the information you are looking for, does it reflect
your needs as a reader?

*Authority

Does the author have a degree in the field from a
credible college? Check references and links. Make sure
the sources are scholarly-peer reviewed academic
journals.

*Accuracy
Did the author cite their sources?

*Purpose
Is the article written to sell information or a product? Or
is it meant to inform the reader?

# data[].attributes.attachment_link.readable_text
Do you trust everything you read? How do you know the psychological article you are reading is accurate, unbiased, and helpful? Perhaps using your intuition.

However, there is a more systematic way of deciding if a post is credible and useful. It is called, cheekily I might add, the CRAAP Test. The letters in CRAAP stand for: Currency, Relevance, Authority, Accuracy, and Purpose.

Currency

An article on mental illness published in Psychology Today 30 years ago, even if written by a top expert, may not reflect recent findings or our current conceptualization of mental illness.

Compared to physics or chemistry, psychology is still a very young science and some of our most basic assumptions in the field have been challenged by new scientific findings. So it is essential not to assume older views of personality, behavior, and cognition are necessarily still accepted by the scientific community.

Some questions to ask regarding the currency of an article you are reading:

1. When was the content written?

2. When was it published?

3. Has it been updated since then?

Relevance

As you begin reading an article, keep in mind the reason you selected to read it. Sometimes the written material does not address the question you thought it would; perhaps the author failed to answer the question, the title was intentionally misleading, or you misunderstood what the author intended to explain.

Perhaps you are not the intended audience (i.e. the information is too technical or too basic for you).

Also important to the relevance of an article are the depth and breadth of coverage. An introductory book on mental health treatments, for example, needs to cover common types of medications (e.g., benzodiazepines, SSRIs) and forms of psychotherapy (e.g., cognitive behavioral therapy, psychodynamic therapy). A post on the benefits of, say, biofeedback for social anxiety, does not.

Questions regarding relevance:

1. Why are you reading this information?

2. Does it deliver what it promises?

3. Are the language and coverage appropriate?

Authority

If the information you are reading comes from an individual's personal experience, make sure the author is experienced enough in the field and has used a systematic approach to analyzing his or her experiences. Why? Because all of us, including doctors, are prone to many biases. (One such bias is explained in the video below).

Greater trust in the author is usually required when the information provided concerns a complex topic, is based solely on the author's personal experience, or disagrees with what is widely believed by respected people in the field. Case in point, if a person says you should spank your children, you might want to carefully examine the person's source of information because the weight of evidence currently suggests spanking is ineffective and harmful.

Questions regarding authority:

1. Does the author have an academic degree in this area from a reputable college?

2. If the information provided is based on experience, is the writer experienced enough?

3. Are the writer's conclusions based on an objective and systematic approach to evaluating his or her experiences?

Accuracy

Psychology is-or inspires to be-an empirical science, so major psychological claims need to be verified by scientific experiments. If what you are reading is said to come from research, check the references and click the links.

Psychology researchers often write in a manner that shows their respect for truth. For instance, they suggest that a variable (e.g., exercise) makes some event (e.g., happiness) more likely or probable, not certain. This is not false modesty but an appreciation for the shortcomings of statistic methods and the elusive nature of the truth. The scientists' certainty increases mainly with more replications of the study (i.e. researchers in other labs getting the same results).

So look for a lot of evidence when someone makes absolute claims.

One last point: Watch out for an expert being quoted out of context. The specialist's claim may be accidentally or deliberately misconstrued. When in doubt, go to the source.

Ask:

1. Has the author cited sources for the assumptions and claims?

2. Are most of the sources scholarly (e.g., peer-reviewed academic journals)?

3. Have the results of these studies been replicated?

Purpose

The last element of the CRAAP test is the purpose of the article. One may write for various purposes: Informing the reader of an occurrence, explaining how something happened, entertaining, selling, persuading, and other motivations.

Also look for ulterior motives, conflicts of interest, and hidden agendas. Even a highly objective researcher may sometimes, intentionally or unintentionally, provide biased guidance or make unsubstantiated claims. The writer might be providing an opinion (in the guise of a science-based article) about a controversial topic or a topic that has affected him or her negatively in a deeply personal way, or writing the piece as a way to promote a product or service.

Conflicts of interest and financial motivations can be so powerful they even influence research studies, which is why The New England Journal of Medicine and many other journals now require authors to disclose any financial ties to the pharmaceutical industry.

So, as you read, ask yourself:

1. What is the author trying to accomplish (e.g., inform, entertain, convince, sell)?

2. Is there any evidence of conflict of interest or hidden agenda?

3. Is the report discussing a sensitive topic? Might the author's personal feelings have negatively influenced the objectivity of the article?

Concluding thoughts on critical reading

To evaluate the usefulness and reliability of the information you are reading, ask a lot of questions, like: What does this mean? Why? How does the author know? Who said that? When? Based on what evidence? Better yet, have a list of the CRAAP Test questions (Figure 1) and get to work. Do not forget to click the relevant links or look up references. This approach may help you not only sharpen your intuition and not waste your time on inferior articles but also understand and recall what you read better.

# data[].attributes.body
“Health misinformation is a serious threat to public health. It can cause confusion, sow mistrust, harm people’s health, and undermine public health efforts.”

—Dr. Vivek H. Murthy
Surgeon General of the United States

A Question and answers put to Dr. Murthy:
As individuals, we can help stop the spread of misinformation by taking the following steps:

Learn how to identify and avoid sharing health misinformation. Verify the accuracy of information by checking with trustworthy and credible sources. If you’re not sure, don’t share.

Engage with your friends and family on the problem of health misinformation. Listen with empathy, ask questions, provide alternative explanations, and don’t expect success from one conversation.

Address health misinformation in your community by working with schools, community groups, and health care professionals to develop local strategies against misinformation.

# data[].attributes.body
A lot has been written about fake news and the COVID pandemic. This article from WHO mentions: “Such spreading of unreliable evidence on health topics amplifies vaccine hesitancy and promotes unproven treatments.” It also mentions that social media needs to step up and be vigilant to make sure that correct information is being put out there.

# data[].attributes.attachment_link.readable_text
Incorrect interpretations of health information, which increase during outbreaks and disasters, often negatively impact people's mental health and increase vaccine hesitancy, and can delay the provision of health care, a new WHO review shows.

The authors conclude that the effects of infodemics and health misinformation online can be countered by "developing legal policies, creating and promoting awareness campaigns, improving health-related content in mass media and increasing people's digital and health literacy".

The systematic review of published studies found 31 reviews that analysed fake news, misinformation, disinformation and infodemics related to health. Misinformation was defined as false or inaccurate information deliberately intended to deceive, while disinformation also included misleading or biased information, manipulated narratives or facts, and propaganda.

The authors gathered, compared and summarized this evidence in order to identify ways to address the negative effects of false health information on public health.

"Twitter, Facebook, YouTube, and Instagram are critical in disseminating the rapid and far-reaching spread of information," the systematic review explains. The repercussions of misinformation on social media include such negative effects as "an increase in erroneous interpretation of scientific knowledge, opinion polarization, escalating fear and panic or decreased access to health care".

The increased spread of health-related misinformation in a health emergency is accelerated by easy access to online content, especially on smartphones. "During crises such as infectious disease outbreaks and disasters, the overproduction of data from multiple sources, the quality of the information and the speed at which new information is disseminated create social and health-related impacts."

The authors found that social media have been propagating poor-quality health-related information during pandemics, humanitarian crises and health emergencies at an increasing rate. They note, "Such spreading of unreliable evidence on health topics amplifies vaccine hesitancy and promotes unproven treatments."

Four studies reviewed in the paper looked at the proportion of health misinformation on social media, and found that it reached up to 51% in posts associated with vaccines, up to 28.8% in posts associated with COVID-19, and up to 60% in posts related to pandemics. Among YouTube videos about emerging infectious diseases, 20-30% were found to contain inaccurate or misleading information.

Experts and health professionals are among those best placed to refute misinformation and direct users to information sources that are evidence-based. Countermeasures include awareness campaigns for patients and health-care professionals, platforms with evidence-based data, the inclusion of scientific evidence in health-related content in mass media, and efforts to improve media and health literacy.

"Promoting and disseminating trustworthy health information is crucial for governments, health authorities, researchers, and clinicians to outweigh false or misleading health information disseminated in social media," the paper states. It highlights that social media channels can also be used to counter false or misleading information, but that further studies may be required to evaluate the best format for such outreach and to determine which channels work best for different populations, geographical settings and cultural contexts.

The systematic review found that people feel mental, social, political and/or economic distress due to misleading and false health-related content on social media during pandemics, health emergencies and humanitarian crises.

However, not all effects of social media have been negative during the COVID-19 pandemic. Eight reviews reported positive outcomes, and some found that several social media platforms generated significantly improved knowledge and awareness, higher compliance with health recommendations, and more positive health-related behaviours among users compared to classic information dissemination models.

The paper acknowledges the role of social media in crisis communication and management during health emergencies, but points to the need to counter the production of misinformation on these platforms. Local, national and international efforts are required, as well as additional research.

"Future research should investigate the effectiveness and safety of computer-driven corrective and interventional measures against health misinformation, disinformation and fake news and tailor ways to share health-related content on social media platforms without distorted messaging."

The new paper, entitled "Infodemics and health misinformation: a systematic review of reviews", is published in the Bulletin of the World Health Organization.

# data[].attributes.attachment_link.title
Infodemics and misinformation negatively affect people's health behaviours, new WHO review finds

# data[].attributes.attachment_link.description
Incorrect interpretations of health information, which increase during outbreaks and disasters, often negatively impact people's mental health and increase vaccine hesitancy, and can delay the provision of health care, a new WHO review shows.

# data[].attributes.body
This article - written pre-COVID mentions that health professionals because of the internet are no longer perceived as:  "authorities with exclusive knowledge about health-related content" and how health care workers can fight back.

# data[].attributes.attachment_link.provider_name
Journal of Ethics | American Medical Association

# data[].attributes.attachment_link.readable_text
Abstract

Broad dissemination and consumption of false or misleading health information, amplified by the internet, poses risks to public health and problems for both the health care enterprise and the government. In this article, we review government power for, and constitutional limits on, regulating health-related speech, particularly on the internet. We suggest that government regulation can only partially address false or misleading health information dissemination. Drawing on the American Medical Association's Code of Medical Ethics, we argue that health care professionals have responsibilities to convey truthful information to patients, peers, and communities. Finally, we suggest that all health care professionals have essential roles in helping patients and fellow citizens obtain reliable, evidence-based health information.

The Growing Problem of False Health Information on the Internet

Over the course of the past century, causes of disease and social conceptions of health have evolved from an infectious-agent theory of disease, to a behavioral theory of disease, to a social-ecological model. 1,2The social-ecological model recognizes that social and environmental conditions, including the information environment and health-related speech, affect health outcomes for both individuals and populations. 3,4

A problem our society currently faces is the pervasive availability and consumption of false health information, 5,6 which can cause individual and social harm by nurturing false beliefs about medicine, disease, and prevention. ⁷ One major source of health-related information is the internet. ⁸⁻¹¹ The internet has democratized health information, but, as a result, health care professionals are no longer perceived as authorities with exclusive knowledge about health-related content. ¹² Search engines like Google allow anyone to easily find information about anything. Social media sites like Twitter, Reddit, and Facebook provide forums for private citizens to freely express their views, including about medicine and health care. Yet the content disseminated through websites and online communities is largely unregulated. Thus, it is largely up to consumers to determine the quality and reliability of the information.

The question this raises is whether the proliferation of health-related information on the internet should be regulated and, if so, by whom. An argument might be made for government oversight because the wide circulation of false health information can lead to real injuries and harms. After all, a well-established role of the government in a democratic society is to "promote the general welfare" of its citizenry. ¹³ Yet, in the United States, the government also has an obligation to protect private citizens' right to free speech. Thus, there exists a tension between the government's commitment to general welfare and its duty to affirm individuals' right to free speech.

This article will explore this tension. First, we review our society's commitment to protecting the free speech of private citizens in the public sphere, although the content of private speech might be false and even harmful. Second, we briefly describe commercial and professional speech as a specific category of speech that can be regulated by the government for the purposes of public health and welfare. Finally, in recognizing the Constitutional boundaries on free speech in society, we discuss the professional and ethical obligations of health care professionals to provide truthful and accurate health information both in clinical practice and in the community. We suggest that all engaged in the biomedical and scientific enterprise have an ethical and social responsibility to share truthful information about health and to correct falsehoods when possible.

Free Speech and the Internet

The First Amendment states, "Congress shall make no law ... abridging the freedom of speech." ¹⁴ Supreme Court jurisprudence interpreting the First Amendment has affirmed that private citizens have a constitutionally protected right to articulate personal views and beliefs in public spaces without unnecessary government regulation or censorship, including public spaces on the internet. The right to free speech prevents the government from suppressing speech even if the content is false or offensive, including when the content is health related. ¹⁵ Examples of constitutionally protected false, health-related speech in both physical and virtual public spaces include advocacy groups' assertions that vaccines are ineffective and cause autism ¹⁶ and prolife advocacy groups' assertions that abortions cause breast cancer. ¹⁷ In the context of online but not health-related information, the Supreme Court ruled in Reno v ACLU that government-instituted, content-based restrictions on nonobscene speech were unconstitutional. ¹⁸As such, it is unlikely that any health-related internet speech that is not obscene can be regulated by the government. Moreover, given the unpredictability of internet expansion and changes in consumer preferences, whether the government can develop long lasting and enforceable solutions to the problem of false health information remains a difficult and unresolved challenge. ¹⁹

Commercial and Professional Speech

There are, however, 2 categories of speech for which the government might have authority to constrain or compel speech to promote the health and welfare of the community: commercial speech and professional speech. Commercial speech is a category of speech defined as speech that (1) identifies a product for sale, (2) is a form of advertising, and (3) confers economic benefits. ³ Courts can uphold regulation of commercial speech based on a 4-part test articulated in Central Hudson Gas and Electric Corporation v Public Service Commission of New York. ²⁰ Historically, examples of the regulation of commercial speech include advertisements for tobacco, alcohol, and gambling. ¹ However, since Central Hudson, courts have demonstrated increasing reluctance to regulate commercial speech, emphasizing the rights of speakers rather than the state's interests in the health and welfare of community members. ⁴ We believe this places an increased burden on physicians to correct inaccurate or false health-related information that can be found in commercial sources, including on the internet.

Professional speech is a category of speech that scholars have defined as speech "uttered in the course of professional practice." ²¹ The Supreme Court indicated in Planned Parenthood of Southeastern Pennsylvania v Casey in 1992 that physicians' First Amendment rights not to speak are implicated, but only as part of the practice of medicine, subject to reasonable licensing and regulation by the state. ²² While this case involved the constitutionality of a law requiring, among other things, that at least 24 hours before performing an abortion (except in an emergency) physicians inform the woman of the nature of the procedure, the health risks of the abortion and of childbirth, and the "probable gestational age of the unborn child," it set the stage for state regulation of professional speech between physicians and their patients. Since then, courts have struggled to articulate a consistent approach to defining the scope and limitations of a state's power to regulate health care professional speech on a range of issues, including physician speech regarding firearm ownership and sexual orientation change efforts. ²³

While the government has some powers to regulate health-related speech, those powers are very limited and are not comprehensive or consistent. Recognizing the constitutional limits on the government's powers to regulate private citizens' free speech in the public sphere, we suggest that government regulation cannot be expected to resolve the problem of false and harmful health-related information that is perpetuated on the internet by private citizens who are speaking with their private citizen rather than their professional "hat" on. Furthermore, the government cannot be relied upon to be the sole speaker of truthful and accurate health information. As recently demonstrated by politically motivated prohibitions of certain words in official documents, the government can publish biased or incomplete statements or refrain altogether from saying anything at all. 24,25 Since the government cannot be relied upon to resolve the problem of false health information found on the internet, it is important for anyone involved in the biomedical enterprise to participate in public discourse. Furthermore, we suggest that physicians, as part of their professional code, have an ethical duty not only not to share bad or false information but also to actively participate in conversations about health and help correct false or harmful information that can be found on the internet.

Implications for Health Care Professionals

Medical professionals have a unique responsibility to confront false or misleading beliefs by virtue of their specialized knowledge and professional obligations. First, medical professionals are members of a community that possesses specialized knowledge about and training in health. Second, licensed professionals are the only people in our society who are allowed to practice medicine. The professional obligation to confront false health beliefs and information is more straightforward within a clinical setting: when patients express false or misinformed beliefs, it is professionally and ethically appropriate to attempt to correct and redirect the patients so that they can hopefully use evidence-based information to make an informed decision about their care. But outside an individual patient-clinician relationship, what is the obligation of a health care professional to the broader community to confront false beliefs and information?

We would suggest that health care professionals have an ethical obligation to correct false or misleading health information, share truthful health information, and direct people to reliable sources of health information within their communities and spheres of influence. After all, health and well-being are values shared by almost everyone. Principle V of the AMA Principles of Ethics states: "A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated" (italics added). ²⁶ And Principle VII states: " A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health" (italics added). ²⁶ Taken together, these principles articulate an ethical obligation to make relevant information available to the public to improve community and public health. In the modern information age, wherein the unconstrained and largely unregulated proliferation of false health information is enabled by the internet and medical knowledge is no longer privileged, these 2 principles have a special weight and relevance.

To withdraw or refrain from public discourse in an environment where false and harmful health information is pervasively disseminated would be an abdication of the ethical obligation to make "relevant information" (or accurate information) available to improve community and public health, as medical and public health professionals possess reliable and truthful information about the nature of health and the causes of disease. For example, educated professionals can embrace invitations to speak at local groups about a particular health-related topic or respond to a blog posting. Another venue is Twitter; some use Twitter in their professional capacity to share news releases and articles and to participate in organized, moderated Twitter chats. Even in their own social circles, health care professionals can have a positive impact by directing people to accurate sources of information and correcting misperceptions when possible. We recognize that this obligation of health care professionals extends outside the clinical setting and into the sphere of their lives. However, as the causes of death and disability extend beyond the boundaries of the clinic, so do the obligations of health care professionals. This is an obligation they take on when they choose the profession of medicine.

Citation

AMA J Ethics. 2018;20(11):E1052-1058.

DOI
10.1001/amajethics.2018.1052.
Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information

Joel T. Wu, JD, MPH, MA is a clinical ethics fellow at Children's Minnesota and Abbott Northwestern Hospital in Minneapolis, Minnesota. He is also a senior lecturer at the University of Minnesota School of Public Health in the Division Health Policy and an affiliate faculty member of the Center for Bioethics at the University of Minnesota. He previously conducted health policy development and research at the Institute of Medicine and the Brookings Institution. His work focuses on clinical ethics practice, organizational ethics and policy in health care, and justice issues in public health.

Jennifer B. McCormick, PhD, MPP is a member of the Penn State Clinical and Translational Science Institute's program leadership and the American Society of Human Genetics' Social Issues Committee. She completed a doctoral degree in molecular and cellular biology, a postdoctoral fellowship in biological chemistry, master's degree in public policy, and a National Human Genome Research Institute Centers of Excellence in ELSI (Ethical, Legal and Social Implications) Research fellowship. She lectures frequently on topics related to research ethics and science policy, responsible conduct in research, informed consent, translational research ethics, translational genomics and policy, and social responsibility in science.

# data[].attributes.attachment_link.title
Why Health Professionals Should Speak Out Against False Beliefs on the Internet

# data[].attributes.attachment_link.description
False health-related speech can cause harm, but it's not restricted unless it's obscene. Physicians are obliged not only to correct patients' false beliefs, but to engage digital spaces in which false claims thrive.

# data[].attributes.body
The article mentions nurses and their role in directing patients to online information that is trustworthy.

# data[].attributes.attachment_link.readable_text
Social media platforms have become a go-to information source for the public, and a soap box for healthcare providers of all types. While this may seem to be a positive influence, the information may not be completely correct or may even be outright false. With so much data being presented in a persuasive manner, how are laypersons or even professionals able to decipher fact from opinion? What is a nurse's role in fighting false information? Moreso, what is the nurse's responsibility to ensure that the information they are presenting is evidence-based and factual, rather than opinion or incorrect?

Misinformation and disinformation: What's the difference?

Let's first talk about two concepts that are related, but different in one important aspect: misinformation and disinformation. Misinformation is defined simply as inaccurate information, whereas disinformation is a deliberate spread of inaccurate information with the intent to spread fear or invoke harm. This is an important distinction, however both types can cause impressions, opinions, and thought processes that are hard to correct and have been identified as a public health threat by the World Health Organization (WHO) and the United Nations (Bautista et al., 2021).

Disinformation directly conflicts with the nurses' tenet of "do no harm" (American Nurses' Association [ANA], 2015). This is unethical and can result in action against one's license in some instances. Per the National Council of State Boards of Nursing (NCSBN), "When nurses identify themselves by their profession, they are professionally accountable for the information they provide to the public" (NCSBN, 2021). Distortion of information, false truths, and purposeful omissions are examples of disinformation.

Misinformation is a little harder to discern. There may be unintentional omissions of information, rumors, or misinterpretations of data that lead to inaccurate information. For instance, a data point in a study that was not adequately investigated may lead to misinformation. Providing sources of evidence can help in preventing misinformation.

How can nurses combat misinformation and disinformation?

In all of these cases, evidence-based investigation can help to alleviate some of the issues. Nurses are in a unique position of trust and clinical knowledge that can help with correcting this information. Many healthcare professionals are personally and professionally motivated to correct this information, however, there have been barriers identified as well. Some include lack of positive outcome when corrections are made, time, harassment, and lack of institutional support (Bautista et al., 2021).

Nurses can help by directing the public to trustworthy online sources of information, such as the Centers for Disease Control and Prevention and Departments of Health. Some nurses feel more comfortable leading others to the source, whereas others may engage in conversation regarding the science and the data. Regardless of the conversation, the information should be supported by evidence. Many nurses consider themselves social media influencers, who can disseminate factual information and education and debunk false information, regardless of intent. There are outlier healthcare professionals and websites providing opinions or information not based on evidence; efforts should be made to correct any misinformation or disinformation to prevent community harm.

Some healthcare providers feel that the correction of misinformation or disinformation is not within their scope. As nurses, we have a social and professional responsibility to provide accurate information supported by evidence to ensure a healthy population. This is championed by nursing leadership organizations such as the ANA and NCSBN, as well as international healthcare interests, such as the World Health Organization (WHO) and United Nations. As nurses, we do have the power to change the way the world sees us and views modern healthcare despite outside (and sometimes) inaccurate influences.

References:

American Nurses Association. (2015). Code of Ethics for Nurses. Retrieved from https://www.nursingworld.org/ practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/

Bautista, J. R., Zhang, Y., & Gwizdka, J. (2021). US Physicians' and Nurses' Motivations, Barriers, and Recommendations for Correcting Health Misinformation on Social Media: Qualitative Interview Study.JMIR public health and surveillance, 7(9), e27715. https://doi.org/10.2196/27715

NCSBN. (2021). Policy Statement: Dissemination of Non-scientific and Misleading COVID-19 Information by Nurses. Retrieved from https://www.ncsbn.org/public-files/PolicyBriefDisseminationofCOVID19Info.pdf

More Reading and Resources

# data[].attributes.attachment_link.title
Misinformation and Disinformation: Nurses' Role in Evidence-Based Commentary

# data[].attributes.attachment_link.description
What is the difference between disinformation and misinformation? How can nurses use evidence-based practice to best inform and educate?

# data[].attributes.body
Evaluating Health Information | NNLM

Information and links to help nurses evaluate online sources of health information.