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How do we communicate about reliable health information in a fluctuating information landscape

Health misinformation: introduction

The Covid-19 pandemic illustrates the challenges of science communication and the dangers of unreliable or false health information. How do we communicate about reliable health information in a fluctuating information landscape, where new research is constantly emerging, often with an absence of scientific consensus or to patrons who lack basic scientific understanding or knowledge?

In a world of competing facts and “alternative facts”, it is increasingly important to adopt evidence-based communication strategies to ensure that people hear, and adopt, public health recommendations. People need to know “how information works’” — not just how to find and select information, but to also understand the social contexts that influence how information is created and disseminated.

"Today medical misinformation is recognized as one of the greatest threats to global health. By undermining trust in science and public health interventions, medical misinformation threatens the health of individuals and communities and the effectiveness of public health interventions. "

MisinfoRx: A Toolkit for Healthcare Providers (p.20)

Historical health misinformation

Health misinformation is far from new, as early knowledge about human disease focused on superstition, myths, and religion. The invention of the printing press in 1450 allowed for invented ‘facts’ to circulate widely in Europe. Similar to modern Facebook posts, cheap weekly publications of broadsides like the Lord Have Mercy, appeared during the seventeenth-century Black Death plague outbreaks. In an effort to be helpful they would publish home remedies to help protect from the disease. There were other strangely bizarre cures for the Black Death. A treatment named the Vicary Method involved plucking feathers from a chicken’s rump and then tying the chicken to the patient, so that the chicken’s now bare backside was touching the person’s swollen lymph nodes. The notion behind this interesting cure was that people believed that chickens breathed through their bottoms, so therefore the chicken would draw the infection out of the person.

Examples of historical misinformation:

The long, strange history of anti-vaccination movements: Here’s what the past can tell us about the future of the pandemic. By Anna North Mar 4, 2022, Vox.com.

When Cigarette Companies Used Doctors to Push Smoking: Before studies showed that cigarettes caused cancer, tobacco companies recruited the medical community for their ads. Becky Little, Updated Sept 11, 2019, original Sept 13, 2018. History.com

Cigarettes were once ‘physician’ tested, approved: From the 1930s to the 1950s, ‘doctors’ once lit up the pages of cigarette advertisements.. Leah Lawrence March 10, 2009. Healio.com

Pipe Dreams: America’s Fluoride Controversy: How did a seemingly benign chemical and a near-miraculous public-health initiative spark decades and decades debate? By Jesse Hicks | June 24, 2011. Science History Institute

The Tuskegee Study

For historically marginalized groups, distrust in the health care system looms large in the sharing of health misinformation. The Tuskegee Study is an example of why this exists. In 1932, the Public Health Service, working with the Tuskegee Institute, began the “Tuskegee Study of Untreated Syphilis in the Negro Male”, a medical study on the long term effects of untreated syphilis, that involved 600 Black men, 399 with syphilis and 201 without the disease. The study designers neglected to tell participants that they had syphilis and did not allow those patients who did have syphilis to receive proper treatment, only placebos. Many participants died from complications of syphilis and many wives, girlfriends and children contracted the disease.

Starck, P.L., Holeman, D.S. (2014). The Ethics of Medical Experiments: Have We Learned the Lessons of Tuskegee and the Holocaust?. In: Rubenfeld, S., Benedict, S. (eds) Human Subjects Research after the Holocaust. Springer, Cham. https://doi.org/10.1007/978-3-319-05702-6_15

Types of health misinformation

Misinformation
- False information that is considered incorrect based on the best available evidence from relevant experts at the time and is spread, regardless of intent to mislead. It can be unintentional mistakes such as inaccurate captions, dates, statistics or translations or when satire is taken seriously.
Disinformation
- Deliberately fabricated or manipulated false information. Often intentionally created to trick people into believing something for financial gain or political advantage or support conspiracy theories or rumors.
Malinformation
- Malinformation is information that is based on the truth but is often exaggerated in a way that misleads and causes potential harm. It can be the deliberate change of context, date or time of genuine content or the revealing of private information publicly.
Midinformation
- Misunderstandings and confusion based on scant or emerging evidence, often about emerging scientific knowledge. It is usually based on knowledge gaps that can be filled with inaccurate or even dated information.

Brennen, J. S., Simon, F. M., Howard, P. N., & Nielsen, R. K. (April 2020). Types, sources, and claims of COVID-19 misinformation: Factsheet. University of Oxford.

Vraga, E.K. & Bode, L. (2020). Defining misinformation and understanding its bounded nature: using expertise and evidence for describing misinformation. Political Communication 37(1): 136-144.

Wardle, C., & Derakhshan, H. (2017). Information Disorder Toward an interdisciplinary framework for research and policymaking. Council of Europe Report DGI (2017) 09. Strasbourg, France.

Psychology of misinformation

Those who spread misinformation are driven by many sociopsychological factors.

We may not be able to fully understand why someone shares or creates harmful information. Their intentions can be mixed, unclear, and even change over time. Human psychology and sociocultural factors leave people highly vulnerable to accepting and spreading false health information. In addition, technological advances such as the internet, social media and smart phones, have fostered an age where misinformation can be widely accessed and shared.

Cognitive biases and disordered thinking can make people more susceptible to misinformation.

Disordered thinking, or cognitive distortions, are negative biases in thinking that are thought to represent vulnerability factors. A cognitive distortion is an exaggerated pattern of thought or biased perspectives that’s not based on facts. It consequently leads the person to view things more negatively than they really are. So cognitive distortions is the mind convincing you to believe negative things about yourself and your world that are not necessarily true. When negative thoughts are treated as facts, people may act in a way based on faulty assumptions.

Cognitive bias refers to a systematic error in the thinking process. Such biases are essentially mental shortcuts, which allow people to make an inference about the credibility of a source of information without extensive deliberation and/or reflective judgment. Biases often work as rules of thumb that help people make sense of the world and reach decisions with relative speed.

Cognitive Distortions and Fluency Examples American Speech Language Hearing Association

Common Cognitive Distortions Sharon Martin LCSW 2016.

Cognitive Biases ACAPS Technical Brief 2016

20 cognitive biases that screw up your decision Businessinsider.com infographic

9 common thinking biases Innerdrive infographic

15 Cognitive Distortions MindMyPeelings.com infographic

Ecker, U.K.H., Lewandowsky, S., Cook, J. et al. The psychological drivers of misinformation belief and its resistance to correction. Nat Rev Psychol 1, 13–29 (2022).

Abrams, Z. (2021, March 1). Controlling the spread of misinformation. Monitor on Psychology, 52(2).

van der Linden, S. Misinformation: susceptibility, spread, and interventions to immunize the public. Nat Med 28, 460–467 (2022).

Ciampaglia, G. L., & Menczer, F. (2018). Misinformation and biases infect social media, both intentionally and accidentally. The Conversation, 20.

Common types of misinformation venues or tactics

Some common types of misinformation tactics

Websites that look professional: they are often designed to look like news/medical sites but the stories are all false or misleading. They have sensational headlines designed to make us click on them. They will often Include the logo of an established organization, like the CDC or a news network logo;
Quotations: Where the beginning or end have been deleted to change the meaning. The person did say that, but without the full context it’s not a fair representation of what they said. People who spread disinformation may create content that looks like a first person experience. It’s very difficult to “fact-check” someone who says, “This happened to me.” or “My brother works for the government and has inside knowledge. He just told me that…” or “My sister is a nurse and just called me from the ICU to tell me…”

Old images: that recirculate as if they are actually very recent but were actually taken at a different time.
Misleading graphs, images or diagrams: that look official but don’t tell the whole story (see cherry-picked statistics) or they use visual cues like someone wearing a white coat, holding a stethoscope, at a hospital bed-side;
Cherry-picked statistics: Too often people choose the number(s) that supports what they want to argue, but without all the data, they haven’t provided all the context.
Videos: that have been edited to change the meaning, including "deep fakes"
Memes: (fun, colorful images or graphics) that were created as a joke, but people started re-sharing thinking it was true.

Propaganda

Propaganda, a misinformation tactic, is nearly as old as human civilization. Propaganda is defined as a communication whose purpose is to influence the attitudes of a community or a group of people for a cause or position. The basic purpose of propaganda is to persuade people by providing distorting information. Most of the time, propaganda is biased and its sole purpose is to inspire people to accept a particular viewpoint. Unfortunately, public health campaigns can inspire propaganda backlash.

Types of Propaganda infographic Storyboardthat.com

The long, lurid tradition of public health propaganda: How the scare tactics of the past shape the Affordable Care Act debate today. By Kevin Hartnett ,December 8, 2013. The Boston Globe.

Fallacies of Logic

Another misinformation tactic is to use logical fallacies, which share many similarities to cognitive biases. Logical fallacies are very common patterns of reasoning that seem true on the surface but have one or more critical flaws. They are super normal and everyone uses them. Many logical fallacies, at their root, are oversimplifications – like cognitive shortcuts. They are appealing because they take something complex, like vaccine safety or the efficacy of masks, and convert it into something simple and easy to understand. This oversimplification however, often leaves out important details, leading to the inaccurate conclusions. When someone uses a fallacy in their argument, it doesn’t automatically mean they’re wrong or stupid, it simply means that they haven’t provided adequate evidence supporting their argument – evidence which may or may not exist.

Fallacies: Internet Encyclopedia of Philosophy

Techniques of Science Denial

John Cook of Skeptical Science.com has been dealing for a long time with disinformation on climate change. He developed a framework of the five most common methods of science denial and called it the Techniques of Science Denial or FLICC which stands: Fake experts, Logical fallacies, Impossible expectations, Cherry picking, and Conspiracy theories.

FLICC 5 Techniques of Science Denial

SkepticalScience, CC BY-SA 4.0 via Wikimedia Commons

How to talk about health misinformation

How to talk about health misinformation with your community starts by showing respect for the user’s beliefs, engaging in a reference interview, steering the user to research tools and verified resources and avoiding arguments as to the “facts” by instead teaching information literacy skills when there is an opportunity to do so.

Office of the U.S. Surgeon General (2021). A Community Toolkit for addressing health misinformation.

CDC How to Address COVID-19 Vaccine Misinformation

Litt, D. (March 2021). Battling Misinformation Through Health Messaging. National Institutes of Health.

Sa;tz.E., Shane, T., Kwan, V., Leibowicz, C., Wardle, C. (9 June 2020). It Matters How Platforms Label Manipulated Media. Here are 12 Principles Designers Should Follow. Medium.com

Roozenbeek J, van der Linden S. How to Combat Health Misinformation: A Psychological Approach. American Journal of Health Promotion. 2022;36(3):569-575.

Pen America. (2020). How to talk to friends & family who share misinformation.

News Literacy Project. (2021) Productive conversations without confrontation. [webinar slides]

Oregon.gov (2021). Tips for talking with family and friends about misinformation

Rogers, K. (2021). How to encourage family and friends to stop spreading misinformation on social media. CNN.com

Hall Jamieson, K. (2021). How to debunk misinformation about COVID, vaccines and masks. Scientific American.

Critically evaluating information

Teaching people to critically evaluate the accuracy of information and sources can reduce the influence of misinformation and the likelihood that people will share misinformation.

There is emerging evidence that it is possible to pre-emptively debunk, or pre-bunk, misinformation before false beliefs or ways of thinking have a chance to take hold. People can be ‘inoculated’ against misinformation.

There are many reliable fact-checking groups such as the Associated Press, Reuters, USA Today, the Washington Post, PolitiFact, and FactCheck.org, including ones that focus especially on health information, such as ScienceUpFirst, iHealthFacts (Ireland), Health Feedback.org (France) and Retraction Watch. These sites attempt to verify scientific or health claims in the media by contacting subject matter experts who provide credible references to recently published, credible scientific literature that supports their analyses.

Fact Checking Sites

FactCheck.org: From the Annenberg Public Policy Center of the University of Pennsylvania, this is a nonprofit, nonpartisan site dedicated to reducing the level of deception and confusion in U.S. politics.
SciCheck.org From FactCheck.org it focuses exclusively on false and misleading scientific claims that are made by partisans to influence public policy.
PolitiFact/HealthCheck:: A partnership with Kaiser Health News to help you find the truth in politics. Politifact is a nonpartisan site featuring the “truth-o-meter,” which assigns levels of truth to political statements.
FAIR: A national media watchdog group, FAIR specializes in critiquing media bias and censorship, with an emphasis on promoting diverse, dissenting media viewpoints.
OpenSecrets: From the Center for Responsive Politics, a research group that tracks the influence of money in American politics, OpenSecrets features reporting, data, and academic resources on money in politics.
Snopes: The original fact-checking and myth-busting site, Snopes is an independent organization that fact-checks any story worth checking.
Chrome Fake News Detector Simple extension that shows an alert when you visit a site known for spreading fake news.
ScienceUpFirst: National initiative that works with a collective of independent scientists, researchers, health care experts and science communicators.
iHealthFacts: A resource where the public can quickly and easily check the reliability of a health claim circulated by social media.
Retraction Watch: Reports on retractions of peer-reviewed scientific journal articles.
Health Feedback: Health Feedback is a worldwide network of scientists sorting fact from fiction in health and medical media coverage

The National Academy of Medicine held a forum in 2021 on identifying credible sources of health information and came up with a set of principles for sources providing health information:

Science-Based: Sources should provide information that is consistent with the best scientific evidence available at the time and meet standards for the creation, review, and presentation of scientific content.
Objective: Sources should take steps to reduce the influence of financial and other forms of conflict of interest (COI) or bias that might compromise or be perceived to compromise the quality of the information they provide.
Transparent and Accountable: Sources should disclose the limitations of the information they provide, as well as conflicts of interest, content errors, or procedural missteps. At the frontiers of understanding, scientific knowledge changes over time as more evidence becomes available and as existing evidence is analyzed in new ways. … To maintain credibility, sources must clearly acknowledge the limitations of the information they share so that consumers can reach fully informed conclusions.

Evaluating Online Information

Know the Science.(National Center for Complementary & Integrative Health). Provides tools to help better understand complex scientific topics that relate to health research so that people can be discerning about what they hear and read and make well-informed decisions about their health. Know the Science features a variety of materials including interactive modules, quizzes, and videos.

Evaluating Health Information. (MedlinePlus). Information on how to evaluation health information found online. Includes additional resources.

Evaluating Internet Health Information: A Tutorial From the National Library of Medicine: tutorial teaches you how to evaluate the health information you find on the Internet.

Understanding Medical Research : Information from MedlinePlus on understanding medical research. Having a basic understanding of what medical research is can help identify quality health information.

Media Landscapes: Disinformation/Misinformation (Minnesota Library Professional Development Network). Series of webinars presented in 2021-2022 on misinformation/disinformation.

Fact Checking Tips

"How can I spot misinformation about the coronavirus and COVID-19?" by the Gerstein Science Information Centre, University of Toronto Libraries used under CC-BY-NC-SA 4.0/modified from original.

Fred Fact Doesn't Fall for Fake News . Be More Like Fred: Here are 7 Tips to get you started. (2018). International Fact Checking Network. (fact checking tips in cartoon format)

Kington, R., S. Arnesen, W-Y. S. Chou, S. Curry, D. Lazer, and A. Villarruel. 2021. Identifying Credible Sources of Health Information in Social Media: Principles and Attributes. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC.

Infographics on fake news/misinformation

It is said that a picture is worth a thousand words. Infographics help people to understand complex concepts through the use of visual data, charts and statistics.

International Federation of Library Associations & Institutions: How to Spot Fake News

International Federation of Library Association & Institutions: How to Spot Fake News - Covid Edition

Compound Interest: A Rough Guide to Spotting Bad Science

EAVI Media Literacy for Citizenship: Beyond 'Fake News' 10 Types of Misleading News

ProQuest Guided Worksheet: How To Identify Fake News in 10 Steps

Cybersecurity & Infrastructure Security Agency: Disinformation Stops With You

Cybersecurity & Infrastructure Security Agency: Disinformation Stops With You Infographics Set

EasyBib: Evaluating A News Article

VisualCapitalist: How To Spot Fake News

Sage: How to Spot Fake News

GroundViews: How to Spot False News

GroundViews: 10 Types of Mis- and Disinformation

Madison County, NY: Spot and Stop Misinformation

NewseumED: Is This Story Shareworthy?

National Institute of Health (NIH): How Research Works: Explaining the Process of Science

News Literacy Project / Checkology: Ten Questions for Fake News Detection

UNESCO: Visual Resources UNESCO produced visuals, graphic and social media messages to counter disinformation, fight discrimination, and promote best practices.

Short videos on misinformation/disinformation

Short videos on recognizing and combating misinformation.

How to understand Misinformation, Disinformation and Malinformation: May 26, 2020 We live in a world where information is very easy to fabricate. Now more than ever, media literacy (the ability to critically analyse information) is critical for us as citizens and for our democracy to function. This video explains the difference between Misinformation, Disinformation and Malinformation and presents you with some examples! This video is part of a resource pack created and designed by Shout Out UK, supported by the US Embassy in London and in collaboration with the Association For Citizenship Teaching.
How to spot manipulated video: Jun 25, 2019 The Internet is increasingly populated with false and misleading videos — spread by politicians, advocacy groups and others — viewed by millions. The Fact Checker set out to develop a universal language to label misleading online video and hold creators and sharers of this misinformation accountable. Some video is taken out of context; other content is deceptively edited or, in the worst instances, deliberately altered. We’ve grouped manipulated video into three categories with further sub-categories. You can see the full guide on The Washington Post's website: https://wapo.st/manipulatedvideo.
Why people fall for misinformation: Sep 3, 2020 How does a fact become a misconception? Dig into the world of misinformation to see how facts can become distorted and misleading. -- In 1901, David Hänig published research that led to what we know today as the taste map: an illustration that divides the tongue into four separate areas. It has since been published in textbooks and newspapers. There is just one problem: the map is wrong. So how do misconceptions like this spread, and what makes a fake fact so easy to believe? Joseph Isaac dives into the world of misinformation. Lesson by Joseph Isaac, directed by CUB Animation.
How false news can spread: Aug 27, 2015 Dive into the phenomenon known as circular reporting and how it contributes to the spread of false news and misinformation. -- In previous decades, most news with global reach came from several major newspapers and networks with the resources to gather information directly. The speed with which information spreads now, however, has created the ideal conditions for something called circular reporting. Noah Tavlin sheds light on this phenomenon. Lesson by Noah Tavlin, animation by Patrick Smith.
How to recognize disinformation and how to stop it: Apr 29, 2021 Deb Lavoy is on a mission to eradicate disinformation. As a former software engineer and digital marketer, she recognized the established social media marketing techniques that disinformation perpetrators appropriating to manipulate us into believing falsehoods. This talk provides tips on recognizing these tricks and how to counter them. Deb Lavoy is on a mission to eradicate disinformation.
Can you outsmart a troll (by thinking like one)? : Oct 29, 2020 Explore the strategies employed by trolls and learn how disinformation campaigns are launched— and how to stop them. -- Your town is holding a mayoral election and the stakes have never been higher. You suspect one of the candidates will begin pushing false information to swing the election. As the cybersecurity expert, your job is to inoculate the townspeople against false information. First, you must learn the strategies of disinformation trolls. Claire Wardle explores the tactics of disinformation campaigns. Lesson by Claire Wardle, directed by Gavin Edwards.
Countering Disinformation in Social Media: Jun 22, 2021 Learn about Disinformation Campaigns within Social Media – What are they, who’s behind them, and how to protect yourself from falling victim to disinformation.
Combating Disinformation: Explained: Oct 16, 2020. DCCC Disinformation Task Force.
Using the Health Belief Model to combat health misinformation: Oct 24, 2021 Misinformation is dangerous. It impacts public health on a daily basis and in many different ways. It can make people more hesitant to receive vaccines and push them towards false and dangerous alternatives. Misinformation can also reduce people’s trust in scientists and health officials. Governments rely on such trust to manage public health issues. How can public health communicators manage health misinformation? This video summarizes the arguments of a recent academic paper, in which the authors propose that public health communicators can use the health belief model to help people understand the risks associated with misinformation and to take preventative action against it
Navigating Digital Information (Crash Course 2020): Series of short videos. In 10 episodes, John Green will teach you how to navigate the internet! By the end of this course, you will be able to: * Examine information using the same skills and questions as fact-checkers * Read laterally to learn more about the authority and perspective of sources * Evaluate different types of evidence, from videos to infographics * Understand how search engines and social media feeds work * Break bad internet habits like impatience and passivity, and build better ones.

Games for learning how to spot fake news/misinformation

Inoculation may be accomplished with library programming that incorporates games that can increase a players’ ability to spot misinformation, understand where it comes from, how it is spread and boost their immunity to false information.

Bad News Game: In Bad News, you take on the role of a fake news-monger. The goal of the game is to expose the tactics and manipulation techniques that are used to mislead people and build up a following. Bad News works as a psychological “vaccine” against disinformation: playing it builds cognitive resistance against common forms of manipulation that you may encounter online.
Factitious 2020: There are three basic steps: (1) Read the article (2) Swipe to the right if you think it’s a real story (3) Swipe to the left if you think it’s fake.
The Euphorigen Investigation: The Euphorigen Investigation is an online escape room that immerses players in a world of manipulated media, social media bots, deepfakes and other forms of deception.. Euphorigen is available in two versions – online and popup. The online version is played over video conferencing software (e.g. Teams, Zoom) and web browser. The popup version is a kit that can be downloaded and printed for in-person play. In both versions a gamehost (e.g. librarian, teacher) facilitates the experience.
Go Viral!: GO VIRAL! is a 5-minute game that helps protect you against COVID-19 misinformation. You’ll learn about some of the most common strategies used to spread false and misleading information about the virus. Understanding these tricks allows you to resist them the next time you come across them online. Scientists who worked with us on the development of GO VIRAL! found that playing the game significantly improves people’s ability to spot misinformation about COVID-19.
Harmony Square: Harmony Square is a game about fake news. The game’s setting is the idyllic Harmony Square, a small neighborhood mildly obsessed with democracy. You, the player, are hired as Chief Disinformation Officer. Over the course of 4 short levels, your job is to disturb the square’s peace and quiet by fomenting internal divisions and pitting its residents against each other. The goal of the game is to expose the tactics and manipulation techniques that are used to mislead people, build up a following, or exploit societal tensions for political purposes. Harmony Square works as a psychological “vaccine” against disinformation: playing it builds cognitive resistance against common forms of manipulation that you may encounter online.
Cranky Uncle: The Cranky Uncle game uses cartoons and critical thinking to fight misinformation. In the Cranky Uncle game, players are mentored by a cartoon personification of climate science denial. Cranky Uncle explains 14 techniques of science denial, from fake experts to cherry picking and a variety of different logical fallacies. The game is available for free on iPhone, Android, and as a browser game.