uploads/2021/04/MENA-Covid-Vaccine-Misinformation-Monitor-1.pdf. Masterson, M., Zaheer, A., Small, C., Cable, J., John, J. (2021, May 4).

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I am urging all Americans to help slow the spread of health misinformation during the COVID-19 pandemic and beyond. Health misinformation is a serious threat to public health. It can cause confusion, sow mistrust, harm people™s health, and undermine public health eˆorts. Limiting the spread of health misinformation is a moral and civic imperative that will require a whole-of-society eˆort. Vivek H. Murthy, M.D., M.B.A. Vice Admiral, U.S. Public Health Service Surgeon General of the United States

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3Table of Contents BACKGROUND WE CAN TAKE ACTION What Individuals, Families, and Communities Can Do 8What Educators and Educational Institutions Can Do 9What Health Professionals and Health Organizations Can Do 10What Journalists and Media Organizations Can Do 11What Technology Platforms Can Do 12What Researchers and Research Institutions Can Do 13What Funders and Foundations Can Do 14What Governments Can Do 15WHERE WE GO FROM HERE REFERENCES 4 616 17A Surgeon General™s Advisory is a public statement that calls the American people™s attention to a public health issue and provides recommendations for how that issue should be addressed. Advisories are reserved for signi˜cant public health challenges that need the American people™s immediate awareness. For additional background, visit SurgeonGeneral.gov .ABOUT THE ADVISORY

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4During the COVID-19 pandemic, people have been exposed to a great deal of information: news, public health guidance, fact sheets, infographics, research, opinions, rumors, myths, falsehoods, and more. ˚e World Health Organization and the United Nations have characterized this unprecedented spread of information as an fiinfodemic.fl 1 While information has helped people stay safe throughout the pandemic, it has at times led to confusion. For example, scienti˜c knowledge about COVID-19 has evolved rapidly over the past year, sometimes leading to changes in public health recommendations. Updating assessments and recommendations based on new evidence is an essential part of the scienti˜c process, and further changes are to be expected as we continue learning more about COVID-19. 2 But without su˛cient communication that provides clarity and context, many people have had trouble ˜guring out what to believe, which sources to trust, and how to keep up with changing knowledge and guidance. 3, 4, 5Amid all this information, many people have also been exposed to health misinformation: information that is false, inaccurate, or misleading according to the best available evidence at the time. 6, 7, 8 * Misinformation has caused confusion and led people to decline COVID-19 vaccines, reject public health measures such as masking and physical distancing, and use unproven treatments. 5, 9, 10 For example, a recent study showed that even brief exposure to COVID-19 vaccine misinformation made people less likely to want a COVID-19 vaccine. 11 Misinformation has also led to harassment of and violence against public health workers, health professionals, airline sta˝, and other frontline workers tasked with communicating evolving public health measures. 12, 13Misinformation can sometimes be spread intentionally to serve a malicious purpose, such as to trick people into believing something for ˜nancial gain or political advantage. ˚is is usually called fidisinformation.fl 14, 15 But many people who share misinformation aren™t trying to misinform. Instead, they may be raising a concern, making sense of con˙icting information, or seeking answers to honest questions.16Health misinformation is not a recent phenomenon. In the late 1990s, a poorly designed study, later retracted, falsely claimed that the measles, mumps, rubella (MMR) vaccine causes autism. Even after the retraction, the claim gained some traction and contributed to lower immunization rates over the next twenty years. Just since 2017, we have seen measles outbreaks in Washington State, Minnesota, New York City, and other areas. Health misinformation is also a global problem. In South Africa, for example, fiAIDS denialismflŠa false belief denying that HIV causes AIDSŠwas adopted at the highest levels of the national government, reducing access to e˝ective treatment and contributing to more than 330,000 deaths between 2000 and 2005. 22 Health misinformation has also reduced the willingness of people to seek e˝ective treatment for cancer, heart disease, and other conditions. 1, 23, 24, 2519, 20, 211817BACKGROUND ˇis advisory focuses on health information speci˘cally, not other kinds of misinformation. De˘ning misinformation is a challenging task, and any de˘nition has limitations. See References for further discussion of the de˘nition used in this Advisory, including the benchmark of ‚best available evidence at the time.™ *

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5In recent years, the rapidly changing information environment has made it easier for misinformation to spread at unprecedented speed and scale, especially on social media and online retail sites, as well as via search engines. Misinformation tends to spread quickly on these platforms for several reasons. 26, 27First, misinformation is often framed in a sensational and emotional manner that can connect viscerally , distort memory, align with cognitive biases, and heighten psychological responses such as anxiety. People can feel a sense of urgency to react to and share emotionally charged misinformation with others, enabling it to spread quickly and go fiviral.fl 24, 3128, 29, 30In recent years, the rapidly changing information environment has made it easier for misinformation to spread at unprecedented speed and scale. Second, product features built into technology platforms have contributed to the spread of misinformation. For example, social media platforms incentivize people to share content to get likes, comments, and other positive signals of engagement. ˚ese features help connect and inform people but reward engagement rather than accuracy, allowing emotionally charged misinformation to spread more easily than emotionally neutral content. One study found that false news stories were 70 percent more likely to be shared on social media than true stories. 313332˚ird, algorithms that determine what users see online often prioritiz e content based on its popularity or similarity to previously seen content. As a result, a user exposed to misinformation once could see more and more of it over time, further reinforcing one™s misunderstanding. Some websites also combine di˝erent kinds of information, such as news, ads, and posts from users, into a single feed, which can leave consumers confused about the underlying source of any given piece of content. 3534˚e growing number of places people go to for informationŠsuch as smaller outlets and online forumsŠ has also made misinformation harder to ˜nd and correct. And, although media outlets can help inform and educate consumers, they can sometimes inadvertently amplify false or misleading narratives. 37, 3836Misinformation also thriv es in the absence of easily accessible, credible information. When people look for information online and see limited or contradictory search results, they may be left confused or misinformed. 39, 40Mor e broadly, misinformation tends to ˙ourish in environments of signi˜cant societal division, animosity, and distrust. For example, distrust of the health care system due to experiences with racism and other inequities may make it easier for misinformation to spread in some communities. Growing polarization, including in the political sphere, may also contribute to the spread of misinformation. 42, 4341Additional r esearch is needed to better understand how people are exposed to and a˝ected by misinformation and how this may vary across subpopulations based on factors such as race, ethnicity, socioeconomic status, education, age, sexual orientation, gender identity, cultural and religious practices, hobbies and interests, and personal networks. 44

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6During the COVID-19 pandemic, there have been signi˜cant e˝orts to address health misinformation. Here are just a few examples: Trusted community members, such as health professionals, faith leaders, and educators, have spoken directly to their communities to address COVID-19-related questions (e.g., in town halls, community meetings, via social and traditional media) Researchers have identi˜ed leading sources of COVID-19 misinformation, including misinformation fisuper-spreadersfl 45Media organizations have devoted more resources to identify and debunk misinformation about COVID-19 46, 47Some technology platforms have improved e˝orts to monitor and address misinformation by reducing the distribution of false or misleading posts and directing users to health information from credible sources 48, 49, 50 Governments have increased their e˝orts to disseminate clear public health information in partnership with trusted messengers 51But there is much more to be done, and each of us has a role to play. Before posting or sharing an item on social media, for example, we can take a moment to verify whether the information is accurate and whether the original source is trustworthy. If we’re not sure, we can choose not to share. When talking to friends and family who have misperceptions, we can ask questions to understand their concerns, listen with empathy, and o˝er guidance on ˜nding sources of accurate information. 52, 53, 54, 55, 56It will take more than individual e˝orts, however, to address health misinformation. ˚e threat of misinformation raises important questions we must answer together: How do we curb the spread of Because it pollutes our information environment, misinformation is harmful to individual and public health. Together, we have the power to build a healthier information environment. Just as we have all bene˜ted from e˝orts to improve air and water quality, we can all bene˜t from taking steps to improve the quality of health information we consume. Limiting the prevalence and impact of misinformation will help all of us make more informed decisions about our health and the health of our loved ones and communities. WE CAN TAKE ACTION Together, we have the power to build a healthier information environment.

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8Learn how to identify and avoid sharing health misinformation. When many of us share misinformation, we don™t do it intentionally: We are trying to inform others and don™t realize the information is false. Social media feeds, blogs, forums, and group chats allow people to follow a range of people, news outlets, and o˛cial sources. But not every post on social media can be considered reliable. And misinformation can ˙ourish in group texts or email threads among friends and family. Verify 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. If someone you care about has a misperception, you might be able to make inroads with them by ˜rst seeking to understand instead of passing judgment. Try new ways of engaging: Listen with empathy, establish common ground, ask questions, provide alternative explanations and sources of information, stay calm, and don™t expect success from one conversation. What Individuals, Families, and Communities Can DoWhen many of us share misinformation, we don™t do it intentionally: We are trying to inform others and don™t realize the information is false If you™re not sure, don™t share. Address health misinformation in your community. Work with schools, community groups such as churches and parent-teacher associations, and trusted leaders such as educators and health care professionals to develop local strategies against misinformation. For example, invite local health professionals to schools or to faith congregations to talk about COVID-19 vaccine facts. WE CAN TAKE ACTION

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WE CAN TAKE ACTION What Educators and Educational Institutions Can Do Strengthen and scale the use of evidence-based educational programs that build resilience to misinformation. Media, science, digital, data, and health literacy programs should be implemented across all educational settings, including elementary, secondary, post-secondary and community settings. In addition to teaching people how to be more discerning about the credibility of news and other content, educators should cover a broader set of topics, such as information overload, internet infrastructure (e.g., IP addresses, metadata), the challenges of content moderation, the impact of algorithms on digital outputs, algorithmic bias, arti˜cial intelligence (AI)-generated misinformation (e.g., deepfakes), visual veri˜cation skills, and how to talk to friends and family who are sharing misinformation. Educate students and the public on common tactics used by those who spread misinformation online. Recent research suggests that teaching people how to spot these tactics can reduce people’s willingness to share misinformation.57 Examples of misinformation tactics used by those who deny scienti˜c consensus on health issues include presenting unquali˜ed people as experts; misleading consumers with logical fallacies; setting impossible expectations for scienti˜c research; cherry-picking data or anecdotes; and introducing conspiracy theories.58 Establish quality metrics to assess progress in information literacy. While there is substantial media and information literacy work being carried out across the United States, there is a need for more consistent and empirically evaluated educational materials and practices. Media, science, digital, data, and health literacy programs should be implemented across all educational settings. 9

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10 What Health Professionals and Health Organizations Can Do Proactively engage with patients and the public on health misinformation. Doctors, nurses, and other clinicians are highly trusted and can be e˝ective in addressing health misinformation. If you are a clinician, take the time to understand each patient™s knowledge, beliefs, and values. Listen with empathy, and when possible, correct misinformation in personalized ways. When addressing health concerns, consider using less technical language that is accessible to all patients. Find opportunities to promote patient health literacy on a regular basis. 59Use technology and media platforms to share accurate health information with the public. For example, professional associations can equip their members to serve as subject matter experts for journalists and e˝ectively communicate peer- reviewed research and expert opinions online. Partner with community groups and other local organizations to prevent and address health misinformation. For example, hospital systems can work with community members to develop localized public health messages. Associations and other health organizations should o˝er trainings for clinicians on how to address misinformation in ways that account for patients™ diverse needs, concerns, backgrounds, and experiences.WE CAN TAKE ACTION Associations and other health organizations should oˆer trainings for clinicians on how to address misinformation in ways that account for patients™ diverse needs, concerns, backgrounds, and experiences.

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11 What Journalists and Media Organizations Can Do Train journalists, editors, and others to recognize, correct, and avoid amplifying misinformation. Media organizations should develop in-house training programs and partner with journalism schools, nonpro˜ts, technology platforms, and others to democratize access to high-quality training for all media outlets.Proactively address the public™s questions. When something is newŠsuch as a vaccineŠ people will understandably have questions. By anticipating and proactively answering those questions, media organizations and journalists can help get ahead of misinformation and increase the public™s health and information literacy. Provide the public with context to avoid skewing their perceptions about ongoing debates on health topics. For example, when discussing con˙icting views on an issue, give readers a sense of where the scienti˜c community stands and how strong the available evidence is for di˝erent views. Consider questions like: How much disagreement is there among experts? Is a given explanation plausible even if it is unlikely? If evidence is not equally strong on all sides of an issue, avoid presenting it as such. Carefully review information in preprints. Preprints are research papers published online before peer review. ˚ey can provide scientists and the public with useful information, especially in rapidly evolving situations such as a pandemic. However, because preprints have not been independently reviewed, reporters should be careful about describing ˜ndings from preprints as conclusive. If reporting on such ˜ndings, include strong caveats where appropriate, seek out expert opinions, and provide readers with context.Use a broader range of credible sourcesŠ particularly local sources. Research shows us that people have varying levels of trust in di˝erent types of people and institutions. In addition to relying on federal and state public health authorities as sources, build relationships with local health professionals and local trusted, credible health organizations. 4Consider headlines and images that inform rather than shock or provoke. Headlines are often what audiences will see and remember. If a headline is designed to fact-check a rumor, where possible, lead with the truth instead of simply repeating details of the rumor. Images are often shared on social media alongside headlines and can be easily manipulated and used out of context. Picture desk and social media editors should consider how provocative and medically inaccurate imagery can be a vehicle for misinformation.60WE CAN TAKE ACTION Give readers a sense of where the scienti˘c community stands and how strong the available evidence is for diˆerent views.

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