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Abstract
Importance The onset of the COVID-19 global pandemic highlighted the increasing role played by social media in the generation, dissemination and consumption of outbreak-related information.
Objective The objective of the current review is to identify and summarise the role of social media in public health crises caused by infectious disease, using a five-step scoping review protocol.
Evidence review Keyword lists for two categories were generated: social media and public health crisis. By combining these keywords, an advanced search of various relevant databases was performed to identify all articles of interest from 2000 to 2021, with an initial retrieval date of 13 December 2021. A total of six medical and health science, psychology, social science and communication databases were searched: PubMed, Web of Science, Scopus, Embase, PsycINFO and CNKI. A three-stage screening process against inclusion and exclusion criteria was conducted.
Findings A total of 338 studies were identified for data extraction, with the earliest study published in 2010. Thematic analysis of the role of social media revealed three broad themes: surveillance monitoring, risk communication and disease control. Within these themes, 12 subthemes were also identified. Within surveillance monitoring, the subthemes were disease detection and prediction, public attitude and attention, public sentiment and mental health. Within risk communication, the subthemes were health advice, information-seeking behaviour, infodemics/misinformation circulation, seeking help online, online distance education and telehealth. Finally, within disease control, the subthemes were government response, public behaviour change and health education information quality. It was clear that the pace of research in this area has gradually increased over time as social media has evolved, with an explosion in attention following the outbreak of COVID-19.
Conclusions and relevance Social media has become a hugely powerful force in public health and cannot be ignored or viewed as a minor consideration when developing public health policy. Limitations of the study are discussed, along with implications for government, health authorities and individual users. The pressing need for government and health authorities to formalise evidence-based strategies for communicating via social media is highlighted, as well as issues for individual users in assessing the quality and reliability of information consumed on social media platforms.
- Epidemiology
- Health policy
- Public Health
- Review
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Little was previously known about the overall role played by social media in public health crises caused by infectious disease, a topic of dramatically increased significance following the COVID-19 pandemic.
WHAT THIS STUDY ADDS
Through a review and analysis of relevant research, this study identifies various themes and approaches in social media and public health crisis research from 2000 to 2021. Three broad themes were revealed: surveillance monitoring, risk communication and disease control. Within these themes, 12 subthemes were also identified.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Social media has become a hugely powerful and ubiquitous force in public health and must be purposively considered by government and public health authorities when developing public health policy.
Introduction
The onset of the COVID-19 global pandemic in early 2020 highlighted the role of social media as a crucial and widely used communication tool for the generation, dissemination and consumption of information related to the outbreak on both a global and local level. 1 ,2 ,3 ,4 ,5 While the COVID-19 outbreak has represented the most significant and widespread threat to public health in the last century, it is not the first instance of social media being used as a communication tool during a public health crisis.6
Data from 2023 show that there are approximately 4.8 billion social media users globally, which represents over 59% of the total population and over 92% of all internet users.7 Research has shown that an increasing number of people are using social media to obtain health information, with figures of up to 85% of social media users acknowledging that they seek health information and advice in this way.8 9
Social media (which may also be referred to as social networking or Web 2.0) is a broad term for a variety of web-based platforms and services that allow users to develop public or semipublic profiles and/or content, and to connect with other users’ profiles and/or content. 10,11 Examples of social media include blogs and micro-blogs (such as Blogger, Twitter and WordPress), discussion forums (such as Quora, Reddit), digital content-sharing platforms (such as Flickr, Instagram, Pinterest and YouTube), and social networking sites (such as Facebook and Google+).
There is significant emerging research specific to the use of social media in the COVID-19 pandemic; however, there is a lack of large-scale, systematic overview of social media use in historical as well as more current public health emergencies. This creates a gap in our understanding of how social media impacts and reflects the course of an outbreak of infectious disease. It is also somewhat unclear how social media can be most effectively harnessed by health authorities as well as individual users in mitigating the risks and impacts of public health emergencies as they unfold in real time.
Sahin et al12 attempted to map the myriad aspects of the COVID-19 pandemic into a causal loop diagram, creating a framework of the environmental, health, economic, social and interventional aspects of the crisis. This framework may provide a useful tool in examining and assessing the coverage of the literature around the use and role of social media in public health crises more broadly. Understanding both the functional and dysfunctional aspects of social media use in public health crises will help to inform targeted strategies for government and health authorities to harness the increasing power of social media to identify emerging public health threats, monitor public behaviour and attitudes, implement effective protective policies and communication strategies that make use of high-quality, evidence-based information as well as to evaluate the outcome of interventional measures.
Research questions and scope
The aim of this scoping review is to summarise the role of social media in public health crises caused by the outbreak of infectious disease. Four specific research questions guided this review:
What social media platforms have been used in public health crises caused by the outbreak of infectious diseases?
What has been studied in terms of the potential roles played by social media in public health crises caused by infectious disease?
How has social media been used by the public and by health authorities in response to public health crises caused by infectious disease?
What are the impacts or effects of social media use in response to public health crises caused by infectious disease?
Methods
The current review explores the role of social media in public health crises using Arksey and O’Malley’s scoping framework.13 The five-step scoping review protocol was followed. The research team consisted of four coauthors with multidisciplinary expertise in public health, epidemiology, quantitative-qualitative research methods and research synthesis. Scoping reviews help summarise and disseminate research findings and identify research gaps in the existing literature. In contrast to systematic reviews, scoping reviews can include multiple sources to map the existing literature in an area of interest based on the number, nature and characteristics of the primary studies.13 This allows researchers to better understand broad hosts that have not been extensively reviewed or have complex or heterogeneous properties.
As defined by the WHO, we consider an infectious disease outbreak as a situation in which more cases of disease occur in a given community, geographic area or season than would normally be expected.14
Some social media platforms and services are used by global audiences (eg, Facebook and Twitter) while others are mainly popular in specific countries or regions (eg, Sina Weibo and WeChat). Therefore, considering the diversity in the types of social media used locally and internationally, this study has explored the most typical and widely used social media in combination with the 2020 Global Digital Report15 and The 46th Statistical Report on China’s Internet Development Status.16 A keyword search using Medical Subject Headings (MeSH) terms found that social media has a specialised terminology thesaurus, but public health crises are not included. At the same time, we found that there are multiple definitions of a public health crisis. Therefore, in order to ensure the integrity of terms and keywords, based on extensive reading of peer-reviewed journals in PubMed, this study refers to the definition of Green and McGinnis,17 which defines the scope of public health crisis events as ‘natural disasters, human system failures and conflict-based disasters’. These include sudden natural disasters, public health emergencies of international concern, such as epidemics and pandemics, as well as wars and conflicts. This study excluded literature examining public health crisis events caused by any agent other than infectious disease.
Search terms and strategy
After refining the keywords and their variants with peer-reviewed literature on similar topics, we generated keyword lists for two categories: social media and public health crisis (table 1). By combining these keywords, we performed an advanced search in various databases to identify all articles of interest from 2000 to 2021. A complete listing of search terms is presented in online supplemental appendix A. A total of six medical and health science, psychology, social science and communication databases were searched: PubMed, Web of Science, Scopus, Embase, PsycINFO and CNKI. The retrieval date was 13 December 2021. The earliest article identified was published in 2010. Although scoping reviews may consider grey literature, given the broad and complex nature of the subject matter, the decision was taken by the research team to omit these sources in order to maintain a manageable volume of material.
Supplemental material
Search keywords
Eligibility criteria
Inclusion criteria were
Social media use, focusing on public health crises caused by serious or unknown infectious diseases.
Reporting at least one health-related activity relating to social media action, function, effect or performance.
Original peer-reviewed articles and empirical studies using various methods. These included intervention studies, observational studies, pilot studies, qualitative and/or quantitative methods, literature and systematic reviews.
Articles published in either English or Chinese language.
Articles published between January 2000 and December 2021.
Full-text studies.
Exclusion criteria were
Book chapters and grey literature (eg, conference proceedings, dissertations and reports, commentaries and editorials).
Research that does not examine the role and/or function of social media in the events of public health crises.
Studies focused on only traditional media sources, including magazines, newspapers, news reports, communications, radio and television.
Public health crises caused by reasons other than infectious diseases, such as natural disasters, wars, etc.
Languages other than English and Chinese.
Study selection and data extraction
All retrieved articles were imported into EndNote software, and systematically screened in three stages. In the first stage, duplicates were identified and removed using the software’s duplicate paper comparison feature. In the second stage, a combination of title and keyword screening was performed to eliminate articles that were obviously irrelevant to the topic or did not meet inclusion criteria. All abstracts of papers with ambiguous titles were read, and those that did not meet predefined criteria were discarded. Publications without abstracts were included in the third round of screening. Finally, in the third stage of full-text screening, the team screened articles according to the inclusion criteria, and included relevant articles that might have been missed by examining article reference lists. An article was excluded if the full text was not available, if only the method was described (ie, building an application programming interface, but no results), or if it did not directly address one of the four research questions. In this way, only eligible articles that met the review purpose were included for further data extraction. During the whole process, two authors (FY and QY) participated in most of the research selection, and where it was difficult to determine whether to include an article or if there was a disagreement regarding inclusion, these two authors undertook discussion and negotiation to reach a consensus on whether to include or discard the article.
Evidence synthesis
Data extraction tables were designed using Microsoft Excel spreadsheets. For each article that met the inclusion criteria, a working group member was designated to extract and document specific details from the full-text article. This information includes title, author, year, country, type of social media, type of public health crisis, study subjects/population (eg, health workers), social media users, type of study, study objectives, data source and sample size, study design, main outcomes and findings, type of function (eg, disease prevention, surveillance) and study limitations. The 15 categories were established based on expert guidance and an initial literature search aimed at developing better classifications to meet review objectives. Following the guidelines for conducting scoping reviews, there was no formal assessment of the methodological quality of the included articles.13
Initially, the Chinese team extracted key themes and classified the included studies into those themes. The Australian team reviewed the full text of the studies published in English and revised the categorisation. The results were then forwarded to the Chinese team for confirmation and further revisions with particular consideration of the full texts of the Chinese language publications. The final results were discussed and agreed on by both teams.
Given the heterogeneity of the literature, descriptive and thematic analyses were presented in the form of narrative summaries (see online supplemental appendix B). Articles that examined multiple roles of social media were categorised according to the research focus, and may have been assigned to more than one category. Studies examining a single role that was difficult to categorise were reviewed by two authors (FY and QY) to identify the research subject, objective/s and results. These three perspectives were used in discussion by researchers to reach a consensus on classification.
Supplemental material
The causal loop diagram developed by Sahin et al12 was used as an additional tool to identify research focus and gaps, as well as the status of current research by using a colour-coded traffic light system to identify the depth and application of existing studies.
A search update was conducted on 2 April 2023 using the established search strategy and terms of articles published between 1 January 2022 and 31 December 2022.7 After removal of duplicates, this search yielded a total of 2159 additional articles. After screening of the additional literature, no novel themes were identified, and therefore, these newer articles are not included in the report of this manuscript.
Patient and public involvement
This study did not involve patient or public participation, as this was not applicable to the study’s aims or design.
Results
Results of the study selection process
A total of 9834 articles were initially retrieved, including 8712 English articles from 5 databases, PubMed, Web of Science, Scopus, Embase, and PsycINFO, and 1122 articles from the CNKI Chinese database. After deleting 3941 duplicate articles, and reading the titles and abstracts, 3379 full-text articles were considered to be potentially relevant. After initial review, 1193 articles that did not fit the type of social media use and role, and 1851 articles that examined other causes of public health crises were excluded. In addition, following the examination of article reference lists, three additional articles were included. A total of 338 articles were identified for inclusion in the data extraction (see figure 1). A full list of included studies along with main findings of each study can be found in online supplemental appendix B.
PRISMA flow diagram illustrating study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Characteristics of the included studies
A summary of the types of diseases that have caused public health crises found that most research has focused on outbreaks of infectious diseases. The research mainly examines COVID-19 (246 articles), which currently poses the most serious threat to public health, followed by infectious diseases such as Zika and Ebola that have posed major threats to public health in the past. 13 studies did not clearly identify the type of disease (table 2). In the instance where a study examined more than one disease or more than one social media platform, it was allocated all relevant categories.
Number of studies investigating the role of social media in public health crises by infectious disease
A summary of social media platforms appearing in search results is presented in table 3. The most frequently studied social media platforms are Twitter (99 articles), Sina Weibo (56 articles), WeChat (18 articles), while YouTube and Facebook both have 13 articles.
Social media platforms
In terms of social media users, it can be seen in table 4 that individual users are by far the most commonly studied, accounting for 82 articles, or 68.9% of the total. 12 studies did not explicitly describe the user. Government users account for nine studies.
Social media users
Table 5 provides a thematic summary of the 338 selected articles on public health crises and social media by publication year. Among them, there are 75 articles in Chinese (22.1%) and 263 articles in English (77.9%). The number of articles published has increased year by year from 2010 to 2021, focusing on a variety of diseases. In line with the explosion of research in the field following the COVID-19 pandemic, the vast majority of studies identified in the search update of 2022 literature focused on this disease.
Thematic framework of social media functions in public health crises by year
Three broad themes were identified from the data examined. These were surveillance monitoring, risk communication and disease control. Within these three themes, twelve corresponding subthemes were also identified.
Surveillance monitoring included the collection and analysis of social media data (both retrospectively and in real-time) to examine the nature, spread and sentiment around disease outbreaks, and was the most prominent theme among the studies reviewed. Within this theme, three subthemes were identified. The first is disease detection and prediction, which allowed researchers use social media data to not only map the spread of disease retrospectively and in real time, but to predict outbreaks and to compare the results with more traditional epidemiological tracking methods. This theme is the earliest identified in the literature, with examples being published in 2011 that found a relationship between social media data and levels of disease activity.18 ,19 Later studies examined the potential of social media data to enhance traditional epidemiological surveillance methods, and improve forecasting and ‘nowcasting’ capabilities of health authorities,20 as well as to track outbreaks geographically21 22
The second subtheme is public attitude and attention, which describes the content focus of social media activity during disease outbreaks. The earliest identified study included in this review provides an example of this, in the content analysis of tweets during the 2009 H1N1 outbreak.23 The researchers concluded that the study ‘illustrates the potential of using social media to conduct ‘infodemiology’ studies for public health. 2009 H1N1-related tweets were primarily used to disseminate information from credible sources, but were also a source of opinions and experiences. Tweets can be used for real-time content analysis and knowledge translation research, allowing health authorities to respond to public concerns.’23
The third subtheme is public sentiment and mental health issues, which describe the public mood around the impact of the illness itself as well as official advice and interventions on mental health. Studies included within this theme examined the impact of lockdowns and other protective measures on the stress levels and emotions of social media users,24 25 as well as the ways in which social media use influenced experience of traumatic emotions, anxiety and depression.26 27
Risk communication examined the seeking and distribution of information on social media related to outbreaks during public health crises. Within this theme, six subthemes were identified. These are health advice, which directly examined the promulgation of public health advice by authorities and individuals, information-seeking behaviour by social media users, the phenomenon of ‘infodemics’ and the circulation of misinformation on social media, help-seeking online, the impact of online distance education and finally the emergence of telehealth services.
Studies grouped within the subtheme of health advice focused on factors such as the nature and impact of official information and advice on public perceptions during an outbreak of infectious disease,28–30 the utility of providing health advice on social media,31 32 as well as the use of social media to disseminate emergency health advice.33
Information-seeking behaviour as a subtheme included studies that examined the behaviour of users and patients seeking help and advice on protective and healthcare issues,34–36 as well as the sources most heavily relied on for health information.37 The relationship between online information seeking and health literacy was also a prominent example of studies within this subtheme. For example, Rosario et al (2020)38 found that users of platforms such as Google and Facebook were less likely to have sufficient digital health literacy than users who sought information from health authority websites.
Infodemics and misinformation circulation as the third subtheme included studies on the rapidly growing issue of inaccurate and misleading information on social media relating to public health crises. This was noted as one of the research topics of greatest growth over the time period studied. Examples within this subtheme include the rise and nature of infodemics, defined as ‘an overabundance of information—some accurate and some not—occurring during an epidemic’.39 These studies tended to focus on high-volume social media activity related to disease outbreak40 41 and the risks inherent in potentially unreliable floods of information on social media.40 42 Other studies explored the ways in which governments and health authorities could begin to respond to this phenomenon to mitigate risk of harm.43 Studies examining misinformation aimed to measure its prevalence and impact on behaviours, as well as to identify those groups most at risk of exposure to misinformation.44–47
The fourth subtheme is seeking help online, which encompasses studies examining ways in which social media users attempted to obtain practical support in conditions of lockdown and isolation, causing them to be cut-off from friends and family.34
Online distance education was an emerging theme that looked at the integration of social media with online learning systems during periods of lockdown and isolation. For example, Greenhow and Chapman48 examined this issue and concluded that social media is best used in conjunction with conventional learning during health crises.
The final subtheme within risk communication, telehealth, is also in its infancy and explored the social media based telehealth as a substitute for traditional, face-to-face care during periods of lockdown.49
Disease control was the third broad theme and involved efforts to reduce the severity and spread of disease. Three subthemes were identified, including government response, public behaviour change and health education information quality.
Studies grouped under the government response theme focused on the ways in which government engaged via social media during various stages of disease outbreak to control spread 50 ,51 and the impact of government activity or lack of engagement on disease control.52 An example is a study conducted by Wang et al,51 which found that government agencies initially underestimated the COVID-19 pandemic risk, with public education efforts increasing throughout the pandemic to increase protective behaviours and limit harm.
The subtheme of public behaviour change encompassed studies that explored the relationship between social media use and the adoption of protective behaviours that limit the spread of disease.53–55 For example, Tang and Wang53 found that frequent WeChat users demonstrated more positive health behaviours and subsequent health status.
The final subtheme, health education information quality, related to studies that aimed to assess the reliability and quality of health information that appeared on social media during outbreaks of infectious disease.56–58 For example, Chan et al56 found that the overall quality and reliability of information on COVID-19 vaccines on YouTube was poor.
It is important to highlight that many studies contained elements of more than one theme. For example, most studies contained an element of surveillance monitoring, even though the primary research focus may have lay elsewhere.
As previously noted, the evolution of research into social media and public health crises has gradually increased in pace and richness since 2010, with a dramatic increase in attention during the COVID-19 pandemic.
Additionally, we classified the studies into three categories according to the type and depth of research conducted for each element of a public health emergency, using the comprehensive causal loop diagram developed by Sahin et al12 as a map. Green indicates the practical application of social media in real-world situations, yellow indicates real-world studies assessing the theoretical value of social media and red indicates early, ad hoc research exploring the potential theoretical use of social media. The areas that have not yet been explored were left blank (figure 2).
Elements of public health emergency studies in the literature (adapted from Sahin et al).12
Discussion
This review provides a systematic and comprehensive examination of the literature around the use of social media in public health crises caused by infectious diseases since 2000. It has allowed for the development of a thematic framework to describe these roles and functions, and to provide answers to the four research questions originally posed.
Q1: What social media platforms have been used in public health crises caused by the outbreak of infectious diseases?
It is clear that activity on popular social media platforms intensifies during public health crises, and that social media is an increasingly ubiquitous and powerful communication tool. In particular, Twitter, Facebook, SinaWeibo, YouTube, Instagram, WeChat and Reddit were the most widely used platforms in the studies examined as part of this review. While the research on government and health authority’s use of social media was far more limited than that of individual users, these organisations were most likely to use Twitter, Facebook and Instagram.59 ,60 There are few studies on other social media platforms (including WhatsApp, social network sites (SNSs), etc).55 ,47 It should be noted that many studies did not focus on a single social media platform. There are often articles that include a comparative analysis of media, with multiple social platforms examined.61 Some studies address broader types of social media, such as digital media, forums, SNS, Google, Yahoo and Wikipedia.62–64 With the diversification of social media platforms and functions, some studies explore the development of digital tools that can be used specifically in times of public health crisis.65 At the same time, with the increasingly serious issue of misinformation on social media, professional rumour-refuting and myth-debunking platforms have also begun to appear and have played an important role in the management of COVID-19 in particular.66 67 The majority of research has focused on local communities or single countries, including several studies which have examined the use of social media to track and predict the course of outbreaks with the use of geolocation data.68 69 However, some studies have taken a global approach.35 ,64 ,70 ,71 ,42
Q2: What has been studied in terms of the potential roles played by social media in public health crises caused by infectious diseases?
Surveillance monitoring and content analysis is overwhelmingly the most frequently studied significant role of social media in public health crises to date. Most studies were observational in nature, and encompassed an element of surveillance, even when the main aim was focused on risk communication or disease control.28 33 72 73 Significantly, all of the earlier studies (pre-2015) were focused on surveillance and content analysis. The first study that specifically examined the issue of misinformation on social media appeared in 2015, which analysed reactions to non-evidence-based, speculative treatments of Ebola virus during a 2014 outbreak.74 As the use of social media by the public has increased, its use by government, health authorities and communities for the purposes of risk communication has also increased and become more complex.75 76 Most recently, elements of disease control functions have emerged, particularly in the context of the recent COVID-19 global pandemic. This research is currently in its infancy, and more studies are required in order to build an evidence base for social media based strategies for health authorities to effectively minimise and contain the spread of infectious disease. Across the 2000–2021 time frame examined as part of this review, it is clear that the rate of emerging diseases capable of triggering a public health crisis is increasing, which poses an increasingly serious threat to the public and a strong impetus to develop tools to harness and maximise the power of social media to limit their damage.
Q3: How has social media been used by the public and by health authorities in response to public health crises caused by infectious diseases?
This review shows that members of the public are by far the most prolific users of social media during public health crises, and primarily use social media to express their experiences, opinions and to seek information. The public is both a producer of information when a health-related crisis occurs, and a receiver and disseminator of information.77 78 People report their disease experience or diagnosis information, share health prevention knowledge through social media, and serve to flag health crisis development through keyword searches or social media activity.19 ,79 ,80 ,81 In the process, false or misinformation may be generated and transmitted extremely quickly.74 ,40 ,82 In the countries studied, government agencies and health officials as well as government-affiliated media agencies (eg, party media, central media in China) used social media during public health crises for news releases, disease updates, protective guidelines, recommendations and mandates, as well as to respond to public concerns. The use of social media platforms geared towards the control of public opinion were most prominently seen in China and the USA, possibly because the majority of studies were focused on these regions.
The global impact and levels of panic brought about by the COVID-19 pandemic in particular highlighted the importance of government and health authorities playing a critical role in correcting falsehoods, rumours and misinformation circulating on social media. The instant communication capability of social media provides an opportunity to immediately fill information gaps during public health emergencies and can quickly convey official emergency warnings. Communicating infectious disease health information to the public, engaging in positive and open exchanges and enabling people to understand and make protective choices are crucial interventions for government health agencies during major public health events.57 In addition, the breadth of audience reach has made social media platforms an indispensable tool for improving health literacy and overall health communication. Many studies strongly recommended that social media surveillance be incorporated in the routine operations of government and health bodies in order to monitor a range of factors, including the prediction and tracking of outbreaks, public mood and sentiment, as well as to directly address misinformation.51 70 83 However, there have not yet been any studies that have tested or piloted a structured surveillance and response protocol by government bodies.24 This will no doubt become a priority for authorities in the future, as well as to examine the political risks involved in such a move. The actions of governments and health authorities have relied on traditional epidemiological data which, a number of studies have demonstrated, often lag behind the disease outbreak and allow for a reactive response. In addition to government organisations, hospitals, social free media, WHO and other organisations are also actively using social media to play an organisational function to respond to public health crises, however protocols have not yet been formalised or evaluated.84
Q4: What are the impacts or effects of social media use in response to public health crises caused by infectious diseases?
Our thematic framework divides the impacts and effects of social media during public health crises into three major functions: surveillance monitoring, risk communication vector and disease control, each of which corresponds to a set of subthemes.
Public health surveillance monitoring can be used as a signpost to identify disease trends and emerging public health risks and to provide early warning for emerging events. Research has shown that a large number of initial outbreak reports often come from informal channels on social media.20 ,85 Social media data monitoring results from Europe are consistent with the geographic distribution of users reporting pneumonia over the same period; posts about COVID-19-related symptoms precede official announcements of local outbreaks and are spatially concentrated in areas that will subsequently become key infection hotspots.86 Geolocated Twitter data can be used to describe the spread of a pathogen and to identify areas with high risk of importation.22 This supports the early detection, reporting and action that form the bedrock of prevention and control strategies. Depending on the reach of the platform in question, the real-time interactivity and personalised information of social media can provide more relevant information about symptoms, accurate and specific information about geographical spread, and allow for the development of increasingly responsive infectious disease models and predictions.87 Monitoring of sensitive information from unofficial channels on social media is an important means of early warning of public health crises.
Studies on public attitudes towards infectious disease outbreaks have shown that social media data can help detect emotional attitudes and mental health impacts in affected populations. However, in the research to date, less attention has been paid to mental health impacts and outcomes88 and more research has been focused on the gauging and interpretation of public sentiment.89–91 Research reveals differences in public focus and emotional states in different geographical regions. For example, SinaWeibo users in areas experiencing severe outbreaks have higher platform engagement levels and report poorer emotional states than users on other platforms, which is likely a reflection of the distress experienced by the community in acute outbreak phases.92
Social media as a risk communication tool encompasses the subthemes of health advice, information-seeking behaviour, infodemics, seeking help online, online distance education and telehealth. While providing data for macrolevel risk management,62 social media also provides a wide range of timely and effective ways for individuals to participate in the crisis response at a local level.93 For example, at the peak of the outbreak of COVID-19 in China, with the severe pressure on medical resources, Sina Weibo users reported their own illnesses or reported illnesses for others in order to obtain medical support, revealing the potential of social media to promote mutually efficient action to improve outcomes.34 In addition, the sharing of accurate information can help to bridge cognitive and behavioural differences, reduce the risk of disease transmission, and reduce inequalities in access to public health resources.94
It is undeniable that rumours, falsehoods and conspiracy theories proliferate on social media in the form of misinformation during times of public health crisis. The convenience and speed of social media communication allows rumours and false information to spread at an unprecedented rate, impacting public risk perception and judgement.95 These issues may lead to a crisis of public trust and collective panic, impacting the healthcare system and public compliance with protective behaviours.25 Government responses via social media are becoming increasingly important in combating misinformation and providing accurate and reliable information to the public.79 At the same time, social media companies are also actively acknowledging their social responsibility to identify and delete false information and rumours, or establishing professional rumour-refuting platforms for real-time clarification. However, the extent to which the correction of misinformation is effective and the extent to which public perceptions change is still unknown. This phenomenon has seriously detrimental consequences for global health as well as individual well-being and is one of the greatest challenges facing the public health system today, both locally and globally.40 96 97 The most widely studied infectious diseases involving health misinformation are COVID-19, Ebola and Zika, as these have been the more recent outbreaks in this rapidly evolving field. Disinformation spread by the antivaccination movement has led to easily preventable disasters, such as the 2021 COVID-19 epidemic in the USA and has a range of impacts on vaccine hesitancy and mental well-being.98–100 In the case of COVID-19, accurate and reliable information gleaned through social media platforms showed the potential for these sources to play a key role in addressing infodemics, misinformation and rumours.71 In addition, real-time monitoring of public opinion on social media can be an important tool for public health agencies and organisations to implement clear communication plans, physical and mental health interventions, and a coordinated emergency response.101
The theme of disease control encompasses the subthemes of government response, public behaviour change and health education information quality. This study revealed that government-initiated knowledge sharing on social media platforms increased over time with each outbreak, which likely reflects an increase in understanding of the utility and popularity of social media on behalf of health authorities. Monitoring and assessing the quality of health education information on social media has also become an increasing focal point for governments.57 The way in which government health advice on social media, such as recommendations on masking and social distancing impacts public behaviour change is also an accelerating area of research48 102 Of the three broad themes, disease control was the least developed in terms of research activity and remains very much in the early stages.
In many ways, the use of social media has brought governments and the public closer together, creating a two-way communication channel and providing governments and health authorities with opportunities for greater responsiveness. For example, China’s health policy during the COVID-19 pandemic was strongly informed by the public’s voice in the expression of their needs. By focusing on public concerns and tracking public comments, not only can various problems and suspicions be solved in a targeted and timely manner, but also help to comprehensively collect epidemiological information to inform better emergency decision-making.103 104 The stronger the availability, authority and trust in the response of government departments in crisis management, the greater the likelihood of public acceptance and compliance.105 However, there has been little research on how efficient and effective these official responses are in influencing public attitudes or behaviours.
When considering the results through the lens of the Sahin et al12 model of public health emergencies, it is clear that health and social elements in the context of social media use have been the most widely studied to date. Observational studies of public and individual well-being, social connectedness, awareness, protective behaviours and government action using real-world data were all well represented. Less well represented in the literature were studies on how social media use impacted elements such as the stability of the supply chain, provision of goods and services and business closures. Product shortages due to panic buying and supply chain disruptions were experienced in many parts of the world during the COVID-19 pandemic in particular, however, the way in which social media use drove these outcomes is not yet well understood. Similarly, impacts on the education and hospitality industries as well as broader economic outcomes are yet to be examined.
This scoping review also identifies two major gaps in the literature regarding the role of social media in public health crisis. First, most, if not all, studies have been anchored at social platforms in their design. In reality, however, one person is likely to be exposed to multiple social platforms. It is important to investigate how various sources of information reach a person and how the person pulls together the information to inform their behaviours. Second, the function of social media as a communication tool has been extensively applied in public health responses.106 However, the applicability of social media in disease monitoring and disease control remains at the stage of theoretical exploration. Further studies are needed to assess the value of social media in disease monitoring and disease control, including its potential risks. It is important to note that there have been increasing calls for strengthening social media regulations.107 This will have a profound impact on the functions of social media in public health emergency responses.
In terms of limitations, a common challenge for studies of social media is the difficulty in data comparison due to differences in quality, such as formats, metrics and even definitions of common variables. For example, the definition of opinion on one social media platform may be different from another. In addition, not every social media platform provides accessible data. In an attempt to address these challenges, selected studies controlled for a number of factors, including social media platform, language, location, time, spelling errors, keywords or hashtags. However, this search strategy resulted in many study limitations, such as a possible non-representative sample size, selection bias, cross-sectional study design or retrospective study design. Social media data contain a combination of personal attribute information that can be traced directly to an individual, threatening personal privacy. Therefore, maintaining a balance between the collection and use of public health information and the protection of citizens’ privacy has always been an important ethical and legal challenge for public health agencies and those studying these topics.
Conclusion
This review identifies various themes and approaches in social media and public health crisis research from 2000 to 2021. Social media has become a hugely powerful force in public health and cannot be ignored or viewed as a minor consideration when developing public health policy, or when considering its impact on individual level decision-making. While significant observational research has taken place, the development, implementation and evaluation of concrete strategies is in its infancy. Aside from outbreak surveillance, there remains little empirical evidence on the ways in which governments and health authorities can incorporate social media-based public health communication strategies in the context of public health crises in ways that are relevant, co-ordinated and agile and support disease control. This evidence is urgently needed, particularly when addressing the increasingly serious problem of health-related misinformation on social media, and the ways that this can be addressed in real time. Also lacking is an understanding of the ways that individual social media users can best engage with and filter information from a variety of online sources to make well-informed choices around health behaviours.
Despite the limitations of this review, the framework identifying key themes should assist in the direction of future research and can serve as a simple, flexible guide for studying and conceptualising social media and epidemiology.
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No data are available.
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References
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Footnotes
Handling editor Seye Abimbola
Twitter @liuchaojie
Contributors CL conceptualised the project and is responsible for the overall content as the guarantor. FY and QY conducted the search and screening of literature and data extraction. KT led the theme analysis and writing of the manuscript. All authors critically reviewed and approved the contents of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.