Beliefs in COVID-19 Vaccine Misinformation Among Unvaccinated Black Americans: Prevalence, Socio-Psychological Predictors, and Consequences.

Health-related misinformation is a major threat to public health and particularly worrisome for populations experiencing health disparities. This study sets out to examine the prevalence, socio-psychological predictors, and consequences of beliefs in COVID-19 vaccine misinformation among unvaccinated Black Americans. We conducted an online national survey with Black Americans who had not been vaccinated against COVID-19 (N = 800) between February and March 2021. Results showed that beliefs in COVID-19 vaccine misinformation were prevalent among unvaccinated Black Americans with 13-19% of participants agreeing or strongly agreeing with various false claims about COVID-19 vaccines and 35-55% unsure about the veracity of these claims. Conservative ideology, conspiracy thinking mind-set, religiosity, and racial consciousness in health care settings predicted greater beliefs in COVID-19 vaccine misinformation, which were associated with lower vaccine confidence and acceptance. Theoretical and practical implications of the findings are discussed.

Moral Foundations Predict COVID-19 Vaccine Hesitancy: Evidence from a National Survey of Black Americans.

In this study we examine the role of moral values in predicting COVID-19 vaccine hesitancy among Black Americans. Guided by moral foundations theory, we assess the associations between six moral foundations (care, fairness, loyalty, authority, purity, liberty) and attitudes and intentions toward COVID-19 vaccination. Results of a national survey of Black Americans (N = 1,497) indicate that the care and loyalty moral foundations consistently predicted less vaccine hesitancy with overall more favorable attitudes and intentions toward COVID-19 vaccination, whereas the purity and liberty moral foundations were consistently associated with greater vaccine hesitancy. Relationships between the foundations and vaccine hesitancy were mediated by perceived vaccine effectiveness and safety. Implications of the findings for COVID-19 vaccine communication are discussed.

Facebook Pages, the "Disneyland" Measles Outbreak, and Promotion of Vaccine Refusal as a Civil Right, 2009-2019.

Objectives. To understand changes in how Facebook pages frame vaccine opposition.Methods. We categorized 204 Facebook pages expressing vaccine opposition, extracting public posts through November 20, 2019. We analyzed posts from October 2009 through October 2019 to examine if pages' content was coalescing.Results. Activity in pages promoting vaccine choice as a civil liberty increased in January 2015, April 2016, and January 2019 (t[76] = 11.33 [P < .001]; t[46] = 7.88 [P < .001]; and t[41] = 17.27 [P < .001], respectively). The 2019 increase was strongest in pages mentioning US states (t[41] = 19.06; P < .001). Discussion about vaccine safety decreased (rs[119] = -0.61; P < .001) while discussion about civil liberties increased (rs[119] = 0.33; Py < .001]). Page categories increasingly resembled one another (civil liberties: rs[119] = -0.50 [P < .001]; alternative medicine: rs[84] = -0.77 [P < .001]; conspiracy theories: rs[119] = -0.46 [P < .001]; morality: rs[106] = -0.65 [P < .001]; safety and efficacy: rs[119] = -0.46 [P < .001]).Conclusions. The "Disneyland" measles outbreak drew vaccine opposition into the political mainstream, followed by promotional campaigns conducted in pages framing vaccine refusal as a civil right. Political mobilization in state-focused pages followed in 2019.Public Health Implications. Policymakers should expect increasing attempts to alter state legislation associated with vaccine exemptions, potentially accompanied by fiercer lobbying from specific celebrities.

Adapting and Extending a Typology to Identify Vaccine Misinformation on Twitter.

Objectives. To adapt and extend an existing typology of vaccine misinformation to classify the major topics of discussion across the total vaccine discourse on Twitter.Methods. Using 1.8 million vaccine-relevant tweets compiled from 2014 to 2017, we adapted an existing typology to Twitter data, first in a manual content analysis and then using latent Dirichlet allocation (LDA) topic modeling to extract 100 topics from the data set.Results. Manual annotation identified 22% of the data set as antivaccine, of which safety concerns and conspiracies were the most common themes. Seventeen percent of content was identified as provaccine, with roughly equal proportions of vaccine promotion, criticizing antivaccine beliefs, and vaccine safety and effectiveness. Of the 100 LDA topics, 48 contained provaccine sentiment and 28 contained antivaccine sentiment, with 9 containing both.Conclusions. Our updated typology successfully combines manual annotation with machine-learning methods to estimate the distribution of vaccine arguments, with greater detail on the most distinctive topics of discussion. With this information, communication efforts can be developed to better promote vaccines and avoid amplifying antivaccine rhetoric on Twitter.

Malicious Actors on Twitter: A Guide for Public Health Researchers.

Social bots and other malicious actors have a significant presence on Twitter. It is increasingly clear that some of their activities can have a negative impact on public health. This guide provides an overview of the types of malicious actors currently active on Twitter by highlighting the characteristic behaviors and strategies employed. It covers both automated accounts (including traditional spambots, social spambots, content polluters, and fake followers) and human users (primarily trolls). It also addresses the unique threat of state-sponsored trolls. We utilize examples from our own research on vaccination to illustrate. The diversity of malicious actors and their multifarious goals adds complexity to research efforts that use Twitter. Bots are now part of the social media landscape, and although it may not be possible to stop their influence, it is vital that public health researchers and practitioners recognize the potential harms and develop strategies to address bot- and troll-driven messages.

Home remedy use and influenza vaccination among African American and white adults: An exploratory study.

Racial disparities in influenza vaccination persist between African American and White adults. It is critical to explore the reasons behind this disparity, which may be linked to the use of "folk" or home remedies for illness prevention and treatment. For this study, The GfK Group was contracted to conduct a nationally-representative survey (n = 819 African American and 838 White respondents). Respondents were asked about behaviors, attitudes, and risk perception related to the influenza vaccine, as well as frequency of home remedy use. Results were analyzed using adjusted logistic regression with 95% confidence intervals. In comparison to those who never use home remedies, those who use home remedies often or almost always were less likely to get vaccinated for influenza (respectively, OR = 0.70, CI 0.49, 0.99; OR = 0.27, CI 0.15, 0.49), less likely to be in favor of the vaccine (OR = 0.47, CI 0.33, 0.67; OR = 0.19, CI 0.10, 0.34), less likely to trust the vaccine (OR = 0.42, CI 0.29, 0.61; OR = 0.34, CI 0.20, 0.61), and more likely to perceive higher risk of vaccine side effects (OR = 1.79, CI 1.19, 2.68; OR = 4.00, CI 2.38, 6.73). These associations did not vary by race. Home remedy users may hold negative views toward the influenza vaccine, such that a combination of little trust in the vaccine process, and overestimation of risk associated with the vaccine itself, may contribute to vaccine refusal. Health care professionals can use these findings to tailor advice toward individuals with a preference for home remedy use to allay fears and correct misconceptions surrounding influenza and its vaccine.

Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate.

OBJECTIVES: To understand how Twitter bots and trolls ("bots") promote online health content. METHODS: We compared bots' to average users' rates of vaccine-relevant messages, which we collected online from July 2014 through September 2017. We estimated the likelihood that users were bots, comparing proportions of polarized and antivaccine tweets across user types. We conducted a content analysis of a Twitter hashtag associated with Russian troll activity. RESULTS: Compared with average users, Russian trolls (χ2(1) = 102.0; P < .001), sophisticated bots (χ2(1) = 28.6; P < .001), and "content polluters" (χ2(1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ2(1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ2(1) = 12.1; P < .001) and antivaccine (χ2(1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive. CONCLUSIONS: Whereas bots that spread malware and unsolicited content disseminated antivaccine messages, Russian trolls promoted discord. Accounts masquerading as legitimate users create false equivalency, eroding public consensus on vaccination. Public Health Implications. Directly confronting vaccine skeptics enables bots to legitimize the vaccine debate. More research is needed to determine how best to combat bot-driven content.

Mission of Mercy emergency dental clinics: an opportunity to promote general and oral health.

BACKGROUND: Mission of Mercy (MOM) emergency dental clinics are a resource for populations lacking access to dental care. We designed a MOM event incorporating health equity components with established community partners who shared a common vision of addressing the oral health, physical health, and social service needs of Maryland and Washington, DC area residents. Although studies have explored associations between oral and chronic health conditions, few studies to our knowledge have examined the relationship between these conditions and receipt of dental services. Therefore, this study explored these associations and the opportunity for better care coordination. METHODS: Oral health data from the 2014 Mid-Maryland Mission of Mercy and Health Equity Festival event was analyzed. A descriptive analysis assessed frequencies and percentages of participant sociodemographics characteristics, oral health and chronic disease risk(s), and dental services delivered. Chi-square tests and multivariate logistic regression were conducted to determine the associations between 1) oral health and chronic disease risk(s) and dental services; and 2) oral health and chronic disease risk(s) and participant characteristics. RESULTS: Approximately 66.2% (n = 666) of the 1007 participants had one or more chronic conditions and/or risk factors (diabetes, high blood pressure, and tobacco use). These individuals had a significantly higher likelihood of receiving an oral surgery procedure (specifically, tooth extraction) (only one condition/risk: OR = 2.40, 95%, CI = 1.48-3.90, p < .001; two conditions/risks: OR = 3.12, 95% CI = 1.78-5.46, p < .001). CONCLUSION: The 2014 Mid-Maryland Mission of Mercy emergency dental clinic attracted people with risk factors for oral and chronic diseases. Those with one or more risk factors were more likely to receive oral surgery (specifically, tooth extraction). These findings strongly suggest that organizers of MOM emergency dental clinics include wrap-around primary care, health promotion and disease prevention services along with provision of dental services. While such events will not solve the general and oral health challenges of participants, we believe they provide an opportunity to provide basic preventive services. These findings also present an opportunity to inform planning for future MOMs and emphasize the importance of using these public health events to create linkages with other services to support follow-up and care coordination.

Commentary: Critical Race Theory Training to Eliminate Racial and Ethnic Health Disparities: The Public Health Critical Race Praxis Institute.

Racism is a fundamental cause of racial and ethnic disparities in health outcomes. Researchers have a critical role to play in confronting racism by understanding it and intervening on its impact on the health and well-being of minority populations. This requires new paradigms and theoretical frameworks that are responsive to structural racism's present-day influence on health, health disparities, and research. To address the complexity with which racism influences both health and the production of knowledge about minority populations, the field must accelerate the professional development of researchers who are committed to eliminating racial and ethnic health disparities and achieving health equity. In this commentary, we describe a unique and vital training experience, the Public Health Critical Race Praxis Institute at the University of Maryland's Center for Health Equity. Through this training institute, we have focused on the experiential knowledge of diverse researchers committed to examining racism and trained them on putting racism at the forefront of their research agendas. The Institute brought together investigators from across the United States, including junior and senior faculty as well as postdoctoral fellows. The public health critical race methodology was purposefully used to structure the Institute's curriculum, which instructed the scholars on Critical Race Theory as a framework in research. During a 2.5-day training in February 2014, scholars participated in activities, attended presentations, joined in reflections, and interacted with Institute faculty. The scholars indicated a strong desire to focus on race and racism and adopt a Public Health Critical Race Praxis framework by utilizing Critical Race Theory in their research.

Discordance Between Human Papillomavirus Twitter Images and Disparities in Human Papillomavirus Risk and Disease in the United States: Mixed-Methods Analysis.

BACKGROUND: Racial and ethnic minorities are disproportionately affected by human papillomavirus (HPV)-related cancer, many of which could have been prevented with vaccination. Yet, the initiation and completion rates of HPV vaccination remain low among these populations. Given the importance of social media platforms for health communication, we examined US-based HPV images on Twitter. We explored inconsistencies between the demographics represented in HPV images and the populations that experience the greatest burden of HPV-related disease. OBJECTIVE: The objective of our study was to observe whether HPV images on Twitter reflect the actual burden of disease by select demographics and determine to what extent Twitter accounts utilized images that reflect the burden of disease in their health communication messages. METHODS: We identified 456 image tweets about HPV that contained faces posted by US users between November 11, 2014 and August 8, 2016. We identified images containing at least one human face and utilized Face++ software to automatically extract the gender, age, and race of each face. We manually annotated the source accounts of these tweets into 3 types as follows: government (38/298, 12.8%), organizations (161/298, 54.0%), and individual (99/298, 33.2%) and topics (news, health, and other) to examine how images varied by message source. RESULTS: Findings reflected the racial demographics of the US population but not the disease burden (795/1219, 65.22% white faces; 140/1219, 11.48% black faces; 71/1219, 5.82% Asian faces; and 213/1219, 17.47% racially ambiguous faces). Gender disparities were evident in the image faces; 71.70% (874/1219) represented female faces, whereas only 27.89% (340/1219) represented male faces. Among the 11-26 years age group recommended to receive HPV vaccine, HPV images contained more female-only faces (214/616, 34.3%) than males (37/616, 6.0%); the remainder of images included both male and female faces (365/616, 59.3%). Gender and racial disparities were present across different image sources. Faces from government sources were more likely to depict females (n=44) compared with males (n=16). Of male faces, 80% (12/15) of youth and 100% (1/1) of adults were white. News organization sources depicted high proportions of white faces (28/38, 97% of female youth and 12/12, 100% of adult males). Face++ identified fewer faces compared with manual annotation because of limitations with detecting multiple, small, or blurry faces. Nonetheless, Face++ achieved a high degree of accuracy with respect to gender, race, and age compared with manual annotation. CONCLUSIONS: This study reveals critical differences between the demographics reflected in HPV images and the actual burden of disease. Racial minorities are less likely to appear in HPV images despite higher rates of HPV incidence. Health communication efforts need to represent populations at risk better if we seek to reduce disparities in HPV infection.

The influence of social norms on flu vaccination among African American and White adults.

Adult influenza vaccination rates remain suboptimal, particularly among African Americans. Social norms may influence vaccination behavior, but little research has focused on influenza vaccine and almost no research has focused on racially-specific norms. This mixed methods investigation utilizes qualitative interviews and focus groups (n = 118) and national survey results (n = 1643) to assess both descriptive and subjective norms surrounding influenza vaccination. Qualitative results suggest a perceived descriptive norm that 'about half' of the population gets vaccinated. Participants describe differing norms by race and vaccine behavior. Quantitative results confirm a perceived descriptive norm that 40-60% of the population gets vaccinated. Both African Americans and Whites accurately identified race-specific vaccination rates relative to the general population. Individuals who report that a majority of people around them want them to be vaccinated were significantly more likely to be vaccinated, suggesting subjective norms are influential for both White and African American adults. While perceived descriptive norms are somewhat accurate (mirroring the actual influenza vaccination rate), emphasizing a suboptimal vaccination rate may not be beneficial. Health promotion efforts, particularly those targeting African Americans, may benefit from focusing on subjective norms and encouraging friends and family members to talk about the benefits of influenza vaccination.

The Role of Risk Perception in Flu Vaccine Behavior among African-American and White Adults in the United States.

Seasonal flu vaccination rates are low for U.S. adults, with significant disparities between African and white Americans. Risk perception is a significant predictor of vaccine behavior but the research on this construct has been flawed. This study addressed critical research questions to understand the differences between African and white Americans in the role of risk perception in flu vaccine behavior: (1) What is the dimensionality of risk perception and does it differ between the two races?  (2) Were risk perceptions of white and African-American populations different and how were sociodemographic characteristics related to risk for each group? (3) What is the relation between risk perception and flu vaccine behaviors for African Americans and whites? The sample, drawn from GfK's Knowledge Panel, consisted of 838 whites and 819 African Americans. The survey instrument was developed from qualitative research. Measures of risk perception included cognitive and emotional measures of disease risk and risk of side effects from the vaccine. The online survey was conducted in March 2015. Results showed the importance of risk perception in the vaccine decision-making process for both racial groups. As expected, those who got the vaccine reported higher disease risk than those who did not. Separate cognitive and emotional factors did not materialize in this study but strong evidence was found to support the importance of considering disease risk as well as risk of the vaccine. There were significant racial differences in the way risk perception predicted behavior.

The Symbolic Value and Limitations of Racial Concordance in Minority Research Engagement.

The well-documented underrepresentation of racial and ethnic minorities in research demands action. The field of health disparities research, however, lacks scientific consensus about how best to respectfully recruit underrepresented minority populations in research. We explore the investigators' perspective regarding how their own racial and ethnic background influenced their ability to recruit minorities, including (a) the influence of racial concordance ("race-matching") in research recruitment, (b) attributes and shared values important in the development of trust with minority communities, and (c) the role self-reflection plays in the development of meaningful research relationships. In 2010, we conducted in-depth, semi-structured, telephone interviews with investigators (N= 31) experienced with minority populations. Through the analysis of this coherent narrative, we uncovered both the symbolic and surface-level assumptions regarding minority recruitment to expose a deep structural understanding of race, ethnicity, and social context that is critical for bridging the true social difference between researchers and participants.

Improving health-related quality of life in older African American and non-Latino White patients.

OBJECTIVE: To compare the effect of problem-solving therapy against a health-promotion intervention (dietary practices) on health-related quality of life (HRQOL) and examine if there is a differential effect on non-Latino white patients and African American patients between the two interventions. This paper also explores participant characteristics (problem-solving style and physical functioning) as potential predictors of HRQOL. METHODS: Secondary analysis of data from a randomized depression prevention trial involving 247 older adults (154 non-Latino white, 90 African American, 3 Asian). Participants were randomly assigned to receive either problem solving therapy for primary care (PST-PC) or coaching in healthy dietary practices (DIET). RESULTS: Both PST-PC and DIET improved HRQOL over two years and did not differ significantly from each other. African American patients in both conditions had greater improvements in mental health-related quality of life (MHRQOL) compared with non-Latino white patients. In addition, higher social problem-solving and physical functioning were predictive of improved MHRQOL. CONCLUSION: PST-PC and DIET have the potential to improve health-related quality of life in a culturally relevant manner. Both hold promise as effective and potentially scalable interventions that could be generalized to highly disadvantaged populations in which little attention to HRQOL has been paid.

Trust during the early stages of the 2009 H1N1 pandemic.

Distrust of the government often stands in the way of cooperation with public health recommendations in a crisis. The purpose of this article is to describe the public's trust in government recommendations during the early stages of the H1N1 pandemic and to identify factors that might account for these trust levels. The authors surveyed 1,543 respondents about their experiences and attitudes related to H1N1 influenza between June 3, 2009, and July 6, 2009, during the first wave of the pandemic using the Knowledge Networks online panel. This panel is representative of the U.S. population and uses a combination of random digit dialing and address-based probability sampling frames covering 99% of the U.S. household population to recruit participants. To ensure participation of low-income individuals and those without Internet access, Knowledge Networks provides hardware and access to the Internet if needed. Measures included standard demographics, a trust scale, trust ratings for individual spokespersons, involvement with H1N1, experience with H1N1, and past discrimination in health care. The authors found that trust of government was low (2.3 out of 4) and varied across demographic groups. Blacks and Hispanics reported higher trust in government than did Whites. Of the spokespersons included, personal health professionals received the highest trust ratings and religious leaders the lowest. Attitudinal and experience variables predicted trust better than demographic characteristics. Closely following the news about the flu virus, having some self-reported knowledge about H1N1, self-reporting of local cases, and previously experiencing discrimination were the significant attitudinal and experience predictors of trust. Using a second longitudinal survey, trust in the early stages of the pandemic predicted vaccine acceptance later but only for White, non-Hispanic individuals.