Social histories of public health misinformation and infodemics: case studies of four pandemics

Recognition of misinformation as a public health threat and interest in infodemics, defined as an inundation of information accompanying an epidemic or acute health event, have increased worldwide. However, scientists have no consensus on how to best define and identify misinformation and other essential characteristics of infodemics. We conducted a narrative review of secondary historical sources to examine previous infodemics in relation to four infectious diseases associated with pandemics (ie, smallpox, cholera, 1918 influenza, and HIV) and challenge the assumption that misinformation is a new phenomenon associated with increased use of social media or with the COVID-19 pandemic. On the contrary, we found that the spread of health misinformation has always been a public health challenge that has necessitated innovative solutions from medical and public health communities. We suggest expanding beyond the narrow scope of addressing misinformation to manage information ecosystems, defined as how people consume, produce, interact with, and behave around information, which include factors such as trust, stigma, and scientific literacy. Although misinformation can spread on a global scale, this holistic approach advocates for community-level interventions that improve relationships and trust between medical or public health entities and local populations.

Beyond misinformation: developing a public health prevention framework for managing information ecosystems

The COVID-19 pandemic has highlighted how infodemics (defined as an overabundance of information, including misinformation and disinformation) pose a threat to public health and could hinder individuals from making informed health decisions. Although public health authorities and other stakeholders have implemented measures for managing infodemics, existing frameworks for infodemic management have been primarily focused on responding to acute health emergencies rather than integrated in routine service delivery. We review the evidence and propose a framework for infodemic management that encompasses upstream strategies and provides guidance on identifying different interventions, informed by the four levels of prevention in public health: primary, secondary, tertiary, and primordial prevention. On the basis of a narrative review of 54 documents (peer-reviewed and grey literature published from 1961 to 2023), we present examples of interventions that belong to each level of prevention. Adopting this framework requires proactive prevention and response through managing information ecosystems, beyond reacting to misinformation or disinformation.

Strengthening COVID-19 vaccine confidence & demand during the US COVID-19 emergency response

In October 2020, the CDC's Vaccinate with Confidence strategy specific to COVID-19 vaccines rollout was published. Adapted from an existing vaccine confidence framework for childhood immunization, the Vaccinate with Confidence strategy for COVID-19 aimed to improve vaccine confidence, demand, and uptake of COVID-19 vaccines in the US. The objectives for COVID-19 were to 1. build trust, 2. empower healthcare personnel, and 3. engage communities and individuals. This strategy was implemented through a dedicated unit, the Vaccine Confidence and Demand (VCD) team, which collected behavioral insights; developed and disseminated toolkits and best practices in collaboration with partners; and collaborated with health departments and community-based organizations to engage communities and individuals in behavioral interventions to strengthen vaccine demand and increase COVID-19 vaccine uptake. The VCD team collected and used social and behavioral data through establishing the Insights Unit, implementing rapid community assessments, and conducting national surveys. To strengthen capacity at state and local levels, the VCD utilized "Bootcamps," a rapid training of trainers on vaccine confidence and demand, "Confidence Consults", where local leaders could request tailored advice to address local vaccine confidence challenges from subject matter experts, and utilized surge staffing to embed "Vaccine Demand Strategists" in state and local public health agencies. In addition, collaborations with Prevention Research Centers, the Institute of Museum and Library Services, and the American Psychological Association furthered work in behavioral science, community engagement, and health equity. The VCD team operationalized CDC's COVID-19 Vaccine with Confidence strategy through behavioral insights, capacity building opportunities, and collaborations to improve COVID-19 vaccine confidence, demand, and uptake in the US. The inclusion of applied behavioral science approaches were a critical component of the COVID-19 vaccination program and provides lessons learned for how behavioral science can be integrated in future emergency responses.

Sexual Risk Behaviors Among Persons Diagnosed With Primary and Secondary Syphilis Who Reported High-Risk Substance Use: Data From the National Notifiable Diseases Surveillance System, 2018

BACKGROUND

Recent increases in high-risk substance use (HRSU; i.e., injection drug use, heroin, methamphetamine, crack/cocaine) have coincided with rising primary and secondary (P&S) syphilis rates. To further understand these trends, we examined sexual risk behaviors among women, men who have sex with women only (MSW), and men who have sex with men (MSM) who were diagnosed with P&S syphilis in 2018 and reported HRSU.

METHODS

Data on HRSU and sexual risk behaviors among persons with P&S syphilis were drawn from syphilis case reports in 2018 from the National Notifiable Diseases Surveillance System. Persons with P&S syphilis were asked about sexual risk behaviors in the past 12 months including exchange sex for drugs/money, sex while intoxicated and/or high on drugs, sex with a person who injects drugs (PWID), sex with an anonymous partner, and number of sex partners. We describe percentages and adjusted prevalence ratios (aPRs) for women, MSW, and MSM reporting these behaviors by age, race/Hispanic ethnicity, type of drug used, and incarceration history (both in the past 12 months).

RESULTS

Among 19,634 persons diagnosed with P&S syphilis in 2018 with information on HRSU, 29.3% of women, 22.7% of MSW, and 12.4% of MSM reported HRSU. Among those reporting HRSU, percentages reporting exchange sex ranged from 17% to 35% (highest for women), whereas reports of anonymous sex ranged from 44% to 71% (highest for MSM). In this population, sexual risk behaviors were more commonly reported among those with a recent incarceration history than those without such history. Among those reporting injection drug use or heroin use, percentages reporting sex with a PWID ranged from 51% to 77%. In adjusted models, HRSU was significantly associated with one or more sexual risk behaviors for women (aPR, 2.63 [95% confidence interval {CI}, 2.39-2.90]; MSW: aPR, 1.38 [95% CI, 1.31-1.46]; and MSM: aPR, 1.30 [95% CI, 1.26-1.34]).

CONCLUSIONS

Collaborative partnerships across the US public health system could help address barriers to timely clinical care among persons diagnosed with P&S syphilis who report HRSU.

COVID-19 Vaccination Coverage, Intent, Knowledge, Attitudes, and Beliefs among Essential Workers, United States

We assessed coronavirus disease vaccination and intent and knowledge, attitudes, and beliefs among essential workers during March-June 2021. Coverage was 67%; 18% reported no intent to get vaccinated. Primary concerns were potential side effects, safety, and lack of trust in vaccines, highlighting the importance of increasing vaccine confidence in this population.

Sexual History Taking in Clinical Settings: A Narrative Review

BACKGROUND

This study aimed to explore gaps between Centers for Disease Control and Prevention's clinical guidelines for obtaining a sexual history and regular clinical practice. We examine how patient, provider, and setting characteristics may influence the likelihood of obtaining comprehensive sexual histories and examine patient outcomes linked to sexual history taking.

METHODS

We performed a narrative review to identify studies that examined clinical practice and sexual history taking via 8 databases. A 2-level inclusion protocol was followed, wherein the abstract and full text of the article were reviewed, respectively. Data were abstracted using a standardized tool developed for this study.

RESULTS

The search yielded 2700 unique studies, of which 2193 were excluded in level 1, and 497 were excluded in level 2, leaving 10 studies for data abstraction. None of the studies reported comprehensive sexual history taking, and 8 studies reported differences in how providers obtain a sexual history when patient and provider demographics are considered. Three studies found a positive link between providers who discuss sexual history and provider sexually transmitted disease testing.

CONCLUSIONS

When sexual histories are obtained, they are not comprehensive, and providers may discuss sexual history differentially based on patients' demographic characteristics. Providers who discuss patients' sexual history may be more likely to also provide sexual health preventive care.

Demographic and Social Factors Associated with COVID-19 Vaccination Initiation Among Adults Aged ≥65 Years - United States, December 14, 2020-April 10, 2021

Compared with other age groups, older adults (defined here as persons aged ≥65 years) are at higher risk for COVID-19-associated morbidity and mortality and have therefore been prioritized for COVID-19 vaccination (1,2). Ensuring access to vaccines for older adults has been a focus of federal, state, and local response efforts, and CDC has been monitoring vaccination coverage to identify and address disparities among subpopulations of older adults (2). Vaccine administration data submitted to CDC were analyzed to determine the prevalence of COVID-19 vaccination initiation among adults aged ≥65 years by demographic characteristics and overall. Characteristics of counties with low vaccination initiation rates were quantified using indicators of social vulnerability data from the 2019 American Community Survey.* During December 14, 2020-April 10, 2021, nationwide, a total of 42,736,710 (79.1%) older adults had initiated vaccination. The initiation rate was higher among men than among women and varied by state. On average, counties with low vaccination initiation rates (<50% of older adults having received at least 1 vaccine dose), compared with those with high rates (≥75%), had higher percentages of older adults without a computer, living in poverty, without Internet access, and living alone. CDC, state, and local jurisdictions in partnerships with communities should continue to identify and implement strategies to improve access to COVID-19 vaccination for older adults, such as assistance with scheduling vaccination appointments and transportation to vaccination sites, or vaccination at home if needed for persons who are homebound.† Monitoring demographic and social factors affecting COVID-19 vaccine access for older adults and prioritizing efforts to ensure equitable access to COVID-19 vaccine are needed to ensure high coverage among this group.

Prescription Opioid Misuse and Use of Alcohol and Other Substances Among High School Students - Youth Risk Behavior Survey, United States, 2019

Adolescence is an important period of risk for substance use initiation and substance use-related adverse outcomes. To examine youth substance use trends and patterns, CDC analyzed data from the 2009-2019 Youth Risk Behavior Survey. This report presents estimated prevalence of current (i.e., previous 30-days) marijuana use, prescription opioid misuse, alcohol use, and binge drinking and lifetime prevalence of marijuana, synthetic marijuana, cocaine, methamphetamine, heroin, injection drug use, and prescription opioid misuse among U.S. high school students. Logistic regression and Joinpoint analyses were used to assess 2009-2019 trends. Prevalence of current and lifetime substance use by demographics, frequency of use, and prevalence of co-occurrence of selected substances among students reporting current prescription opioid misuse are estimated using 2019 data. Multivariable logistic regression analysis was used to determine demographic and substance use correlates of current prescription opioid misuse. Current alcohol, lifetime cocaine, methamphetamine, heroin, and injection drug use decreased during 2009-2019. Lifetime use of synthetic marijuana (also called synthetic cannabinoids) decreased during 2015-2019. Lifetime marijuana use increased during 2009-2013 and then decreased during 2013-2019. In 2019, 29.2% reported current alcohol use, 21.7% current marijuana use, 13.7% current binge drinking, and 7.2% current prescription opioid misuse. Substance use varied by sex, race/ethnicity, grade, and sexual minority status (lesbian, gay, or bisexual). Use of other substances, particularly current use of alcohol (59.4%) and marijuana (43.5%), was common among students currently misusing prescription opioids. Findings highlight opportunities for expanding evidence-based prevention policies, programs, and practices that aim to reduce risk factors and strengthen protective factors related to youth substance use, in conjunction with ongoing initiatives for combating the opioid crisis.

Sexual risk behaviors and STDs among persons who inject drugs: A national study

Opioid use and the rising case reports of STDs represent co-occurring epidemics; research indicates that persons who inject drugs (PWID) may be at increased risk for acquiring STDs. We use the National Survey of Family Growth (NSFG, 2011-2015) to examine the prevalence of risky sexual behaviors and STD diagnoses among PWID. We describe demographic characteristics, sexual behaviors, and self-reported STD diagnoses of sexually active women and men, separately, by whether they had ever engaged in injection-related behaviors (age 15-44; N = 9006 women, N = 7210 men). Results indicate that in 2011-15, 1.4% of women and 2.6% of men reported ever engaging in injection-related behaviors. Examining the full logistic regression models indicate that for women, sex with a PWID in the past 12 months (AOR = 5.8, 95% CI: 2.9, 11.7), exchanging money/drugs for sex in the past 12 months (AOR = 3.6, 95% CI: 1.2, 10.9), chlamydia and/or gonorrhea diagnosis in the past 12 months (AOR = 2.6, 95% CI: 1.2, 5.3), ever having a syphilis diagnosis (AOR = 8.5, 95% CI: 3.1, 23.4), and ever having a herpes diagnosis (AOR = 3.3, 95% CI: 1.0, 10.3) were associated with increased odds of engaging in injection-related behaviors. For men, sex with a PWID in the past 12 months (AOR = 10.9, 95% CI: 4.3, 27.7), ever being diagnosed with syphilis (AOR = 5.8, 95% CI: 1.8, 18.0), and ever being diagnosed with herpes (AOR = 2.7, 95% CI: 1.0, 7.1) were significantly associated with increased odds of engaging in injection-related behaviors. Future research may examine critical intervention points, including co-occurring factors in both STD acquisition and injection drug use.

Chronic immune barrier dysregulation among women with a history of violence victimization

We explored the association between violence victimization and increased risk for acquiring sexually transmitted infections (STIs) in women by measuring cellular immune barrier properties from the female reproductive tract. STI-negative participants reporting repeated prior victimization occurrences through the lifetime trauma and victimization history (LTVH) instrument were more likely to exhibit alterations in barrier homeostasis and the composition of critical immune mediators irrespective of demographic parameters or presence of bacterial vaginosis. By combining cellular data with mixed-effect linear modeling, we uncovered differences in local T cells, MHCII+ antigen-presenting cells, and epithelial cells indicative of altered trafficking behavior, increased immunosuppressive function, and decreased barrier integrity at sites of STI exposure that correlate most strongly with LTVH score. These data evidence a biological link between a history of violence victimization and risk of STI acquisition through immune dysregulation in the female reproductive tract.

Chronic immune barrier dysregulation among women with a history of violence victimization

We explored the association between violence victimization and increased risk for acquiring sexually transmitted infections (STI) in women by measuring cellular immune barrier properties from the female reproductive tract (FRT). STI-negative participants reporting repeated prior victimization occurrences through the lifetime trauma and victimization history (LTVH) instrument were more likely to exhibit alterations in barrier homeostasis and the composition of critical immune mediators irrespective of demographic parameters or presence of bacterial vaginosis. By combining cellular data with mixed-effect linear modeling, we uncovered differences in local T cells, MHCII+ antigen presenting cells, and epithelial cells indicative of altered trafficking behavior, increased immunosuppressive function, and decreased barrier integrity at sites of STI exposure that correlate with LTVH score. These data evidence a biological link between a history of violence victimization and risk of STI acquisition through immune dysregulation in the female reproductive tract.

Understanding the Effects of Forced Sex on Sexually Transmitted Disease Acquisition and Sexually Transmitted Disease Care: Findings From the National Survey of Family Growth (2011-2013)

BACKGROUND

Although there is evidence for heightened sexually transmitted disease (STD) acquisition among women who experienced sexual violence, little is known about their patterns of STD testing, STD diagnosis, and STD treatment.

METHODS

Data was drawn from cycle eight of the National Survey of Family Growth (2011-2013). Logistic regression analyses used SUDAAN to examine the link between forced sex and risky sexual behavior as well as forced sex and STD testing, diagnoses, treatment, and connection to care.

RESULTS

Women who experienced forced sex were more likely to have risky sex (adjusted odds ratio [AOR], 1.56; 95% confidence interval [CI], 1.08-2.24), risky partners (AOR, 1.90; 95% CI, 1.11-3.23), and report substance abuse (AOR, 1.80; 95% CI, 1.28-2.53) than women who never experienced forced sex. Women who reported forced sex were more likely to be tested for an STD (AOR, 1.67; 95% CI, 1.34-2.09), and be diagnosed with herpes (AOR, 1.94; 95% CI, 1.13-3.32), genital warts (AOR, 2.55; 95% CI, 1.90-3.41), and chlamydia (AOR, 1.83; 95% CI, 1.03-3.25) than those who have never had forced sex. Results indicated a direct relationship between particular STD diagnoses and treatment in the past 12 months (AOR, 6.81; 95% CI, 4.50-10.31). Further analyses indicate that forced sex moderated the link between STD diagnoses and STD treatment (AOR, 0.43; 95% CI, 0.19-0.98).

CONCLUSIONS

Results indicate that women who reported experiencing forced sex were more likely to be diagnosed with chlamydia, herpes, and genital warts than women who never had forced sex. There may be a need to pay particular attention to women who experienced forced sex and a history of STDs to ensure that they are retained in care.

Sexual Violence Against Female and Male Children in the United Republic of Tanzania

During a household survey in Tanzania, a nationally representative sample of females and males aged 13-24 years reported any experiences of sexual violence that occurred before the age of 18 years. The authors explore the prevalence, circumstances, and health outcomes associated with childhood sexual violence. The results suggest that violence against children in Tanzania is pervasive, with roughly three in 10 females and one in eight males experiencing some form of childhood sexual violence, and its health consequences are severe. Results are being used by the Tanzanian government to implement a National Plan of Action.

Gender Role Discrepancy Stress, High-Risk Sexual Behavior, and Sexually Transmitted Disease

Nearly 20 million new sexually transmitted infections occur every year in the United States. Traditionally, men have demonstrated much greater risk for contraction of and mortality from STDs perhaps because they tend to engage in a number of risky sexual activities. Research on masculinity suggests that gender roles influence males' sexual health by encouraging risk-taking behavior, discouraging access to health services, and narrowly defining their roles as partners. However, despite the propensity of highly masculine men to engage in high-risk sexual behavior, there is reason to suspect that men at the other end of the continuum may still be driven to engage in similar high-risk behaviors as a consequence of gender socialization. Discrepancy stress is a form of gender role stress that occurs when men fail to live up to the ideal manhood derived from societal prescriptions (i.e., Gender Role Discrepancy). In the present study, we surveyed a national sample of 600 men via Amazon Mechanical Turk to assess perceived gender role discrepancy, experience of discrepancy stress, and the associations with risky sexual behavior and potential contraction of STDs. Results indicated that men who believe they are less masculine than the typical man (i.e., gender role discrepancy) and experience distress stemming from this discrepancy (i.e., discrepancy stress) engage in high-risk sexual behavior and are subsequently diagnosed with more STDs. Findings are discussed in relation to implications for primary prevention strategies.

A systematic qualitative review of risk and protective factors for sexual violence perpetration

The current review summarized results of 191 published empirical studies that examined the risk and protective factors for sexual violence perpetration. Studies in the review examined factors for perpetration by and against adolescents and adults, by male and female perpetrators, and by those who offended against individuals of the same sex or opposite sex. Factors associated with child sexual abuse (CSA) perpetration were not included. In all, 2 societal and community factors, 23 relationship factors, and 42 individual-level factors were identified. Of these 67 factors, consistent significant support for their association with SV was found for 35, nonsignificant effects were found for 10, 7 factors had limited or sample-specific evidence that they were associated with SV but were in need of further study, and 15 demonstrated mixed results. The factors identified in the review underscore the need for comprehensive prevention programs that target multiple risk and protective factors as well as factors that occur across the social ecology. Moreover, we identified two domains of factors--the presence and acceptance of violence and unhealthy sexual behaviors, experiences, or attitudes--that had consistent significant associations with SV but are not typically addressed in prevention programs. Therefore, SV prevention may also benefit from learning from effective strategies in other areas of public health, namely sexual health and youth violence prevention.

Schools, parents, and youth violence: a multilevel, ecological analysis

Using data from the National Longitudinal Study of Adolescent Health (Add Health), this study utilized an ecological approach to investigate the joint contribution of parents and schools on changes in violent behavior over time among a sample of 6,397 students (54% female) from 125 schools. This study examined the main and interactive effects of parent and school connectedness as buffers of violent behavior within a hierarchical linear model, focusing on both students and schools as the unit of analysis. Results show that students who feel more connected to their schools demonstrate reductions in violent behavior over time. On the school level, our findings suggest that school climate serves as a protective factor for student violent behavior. Finally, parent and school connectedness appear to work together to buffer adolescents from the effects of violence exposure on subsequent violent behavior.

The social context of adolescent suicide attempts: interactive effects of parent, peer, and school social relations

An ecological developmental model of adolescent suicidality was used to inform a hierarchical logistic regression analysis of longitudinal interactions between parent, peer, and school relations and suicide attempts. Reanalyzing data from the National Longitudinal Study of Adolescent Health, it was found that parent relations were the most consistent protective factor, and among boys with prior suicide attempts, school relations augmented the effects of parent relations when peer relations were low. Results indicated the need to understand suicidal behavior as a component of interactive social processes in the design of clinical interventions.

Adolescents who witness community violence: can parent support and prosocial cognitions protect them from committing violence?

This longitudinal study investigated the effects of witnessing violence on committing violence among diverse urban middle school students (11-15 years old) over a 1-year period (N = 1,599). It examined parent support and prosocial cognitions as moderators that might interact with one another in buffering adolescents from the effects of witnessing violence. The study also explored gender and ethnicity differences across these protective processes. According to the results, both average and high levels of parent support may offer male adolescents who witness violence protection against committing subsequent acts of violence. Adolescent females who witness violence appear to be uniquely protected from committing acts of violence if they have highly prosocial cognitions. Applications to resilience and competency models are discussed.

Weapon violence in adolescence: parent and school connectedness as protective factors

PURPOSE

Using data from the National Longitudinal Study of Adolescent Health (Add Health), we investigated weapon violence involving violence exposure and commission, as well as the protective roles of parent and school connectedness over time.

METHODS

Adolescents from Add Health's core sample (N = 7033) were followed for one year over two waves of measurement.

RESULTS

Consistent with hypotheses, violence exposure and violence commission uniquely predicted each other over time. Also, adolescents who were more connected with their parents were less likely to commit weapon violence over time, and adolescents who were more connected to school were less likely to be exposed to weapon violence over time. However, neither domain of connectedness buffered adolescents from the effects of violence exposure on committing violence. Further, parent and school connectedness seemed to have more power as preventive rather than as mitigating factors in relation to weapon violence.

CONCLUSION

Further research using a broader array of violence measures may reveal additional processes through which protective factors can help sever the link between weapon violence exposure and commission.

Supportive relationships and sexual risk behavior in adolescence: an ecological-transactional approach

OBJECTIVE

To examine the longitudinal associations between supportive relationships with friends and parents and sexual risk behavior in adolescence based on an ecological-transactional perspective.

METHODS

Analyses were conducted on 2,652 sexually active adolescents from the first two waves of the National Longitudinal Study of Adolescent Health (Add Health).

RESULTS

African-American adolescents had lower risk for sexual risk behavior. Supportive friendships and parent connectedness interacted in predicting decreased likelihood of sexual risk behavior. Mother-child communication about sex contributed to decreased likelihood of sexual risk only for girls. There were also small reciprocal effects of sexual risk behavior on decreased relationship quality over time.

CONCLUSION

To better understand the parents' role in adolescent sexual risk behavior, multiple facets of parenting, the social contexts of parenting and adolescents' peers, and the effects of adolescents' behavior on these relationships should be taken into consideration.