Introduction
The study of misinformation and disinformation and how to counter them is not new. There are centuries-old examples of the challenges in rebutting misleading or manipulative information [1-3]. However, although false and manipulative media are not new, “the digital age has changed how such messages are created, circulated, and interpreted, as well as their potential effects” [4]. As features of the COVID-19 media ecosystem, misinformation and disinformation are functionally similar, in that both either contradict or distort the current scientific and public health consensus as to the nature of the virus and appropriate steps to combat it [5,6]. However, the 2 terms refer to separate phenomena insofar as concerns motive. “Misinformation” is unintentionally inaccurate, while “disinformation,” is intentionally inaccurate and meant to mislead [7]. In the context of public health, the term “infodemic” was coined to refer to “an overflow of information of varying quality that surges across digital and physical environments during an acute public health event” [8]. Infodemiology, as a field of study and intervention, dates back to 1996 [9,10]. Eysenbach defines infodemiology as the “science of distribution and determinants of information in an electronic medium, specifically the Internet, or in a population, with the ultimate aim to inform public health and public policy” [9]. As Eysenbach describes it, infodemiology rests on the premise that public health and patterns of communication are correlated, and perhaps even causally connected.
Since the pandemic’s beginning, a variety of COVID-19-related misinformation and disinformation has spread and been amplified online [11]. The content and spread of misinformation can influence COVID-19 beliefs and protective actions [12,13]. Despite the availability of the COVID-19 vaccine in the United States, hesitancy among the general population remains a challenge. In their review of 39 nationally representative polls taken in the first half of 2021, Steelfisher et al [14] found that nearly 30% of the population remains hesitant to get the COVID-19 vaccine. Belief in vaccine misinformation is associated with lower vaccination rates and higher vaccine resistance [15]. The spread of misinformation and disinformation online can increase COVID-19 vaccine hesitancy [16]. Studies conducted at varying time points in 2020 have found that reliance on social media is associated with higher levels of holding both conspiracy beliefs and higher levels of vaccine hesitancy [17-20].
Studies of how to address the current infodemic are nascent. The inaugural World Health Organization (WHO) Infodemiology Conference of 2021 called for more research on interventions to address the infodemic [11]. Countering misinformation is a critical piece of infodemic management because misinformation impacts protective actions and vaccine hesitancy. Infodemiology research has shown that quality health information can be elusive to the public, especially in evolving situations, such as a pandemic [21]. One common approach used by public health risk communicators focuses on “facts.” However, as Eysenbach [21] points out, in times of evolving science, factual information can be hard to determine, and initial reports and decisions are made based on the best information available at any given time. Currently, the most common approach to countering misinformation is to engage in fact checking. Research evaluating the utility of online fact checking suggests that even under less uncertain conditions, it remains an uneven but relatively effective counterstrategy to disinformation [22-26]. However, fact checking carries with it 2 challenges: asymmetry and volume. Feelings of social ostracism are shown to decrease receptivity to counter disinformation fact checking [27]. Media consumers with less overall political knowledge are likewise less receptive, as are political conservatives more generally [28]. Meanwhile, the sheer volume with which bad actors are increasingly equipped to “flood the zone” with mis- and disinformation [29] can exhaust most audience’s ability to sift good information from bad, apart from more formal, time-and-resource-intensive fact-checking projects. Human moderators cannot match the speed and volume of false information and, furthermore, require an ever-changing range of subject expertise that content moderators cannot reasonably be expected to acquire [30,31]. Studies into the relative efficacy of logic-based versus emotionally based public health communication have suggested that the use of narrative [32-34], appeals to values [35,36], and rhetoric of personal, lived experience [37-39] yield better persuasive outcomes than more abstract, fact-based, or logical counterparts. Per Maertens et al [40], this might relate to the “broad spectrum” of potential viewpoints that such approaches address. That is, fact checking’s narrower focus on specific content addresses fewer points of persuasive vulnerability than a broader focus on form offered by rhetoric, narrative, and values.
Attitudinal inoculation (or, simply, “inoculation”) is a preventative approach to combating misinformation and disinformation that leverages the power of narrative, rhetoric, values, and emotion. Inoculation theory promises that people can become resistant to persuasion if they perceive a threat from an attempt to change their beliefs or attitudes and if they receive information to refute this attempt [41]. It originates in the midcentury work of William McGuire [41-43]. It uses the biological metaphor of viral inoculation to propose that “[t]hrough exposing individuals to messages containing a weakened argument against an attitude they hold, it is possible to ‘inoculate’ the individuals against future attacks on the attitude” [44]. Inoculation consists of exposing someone to a persuasive message that contains weakened arguments against an established attitude, which develops resistance against stronger persuasive attacks in the future [41].
Inoculation is preemptive, addressing audiences holding “healthy (ie, preferred) positions,” or agnostic and undecided [45]. It scales against the “flooded zone” of information, allowing individuals to bypass entire categories of misleading, manipulative, or simply distracting information. Inoculation is suited to address the needs of low-information audiences, ideologically polarized and conspiratorial groups, and groups that are traditionally difficult audiences to reach with corrections [46]. Inoculation may partially overcome the post hoc correction challenges of asymmetry and volume, while accounting for variations in the efficacy of fact-based versus narrative/rhetoric-based approaches.
Studies have supported the effectiveness of attitudinal inoculation as a tool for strengthening resistance to persuasion on public health topics, such as underage alcohol consumption, adolescent smoking initiation, deceptive nutrition-related food claims, unprotected sex, and child vaccine safety claims [47,48]. Additionally, attitudinal inoculation has been shown as an effective strategy for counterradicalization. In a foundational study, inoculation conferred resistance to persuasion by far-right and far-left extremist propaganda by reducing the credibility of the extremist groups that produced the propaganda and increasing reactance (the combination of anger and counterarguing) against the propaganda itself. By reducing source credibility and increasing reactance, inoculation ultimately reduced participant intentions to support the group that produced the propaganda [49].
The potential for attitudinal inoculation to combat COVID-19 vaccine misinformation was proposed by van der Linden et al [50]. Although attitudinal inoculation enjoys a rich body of literature, and infodemiology likewise can claim extensive source material, the specific application of both approaches to the crisis of the COVID-19 pandemic is scant at best. This study is among the first to answer the call made by van der Linden et al [50]. It not only sought to test the effectiveness of attitudinal inoculation against COVID-19 misinformation and disinformation but also attempted to address questions relating to persuasive communication, which bear direct relevance to the matter of public health communication in the pandemic. As described before, the relative efficacy of fact versus narrative or rhetoric in persuasive messaging has been studied across many dimensions of public health. Our study testing the use of video-based attitudinal inoculation to inoculate viewers against misinformation on COVID-19 vaccine injury is the first of its kind to compare the effectiveness of using facts versus narrative-rhetoric approaches to attitudinal inoculation messages relating to COVID-19 vaccine misinformation and disinformation. The goal of our research was to build upon the work of Braddock, van der Linden, and other inoculation theorists by using inoculation messages in the form of short video messages to promote resistance against persuasion by COVID-19 vaccine misinformation.
Methods
Identification of Antivax Narratives
This study was built upon our formative evaluation work that identified common rhetorical strategies and COVID-19 vaccine misinformation narratives and used formative surveys to explore their prevalence and validate select survey items that were used in this study [20,51,52]. The narratives were identified by analyzing 6 months of content from 10 online channels of antivaccine or COVID-19 denialist propaganda. These took the form of Twitter accounts, amateur videos, documentaries, Facebook groups, blogs, and Instagram pages. From these media sources, we created a list of 22 key narrative tropes and 16 rhetorical strategies, which represented the discursive foundation of the antivaccine and COVID-19 denialist media data collected, and created a codebook [53]. Narratives ranged from general claims that the COVID-19 vaccine could cause physical injury to the theory it was a bioweapon promoted by intelligence agencies for shadowy and perhaps even supernatural purposes. Some rhetorics framed their arguments along the lines of bodily autonomy by co-opting the language of women’s reproductive rights, while others relied on audio-visual cues, such as nauseating colors and low-frequency sounds, to cue unease in their audience.
Development of Inoculation Messages
Based on the identification of the antivax narratives, we selected a prominent metanarrative related to vaccine injury that was used to develop 3 different inoculation messages: (1) a fact-based video, focused on countering false statistics about the science and safety of vaccines; (2) a narrative and rhetoric-focused video, which “prebunked” (ie, practice of
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Details
; Su, Max
; Hughes, Brian
; Testa, Marcia
; Goldberg, Beth
; Braddock, Kurt
; Miller-Idriss, Cynthia
; Maturo, Vanessa
; Savoia, Elena