Social media as a platform for health-related public debates and discussions: the Polio vaccine on Facebook

In March 2013, a type 1 wild Polio virus (WPV1) was found during routine environmental surveillance of the sewage system in a southern town in Israel¹ [32]. Epidemiological analysis showed that children under 9 years of age were the carriers and the main distributers of the virus [44].

Children in Israel are regularly vaccinated with Inactivated Poliovirus Vaccine (IPV) which protects them from developing Poliomyelitis but does not prevent them from becoming transmitters and spreading the disease if infected with the virus, nor from spreading the virus [43]. Older citizens of Israel received both the IPV and the live (attenuated) Oral Polio Vaccine (OPV), which were routinely given to all infants between 1990² and 2005 [44]. The WHO declared Israel Polio-free on June 21, 2002 [44]. The OPV was removed from routine vaccination and replaced by IPV, due to its better safety profile.³

Following the isolation of WPV1 from sewage samples in March 2013, on August 5, 2013 the Ministry of Health launched a vaccination campaign called “Two drops” targeted at children in southern Israel [24]. However, two weeks later, when analysis showed that the Polio virus had circulated more widely, the campaign was extended to the entire country [20]. OPV was only administered to children who had already been vaccinated with IPV. This additional vaccination was in fact meant to protect society more than the children themselves. In other words, OPV was added to prevent children from becoming carriers of WPV1 and from spreading the virus, or to promote herd immunity. Even though the scientific consensus which led to the recommendation to add OPV to young children’s vaccination routine was very solid [24, 26], this guideline sparked intense public debates and discussions, which were widely reviewed in the traditional as well as electronic mass media and in the social media⁴ including platforms such as Facebook, various online forums, and blogs.

By November 2013, Israel’s sewage samples all came back negative for wild Polio virus [26]. By January 2014, Israel’s official national campaign was over [20]. Overall, 945,000 children constituting 78.75 % of the target population were vaccinated with the OPV during the 2013 campaign [23]. By the end of the campaign, the Israeli Ministry of Health announced that the OPV would once again become the routine vaccination for children in Israel.⁵ Since the campaign was initiated, and to this day, there has not been a single case of Polio virus [24]. In April 2015, Israel was officially once again Polio-free, as declared by the World Health Organization.⁶

Scientific information is playing a growing role in the social media [30]. Numerous debate and discussion groups have emerged to address scientific topics [1, 13]. The reliance on social media is one of the newer uses of online resources more generally; as of 2014 the Internet surpassed television as Americans’ primary source of information about science and technology. Social media are also a rapidly expanding feature of online life: today, 65 % of American adults use social media [40]. Facebook is the most popular and frequently used social media platform among American 13 to 17 year olds, with 71 % of all teens using the platform [29]. Facebook had one billion daily active users on average in September 2015.⁷ Of these users, 700 million are members of Facebook groups [34].

As a result of this emergent association between science communication and social media, scientific magazines such as ‘Science’ and ‘PNAS’ have recently issued calls to better understand how online environments affect the communication of science information to the public. A number of researchers have drawn attention to the paucity of systematic empirical explorations of the ways in which the new media in general and social media in particular have changed the science communication landscape [6, 7]. It has been shown, for example, that people use Facebook as an information source for socio-scientific issues [16]. But how do people integrate online science resources into their decision- making and meaning- making processes?

In general, public participation in scientific issues, and public understanding of scientific information are essential to modern society. Public engagement with health-related information is even more so. In 2013, 59 % of all American adults searched for health information online and of these, 16 % looked for others who shared the same health concerns [14]. In France, almost half of all Web users aged 15–30 used the Internet for health purposes [3]. A recent paper exploring health information seeking in Europe showed that social media can act as a complementary source of information to traditional and online media [25]. Individuals who showed an inclination to use social media in conjunction with other channels considered it more important to be well informed, were more motivated to find additional information, and were more sensitive to risks in general [25]. In Israel, there are several online forums and social media outlets which support patients and people interested in health issues. One for example, is “Kamoni”, an online health forum where patients can find others with similar health problems and seek advice and consultation from experts. This forum is mainly oriented toward patients with chronic illnesses. In this paper, we show that in non-chronic situations as well, social media can act as a health information seeking and providing resource, in addition to a space for non-mediated debate, discussion, and support.

Internationally, social media have been found to play a profound role in health promotion [9, 37], where, unlike in Israel, other social media outlets, such as Twitter, are equally popular. For example, the Facebook and Twitter accounts of the Center for Disease Control (CDC) are comparable in terms of number of users (559,987 users for CDC official Facebook page vs. 645,121 followers for the CDC gov. Twitter account respectively).

In 2012, the journal ‘Vaccine’ devoted a special issue to the role of internet use in making vaccination decisions.⁸ The articles in that issue all stressed the potential of the social media to serve as an essential agent in influencing and shaping scientific and medical decisions [4].

In the Israeli context, the Israeli media 2013 report [31] indicated that the social media platform Facebook is the most widely used social media site in Israel, and spans users with diverse socio-economic backgrounds. In Israel, there are about 4 million Facebook users, 2.4 of whom check their Facebook account on a daily basis. Of these, 52 % are females. Many users are in the 18–24 age range (28 %), followed by the 25–34 (27 %), 35–44 (15 %), 13–17 (13 %), 45–54 (9 %), and 55 and over (about 9 %) age brackets [31].

Only a few scholarly papers have provided a thorough description of the contemporary social media landscape in Israel in the context of health and science communication [15, 20, 38]. However, documentation shows that 56 % of all online users in Israel read about a medical issue online before going to the doctor [31]. This article analyzes the role played by social media as a public platform in vaccination-related debates and discussions. We present data collected from the Israeli mainstream media and Facebook focusing on a specific content-driven group called “Parents talk about Polio vaccination”, the only diversified Facebook Polio-related group. The exploration of the texts submitted and shared by this particular group provides a unique opportunity to analyze authentic exchanges while the debates and discussions were ongoing. From this point on, when we use the term authentic, we mean that an authentic public voice is unmediated by the media or other political actors.

Our objectives were to map and describe the role played by social media and mainstream web-based media as platforms for vaccination-related public debates and discussions during the Polio crisis in Israel in 2013.

Two hundred and thirty-five Polio-related news items collected from seven mainstream popular media news sites (Ha’aretz, Israel Hayom, Mako, NRG, The Marker, Walla, and Ynet) primarily contained information sourced from the Ministry of Health (87 %), including interviews with officials and guidelines (for example: “The Ministry of Health has ordered a million Polio vaccinations”¹¹). The remainder (13 %) of the items did not voice formal positions, but rather expressed concerns and complex positions of individual parents, or pro-vaccination and positive opinions (for example: “The Polio vaccination: Now everyone is hesitating”¹²).

This longstanding anti-vaccination site (set up in 2010), declared itself to be “a reliable source of news and criticism about vaccinations and other health issues where the full truth is not being told”. The administrators of this page are practically all members of the previous group. This page was very active in the 2013 Polio crisis, and remains active to this day.

According to the third writer, one of the founders of the group, “Parents talk about the Polio vaccination”²¹ was set up on August 14, 2013. All the types of comments and commentators mentioned above in the anti-vaccination groups were present in this group as well, but the administrators and their goals were very different.

This group constituted the most diverse public debate and discussion platform in the 2013 Polio crisis context, since it included participants from different professional and socio-economic backgrounds. Thirty-one percent of the commentators wrote only one item, but 12 % of the commentators were frequent contributors (i.e. people who contributed over 10 items). Of the frequent contributors, 55 % (n = 22) were physicians, who provided answers to the public’s questions.

Much like the other Facebook groups reviewed above, this group proclaimed itself neutral; in other words it did not have an official position concerning the Polio vaccination or any other vaccination. But while the other groups in fact disseminated an anti-vaccination ideology, this group identified itself as an evidenced-based pro- science group.

This Facebook group was set up by parents, physicians, and science enthusiasts. These parents stated that their sole concern was the wellbeing of their children, and wanted to present the facts and the best action plan for all parents in Israel. For the members of the group, the site served as their platform for debating, discussing, and question-presenting. As the group grew in numbers (as of November 12, 2013, it had 1741 members), it included physicians from the private sector (pediatricians and epidemiologists) as well as officials from the Ministry of Health, parents, pro-vaccination and anti-vaccination advocates, all arguing their case for or against the Oral Polio Vaccine.

Figure 1 lists the number of posts in the group by date. The number of posts per day increased rapidly from the day the group was founded. This number peaked on August 21, with 109 daily posts (and their respective comments). From that day on, the number of posts per day slowly decreased until it reached a fixed level of a few (2-4) posts per day on November 12, 2013, the day we stopped collecting data. The data were collected continuously.

Most questions in the group were raised by concerned and skeptical parents, who primarily asked questions about their individual situation and personal issues. These questions were mainly answered by physicians and health administration officials, but also by other parents and sometimes even by anti-vaccination activists. According to the third author, who was one of the physicians who answered questions in the group (and also a co-founder and administrator of the group), they tackled misinformed opinions. They provided honest, reliable, and more importantly rapid information in a personalized manner.

This paper described the social media component of the public debates and discussions during the 2013 Polio vaccination crisis in Israel. The findings show that while most of the web-based traditional media assessed in this report echoed the formal positions of the Ministry of Health, the social media (i.e. Facebook) served as a platform for lay audiences to express their opinions about the campaign’s merits or perils, and to get advice from peers, experts and pseudo-experts.

Vaccination-related messages on social media are an emerging issue, which is attracting growing attention in the scientific literature [4, 22]. In this context, the role of social media in disseminating anti-science and specifically anti-vaccination messages is very alarming and troubling [21, 22]. The 2013 Polio vaccination debates and discussions were used in this paper as a case-study to better understand how vaccination-related messages on social media can be described.

The 2013 Polio crisis can be better understood when set in its wider social context. The Health Ministry’s decision to launch a campaign to vaccinate children with OPV came at a time when there was little trust in governmental decisions in general in comparison to other Western democracies, or Israel in earlier eras [18]. According to the “Israeli Democracy Index 2014”, in 2013 only 37 % of Israeli Jews trusted the government, and only 28.4 % had faith in the mainstream media. It is important to note that the Israeli population is inherently divided into many ethnic and religious groups, which have different cultural assumptions [18]. The data showed that the Jewish population in general did not trust politicians, and felt that the government was not doing a good job in handling Israel’s problems [18]. It was not possible to obtain similar data about other specific ethnic and religious groups in Israel. These findings are consistent with a longstanding European trend of public skepticism toward political and social decisions [42]. Notwithstanding that European trend, the status of science and medicine as social institutions in Israel remains relatively sound [39, 45, 49]. However, groups such as “Parents talk about the Polio vaccination” are an important arena for the public to voice their stances, regardless of the degree of trust they have in science and medical institutions.

Trust (or the lack there of) in the Ministry of Health was only one of five reasons voiced by parents who turned to anti-vaccination groups. The other four, according to our findings, were individualism, concerns about th This highlights a problematic feature of the e safety of the OPV, the idea that the Ministry of Health had simply purchased too much of the OPV, and has to “get rid” of it, and finally, denying the existence of Polio. The targeting of OPV shows that some of the opposing parents in the case of the 2013 Polio crisis were not categorically against any vaccination, as is the case for classic vaccination opponents [36], but were made up in part of people who vaccinated their children, but opposed the OPV specifically.

The media ecosystem in Israel is heterogeneous, rich and diverse. There are a number of popular mainstream media platforms (such as Ynet, Mako, etc.), many sectorial media platforms (such as “Be-hadrey Haredim”, which is directed to the ultra-orthodox religious Jewish sector), and numerous social media platforms including Facebook, as well as a range of forums and interactive blogs [31]. Types of online and mobile media are expanding and traditional media are rapidly transforming their activity to online and mobile platforms. Thus the traditional media are still a solid component of the Israeli media landscape. Nevertheless, the Israeli media tend to direct considerable attention to certain subjects, for a relatively short period of time, and then cease to give them any attention [31]. The 2013 Polio crisis in the Israeli media was exposed for a short period of time, and its coverage was lowered to a minimum. The “Google trends” search clearly showed that the issue of Polio and Polio vaccinations was almost non-existent in the traditional online news media, except during our sampling period.

Now that the mainstream media are no longer the sole channel of communication between the government, the medical profession, and the public, social media enable discussions involving new authentic voices. These can be useful for informing policy-making [17, 42, 50]. In the case of “Parents talk about the Polio vaccination” these voices were more diverse than those appearing in the mainstream media, but were not representative of the entire population e.g. the participants were 64 % women and more educated than the average population. The relatively high level of education of the participants may be the result of the fact that most participants did not reveal their education level publicly (66 %). It is possible that commentators without a higher education simply provided less information about this aspect of their lives. Nevertheless, it has been found that attitudes toward vaccination are not correlated with education [47].

The value of revealing different public opinions and directly communicating with audiences is independent of their representativeness [27]. While analysing a health related public debate and discussion on social media is by no means a replacement for a representative survey it does provide an unobtrusive, updated and authentic view of the range of public attitudes and their trends.²³ More importantly, social media health related public debates and discussions may provide a deliberative space for public and expert-public interactions.

Recent findings indicate that the Israeli public tend to put their trust in the government but choose not to comply with governmental instructions [48]. In our data, however, mistrust in the government was prevalent.

Social media have many advantages in comparison to mainstream media such as facilitating public participation in science and health communication [5, 28, 33, 50]. Also, as we have seen, social media hold the advantage of providing a platform for the public to debate, discuss, and voice their opinions and concerns. Nevertheless, social media clearly have negative aspects, most of which are true for traditional media too. One example is the uneven quality of information. The public, if exposed to misleading and biased information, will eventually develop trust problems and may choose not to follow formal medical advice [36].

Many questions remain unanswered. For example, is information or recommendations from accredited professionals treated differently by commentators than information or recommendations from lay people? Do groups such as ‘Parents talk about the Polio vaccination’, and social media in general, provide adequate tools to address vaccination opponents and conspiracy theories? How do the social media affect the decision to vaccinate? How can social media be harnessed to promote public health?

Further research is hence called for, to study what people actually learn in social media environments, what information and messages they remember and use for future reference, and the differences between those who are actively and passively engaged in social media debates and discussions.

The social media serve as an outlet for the public, a platform for expressing doubts, worries, and criticism of political, medical and social issues. The social media thus constitute active and versatile debate and discussion-facilitating platforms in the context of vaccination discussions.

The importance of this paper lies in the presentation of the authentic voices of the public which should be acknowledged as useful for policy making purposes. While this article presented the findings of a descriptive study, its conclusions and recommendations should be further tested empirically.

The traditional online media supported the Ministry of Health in the Polio crisis of 2013. This in turn led to responses from both opponents and supporters in the social media. The social media were, in fact, the actual locus of debates and discussions (and the battle for public opinion). Our findings suggest that there are authentic voices which strongly object to formal health stances and recommendations. It has recently been shown that if decision makers wish to create an authoritative atmosphere they must convey their message by exhibiting professionalism, building trust and offering to share information [10].

Decision makers need to be cognizant of the authentic public voices we explored, and find ways to change public opinion in those forums where debates and discussions actually take place. Decision makers and formal authorities need to invest resources and manpower in answering questions and countering typical anti-vaccination messages when they are most likely to influence public decisions.

CDC, Centers for Disease Control; IPV, inactivated poliovirus vaccine; OPV, oral polio vaccine; WPV1, type 1 wild polio virus