title: Associations Between Exposure to and Expression of Negative Opinions About Human Papillomavirus Vaccines on Social Media: An Observational Study.
abstract: BACKGROUND
  Groups and individuals that seek to negatively influence public opinion about the safety and value of vaccination are active in online and social media and may influence decision making within some communities.
  
  
  OBJECTIVE
  We sought to measure whether exposure to negative opinions about human papillomavirus (HPV) vaccines in Twitter communities is associated with the subsequent expression of negative opinions by explicitly measuring potential information exposure over the social structure of Twitter communities.
  
  
  METHODS
  We hypothesized that prior exposure to opinions rejecting the safety or value of HPV vaccines would be associated with an increased risk of posting similar opinions and tested this hypothesis by analyzing temporal sequences of messages posted on Twitter (tweets). The study design was a retrospective analysis of tweets related to HPV vaccines and the social connections between users. Between October 2013 and April 2014, we collected 83,551 English-language tweets that included terms related to HPV vaccines and the 957,865 social connections among 30,621 users posting or reposting the tweets. Tweets were classified as expressing negative or neutral/positive opinions using a machine learning classifier previously trained on a manually labeled sample.
  
  
  RESULTS
  During the 6-month period, 25.13% (20,994/83,551) of tweets were classified as negative; among the 30,621 users that tweeted about HPV vaccines, 9046 (29.54%) were exposed to a majority of negative tweets. The likelihood of a user posting a negative tweet after exposure to a majority of negative opinions was 37.78% (2780/7361) compared to 10.92% (1234/11,296) for users who were exposed to a majority of positive and neutral tweets corresponding to a relative risk of 3.46 (95% CI 3.25-3.67, P<.001).
  
  
  CONCLUSIONS
  The heterogeneous community structure on Twitter appears to skew the information to which users are exposed in relation to HPV vaccines. We found that among users that tweeted about HPV vaccines, those who were more often exposed to negative opinions were more likely to subsequently post negative opinions. Although this research may be useful for identifying individuals and groups currently at risk of disproportionate exposure to misinformation about HPV vaccines, there is a clear need for studies capable of determining the factors that affect the formation and adoption of beliefs about public health interventions.
authors.affiliation: Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia. adam.dunn@mq.edu.au.
authors.forename: Adam G
authors.identifier: http://orcid.org/0000-0002-1720-8209
authors.initials: AG
authors.lastname: Dunn
authors.forename: Julie
authors.identifier: http://orcid.org/0000-0001-5095-1443
authors.initials: J
authors.lastname: Leask
authors.forename: Xujuan
authors.identifier: http://orcid.org/0000-0002-1736-739X
authors.initials: X
authors.lastname: Zhou
authors.forename: Kenneth D
authors.identifier: http://orcid.org/0000-0002-9781-0477
authors.initials: KD
authors.lastname: Mandl
authors.forename: Enrico
authors.identifier: http://orcid.org/0000-0002-6444-6584
authors.initials: E
authors.lastname: Coiera
mesh_terms: D001294:Attitude to Health; D006801:Humans; D053918:Papillomavirus Vaccines; D011634:Public Health; D011639:Public Opinion; D012189:Retrospective Studies; D061108:Social Media; D060756:Social Networking
chemical_list: D053918:Papillomavirus Vaccines
keywords: HPV vaccines; Twitter messaging; public health surveillance; social media; social networks