To understand public health organization perspectives this study created a stratified sample of (1) individuals that were public health practitioners with a range of experience using social media, from those who were very active online to those who rarely or never used social media in their professional role; (2) individuals with known social media presence in the area of public health; and (3) individuals with research or practice expertise in the area of trust-building and social media for public health. The research team solicited names of potential interviewees from our Centers for Disease Control and Prevention project officer, the Public Good Projects and Public Health AmeriCorps project partners and from recent webinars or panels on public health communication and trust (e.g., ABIM Foundation’s Trust Building Initiative webinar series²⁰). Overall, 42 individuals were invited to participate via email, which was hypothesized to be a sufficient sample size to achieve saturation across strata.²²

Thirty-one of these individuals were interviewed. Thirteen participants were state or local public health practitioners, representing 10 US states (from across all four census regions). Twelve were subject matter experts on the topics of trust, public health communication, and the public health workforce, some of whom also had on-the-ground experience utilizing social-media for public health communication and trust-building. The remaining six interview participants were federal public health practitioners in communications roles.

Interviews were conducted via Microsoft Teams between March and May 2023. A semi-structured interview guide was used to ask about participants’ experiences with using social media in their work, particularly during public health emergencies. The interview guide included questions on the extent of their experience using social media to communicate about public health and barriers to effective online public health engagement and trust-building. Content of the interview guide was informed by a literature review and environmental scan on how social media interactions shape trustworthiness of public health science and officials. Questions on barriers to use were also informed by the Consolidated Framework for Implementation Research (CFIR). ²¹ After obtaining verbal consent from the interview participant, interviews were conducted in pairs, with one team member leading the interview while the other took detailed notes. Interviews lasted approximately 45 minutes.

A rapid thematic analysis²³ was conducted using a deductive approach to synthesize interview findings. Study team members abstracted summaries from the detailed interview notes into an Excel matrix, with direct quotations documented when relevant. Each row in the matrix represented a respondent, and each column corresponded to an interview question. Within cells, responses were further divided inductively into thematic subcategories to facilitate further analysis. We did not conduct formal double coding or inter-rater reliability tests as these steps are not typically part of rapid thematic analyses. The study team then reviewed the matrix to identify common themes across respondents, with a focus on barriers to using social media for trust-building. After reviewing all barriers that were identified, the team agreed on the socio-ecological model as an emergent organizing framework. ²⁴

RAND’s Human Subjects Protection Committee approved this study (2022-N0520).

Participants identified several barriers to social media trust-building at the individual level. One of the most mentioned barriers was a lack of time. Participants explained that competing public health priorities, especially during a crisis, limit the time that practitioners can spend using social media and staying up to date on the latest social media strategies, platforms, and trending topics. One participant described how practitioners often think, “I have to handle the issue [i.e., the public health emergency], why would I be on social media?” Participants also reported that public health practitioners lack training on how to use social media, employ culturally sensitive communication strategies, and translate complex science to a lay audience. For example, one practitioner noted that social media training is often only provided to communications teams, so staff on the epidemiology or nursing teams will defer to the communications team to engage on social media and not pick up the skills or gain experience themselves. Relatedly, participants mentioned a dearth of ready-made social media communications materials for public health practitioners such as social media toolkits. As one local practitioner described,

Several participants indicated that public practitioners were uncertain whether the time spent to learn and use social media would produce proportional benefits for trust-building, essentially – wondering whether “the juice would be worth the squeeze.” However, participants who were actively engaged on social media acknowledged that this work is time-consuming and that it took some initial “start-up energy” to learn the nuances of different social media platforms, but they felt that the need to meet their community members where they are made it imperative to invest that time.

Some interviewees mentioned that public health practitioners feared harassment and personal threats from their use of social media. Indeed, one interviewee who developed a strong social media presence during the COVID-19 pandemic mentioned receiving multiple death threats. The few participants that had directly experienced online attacks noted that it was intimidating and stressful at times, but they felt that this was an expected consequence of being in public service during a pandemic and the benefits outweighed the risks for them on a personal level. Other who were less active online described being hesitant to engage on social media due to a general fear of backlash from the public. Another participant who infrequently used social media noted that in their organization, “the people who’ve been more active in putting out messages [got] a lot of coordinated pushback, often on email too. Seeing that didn’t make me want to engage broadly on social media.” To address this fear of online backlash, one participant described a need for online collaboration between public health professionals to support one another in efforts to combat misinformation, stating,

At the interpersonal level, several participants noted that public health practitioners’ lack of relationships and external partnerships, both online and offline, limits their ability to build trust over social media. For example, one participant shared that most of their organization’s social media followers were employees, donors, and members of their board of directors, not the members of the public that they primarily aimed to reach through their social media accounts.

Some participants noted that partnerships with influencers or celebrities can be a powerful tool to expand online reach of public health messages, but that it is a challenge for public health practitioners to pick partners who will share consistent, accurate messages, serve as positive role models, and not do anything controversial that could discredit their message. One participant noted, “for us it would be a red flag if an influencer posted content supportive of tobacco use. There’s a lot of nuances to working with [influencers] we have to flesh out.” Additionally, participants indicated that public health practitioners need offline relationships with organizations and trusted messengers in their communities to ensure their online messaging (regardless of format or platform) was aligned with community concerns and questions. As one participant stated, “The digital landscape is best is when it’s an amplifier for what’s happening offline – or in line with what’s happening offline.”

Participants who were active on social media described how public health practitioners can integrate their social media activity with on-the-ground engagement through in-person town halls, frequent radio or local news media appearances, press briefings, and health-related events in their communities. One interviewee from a foundation noted success with combining social media with local news and radio, explaining that “diversifying messaging is really important for … the normalization [of a message] and just seeing it in multiple areas of your day-to-day really kind of helps bring the message [home].” Participants noted that online engagement cannot replace on-the-ground trust-building and has not yet become public health practitioners “go to” mode of communication. One participant described an instance in which they shut down a viral post because there was a lot of back-and-forth in the comments, stating,

Many respondents described barriers at the organizational level. Participants from public health agencies, nonprofits, and other health care organizations noted that their organizations often lacked support for social media engagement from leadership (although several felt that this was changing with time) and the resources to support such engagement. As one communication specialist described, “most people in leadership are 50 or older. Some of them don’t understand the value of social media. . . the first year of me being in my position was convincing the director you need to be out here tweeting about stuff.” Respondents mentioned that limited funding and staff inhibited their ability to expand social media outreach by translating materials, paying for advertisements, or having access to internal or external social media specialists. As one participant from a public health organization’s communications department described,

A few participants also noted that public health organization’s lack of a coherent social media strategy inhibited their ability to reach the public. Finally, some participants with low social media use described organizational policies or processes that slowed or limited their social media communications. One interviewee from a public health department noted that, by organizational policy, all social media messages had to be passed through several levels of leadership for approval, and that they were not allowed to respond directly to public questions on social media – they had to wait until members of the public emailed the organization with questions. In contrast, participants who were frequent users of social media often described supportive leadership and relatively streamlined processes that allowed them to directly communicate with the public in a timely fashion.

Finally, participants reflected on societal barriers to trust-building over social media, including the increasing polarization of public health viewpoints on social media platforms and overall negative views of public health institutions. Several participants discussed features that make the general social media environment difficult for public health practitioners to navigate, noting that social media interactions allow for two-way interactions. When anyone can comment or respond to a public health department’s post, this can inadvertently create a forum for misinformation and backlash. Practitioners are then faced with the difficult choice of deleting comments, which in and of itself can fuel distrust and concerns of censorship, acknowledge and take the time to craft sound responses to the comments, or not respond and allow uncorrected misinformation to reach more people. One local public health practitioner described an online panel on vaccines in which the chat “was extremely negative and [felt] like a trap.” This environment greatly differs from traditional media communications that practitioners have more experience with where communication is more structured and unidirectional from the public health practitioner to the public. As one participant noted,

Another participant described how the social media environment can vary by platform, noting that those with more bots are much more challenging to have engaging dialogue on.

Overall, interviewees perceived that trust in public health institutions was declining, both online and more generally. Several participants who worked at local and state health departments commented on the political polarization of public health viewpoints and how that polarization has led to distrust in the government. For example, one participant noted, “we heard from primarily our conservative community . . . that when we only site CDC or use them as a reference, certain members of the public immediately distrust what we’re sharing because there is a lack of trust in the CDC.” Another participant described how they were not allowed to create a blog post about the harms of misinformation because their organizational leadership deemed it too political.