This paper is available on arxiv under CC 4.0 license. Authors: (1) Pietro Ghezzi, Brighton & Sussex Medical School, Falmer, Brighton, UK; (2) Peter G Bannister, Brighton & Sussex Medical School, Falmer, Brighton, UK; (3) Gonzalo Casino, Communication Department, Pompeu Fabra University, Barcelona, Spain and Iberoamerican Cochrane Center, Barcelona, Spain; (4) Alessia Catalani, Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, PU, Italy; (5) Michel Goldman, Institute for Interdisciplinary Innovation in healthcare (I3h), Université libre de Bruxelles; (6) Jessica Morley, Oxford Internet Institute, University of Oxford, Oxford, UK; (7) Marie Neunez, Institute for Interdisciplinary Innovation in healthcare (I3h), Université libre de Bruxelles; (8) Andreu Prados, Communication Department, Pompeu Fabra University, Barcelona, Spain, Iberoamerican Cochrane Center, Barcelona, Spain, Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, PU, Italy, Institute for Interdisciplinary Innovation in healthcare (I3h), Université libre de Bruxelles, Oxford Internet Institute, University of Oxford, Oxford, UK, and Blanquerna School of Health Sciences, Universitat Ramon Llull, Barcelona, Spain; (9) Mariarosaria Taddeo, Oxford Internet Institute, University of Oxford, Oxford, UK, Blanquerna School of Health Sciences, Universitat Ramon Llull, Barcelona, Spain, and The Alan Turing Institute, London, UK; (10) Tania Vanzolini, Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, PU, Italy; (11) Luciano Floridi, Oxford Internet Institute, University of Oxford, Oxford, UK, Blanquerna School of Health Sciences, Universitat Ramon Llull, Barcelona, Spain, and The Alan Turing Institute, London, UK. Table of Links Abstract and Introduction Methods Web search and content analysis Results Discussion Conclusion and References Table 1. Example of classification of webpages Table 2. Percentage of vaccine-negative webpages in different SERPs Corresponding author: Professor Pietro Ghezzi, Brighton and Sussex Medical School, Trafford Centre, University of Sussex, Falmer, Brighton, BN19RY, UK. Email: p.ghezzi@bsms.ac.uk; phone: +44-(0)1273-873112 Abstract The fact that Internet companies may record our personal data and track our online behaviour for commercial or political purpose has emphasized aspects related to online privacy. This has also led to the development of search engines that promise no tracking and privacy. Search engines also have a major role in spreading low-quality health information such as that of anti-vaccine websites. This study investigates the relationship between search engines’ approach to privacy and the scientific quality of the information they return. We analyzed the first 30 webpages returned searching “vaccines autism” in English, Spanish, Italian and French. The results show that “alternative” search engines (Duckduckgo, Ecosia, Qwant, Swisscows and Mojeek) may return more anti-vaccine pages (10-53%) than Google.com (0%). Some localized versions of Google, however, returned more anti-vaccine webpages (up to 10%) than Google.com. Our study suggests that designing a search engine that is privacy savvy and avoids issues with filter bubbles that can result from user-tracking is necessary but insufficient; instead mechanisms should be developed to test search engines from the perspective of information quality (particularly for health-related webpages), before they can be deemed trustworthy providers of public health information. Introduction The World Health Organization lists vaccine hesitancy as one of the top ten threats to global health in 2019 1, requiring ongoing global monitoring. Despite the fact that the 1998 study which incorrectly suggested that the MMR vaccine could cause autism in children and prompted antivaccine beliefs 2 has now been discredited, misinformation, and indeed, disinformation, about vaccines continues to be published on the Internet perpetuating such beliefs. It has been suggested that this misinformation plays a role in the current low uptake of vaccines in developed countries 3. Understanding whether this is actually the case, and how to address this issue, is crucial as web-based sources of health information may be instrumental to solve the sustainability challenge currently facing health systems across the globe. The accuracy of information provided by a website is a key indicator of its overall information quality (IQ). The broader aspects of IQ have been the subject of many studies 5, but health IQ and trustworthiness of the sources have only partially been characterized 6. Studies looking at the influence of variations in eHealth literacy levels 7 and trust in different sources of online health information2 indicate that the relationship is not linear in all cases, i.e. higher health IQ does not result automatically in higher perceived levels of trustworthiness. For example, in a study by Chen et al. 8, 618 people were recruited to complete a survey which tested their eHealth literacy level, asked them to identify which of 25 sources of health information they used, and how much they trusted each source. The study showed that people with lower eHealth literacy were less likely to trust medical websites (typically higher IQ) and more likely to trust social media, blogs, and celebrity webpages (typically lower IQ). This might seem a spurious result, were it not for the fact that research has shown that those with high eHealth literacy assess more accurately the credibility and relevance of online health information, whereas those with low eHealth literacy often struggle to locate and understand eHealth information 9. This difficulty lowers their self-efficacy 10, distorts their perception of source credibility, and impacts negatively perceived trustworthiness 9, ultimately creating a need for individuals with low eHealth literacy to find an alternative means of determining trustworthiness in online sources of information. One such alternative is social endorsement. Visible social endorsement, e.g. ‘likes,’ 11 enables those with low eHealth literacy to determine trust based on the bandwagon heuristic and assume that, if the source has already been deemed valid by others, then it is safe for them to trust it too 10,12. Traditional medical websites afford those with low eHealth literacy no such alternative means of determining credibility and trust. This suggests that those who are more vulnerable to the real-world effects of both disinformation and misinformation (e.g. declining to vaccinate their children) are more likely to rely on online sources with lower health IQ, which are more prone to spread such inflammatory and inaccurate information. Personalisation of online search results may favour this phenomenon and lead to a vicious cycle where the more one searches and reads dis- and mis-information about vaccines the less one finds and reads scientific information on the same topic. At the same time, there are increasing concerns about the privacy risks associated with Internet search engines storing potentially sensitive and private health information contained within users search histories, combining it with additional information collected for tracking purposes, and using these data for commercial or other purposes 13,14. This creates a public push back against the idea that search engines or public health providers should interfere in the results people see when searching for health information online. This makes it hard to address concerns about health disinformation/misinformation in a way that is at least socially acceptable if not ideally preferable 15. The UK’s National Health Service (NHS) discovered this when its announcement of Amazon Alexa responding with guaranteed high-IQ content from NHS.UK to user voice queries such as “Alexa, how do I treat a migraine,” resulted in a public outcry over privacy infringement 16. This raises the question whether, in the context of online vaccination information, it is possible at all to balance concerns about user privacy and IQ. The following pages seek to lay the foundations for answering this question by reporting on the methodology for, and results of, a study concerning the following research question: “What is the current relationship between search engines’ approach to privacy and the scientific quality of the information they return?”.

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Online Information of Vaccines: Abstract and Introduction

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