This exploratory qualitative research was employed to assess the role of infodemics through mHealth, electronic media, and social media in Pakistan to explore the unique experiences and insights of populations, which may be overlooked in quantitative studies [19,20]. This study was implemented between May 2020 and August 2021 at 3 sites in Pakistan: the periurban Aga Khan University (AKU) Health Demographic Surveillance System at primary health care centers of Ali Akbar Shah Goth and Bhains Colony, the rural Sindhi district of Matiari, and the community health center (CHC) vaccination clinic at the AKU hospital in urban Karachi. The 3 selected sites in Pakistan were chosen to represent diverse populations and to capture unique socioeconomic and cultural factors influencing vaccine acceptance and hesitancy. The vaccination center at the periurban sites targeted low-to-middle and low-income populations. The rural area represented a low-income population, and the vaccination center at AKU hospital (urban site) represented both high-income and low-to-middle-income populations. This approach ensured a comprehensive understanding of vaccination behaviors by assessing the role and impact of mHealth, social media, and electronic media on vaccine-related attitudes and behaviors across different socioeconomic contexts. Focus group discussions (FGDs) were implemented among health care workers (doctors, nurses, pharmacists, lady health visitors, vaccinators, lady health workers, and community health workers) in Karachi and Matiari who worked in selected centers, and in-depth interviews (IDIs) were conducted with parents/caregivers of children aged <1 year. Figure 2 shows the flowchart of participant recruitment.

Ethics approval for this study was obtained from the ethics review committee of AKU (2020-5316-14620).

We used purposive sampling for recruiting HCPs, and convenient sampling was performed for parent selection. Parents or child caregivers were eligible for IDIs if (1) they had at least one child younger than 1 year and (2) their telephonic contact number was listed in either the registry maintained by the AKU hospital and its associated centers at the study sites or provided by community health workers affiliated with the study sites. The IDI was conducted with 1 caregiver at a time. HCPs such as doctors, nurses, pharmacists, lady health visitors, vaccinators, and community health workers at each of the 3 study sites were eligible as FGD participants; 6-8 participants were included in the FGDs. The parents/caregivers and HCPs who did not provide consent were excluded from this study.

Semistructured qualitative interview guides were developed for both IDI and FGD data collection in English and local Urdu language with the help of a literature review [21-23]. The main topics discussed were access to electronic and social media among diverse populations, barriers and perceived challenges, caregivers/parental concerns about vaccine safety, understanding of content available on digital media, and word-of-mouth communication within the community. Moreover, HCPs were more focused on factors associated with COVID-19 fear and dis/misinformation in the data, which may lead to vaccine hesitancy. We used the process defined in Figure 2 to gather data.

A team of researchers from AKU designed and piloted the research tools and trained qualitative research staff for conducting FGDs and IDIs. Due to the ongoing pandemic, all data collection was conducted remotely as per COVID-19 standard operating procedures (SOPs). Seven FGDs with HCPs and 60 IDIs with caregivers were conducted using semistructured interviews through virtual platforms (ConnectOnCall and Zoom) till the point of saturation. Two alternative methods were employed to acquire data: IDIs of 40-60 minutes were conducted telephonically, while FGDs of 60-90 minutes with HCPs were conducted using the Zoom videoconferencing platform. After obtaining verbal informed consent for participation, the respondents affiliated with all 3 study sites were given an overview of the study objectives, and parents/caregivers were provided training or guidance on how to attend virtual interviews on phone, which was helpful for individuals who were not tech-savvy or had limited experience with virtual communication. HCPs were debriefed about the Zoom platform and its related features to avoid any hindrance while interviews were being conducted. Data were recorded on the phone and a Zoom password-protected device.

Thematic analyses were adopted as part of the qualitative study. Each audio recorded Sindhi and Urdu-spoken IDIs, and FGDs were transcribed and translated to English. The English transcripts were then assessed and coded separately and connected to text fragments that reflected crucial user perspectives. The data were subsequently organized into thematic categories by looking for topics and then reviewed, defined, and named. We ensured trustworthiness of the data analysis by using Lincoln and Guba guidelines [24] to reduce researcher bias. Further, all discrepancies were resolved after team discussion; codes were finalized to generate the major themes emerging through FGDs and IDIs. The team then contrasted the themes before more targeted coding, focusing on ideas linked to mHealth, social media, and electronic media.

The key findings with regard to the COVID-19–related infodemic are listed in Table 1.

HCPs and caregivers shared that COVID-19–related information was commonly disseminated through print media, mHealth, and social and electronic media. The HCPs of the urban site reflected their beliefs about the use of the medium as authentic, as mobile phones (WhatsApp) were easily accessible and conveniently used. Moreover, HCPs also used Facebook to access information from the official pages of World Health Organization, Centers for Disease Control, and other international websites. Although a few caregivers also used international media for more reliable information related to COVID-19, caregivers in rural areas showed concern about the lack of media access and limited services on mobile networks.

During the pandemic, SMS text message–based mobile interventions were used to promote COVID-19 prevention techniques and register the general population for COVID-19 vaccination at both urban and rural sites. These messages tried to influence public behaviors such as SOPs related to COVID-19 prevention, follow-up appointments, and immunization advantages. Caregivers endorsed these government services. Caregivers shared that they received messages for the registration for COVID-19 vaccination of people older than 60 years. HCPs stated that conducting vaccination registration with national identity card numbers was a good initiative and felt an automated system that shared reminder messages would help reduce the defaulters.

Urban caregivers were suspicious whenever the national identity card number was asked for vaccination or other treatments, as a circulating rumor via Twitter stated that these local data were being gathered for use by foreign agencies such as the United States or China.

The COVID-19 pandemic has had both health and societal implications, which were not comparable to any recent event in global history. Social distancing during COVID-19 had a great impact, which led to an increase in the widespread use of digital platforms for acquiring the latest updates and COVID-19–related communication. Our qualitative study highlights many critical issues based on the usage of mHealth and social and electronic media related to the COVID-19 pandemic and vaccine coverage. The primary findings of our study indicate that according to HCPs and caregivers, electronic media and mHealth were used more broadly to promote COVID-19 pandemic-related information and communication. However, the social and electronic media–driven infodemics and urban-rural divide posed major obstacles. Further, digital media not only enabled individuals to quickly access and share information on disease spread and emerging health policy changes but also provided access to resources, community engagement, and misinformation.

Our study shows electronic media as the most effective tool for communicating health-related messages such as awareness of COVID-19 SOPs and vaccination to reduce the general population’s fear of acquiring infection. Electronic media provided the most reliable information related to the pandemic and hence became the most dependable medium to receive information, especially for the rural population. Electronic media was the primary source for filling the information gap among the general populations in Pakistan. However, there was an element of misinformation and disinformation in the news broadcasts related to the COVID-19 pandemic, which created confusion and misled the general population. This finding was similar to findings in Korea [25], wherein using electronic media to access vaccine-related information had a positive impact on the population’s vaccination-related decision-making as well as higher perceived benefits of the COVID-19 vaccine and greater trust in the government to address vaccine hesitancy. Further, an Italian study highlighted the importance of health information transmitted to raise awareness among individuals through radio, television, and journalistic communications [26]. However, despite motivating the population to reduce their fear and stress related to the COVID-19 pandemic, television broadcasts commonly used complicated language, technical jargon, and disseminated debates, thereby creating more confusion about the situation [27].

Our study explores the usefulness of mHealth as a communication media to disseminate information and support the population and HCPs during the pandemic. Participants in our study reported that mHealth strategies such as ringtone messages disseminated COVID-related awareness and preventive strategies and were actively used as a communication medium about public health awareness messages during different phases of the pandemic in the overall population. Most people could understand the ringtone because it was played in local languages. A similar strategy has been recommended to replace entertainment and religious ringtones with health promotion, particularly for LMICs [28]. Our findings also revealed that HCPs approached the COVID-19 dashboard and national and international resources for credible sources of information, which motivated them to deliver services and enabled vaccination uptake. SMS text messaging also played a critical role in the web-based registration for the COVID-19 vaccine. Moreover, reminders were automatically forwarded to the general population for missing doses of COVID-19 vaccine. Another study revealed that sending SMS text messages, emails, and postal messages enhanced influenza vaccination appointments [29]. According to our study participants, SMS text message–based vaccine registration was significantly accepted by the population and could potentially be further expanded to other adult and child vaccinations in Pakistan and other LMICs.

During the pandemic, the role of social media was widespread in providing information about COVID-19 and its vaccines through Facebook, Twitter, and WhatsApp. However, social media also propagated misinformation and disinformation related to COVID-19, hence introducing the phenomena of infodemics. In Pakistan, WhatsApp was widely used for disseminating pandemic-related information. Similarly, a study conducted in the United Arab Emirates reported WhatsApp as being mostly used to acquire COVID-19–related information [30].

We found that social media news and its content contributed to increasing COVID-19–related anxiety and stress among the population, as stated by HCPs. In our study, political tweets received more engagement, as leaders’ tweets had an enormous influence on the public, creating confusion and misconception. Another study showed that leaders’ tweets had higher interactions in high-income nations like the United Kingdom as well, and the leader’s tweets had a stronger impact on the general population, creating misinterpretation, which ultimately impacted vaccine uptake [31].

During the pandemic, information regarding vaccine adverse effects and misinformation was circulating on television and social media, adding fear and uncertainty among the population, and leading to a decline in vaccine acceptance. Our study participants also reported infertility, brain stroke, and death-related misinformation related to COVID-19 vaccines. Our findings are consistent with those of a US-based study, which reported similar misinformation falsely correlating COVID-19 vaccination with infertility and population growth control, electronic tattooing or microchipping individuals for global surveillance, and autism, which resulted in low vaccine uptake by the general population overall [32]. Thus, our HCP participants emphasized that lack of news verification and monitoring and incorrect information dissemination resulted in confusion and vaccine hesitancy among caregivers. This qualitative study provides insights that lack of technological literacy in the rural population was a hindrance in adopting mHealth interventions in the rural setting. Our study participants were not aware of or did not report about the official COVID-19 Government of Pakistan website. Besides that, the rural population, especially women, did not own personal mobile phones and were unfamiliar with its usage due to lack of technological literacy. However, in a rural setting in India, where the literacy rate of women was 40.35%, nearly 85% of the rural illiterate women were found to be using a mobile phone without necessarily owning it. It was their quickest means of communication and receiving information [33].

The digital pathway model that we conceptualized is based on national policy interventions (SMS text message–based interventions, caller tunes, vaccine registration through SMS text messages) and the responses of our research participants, which enabled them to communicate and disseminate information during the COVID-19 pandemic and assisted them in the fight against pandemic-related infodemics (Figure 3). We have discussed the diversity of mHealth interventions and their usage along this pathway. This framework is required to understand how digital methods might be integrated into COVID-19 control efforts and to aid in future pandemic preparedness (Textbox 1).

We examined platforms commonly used in misinformation campaigns in our settings, such as mHealth and social and electronic media. The flowchart’s development revealed a critical insight into how different media play distinct roles in supporting the spread of misinformation via different paths. Our model has crucial information for policy makers who want to combat the phenomena of infodemics and the digital divide. Policy makers at the government level across the world need to strategize social and legal regulatory frameworks to curb the spread of misinformation and disinformation in digital media.

Our results were based on participants visiting primary health care centers operated by private health entities with limited opening hours, staffing, and financial resources, constituting a significant study limitation. Further, the findings related to COVID-19 vaccine hesitancy cannot be generalized to other groups with different social and cultural backgrounds of other provinces. Thus, quantitative research is required to mitigate infodemics in larger populations.

The COVID-19 pandemic has necessitated the use of digital platforms for communication and information dissemination, with electronic media, mHealth, and social media playing crucial roles. Electronic media emerged as an effective tool for promoting COVID-19–related information and reducing fear among the general population. However, it also became a source of confusion causing mis/disinformation. Further, to improve public health interventions, precise and accurate information that pertains to World Health Organization or Centers for Disease Control guidelines should be allowed to be aired on televisions and media so that they can function as a bridge for people to connect with health officials and local governments for assistance, and collaborations between government and media outlets can establish guidelines for responsible reporting [34]. mHealth strategies such as SMS text message notifications, ringtone messages, and mobile apps proved useful in raising public awareness, especially in rural areas. Policy makers should invest in user-friendly mHealth platforms to ensure that timely and accurate information reaches individuals, particularly in low-income settings. Lastly, social media platforms also played a pivotal role in providing pandemic-related information, which was not previously seen on that scale, but they unfortunately also contributed toward infodemics. Regulatory bodies should develop frameworks to mitigate misinformation on social media, including collaboration with social media companies, monitoring mechanisms, and awareness campaigns. These frameworks should include collaboration with platforms for fact-checking and prioritizing authoritative sources, real-time monitoring using artificial intelligence, public awareness campaigns promoting critical thinking, and regulatory oversight ensuring transparency and accountability [35]. Addressing the challenges posed by infodemics and the digital divide requires enhancing information verification, promoting digital media literacy in rural areas, and strengthening public health communication through partnerships with influencers and HCPs. By implementing these strategies, policy makers can improve information dissemination, mitigate misinformation, and enhance future pandemic preparedness efforts.

This study proposes the implementation of a communication pathway focused on diseases and pandemics to be integrated into a national digital policy in resource-constraint setups, including Pakistan. This would enhance the country’s readiness to respond to health crises and boost public awareness and comprehension of these matters. Although digital media emerged as the primary source of information during the pandemic, it also contributed to misinformation and disinformation, causing infodemics. It is therefore essential to comprehend the sources and content of information within each digital medium element that triggers infodemics. LMICs are more vulnerable to infodemics because they have limited access, awareness, and lower literacy levels to comprehend and evaluate health-related information. Our research findings further revealed a digital divide between urban and rural populations, resulting in digital inequalities. To address these challenges, both digital and nondigital solutions must play a vital role. Moreover, credible information must be widely disseminated from trustworthy sources, verified by subject matter experts, and tailored to fit the local context. Lastly, training programs on the usage of digital media, dissemination strategies, and information reliability need to be conducted, particularly for HCPs and different settings, especially to reach rural communities.