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Introduction
In the contemporary information society, the advancement in communication and information technologies leads to emergence of social networks. The emergence of virtual social networks is a great revolution in information and communication technology. The networks are widely used by the users, and many people all over the world have access to them. Users could communicate with others through the facilities provided by these networks. Molaei Noshar1 argues that virtual social networks are a new generation of media that has changed the nature of news production and broadcasting as a result of incorporating the news providers and receivers and provided the possibility of accessing a new form of communication and content sharing.
Virtual social networks have offered some facilities for users, which caused various people with different characteristics to be attracted to this media. The number of users of these networks is ever increasing. Easy access and convenient use of these networks motivated people to follow or share their favorite content and news in these networks.
Nowadays, one of the main topics published in most virtual social networks is COVID-19 crisis. This infection which has engaged the world for several months is one of the main news headlines followed by people all over the world. It is to the extent that publishing inaccurate information on COVID-19 might lead to actions that threaten the individuals’ health against this disease. In this regard, Zarocostas2 states that with the onset of Corona, a global epidemic of misinformation has been created, which is rapidly spreading through social media platforms and other media, that is a serious public health problem and motivated the World Health Organization (WHO) launch platforms to deal with misinformation.
Abel & McQueen3 claims that along with the spread of COVID-19, lots of misinformation have been published which caused the spread of fear and panic among people. This trend has been even quicker than the spread of infection. He holds that health literacy is important for slowing down the spread of misinformation, preventing the disease and preparing for health care measures in situation when quick reaction is a necessity.
Health literacy is one of the main skills in health and hygiene of society and of high importance for perception of health care related issues. Health literacy was proposed for the first time in 1974 in a training panel on health training as a cognitive skill and an important and effective issue in health care system. It has been so far discussed by researchers of education and health areas and various definitions have been proposed.4 Generally, health literacy is defined as a wide spectrum of knowledge and skills in acquisition, perception and application of health-related information.5,6 The significance of health literacy on influencing the health results of patients has been well recognized as well it plays a main role in individual’s decision making on their health needs.7
In recent years, the study of health literacy in Iran, as well as other countries, has been considered by the scientific community as an important issue. Despite COVID-19 which has disrupted the social life and health of individuals and created a crisis in the health area, the health literacy skill could be a practical technique in confronting this disease and taking cautious measures.
Concerning what has been said about each variable and its significance in contemporary world, the researchers seek to investigate the extent to which the health literacy skill of Iranian users has been influential on the accuracy of information published in this area, concerning the spread of information on COVID-19 in social networks. And, whether the educational level influences the health literacy level of Iranian users and the accuracy of information on COVID-19 in virtual social networks or not? It is clear that achieving useful results in this area could have significant achievement for the health community of the country so that fundamental measures could be taken for promotion of health literacy of Iranian users and optimal use of virtual social networks for publishing information on COVID-19.
Theoretical principles and related literature
Virtual social networks have the highest similarity with the human community and provides the individual with the ability to communicate with lots of individuals regardless of the time, spatial, social, cultural and economic limits.8
Social network is used to refer to a space with the focus on the virtual and online structure and is accessible through web and mobile devices and used for making relations, sharing resources and collaboration.9 The most extensive interactive communication takes place within virtual social networks.
These networks, which are the result of the communication and technology revolution in the world, have confronted human beings with another type of relationship. In addition to these facilities, there are also abuses of these networks. Data transfer, which can be one of the most important functions of virtual social networks, is one of the most important problems of these networks.
Incorrect information transfer by some users and uncertainty about the accuracy of the information has caused the ratio Criticize these networks and on the other hand, due to their prevalence, there is a possibility of rejecting this technology does not have. Therefore, users should be able to be more aware of the information published by these networks. Publishing/republishing various correct or incorrect messages in these networks has a tangible effect on users' behavior and views. With the growing popularity of virtual social networks and mobile messaging networks, the information market seems to be false and, according to rumors, hotter and, of course, much more accurate, smarter and faster. Therefore, it is necessary to pay attention to the accuracy of the published information so that users have the ability to distinguish right from wrong.
Accuracy of published information means that users can identify which information published in virtual networks is true and which is false. Are the users who publish / republish this information daily aware of their accuracy? Therefore, the accuracy of the information is more and more necessary due to the fact that it is considered correct by the users and the publication and use of the content of the messages in a wide range. In this regard, according to the epidemic of COVID-19, which has spread around the world, we are witnessing the publication of health, treatment and prevention information about this disease in virtual social networks, which are published and republished among users, regardless of their accuracy.
Concerning the role of social networks and health related information, Maeen & Zykov10 found that some users get the advises concerning their health-related problem through the social networks. They find it useful to use these networks as they are an alternative to going to a hospital or clinic, which can be very time consuming. According to Maeen & Zykov,10 the protective effects of social networks might be the result of several factors, including positive access to health care information and services, encouraging healthy behaviors and taking care for being healthy. They believe that interaction between end users and service providers is made possible by relatively easy provisioning and access without any effective sharing factor. Moreover, Strekalova11 argues that the health organizations such as disease control and prevention centers use the social media for health promotion and even for providing information about health risks. In recent years, some studies have focused on health and its relation with social networks in Iran and other countries. Concerning the use of virtual social networks, View12 believes that virtual social networks enables individuals to quickly get information and knowledge, make use of applications for interpersonal communications and sharing information. Mano13 believes that social media helps us in getting a better view of the health and hygiene problems and alleviates such concerns. Findings of Hussain et al14 showed that the use of social networks promotes educational performance of the students. The respondents of these studies mentioned social networks, Internet, printed sources and audiovisual media as the main sources of information, respectively.
There have been some studies on e-health literacy and published information related to COVID-19. In fact, e-health literacy is based on the concepts of health literacy and media literacy, which refers to the individual’s ability to search, understand and evaluate health related information from electronic resources and make informed health decisions to address a health problem in daily activities.15 In this regard, Chang et al16) claim that perception of the role of e-health literacy is critical in controlling the prevalence of COVID-19. Irrespective of using valid tools for evaluating the prevalence of e-health literacy in infectious diseases, it is also important to examine the interconnected roles of e-health literacy and health-related misinformation about people's decisions to take action to reduce the spread of COVID-19. They believe that empowering public with better health literacy, enhancing the capabilities of society through social participation and conversation can be one of the ways to deal with misinformation related to COVID-19 on social media. Concerning the definition the health literacy could be taken in the present study as somehow e-health literacy.
Szmuda et al (17 in their study investigate the reading abilities of people on COVID-19 in Internet.They perceived that Internet is one of the most popular information resources for people; however, recognition of true information is difficult and treading information on COVID-19 is a complicated task. Aharon et al18 studied the readiness of nurses in collecting and evaluating information on COVID-19. The results indicated that nurses are better capable of verifying the validity or invalidity of information published about COVID-19 in virtual social networks.
Moreover, Hatami19 in Iran concluded that social health, as a social structure, is affected by the quality and quality of presence and activity in social networks. Memar et al20 believe that based on a classification, the cyberspace users in Iran are mostly from third generation, who are more exposed to the effects of virtual social networks than others. Montazeri et al7 studied the role of media in promoting the health literacy level. They believe that social media play significant role in creating, encouraging and motivating some behaviors, habits and attitudes and it is possible to use them to provide health training in the society.
The investigation of overseas studies showed that health literacy and information published in the field of COVID-19 in virtual networks have been considered and studies have been conducted in this field, including research.16,17,18 But in studies conducted in Iran, the results showed This issue has not been considered by researchers. Therefore, the authors of the present study perceived that in Iran, there is research gap concerning the health literacy and the accuracy of information published on COVID-19. Hence, concerning the significance of health literacy and the information on COVID-19 in virtual social networks, there is a need to perform study in this area. Moreover, as far as in the studied researches, the demographic information of users including education level and descriptions about most used network, motivation to use network, the rate of using the desired network, user’s history in the network, attention to accuracy of published information has been rarely considered; in this study, in addition to examining the impact of health literacy on the accuracy of the published information related to COVID-19, the above-mentioned cases were also considered. So that it is possible to gain a deep understanding of the research results by studying these variables.
Research questions
From what source do Iranian users get most information on COVID-19?
How many Iranian users republish the information on COVID-19 on social networks without paying attention to its accuracy?
In which virtual social network do Iranian users have the most activity? How long have they been active in the network? How long have they been active in the network?
How much time do Iranian users spend browsing virtual social networks?
What is the main motivation of Iranian users to use virtual social networks?
How many posts do Iranian users publish or republish on virtual social networks related to COVID-19?
Research hypotheses
There is meaningful direct relation between the health literacy level of users and the accuracy of published information on COVID-19 in virtual social networks?
There is meaningful relation between the health literacy and the education level of users of virtual social network.
There is meaningful direct relation between the accuracy of published information on COVID-19 by the users in virtual social networks and their education level.
Methodology
The present study is applied in terms of objective and descriptive survey in terms of method. The population of this study includes all users of virtual social networks (Telegram, WhatsApp, Instagram, Twitter and etc.). Finally, 121 questionnaires were returned back through sending the electronic questionnaire link in these networks. In this study, a two-part questionnaire has been used for data collection (annex). The first part includes the health literacy of users and the second part the accuracy of published information on COVID-19 by the users in virtual social networks. The health literacy questionnaire has been designed by Montazeri et al.7 This questionnaire includes 33 items which evaluate the subscales of reading (4 questions), accessibility (6 items), perception and understanding (7 items), evaluation (4 items) and decision making and behavior (12 items). In the present study, the validity of questionnaire was confirmed by several experts in health field. For testing reliability, Cronbach Alpha test was used and the reliability coefficient was estimated as 0.95.
The questionnaire of accuracy of published information in social networks has been designed by Esmaeilzade & Hasanzade21 In the present study, this questionnaire has been used with a few modifications to verify the accuracy of published information on COVID-19 in virtual social networks. For measuring the users’ attention to the accuracy of the published information in these networks, some indices were defined and for each index, some items were considered and defined. The documentality of information, health of content and the expertise of the message transmitter are some of these indices. In the present study, the opinions of 5 members from department of Science and Knowledge of Shahid Chamran University of Ahwaz have been asked and the questionnaire was confirmed. The reliability coefficient of the questionnaire was estimated as 0.93 in the present study.
In the present study, for data analysis, descriptive statistics (frequency and percentage) and inferential tests (one-sample t-test, Spearman and Pearson correlation test and structural equation model) were used. For measuring data normality, Kolmogorov-Smirnov test, skewness and elongation were used.
Health literacy
Conceptual definition: The World Health Organization (WHO) defines health literacy as cognitive and social skills that determine the motivation and ability of individuals to acquire, understand and use health information to promote and maintain good health.22).
Operational definition: In this study, health literacy is the amount of points that users receive in response to the health literacy questionnaire in indicators (reading, access, comprehension, evaluation, decision making and behavior).
Virtual social networks
A virtual social network is a set of web-based services that allow people to create public or private profiles for themselves, or to interact with other network members, share resources with them, and share descriptions. Use other people to find new connections.23
Operational definition: In this research, the meaning of virtual social network is networks (WhatsApp, Telegram, Instagram, Likendin, etc.) that are used to exchange information among Iranian users.
Published information: In this study, we mean information, news messages and information about COVID-19 disease that people publish / republish on virtual social networks such as (WhatsApp, Telegram, Twitter, Instagram).
Accuracy of published information: In this research, the meaning of information accuracy is the ability of users of virtual social networks to distinguish correct from incorrect information related to COVID-19.
Social network users: Social network users are people who do not use the various capabilities and features of virtual social networks to the same extent and at the same level. Some Internet users are members of several social networks, they visit these sites daily and use most of their features, and others may be members of only one site and from time to time only refer to their personal page.
Research findings
121 subjects have participated in the present study out of which 42 subjects (35%) are male and 79 subjects (65%) are female. Concerning the age of participants, 21.49% were up to 25 years old, 45.45% were 26-35 years old, 23.97% were 36-45 years old, 9.09% were 36-45 years old and 9.09% were above 46 years old. Examination of the education variable, 24.79% hold diploma, 0.83% hold associate degree, 40.50% hold bachelor, 19.01 hold master degree and 14.88% hold PhD degree. Concerning the age of participants, 28.1% were staff, 18.2% were households, 4.1% were student, 21.5% were university student, 8.3% were self-employed, 6.6% were unemployed and 13.2% selected the “other” option. In following section, the descriptive findings related to how the content on COVID-19 are obtained have been reported (fig. 1).
The resources of content about COVID-19
Concerning figure 1 on how the content on COVID-19 are obtained, the highest percentage (62.8) is related to Internet (Instagram, Telegram, WhatsApp, Twitter and others) and the lowest is related to satellite networks and booklet, training and advertising brochures (0.8%). about the accuracy of published information on COVID-19 in social networks, the descriptive indices have been obtained as follow:
Taking action to republish information on COVID-19 on social networks without paying attention to its accuracy
Table 1 Republishing information on COVID-19 in social networks without being informed of its accuracy
| Variable | Component | Frequency percentage |
|---|---|---|
| Republishing information on COVID-19 in social networks without being informed of its accuracy | Yes | 4/36 |
| No | 6/63 | |
| Total | 100% |
Concerning the results of table 1 on republishing information in social networks without being informed of its accuracy, 36.4% of the participants republish information without enduring its accuracy; while 63.6% of individuals do not republish it in social networks without ensuring its accuracy.
The highest activity in each virtual social network
Table 2 The highest activity in each virtual social network
| Variable | Component | Frequency percentage |
|---|---|---|
| Activity in virtual social networks | 26 | |
| Telegram | 18 | |
| 49 | ||
| Others | 7 | |
| Total | 100 % |
As reported in table 2, concerning activity in each of virtual social network, the highest participation is in WhatsApp with 49%, Instagram with 26%, Telegram with 18% and the lowest participation rate is in other networks with 7%.
Membership in virtual social networks
Table 3 Membership in virtual social networks
| Variable | Component | Frequency | Frequency percentage |
|---|---|---|---|
| Membership in virtual social networks | Less than one year | 6. | 5 |
| Between one to two years | 7 | 8/5 | |
| Between 2 to 3 years | 17 | 14 | |
| Above 3 years | 91 | 2/75 | |
| Total | 121 | 100% |
Concerning the results of table 3, 75.2% of the participants have more than 3 years membership in virtual social networks, which means that most participants have good history on the use of virtual networks.
The time spent for browsing virtual social networks
Table 4 The time spent for browsing virtual social networks
| Variable | Component | Frequency | Frequency percentage |
|---|---|---|---|
| Time spent for browsing virtual social networks? | Less than one hour in a day | 12 | 9/9 |
| 1-3 hours in a day | 58 | 9/47 | |
| 3-5 hours in a day | 29 | 24 | |
| Above 5 hours in a day | 22 | 2/18 | |
| Total | 121 | 100% |
As seen in table 4, concerning time spent for browsing virtual social networks, it is seen that most participants of this study (about 47.9%) spent 1-3 hours in a day for browsing virtual social networks. This is while, the least amount (9.9%) spend less than one hour in a day for browsing social networks.
The main motivation to use virtual social networks
Table 5 The main motivation to use virtual social networks
| Variable | Component | Frequency | Frequency percentage |
|---|---|---|---|
| The main motivation to use virtual social networks | Communicating with friends | 31 | 6/25 |
| Entertainment | 26 | 5/21 | |
| News and information | 50 | 3/41 | |
| Others | 14 | 6/11 | |
| Total | 121 | 100% |
Concerning the results of table 5, most participants of the study (41.3%) has reported reviewing news and information as the main motivation to use virtual social networks. Therefore, the significance of the accuracy of information is highlighted.
The number of posts related to COVID-19 (publishing and republishing) per day in virtual social networks
Table 6 The number of posts related to COVID-19 (publishing and republishing) per day in virtual social networks
| Variable | Component | Frequency | Frequency percentage |
|---|---|---|---|
| The number of posts related to COVID-19 | 1 Post | 82 | 8/67 |
| 2 Posts | 15 | 4/12 | |
| 3 Posts | 5 | 1/4 | |
| More than 3 posts | 19 | 7/15 | |
| Total | 121 | 100% |
According to table 6, concerning the number of posts about COVID-19 (published or republished) on social virtual networks, the highest percentage (68.8%) is related to 1 post about COVID-19 per day. In follow, in order to test research hypotheses, the normality or non-normality of data has been studied.
In this study, in order to find out whether the data are normal or non-normal, the Kolmogorov-Smirnov test, skewness and elongation of the data were used, the results of which are reported in table 7.
Table 7 Kolmogorov-Smirnov test, skewness and elongation of the data for measuring normality of data
| Variables | Kolmogorov-Smirnov test | Skewness | Elongation | |
|---|---|---|---|---|
| Statistics | Significance level | |||
| Health literacy | 104/0 | 053/0 | -511/0 | -481/0 |
| Accuracy of published information on COVID-19 | 102/0 | 074/0 | -611/0 | -219/0 |
As reported in table 7, the results of Kolmogorov-Smirnov test (p > 0.50) and data skewness and elongation show that research data have normal distribution; therefore, it is possible to use parametric tests to test research hypotheses.
There is direct meaningful relation between health literacy level of users and their precision about the accuracy of information related to COVID-19.
Table 8 Correlation matrix
| Accuracy of information | Health literacy | Accessibility | Reading | Understanding | Evaluation | Decision making and application | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Accuracy of information | ||||||||||||||
| Health literacy | 561/0 | |||||||||||||
| Accessibility | **442/0 | **809/0 | ||||||||||||
| Reading | **414/0 | **780/0 | **683/0 | |||||||||||
| Understanding | **474/0 | **840/0 | **743/0 | **728/0 | ||||||||||
| Evaluation | **443/0 | **809/0 | **714/0 | **642/0 | **786/0 | |||||||||
| Decision making and application | **519/0 | **845/0 | **606/0 | **527/0 | **616/0 | **611/0 | ||||||||
| ** p < 005/0 | ||||||||||||||
The results of table 8 show that there is a good pair correlation between variables and it is possible to use the structural equation model to measure the effect (relation) of health literacy (HL) and accuracy of information on COVID-19 (AI) in the virtual social networks by confirming the presence of good correlation between variables. In the following figure 2, the standard coefficients related to research variables have been reported.
Concerning the results of above model and meaningfulness of the relation between the health literacy of users and the accuracy of information on COVID-19 at significance level of p < 0.001 and T-value of 6.90, the research hypothesis is confirmed. Therefore, it can be said that there is direct and significance relation between the fitness indices of the model (table 9) indicate appropriate fitness of the model. results of Chi-square on the degree of freedom 1.971; the reported GFI value for this model is 0.83. In order to investigate how the intended model combines the goodness of fit and saving, RMSE has been used. RMSEA value in this model (0.090) indicates the good explanation of variance. GFI (0.83), NFI (0.94), IFI (0.97), CFI (0.97) and high value of other indices indicate good fit of designed model.
Table 9 GFT
| Index name | The estimations of main model | Good index (Gefen et al. 2001) |
|---|---|---|
| Chi2 on Degree of Freedom | 971/1 | Better if close to 3 and less. |
| FGI | 83/0 | Above 0.80 |
| RFI | 93/0 | Above 0.80 |
| PGFI | 81/0 | Above 0.80 |
| RMSEA | 090/0 | Below 0.50 |
| CFI | 97/0 | Above 0.80 |
| NFI | 94/0 | Above 0.80 |
| IFI | 97/0 | Above 0.80 |
In follow, the results of analyzing direct effect of health literacy of users on the accuracy of published information on COVID-19 have been calculated and reported in table 10.
Table 10 Direct effect of health literacy of users on accuracy of published information on COVID-19 in virtual social networks
| Predictive variable | B | SE | Beta | T | P | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Health literacy | 687/0 | 093/0 | 561/0 | 389/7 | 000/0 | |||||
| 361/0 = R 314/0 = R2 309/0 = ADJ.R2 | ||||||||||
As seen in table 10, health literacy variable (p < 0.561, β = 0.000) has positive meaningful effect on the accuracy of published information related to COVID-19 in virtual social networks. This means that increased score of health literacy variable leads to increase in the accuracy of information and vice versa, i.e. decrease in the score of this variable leads to decrease in the accuracy of published information on COVID-19 in virtual social networks. Moreover, concerning the reported results above, in the table 11, the health literacy is capable of explaining 40% of variance of accuracy of published information on COVID-19 in virtual social networks.
Relation between health literacy and education level of users of virtual social networks
With regards to the scale of variables for testing the above hypothesis, Spearman correlation coefficient has been used.
Table 11 Correlation between health literacy level and education level of users of virtual social networks
| Spearman correlation coefficient | Significance level | Number | |
|---|---|---|---|
| Health literacy level and education level | 249/0 | 006/0 | 121 |
According to the results of table 11, and the significance level (p < 0.50) and Spearman correlation coefficient (0.249), the research hypothesis is confirmed. Therefore, it can be said that there is direct meaningful relation between the health literacy level and education level of users of virtual social networks.
The relation between accuracy of published information on COVID-19 and education level of users of virtual social networks
To test the above hypothesis, Spearman correlation coefficient has been used.
Table 12 Correlation between the accuracy of information on COVID-19 and education level of users of virtual social networks
| Spearman correlation coefficient | Significance level | Number | |
|---|---|---|---|
| Accuracy of information on COVID-19 and education level | 303/0 | 001/0 | 121 |
According to the results of table 12, concerning the significance level (p < 0.50) and Spearman correlation coefficient, the research hypothesis is confirmed. Therefore, it can be said that there is direct meaningful relation between the accuracy of information on COVID-19 and education level of users of virtual social networks.
Discussion
The present study has been done aiming at investigating the effect of health literacy of Iranian users and the accuracy of information on COVID-19 in virtual social networks.
The descriptive findings of this study showed that according to Iranian users, Internet is one of the main sources of getting required information on COVID-19.
The study of the research hypothesis showed that there is direct and meaningful relation between the health literacy and accuracy of information on COVID-19 in virtual social network and the health literacy has direct effect on the accuracy of information on COVID-19. This result is consistent with the results of Aharon et al.18) and Chang et al.16)
Health literacy is one of the skills that seems to be effective and useful in individuals’ ability to understand the correctness and accuracy or inaccuracy of content published on COVID-19. Obviously, only experts can provide accurate opinions on how to prevent COVID-19 infection and how to treat it and provide proper diet; however, sometimes some untrue and even contradicting views with that of health experts are published in cyberspace. In this regard, the findings of Aharon et al.18) showed that nurses are better able to identify the validity or invalidity of published information on COVID-19 in social networks.
The other findings of the present study showed that there is direct and meaningful relation between health literacy and accuracy of information on COVID-19 with the education level of users of virtual social network. This finding is consistent with the results of Szmuda et al.17
The research results showed, individuals who had higher educational level benefit from good health literacy level and their attention to the accuracy of information on COVID-19 in virtual social network has been higher than others. Based on this result, it can be said that individuals with higher education level are more familiar with health literacy than others, and it is important for them what information and from what source they receive or share with others.
Concerning the results of this study and the meaningfulness of the relation between health literacy and attention to the accuracy of information on COVID-19 in Iranian users, it is recommended that the authorities of health organization consider special programs to increase the health literacy of users in virtual social network so that the users will be able to evaluate whether the information are correct or not. In this way, there will be less losses due to ignorance of health literacy and its complications. Moreover, in order to promote the health literacy level of society, the health officials of the country are recommended to consider a team for inspecting the health messages related to COVID-19 in cyberspace and surely, take action to publish accurate health and treatment content on COVID-19 in these networks so that the health literacy level of the society will increase and this crisis could be overcome without significant casualties.
Among the limitations of the present study was the lack of quick and easy access of users to some virtual social networks (Telegram, Facebook, Twitter, etc.). Following the Iranian protests in January 2017, the government filtered two well-known messengers, Telegram and Instagram. Telegram was filtered after about two weeks. But in May 2018, Telegram was filtered by court order. Also, since 2012, blocking or slowing down the connection to port 443 has been one of the tricks used to cut off or make it difficult for users to access hackers, messengers, and other software based on the HTTP protocol These are some of the restrictions that exist for Iranian users.
Recommendations
Concerning the results of this study, there are some recommendations:
1. Evaluate the health literacy of Iranian users and present strategies for its elevation.
2. Provide required training on recognition of the accuracy of information on health and COVID-19.
3. Inform Iranian users of the channels that they should refer to get information on COVID-19.
4. Ask the users about what channels they use to receive information on COVID-19 and provide necessary training in these channels by health teams.
