Identifying Health Equity Factors That Influence the Public’s Perception of COVID-19 Health Information and Recommendations: A Scoping Review

The COVID-19 pandemic has impacted global public health and public trust in health recommendations. Trust in health information may waver in the context of health inequities. The objective of this scoping review is to map evidence on public perceptions of COVID-19 prevention information using the PROGRESS-Plus health equity framework. We systematically searched the MEDLINE, Cochrane Central Register of Controlled Trials, PsycInfo, and Embase databases from January 2020 to July 2021. We identified 792 citations and 31 studies published in 15 countries that met all inclusion criteria. The majority (30/31; 96.7%) of the studies used an observational design (74.2% cross-sectional, 16.1% cohort, 6.5% case study, 3.2% experimental trials). Most studies (61.3%) reported on perception, understanding, and uptake, and 35.5% reported on engagement, compliance, and adherence to COVID-19 measures. The most frequently reported sources of COVID-related information were social media, TV, news (newspapers/news websites), and government sources. We identified five important equity factors related to public trust and uptake of recommendations: education and health literacy (19 studies; 61.3%), gender (15 studies; 48.4%), age (15 studies; 48.4%), socioeconomic status (11 studies; 35.5%), and place of residence (10 studies; 32.3%). Our review suggests that equity factors play a role in public perception of COVID-19 information and recommendations. A future systematic review could be conducted to estimate the impact of equity factors on perception and behavior outcomes.


Introduction
The COVID-19 pandemic has disrupted health systems and economies worldwide [1] with morbidities and mortalities [2]. Public health measures, including lockdowns and public health recommendations, have also led to various unintended outcomes, such as isolation and mental health issues, which have magnified existing health inequities [3].

Research Question
This scoping review was guided by the question: "What health equity factors influence the public's perception and uptake of COVID-19 health information and recommendations?" The review aimed to identify and map characteristics associated with health inequities that influence the uptake of COVID-19 prevention information and guidelines.

Data Sources and Search
We searched the following four databases (through Ovid) from 1 January 2020 (the month of detection of the first confirmed case of COVID-19) to 26 July 2021, without language restrictions: MEDLINE, Cochrane Central Register of Controlled Trials, APA PsycInfo, and Embase. Our search strategies reflected the principal concepts of our research question: the public perception and uptake, and COVID-19 information and recommendations. The search strategy was peer-reviewed by a librarian (VL) from the University of Ottawa with expertise in health sciences (see Supplementary File S2). We supplemented our search by reviewing the references of included articles.

Eligibility Criteria
We included studies that met the following criteria: (1) targeted the general public, including adults, youth, patients, and seniors (excluding those studies focusing on physicians, researchers, health professionals, academics, and others with specialized health knowledge); (2) described the perception, engagement, adherence, and uptake of COVID-19 health information as our outcomes of interest; and (3) reported on the COVID-19 health information and recommendations and their sources (e.g., the internet, social medial, government sources). Table 1 describes the inclusion and exclusion criteria. Table 1. Selection criteria for studies included in the review.

Types of Participants/Population (Sample)
General public (e.g., students, patients, caregivers, etc.) Physicians, researchers, health professionals, academics, and other people that are not general health information users

COVID-19 health information and recommendations provided by the different sources of information
Health information other than COVID-19

Research Type
Research publications (that have methods, data and analysis), quantitative, qualitative, or mixed-method documents published in peer-reviewed publications Commentaries, literature reviews, gray literature Year of Publication 1 January 2020-26 July 2021 Prior to 2020

Language of Publication
All languages Not applicable

Study Selection
Search results were imported into Covidence, an online software for systematic review management [33]. Two trained reviewers (SS, IA) screened the titles and abstracts independently, and discrepancies were resolved by a third reviewer (KP). Subsequently, two reviewers (SS, IA) independently screened full texts for eligibility, and discrepancies were resolved through discussion between reviewers.

Methodological Quality Appraisal
In accordance with scoping review methodology [30,31], we did not appraise the methodological quality of the studies.

Data Mapping and Synthesis
We digitally produced a word cloud using WordItOut [34], an online program, to display the frequency of the terms used in the titles relevant to our objectives (e.g., terms related to equity factors, perception, uptake). The most reported terms in the titles are shown with a larger font size. We then reported the frequency of study characteristics, including source country, study design, source of information, and outcomes (See Table 2). We identified reports on health equity factors using the PROGRESS-Plus framework [7]. PROGRESS-Plus is an acronym for health equity factors, which include: Place of residence, Race/ethnicity/culture/language, Occupation, Gender/Sex, Religion, Education/health literacy/digital health literacy, Socioeconomic status, Social capital and additional context specific factors such as personal characteristics concerning discrimination (age and disability), features of relationships, and time-dependent relationships [7]. We mapped the health equity factors with the outcomes of interest, including the public's perception and uptake of COVID-19 health information and recommendations (See Table 3).       Table 3. Mapping PROGRESS-Plus health equity factors on perception and uptake of health information.

Mapping Health Equity Factors Related to the Perception and Uptake of COVID-19 Health Information and Behaviors
Place of Residence (P) ( [51]): When compared to those with a high health literacy level, those with a low health literacy score were more likely to be "hesitant" rather than "pro-vaccination".

Literature Search
Our search identified a total of 792 unique citations; of these, 746 were excluded. Fortysix studies were assessed at full-text screening, and thirty-one met all eligibility criteria (See Figure 1). The most common reason for exclusion was irrelevant outcomes for the scope of this paper (i.e., study did not report the perception, engagement, adherence, or uptake of COVID-19 health information).

Figure 1.
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) study flow diagram. Figure 2 presents the most popular terms used in the titles of our included articles. This figure helps to identify what proportion of the included papers outline the equity factors in their titles. The font size of the word corresponds to its frequency of use in the included studies' titles. The larger the terms, the higher the frequency. Health literacy was the most frequent equity term and was mentioned in 11 titles of the 31 papers (11/31, 35.5%). The next most common terms were highlighting COVID-19 information, misinformation, and information sources (8/31, 25.8%). Terms such as gender, socioeconomic status, and race and ethnicity, as equity factors, were not commonly included in titles. Further details are presented in Table 2.  Figure 2 presents the most popular terms used in the titles of our included articles. This figure helps to identify what proportion of the included papers outline the equity factors in their titles. The font size of the word corresponds to its frequency of use in the included studies' titles. The larger the terms, the higher the frequency. Health literacy was the most frequent equity term and was mentioned in 11 titles of the 31 papers (11/31, 35.5%). The next most common terms were highlighting COVID-19 information, misinformation, and information sources (8/31, 25.8%). Terms such as gender, socioeconomic status, and race and ethnicity, as equity factors, were not commonly included in titles. Further details are presented in Table 2. The larger the terms, the higher the frequency. The frequency of the terms displayed on the word cloud are shown in the above table.

Characteristics of Included Studies
The 31 included studies were conducted in 15 different countries. A little more than a third of the studies were based in the United States of America (12 studies; 38.7%), followed by China (4 studies; 12.9%), France (3 studies; 9.7%), Germany (3 studies; 9.7%), and the United Kingdom (3 studies; 9.7%). Most studies used a quantitative research type (29 studies; 93.5%), and others used qualitative methods solely or along with quantitative approaches (5 studies; 16.1%). The majority (30/31; 96.7%) of the studies used an observational design (74.2% cross-sectional, 16.1% cohort, 6.5% case study, 3.2% experimental trials). All studies included women and men, and several studies also reported on non-binary genders. Most studies included a broad age range of participants, and 4 studies (13%) focused only on youth or the elderly. Of 31 studies, 23 studies (74.2%) reported on the COVID-19 sources of health information. The most frequent sources of health information were social media (58% of studies), TV (48% of studies), news (newspapers/news websites) (42% of studies), government sources (26% of studies), family and friends (26% of Figure 2. Word cloud displaying the frequency of the popular terms used in the titles of extracted papers. The font size of the word corresponds to its frequency of use in the included studies' titles. The larger the terms, the higher the frequency. The frequency of the terms displayed on the word cloud are shown in the above table.

Characteristics of Included Studies
The 31 included studies were conducted in 15 different countries. A little more than a third of the studies were based in the United States of America (12 studies; 38.7%), followed by China (4 studies; 12.9%), France (3 studies; 9.7%), Germany (3 studies; 9.7%), and the United Kingdom (3 studies; 9.7%). Most studies used a quantitative research type (29 studies; 93.5%), and others used qualitative methods solely or along with quantitative approaches (5 studies; 16.1%). The majority (30/31; 96.7%) of the studies used an observational design (74.2% cross-sectional, 16.1% cohort, 6.5% case study, 3.2% experimental trials). All studies included women and men, and several studies also reported on nonbinary genders. Most studies included a broad age range of participants, and 4 studies (13%) focused only on youth or the elderly. Of 31 studies, 23 studies (74.2%) reported on the COVID-19 sources of health information. The most frequent sources of health information were social media (58% of studies), TV (48% of studies), news (newspapers/news websites) (42% of studies), government sources (26% of studies), family and friends (26% of studies), and radio (26% of studies). The studies mainly reported on COVID-19 public health prevention recommendations and related health behaviors (21 studies; 67.7%) and COVID-19 vaccination (3 studies; 9.7%). Characteristics of the included studies are summarized in Table 2 (see Supplementary File S3 for a detailed version of the table).

PROGRESS-Plus Health Equity Factors and Perception and/or Uptake of COVID-19 Health Information
For the 31 included studies, we mapped the PROGRESS-Plus [7] health equity factors as they relate to the uptake of COVID-19 health information and recommendations. The following factors were frequently studied and reported regarding the observational outcomes of interest: place of residence, race/ethnicity/language, occupation, gender, religion, education (health literacy/digital health literacy), socioeconomic status, social capital, and plus factors such as age, disability, and chronic illnesses.

Frequently Examined Health Equity Factors
The most common health equity factors examined in our selected papers on COVID-19 health information were education (E), health literacy, and digital health literacy (19/31, 61.3%). A total of 15 studies (48.4%) found that gender (G) was associated with individuals' perceptions of and behaviors regarding COVID-19 health information. Another health equity factor influencing the perception of COVID-19 information and recommendations was age (Plus), which was suggested in 15 studies (48.4%). Socioeconomic status (S) was identified in 11 studies (35.5%) as influencing health behaviors related to COVID-19 prevention. Another important correlate reported as influencing the perception of COVID-19 information was the place of residence (P), which was examined in 10 studies (32.3%). Nine studies (29%) highlighted the significance of race, ethnicity, culture, and language (R). Additionally, one study (3.2%) reported on people with disabilities and chronic diseases (Plus).

Outcome Characteristics
Of the 31 included studies, 19 (61.3%) reported on perception, understanding, awareness, knowledge, adoption, and uptake of COVID-19 health information and recommendations. There were 11 studies (35.5%) that reported on intention, engagement, compliance, and adherence to COVID-19 measures and recommendations. Furthermore, 7 studies (22.6%) highlighted the role of attitudes, behaviors, and beliefs toward COVID-19 information and recommendations. There were 2 studies (6.5%) that examined information seeking and sharing health information as their outcomes of interest. Only 1 study (3%) reported on the public's decision making about vaccination and vaccine uptake.

Characteristics of COVID-19 Information Content
Our findings suggested that COVID-19 messages are delivered via various pathways and in different forms or actionable statements. Four studies (13%) populated COVID-19 vaccine information and recommendations in their delivered messages. Four studies (13%) reported on COVID-19 health guidelines as an approach to inform decision making among the public. Our 31 included studies broadly examined COVID-19 information, recommendations, protective measures, and news.

Discussion
Equity factors may play an important role in the dissemination and implementation of guidelines [66,67]. Our study sheds light on the existence of evidence gaps around the relative influence of health equity factors on the understanding and uptake of COVID-19 health information and recommendations. Health literacy was a predominant term and concept in our included studies. Studies often reported on education and health literacy in relation to perceptions on COVID-19 health information. We also found that age, gender, socioeconomic status, and race/ethnicity correlated with COVID-19 attitudes and behaviors.
Our review suggests that health equity factors may be associated with susceptibility to misinformation. For example, persons with a low level of health literacy showed a preference for social media [49] and a stronger acceptance of COVID-19 misinformation circulating on social media platforms [56]. Our review also showed that COVID-19 health information sources vary across countries, ranging from local non-official information sources to official government-based organization publications. The UK DISCERN Instru-ment recognizes that not all health information is good-quality and that information may be inaccurate or confusing [68]. DISCERN highlights the importance of credibility of source of information to help consumers judge the quality of the information. Our review also suggests that access to credible and trusted sources of health information is essential since many platforms may disseminate misinformation, which may threaten public health [69].
Health literacy stood out as a frequently reported factor associated with the uptake and trust of information. More than half of our studies reported that perceptions of COVID-19 health information and recommendations, as well as health-related decision-making, are influenced by the level of education and health literacy. This is critical as the effectiveness of COVID-19 mitigation measures demands a comprehensive perception and support from the public [70]. This finding suggests that information sources should possibly invest in improving public understanding as well as simply communicating health information statistics. The eCOVID-19 RecMap project [26] has identified the importance of public engagement and plain language in the development of health information summaries and has developed a community process to draft and produce plain-language recommendation summaries that improve both the understanding of science and relevant scientific findings [71]. These health information "ingredients" are relevant for other health information implementation efforts.
Gender also emerged as another frequently reported health equity factor; however, there was considerable inconsistency of reported outcomes across the studies. The COVID-19 pandemic has highlighted gender disparities in health-related decision making [72]. Research suggests that the gender gaps in seeking health information and in the social and economic consequences of COVID-19 may have lessened with the passage of time in the pandemic [73]. For example, vaccination acceptance may differ by gender [51]. Efforts are needed to make COVID-19 health information understandable for the general public and people with lower health literacy and education levels. Our included studies almost exclusively focused on male and female gender, and this suggests an urgent need for research considerations for other gender types.
Race, ethnicity, or language is another health equity factor that might influence attitudes and behaviors toward COVID-19 health information and potentially result in health inequities. There are inconsistencies in outcomes across the extracted papers in relation to ethnicity. Different racial-ethnic groups of people showed different willingness to adopt the COVID-19 recommendations or get vaccinated; for example, studies showed an association between the intention to get vaccinated and different racial-ethnic groups in the population [74]. The future design of digital patient information may need to be both community participatory as well as user-centric [75]. As well, to reduce inequity related to limited English language proficiency, initiatives such as the eCOVID-19 RecMap [26] have developed multilingual plain-language recommendation summaries that could be easily accessible to both health professionals and the public [27].
COVID-19, with its higher morbidity and mortality in patients with chronic conditions, for example, disproportionately affects marginalized populations in healthcare and public health [76]. To combat virus-related pandemics with large outbreaks, equitable and fair access to the healthcare system and services is a requisite to address healthcare disparities. The Commission on Social Determinants of Health (CSDH) also accentuated the importance of addressing health inequities by recommending the development of a solid evidence base [6]. The health equity factors reported in this paper reflect an initial list of equity factors that governments could consider when formulating their policy interventions and mitigation measures.

Implications for Research and Knowledge Translation
Our report on 31 studies suggests a potential health equity role in the development and dissemination of digital health information and guidelines for the public. Our research suggests a role for a systematic review (including appraisal and synthesis of evidence) on the influence of health equity factors on uptake of health information. Reducing and mitigating health inequities will require community-oriented design and participation and ongoing policy and practice research.

Strengths and Limitations
Strengths of our approach include the use of a predefined protocol and reporting guidelines to guide this review. The reviewers independently reviewed and selected the articles based on the inclusion criteria. Nevertheless, there are some limitations to our scoping review process. We were not able to search unpublished literature, and as per the scoping review convention, reviewers did not critically appraise the quality of the evidence, limiting the depth of our interpretation. We focused on the PROGRESS-Plus framework but recognize that many other theoretical psychological and choice frameworks could be also useful in understanding the dynamic nature of how the public makes choices.

Conclusions
Our studies suggest that the public turned in to several communication channels to learn about COVID-19 prevention guidelines. The most commonly reported outcomes included perception, understanding, and uptake of information. Our results showed several gaps in the literature related to the influence of health equity factors that are worth further study. The most commonly examined health equity factor was education and health literacy, followed by gender, age, and SES. More systematic research is needed to better estimate the impact of these health equity factors on public perceptions and behaviors related to COVID-19 information and recommendations.
Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/ijerph191912073/s1, File S1: Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist; File S2: Search strategies for all databases; File S3: Data extraction sheet.