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Online filter bubbles and 
confirmation bias in healthcare: 
Narrative of a vaccine skeptic 
Giordano Pérez Gaxiola, Douglas Badenoch 
22nd Cochrane Colloquium, Hyderabad, India 
Giordano Pérez Gaxiola, Douglas Badenoch 
22nd Cochrane Colloquium, Hyderabad, India
We have no actual or potential conflict of 
interest in relation to this presentation 
Image author: Banksy
Outline 
testingtreatments.org 
• Filter bubbles 
• Clinical experience of vaccine scepticism 
• The experiment 
• Discussion 
Image author: Banksy
DuckDuckGo Google
Eli Pariser: Beware online "filter bubbles"
At the office 
• Mom of a 2 yo boy who doesn’t have MMR 
• “…I read that it causes autism” 
testingtreatments.org 
• Mom of a 9 mo girl 
• “…do you have mercury free vaccines?”
Anti-vaccine movement 
testingtreatments.org
Where does it come from? 
• Nobody likes shots 
• Generation that did not see diphtheria, measles, 
testingtreatments.org 
polio… 
• Atrocities that have reduced trust in vaccines
Image: Star Trek 
Atrocity # 1 
One that cast doubt in the safety of a vaccine
1998 
testingtreatments.org
testingtreatments.org
http://www.cfr.org/interactives/GH_Vaccine_Map/#/intro 
testingtreatments.org
Image: Star Trek 
Atrocity # 2 
One that cast doubt in goals of vaccination campaigns
1988 Global Polio Eradication Initiative 
125 countries 
testingtreatments.org
2011 Global Polio Eradication Initiative 
4 countries 
testingtreatments.org
testingtreatments.org
testingtreatments.org
May 2014… back to 9 countries 
who.int 
testingtreatments.org
Where does it come from? 
• Nobody likes shots 
• Generation that did not see diphtheria, measles, 
testingtreatments.org 
polio… 
• Atrocities that have reduced trust in vaccines 
• Information from the internet
To vaccinate 
or not to 
vaccinate? 
testingtreatments.org
Recommendation 
by doctors Social norm 
Factors that influence in 
vaccination decisions 
Previous 
experiences 
testingtreatments.org 
Advice from 
people we 
trust 
Advice from 
trustworthy 
organisations 
Betsh C, et al. Opportunities and challenges of Web 2.0 
for vaccination decisions. Vaccine 2012;30:3727–3733
Recommendation 
by doctors Social norm 
Influenced by the internet? 
Previous 
experiences 
testingtreatments.org 
Advice from 
people we trust 
Advice from 
trustworthy 
organisations 
Betsh C, et al. Opportunities and challenges of Web 2.0 
for vaccination decisions. Vaccine 2012;30:3727–3733
Phases in vaccination decisions 
Betsch C. Innovations in communication: the Internet and the 
testingtreatments.org 
psychology of vaccination decisions. Euro Surveill. 2011;16(17):1–6
testingtreatments.org
testingtreatments.org
The role of the 
internet 
testingtreatments.org
> 70% trust health 
information online 
> 75% do not consider 
source nor critically 
appraise 
Betsh C, et al. Opportunities and challenges of Web 2.0 
for vaccination decisions. testingtreatments.Vaccine org 
2012;30:3727–3733
Health information online 
Correct Incorrect 
MMR/Autism 44 23 
Scullard P, et al. Googling children’s health: reliability of medical advice 
on the internet. Arch testingtreatments.Dis Child org 
2010;95(8):580-2 
Mastitis/breastf 
eeding 59 0 
Sleep position 
infants 43 0 
Green vomit in 
infant 16 1
Health information online 
Information correct Incorrect 
testingtreatments.org 
27 
35 
17 
40 
68 
10 
0 
6 
14 
9 
17 
2 
90 
67.5 
45 
22.5 
0 
Gov Educational News Companies Interest groups Individual 
Scullard P, et al. Googling children’s health: reliability of medical advice 
on the internet. Arch Dis Child 2010;95(8):580-2
English Spanish
Personalisation of 
the internet 
testingtreatments.org
What happens if a vaccine 
skeptic decides to look at 
what people are saying 
about vaccines harms? 
testingtreatments.org
testingtreatments.org
testingtreatments.org
testingtreatments.org
testingtreatments.org
12,278 
+ 40,654 
+ 71,585 
124,517 
testingtreatments.org
“Type a quote here.” 
–Johnny Appleseed 
testingtreatments.org 
17,842 
13,345 
22,705 
71,809
More narratives 
Perception of more risk! 
Betsch C, et al. The influence of narrative vs. statistical 
information on perceiving vaccination risks. Medical 
Decision Making testingtreatments.2011;31(org 
5):742–53.
Two positive narratives 
Two negative narratives 
Perception of 50% risk! 
Fagerlin A, Wang C, Ubel PA. Reducing the influence of anecdotal 
reasoning on people’s health care decisions: is a picture worth a 
thousand statistics. Medical testingtreatments.Decision org 
Making 2005;25:398–405.
Anti Pro
Phases in vaccination decisions 
Euro Sutrevsetinilglt.r e2a0tm1e1nt;s1.o6rg(17):1–6
This is just a case study… 
testingtreatments.org 
• Narrative 
• Obvious limitations of “Likes” 
…but
Personalisation of the 
internet might be increasing 
confirmation bias 
If I believe in something, it’s because it is true 
testingtreatments.org
And it does 
matter! 
testingtreatments.org
It’s not just health 
17/21 comments from 
climate change deniers 
testingtreatments.org
People prefer 
information they agree 
with 
testingtreatments.org 
They are more likely to 
search for and read 
information that agrees with 
their voting behaviour. 
Borra E, Weber I. Political Insights: Expl 
oring partisanship in Web search queries. 
First Monday 2012; 17 (7): 2 July 2012.
About 30% of Facebook health pages 
are for marketing & advertising 
Hale et al. Representation of Health Conditions on Facebook: 
Content Analysis and Evaluation of User Engagement. JMIR 2014; 16(8): e182 
testingtreatments.org
But they account for about 47% of “Likes” 
Hale et al. Representation of Health Conditions on Facebook: 
Content Analysis and Evaluation of User Engagement. JMIR 2014; 16(8): e182 
testingtreatments.org
Can we do anything 
about it? 
• It’s possible to influence opinion 
with alternative viewpoints 
• Engage with online communities 
• Tell stories about evidence-based health care 
testingtreatments.org
Shareable content 
testingtreatments.org
Evidence of what 
works 
• Social marketing for HIV/STI 
testingtreatments.org 
testing uptake… 
• Social media may lead to 
increased exposure to different 
viewpoints but tend to be more 
biased 
Wei C, Herrick A, Raymond HF, Anglemyer A, 
Gerbase A, Noar SM. Social marketing interve 
ntions to increase HIV/STI testing uptake amo 
ng men who have sex with men and male-to-fe 
male transgender women. Cochrane Database 
of Systematic Reviews 2011, Issue 9. Art. No.: 
CD009337. DOI: 10.1002/14651858.CD00933 
7. 
Yardi S et al. Dynamic debates: An analysis of 
group polarization over time on twitter. 
Bull Sci Tech Soc 2010; 30 (5): 316-327
Evidence of what 
works Current evidence is: 
testingtreatments.org 
• Non-randomized 
• Short duration 
• Heterogeneity 
• Poor description of 
interventions 
• Poor quality or absent control 
groups 
• Substantial attrition Maher et al. Are Health Behavior Change Interventions 
That Use Online Social Networks Effective? A Systemat 
ic Review. J Med Internet Res 2014;16(2):e40)
Imitations of success? 
testingtreatments.org
“A squirrel dying in front of your 
house may be more relevant to 
your interests right now than 
people dying in Africa” 
- Mark Zuckerberg, Facebook 
Eli Pariser: Beware online "filter bubbles"
Questions… 
…comments, advice, warnings, 
suggestions for future research…. 
testingtreatments.org

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Online Filter Bubbles and Confirmation Bias in Healthcare

  • 1. Online filter bubbles and confirmation bias in healthcare: Narrative of a vaccine skeptic Giordano Pérez Gaxiola, Douglas Badenoch 22nd Cochrane Colloquium, Hyderabad, India Giordano Pérez Gaxiola, Douglas Badenoch 22nd Cochrane Colloquium, Hyderabad, India
  • 2. We have no actual or potential conflict of interest in relation to this presentation Image author: Banksy
  • 3. Outline testingtreatments.org • Filter bubbles • Clinical experience of vaccine scepticism • The experiment • Discussion Image author: Banksy
  • 4.
  • 6. Eli Pariser: Beware online "filter bubbles"
  • 7. At the office • Mom of a 2 yo boy who doesn’t have MMR • “…I read that it causes autism” testingtreatments.org • Mom of a 9 mo girl • “…do you have mercury free vaccines?”
  • 9. Where does it come from? • Nobody likes shots • Generation that did not see diphtheria, measles, testingtreatments.org polio… • Atrocities that have reduced trust in vaccines
  • 10. Image: Star Trek Atrocity # 1 One that cast doubt in the safety of a vaccine
  • 12.
  • 15. Image: Star Trek Atrocity # 2 One that cast doubt in goals of vaccination campaigns
  • 16. 1988 Global Polio Eradication Initiative 125 countries testingtreatments.org
  • 17. 2011 Global Polio Eradication Initiative 4 countries testingtreatments.org
  • 20. May 2014… back to 9 countries who.int testingtreatments.org
  • 21. Where does it come from? • Nobody likes shots • Generation that did not see diphtheria, measles, testingtreatments.org polio… • Atrocities that have reduced trust in vaccines • Information from the internet
  • 22. To vaccinate or not to vaccinate? testingtreatments.org
  • 23. Recommendation by doctors Social norm Factors that influence in vaccination decisions Previous experiences testingtreatments.org Advice from people we trust Advice from trustworthy organisations Betsh C, et al. Opportunities and challenges of Web 2.0 for vaccination decisions. Vaccine 2012;30:3727–3733
  • 24. Recommendation by doctors Social norm Influenced by the internet? Previous experiences testingtreatments.org Advice from people we trust Advice from trustworthy organisations Betsh C, et al. Opportunities and challenges of Web 2.0 for vaccination decisions. Vaccine 2012;30:3727–3733
  • 25. Phases in vaccination decisions Betsch C. Innovations in communication: the Internet and the testingtreatments.org psychology of vaccination decisions. Euro Surveill. 2011;16(17):1–6
  • 28. The role of the internet testingtreatments.org
  • 29. > 70% trust health information online > 75% do not consider source nor critically appraise Betsh C, et al. Opportunities and challenges of Web 2.0 for vaccination decisions. testingtreatments.Vaccine org 2012;30:3727–3733
  • 30. Health information online Correct Incorrect MMR/Autism 44 23 Scullard P, et al. Googling children’s health: reliability of medical advice on the internet. Arch testingtreatments.Dis Child org 2010;95(8):580-2 Mastitis/breastf eeding 59 0 Sleep position infants 43 0 Green vomit in infant 16 1
  • 31. Health information online Information correct Incorrect testingtreatments.org 27 35 17 40 68 10 0 6 14 9 17 2 90 67.5 45 22.5 0 Gov Educational News Companies Interest groups Individual Scullard P, et al. Googling children’s health: reliability of medical advice on the internet. Arch Dis Child 2010;95(8):580-2
  • 33. Personalisation of the internet testingtreatments.org
  • 34.
  • 35. What happens if a vaccine skeptic decides to look at what people are saying about vaccines harms? testingtreatments.org
  • 40. 12,278 + 40,654 + 71,585 124,517 testingtreatments.org
  • 41. “Type a quote here.” –Johnny Appleseed testingtreatments.org 17,842 13,345 22,705 71,809
  • 42.
  • 43. More narratives Perception of more risk! Betsch C, et al. The influence of narrative vs. statistical information on perceiving vaccination risks. Medical Decision Making testingtreatments.2011;31(org 5):742–53.
  • 44. Two positive narratives Two negative narratives Perception of 50% risk! Fagerlin A, Wang C, Ubel PA. Reducing the influence of anecdotal reasoning on people’s health care decisions: is a picture worth a thousand statistics. Medical testingtreatments.Decision org Making 2005;25:398–405.
  • 46. Phases in vaccination decisions Euro Sutrevsetinilglt.r e2a0tm1e1nt;s1.o6rg(17):1–6
  • 47. This is just a case study… testingtreatments.org • Narrative • Obvious limitations of “Likes” …but
  • 48. Personalisation of the internet might be increasing confirmation bias If I believe in something, it’s because it is true testingtreatments.org
  • 49. And it does matter! testingtreatments.org
  • 50. It’s not just health 17/21 comments from climate change deniers testingtreatments.org
  • 51. People prefer information they agree with testingtreatments.org They are more likely to search for and read information that agrees with their voting behaviour. Borra E, Weber I. Political Insights: Expl oring partisanship in Web search queries. First Monday 2012; 17 (7): 2 July 2012.
  • 52. About 30% of Facebook health pages are for marketing & advertising Hale et al. Representation of Health Conditions on Facebook: Content Analysis and Evaluation of User Engagement. JMIR 2014; 16(8): e182 testingtreatments.org
  • 53. But they account for about 47% of “Likes” Hale et al. Representation of Health Conditions on Facebook: Content Analysis and Evaluation of User Engagement. JMIR 2014; 16(8): e182 testingtreatments.org
  • 54. Can we do anything about it? • It’s possible to influence opinion with alternative viewpoints • Engage with online communities • Tell stories about evidence-based health care testingtreatments.org
  • 56. Evidence of what works • Social marketing for HIV/STI testingtreatments.org testing uptake… • Social media may lead to increased exposure to different viewpoints but tend to be more biased Wei C, Herrick A, Raymond HF, Anglemyer A, Gerbase A, Noar SM. Social marketing interve ntions to increase HIV/STI testing uptake amo ng men who have sex with men and male-to-fe male transgender women. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD009337. DOI: 10.1002/14651858.CD00933 7. Yardi S et al. Dynamic debates: An analysis of group polarization over time on twitter. Bull Sci Tech Soc 2010; 30 (5): 316-327
  • 57. Evidence of what works Current evidence is: testingtreatments.org • Non-randomized • Short duration • Heterogeneity • Poor description of interventions • Poor quality or absent control groups • Substantial attrition Maher et al. Are Health Behavior Change Interventions That Use Online Social Networks Effective? A Systemat ic Review. J Med Internet Res 2014;16(2):e40)
  • 58. Imitations of success? testingtreatments.org
  • 59. “A squirrel dying in front of your house may be more relevant to your interests right now than people dying in Africa” - Mark Zuckerberg, Facebook Eli Pariser: Beware online "filter bubbles"
  • 60. Questions… …comments, advice, warnings, suggestions for future research…. testingtreatments.org