The use of social media platforms by migrant and ethnic minority populations during the COVID-19 pandemic: a systematic review

Objective: To determine the extent and nature of social media use in migrant and ethnic minority communities for COVID-19 information, and implications for preventative health measures including vaccination intent and uptake. Design: A systematic review of published and grey literature following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Eligibility Criteria for study selection: Global research reporting the use of social media by migrants and/or ethnic minority groups in relation to COVID-19. Data extraction: We extracted data on key outcomes, study design, country, population under study, and sample size. Results: 1849 unique records were screened, and 21 data sources included in our analysis involving migrant and ethnic minority populations in the UK, US, China, Jordan, Qatar, and Turkey. We found evidence of consistent use of a range of social media platforms for COVID-19 information in some migrant and ethnic minority populations (including WeChat, Facebook, WhatsApp, Instagram, Twitter, YouTube), which may stem from difficulty in accessing COVID-19 information in their native languages or from trusted sources. There were positive and negative associations with social media use reported, with some evidence suggesting circulating misinformation and social media use may be associated with lower participation in preventative health measures, including vaccine intent and uptake, findings of which are likely relevant to multiple population groups. Conclusions: Social media platforms are an important source of information about COVID-19 for some migrant and ethnic minority populations. Urgent actions and further research are now needed to better understand the use of social media platforms for accessing health information by different population groups - particularly groups who are marginalised from health systems - effective approaches to tackling circulating misinformation, and to seize on opportunities to make better use of social media platforms to support public health communication and improve vaccine uptake. Registration This study has been registered with PROSPERO (CRD42021259190).


Introduction
The pandemic has been accompanied by an infodemic, defined as an excess of information during a disease outbreak -including false or misleading information in digital and physical environments 1 -that makes it difficult to distinguish reliable information from misinformation including disinformation (deliberate misinformation) and conspiracy theories. The World Health Organization (WHO) highlights that in all communities, infodemics cause 'confusion and risktaking behaviours that can harm health…it leads to mistrust in health authorities and undermines the public health response, and can intensify or lengthen outbreaks' 1 . The rapid expansion of internet and social media use, in particular, in recent years (including platforms such as Twitter, WhatsApp, and YouTube; Table 1) has meant that both useful and potentially harmful health information can spread rapidly. A large proportion of the most popular COVID-19 videos on YouTube, for example, have been found to contain misinformation, or no factual information, reaching millions of people worldwide 2 3 . YouTube is considered a major platform for information concerning the control of COVID-19, but most COVID-19 videos were of 'undesirable quality' containing few government/public health recommendations according to a recent study 4 . A review of YouTube videos on general vaccination found 65% expressed anti-vaccination sentiment 5 , with anti-vaccine posts more likely to be recirculated on Twitter 2 . The spread of misinformation and disinformation has been highlighted as a major risk to ending the COVID-19 pandemic -including undermining trust in vaccines 6 -with researchers highlighting links between misinformation on social media and public doubts around vaccine safety, self-reported compliance with public health guidelines, and intent to vaccinate 7 8 .
Although social media platforms are commonly used in the general population, and patterns of use are complex across different population groups 8 9 , some migrant and ethnic minority groups -who may experience barriers to accessing health information and health systems -may be more reliant on social media and the internet as a source of health information. These communities may also draw on diaspora media as a source of health information 10 . The COVID-19 pandemic has disproportionately impacted and exacerbated inequalities faced by migrants and ethnically diverse communities 11 12 10 13 14 , with lower take-up of preventative health measures, such as vaccines, noted in some groups due to a range of personal, societal, and physical barriers 12 14 15 . Some migrant and ethnic minority communities may be more exposed to social media misinformation because of access barriers to accurate information (eg, from official government sources) 16 17 , due to restricted eligibility and access to services, language barriers, and low health literacy. However, little is known about the extent and nature of social media use in these populations, nor the impact that social media use has had on preventative health measures during the pandemic, including COVID-19 vaccine uptake. In addition, there is an opportunity now to explore the extent to which social media platforms could be better used to support information sharing and promote public health messaging in marginalised communities during the pandemic and beyond.
We therefore did a systematic review to explore and assess the extent and nature of social media use by migrant and ethnic minority groups to access COVID-19 health information, the extent to which misinformation on social media may have influenced views about COVID-19 preventative measures including vaccination intention and uptake, and to explore good practice.

Search Strategy
The review was registered with PROSPERO (CRD42021259190) 18 and followed PRISMA guidelines 19 . A Boolean search strategy was developed containing terms relating to migrants, ethnic minorities, COVID-19, social media, and misinformation (see supplementary information 1). We searched the following databases: Embase, Web of Science, Oxford Academic Journals, PubMed NIH, Clinical Trials, China CDC MMWR, CDC reports, ProQuest Central (Proquest), . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Records were imported to Rayyan QCRI 21 . Both title and abstract screening and full text screening were conducted independently by two reviewers (MR-P and LG) using Rayyan QCRI 21 , with discrepancies resolved by a third reviewer (SH). Additional relevant papers and grey literature (e.g. from third-sector organisation websites) were identified using hand searching including backwards and forwards citation tracking.

Selection criteria and primary outcomes
Papers reporting the use of social media platforms and implications for preventative health measures and vaccination intent of migrants and/or ethnic minority groups to COVID-19 globally were eligible. All types of scientific articles, reports and commentaries, editorials, correspondence letters were eligible for inclusion. Social media platforms were defined as any medium whereby content (including images, videos, and messages) is circulated to the general public and may include YouTube, Facebook, Twitter, TikTok, and Snapchat. 'Migrants' were defined as foreign-born, residing outside of their country of birth. An ethnic minority group was defined as a group of people with a shared culture, tradition, language, history, living in a country where most people are from a different ethnic group, and will include migrants/foreign-born populations alongside individuals born in the host country. Where studies reported a general population sample, results about migrant/ethnic minority groups within that sample were eligible for inclusion. No papers were excluded based on language or . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint geographical origin. Studies were excluded if it was not possible to determine whether individual(s) in the population studied were migrants or from an ethnic minority group.
Data Extraction, critical appraisal, and synthesis Data extraction was completed independently by two researchers (MRP and LG) using a piloted, structured data extraction sheet in Microsoft Excel and data were collated and assessed using narrative synthesis. Risk of bias was assessed independently by two researchers (LG, MRP) using the Quality assessment for Survey Studies in Psychology for Surveys (Q-SSP) 22 for quantitative studies. The twenty items on this scale can be rated as "yes", or "no", "not stated clearly", or "not applicable". Scores are calculated by dividing the "yes" answers by the total number of applicable items, with scores over 70% indicating "acceptable" quality. The Critical Appraisal Skills programme (CASP) checklist was used for qualitative studies 23 . The ten items can be rated 'yes', 'can't tell' or 'no'. We rated the CASP by dividing the "yes" answers by the total number of applicable items, with a score of over 60% indicating "acceptable" quality. We did not exclude any papers on the basis of quality.

Overview of data sources
Following de-duplication, 1849 unique data sources were identified and screened and ultimately 129 were full-text screened. 21 data sources were included in the final analysis ( Figure 1). Six studies were conducted in the UK [24][25][26][27][28][29] , two were jointly conducted in the UK and US 30 31 . An additional eight studies were conducted in the US, [32][33][34][35][36][37][38][39] and one each in China, 40 Jordan, 41 Qatar, 42 and Turkey. 43 Eight studies reported on migrants, 27 29 32 40-44 including migrants in the host countries of China 40 , Jordan 41 , Quatar, 42 Turkey 43 , and the US 32 and UK 27 29 , and one study involved predominantly migrants from Venezuela residing in other countries. 44 Nine studies reported about a specific ethnic minority or group (Latino individuals, 32 34 36 37 Black American citizens, 35 39 , Jain community members 28 and Syrian migrants 41 43 ). Seven studies . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Characteristics of included studies are presented in Table 2, including the risk of bias assessment scores. Quality scores ranged from 76% to 90% for included papers, suggesting acceptable quality of all included data sources where quality assessment was applicable. Figure   2 shows the geographical location of data sources, highlighting the absence of published and unpublished data on this topic from most regions of the world.

Use of social media platforms as a source of information about COVID-19
For some migrants and ethnic minority groups, consistent use of social media platforms for sharing and receiving COVID-19-related health information was reported in several included studies 29 34-36 40-42 44 43 . Social media was reported to be the preferred source of information about COVID-19 for international migrants in China (WeChat was used by 94.5% of respondents for COVID-19 information). 40 Among 389 Syrian refugee mothers in Jordan 41 , Facebook and WhatsApp were the main sources of information for 87% and 69% of respondents respectively for COVID-19 information; with 21% indicating that they accessed information from professional databases or government websites, and 53% via television (this survey was circulated via Facebook and WhatsApp). Migrants from Venezuela (residing in numerous countries) reported Facebook and WhatsApp were their two primary sources of information about COVID-19 in a survey of 334 migrants 44 . A survey of 774 refugee households in Southeast Turkey 43 found the majority (75%) obtained COVID-19 information from Facebook, YouTube, Twitter and the internet in general, 15% via SMS/WhatsApp messages, followed by radio/TV (64%) and members of their community/family (34%); only 10% reported getting information from NGO/UN sources. This study concluded that the heavy reliance on social media for information may expose a sizeable proportion of refugee households to fake or inaccurate information. In a US study of Black women aged 18-31 years, 58% of respondents reported using social media (Instagram and Facebook) to obtain COVID-19 information 35 . Participants from the US Latino community described relying on social media for information about the . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint pandemic 34 . In Qatar, migrants reported they preferred to find out about COVID-19 using their own personal research or searching for information, including using social media as a source 42 .
A study of precarious migrants (asylum seekers, undocumented migrants) in the UK found many relied on social media (WhatsApp groups, Facebook) for information on the pandemic and the ongoing vaccination programme 29 .
A key theme emerging in one UK study of ethnic minority groups 24 was that the "avalanche" of information surrounding COVID-19 had led to interviewees feeling overwhelmed and confused: participants reported using a variety of sources of information, including TV, radio, news stations in Pakistan, India, Slovakia, and Poland, online newspapers, Facebook, WhatsApp, Twitter, Google, and medical journals. A number of these participants said they dismissed some stories encountered on WhatsApp and Facebook; however, the sheer volume of messages coupled with the fact that people they trusted were sharing them, proved difficult to ignore, with participants raising concerns about how quickly social media stories were shared. One study exploring the views of US Latinos reported that they consulted national and local news reports for information about COVID-19 and many reported that they got their news from Spanish-language news due to difficulty in understanding news in English; some received their news from social media sources, including Facebook, but expressed caution around messages from social media as there was no way to ensure the accuracy of the reports. 37 According to one study, member of ethnic minority groups were also more likely to post COVID-19 content on social media than White individuals 33  . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint

Drivers of social media reliance
Studies reported that some migrant and ethnic minority groups turned to social media due as a result of a need for connection and to acquire accessible information from people they considered to be reliable sources. For the Latino community in the US, faith and community bonds were valued ways of coping with the difficulties of the pandemic which included feelings of social isolation, stress, and uncertainty and -according to one study -social media facilitated these connections in a virtual space 37 . The Jain community in London used social media to communicate news and knowledge about COVID-19 and stay connected online, with events moving to a virtual space; individuals reportedly benefited from and were grateful for this community use of social media 28 .
Several studies highlight concerns that some migrant and ethnic minority groups were unable to find official information in their host country in their native language about various aspects of COVID-19, hence their reliance on social media 24 27 29 40 43 . For example, a UK study of precarious migrants (asylum seekers, undocumented migrants) reported that those feeling most abandoned or scared due to a lack of understandable, clear official information in the early stages of the pandemic were more likely to rely on word-of-mouth or social media (WhatsApp groups, Facebook) for information, including around the vaccination programme 29 .
One study of international migrants in China (94.5% of whom preferred social media for news about COVID-19) had lower rates of correct knowledge about COVID-19 compared to rates reported for Chinese residents 40 . The authors speculate that this might be due to a lack of available public health information in a range of languages.
Other studies showed positive associations with use of social media and access to information.
One study highlighted that social media can support migrants to navigate the complex medicolegal context of their host countries by accessing information about public health measures and how to access medical help 32 . Social media use was associated with improved knowledge about COVID-19 and how to stay safe, in studies of Syrian refugee mothers 41 and US Latinos 36 . In another study specifically curated, culturally relevant digital content was . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint considered to be an effective health promotion tool to share knowledge about practical actions to be taken to address the inequitable impact of the pandemic on US Latinos 36 .

Misinformation and social media use
A summary of some of the key misinformation narratives identified in studies are provided in Table 3. Some studies made links between social media and circulating misinformation in migrant and ethnic minority groups. For example, a UK cohort study found that both belonging to an ethnic minority group and socioeconomic disadvantage was associated with both exposure to misinformation about vaccines, and mistrust in information about COVID-19 25 . A study of Syrian refugee mothers in Jordan, who reported receiving most of their COVID-19 information through social media, identified some erroneous beliefs about pregnancy, COVID-19 and breast milk 41 . A UK study among ethnic minority groups reported that participants encountered a range of misinformation, usually through social media sources and that vaccine hesitancy could be attributed to safety concerns, negative stories and personal knowledge, all of which had been amplified by recent exposure to misinformation via social media 24 . Myths identified included the idea that health professionals at the local hospital were injecting people with COVID-19 or killing people with the COVID-19 vaccine; there were wider beliefs reported about vaccines containing a microchip; making people infertile, or that vaccines are being tested on ethnic minority individuals 24 . These participants described the dilemma of not knowing what to trust or who to listen to, including the videos /posts that appeared to be from trusted professionals; therefore, they could not entirely dismiss negative stories circulating via social media and elsewhere.
In a study of 60 Latinx adults hospitalised for COVID-19 in the US, many participants reported that they relied on social media for COVID-19 recommendations and described a lack of information and circulating misinformation, with suspicion of the government and immigration departments was a common misinformation theme: "some of us see [COVID] as a tactic for the government to access our documentation status and deport us" 34 . One Mexican male (age 45) . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. in one US study 37 noted: "When someone uploads something to Facebook then no-one believes in it 100%"; a Mexican female (age 33) was also quoted as saying "[I get my information] well through the news, TV, Facebook and all of that…not everything I see is credible".
In a UK qualitative study 24 , participants who initially disregarded conspiratorial beliefs found it challenging to maintain their confidence that the rumours were untrue due to a number of  26 . A UK qualitative study reported that ethnic minority groups were influenced by anti-vaccine misinformation, including from social media. 24 A UK qualitative study of precarious migrants found that among 23 participants who were hesitant about receiving a vaccine some participants described fears around theories based on misinformation, often originating from social media or word of mouth, with many describing feeling conflicted about which information sources to trust 29 . Community leaders from African, Caribbean, Asian and Eastern Mediterranean migrant groups in London, UK reported substantial COVID-19 vaccine hesitancy due to misinformation circulating on social media and word of mouth combined with a lack of accurate, translated and clear guidance 27 . Similarly, in a US qualitative study of Latino adults, some participants reported encountering a lack of knowledge . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint accompanied by misinformation on social media causing them to dismiss preventative measures 34 . Another US study among Latino people reported that social media acted as a potential deterrent for following some public health measures to prevent infection by allowing people to observe the negative, guideline-breaking behaviours of others in social media posts 37 .
On the other hand, a large (8,001 participants) US/UK randomised controlled experiment 30 found no significant differences in the response of different ethnic groups to misinformation in relation to vaccine intent. A large US/UK study 31 found membership of an ethnic minority group was associated with reduced vaccine intention, a relationship which was significant in three out of four studies (p<0.001, n=3890; p=0.017, n=1663; p<0.001, n=2237). The relationship persisted even when use of legacy (print and broadcast media) and frequency of use of social media was controlled for. High levels of social media use was not associated with vaccine intent in any of the three studies exploring this relationship; however, high information reliance on social media was significantly associated with negative vaccine intent (p=0.028, n=2237), suggesting a reliance on social media for information can make users vulnerable to misinformation. This study did not include interaction terms between ethnicity and information reliance on social media, which could have indicated whether the effect of information reliance on social media on vaccine intent differs by ethnicity.

Good practice in promoting information and countering misinformation
Evidence suggests the important role of strong connections with the local community to identify and counter misinformation and rumours by trusted and valued sources of information.
Most studies recommended improving the accessibility of public health information for migrant and ethnic minority communities. 25 27 32 34 35 37-40 44 For example, providing public health information in the media channel preferred by that group 34 , in multiple languages 24 , and using local, trusted voices delivering specific and targeted messages to counter fake news 24 34 . A strong interest in online, personalised information was identified 36 37 . Where social media was used to share personalised and culturally tailored public health information, it has a positive influence with good health knowledge, health seeking behaviours and vaccine intent 24-27 32 34-36 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint 38-41 44 . Studies indicated the need for culturally tailored health messaging to ensure equitable health knowledge for improving vaccine intent and health seeking behaviours 27 34-36 .
More personalised means of health information communication was highlighted as a demand for informational reliance. A national US organisation which provides online health information tailored to the US Latino community found a high level of interest in their COVID-19 curated content, suggesting a strong demand for tailored and culturally relevant material 36 . In a new approach, 'virtual patient navigators', helpers working online, typically using messages to provide individually tailored health information, were made available to Latino migrants through a New York-based communication platform 32 .
Working through trusted sources was also emphasised. Providing accurate and tailored information about COVID-19 via trusted community members and organizations was suggested in a study of Black women aged 19-31 years in the US 35 .The study recommended that health professionals take an active role collaborating with the community to address inequities that Black women are experiencing in the pandemic 35 . Participants in a randomised controlled study to explore the impact of misinformation on vaccine intent on different populations groups reported finding videos on social media very engaging, especially when delivered in multiple languages by someone in a trusted profession (e.g., doctor/teacher/nurse) 30 .
Successful countering myths was reported in a UK study wherein the local council rapidly responded to fake news circulating in the local population (e.g., a rumour about children who test positive in school for COVID-19 being removed from the school and/or their parents until they test clear) 24 . Videos to refute the myth were swiftly posted online in both Urdu and Punjabi, and these were reported to be effective by members of the local population 24 .
Additional studies report successfully countering misinformation using a network of patient navigators 32 and community household surveys 24 . Social media use to communicate with family was also reported to be effective in challenging COVID-19 denial misinformation rumours through reporting of lived experience of COVID-19 34 .
. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. However, it is limited by the availability and quality of the datasets available. We acknowledge the limited geographical scope of included studies, with 16 of 21 studies focused on migrant . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint and ethnic minority populations residing in the UK and US and no data at all from low-income countries. We acknowledge that definitions and terms pertaining to migrants and ethnic minorities and social media are used inconsistently in research; this is an ongoing challenge within the field, which has previously been evidenced in similar reviews, and may mean we have missed papers. This was mitigated against by searching the published and grey literature more widely. In addition, we acknowledge that migrants and ethnic minorities are a highly diverse group with a range of health and socioeconomic situations making it hard to generalise; however there is evidence in several contexts that these populations may have been disproportionately impacted by the COVID-19 pandemic 13 15 45 .
The findings of our review have been confirmed by more recent studies. For example, a survey of migrants in Greece found their main source of information about the vaccine was via social media platforms and the internet in general, and that vaccine hesitancy was linked to a lack of adequate information and driven by fear, anxiety, exposure to negative news and misinformation 46 47 . In Turkey, a 2021 survey and feedback mechanism in refugee communities found information gaps, misconceptions, and rumours about COVID-19 vaccines circulating mainly by word of mouth and on social media, undermining health information 48 . In a recent study of Venezuelan migrants in Latin America, 70% said they had access to a mobile phone, with the main communication channels being WhatsApp and Facebook, yet half said they felt uninformed 49 . We also found that some migrants and ethnic minorities used diaspora media as a source of COVID-19 related information during the pandemic, which merits further consideration in terms of understanding how to better engage these groups in preventative health care and vaccination, and has been previously reported in studies as influencing views and beliefs around vaccination 50 . Misinformation on social media correlated negatively with vaccine intention and our findings align with other research in this area and will undoubtedly be relevant to many other population groups 2 7 29 . A recent study among migrants and nationals in Qatar acknowledged 'personal research' via social media as important to them for seeking information about COVID-19 vaccines, underlining the key role social media has in influencing people's attitudes towards vaccine uptake 51 .
. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint The European Centre for Disease Prevention and Control (ECDC) and other public health bodies have raised concerns around barriers to public health information among migrant populations and ethnic minority groups residing in Europe and other high-income countries during the pandemic 13 14 . Public health guidance in some countries was not initially tailored to the needs of migrant and ethnic minority groups 17 52-54 . A review of the availability of government produced risk communications across Council of Europe member states in June 2021 found only 48% (23/47) of countries translated COVID-19 information into at least one migrant language, with information on testing or healthcare entitlements in common migrant languages only found in 6% (3/47), suggesting individuals not able to access information in the host country language may have been excluded to some extent from governments' public health messaging 17 . In Denmark, a series of qualitative interviews with migrants found that they felt uncertain regarding government guidance for COVID-19; although written material was translated into 19 languages, it was not effectively disseminated 55 . In Montreal, Canada, there were delays to publishing official multilingual fact sheets on COVID-19 guidelines, and information phone lines only operate in French and English; those who had arrived most recently, had lower language (French/English) ability or lower literacy had more difficulty accessing local COVID-19 information 56 . Lack of English or French language at the time of immigration to Canada were associated with lower rates of testing and higher percent positivity for COVID-19 in recently arrived adult immigrants and refugees 57 . A study among refugees and migrants in deprived areas in Greece found that migrants may have difficulties understanding public health messaging due to cultural and language barriers. 17 53 58 Merely translating public health information is not likely to be sufficient; information needs to be tailored and targeted so it is conveyed in ways that resonate with the target population. A range of key resources and guidelines on risk communication and engagement strategies for COVID-19 public health responses, including vaccination, among marginalised populations globally are available, as well as a social media toolkit for healthcare practitioners (https://www.who.int/publications/m/item/a-social-media-toolkit-for-healthcare-practitioners---desktop) [59][60][61] . However, it will be vitally important that the lessons learned around . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint communication of public health information to marginalised groups during the pandemic are meaningfully carried forward.
Where social media is used to share personalised and culturally tailored public health information, it has a positive correlation with good health knowledge, health seeking behaviours and vaccine intent 36 41 Our research shows the need for culturally tailored health messaging to ensure equitable health knowledge and to improve vaccine uptake, by accurate public health messaging through trusted sources of information 27 34-36 . We make a number of recommendations for policy and practice (Table 4), which include the need for systematic monitoring of information and attitudes circulating on social media 62 , as well as timely rebuttal of misinformation from trusted professionals. Several resources are now available to support addressing misinformation about COVID-19 vaccines as well as fostering demand for vaccines. [63][64][65] There is a stark lack of data on social media use from low and middle-income countries, which merits greater consideration as COVID-19 vaccination gathers pace in these contexts. In addition, more evidence is needed to examine the role social media platforms play in positively or negatively influencing health behaviours such as vaccine intent and uptake for COVID-19 in all populations (including other excluded groups eg, homeless, internally displaced people/IDPs). Social media is an important source of health information for some migrant and ethnic minority communities and tacking misinformation needs to be done using this medium given the lack of trust in government messaging in some of these communities 66 . Our findings are consistent with those of others working in this field, which show that social media can have a crucial role in disseminating health information, tackling infodemics and misinformation 4 .
There is an opportunity now to more effectively use social media to make vaccine intent desirable, appealing and normative among migrants and ethnic minority groups. There is an urgent need to address infodemic-related challenges in a rapidly changing information environment, including real-time monitoring of social media messages and misinformation and the development of online tools to fight disinformation, with a focus on collecting stratified . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint population data to enable targeted and tailored responses. Robust interventions relying on behavioural science to tackle misinformation using social media and evaluations are a plausible next step to address immunisation challenges for COVID-19 vaccines but also routine vaccines.
Building trust in public health messaging, identifying information gaps, finding innovate ways of disseminating health information, and detecting and responding to misinformation as it emerges remain a priority for public health 66 67 .

Conflicts of Interests
All authors report nothing to declare.

Data availability statement
All data used in the systematic review are appropriately referenced and available online in the sources cited.

Ethics statements
Not applicable.

Patient consent for publication
Not applicable. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Research Council (MRC/N013638/1). KR is funded by the Rosetrees Trust (M775). MR is funded by an NIHR In-Practice Clinical Fellowship (NIHR 302007). JC is funded by an NIHR In-Practice
Clinical Fellowship (NIHR300290). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Contributors
The study was conceptualised by SH, and the protocol and research question were developed by SH, LPG and MRP. Searches were developed by MRP and LG, with input from SH and SEH.
Screening was done by LPG and MRP. Data extraction and analysis was done by LPG and MRP, with input from SH. The first draft of the manuscript was produced by LG, MRP, and SH, and developed with KH and TV, who all contributed to interpretation of the results. All authors commented upon and approved the final manuscript. SH is guarantor of this study.

Disclaimer
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Competing interests None declared.
. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
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(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint  . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted February 7, 2022. ; *Scores were calculated on both scales by dividing the "yes" answers by the total number of applicable items. 1 Quality assessment for Survey Studies in Psychology for Surveys (Q-SSP) Checklist for surveys 2 N/A = not applicable due to research item design. 3  . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint  "The new vaccine for COVID-19 will be the first of its kind EVER. It will be an mRNA vaccine which will literally alter your DNA. It will wrap itself into your system. You will essentially become a genetically modified human being" . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022.

COVID-19 is caused by 5G
COVID-19 has been invented to make people use contactless payments so that the government can track individuals COVID-19 testing gives so many false positives that it is ineffective and you should not selfisolate COVID-19 exists but is not as virulent as the government says it is If children test positive for COVID-19 during school hours, they can be taken away into care and will not be able to see their parents until they test negative The COVID-19 vaccine contains a chip that will track individuals, stop them travelling etc The COVID-19 vaccine will make people infertile and is an attempt to reduce the population, particularly targeted at people from BAME communities BAME people are being used as 'guinea pigs' to test out the COVID-19 vaccine The COVID-19 vaccine has been developed and approved too quickly and has not been fully tested The COVID-19 vaccine will negatively disrupt your natural immune system Herbal remedies will be more effective than the COVID-19 vaccine 1 Engagement measures the number of likes and retweets. 2 Reach measures the number of followers and thus potential audience size. NK=Not known.
. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint Table 4: Key messages and recommendations • Social media is an important source of health information for some migrant and ethnic minority communities, who may face barriers to accurate public health information, health, and vaccinations systems. More evidence is urgently needed to examine the role social media platforms play in positively or negatively influencing health behaviours such as vaccine intent and uptake for COVID-19 in marginalised populations.
• There is a stark lack of data on social media use from low and middle-income countries which merits greater consideration as COVID-19 vaccination gathers pace in these contexts.
• More emphasis must be placed on exploring opportunities for sharing and transmitting accurate information via social media platforms, for example, to make vaccine intent desirable, appealing and normative.
• Use of diaspora media by migrant populations, as a source of COVID-19 related information during the pandemic and for other health information, merits further research and greater consideration when designing and delivering public health interventions.
• Proactively monitor social media platforms and other media sources to identify antivaccine sentiment, misinformation, fake news, and rumours, and address them in real-time.
• There is a need to promote targeted and tailored health information to marginalised populations who face access barriers to health and vaccination systems, through preferred and trusted sources and channels of information including social media platforms, and to ensure investment in workforce and infrastructure to support this.
• Engage with and involve communities in developing culturally specific messages and approaches, and support community-driven initiatives to identify at-risk groups, map local influencers, and define content for locally meaningful communication campaigns. Facilitate partnership working at the local level through involvement of diverse stakeholders and ensure community partners are recognised and reimbursed for their contributions and expertise.
• Social media platforms should exercise more accountability and sign pledges to systematically track and remove harmful content that undermine public health . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint measures, particularly during a public health crisis. The public must be empowered to identify and flag misinformation on social media • Public health bodies and healthcare professionals should avoid a narrow focus on misinformation and a one-way communication of 'more accurate' information. They should seek to understand the underlying causes of exposure to and belief in misinformation including genuine knowledge void, access barriers and health literacy.
• Lessons must be learned around shortfalls in the communication of public health information to marginalised groups during this pandemic. Importantly, countries should gather and evaluate innovations and models of best practice in this area, which must be meaningfully carried forward to strengthen uptake of routine vaccinations and other public health interventions.

Online supplement 1: Boolean search terms
Migrant and ethnic minorities Ancest* OR Diaspor* OR ethnic* OR Ethnoc* OR Ethnog* OR "Identity politics" OR Ingroups OR outgroups OR Intersectionality OR Kinship OR "Minority group*"~3 OR "minority population*"~2 OR minorities OR Multicultu* OR Polyethnic* OR "Population genetics" OR Race OR races OR racial OR Tribe* OR latino*) OR AB:(Ancest* OR Diaspor* OR ethnic* OR Ethnoc* OR Ethnog* OR "Identity politics" OR Ingroups OR Outgroups OR Intersectionality OR Kinship OR "Minority group*"~3 OR "minority population*"~2 OR minorities OR Multicultu* OR Polyethnic* OR "Population genetics" OR Race OR races OR racial OR Tribe* OR latino*) OR "afro american*"~3 OR BAME OR latino* OR roma OR romani OR refugee* OR immigrant* OR "migrant" OR "displaced person" OR "displaced persons" OR "social determinant*"~2 OR "latin population" OR "latin group*" OR "people of color" OR "people of colour" Social media social media OR social network OR online communit* OR online discuss* OR online communicat* OR online post OR messag* OR chat OR media OR . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.07.22270579 doi: medRxiv preprint