COVID-19, commonly referred to as the novel coronavirus disease, was first reported in Wuhan city, Hubei Province, in the People’s Republic of China in late December 2019 [1]. Since then, it has spread to over 3.4 million people across 212 countries around the world and claimed the lives of over 239,892 people as of May 2, 2020 [2]. The first case of COVID-19 in India was reported in the state of Kerala on January 30, 2020 [3], and as of May 2, 2020, the number of active COVID-19 cases was 26,167 with 1218 deaths reported [4]. A simple Google search about “coronavirus” yields over 5 billion results. These numbers are in line with the fact that COVID-19 has been declared as not only a pandemic but also an infodemic [5].

The established treatment options available for COVID-19 are limited, and the disease outcomes are worrisome. Such sensitive scenarios may lead people to believe or, even worse, act on information such as unverified remedies for COVID-19 without confirming its authenticity [6]. This might lead to serious adverse events, which mandates limiting misinformation on public platforms.

Social networking sites (SNS) are an important source of communication as well as information due to their easy accessibility, rapid transmission, simple user interface, dependability, and widespread outreach. Along with its advantages, social media also has a dark side of propagation of rumors or misleading information, to the extent that Goolsby [7] demonstrated that social media can be potentially used to orchestrate crime. Kumar et al [8] has defined misinformation as the spread of false information without the intent to deceive. Several studies have evaluated the resourcefulness of Facebook and Twitter during natural disasters and health care crises, including the COVID-19 pandemic [9-11]. Studies have also described problems related to misinformation on Facebook and Twitter, especially during health crises. Sharma et al [12] reported that misleading posts were far more popular than the posts dispersing accurate relevant public health information about the Zika virus disease. Kouzy et al [10] reported alarming rates of COVID-19–related misinformation being disseminated on Twitter [10]. The social media platform WhatsApp has over 2 billion users across 180 countries, enabling global peer-to-peer and mass communication [13], with over 400 million users in India alone [14]. One in two Indians received some sort of misinformation via WhatsApp or Facebook within the span of merely 30 days in the year 2019 [15]. This kind of misinformation, especially related to health care, on a platform with minimal surveillance such as WhatsApp could have far-reaching adverse consequences. Thus, efforts to better identify and potentially rectify this issue are crucial.

Dodda et al [16] reported that certain age groups could be more vulnerable to misinformation via WhatsApp. Our study aimed to identify specific demographic groups that may be more vulnerable towards misinformation via WhatsApp. Vulnerability of users towards content on WhatsApp may be influenced by several factors, ranging from the mere appearance of a message to different types of evidence included in a message [8].

Our study aimed to analyze the effect of evidence included in a message on the credibility of a message shared on WhatsApp.

COVID-19 has caused an unprecedented biopsychosocial crisis. It has been declared not only as a pandemic but also as a worldwide infodemic [5]. Mentions about coronavirus in the form of news, updates, and especially misinformation on SNS are rising exponentially. In this study, we broadly analyzed factors influencing misinformation related to the disease (COVID-19) on WhatsApp. van Velsen et al [25] studied the reliability of Facebook and Twitter during an infective health crisis. They concluded that the majority of their study sample did not find these platforms to be reliable sources of information, and only 11% of the participants used them passively for information [25]. However, 39.92% (454/1137) of our sample considered WhatsApp as a useful information tool during this health crisis. Moreover, our study demonstrates active WhatsApp use by only 31.22% (355/1137) of the sample for COVID-19–related information. This finding suggests an almost 4-fold increase in reliance of individuals on SNS, particularly WhatsApp for news and information in recent times. Although trust levels in traditional sources of news have been higher, 57.78% (657/1137) of our study sample demonstrated a certain level of trust in CRWMs. With every 1 in 2 Indians receiving some false news on WhatsApp or Facebook, the consequences of the trust placed in these platforms could be serious [15].

Community preventive measures against COVID-19, particularly social distancing and using face masks, have proven to be effective and have been strongly recommended by the Government of India [48]; however, our study demonstrated that 16.18% (184/1137) and 20.93% (238/1137) of our study participants, respectively, did not implement these measures. This finding indicates that a considerable proportion of individuals demonstrate reluctance towards authorized recommendations.

Currently, no pharmacological agent has been proven to reduce mortality in COVID-19 cases [6]. Nevertheless, our findings confirmed that 1.85%-7.74% of the respondents were using or had used some form of complementary or alternative medicines for COVID-19 (Table 4). This finding suggests an interesting paradox wherein there is reluctance to accept evidence-based recommendations in favor of easy acceptance of novel but unverified remedies. This could result in serious health-related adverse events [49].

In addition, our study identified certain age groups were at a higher risk of getting influenced by COVID-19–related misinformation via WhatsApp. In particular, users over 65 years demonstrated the highest vulnerability to misinformation, whereas those under 18 years demonstrated the lowest. Vulnerability to misinformation progressively increased with users’ age. Limited knowledge of fact-checking resources, unawareness about existing misinformation on WhatsApp, and positive reinforcement from echo chambers could possibly explain these results [8]. This is particularly worrisome considering that older users tend to be more susceptible to the adverse effects of unsupervised remedies and are at a higher risk of severe COVID-19. Dodda et al [16] reported that WhatsApp users aged below 20 years and those above 50 years were the most susceptible to fake news. In contrast, our study findings showed that users aged under 25 years were the least susceptible to misinformation. Users aged between 19 and 25 years were at a significantly lower risk than those over 25 years (P<.05). Users in this age group tend to be well versed with SNS, including WhatsApp. Awareness about fact-checking resources and existence of misinformation on WhatsApp could possibly have reduced their vulnerability.

Among the different occupation groups, those employed in elementary occupations demonstrated the highest vulnerability to false news (K_mean=0.38). These users were significantly more vulnerable to misinformation than students and professionals (K_mean=0.34 for both, P<.05). A possible explanation for this observation could be the lower levels of education among the elementary occupation subgroup. Managers demonstrated the least vulnerability among the sample. However, a statistically significant difference could not be established, presumably due to the small sample size of this subgroup.

The vulnerability among HCWs was found to be consistent with all other occupation groups. During a health care crisis like the COVID-19 pandemic, HCWs are considered reliable sources of information by the community. Kumar et al [8] concluded that if false information is purposefully made to appear genuine, it can deceive trained and casual readers alike. COVID-19 is an evolving global health crisis wherein the mortality rate is high, established treatment options are limited, and HCWs are at a high risk of contracting the disease [6,50]. This vulnerability, coupled with a desire to treat patients, could possibly lead even HCWs to accept novel but unverified information. Such medical misinformation inadvertently propagated by HCWs may have unbeknownst consequences on the community.

Dodda et al [16] reported that background evidence and trust in organizations and individuals can make people believe in information received on SNS. Kumar et al [8] reported that that lengthy and well-referenced hoaxes were frequently misjudged to be true. In our study, for more than half the sample (659/1137, 57.95%), an attached link or source was a factor associated with increasing trust in a CRWM. Presence of background evidence was strongly associated with an erroneously higher trust of a false CRWM (P<.001). This finding indicates that individuals are likely to place emphasis on the presence of background evidence in a false CRWM in addition to its content while judging its veracity. Identification of such factors and ways to limit seemingly credible misinformation on SNS are pertinent questions that need to be evaluated in this digital age.

SNS usage patterns in developing countries are broadly comparable, although regional preferences regarding the choice of SNS may be different [51]. WhatsApp is a popular SNS globally with over 2 billion users worldwide, of which 400 million users are from India [13,14]. In our web-based survey study on WhatsApp users from India, all survey responses obtained were anonymous and voluntary. The study sample was representative of all age groups and majority of the occupation groups. We, therefore, are of the opinion that the findings of this study are representative of WhatsApp usage patterns in developing countries.

Our study had certain limitations. First, it was a survey-based study wherein data was self-reported; therefore, the sample may be tainted by observer bias (Hawthorne effect [52]). Second, the number of respondents in certain age and occupation subgroups were fewer, which could increase the risk of type 2 error during subgroup analysis. Third, the respondents’ opinions regarding CRWMs may have been formed through sources other than WhatsApp. The questionnaire was specifically designed to include the terms “WhatsApp” and “coronavirus” in the questions to address this limitation. Fourth, this study tested 4 message-based factors that could affect users’ trust in CRWMs. However, it was possible that other personal, regional, or community-based factors could also affect the users’ trust. To ensure generalizability of the results of this study, we chose not to analyze these belief systems. Fifth, the research model has limited support from the existing literature owing to its specific nature. It could be implemented in further similar studies to improve its validity. Finally, although well-referenced, the parameters P₁-P₉ used in this study are based on theories supported by the existing literature; hence, the results should be interpreted as correlational.

The results of this study present several challenges regarding the current COVID-19 pandemic for WhatsApp, fact-checking bodies, health organizations, and government authorities in developing countries. Cuan-Baltazar et al [53] found that the use of the internet during a pandemic is a risk to public health and recommend that the authorities should develop strategies to regulate online health information without censuring the public. Disasters mandate the circulation of timely information, which may at times compromise its genuineness. SNS have traditionally faced the issue of credibility at the cost of rapid transmission of information [23,54]. This may reduce the resourcefulness of a highly efficient communication tool such as WhatsApp, as seen in recent trends of decreasing trust in SNS in developed countries [51,55].

To address these challenges, health and government authorities in developing countries could collaborate with WhatsApp to develop methods to authenticate and tamper-proof messages from official sources. Leadership in health care organizations could actively work towards addressing digital awareness among health care workers who are the anchor points of information for the rest of the community. Fact-checking organizations could increase their presence on and integrate with SNS to improve their resourcefulness. Authorities could undertake awareness campaigns to educate users of SNS to recognize misinformation. WhatsApp could allow users to report messages containing suspected misinformation to allow necessary measures to be undertaken. WhatsApp, if used as a platform to broadcast validated information to a userbase as large as 400 million while providing measures enabling them to discern genuine news from misinformation, could revolutionize disaster management in a developing country.

In conclusion, our study analyzed factors influencing COVID-19–related misinformation among WhatsApp users in a developing country. Older adults (above 65 years) were more vulnerable to misinformation circulated on WhatsApp, as were individuals employed in elementary occupations. HCWs were also not spared from the influence of misinformation and were found to be as vulnerable as any other occupations. Presence of background evidence in a false CRWM was strongly linked to an increase in its credibility. These findings may provide important insights to health organizations and government authorities of developing countries to formulate suitable guidelines to contain the COVID-19 infodemic. Further experimental studies about parameters tested in this study could be considered.