Johns Hopkins University Press

In the first years of the COVID-19 pandemic, social science was underrepresented in shaping government health policy. There are several reasons for this, which reflect the perceived low status of social science in health science. Nevertheless, social science is important to health science in confronting misinformation about the pandemic.

the covid-19 pandemic had unprecedented impacts on populations and societies worldwide. The effects were multifold and included health-related, mental, social, and economic consequences. Existing health and economic disparities in societies were made visible and have probably grown. In order to mitigate the COVID-19 pandemic, authorities across the world applied various strategies, such as public health measures (e.g., vaccination campaigns), scaling-up health services for patients with COVID-19, and financial support for affected citizens and firms (Turner et al. 2021). Political decision-making about these strategies and their implementation was complicated by societal realities, such as international political conflicts (e.g., China versus the United States) and the fragmentation of societies into separated worlds of like-minded people (e.g., Republicans versus Democrats in the United States). Large variations between countries were found regarding infection rates and number of fatalities related to COVID-19, including among countries that are geographically and economically close to each other. Analysis of 177 countries during the period from January 2020 to September 2021 found that the population profile (e.g., age structure and percentage of people with high body-mass index) and country characteristics (e.g., altitude, gross domestic product) explained only a small number of these variations (COVID-19 National Preparedness Collaborators 2022).

From the beginning, science has played a central role in the management of the COVID-19 pandemic. In current times of skepticism about science, the pandemic seems to have boosted trust in [End Page 175] science (Oude Groeniger et al. 2021). This seems particularly true for specific health disciplines such as virology and epidemiology. The clinical professions conducted scientific research to examine the disease, health workers' experiences with the pandemic, and new models of healthcare delivery (e.g., online consultations with patients). Beyond the health sciences, economic science supported governments by advising generous financial relief to affected individuals and firms. On the other hand, the social sciences and (to a lesser extent) the behavioral sciences seem underrepresented in the management of the COVID-19 pandemic in many countries (certainly until early 2022). Social and behavioral scientists conducted studies that could have contributed to the management of the pandemic, and some also provided policy recommendations, for instance regarding behavioral changes to implement public health policies (Michie and West 2021). However, these studies and recommendations seemed to have little impact on health policies in many countries.

A clear example of underrepresentation of the behavioral and social sciences in the management of the COVID-19 pandemic is the Netherlands, a high-income country in northwest Europe. In terms of performance in the years 2020 and 2021, it had high infection rates (standardized ratio of 344 per 1,000 inhabitants) compared to most high-income countries (e.g., 188 per 1,000 inhabitants in Germany, a neighboring country). The standardized case fatality rate was 5.95 per 1,000 inhabitants, also on the higher end (COVID-19 National Preparedness Collaborators 2022). After the start of the pandemic in the spring of 2020, a so-called outbreak management team was established as the main advisory body for the national government regarding the management of the pandemic. By the end of 2021, it had about 90 permanent or advisory members, nearly all of whom had medical degrees, with strong representation of virologists and epidemiologists. This body issued recommendations that were largely based on a quantitative model for the prognosis of infections and hospital admissions that was developed and owned by the National Institute for Public Health and the Environment. Most of the team's recommendations [End Page 176] were fully implemented by political leaders in 2020 and 2021. In these years, management of the pandemic was targeted at controlling the spread of the virus and avoiding hospital overload. Behavioral and social determinants of the spread of infections and hospital admissions, health outcomes in other diseases, and non-health effects of the pandemic were not visibly considered. Over time, calls for a more integral and sustainable approach to the pandemic grew, coming both from scientists in other disciplines (e.g., geriatrics, pediatrics, and social science) and from advocates of other (nonscientific) ideas and interests (e.g., libertarians). However, the national policy changed only in 2022, after a new government with a new minister of health was installed and the omicron variant of the virus led to few hospital admissions. In the first months of 2022, public trust in the governments' approach to the pandemic had declined to a low level, which recovered after restrictions were loosened later that year.

The importance of societal factors for the pandemic and its management was illustrated by the international study mentioned earlier (COVID-19 National Preparedness Collaborators 2022). This study found that high interpersonal trust in society and high trust in the government were associated with lower infection rates. Trust in science did not have a direct association with infection rates and number of fatalities but seemed indirectly linked to them, as vaccination rates were higher in high-trust countries. Nevertheless, nonscientific ideas from citizen science to conspiracy theories about the COVID-19 pandemic and its management spread in all societies in the first years of the pandemic (Erikainen and Stewart 2020). It is plausible that these ideas were associated with lowered trust in science, society, and government. For instance, a modeling study found that misinformation aggravates the impact of a pandemic, because it reduces the effectiveness of public health measures (Prandi and Primiero 2020). In summary, trust in society seems to have an impact on the effectiveness of strategies to reduce infection and disease. [End Page 177]

REASONS FOR UNDERREPRESENTATION OF SOCIAL SCIENCE

While there are some examples of behavioral science inputs into the management of the COVID-19 pandemic in 2020 and 2021, social science seemed largely absent in many countries. In this essay, social science in health refers to the sciences that focus on interconnected human behaviors (including thinking) that are relevant for health, such as (medical/health) sociology, anthropology, and geography. Central topics of social science research are equity, social cohesion, social identity, and modernization of societies. The interconnectedness of behaviors can be conceptualized in terms of social systems, social context, and social networks. As a consequence of the interconnectedness of behaviors, social scientists argue that the outcomes of the COVID-19 pandemic are not a simple function of infection rates and mitigation strategies, but are influenced by human behaviors that are nonrandomly distributed in populations. Apparently minor events and chance can therefore have large consequences, which explains the nonlinear character of some processes. For instance, Germany's COVID-19 infection rates in 2020 were low in comparison to other countries in Europe, mainly due to strict public health measures. Nevertheless, the overall excess mortality in the population was about as high as in neighboring countries (with much higher infection rates), which was probably caused by deadly outbreaks in nursing homes that occurred in Germany at similar rates as in other countries and accounted for a substantial portion of all deaths.

A primary reason for the underrepresentation of social science in the management of the COVID-19 pandemic is that knowledge from this field was not considered relevant for the pandemic's management. This view was demonstrated by medical professionals who seemed surprised that part of the population did not comply with pandemic-related regulations and expert recommendations such as to get vaccinated or practice social distancing. It is probably too simplistic to regard these experts' views as coming from the ivory tower of science. Such views seem to reflect the assumption that individuals [End Page 178] are essentially active, rational decision-makers who seek to optimize long-term benefits in their decisions. A further assumption may be that change in the population is essentially the aggregate of individual changes. Given these assumptions about human behavior, it would be sufficient to provide data and guidance to the public on the basis of the best available research evidence. Probably closer to reality, however, is that a substantial part of the population rarely practices rational decision-making. Many people are not easily motivated for planned behavior change to achieve individual or collective goals, which is directly obvious from the small effects of many interventions to improve individual health-related lifestyles. This raises issues of effectiveness and efficiency, as many behavioral change interventions (e.g., individual counseling) are expensive and unsuccessful in reaching individuals in deprived conditions.

A second reason for the underrepresentation of social science in the management of the COVID-19 pandemic is the opinion that these sciences might be relevant in principle but in practice have little to offer that is useful for the management of a pandemic. A milder version of this view may be that decision-makers believe that the relevant parts of this expertise are sufficiently covered by other disciplines, such as public health. Indeed, it cannot be denied that parts of social science are dedicated to description, analysis, and critique of phenomena in the world. Some social scientists seem to lack interest or competence to provide practically useful knowledge. Nevertheless, other social scientists have contributed knowledge on interventions and policies that aim to influence collective behaviors, for instance using knowledge of social networks and patterns of social exchange to influence health and other outcomes. Knowledge of such interventions could be relevant for the management of pandemics.

A third reason for the underrepresentation of social science may be that these sciences have yet to become relevant for policymakers, if the focus shifts from the prevention of infection outbreaks toward the management of the long-term consequences of the COVID-19 pandemic. The consequences of this pandemic are indeed impressive [End Page 179] and include, for instance, higher rates of mental health problems, addictions, domestic violence, and unhealthy lifestyles. Delays and dropping-out in schooling, unemployment, and financial debts are further consequences of the pandemic. Particularly for children and young adults, the impacts include lost opportunities for individual development in education, work, and relationships. The role of social scientists in policies and programs to address these long-term problems may indeed grow, as it will take several years to cope with all negative consequences of the pandemic and its management.

DYNAMICS OF SOCIAL SCIENCE IN HEALTH

The underrepresentation of social science during the COVID-19 pandemic is largely consistent with the dynamics of social science in health before the pandemic emerged. Like all disciplines and fields in the health sciences, social science has to compete for reputation, institutional integration, funding, and impact on decision-makers. In the politics of the health sciences, power and influence are associated with specific resources, none of which are easily available for social scientists in health. In the health domain, a major resource is first and foremost a clear role in healthcare delivery, as providers of treatment and care (e.g., physicians and nurses) or direct support roles (e.g., clinical laboratories). Particularly in the biomedical and clinical sciences, scientists can also gain power and influence by generating financial revenue from scientific work (e.g., through patented discoveries). This is rarely possible for social scientists. Pure scientific reputation is a further resource on which power and influence in the health sciences may be built. However, this is much easier to achieve for scientists who operate in the center of established scientific domains. Despite rhetoric that suggests otherwise, many scientists operating at the borders of these domains (e.g., medicine and social science) struggle to survive and thrive.

In addition, cultural factors impact the role of social science in health. While many social scientists approach phenomena as observable facts in an external world—similar to the natural sciences—some [End Page 180] assume that phenomena are socially constructed. As a consequence of this constructivist view, these social scientists apply principles and methods that do not easily match those of dominant parties in the health sciences, such as qualitative research methods (e.g., field observations and unstructured interviews). While most social science fields predominantly use quantitative methods, qualitative research methods may be perceived by health scientists as the only contribution of social science to health research (Wensing 2008).

Social scientists in health have applied various strategies to cope with their precarious situation. They may focus entirely on what other scientists regard as the specific contribution of social science, such as qualitative research or process evaluation in intervention research. This implies that they primarily respond to the needs of other fields and disciplines, thus transforming social science into a support service for other disciplines and fields. The development of ethical, legal, and social issues or implications in the life sciences (ELSI) may be an example of this strategy. Another coping strategy of social scientists is to build relationships with powerful parties outside medicine (e.g., health ministries) and use these as a basis for developing influence within the health sciences and the healthcare system. This strategy is commonly used in disciplines such as health economics, health services research, and health systems research. Also, social scientists have created new interdisciplinary fields (e.g., health services research) within the health sciences that integrate social science, yet in an implicit way. As a result of the application these strategies, social scientists in health research may feel decoupled from social science (Albert, Paradis, and Kuper 2015).

A possible scenario is that social scientists will become better integrated in multidisciplinary academic groups, because the COVID-19 pandemic has reinforced cooperation in applied research among scientists. For instance, this is the vision of a high-level committee for the development of science in Germany (Wissenschaftsrat 2021, 18); it argues that the pandemic has reinforced the need for integration of all scientific disciplines and fields. Given the stability of [End Page 181] social systems, another (maybe more likely) scenario is that nothing will change fundamentally in the dynamics that existed before COVID-19. Some powerful parties have probably strengthened their position during the pandemic (e.g., the medical profession and hospitals). The pandemic-related investments in some fields of health research (e.g., virology and epidemiology) imply a relative loss of power and influence for all other fields, including social science.

THE ROLE OF MISINFORMATION

During the COVID-19 pandemic, decision-makers were guided by other factors besides science. Since the start of the pandemic, many people launched ideas on aspects of COVID-19 and its management. For instance, lay people in the Netherlands developed and tested the hypothesis that ventilation in closed rooms is important for the spread of the virus, although virologists and epidemiologists initially did not prioritize this factor. While this proved to be a reasonable hypothesis, many other ideas on the COVID-19 pandemic can be described as misinformation: "information that is false, but not distributed with intent to cause harm" (Gradon et al. 2021). Examples are the belief that COVID-19 is similar to the common cold and the belief that vaccination prohibits pregnancy. Misinformation can be distinguished from other types of false information, such as disinformation and "malinformation," both of which are intended to cause harm. Misinformation has been associated with conspiracy theories and to a lesser extent with citizen science (Erikainen and Stewart 2020). Whether the latter can provide scientific knowledge is open to debate.

Although science uses various strategies to reduce bias (e.g., systematic methods and peer review), it produces many results that have been qualified as "waste" by leading scientists, because the methods do not meet scientific standards (Glasziou, Sanders, and Hoffmann 2020). Thus, it might be argued that the health sciences also contributed to the emergence and spread of misinformation about COVID-19. The increased use of preprint publications (in other [End Page 182] words, dissemination of study reports before peer review) and rapid production of many reviews of studies on various pandemic-related topics since the COVID-19 pandemic have probably accelerated the distribution of misinformation. In the longer run, however, bias in scientific research can be detected and addressed through continued and fact-driven review and debate, mechanisms that are often absent outside science. These mechanisms are less effective in the short run, which is the time horizon of many decision-makers, particularly in a crisis situation. Nonacademic users of research can in fact learn to distinguish between validated knowledge and misinformation. For instance, training helped nonexperts to understand the exponential character of the spreading of a virus and thus to align lay perceptions with scientific knowledge (Lammers, Crusius, and Gast 2020).

The spread and uptake of knowledge in healthcare is the topic of a dedicated field in the health sciences, which has been termed "implementation science": "the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services" (Eccles and Mittman 2006). Implementation science is firmly grounded in the behavioral and social sciences and at the same time closely linked to clinical and public health research. Over time, the field has broadened its focus to include the stopping of practices that are not, or no longer, evidence based ("de-implementation"). However, the field has not (yet) developed an explicit interest in the spread and uptake of misinformation in healthcare. The COVID-19 pandemic has highlighted that this is an important topic for the research agenda of social science in health.

The perspective of implementation science is useful in providing a first orientation to misinformation in health. Focusing on the knowledge that is generated or adopted first, modern healthcare aims to be evidence based: informed by the best available research evidence, clinical experience, and patients' preferences. The practice of evidence-based healthcare has been criticized as rigid, detached from patients' and healthcare providers' preferences and experiences, and [End Page 183] influenced by the interests of powerful health system stakeholders (Greenhalgh, Howick, and Maskrey 2014). Several alternative practices to provide information during the COVID-19 pandemic were consistent with these criticisms of evidence-based healthcare. For instance, in groups of like-minded people, many alternative practices emerge to pursue their preferences and build on their individual experiences. Engaging stakeholders in the design and conduct of health research ("integrated knowledge transfer") has been proposed to address this issue and thus strengthen the relevance of scientific research (Gagliardi et al. 2016). While this is an attractive idea, it comes with challenges. First, the replicability and validity of many methods for stakeholder involvement are unclear and need attention (Wensing 2017); the methods for engaging stakeholders need to be described more accurately to facilitate replication. Second, the integrity of the researcher vis-à-vis stakeholder interests or subjective views can be at stake, as the views may contradict existing research evidence. This topic needs more priority in the research on codesign, stakeholder involvement, and similar approaches.

Implementation science focuses on the design and evaluation of implementation strategies while emphasizing the roles of context and targeted individuals on the impact of these strategies. This approach has been conceptualized in various ways. For instance, context has been described as a complex system, which implies that its many components and processes influence outcomes in unpredictable ways (Gradon et al. 2021). Context has also been operationalized as social networks that influence the spread of innovations, similar to the spread of infectious diseases in social networks (Christakis and Fowler 2013). The underlying drivers of behavior change are mechanisms such as imitation of successful others and role modeling, but network structures and dynamics influence how these mechanisms play out. Insight into the role of social networks and social systems in the spread of knowledge and misinformation is an important topic for implementation science and social science in health generally. In order to be practically useful, this research should also consider interventions [End Page 184] that influence the spread of evidence-based information and misinformation.

CONCLUSIONS

The COVID-19 pandemic has highlighted the position and dynamics of social science in health. Although there are clues that the pandemic offers opportunities for this field, it remains to be seen whether those will materialize. The pandemic has also pointed to a number of exciting topics for social science in health, such as the roles of scientific knowledge and misinformation in the management of the pandemic. Research on the spread of misinformation is an important topic for social science in health, as it is in other fields (e.g., communication on climate change, nation building, and modern warfare). Better involvement of stakeholders in scientific work can enhance trust and counterbalance misinformation, but the methods for achieving this need to be strengthened.

Michel Wensing

michel wensing is a full professor of health services research and implementation science at Heidelberg University. He is embedded in the Department of General Practice and Health Services Research of Heidelberg University Hospital. His academic work focuses on the organization, performance, and outcomes of healthcare, with a particular interest in primary care.

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