JMIR Publications

ABSTRACT

Background:

In the last decade, social media has evolved from a mere communication tool into a dominant ecosystem for commerce and information dissemination. The healthcare sector has not been immune to this shift, with digital platforms offering healthcare providers unprecedented reach to engage with patients [1]. However, this digital transformation has introduced a "double-edged sword": while it democratizes access to health information, it also facilitates the rapid spread of medical misinformation and unethical marketing practices [2]. Misleading healthcare advertising is defined as promotional communication that exploits the "asymmetry of information" between the doctor and the patient, promoting exaggerated claims, unverified treatments, and manipulated success stories [3]. This issue is not merely a matter of consumer protection; it is a profound bioethical crisis. When healthcare is marketed with the same aggressive tactics as consumer goods, the fundamental medical principle of primum non nocere (first, do no harm) is often compromised. Medical advertising is ethically governed by the pillars of Autonomy, Beneficence, Non-maleficence, and Justice [4,5]. In Somalia, this situation is particularly acute. Following the collapse of centralized systems in 1991, the Somali healthcare system became largely privatized. Today, while the Federal Government has made significant strides in public health governance, the private sector remains the primary provider of care for many citizens [6]. This has created a unique ecosystem characterized by high digital connectivity and a deregulated health market. The fierce competition among private hospitals and clinics in cities like Mogadishu, Hargeisa, and Garowe has driven providers to aggressive digital marketing [7].

Objective:

This study aims to empirically document the trends, ethical challenges, public health risks, and existing regulatory gaps regarding misleading healthcare advertising on Facebook and TikTok in Somalia. Specifically, the objectives are: 1. To analyze the prevalence and nature of misleading healthcare advertising on Facebook and TikTok in Somalia. 2. To assess the ethical challenges, specifically regarding patient autonomy and confidentiality. 3. To evaluate the gap between existing Somali health regulations and the reality of the digital marketplace. 4. To propose evidence-based recommendations for the Ministry of Health and medical associations.

Methods:

Methods Research Design This study employed a Descriptive Cross-Sectional Design utilizing Mixed-Methods Content Analysis. This approach allowed for the quantitative measurement of violation frequencies and the qualitative interpretation of the messaging used in advertisements. Study Population and Sampling The study focused on the digital footprint of healthcare providers in Somalia. The platforms selected were Facebook (Meta) and TikTok, as they hold the largest market share in Somalia for social media engagement. Sampling Method Purposive sampling was used to identify the top 20 most active healthcare pages (based on follower count >10,000 and posting frequency) on Facebook and TikTok that explicitly marketed healthcare services in Somalia. Sample Size A total of 150 advertisements (videos and static posts) were extracted between January 1, 2024, and June 30, 2024, ensuring a balanced representation across different types of healthcare services and platforms. Inclusion and Exclusion Criteria ● Inclusion: Posts by private hospitals, clinics, or individual healers explicitly marketing a service, surgery, or product within Somalia. ● Exclusion: General public health awareness posts (e.g., vaccination drives by NGOs) that were not commercial in nature. Data Analysis Data was coded using a structured checklist developed based on the WHO Ethical Criteria for Medicinal Drug Promotion and general bioethical principles. Key variables extracted and analyzed included: 1. Identifiability: Was the patient’s face or other identifiable features visible? 2. Consent: Was there explicit visual or verbal evidence of informed consent for broadcasting? 3. Claims: Were words like “Miracle” (Mucjiso), “Guarantee” (Damaanad), or other absolute, unscientific terms used? 4. Endorser: Were the advertisements presented by a qualified medical doctor or a non-medical social media influencer? 5. Content Type: Was the content a testimonial, live procedure, product promotion, or general information? Quantitative data were analyzed using descriptive statistics (frequencies and percentages). Qualitative data involved thematic analysis of the content to identify recurring patterns and narratives related to ethical breaches and marketing strategies.

Results:

Results Quantitative Trends The analysis indicates that ethical misconduct is a systemic issue across the sector. Among the 20 healthcare pages monitored, 90% (n=18) were found to have published at least one advertisement containing a direct ethical violation during the study period. This suggests that misleading advertising is not limited to a few bad actors but is an industry-wide marketing standard. Within the sample of 150 posts, the detailed breakdown of ethical violations by category is summarized in Table 1. Table 1: Frequency of Ethical Violations in Healthcare Advertisements (n=150) Violation Category Count (n=150) Percentage (%) Breach of Patient Confidentiality (Visible faces/identifiers) 68 45.3% Exaggerated/Absolute Claims (“100% Cure”, “Miracle”) 57 38.0% Unverified Testimonials 40 26.6% Influencer Endorsements (Non-medical personnel) 35 23.3% Fear-Mongering 18 12.0% Qualitative Themes The “Live Case Study” and Patient Autonomy A significant finding was the pervasive use of “live” surgical footage or patient recovery scenes. In 45.3% of the sample, patients were shown in operating theaters, consultation rooms, or recovery rooms. A deeper qualitative analysis of this footage revealed a concerning lack of patient engagement or apparent consent. In approximately 60% of the videos featuring identifiable patients, the subjects did not make eye contact with the camera or acknowledge the recording. They often appeared disoriented, sedated, or focused entirely on their pain, suggesting they were unaware they were being filmed or were in no condition to provide informed consent. Several videos depicted patients in states of partial undress or visible distress (e.g., moaning in pain) while the physician narrated the procedure enthusiastically for marketing purposes. This indicates “passive participation," where the patient is treated as a prop for the doctor's marketing rather than an autonomous participant. There was no visual or verbal indication in these clips that informed consent for broadcasting (distinct from treatment) had been obtained, suggesting a direct violation of the patient’s right to privacy as outlined in the Declaration of Helsinki. The Rhetoric of the “Miracle” (Mucjiso) The term *Mucjiso* (miracle) was prevalent in 38% of advertisements, particularly in dermatology, fertility, and herbal medicine sectors. Ads for chronic diseases (e.g., Diabetes, Hypertension) frequently promised “permanent eradication” (Ciribtir), directly contradicting established medical consensus that these are manageable but lifelong conditions. This rhetoric often leveraged cultural beliefs in divine intervention, framing medical procedures as miraculous cures rather than scientific interventions. The Influencer-Doctor Dynamic The study observed a distinct trend of “white coat appropriation,” where social media influencers, lacking medical qualifications, donned medical attire to promote clinics, procedures, or specific products. These influencers often presented themselves in clinical settings, mimicking medical professionals. Comments on these posts indicated that the public frequently mistook the influencer for a medical professional, seeking medical advice directly from them in the comment sections, thereby blurring the critical line between entertainment and clinical advice. The Institutional Void on Digital Accountability The content analysis not only revealed widespread ethical violations but also highlighted a profound institutional void in oversight. Throughout the observation period (January–June 2024), not a single advertisement (n=150) displayed a medical license number or a disclaimer required by the Ministry of Health, which is standard practice in regulated markets. The study found that the current regulatory mechanism is entirely reactive. Interviews with stakeholders (or analysis of public records) suggest that the NHPC and Ministry of Health primarily respond to physical malpractice complaints filed by patients after harm has occurred. There appears to be no proactive monitoring system (e.g., a Digital Health Taskforce) capable of flagging misleading content before it reaches the public. Consequently, dangerous claims, such as herbal mixtures replacing dialysis, remained active on platforms for months, gathering hundreds of thousands of views without intervention. The findings indicate that in the absence of state regulation, social media algorithms have become the de facto regulators of Somali healthcare. The study observed that the TikTok algorithm, in particular, favored high-engagement, sensationalist content (e.g., graphic surgery videos, "miracle" claims) over evidence-based health education. For instance, most NGO posts promoting evidence-based health information received low engagement (<1,000 views), while sensationalist "Guaranteed Cure" posts frequently garnered high engagement (>50,000 views). Because there is no legal framework defining "misleading digital health claims" as a punishable offense, bad actors operate with impunity, leveraging these algorithms to maximize profit while the NHPC lacks the statutory power to issue "takedown notices" to these platforms.

Conclusions:

This study provides compelling evidence that misleading healthcare advertising on social media in Somalia represents a significant public health threat and a systemic ethical crisis. The widespread breaches of patient confidentiality, the proliferation of unscientific "miracle cure" claims, and the commodification of medical authority by non-medical influencers underscore a critical regulatory vacuum. This environment not only erodes public trust in healthcare providers but also directly endangers patient safety by promoting misinformation, potentially leading to delayed or inappropriate care, and increased morbidity and mortality. To mitigate these severe risks, urgent and comprehensive interventions are required. The Government’s Health authorities, specifically the Ministry of Health and the National Health Professionals Council, must prioritize the establishment of a robust digital regulatory framework. This includes enacting a specific Digital Health Marketing Act that prohibits the use of absolute terms (e.g., “Guaranteed,” “Miracle”) in medical advertising and mandates transparency regarding medical qualifications and licensing. Furthermore, a dedicated Digital Health Taskforce should be established to proactively monitor social media platforms, flag misleading content, and enforce strict penalties, including fines and potential license revocation, for privacy violations and unethical marketing practices. Medical associations must also play a crucial role by developing mandatory media consent forms, distinct from surgical consent, and by integrating comprehensive ethics training focused on digital presence for all healthcare professionals. Finally, collaboration with social media platforms is essential to facilitate the identification and removal of dangerous health misinformation in the Somali language, complemented by public digital health literacy campaigns to empower citizens to critically evaluate online health information. Addressing these gaps is paramount to safeguarding public health and restoring ethical standards in Somalia’s rapidly evolving digital healthcare landscape. Clinical Trial: N/A