A recent survey of more than 400 000 American adults found that during the pandemic, trust in physicians and hospitals decreased sharply, and higher levels of trust were tied to greater odds of getting vaccinated for Covid-19 or flu, said the researchers.
Their findings showed that the proportion of adults who agreed they had “a lot of trust” in physicians and hospitals declined from 71.5% in April 2020 to 40.1% in January 2024, reported Roy Perlis, MD, MSc, of Massachusetts General Hospital and colleagues in JAMA Network Open.
In regression models, factors associated with lower trust in 2023 included being 25 to 64-years-old, female, lower educational level, lower income, black race, and living in a rural setting.
Even when the researchers controlled for partisanship, these associations persisted.
“We were surprised by the magnitude of the shift,” Perlis told MedPage Today. “I think early in the pandemic trust probably increased above pre-pandemic levels, but it certainly came way down over the course of the pandemic.”
Not surprisingly, high levels of trust in physicians and hospitals were associated with greater odds of getting vaccinated for Covid-19 (adjusted OR 4.94, 95% CI 4.21-5.80) and influenza, (aOR 5.09, 95% CI 3.93-6.59) compared with having no trust at all. Greater trust also increased the odds of receiving a Covid-19 booster (aOR 3.62, 95% CI 2.99-4.38).
Even reporting “some” trust was associated with higher odds of getting a Covid-19 vaccine (aOR 2.48, 95% CI 2.12-2.90) versus having no trust.
“As physicians and public health officials we can talk until we’re blue in the face about things like vaccination and other public health behaviours,” Perlis commented. “But if people don’t trust us, it doesn’t matter – we’re talking to ourselves.”
The decrease in trust during the pandemic could have long-lasting implications for public health in the US, he added.
Perlis and his team also gathered information about why respondents had low levels of trust. Those with the two lowest levels of trust identified the following reasons: financial motives over patient care (35%), poor quality of care and negligence (27.5%), influence of external entities and agendas (13.5%), and discrimination and bias (4.5%).
“One of the most important parts of the study involved actually asking people why they indicated low levels of trust, in their own words,” Perlis said.
“What we found was a number of common themes – but not all the same. Understanding that people develop mistrust of doctors and hospitals for multiple reasons is critical if we are to find a way to communicate with those people.”
Results were also not fully accounted for by a general distrust in science, “suggesting some specificity for medicine per se”, the authors wrote.
On a brighter note, despite the decline in trust in physicians during the pandemic, “aggregate levels of trust were still substantial”, they noted. Of more than 50 000 respondents who answered the survey in 2023, a large majority had “some” (46.8%) or “a lot” (42%) of trust in physicians and hospitals.
By and large, physicians are well aware of the lack of public trust in healthcare systems, but there are no quick fixes. Building Trust, an initiative of the American Board of Internal Medicine (ABIM), formed in 2021, is one example of an organised effort to address the issue.
The initiative urges clinicians to use the five Cs in their interactions with patients and other key stakeholders in the healthcare community – communication, caring, competency, comfort, and cost – to build and reinforce trusting relationships.
Survey breakdown
The study analysed 582 634 responses from 443 455 unique respondents to online surveys offered by multiple recruitment vendors. Surveys were conducted every one to two months from April 2020 to January 2024 for a total of 24 waves.
Survey participants were asked, “How much do you trust the following people and organisations to do what is right? Hospitals and doctors,” with four possible answers: “a lot”, “some”, “not too much”, or “not at all”.
Participants were asked a similar question about scientists and researchers, and whether they had received the Covid-19 and flu vaccines.
Respondents received incentives for survey participation, such as cash or gift cards, airline miles, vouchers, redeemable points, or entry into sweepstakes. Mean respondent age was 43.3 years, 65% were women, 71% were white, 11.1% were black, 8.7% were Hispanic, and 5% were Asian American.
The study had a number of limitations, the authors pointed out. They used a single survey question to assess trust levels, precluding a more nuanced understanding. The survey also lacked a true panel design. Although respondents could return for more than one survey, most did not.
In addition, the study relied on non-probability sampling methods, which may have yielded less representative samples. The survey was also only administered in English, which may have led to an under-sampling of people with lower literacy or English proficiency. Finally, the researchers did not gather health-specific information on respondents.
Study details
Trust in Physicians and Hospitals During the COVID-19 Pandemic in a 50-State Survey of US Adults
Roy Perlis, Katherine Ognyanova, Ata Uslu et al.
Published in JAMA Open Network on 31 July 2024
Abstract
Importance
Trust in physicians and hospitals has been associated with achieving public health goals, but the increasing politicisation of public health policies during the Covid-19 pandemic may have adversely affected such trust.
Objective
To characterise changes in US adults’ trust in physicians and hospitals over the course of the Covd-19 pandemic and the association between this trust and health-related behaviours.
Design, Setting, and Participants
This survey study uses data from 24 waves of a non-probability internet survey conducted between April 1, 2020, and January 31, 2024, among 443 455 unique respondents aged 18 years or older residing in the US, with state-level representative quotas for race and ethnicity, age, and gender.
Main Outcome and Measure
Self-report of trust in physicians and hospitals; self-report of SARS-CoV-2 and influenza vaccination and booster status. Survey-weighted regression models were applied to examine associations between sociodemographic features and trust and between trust and health behaviours.
Results
The combined data included 582 634 responses across 24 survey waves, reflecting 443 455 unique respondents. The unweighted mean (SD) age was 43.3 (16.6) years; 288 186 respondents (65.0%) reported female gender; 21 957 (5.0%) identified as Asian American, 49 428 (11.1%) as black, 38 423 (8.7%) as Hispanic, 3138 (0.7%) as Native American, 5598 (1.3%) as Pacific Islander, 315 278 (71.1%) as White, and 9633 (2.2%) as other race and ethnicity (those who selected “Other” from a checklist). Overall, the proportion of adults reporting a lot of trust for physicians and hospitals decreased from 71.5% (95% CI, 70.7%-72.2%) in April 2020 to 40.1% (95% CI, 39.4%-40.7%) in January 2024. In regression models, features associated with lower trust as of spring and summer 2023 included being 25 to 64 years of age, female gender, lower educational level, lower income, black race, and living in a rural setting. These associations persisted even after controlling for partisanship. In turn, greater trust was associated with greater likelihood of vaccination for SARS-CoV-2 (adjusted odds ratio [OR], 4.94; 95 CI, 4.21-5.80) or influenza (adjusted OR, 5.09; 95 CI, 3.93-6.59) and receiving a SARS-CoV-2 booster (adjusted OR, 3.62; 95 CI, 2.99-4.38).
Conclusions and Relevance
This survey study of US adults suggests that trust in physicians and hospitals decreased during the COVID-19 pandemic. As lower levels of trust were associated with lesser likelihood of pursuing vaccination, restoring trust may represent a public health imperative.
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