21.1 Introduction
Trust is a key component of decision-making and is interconnected with notions of reliability, dependability, and confidence in individuals and institutions. It also has an important role in the development and implementation of successful public policy as the public must rely on others (e.g., elected officials, political appointees, government employees) to design and implement policies in the public’s best interest. Trust is particularly important in health-related contexts because of inherent information asymmetry between laypeople and professionals (e.g., scientists, clinicians) in public health and medicine. When considering decisions regarding individual and societal health, laypeople must often rely on others to distil complicated medical and epidemiological information and to assess the risks and benefits associated with particular health actions (or inactions). Specifically, within healthcare settings, individuals often know little about the aetiology, diagnosis, treatment, and prognosis of medical conditions and must rely on actors within the healthcare system, including trusted healthcare providers, to provide accurate information and advice.
In the case of the COVID-19 pandemic, individuals sift through rapidly evolving information and recommendations conveyed from multiple sources, including political leaders, healthcare providers, and experts from public health and medicine. Recommendations from local, national, and global organisations have – at times – been in conflict, particularly early in the pandemic when scientific understanding of the virus and its transmission was in nascent stages.
Changing recommendations on issues such as masks has been a key source of mistrust among laypeople – and this highlights an interesting aspect of trust and infectious disease. The inherent nature of a pandemic means scientific evidence and subsequent clinical recommendations and best practices shift rapidly; laypeople are living in a situation where scientific research unfolds in front of them and this presents a new decision-making context and environment where trust can easily be shaken.
In winter and spring of 2020, there was asymmetry about what the SARS-CoV-2 virus was and the risks it posed. While scientific experts and public health leaders were rapidly working to understand the virus and develop action plans, individuals had no personal experience with the virus until cases emerged in their own social networks. While information asymmetry may have diminished as basic understanding of the SARS-CoV-2 virus has advanced, the emergence of new variants and subsequent changes to recommended mitigation strategies have created renewed confusion and uncertainty for many individuals.
The context of the pandemic, including the urgent nature of the threat and rapidly changing knowledge about the virus, creates a principal–agent relationship whereby key actors (e.g., public health scientists, healthcare providers) act as agents on behalf of the public (i.e., principals). This principal–agent relationship is made stronger by the degree to which informational asymmetry exists. During the COVID-19 pandemic, laypersons have relied on their healthcare providers, public health professionals, the scientific community, and government officials to be decision-makers on their behalf in an environment of great uncertainty. The principal–agent relationship raises questions of whether the agent is acting to maximise their own utility or that of the principal or both jointly. Inducing demand for services or actions could be perceived as utility maximising for the principal but not the agent. For instance, the pandemic stoked fears among some groups that government officials would use the public health emergency as a guide to grab power and enact government restrictions over citizens. Concerns were also raised by individuals about whether healthcare providers and broader healthcare systems stood to profit from the prevention and treatment modalities that they were endorsing.
Good governance and use of clear and effective health communication may counteract such concerns. While known strategies that benefit public health (and thus both the principal and the agent) may be recommended (e.g., vaccination), perceptions could exist about motivations, the scientific process, and the strength of evidence. Trust is a key element in such a context. If the recommendations provided are clear, able to be accomplished (i.e., feasible), and from a trusted actor, then questions of whose utility is being maximised are less prominent. For instance, across a large body of literature, receiving a strong vaccination recommendation from a trusted healthcare provider is strongly associated with an individual’s decision to vaccinate themselves or their child (Nagata et al., 2013; Radisic et al., 2017; Smith et al., Reference Smith, Amlôt, Weinman, Yiend and Rubin2017) against an infectious disease.
The definition of trust varies across broader socio-cultural contexts, communities, and individuals, and a universal definition of trust is lacking. For instance, a recent review of the literature identified forty-five separate measures that have been utilised in research to quantify trust in healthcare systems, with measures of trust most often focusing on constructs of honesty, communication, competence, and confidence in care (Ozawa & Sripad, 2013). The review also highlighted current gaps in trust-related research, including a lack of trust-focused measures that have been validated for non-Western samples.
Beyond variations in measures of trust, greater understanding is needed in how trust varies across individual characteristics, such as the personality or developmental context. Some people are inherently more likely to trust the words and advice of others; for instance, trust has been linked to agreeableness (Mooradian et al., 2006) – one of the ‘Big Five’ personality traits that have been extensively studied by developmental psychologists. The ability to rely on the advice and opinions of others is also related to one’s approach to risky behaviours (risk-seeking vs risk-avoiding) (Hurley, Reference Hurley2006). Inherent risk-takers would be more likely to trust quickly while those who are more inclined to be cautious need to feel more control before trusting a situation or person. One’s culture and personal experiences are also important for shaping trust. Baumrind’s seminal work examined the critical role of parenting style in shaping many aspects of children’s developmental trajectory, with authoritative parenting (i.e., high responsiveness, developmentally appropriate demands/expectations, trust between caregiver and child) linked to positive socialisation (Baumrind, Reference Baumrind1967, Reference Baumrind1971, Reference Baumrind1991). Attachment theory also established the critical nature of attachment figures – particularly that of caregiver–child during infancy – in shaping individuals’ later-life expectations about others (i.e., with secure early attachments fostering positive and trusting expectations about the self and others in the future) (Bowlby, Reference Bowlby1988). More recent research suggests that intra-family processes, including value messages (i.e., about fairness) and discussions about whether people are generally fair and trustworthy, also influence individual beliefs about whether to trust in others (Wray-Lake & Flanagan, 2012).
Trust is a key individual-level factor relating to the acceptance and uptake of health-related advice. Others include perceived risk of action and inaction, barriers ranging from lack of transportation to costs of services to service availability and opportunity costs associated with behaviour (e.g., time, money, effort). Individual-level factors such as self-efficacy sit within contexts of social norms, historical experience, and structure and access to healthcare and the public health system.
Importantly, trust in government, the media, and healthcare systems have shaped individual behavioural responses to a previous pandemic (i.e., H1N1 virus) (Prati et al., 2011; Rubin et al., 2009; Rudisill, Reference Rudisill2013; van der Weerd et al., 2011) and appear to play a similar role for COVID-19. Trust in the government as an information source has been found to be related to COVID-19 vaccine acceptance in a nineteen-country survey (n = 13,426) in June 2020 (Lazarus et al., Reference Lazarus, Ratzan, Palayew, Gostin, Larson and Rabin2021). Further, it is also positively related to cooperation with an employer’s vaccine recommendation (Lazarus et al., Reference Lazarus, Ratzan, Palayew, Gostin, Larson and Rabin2021). Another survey in the United States (n = 3,000) in March 2020 found a positive association between trust in government and COVID-19 vaccination intentions (Thunström et al., 2021).
Evidence about the relationship between trust and perceptions of COVID-19 risk is less clear, and there is limited research on this issue. An online survey examining trust in governmental response and trust in scientists, medical doctors, and nurses conducted in March and April 2020 in ten countries (n = 6,991) found that trust in government was negatively related to risk perceptions for the total sample. However, this result was only maintained at the individual country level for two sample countries (i.e., Spain and South Korea). Trust in scientists, medical doctors, and nurses was positively related to risk perceptions about COVID-19 in the total sample. Again, results varied by country, with only the United States and South Korea showing a positive relationship between trust in medical doctors and nurses and risk perceptions; no individual country demonstrated a relationship between trust in scientists and risk perception (Dryhurst et al., Reference Dryhurst, Schneider, Kerr, Freeman, Recchia and van der Bles2020).
Given the important role of trust in shaping individual perceptions and behaviours, this construct has unique importance during a global pandemic, which is, by nature, a time of great uncertainty. Trust also has unique salience because widespread and rapid uptake of mitigation behaviours may be needed to reduce the morbidity and mortality of highly infectious new viruses. Thus, this chapter will examine the role of trust in decision-making during ambiguous situations with COVID-19 as the key context of discussion. We will utilise a recent multi-country study examining trust in a variety of key pandemic-related stakeholders (e.g., government and public health institutions) as a means of exploring variation in trust and potential implications for risk perceptions and key health behaviours.
21.2 The Role of Trust in Decision-Making during Times of Uncertainty
In contexts of risk, we evaluate information and attach credibility to that information when making decisions. This is amplified in situations of uncertainty. Trust generally acts as a mechanism (heuristic) to reduce complexity in decision-making (Siegrist, Reference Siegrist2021). If one trusts an institution or a person, then they can circumvent the cognitively costly process of deeming whether information provided from that entity is accurate and relevant to them. Mistrust will reduce credibility in messaging, making it less effective. The informational asymmetry inherent in healthcare decision-making is magnified in situations of uncertainty like the COVID-19 global pandemic, especially at the beginning of the pandemic when there was limited knowledge about the novel SARS-CoV-2 virus.
Responses to epidemiological risks vary depending on the values individuals and societies hold, as well as institutional norms and practices (Brown, Reference Brown2020; Szmukler, Reference Szmukler2003). Critically important is whether individuals trust key institutional stakeholders who are leading public health responses and key scientific tasks such as vaccine development, testing, and distribution. Trust in healthcare systems and medical experts also likely plays an important role in the adoption of various recommended mitigation measures during a viral outbreak; individuals’ beliefs about whether various institutions can be trusted to ‘do the right thing’ or ‘protect them’ are important if associated with key behaviours recommended by those institutions (e.g., social distancing and vaccination) (Gerhold, Reference Gerhold2020).
During the COVID-19 pandemic, the World Health Organization (WHO) has repeatedly invoked the importance of trust to encourage the uptake of COVID-19 vaccines using perspectives from behavioural science. For instance, in a report from an October 2020 meeting of the WHO Technical Advisory Group (see Figure 21.1) (World Health Organization, 2020), principles of behavioural science were highlighted as critical to encourage COVID-19 vaccine uptake. This includes engaging with trusted members of the community who the public can associate with (i.e., through ‘shared identity and values’) to promote vaccine uptake. Second, the WHO purports that people must have trust in the vaccine itself and its related safety profile. Finally, issues with mistrust were deemed critical for vulnerable populations who may require targeted efforts from trusted healthcare workers, friends, and neighbours to be reached with key vaccination messages and services.
Figure 21.1 Acceptance and uptake of safe and effective vaccines against COVID-19 (WHO)
Note: Circles added by chapter authors.
The WHO thus prioritised trust building even in very early stages of the pandemic, before people had the chance to have entrenched opinions, feelings, and thoughts about the COVID-19 vaccine (Brewer, Reference Brewer, Chapman, Schwartz and Bergus2007). It also focused on the handling of adverse events as part of reinforcing or maintaining trust, recognising that poor handling of messaging could result in the eroding of future vaccine acceptance (World Health Organization, 2020). Good communication with the incorporation of uncertainty and risk–benefit profile also supports trust. This framework set forth by experts convened by the WHO places trust as a central construct in efforts to encourage COVID-19 vaccination globally, but this framework could also be a basis for communicating other important pandemic-related behaviours such as social distancing, following quarantine/isolation recommendations, engaging in COVID-19 testing, and adhering to masking recommendations.
21.3 The Public’s Trust in Handling of the Pandemic
21.3.1 Results from Our Rapid Response Online Survey in July 2020 about Trust
The rapid pace of change in policy and public health guidance during the early months and years of the COVID-19 pandemic (e.g., changes to mitigation recommendations, travel policy, vaccination requirements) created a high level of uncertainty and even bewilderment for many. This is particularly the case for laypeople who are unlikely to be familiar with scientific methodologies and processes (i.e., vaccine development, manufacturing, and testing practices) from which public policy and clinical recommendations are ideally derived. This uncertainty was compounded by widespread upheaval caused by the global pandemic (e.g., economic impacts, supply chain disruption, school and work closures), as well as by the suffering experienced by millions who have lost loved ones, become disabled, and/or experienced ongoing illness because of the SARS-CoV-2 virus.
To understand public perceptions of the COVID-19 pandemic – including the role of trust in institutions in predicting key pandemic-related behaviours, we surveyed adults from four countries highly impacted by COVID-19 over 10–14 July 2020. We recruited individuals to participate in the web-based survey using the Ipsos MORI online global omnibus panels that use quota sampling to derive nationally representative samples. In total, 4,313 adults completed the survey, including residents of Italy (n = 1,051), Spain (n = 1,079), the United Kingdom (UK) (n = 1,098), and the United States (n = 1,085). These countries were selected because they each had experienced high morbidity and mortality, as well as concentrated outbreaks, during the initial 2020 wave of the pandemic; by the time of the survey, the initial wave was receding in all four countries. Their responses to COVID-19 have been heterogenous (Brown, Reference Brown2020), ranging from early national stay-at-home orders (i.e., Italy) to never enacting stay-at-home orders (e.g., some US states). Each had unique experiences with other recent pandemics (e.g., severe acute respiratory syndrome, avian flu, H1N1) and range in healthcare system structure (e.g., single payer national health service, hybrid public/private funding), as well as COVID-19 policy authority (e.g., national, regional, state, local).
All participants were recruited through the Ipsos MORI national online panel, were aged eighteen years or older, and were provided with the survey in their country’s official language. We asked respondents about their COVID-19-related experiences, risk perceptions, behaviours, financial impacts, and vaccination intentions regarding a potential COVID-19 vaccine. We elicited respondents’ trust in five key institutional stakeholders, namely the national government, the local government, the healthcare system, the European Union, and the WHO (Table 21.1). All these stakeholders play a key role in either communicating about and/or regulating and implementing COVID-19-related policy.
Table 21.1 Trust in handling of the COVID-19 pandemic
| Italy (n = 1,051) | Spain (n = 1,079) | United Kingdom (n = 1,098) | United States (n = 1,085) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Trust | Don’t trust | Don’t know | Trust | Don’t trust | Don’t know | Trust | Don’t trust | Don’t know | Trust | Don’t trust | Don’t know | |
| National government | 510 (48.6) | 501 (47.6) | 40 (3.8) | 438 (40.6) | 605 (56.1) | 36 (3.3) | 518 (47.2) | 516 (47.0) | 63 (5.8) | 356 (32.8) | 692 (63.8) | 38 (3.5) |
| Local government | 505 (48.0) | 506 (48.1) | 40 (3.8) | 443 (41.0) | 589 (54.6) | 48 (4.4) | 585 (53.3) | 407 (37.1) | 106 (9.6) | 661 (60.9) | 379 (34.9) | 46 (4.2) |
| Healthcare system | 748 (71.2) | 273 (26.0) | 30 (2.9) | 859 (79.6) | 191 (17.7) | 29 (2.7) | 909 (82.8) | 139 (12.6) | 50 (4.6) | 687 (63.3) | 352 (32.4) | 46 (4.3) |
| European Union | 413 (39.3) | 593 (56.4) | 45 (4.3) | 456 (42.2) | 574 (53.2) | 50 (4.6) | 467 (42.5) | 480 (43.7) | 151 (13.8) | 454 (41.8) | 316 (29.1) | 316 (29.1) |
| World Health Organization | 526 (50.1) | 478 (45.4) | 47 (4.5) | 532 (49.3) | 510 (47.3) | 37 (3.5) | 690 (62.8) | 309 (28.2) | 99 (9.0) | 616 (56.8) | 380 (35.0) | 90 (8.3) |
Note: Number (percentage), number is rounded to the nearest integer.
Uses weighted sample with sampling weights provided by IPSOS MORI to ensure that the study population is representative of the target population (age: eighteen to sixty-five for Spain, eighteen to seventy for Italy, and eighteen to seventy-five for the United Kingdom and the United States). Weights were based on age within gender, region, and working status. UK data was also weighted by social grade, and for the United States, household income.
Question: To what extent do you trust or not trust the way the following (‘your national government officials’, ‘your local government officials’, ‘the healthcare system in your country’, ‘The European Union’, ‘World Health Organization (WHO)’) are dealing with the COVID-19 pandemic? Answer choices are ‘trust a great deal’, ‘trust a fair amount’, ‘do not trust very much’, ‘do not trust at all’, and ‘don’t know’.
Trust = ‘trust a great deal’ and ‘trust a fair amount’.
Don’t trust = ‘do not trust very much’ and ‘do not trust at all’.
The following question assessing institutional trust was presented to participants:
To what extent do you trust or not trust the way the following are dealing with the COVID-19 pandemic?
COLUMNS
Trust a great deal
Trust a fair amount
Do not trust very much
Do not trust at all
Don’t Know
ROWS
Your national government officials
Your local government officials
The healthcare system in your country
The European Union
World Health Organization (WHO)
The total sample had a mean age of 45.0 years. Participants were 50.6 per cent female and 49.3 per cent male and 85.5 per cent urban and 14.5 per cent rural. There were an average of 2.9 people in respondents’ households, and 31.9 per cent of respondents had children in the household. A total of 61.1 per cent of the sample was working full- or part-time at the time of the survey.
Across all four countries, respondents were most likely to say they trusted their country’s healthcare system either a great deal or a fair amount (ranging from 63.3 per cent in the United States to 82.8 per cent in the United Kingdom). Importantly, respondents in the United Kingdom and the United States also reported relatively high levels of trust in the WHO and local governments. Among US respondents, local governments ranked second in trust (60.9 per cent), while for UK respondents, local governments (53.3 per cent) ranked third, behind the WHO (62.8 per cent). Local governments did not have as high levels of trust in Spain (41.0 per cent) and Italy (48.0 per cent).
Conversely, respondents from Italy (47.6 per cent), Spain (56.1 per cent), the United Kingdom (47.0 per cent), and the United States (63.8 per cent) reported that they did not trust the national government (i.e., not very much or not at all). Most respondents from Italy (56.4 per cent) and Spain (53.2 per cent) reported lacking trust in the European Union.
Trust in individuals and stakeholder organisations, particularly governments, plays a key role in predicting whether individuals follow public health guidance (Rubin et al., 2009), including vaccination recommendations. While trust in healthcare systems was high across respondents from the four countries highly impacted by the COVID-19 pandemic, low levels of trust in national governments in all countries surveyed at the end of the first wave of the pandemic presents a cause for concern and may have had important effects on engagement in recommended mitigation policies such as vaccination and mask-wearing during later stages of the pandemic. Mistrust may reduce the credibility of government-led risk communication, making it less effective. Trusted entities are more likely to successfully deliver the messages of public health and health policy planners.
21.3.2 Conveying Uncertainty to the Public
Science is not a study of certainty but instead focuses on investigating uncertainties and understanding errors in findings and the possibility for new evidence to emerge that refutes previously accepted beliefs. The phenomenon of having laypeople watch science ‘play out’ in front of their eyes is one that needs close study, as changes in understanding of the virus and its transmission and shifts in recommended mitigation strategies have been met with mistrust, scepticism, hostility, and even violence from some segments of the population.
The scientific process and thus recommendations to the public about preventive behaviours during COVID-19 have evolved from high levels of uncertainty at the start of the pandemic to a much richer understanding of the virus and its means of transmission, prevention, and treatment today. Initial advice that masks do not substantially curb the spread of COVID-19 enough to recommend universal masking shifted to many jurisdictions adopting mask mandates. Initial recommendations for surface cleaning were later displaced by mitigation approaches designed to curb spread via droplets and aerosols. Communicating the likelihood of future changes in recommended policy may be helpful in building trust in messaging. Evidence also suggests that communicating uncertainty to the public does not greatly diminish trust and does not increase mistrust in the entity conveying the uncertainty or in the message itself (van der Bles, Reference Dryhurst, Schneider, Kerr, Freeman, Recchia and van der Bles2020).
21.4 The Public’s Trust in Information Sources
Information that is relevant, timely, and comprehensible enables individuals to make decisions about health risks for themselves and incorporate public health advice into everyday behaviour (World Health Organization, 2017). Information sources about COVID-19 are many and constitute a range of experience and knowledge of different types (from scientists and experts to friends and family). In general, who individuals trust for health information varies depending on health literacy levels – individuals with low health literacy tend to rely on social media, the television, and celebrity websites and are less likely to trust the advice of specialist doctors and dentists (Chen et al., 2018).
21.4.1 Role of Science, Experts, and Government
It does not help encourage the public’s trust in scientists when it appears that government is debating the public-facing role of scientists in a public health emergency. This is not a partisan issue. The WHO was repeatedly attacked in political spheres by some US politicians, leading to Trump administration’s plans to withdraw from the WHO, which were reversed by the Biden administration. Our international survey took place less than one week after the Trump administration announced the withdrawal. The WHO was still the third highest trusted group in the United States, after healthcare systems and local governments, and the United States had the second highest percentage of respondents trusting in the WHO (56.8 per cent), after the United Kingdom (62.8 per cent). Therefore, these attacks did not seem to undermine trust in the WHO as one might expect – at least in the early weeks following continued public discussion of the WHO’s handling of the pandemic.
21.4.2 Local Voices to Build Trust
National level political and scientific leaders are important for conveying reliable information, but local actors can reinforce and convey these messages as trusted entities in local contexts, which is more likely to lead to behavioural change and cooperation (Bavel et al., Reference Bavel, Baicker, Boggio, Capraro, Cichocka and Cikara2020). Such local leaders include civic and religious figures. A survey of underserved and vulnerable populations (n = 8,759) in the United States found that trust in health information was greatest when coming from doctors, then government followed by family, friends, charities, and religious groups. Those not fluent in English trusted religious organisations more than those fluent in English, while those fluent in English were more likely to trust doctors (Wheldon et al., 2020). Overall, doctors have consistently been reported to be the most trusted source of information in multiple studies over time (e.g., see data from 2005 to 2015 across five waves of the Health Information National Trends Survey) (Jackson et al., 2019).
21.4.3 Social Trust: What Will Others Do and Social Norms
The role of peers also matters, particularly with young people. They are more likely to rely on social media as a trusted source for information regarding COVID-19 than older people (Fridman, 2020). A study of US college students (n = 647) found that thinking more peers would get vaccinated was positively associated with intentions to vaccinate against COVID-19 and flu (Graupensperger, 2021a). There is evidence of peer effects in the COVID-19 context where young adults who perceived that their peers had lower adherence to COVID-19 guidelines (e.g., masks) also had lower adherence themselves (Graupensperger, 2021b).
21.5 The Role of Trust in Vaccination Uptake
Given the uncertainty regarding the SARS-CoV-2 vaccine (e.g., dozens of vaccines have been under development, with fast-tracked timeline), individuals may rely on heuristic shortcuts – such as whether they trust an institution – to reduce complexity in vaccination decision-making. For instance, some evidence from the United States suggests that acceptance of COVID-19 vaccines under initial Emergency Use Authorizations (EUAs) is lower when compared to vaccines that have received full approval from the US Food and Drug Administration (FDA); yet the urgent nature of a deadly new virus necessitates the existence of the EUA process that adheres to the rigor of traditional standards for vaccine development and clinical trials yet fast-tracks the process during public health emergencies (Kreps et al., Reference Kreps, Prasad, Brownstein, Hswen, Garibaldi, Zhang and Kriner2020). Public health support (CDC or WHO) as opposed to support from a politician for the COVID-19 vaccine (President Trump) was also found to be related to higher acceptability amongst a sample of 1,971 US residents (Kreps et al., Reference Kreps, Prasad, Brownstein, Hswen, Garibaldi, Zhang and Kriner2020). Moreover, trust in vaccine development, approval, and delivery is necessary for public support of the vaccine (Opel et al., 2020). Leaders and other high-profile citizens such as medical experts receiving their vaccines publicly can increase public trust because of the visual image of their behaviour (Vergara et al., 2021).
21.5.1 Vaccine Development and Information and Reporting about Side Effects
Concerns about the COVID-19 vaccine range widely and include worries about the fast pace of development, possible side effects, and lack of belief in its efficacy or necessity. These stem from many sources, including rumour and conspiracy theories (Islam et al., 2021), which emerge in micro (e.g., household, peer circles) to macro (e.g., social media) contexts. Understanding such concerns is important as beliefs and attitudes about vaccination are directly linked with vaccination refusal. Ensuring high levels of trust in the vaccine development, testing, and surveillance systems is critical to achieve widespread vaccination and, thus, to ensure both individual and public health protection from a variety of infectious diseases. Mistrust in the benefits of COVID-19 vaccination (alongside lower levels of concerns about COVID-19) was found to be the greatest predictor of COVID-19 vaccine hesitancy in four US states (California, New York, Texas, and Florida) and English-speaking Canada (n = 7,678) (Gerretsen et al., 2021). Trusted stakeholders disseminating information about the benefits and safety profile of the COVID-19 vaccine can assist in overcoming these concerns, particularly in lower socio-economic status communities and minority populations (Ayers et al., 2021).
21.5.2 Using Financial Incentives to Encourage Uptake
Financial incentives have, thus far, largely been unsuccessful in efforts to increase COVID-19 vaccination uptake (Chang et al., Reference Chang, Jacobson, Shah, Pramanik and Shah2021; Dave et al., 2021; Walkey et al., 2021); however, a programme focused on incentivising those who take individuals to get the vaccine has shown some success (Wong et al., Reference Wong, Pilkington, Doherty, Zhu, Gawande, Kumar and Brewer2022), and an experiment in Sweden showed a positive effect of incentives on vaccination (Campos-Mercade et al., 2021). This differs from evidence on the effectiveness of financial incentives for flu (Bronchetti et al., Reference Bronchetti, Huffman and Magenheim2015; Yue et al., 2020), Hepatis B (Topp et al., 2013; Weaver et al., 2014), and HPV vaccinations (Mantzari et al., 2015). In the context of the polarised COVID-19 pandemic, financial incentives may reinforce the notion that people are being pushed to do something they do not want to do by the government or their employer and may perceive payment as an attempt to convince them to do something in the government’s or employer’s interest. Even more, some question whether the use of financial incentives is coercive or exploitative – particularly for individuals made vulnerable by their low socio-economic status. If not coercive, financial incentives may certainly shift decision-making processes around vaccination and the ways that individuals value this health behaviour (Savulescu et al., 2021). However, context is an important consideration for incentive-based interventions. A recent systematic review found moderate to large impacts of non-financial incentives on reducing vaccination hesitancy in low-income communities (Jarrett et al., 2015). Thus other types of incentives may need to be considered beyond traditional financial incentives. Social incentives are one such alternative, such as requiring vaccination from patrons if they wish to eat indoors at a restaurant (Volpp & Cannuscio, Reference Volpp and Cannuscio2021).
Text reminders (a nudge) have been successful at encouraging COVID-19 vaccination appointments and uptakes in the general population (Dai et al., Reference Dai, Saccardo, Han, Roh, Raja and Vangala2021), and targeted reminder messages using behavioural science-underpinned design among healthcare workers increased COVID-19 vaccine registration (Santos et al., Reference Santos, Goren, Chabris and Meyer2021). Similar other systems-based interventions including the use of reminder–recall systems and educational interventions about vaccines or vaccination that are embedded within existing trusted healthcare systems show efficacy in reducing mistrust and hesitancy (Jarrett et al., 2015).
21.6 Policymakers’ Trust in the Public
Promoting shared identity, collective self-efficacy, and hope has been shown to encourage cooperation. At the opposite end of the spectrum, threatening and punitive policies that make individuals feel like they are not trusted may lead to a vicious cycle of them being less likely to follow advice, resulting in the potential for greater societal division and discord (Bavel et al., Reference Bavel, Baicker, Boggio, Capraro, Cichocka and Cikara2020).
Trust is important for predicting not only behavioural response but also the feasibility of policy approaches. Assuming that people cannot be trusted to do as they are told and designing policies as such (highly regulated and punitive) runs the risk of further deteriorating adherence by both parties (Brown, Reference Brown2020). That is, it is important to convey to the public that those who are setting forth advice recognise that people are likely to follow this advice also encourages cooperation (Bavel et al., Reference Bavel, Baicker, Boggio, Capraro, Cichocka and Cikara2020). This is likely dependent on the country context, as some countries have successfully secured high vaccination rates through mandates with little resistance (e.g., Portugal). Other European countries (e.g., Austria) have seen significant internal disagreement about vaccination mandates but still have vaccination rates higher than the United States, where vaccination mandates are much more limited.
21.7 The Way Forward
Trust is not static. Trust in institutions can be strengthened or weakened through action and inaction, and, during a global pandemic, trust plays a central role in decisions to adopt a wide variety of health behaviours that impact not only individual health but public health as well. The nature of trust and in whom one trusts may change over time. The rapidly shifting nature of the COVID-19 pandemic has created a unique opportunity to better understand how trust informs decision-making and engagement in recommended public health behaviours and strategies, including COVID-19 precautions (Algan et al., 2021). Identifying ways to build trust in our medical and public health professionals, as well as in the broader scientific community, is important not only to continue to make progress in quelling the current pandemic but also to be better prepared for future public health emergencies. The COVID-19 pandemic presents an opportunity to engage the public in science in a way that impacts their daily lives. If done well, this could have positive outcomes for the appreciation of scientific efforts and encouragement of future scientists and public health professionals. Whatever trust has been lost or gained during the pandemic can also shift in the opposite direction. Thus, the importance of conveying accurate and clear information from trusted actors and addressing misinformation must remain at the forefront of efforts to end the current pandemic and prevent future ones.
