Erosion of Trust in Health Care: A Public Health Crisis

The erosion of trust in physicians and hospital systems that became ever apparent during the height of the COVID-19 pandemic and which persists even today has experts sounding an alarm to make restoring that trust a “public health imperative” because public health policies have become so politicized.

In JAMA Network Open,¹ they published their findings from 24 waves of a nonprobability survey that included 443,455 adults respondents (18 years or older) and 582,634 survey responses from April 1, 2020, through January 31, 2024; the survey was distributed every 1 to 2 months during this period. All data were self-reported, and every sociodemographic group related a substantial decrease in trust. In addition to trust, the authors also investigated correlations between select health behaviors and trust, and the effect of that relationship on public health–related outcomes.

Experts believe that the persistent distrust in physicians and hospital system following the COVID-19 pandemic requires more targeted interventions, due to the heterogeneity of the survey respondents| Image Credit: Olivier Le Moal - stock.adobe.com

Overall, from baseline in April 2020 to January 2024, there was a 31.4 percentage point sharp decrease in patients reporting they trusted their physicians and hospital systems:

• April 2020: 71.5% (95% CI, 70.7%-72.2%)
• January 2024: 40.1% (95% CI, 39.4%-40.7%)

This finding was echoed regardless of gender (female vs male), race/ethnicity, or age (18-24, 25-44, 45-64, and > 65 years), and is in stark contrast to 2022 data that show physicians and nurses to be among the most trusted individuals,^2,3 and 2019 data showing they were thought to have high ethical standards.⁴

Another analysis specifically examined responses from surveys administered April 5 to May 5, 2023, and June 29 to August 1, 2023, and found several demographics to be independently associated with decreased trust: age 25 to 64 years, female gender, lower educational level, lower income, Black race, and rural residence.

Also during these periods, the impact of trust on COVID-19 vaccination was an outcome of interest. Compared with having no trust, having a little trust (OR, 1.63; 95% CI, 1.40-1.90), some trust (OR, 3.38; 95% CI, 2.95-3.88), or a lot of trust (OR, 7.59; 95% CI, 6.59-8.75) correlated with higher chances of receiving a COVID-19 vaccine. Political affiliation did not influence these outcomes. Prior research echoes these findings. A study published last year in Pediatrics found that hesitancy toward childhood vaccines trended toward decreased trust in vaccine information; for this analysis, outcomes were compared among 3 periods: prepandemic (April 1, 2018-February 29, 2020), pandemic prevaccine (April 1, 2020,-December 31, 2020), or pandemic post vaccine (January 1-August 31, 2021).⁵

When looking at SARS-CoV-2 boosters and flu vaccines, similar results were again seen. Compared with having no trust, having little, some trust, and a lot of trust translated to higher odds of receipt of both:

• SARS-CoV-2 boosters:
  • Little trust: 1.54 (95% CI, 1.27-1.86)
  • Some trust: 3.29 (95% CI, 2.77-3.92)
  • A lot of trust: 5.96 (95% CI, 5.02-7.09)
• Flu vaccine:
  • Little trust: 1.40 (95% CI, 1.06-1.83)
  • Some trust: 3.48 (95% CI, 2,72-4.46)
  • A lot of trust: 7.43 (95% CI, 5.79-9.53)

Most survey respondents reported a White race/ethnicity (71.1%; n = 315,278), followed by Black (11.1%; n = 49,428), Hispanic (8.7%; n = 38,423), Asian American (5%; n = 21,9576), other race/ethnicity (2.2%; n = 9633), Pacific Islander (1.3%; m = 5598), and Native American (0.7%; n = 3138). Their mean (SD) age was 43.3 (16.6) years, and 65% (n = 288,186) reported a female gender. Most had a college degree (34%) or some college (27.1%); an income from $25,000 to less than $50,000 (27.3%) or $50,000 to less than $100,000 (31.9%); and had a suburban residence (55.4%). Political affiliations primarily were Democrat (30.7%) or Independent/other (41.0%).

Lagged trust was also investigated. With this, the authors evaluated the odds of becoming vaccinated against SARS-CoV-2 by the next wave. Again, highly trusting physicians and hospitals had a positive correlation with vaccine receipt, with ORs of 1.94 (95% CI, 1.56-2.44) to 4.36 (95% CI, 3.30-5.81) seen for January 2021 to August 2022.

The authors note their findings may be unique to the US, as “prior studies suggested wide variation in levels of trust between countries before the pandemic, complicating any crossnational comparisons.” As well, that they can’t establish causation and may be limited in their applicability due to the complexity of trust, and that their nonprobability sampling method is known to produce results that do not represent the full scope of the issue investigated.

“Whether interventions to restore trust could increase compliance with vaccination and other positive health behaviors merits further investigation,” they concluded. “In particular, our analyses of open-ended results suggest that factors associated with mistrust are heterogeneous, which may require more targeted interventions.”

References

1. Perlis RH, Ognyanova K, Uslu A, et al. Trust in physicians and hospitals during the COVID-19 pandemic in a 50-state survey of US adults. JAMA Netw Open. 2024;7(7):e2424984. doi:10.1001/jamanetworkopen.2024.24984

2. SteelFisher GK, Findling MG, Caporello HL, et al. Trust in US federal, state, and local public health agencies during COVID-19: responses and policy implications. Health Aff (Millwood). 2023;42(3):328-337. doi:10.1377/hlthaff.2022.01204

3. Lopes L, Kearney A, Washington I, Valdes I, Yilma H, Hamel L. KFF health misinformation tracking poll pilot. KFF. August 22, 2023. Accessed August 5, 2024. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-healthmisinformation-tracking-poll-pilot/

4. Brenan M, Jones JM. Ethics ratings of nearly all professions down in U.S. Gallup. January 22, 2024. Accessed August 5, 2024. https://news.gallup.com/poll/608903/ethics-ratings-nearly-professionsdown.aspx

5. Steinzor P. Did the COVID-19 pandemic change parental vaccine hesitancy in the United States? The American Journal of Managed Care^®. December 12, 2023. Accessed August 5, 2024. https://www.ajmc.com/view/did-the-covid-19-pandemic-change-parental-vaccine-hesitancy-in-the-united-states-