In a recent study published in the JAMA Network Open, researchers examined changes in United States (US) adults’ trust in physicians and hospitals during the coronavirus disease 2019 (COVID-19) pandemic and its association with health-related behaviors.

Study: Trust in Physicians and Hospitals During the COVID-19 Pandemic in a 50-State Survey of US Adults. Image Credit: Prostock-studio / Shutterstock

Background 

Physicians play a crucial role in public health outreach, as regular appointments provide opportunities to promote healthy behaviors like exercise, diet, seatbelt use, smoking cessation, and firearm safety. Trust in physicians has traditionally been high, with a 2022 survey showing more trust in physicians and nurses than in other institutions, including the Centers for Disease Control and Prevention (CDC). Early in the COVID-19 pandemic, trust in physicians increased, but the politicization of health policies and the spread of misinformation led to a decline. However, the study highlighted the need for further research to explore strategies for restoring trust in physicians and hospitals, which is crucial for effective public health interventions.

About the study 

Data were collected from 24 waves of a nonprobability internet survey using PureSpectrum, aggregating participants from multiple national panels and incentivizing respondents with rewards such as gift cards, cash, and airline miles. The COVID States Project conducted the survey from April 1, 2020, to January 31, 2024, targeting individuals aged 18 and older across all 50 states and the District of Columbia. Participants provided informed consent online, and the study was approved by Harvard University’s institutional review board (IRB) as exempt. 

To ensure representativeness, quotas were set for age, gender, race, and ethnicity. Attention checks and open-ended responses filtered out unreliable participants. Sociodemographic characteristics, including race and ethnicity, were self-reported to reweigh the sample. Trust in physicians and hospitals was assessed using questions about trust levels, and vaccination status for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and influenza was collected.

Survey results were reweighted using data from the 2019 US Census for demographic factors. Ordinal logistic regression examined associations between physician trust scores and sociodemographic features. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were used to measure these associations. Logistic regression models assessed the relationship between vaccination status and trust in physicians and hospitals. Additional analyses explored the impact of prior trust on subsequent vaccination likelihood.

An open-ended question in one survey wave gathered reasons for varying trust levels. Using Generative Pre-trained Transformer 4 (GPT-4), major themes from responses were identified and categorized, revealing factors contributing to trust disparities and their broader implications during the COVID-19 pandemic.

Study results 

The combined data comprised 582,634 responses across 24 survey waves, including 443,455 unique respondents. The unweighted mean (SD) age was 43.3 (16.6) years; 65.0% of respondents reported female gender, and 35.0% reported male gender. Racial and ethnic demographics included 71.1% White, 5.0% Asian American, 8.7% Hispanic, 0.7% Native American, 11.1% Black,1.3% Pacific Islander, and 2.2% identified as other.

Over time, trust in physicians and hospitals significantly declined, from 71.5% in April 2020 to 40.1% in January 2024. Analyzing responses from June and July 2023, the correlation between different forms of the trust question was strong (Spearman ρ = 0.76). Detailed analysis of two survey waves in the spring and summer of 2023 revealed state-by-state variations in trust levels. Ordinal regression models showed decreased trust associated with being aged 25 to 64, female, having lower educational levels, Black race, lower income, and living in rural areas. These associations persisted even after adjusting for political affiliation.

Higher trust levels were significantly linked to a greater likelihood of being vaccinated for COVID-19. Unadjusted models indicated that any amount of trust (a little, some, or a lot) increased the odds of vaccination compared to no trust, with adjusted ORs showing significant increases: 1.38 for a little trust, 2.48 for some trust, and 4.94 for a lot of trust. Including political affiliation did not alter these associations. Similar patterns emerged when examining COVID-19 booster shots.

The association between trust and vaccination status was also significant when analyzing influenza vaccination. Again, higher trust levels correlated with higher vaccination rates in both unadjusted and adjusted models, with political affiliation inclusion yielding similar results. Further, adding overall trust in people and scientists to the model showed that trust in physicians and hospitals remained a significant predictor of SARS-CoV-2 vaccination.

Logistic regression models estimating the impact of lagged trust on subsequent vaccination status confirmed that high trust in physicians and hospitals consistently predicted greater odds of vaccination in the following waves. Adjusted ORs ranged from 1.94 in January 2021 to 4.36 in August 2022.

To identify reasons for varying trust levels, open-ended responses from a subset of participants in one wave were analyzed. Themes included financial motives over poor quality of care, patient care, influence of external entities, and discrimination and bias. 

Conclusions

To summarize, among over half a million survey responses from US adults between April 2020 and January 2024, trust in physicians and hospitals decreased across all sociodemographic groups. Lower trust was linked to a reduced likelihood of vaccination against SARS-CoV-2 and influenza, unaffected by political affiliation or general trust in science, indicating a specific decline in medical trust. This decline aligns with literature linking greater trust to better health outcomes. Despite the drop, trust in physicians remained relatively high. Effective interventions to restore trust could benefit public health, emphasizing the importance of addressing financial conflicts of interest and other mistrust factors.