A Towering Babel of Risk Information in the COVID-19 Pandemic: Trust and Credibility in Risk Perception and Positive Public Health Behaviors Arch G

EDITORIAL

A Towering Babel of Risk Information in the COVID-19 Pandemic: Trust and Credibility in Risk Perception and Positive Public Health Behaviors Arch G. Mainous III, PhD

(Fam Med. 2020;52(5):317-9.) doi: 10.22454/FamMed.2020.530121

n December 2019, the acute respiratory Different Sources Have illness now known as novel coronavirus- Different Numbers Iinfected pneumonia (NCIP) occurred in Risk perception is part of everyone’s decision- Wuhan, Hubei Province, China. Coronavirus making process and that perception of risk af- disease (COVID-19) is an infectious disease fects the person’s subsequent behavior.3 The that over the previous several months has be- perception of risk affects compliance with pub- come a worldwide pandemic. As such, the public health messages for positive behaviors.4 If lic has been bombarded with information about one doesn’t perceive themselves at risk they COVID-19 from many different sources provid- will likely not comply with a message like ing information on symptoms, behaviors to pre- “don’t congregate in groups and keep social vent transmission and contracting the virus, distance” during the COVID-19 pandemic. and importantly, one’s risk of contracting the A variety of authorities including the World disease and risk of severe outcomes and death. Health Organization (WHO), the US Centers Sources like the Johns Hopkins Coronavirus for Disease Control and Prevention (CDC), the Map constantly update identified cases and President of the United States, and the Direc- deaths throughout the world (https://corona- tor of the National Institute of Allergy and In- virus.jhu.edu/map.html).1 It is frightening to fectious Diseases (NIAID), along with many see one column listing the number of identified academics and television pundits have provid- cases worldwide at more than 550,000 and the ed predictions on the risk of COVID-19 to pa- number of deaths at more than 25,000 at one tients. They have been staggeringly different in point in the day, a higher number later in the their statements of mortality risk and predic- same day, and more than 650,000 cases the tions for the number of potential deaths from next day. Further, even international leaders COVID-19. Countries and municipalities have like Prime Minister of the United Kingdom responded to this plethora of risk models with Boris Johnson, and his Secretary of State for different strategies to control the pandemic fo- Health have tested positive for COVID-19.2 cusing on social distancing. Many young adult Patients are looking for guidance on how to patients have refused to comply with the social protect themselves and interpretation of their distancing recommendations to the chagrin symptoms. How likely am I to get sick? Is this of political leaders and public health experts. cough just a cough or does it mean that I am likely to die? From the Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL.

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An illustration of the inconsistent commu- Some have commented that many of the risk nication on health risks for COVID-19 among models have been based on faulty data because authority figures can be found in the early the population testing needed to establish a de- communication of the mortality risk of CO- nominator was not done.10 If the recommenda- VID-19. Imperial College London’s estimate tion on risk is perceived to be based on faulty of 2.2 million Americans dying within a year data it is unlikely to be complied with, thereby from the COVID-19 pandemic can be contrast- exacerbating compliance with the public health ed with Dr Anthony Fauci’s mortality risk as- intervention and putting patients at risk. sessment of 1% mortality rate and a death toll Is the amount of risk presented in a way of between 200,000 and 520,000 Americans. to indicate a tradeoff between health and eco- This in turn can be contrasted with President nomics? Trust cannot be maintained if the Trump’s much lower estimate of the sever- entities presenting the health message are ity of the problem.5-7 On February 26, Presi- perceived as making a recommendation that dent Trump said, “Because of all we’ve done, benefits them economically at the expense of the risk to the American people remains very the individual.11 The US Preventive Servic- low. … When you have 15 people, and the 15 es Task Force does not consider cost in their within a couple of days is going to be down recommendations as a way to increase trust to close to zero.” On February 28, President that the recommendation is based solely on Trump said, “It’s going to disappear. One day, health benefits. Consequently, the COVID-19 it’s like a miracle, it will disappear.” So our pa- pandemic and the associated municipal, state, tients are hearing mortality estimates ranging and country lockdowns have a challenge with from “… close to zero” to 2,200,000 deaths. trust and perception of risk by patients be- This is a remarkable disparity and all come cause of the huge impacts on the economy and from seemingly credible sources. patient jobs. Public health officials may present Polls have shown the confusion among the worst-case scenarios without considering eco- population about the severity of the disease nomics while politicians are considering jobs and the risk to their health. In a poll conduct- in a tradeoff against deaths. The patient needs ed on March 18-24 by Reuters, 91% of respon- to understand both the inherent biases in the dents said that they were somewhat or very numbers and the information source to have familiar with COVID-19.8 Patients clearly are trust and comply with recommendations like not ignorant about the topic, but they are hear- shelter in place or social distancing. ing many different things. In an NBC News/ Wall Street Journal poll conducted March 11- The Role of the Family Physician 13, 89% reported that they had heard “a lot” and the Health System about the coronavirus and found that 68% of What is the role of family physicians in pro- Democrats were worried that someone in their tecting the health of patients during the family could catch the virus, compared with COVID-19 pandemic and beyond? The pa- just 40% of Republicans.9 tient-physician relationship and the trust en- gendered between the patient and physician Importance of Trust, Credibility, is critical in a time like this. The trust pa- and Risk Perception tients put in their physicians to act in their A number of factors influence perceptions of best interest contributes to the effectiveness of risk including the source of the message and medical care, and physicians act as patients’ the credibility and trust of the entity provid- advocates.12 Even in the more modern health ing the message. To maintain trust, the in- care system where the high-continuity, one-to- formation presented must be seen as credible one relationship is difficult to maintain and and in the best interest of the patient. If only more providers are involved in patient care the very ill are tested for COVID-19, then the (eg, within the patient-centered medical home), mortality rate is likely to be much higher than trust can still be maintained with the overall if testing includes individuals who are asymp- practice. The message from Christy Ledford, tomatic or have mild disease (estimated to be PhD, and LaKesha Anderson, PhD in this is- more than 80% of those infected are includ- sue of Family Medicine provides insight and ed in the denominator). Many health systems direction on the communication that needs have thus far discouraged testing individuals to come from family physicians in times of with mild symptoms because of the limited health crisis.13 Patients are looking for guid- number of test kits available and the limit- ance in times like these. Family physicians ed amount of personal protective equipment. can and must play an integral role not only

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in providing treatment, but also in sorting 6. Bailey R. COVID-19 Mortality rate “ten times worse” than through the numerous voices that patients seasonal flu, says Dr Anthony Fauci. Reason. https://reason. com/2020/03/11/covid-19-mortality-rate-ten-times-worse- hear to provide reliable advice and reassur- than-seasonal-flu-says-dr-anthony-fauci/. Published March ance. 11, 2020. Accessed March 28, 2020. 7. Blake A. A timeline of Trump playing down the coronavirus CORRESPONDENCE: Address correspondence to: Dr threat. The Washington Post. https://www.washingtonpost. Arch G. Mainous III, Department of Health Services Re- com/politics/2020/03/12/trump-coronavirus-timeline/. Pub- search, Management and Policy, University of Florida, lished March 17, 2020. Accessed March 28, 2020. Gainesville, FL 32610. 352-273-6073. Fax: 352-273-6075. [email protected]. 8. Reuters/Ipsos Poll: Coronavirus Tracker, March 18-24, 2020 [press release]. Washington, DC: Ipsos. https://fingfx.thom- sonreuters.com/gfx/mkt/13/3885/3841/Topline%20Reuters%20 References Coronavirus%2003%2024%202020.pdf. Accessed March 28, 1. Johns Hopkins University. Johns Hopkins COVID-19 Map: 2020. Coronavirus COVID-19 Global Cases by the Center for 9. NBC News-Wall Street Journal Survey, March 2020. Wasing- Systems Science and Engineering. https://coronavirus.jhu. ton, DC: Hart Research Asssociates. https://www.document- edu/map.html Accessed March 28, 2020. cloud.org/documents/6810602-200149-NBCWSJ-March-Poll- 2. Dewan A, Dean S. Coronavirus strikes UK Prime Minister Final-3-14-20-Release.html. Accessed March 28, 2020. Boris Johnson, his health secretary and his chief medical ad- 10. Ioannidis JPA. A fiasco in the making? As the coronavirus viser. Cable News Network. https://www.cnn.com/2020/03/27/ pandemic takes hold, we are making decisions without uk/uk-boris-johnson-coronavirus-gbr-intl/index.html. Pub- reliable data. Stat. https://www.statnews.com/2020/03/17/a-fi- lished March 28, 2020. Accessed March 28, 2020. asco-in-the-making-as-the-coronavirus-pandemic-takes-hold- 3. Williams DJ, Noyes JM. How does our perception of risk we-are-making-decisions-without-reliable-data/. Published influence decision-making? Implications for the design of March 17, 2020. Accessed March 28, 2020. risk information. Theor Issues Ergon Sci. 2007;8(1):1-35. 11. Mainous AG III. Physicians should declare financial incen- 4. Zungu NP, Simbayi LC, Mabaso M, et al. HIV risk perception tives for recruiting minority ethnic patients into clinical and behavior among medically and traditionally circumcised trials. BMJ. 2014;348(may07 4):g2985. males in South Africa. BMC Public Health. 2016;16(1):357. 12. Mainous AG III, Smith DW, Geesey ME, Tilley BC. Factors 5. Walker PGT, Whittaker C, Watson O, et al. The Global Im- influencing physician referrals of patients to clinical trials. pact of COVID-19 and Strategies for Mitigation and Sup- J Natl Med Assoc. 2008;100(11):1298-1303. pression. London, Imperial College London; 2020. https:// 13. Ledford CJW, Anderson LN. Communication strategies for www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/ family physicians practicing throughout emerging public gida-fellowships/Imperial-College-COVID19-Global-Impact- health crises. Fam Med. 2020;52(5):320-323. 26-03-2020v2.pdf. Published March 26, 2020. Accessed March 28, 2020.

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