How does trust influence response to public
health messages during a bioterrorist event?
Lisa S. Meredith, Ph.D., RAND
AcademyHealth
June 27, 2006
Coauthors
• David P. Eisenman, M.D., M.S.H.S., UCLA and RAND
• Hilary Rhodes, M.Sc., RAND
• Gery Ryan, Ph.D., RAND
• Anna Long, Ph.D., Los Angeles County Department
of Health Services
Funded by the RAND Corporation’s continuing program of self-sponsored
independent research from donors and development funds through
contracts for the operation of its U.S. Department of Defense federally
funded research and development centers and from the Centers of
Disease Control and Prevention Bioterrorism Cooperative Agreement
awarded to Dr. Eisenman.
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Background and Motivation
• Trust is crucial for insuring appropriate public health
response during crises, including bioterrorism
• Trust varies by racial/ethnic group
– Particularly low among African Americans who
recall adverse treatment in historical events
• Postal workers affected by the 2001 anthrax attacks
perceived lack of fairness
• African Americans report that the public health system
will respond unfairly in a bioterrorism event
• Need to know what specific components of trust
influence responses to public health messages
during an evolving bioterrorist attack
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Study Objectives
• Characterize the components of trust in public
health identified by African Americans
• Understand which specific components of trust
need to be addressed in public health
communications
• Investigate the importance of characteristics that
might influence attitudes and attitude change
– Source or messenger (expertise, credibility)
– Message (content, structure)
– Medium (media vs. the internet)
– Audience (age, sociodemographics)
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Study Design
• 8, 2-hour focus groups stratified by age and SES
– 7-11 per group (total N=75)
– Recruited from the community during June, 2004
– Eligibility requirements:
• African Americans living in Los Angeles
• Age 18-65
• Able to participate in a discussion group
– Exclusion criteria:
• LA County employees
• First responders (fire, police, emergency
services)
– Paid $50 for their time
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Escalating Bioterrorism Scenario
Stage 1:
Media reports a potential
bioterrorist attack with
increased hospitalization
utilization due to rashes
Stage 4:
Rumor of people in high
SES neighborhoods
getting vaccinated even
though they were not
exposed
Stage 2:
Public Health Officials
identify illness as
smallpox; introduce plan
for targeted ringvaccination near site of
exposure & quarantines
Stage 5:
Two conflicting reports
by the media
Stage 3:
Reports of people trying
to get vaccinations and
being turned away if not
exposed or sick
Stage 6:
Local health workers
assigned to communities
Stage 7:
Local community
representatives assist
people in their
immediate
neighborhoods
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New Information Presented in Each Stage
• For each stage we asked:
– What is your first reaction to this information?
– What would you do?
• How would you decide what to do?
– Would you trust this information?
– Would you try to get more information?
• What type?
• From who or where?
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Participant Characteristics
Characteristic
SES Group*
Low (Up to 200% of Federal poverty
guidelines)
High (Above 200% of poverty
guidelines)
Age Group*
18-39
40-66
Other Demographic Characteristics
Female
Married
Kids
Some college (vs. no college or
below)
Currently working (full & part time)
N
%
34
45
41
55
37
38
49
51
38
17
34
24
51
23
45
32
56
75
*Focus group stratification characteristic
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Data Analysis
• Verbatim transcripts entered into text-management software
• Investigators marked all passages related to trust
• To identify themes, investigators cut out and then sorted trust
passages into thematic categories based on similarity*
– Fiduciary responsibility
– Honesty
– Competency
– Consistency
– Faith
– Other
• To assess theme salience, frequency of mention was calculated
• To assess the distribution of themes, theme frequency was
crossed with:
– Scenario
– Group socio-demographic characteristics
*(Lincoln & Guba, 1985; Ryan & Bernard, 2003)
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Description of Trust Themes
“And the bottom line is we don’t have another choice but to trust them…
you’ve got no choice but to trust them.”
Faith
(N=59)
“I wouldn’t trust just one [website].
I think I would just [check out] different
sites on the smallpox disease.
Because [only] one, something
might be different, just like it’s
picking up different information…
So to feel comfortable, you
can’t stick to just one site.”
Consistency
(N=140)
Other
(N=31)
“I think a person coming to my home
and talking to me is more comforting
than trying to call a hotline number or
trying to wait for the news to tell me
something else. At least I'm getting
some more one-on-one
personal information.”
Trust
“If they’re going to send someone
out in [to] the community, you have
to hope that these people have
the credentials to prevent the
community from panicking…
and you can ask for the person’s
credentials.”
Fiduciary
Responsibility
(N=115)
Competency
(N=58)
Honesty
(N=143)
“I don’t trust the information at all.
I remember what happened in the
World Health Organization with the
AIDS virus. And [at] Tuskegee
with Syphilis and [smallpox] with
the Indians. Our government
has a history of using bioterrorism
as a method of population control,
so why would I suddenly trust them
to save my life?”
“The people at the top are only giving the people at the bottom maybe 30 percent
of the truth, so you’re only working with what they’re telling you, which is probably
not even half because they don’t want everybody panicking.”
Because they have been known to not put the truth out or to
hold the truth back and give you bits and pieces of things and
sometimes give you bits and pieces of things that are not even true.”
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Patterns of Trust by Stratification Group
Group
Fiduciary
Honesty
Competency
Consistency
Faith
Other
Younger (18-39):
Low SES
37
37
14
32
7
2
High SES
38
60
10
40
22
11
Low SES
25
25
11
38
10
7
High SES
15
21
23
30
20
11
115
143
58
140
59
31
Older (40-65):
Total (across all groups)
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Patterns of Trust by Scenario Stage
Scenario Stage
Fiduciary
Honesty
1. Initial Report
6
20
5
12
34
6
Faith
Other
13
5
1
12
22
4
4
6
15
4
0
2
28
22
2
13
5
2
2
12
5
15
2
5
6. Local Health Workers
19
22
7
27
10
11
7. Local Community
Representatives
12
9
7
27
12
5
Total (across 7 stages)
85
125
53
121
38
30
2. Illness Identification
3. No Vaccination
4. Others Get Vaccinated
5. Conflicting Reports
Competency
Consistency
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Conclusions
• Trust is a complex and multi-dimensional
concept
• Honesty and consistency of information were
the most common trust-related concerns
• Government and public health officials were
seen as less trustworthy than personal health
clinicians
• Trust components differed by scenario stage:
– honesty competency fiduciary consistency
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Implications
• To build trust and promote health and safety during a
bioterrorist event:
– Use social marketing (audience segmentation)
• Information tailored to specific populations
– Present information that is accurate, complete,
and consistent across multiple sources
• Protective measures that the public can take
– Use trusted sources
• Medical professionals, CDC officials, CNN, NPR
– Demonstrate sincerity
• Eye contact, personal risk to help the public
– Involve the public early on in the process
• Make them a legitimate partner
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Citation:
Meredith, L. S., Eisenman, D. P., Rhodes, H.,
Ryan, G., & Long, A. (in press). Trust influences
response to public health messages during a
bioterrorist event. Journal of Health Communication.