1. How does trust influence response to public health messages during a bioterrorist event? Lisa S. Meredith, Ph.D., RAND AcademyHealth June 27, 2006

2. AcademyHealth 2 6/27/2006 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 Corporations 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.

3. AcademyHealth 3 6/27/2006 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

4. AcademyHealth 4 6/27/2006 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)

5. AcademyHealth 5 6/27/2006 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

6. AcademyHealth 6 6/27/2006 Escalating Bioterrorism Scenario Stage 7: Media reports a potential bioterrorist attack with increased hospitalization utilization due to rashes Public Health Officials identify illness as smallpox; introduce plan for targeted ring- vaccination near site of exposure & quarantines Stage 1: Reports of people trying to get vaccinations and being turned away if not exposed or sick Rumor of people in high SES neighborhoods getting vaccinated even though they were not exposed Two conflicting reports by the media Local health workers assigned to communities Local community representatives assist people in their immediate neighborhoods Stage 3: Stage 2: Stage 4: Stage 5: Stage 6:

7. AcademyHealth 7 6/27/2006 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?

8. AcademyHealth 8 6/27/2006 Participant Characteristics *Focus group stratification characteristic

9. AcademyHealth 9 6/27/2006 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)

10. AcademyHealth 10 6/27/2006 Description of Trust Themes Trust Faith (N=59) Other (N=31) Fiduciary Responsibility (N=115) Honesty (N=143) Competency (N=58) Consistency (N=140) I dont 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 youre only working with what theyre telling you, which is probably not even half because they dont 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. 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. And the bottom line is we dont have another choice but to trust them… youve got no choice but to trust them. If theyre 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 persons credentials. I wouldnt 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 its picking up different information… So to feel comfortable, you cant stick to just one site.

11. AcademyHealth 11 6/27/2006 Patterns of Trust by Stratification Group Group FiduciaryHonesty CompetencyConsistency FaithOther Younger (18-39): Low SES37 143272 High SES386010402211 Older (40-65): Low SES25 1138107 High SES152123302011 Total (across all groups)115143581405931

12. AcademyHealth 12 6/27/2006 Patterns of Trust by Scenario Stage Scenario Stage FiduciaryHonestyCompetencyConsistencyFaithOther 1. Initial Report62051351 2. Illness Identification1234122244 3. No Vaccination6615402 4. Others Get Vaccinated282221352 5. Conflicting Reports21251525 6. Local Health Workers19227271011 7. Local Community Representatives 129727125 Total (across 7 stages)85125531213830

13. AcademyHealth 13 6/27/2006 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

14. AcademyHealth 14 6/27/2006 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

15. 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. Citation: