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. 2025 Jun 26;5(6):e0004747. doi: 10.1371/journal.pgph.0004747

Change in confidence in public health entities among US adults between 2020–2024

Hannah Melchinger 1, Saad B Omer 1, Amyn A Malik 1,*
Editor: Nafis Faizi2
PMCID: PMC12200701  PMID: 40569895

Abstract

The COVID-19 pandemic introduced significant uncertainty among Americans, and eroded trust in US health entities and institutions. This study describes a longitudinal assessment of Americans’ change in confidence in these public health entities from 2020 to 2024. We conducted four surveys assessing confidence in public health entities among US adults conducted between February 2020 and October 2024. Surveys were hosted by CloudResearch and administered to a representative sample of US adults (18+). Data was weighted using age, gender, and race estimations sourced from the American Community Survey (ACS) 2022. From February 2020 to June 2022, Americans’ confidence declined for all entities asked about, most notably the Centers for Disease Control and Prevention (CDC, 26%). Despite slight increases between 2022 and 2024, levels of confidence have not recovered to pre-pandemic values. In contrast, Americans’ confidence in their own doctor and their local health department increased from 2022 to 2024 (5% and 19%, respectively), as did confidence in the White House (7%). Our study saw a marked decrease in confidence in public health institutions among US adults, a finding which has implications for the effectiveness of public health communication. Our results highlight the potential for local entities, including personal doctors and local health departments, to leverage the existing trust between them and their public to provide essential public health information and address low confidence in national entities.

Introduction

The COVID-19 pandemic introduced an unprecedented level of uncertainty among the United States public. Notably, survey data has shown that confidence in public health entities among adults in the United States has decreased significantly since 2020. Here we describe one of the first academic studies to longitudinally assess changes in confidence in health entities among US adults between 2020 and 2024.

Methods

Survey development and dissemination

Between February 2020 and October 2024, we conducted four discrete, cross-sectional surveys assessing confidence in public health entities among US adults [1–4]. Surveys were constructed using Qualtrics (Qualtrics, Provo, UT) and administered by CloudResearch, an online survey company, to a census-matched sample of US adults (18+). A representative sample was recruited from CloudResearch’s pre-existing survey panels, which consist of individuals recruited by word-of-mouth and advertising to take surveys. Respondents were recruited according to demographic quotas proportional to the U.S. Census; within each quota, respondents were selected randomly [5]. Participants who completed the survey received a nominal incentive (~2 USD), which they could redeem in several ways, for example as cash, subscription credits, or donations. Distinct representative study populations were recruited from the same panels for all studies. Survey 1 was conducted from February 4–7, 2020; Survey 2 from May 6–7, 2020; Survey 3 from June 8–13, 2022; and Survey 4 from September 20–27, 2024. Sample sizes for Surveys 1–4 were 718, 672, 856, and 828, respectively.

Surveys 1 and 2 asked questions about to the COVID-19 pandemic, while Surveys 3 and 4 asked questions around the 2022 and 2024 mpox outbreaks. In addition to these disease-specific questions, we asked participants a series of questions about their perceptions of public health entities, including who they thought should lead the US response to infectious disease outbreaks, and how they would rate their confidence in different public health entities.

Analysis

Survey results were analyzed using STATA SE 18.5. Survey weights were calculated based on age, gender, and race estimations sourced from the American Community Survey (ACS) 2022. Confidence was measured on a scale of 1–5, with ratings of 4 and 5 categorized as “high confidence.” Statistical significance was defined as p < 0.05. Means, proportions, and 95% confidence intervals (CI) were calculated and adjusted for survey weights. Data from Surveys 1–3 were analyzed in October 2024, along with data from Survey 4; no personal respondent data was accessed or analyzed.

Ethics statement

Approval for Survey 1 (2000027402), Survey 2 (2000027891), and Survey 3 (2000032980) was granted by the Institutional Review Board (IRB) at Yale University, and by the IRB at University of Texas Southwestern Medical Center for Survey 4 (STU-2024–0933). Respondents were advised at the start of the survey that by continuing with the questionnaire, they were consenting to study participation. Participation was voluntary and all survey results were kept confidential. No personal data was collected from respondents; survey metadata, included IP address, device type, and location, were not stored or used.

Results

From February 2020 to October 2024, there has been a significant decline in mean confidence among US adults in health institutions including the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), the Department of Health and Human Services (DHHS), state health departments, and professional medical organizations (Fig 1). Between February and May 2020, the percentage of respondents reporting high confidence in the CDC decreased from 82% to 68%, before dropping to 56% in 2022 (Fig 2). Between 2022 and 2024, confidence in the CDC increased to 60%; however, the change was not statistically significant (S1 Table). Similarly, confidence in the NIH, DHHS, state health departments, and professional medical organizations dropped by 25%, 13%, 16%, and 26%, respectively, from February 2020 to June 2022. Despite slight increases between June 2022 and October 2024, confidence in all institutions remained significantly lower than in February 2020.

Fig 1. Mean confidence in public health organizations among US adults.

Fig 1

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Fig 2. Percentage of US adults reporting high confidence in public health organizations.

Fig 2

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Despite decreasing from February 2020 to June 2022, respondents’ confidence in their own doctor and local health departments increased significantly between 2022 and 2024 by 5% and 19%, respectively. Between February 2020 and 2024, confidence in physicians decreased overall by only 6%, while local health departments increased overall by 6%. Similarly, confidence in the White House increased by 10% from February 2020 (29%) to October 2024 (39%). Overall confidence in the Food and Drug Administration (FDA) remained largely unchanged.

Discussion

Public health institutions like the CDC and NIH provide essential communication and resources to the American public, particularly during health emergencies. Our study documents a marked decrease in trust of public health entities among Americans, especially in premier institutions like the CDC and NIH. Several factors have been shown to contribute to this lack of confidence, including misinformation about healthcare and public health services, and socio-economic challenges caused by the pandemic [6]. Recent studies have suggested that behavioral interventions – especially those which use trusted messengers to communicate with less confident communities – may play a role in reestablishing trust in public health institutions and interventions [7]. Importantly, this study highlights the potential of local health entities, including physicians and local health departments, to act as those messengers and effectively communicate about public health. Local health authorities should be aware of this influence when they interact with patients and public, particularly when discussing complex health topics like COVID-19 vaccination [8]. The findings highlight the urgent need to address American’s confidence in US health institutions through evidence-based interventions.

Supporting information

S1 Table. Change in weighted percentage reporting high confidence (2020–2024).

(DOCX)

pgph.0004747.s001.docx (21.3KB, docx)

Data Availability

Data can be accessed here: https://github.com/OmerResearchGroup/Change-in-confidence-in-public-health-entities-among-US-adults-between-2020-2024.

Funding Statement

The authors received no specific funding for this work.

References

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0004747.r002

Decision Letter 0

Nafis Faizi

7 May 2025

PGPH-D-25-00251

Change in confidence in public health entities among US adults between 2020-2024

PLOS Global Public Health

Dear Dr. Malik,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Nafis Faizi, MD, MPH

Academic Editor

PLOS Global Public Health

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Reviewer #2: Yes

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Reviewer #2: I don't know

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Reviewer #1: Your methods section is well-organized and provides a clear overview of survey development, analysis, and ethical considerations. However, there are a few areas where clarity, consistency, and detail can be improved.

Strengths: the sections flow smoothly. You specify the use of CloudResearch and Qualtrics, as well as the survey timeframe and incentives. Appropriate statistical analysis methods – Use of survey weighting, confidence intervals, and p-values is correctly described. IRB approvals and ethical considerations are well-documented.

Areas of improvement:

Clarify survey design (cross-sectional, longitudinal, or sampling?).

The sentence "Between February 2020 and October 2024, we conducted four surveys assessing confidence in public health entities..." implies a continuous process, but surveys were conducted at four distinct time points (not continuously). Specify whether the surveys were discrete cross-sectional assessments or an ongoing study.

Standardize date formatting for consistency.

"Participants were recruited from February 4-7, 2020, for Survey 1, from May 6-7, 2020, for Survey 2, from June 8-13, 2022, for Survey 3, and from September 20-27, 2024, for Survey 4." The mix of different prepositions and punctuation makes this harder to read. Consider "Survey 1 was conducted from February 4–7, 2020; Survey 2 from May 6–7, 2020; Survey 3 from June 8–13, 2022; and Survey 4 from September 20–27, 2024."

Were participants randomly selected? Stratified? Quota-based?

"Survey weights were calculated based on age, gender, and race estimations sourced from the American Community Survey (ACS) 2022." What about education level, geographic region, or income? Why were they excluded?

Strengthen survey weighting and statistical analysis description.

"Significance was determined as anything with a p-value less than an alpha of 0.05." sounds too informal—use "statistical significance was defined as p <0.05."

Improve ethical statement to ensure clarity on data privacy & consent.

"Participants were advised at the start of the survey that by continuing with the questionnaire, they were consenting to participating in the study." Consider "consenting to participate."

Address potential metadata collection concerns for better confidentiality assurances.

The statement "No personal data was collected from respondents." is good, but does it include IP addresses, cookies, or metadata? Qualtrics automatically collect metadata (e.g., location, device type). If this data was not stored or used, clarify this to strengthen data privacy assurances.

Reviewer #2: The topic is interesting. The manuscript has a good flow and is written in brief and an interesting way. I have a few suggestions to consider.

Was the study population same for all four surveys? While the method section describe the participants were recruited from pre-existing panels in the CloudResearch survey system, but do not explicitly state whether the same individuals participated in all four surveys or if each survey comprised a new, independent sample drawn from the same pool.

What was the sample size of all four surveys?

The IRB permission from two different universities also create slight confusion. For the first three survey (2020 and 2022) Institutional Review Board permission taken from Yale University while for 4th survey (2024) taken from University of Texas. These two university are located in different states, and their residents may differ in perception regards public entities. Consider highlighting it in limitation section, if the survey population is different in these four surveys.

In methods section last para – ‘Among disease-specific questions’, can you explain what do you mean by this, I could not see its relevance in the current study. Kindly rewrite the sentence for clarity (confidence in public health entities repeated twice in same sentence)

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Reviewer #1: Yes:  Obianuju Genevieve Aguolu

Reviewer #2: No

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0004747.r004

Decision Letter 1

Nafis Faizi

4 Feb 2025

Change in confidence in public health entities among US adults between 2020-2024

PGPH-D-25-00251R1

Dear Dr. Malik,

We are pleased to inform you that your manuscript 'Change in confidence in public health entities among US adults between 2020-2024' has been provisionally accepted for publication in PLOS Global Public Health.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Nafis Faizi, MD, MPH

Academic Editor

PLOS Global Public Health

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Reviewer Comments (if any, and for reference):

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Change in weighted percentage reporting high confidence (2020–2024).

    (DOCX)

    pgph.0004747.s001.docx (21.3KB, docx)
    Attachment

    Submitted filename: Confidence Brief_Response to Reviewers_2025 05 08.docx

    pgph.0004747.s003.docx (27KB, docx)

    Data Availability Statement

    Data can be accessed here: https://github.com/OmerResearchGroup/Change-in-confidence-in-public-health-entities-among-US-adults-between-2020-2024.

    Articles from PLOS Global Public Health are provided here courtesy of PLOS

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