Perceptions of risk around COVID‐19 and COVID‐19 vaccines

The only thing we have to fear is…fear itself

Franklin D Roosevelt, 1933

Risk perception is important to all of us because it influences how we behave (Fig. 1). It is pertinent to our responses to COVID‐19 and COVID‐19 vaccines, yet perception of risk is highly subjective. It varies according to a wide range of factors, some individual, such as our world view as well as how anxious we are, and some societal, such as our community values and how authorities and the media communicate risk. Although we like to think we are rational about risk, research shows that we are not. We all, including ‘experts’, use mental short cuts or heuristics to calculate the likelihood of an adverse outcome. As a result, we often make biased judgements or use only a small amount of the information available when making decisions about risk.

Fig 1.

Juggler in Paris, photograph by Krzysztof Mizera.

In the 1970s, Israeli economists Nobel laureate Daniel Kahneman and the late Amos Tversky showed that not only do people make judgements about the magnitude of risk and make decisions about risk which do not accord rationally with statistics, but also these ‘errors’ are common and predictable. For example, when asked whether gun homicides or gun suicides are more common in the USA, most people will say homicides, although in fact gun suicides are twice as common. ¹ The likely reason is that the media often covers homicides, but rarely suicides. Media coverage can lead to what Kahneman and Tversky called the availability heuristic. The availability heuristic or availability bias says that something that immediately springs to mind must be more important and thus more likely to occur than something that does not.

Peter Sandman, Professor of Environmental Journalism at Rutgers University, frames risk perception as a combination of ‘hazard + outrage’. ² For Sandman, hazard is the magnitude and probability of undesirable outcomes while outrage refers to everything negative about the situation itself. People assess risks using factors such as trust, control, voluntariness, dread and familiarity (what Sandman calls ‘the outrage factors’), which are as important as mortality or morbidity in how we perceive risk. Perceptions of risk, he says, depend on many factors. For example, people are less anxious about risk if they feel in control (it is well known that drivers think driving their car is safer than being flown in an aeroplane, although the statistics clearly say the opposite). Almost 90% of drivers think they drive better than the average, ³ allowing them to maintain an illusion of control when driving.

The way people frame and perceive risk has particular resonance for the novel coronavirus pandemic, COVID‐19. Amongst health‐care workers, many have learned to trust proven infection control measures such as personal protective equipment especially those familiar with infection control practice, whereas others feel more uncertain, even when assured of the high efficacy of personal protective equipment. ⁴ Ethiopian health‐care professionals who had previously provided clinical care to Ebola, SARS and cholera patients had highly significantly lower levels of worry about COVID‐19 than participants with no such experience. ⁴ Familiarity is reassuring; novel risks are scarier. Countries such as Singapore and South Korea that had coped with SARS were generally better at limiting the spread of COVID‐19, at least initially. Invisible risks are also scarier than more visible ones: this was known for polio which, as described by Philip Roth in his novel Nemesis, caused panic as an epidemic swept silently through the USA. The fact that asymptomatic people can transmit COVID‐19 adds to its mystique and fear.

Sandman says that when hazard is high and outrage is also high, the task is ‘crisis communication’: helping people who are appropriately worried cope with serious risks. ‘We're all in this together’ was an early pandemic catchphrase that resonated with many, although some have pointed out that COVID‐19 disproportionately affects the disadvantaged, so some are ‘in this’ more than others. However, when outrage is high but hazard is low, Sandman recommends ‘outrage management’. ⁵ When people are excessively frightened or angry about a perceived but objectively small hazard, telling them to ‘calm down’ is unlikely to succeed. Surprisingly, according to Sandman, ‘the strategies that actually work turn out to be profoundly counter‐intuitive: apologising for your mistakes, giving others credit for your improvements and acknowledging their grievances and concerns’. ⁵ We are unaware of any direct evidence that this approach works, but if it helps us to talk to our anxious colleagues and to the worried public in a more respectful, constructive way and perhaps to consider compromises, it must surely be better than being disparaging.

Aspects of the COVID‐19 experience exemplify the ideas of Kahneman, Tversky and Sandman about risk perception. Repeated surveys on public risk perception of COVID‐19 and associations with health protective behaviours in the UK found that world view, experience with the virus and trust in government, science and medical professionals were significant predictors of perceived risk. ⁶ Psychological factors were more predictive of risk perception than the number of confirmed COVID‐19 cases at the time of data collection. ⁶

The rapid development of safe, effective vaccines against COVID‐19 has been a remarkable success story. Australians are generally (80%) in favour of COVID‐19 vaccination, women more than men, elderly more than young and those with co‐morbidities more than those with none. ⁷ Yet, although the risks from COVID‐19 far outweigh vaccine risks at almost all ages, the concurrence of a serious but rare adverse effect (thrombosis with thrombocytopenia syndrome caused by Astra‐Zeneca vaccine), a predictably short period of absent COVID‐19 in the community and difficult communication about the risk of the vaccine compared with the risk from COVID‐19 arguably resulted in increased vaccine hesitancy. ⁸ Serious adverse effects with COVID‐19 vaccines were reported disproportionately by the Australian media, an example of availability bias which contributed to delayed vaccination uptake. Meanwhile, severe COVID‐19 is becoming a disease of the unvaccinated in settings where COVID‐19 vaccine coverage is increasing.

How we deal with COVID‐19 and COVID‐19 vaccines depends on many factors including our values, ⁹ how well decision‐makers consult us and procedural justice around mandates. But, how we perceive risk and so how much we are prepared to tolerate it are also relevant. There is increasing recognition that we must also balance the benefits of lockdowns against the risk of causing harm to vulnerable populations, especially children, who have suffered disproportionately from the epidemic despite COVID‐19 posing a much smaller hazard to them. Arguably closing schools, which has had a profound effect on children's well‐being, has been primarily to reduce the risk to adults rather than to benefit children. ¹⁰ , ¹¹ Here, we face the problem of comparing dissimilar risks, the risk of spreading COVID‐19 in schools with the risk of harm to children's mental health, learning and future opportunities.

We all face a myriad of risks each day. In order to balance risks during the COVID‐19 pandemic, we need to be aware of those factors that contribute to how we and others perceive risk, and try to use this knowledge to improve our communication, to the general public as well as in our personal interactions. ⁹