Last year, the MIT Governance Lab (MIT GOV/LAB) helped conduct two national surveys in Sierra Leone to inform the government’s response to the Covid-19 pandemic. Questions measured people’s understanding of how the virus was transmitted, the prevalence of mask-wearing and other preventative measures, levels of food insecurity, and more.
The first survey took place in person in April, at which point there had been only a handful of cases of Covid-19 nationwide. We shared some preliminary results in May. The second survey began as a phone survey in July, but it proved difficult to reach a nationally representative sample over the phone (women and rural residents were especially hard to reach). Fortunately, case numbers remained low throughout the summer (~1 positive test daily per million people), so the research team was able to safely return to the field for some more in-person surveying.
In the graphs below, we share some findings from the second survey that show how much trust people have in different authorities, which can inform how to best communicate public health measures and promote compliance. The surveys, which each had around 2,400 respondents and included people from each of Sierra Leone’s 16 districts, were conducted in partnership with the Institute for Governance Reform (IGR) and Sierra Leone’s Directorate of Science, Technology and Innovation (DSTI) and Ministry of Finance’s Research and Delivery Division (MoF-RDD).
Trust matters for effective public health policy
Why do we care about trust, and how can it impact public health? Our research in Liberia during the Ebola epidemic showed that community health workers were able to improve public compliance with safety precautions by sharing their home addresses with people and telling people they could harass the health workers’ families if the health workers were lying about the Ebola crisis. Since people had a way to hold health workers accountable, they trusted the information the health workers shared about the disease and followed public health measures. The actions of the health workers also demonstrated how costly signaling — behavior that puts something of personal value at risk — can build trust.
People in Sierra Leone generally have high levels of trust in different authorities
During the second survey in July and August 2020, people were asked how much they trusted the government, the Ministry of Health, traditional leaders, and other authorities, and they were given four response options: that they trusted that authority “a lot,” “somewhat,” “just a little,” or “not at all.”
Trust levels were very high for most authorities, with at least 60% of respondents trusting religious leaders, international NGOs, the Ministry of Health, the government, and traditional leaders (like a local chief) “a lot.” For these five authorities, the percentage of respondents who trusted either “a lot” or “somewhat” ranged from 91% for religious leaders to 73% for traditional leaders.
Levels of trust in police were significantly lower, with only 45% of respondents trusting police “a lot,” and 38% trusting police either “just a little” or “not at all.”
This high level of trust in the Ministry of Health and the government in particular is in line with a recent paper in Nature Medicine, which found that among the twelve countries surveyed, Sierra Leone had the highest percentage of respondents naming health care workers or the Ministry of Health and government as their most trusted source of information on Covid-19 vaccines.
Trust levels were higher in July and August than they had been at the beginning of the pandemic
Not only was trust high during the second survey, but it had increased significantly in the four months after the first survey conducted at the beginning of the pandemic. The percentage of people who trusted the Ministry of Health “a lot” grew by 63%, from 45% to 73%. The percentage of people who trusted international NGOs and the government grew by 54% (from 51% to 79%) and 45% (from 49% to 71%), respectively. The percentage of people who trusted police “a lot” was relatively low in both waves, but it also increased significantly — by 51%.
While the difference from the first survey between the percentage of respondents who trusted the government “a lot” and the percentage who trusted the Ministry of Health “a lot,” for example, isn’t meaningful (since the confidence intervals overlap), all of the increases in trust between the first and second surveys are statistically significant.
This increase in trust could be due in part to how few Covid-19 cases there were in Sierra Leone relative to other parts of the world. Washington state in the U.S. and Sierra Leone have similar populations, but around 120 deaths from Covid-19 have been confirmed in Sierra Leone, compared to over 6,100 in Washington. Sierra Leone’s government also acted quickly at the start of the pandemic to contain the spread of Covid-19, implementing a three-day lockdown and two-week inter-district travel ban in April 2020. These actions, along with the relatively low case numbers, might have made the government and Ministry of Health seem more trustworthy and reliable to citizens.
Rural respondents had higher levels of trust than urban respondents in different authorities
The above graph shows the percentage of respondents who said they trusted each authority “a lot,” broken down by urban and rural respondents. Generally, rural respondents were more likely to say they trusted an authority “a lot.” This difference was greatest for trust in traditional leaders — 70% of rural respondents trusted traditional leaders “a lot,” compared to 46% of urban respondents. We also separated people by gender, and found that men and women had similar levels of trust in different actors.
Why might there be more trust in the government and the Ministry of Health in rural areas? It could be because people in rural areas are more supportive of Sierra Leone’s ruling party. Sierra Leone’s president, Julius Maada Bio, is a member of Sierra Leone’s People’s Party. During the second survey, we asked respondents if they felt close to any particular political party. Among rural respondents, 57% picked Sierra Leone’s People’s Party, compared to 42% of urban respondents (see the graph below). People might have more trust in traditional leaders (like local chiefs) in rural areas because rural residents are more likely to interact or have contact with a traditional leader.
Trust and vaccination
Trust in government could be an important factor in determining whether or not people are willing to get a Covid-19 vaccine. The first survey not only asked about people’s trust in authorities, but also asked if people would be willing to let their child get a measles or polio vaccination. The question was posed to all respondents, regardless of whether or not they had children.
The results show that people with higher levels of trust in government also had a higher willingness to vaccinate their children. Of respondents from the first survey who said they trusted government “a lot,” 54% said they were willing to give their children these routine vaccinations, compared to only 26% of respondents who said they trusted the government “not at all.” The difference in willingness between respondents with “a lot” of trust and the rest of respondents was statistically significant, as was the difference between respondents who trusted “not at all” and the rest of respondents. The difference in willingness between respondents who trusted “somewhat” and “just a little” was not statistically significant.
We talked to our partners at IGR, and they cautioned that people who are willing to give their children routine vaccinations might not be as willing to give their child a Covid-19 vaccine. IGR pointed out that routine vaccinations are more established in society, people might have more questions and concerns about Covid-19 and the vaccine, and misinformation about the disease and vaccines is prevalent. Furthermore, Covid-19 vaccines are currently not recommended for young children.
While the previously cited Nature Medicine article found high levels of Covid-19 vaccine willingness in Sierra Leone — in two separate surveys, 78% and 88% of respondents said they would take the vaccine if it were available — it also notes that “reports about side effects and risks associated with expedited vaccine development may have increased hesitancy.” Several countries in Africa paused their rollout of the AstraZeneca vaccine in the spring due to concerns about side effects, as did many countries in Europe.
Increased levels of trust in government and health workers between our first and second survey could be a good sign at a time when governments are working to promote vaccine acceptance. But people don’t just need to be willing to get vaccinated or vaccinate their children — they also need access to vaccines. Countries in Africa have had a limited supply of doses, and in Sierra Leone, Reuters estimates that only 1% of people are vaccinated.
Facemasks, photo by Anton on Unsplash.