COVID-SCORE: A Global Survey to Assess Public Perceptions of Government Responses to COVID-19 (COVID-SCORE-10)

"Effective control of COVID-19 requires governments and their constituencies to engage in mutually trusting relationships with a shared understanding of what is expected by both sets of actors. The ability of government and public health leaders to gauge how the population perceives the effectiveness of government responses to COVID-19...is essential for identifying potential obstacles to achieving disease control objectives."

Worldwide, governmental efforts to contain the COVID-19 pandemic by imposing restrictions on activities that enable SARS-CoV-2 to spread have met some resistance. Reasons for limited or non-compliance include distrust of government and confusion among some segments of the population about conflicting or unclear COVID-19 information disseminated by government sources. Trust in government has been correlated with willingness to adopt protective behaviours in the face of other health threats, such as the 2009 H1N1 pandemic and the 2014-2016 West African Ebola epidemic. COVID-SCORE is an instrument designed to measure the public's perceptions of government responses to COVID-19 in relation to key domains of performance such as health communication, social welfare, and access to healthcare services. This paper seeks to validate COVID-SCORE, which is designed to capture information across multiple countries while being sensitive to language and cultural differences, and to report findings on public perception in 19 countries heavily affected by COVID-19.

Developed through an iterative process that involved testing the validity of the content and reliability of the questions with both experts and members of the general public, the COVID-SCORE-10 questionnaire items are:

1. The government helped me and my family meet our daily needs during the COVID-19 epidemic in terms of income, food, and shelter.
2. The government communicated clearly to ensure that everyone had the information they needed to protect themselves and others from COVID-19, regardless of socioeconomic level, migrant status, ethnicity, or language.
3. I trusted the government's reports on the spread of the epidemic and the statistics on the number of COVID-19 cases and deaths.
4. The government had a strong pandemic preparedness team that included public health and medical experts to manage our national response to the COVID-19 epidemic.
5. The government provided everyone with access to free, reliable COVID-19 testing if they had symptoms.
6. The government made sure we always had full access to the healthcare services we needed during the epidemic.
7. The government provided special protections to vulnerable groups at higher risk, such as the elderly, the poor, migrants, prisoners, and the homeless during the COVID-19 epidemic.
8. The government made sure that healthcare workers had the personal protective equipment they needed to protect them from COVID-19 at all times.
9. The government provided mental health services to help people suffering from loneliness, depression, and anxiety caused by the COVID-19 epidemic.
10. The government cooperated with other countries and international partners such as the World Health Organization (WHO) to fight the COVID-19 pandemic.

Survey data were collected from June 16-20 2020 from an online panel of 13,426 respondents aged 18 years and older from 19 different countries, ranging between 619 and 773 participants per country. A country could receive a maximum of 100 points on COVID-SCORE, with higher scores indicating that, on average, respondents across the country perceived their government's response to COVID-19 as more adequate. China had the highest score, 80.48, followed by South Korea with 74.54 and South Africa with 64.62. The 3 lowest-scoring countries were Ecuador with a score of 35.76, Brazil with 36.35, and Poland with 41.28. In general, higher-scoring countries were primarily located in Asia, while lower-scoring countries were found in Latin America and Europe.

National scores correlated with respondents' reported levels of trust in government and with country-level COVID-19 mortality rates. The country with the most variability in its responses was the United States (US), as there is a uniform distribution of people rating the government response well and a similar distribution scoring it poorly. (Notably, the US ranked 17th among the 19 countries surveyed with regard to government cooperation with other countries and international organisations such as the WHO). Compared to this apparent lack of population consensus about the quality of government response, the lowest amount of variability in scores was seen in China and South Korea, indicating greater homogeneity in perceptions among responses, which tended to be very positive.

Of the 10 items, item 2, which directly measures government communication responsibilities, scored as the second-highest-rated item across all countries. Other items indirectly related to communication responsibilities also scored well. In contrast, questions about protection and assistance to vulnerable groups and help in meeting daily needs related to income, food, and shelter rated poorly in all countries, which underscores the need to give particular attention to the most vulnerable. Provision of mental health services was the lowest-rated item across all countries. (On the flip side, lack of trust during the COVID-19 pandemic has been associated with poorer mental health.)

Although there were differences in the distribution of COVID-SCORE values across countries, scores did not vary significantly across gender, age group, education, or income level.

The researchers also examined the internal and external validity of the index using appropriate predefined variables, finding that the tool is both reliable and unidimensional. They note: "The apparent reliability of this new instrument suggests that it may be a new tool that governments can refine and use to monitor how individuals and communities perceive their country's response to COVID-19....Longitudinal studies using this instrument at recurring intervals could measure variations in public perceptions over time..."

In conclusion, "crises, and particularly epidemics, raise real barriers to efforts to align individual and collective interests, which challenge the adoption of behavioural changes that are essential to prevent the spread of disease....In this context, governments bear great responsibility to communicate effectively the collective benefits of adhering to evidence-based measures, and public trust in government is an essential component of this process..."