In both countries, there was an overall intensification in average risk perception from August to November 2020, characterized by an increase in perceived likelihood and impact of epidemics, along with a decrease in perceived individual and authorities’ preparedness and knowledge. This may be of concern as, according to the Protection Motivation Theory 17,18, a high threat appraisal paired with a low coping appraisal may result in the choice of not protecting oneself. In the case of COVID-19, this poses a risk not only to the individual, but also to others around them. Being male, older age along with having a higher relative income were associated with a lower perception of the likelihood of epidemics, while excess mortality was marginally related to a higher odds. People in Italy had a higher increase in perception of likelihood and impact of epidemics compared to Sweden and a greater decrease in perceived preparedness and knowledge were observed over time. Regional differences in excess mortality within each country only marginally explained differences in the risk perception.
How a pandemic affects a population stems from the interplay of different factors: population characteristics, prompt response to the spreading, and preparedness of the health care system10. While preparedness of the health care system requires years to establish and is continuously evolving, a prepared contingency plan can be implemented within days. From past pandemics, we know that the success of policies and responses to reduce the infection rate and to avoid epidemics depends on risk perception and behavioral adaptation to such policies and response measures19. Increasing COVID-19 cases, media coverage and implementation of more restrictive measures may have contributed to the increase in the average risk perception from August 2020 to the beginning of the second wave of the COVID-19 pandemic (November 2020) in our sample. Cross-sectional surveys on risk perception of the COVID-19 pandemic found a positive association between higher risk perception and higher compliance to preventive measures20,21. Thus, the increased risk perception in the present study may result in people applying behavioral measures such as social distancing, hand washing, avoidance of public places and transports, and wearing face masks.
As reported in previous studies, our findings support the theory of lower risk perception among individuals with a traditionally higher status in society22. Men, the elderly population and individuals with a higher income perceived a lower risk compared to women, younger generations and individuals with lower income, respectively as shown in other surveys23,24. Media coverage and public messages from the authorities can increase awareness of the impact of COVID-19 infection, in turn facilitating engagement in protective behaviors, especially among men and the elderly - two groups at risk for severe consequences if infected25. Along with this, governments should consider the negative consequences that disadvantaged socio-economic groups are facing and should address rising inequalities following the pandemic.
How excess mortality and national policies during the first wave affect the epidemic risk perception is another important aspect to disentangle. In the present study, excess mortality at regional level was marginally associated with perceived likelihood of epidemics. Comparing Italian and Swedish authorities’ responses during the COVID-19 pandemic may help to untangle the role of national policies. The more stringent measures in Italy during the first wave may explain the higher risk perception in August, and the application of stronger measures at the beginning of the second wave (November 2020) may justify a higher increase of risk perception in Italy than in Sweden over three months. Generally, national policies rather than excess mortality may influence the risk perception since national recommendations and restrictions affect all the population, while few households are affected by the epidemic, even in a scenario with 100% excess mortality.
Findings from this study shed light on the change of public risk perception during the current pandemic informing the scientific community and policymakers. At odds with other threats, individuals have a double role during a pandemic: protecting themselves and safeguarding vulnerable groups at the greatest risk. Implementing personal hygiene measures and adhering to national policies are both required to slow the speed of infection and reduce the burden on the health care system. In our study, high levels of risk perception resulted in a lower trust in authorities with a possible shift of responsibility from trusted authority to individuals. This reduction in perceived authority knowledge and preparedness was stronger in Italy, a country where the restrictions were imposed, compared to Sweden, where the policies have been mainly based on recommendations. A reduction over time of trust in the authorities is of concern since it may affect the adherence to imposed measures. Modern democracies rely on a social contract where each individual should contribute to the collective well-being in proportion to their abilities and exercise their right to vote through their representatives26. Imposing measures to limit personal freedom has a positive effect in the short term to reduce the spread of infection. From a long-term perspective, a paternalistic approach may lead to the emergence of conflicts, non-adherence of imposed measures, and the disruption of the social contract. Policymakers should encourage community involvement and make communities the centre of the response to this pandemic. This approach can help to obtain adherence to the necessary preventive measures and defend the social contract on which modern democracies are based.
A number of additional limitations should be kept in mind when interpreting findings from our study. First, domains of risk perceptions should be interpreted in terms of change over time rather than absolute values given that cultural belief and other country-level factors may affect absolute values. Second, we considered independent samples of the population in the first and second survey wave. Although the samples should be considered representative of the general populations for age and gender, other individual differences may influence the changes over time. Third, this study does not allow to disentangle the specific role of restrictive measures and media coverage as determinants of risk perception.
Conclusively, our findings indicate an increased average epidemic risk perception during the COVID-19 pandemic from August to November 2020. Being male, elderly and a high income was related with a lower risk perception. Considering country-level factors, national policy response rather than excess mortality was an important determinant of the risk perception. In the future months, efforts should be directed towards monitoring the change of risk perception over time, investigating if a higher risk perception is associated with adherence to national recommendations also for the COVID-19 pandemic and untangling the role of media coverage and recommendations on risk perception.