Trust is the single most important determinant of attitudes towards vaccination – trust in the vaccine itself, trust in the system developing and delivering the vaccines, trust in those sharing information about the vaccine – but also, trust in government and institutions, trust in local leaders and community, trust in healthcare, and trust in each other.
The medical historian Maya Goldenberg explains how the common mischaracterization of vaccine hesitancy as ignorance or misunderstanding of science has led to ineffective interventions that rely on the deficit model – where authorities think people just need to be told the facts rather than on building trust in order to lay the foundation for effective communication and vaccine demand strategies.
“The pervasive and reinforcing assumption that the public only hesitates because it is ignorant shields science and government institutions from examining their own practices with respect to earning and maintaining the public trust,” Goldenberg writes in Vaccine Hesitancy: Public Trust, Expertise, and the War on Science.
“To really be able to get people comfortable enough to get vaccinated, what needs to happen is something that we can’t rush or speed and that is basically trust, which comes with time and which comes with information sharing and transparency.”
“Closing the gap between the vaccinated and the unvaccinated must be rooted in how we give time, use time, and create time.”
Trust is an understudied facet of vaccine confidence, though that is changing, with one recent study showing higher trust in government regarding Covid-19 led to higher adoption of health behaviors across 23 nations.
In our work, we find that distrust is emerging as a common current across political, racial, economic and information divides in unvaccinated Americans, with the harms inflicted by institutions, politicization, and mis- and disinformation functioning as fueling forces. Since before the pandemic, Americans have known and been concerned about the increase in distrust in society.
There are many reasons for distrust, some rooted in lived experiences today, some rooted in past experiences and intergenerational memory, some rooted in ideologies, and some rooted in a combination of these or other reasons. Trust and distrust require careful study and consideration, as vaccine demand strategies depend heavily on our collective ability to build or rebuild trust. Accountability is essential in this process: Without recognition from and change in the leaders and institutions that have and are causing harm, healing and trust cannot be built. Recognizing this, we can also begin to see that investing in vaccine demand, and other Covid protections, is an important opportunity to build trust as the pandemic rages on, and to improve health outcomes more broadly.
The Equity-First Vaccination Initiative partners have showcased how to do this essential work. They demonstrate how activities organized by community organizations such as hosting listening sessions, organizing vaccination events, handing out free masks, providing free testing, connecting folks with resources such as food and housing, and sharing hyper-local, engaging messages designed to speak to very specific groups, are all part of trust-building – and that investment in trust-building as a long-term strategy, including pushing institutions and government leaders to demonstrate trustworthiness, is a pathway to pandemic resilience.
“We must not create equity for communities, but with communities.”
A concrete example for the urgent need to expand the concept of trust in vaccine demand work is national polls that ask people about their trusted sources. The results often show that people trust local government more than national government, experts more than politicians, and people more than institutions. Healthcare providers often emerge from these polls as the most trusted source for vaccine information. For people who have an established relationship with a physician, for example, trust in their personal doctor is greater than in any other single source of vaccine information, including Covid vaccine information. This is important for decisions about vaccine distribution strategies.
But there is a caveat: All of this depends heavily on the population, down to neighborhoods, demographics and identity groups. Underserved communities, for example, often don’t have access to healthcare providers, so doctors are not on top of their list of trusted sources. In some U.S. states, more than a quarter of children don’t have access to regular pediatric care, so parents don’t have familiar nurses or doctors to approach with questions about Covid-19 vaccines for children.
“The community doesn’t trust doctors, and rightfully so because of what’s happened in the Latino community.”
“Who are your trusted messengers?”
In addition, negative experiences with the healthcare system, from bias in care to lack of access to health insurance to surprise billing, often contribute to a deep distrust in healthcare providers. And trust is further eroded as Black, Hispanic and Native Americans continue to confront the disproportionate impact of the pandemic on their families, friends and communities, caused by long standing inequities and systemic racism.
There is also the impact of mis- and disinformation efforts on trust in healthcare providers. For example, profiteers, politicians and media sources that drive conspiracy theories – such as a “government-medical complex” selling vaccines for profit – tend to be effective with people who are already primed on believing in conspiracy theories, and who are ready to dismiss the expertise of physicians and experts.
Unsurprisingly, a key finding from the Equity-First Vaccination Initiative is that unvaccinated Americans in low-wage communities sometimes have no trusted messengers, which aligns with the research by Goldenberg, our team, and others. Similarly, recent research shows that while vaccine endorsements from Republican leaders are effective in reaching conservative Americans – even endorsements from Donald Trump no longer work with the most ardent Trump supporters.
Sophisticated messaging alone can’t fix such significant rifts – vaccine demand strategies need to anticipate trust challenges, and enlist diverse tools, messengers and community partners from the start.
Ohio County, Indiana, which voted 75 percent for Trump in the 2020 election, for example managed to become the highest vaccinated county in Indiana by August 2021 by taking politics out of the equation and making vaccinations about the community.
More recent efforts to reach Americans who remain unvaccinated and undervaccinated have been successful when built on trust and strong local connections. As national daily vaccinations consistently decreased in early 2022, EVI communities for example were able to increase their impact and vaccine uptake.