Democracy, trust, and political orientation: disentangling mechanisms shaping individuals’ vaccine attitudes

Context: In recent decades, many countries experienced a reduction in the quality and functioning of democratic institutions and norms accompanied by rising social distrust and opposing political views. The decline in vaccine confidence might be linked to these trends. This study explores the political factors influencing individual attitudes toward vaccination across 22 upper-middle-income and high-income countries, examining the interaction between political orientation, trust in public health authorities, and levels of democracy. Methods: The authors used the VaxPref database, encompassing demographically representative data from 50,242 respondents collected between July 2022 and June 2023, to conduct an analysis on three levels: pooled sample, democracy groups, and country-specific analyses. Results: The authors found that higher democracy scores generally correlated with lower levels of vaccine skepticism. People in the political center and on the political right expressed more skepticism toward vaccines overall. However, trust in public health authorities emerged as the determinant that explains the largest variation in vaccine attitudes. Conclusions: These findings suggest a greater effectiveness of democratic systems in fostering vaccine confidence and the need to depoliticize vaccination efforts. Building and maintaining trust in scientific information and technical expertise is critical. Blunt measures like vaccination mandates may not sustain long-term confidence, particularly in democratic contexts. Effective interventions should prioritize comprehensive school-based education to promote preventive health behaviors coupled with targeted trust-enhancing communication strategies.