Public trust and mistrust of COVID-19 vaccines: Mapping the conceptual landscape

Opinion:

This review argues that a lot of research on “trust in vaccines” is fuzzy about what trust actually means and measures. Ledderer et al. are bringing order into this chaos and offer a clear way to think about different kinds of trust and how they are studied.

In simpler terms, the authors show that many studies treat trust almost like a number to push up, instead of as a real, two‑way relationship between people, professionals, and institutions. They point out that big surveys and simple questions can be useful in a crisis, but they risk flattening trust into something purely technical. The review suggests that future work should look more seriously at how people think and feel, and how they communicate about vaccines, so that policies don’t just “manage” trust but actually build it through more honest, social, and respectful engagement.

Summary

In this systematic meta-narrative review, Ledderer and colleagues examine how public trust and mistrust have been conceptualized, operationalized, and linked to COVID-19 vaccine uptake across a rapidly expanding and methodologically diverse literature. Motivated by the central role trust played during the pandemic—particularly in the context of unprecedented vaccine development speed—the authors argue that trust is not a singular or self-evident construct, but rather a multifaceted phenomenon that has been inconsistently defined and measured across disciplines. Their primary aim is twofold: first, to map how trust has been studied in COVID-19 vaccination research; and second, to assess whether six previously developed “narratives of trust” can meaningfully synthesize this heterogeneous body of work.

Using a systematic meta-narrative review methodology, the authors searched six major academic databases and identified 79 peer-reviewed studies published between 2021 and 2023 that explicitly addressed public trust or mistrust in relation to COVID-19 vaccines. The final sample was dominated by studies from Europe and the United States and was heavily skewed toward quantitative, survey-based designs. Most studies relied on Likert-scale measures of trust, with sample sizes ranging from fewer than 200 participants to more than 50,000. This methodological concentration reflects the public health imperative for rapid, comparable evidence during a global crisis, but it also shapes how trust is understood and analyzed.

A key empirical finding of the review is the conceptual fluidity of “trust.” Across the literature, trust is directed toward a wide range of objects: science as an abstract enterprise, individual scientists, public health authorities, medical institutions, information sources, vaccine development processes, and the vaccines themselves. These referents are often grouped under the umbrella term “trust,” despite representing distinct relationships with potentially different determinants and consequences. Similarly, trust is linked to diverse outcomes, including vaccination intention, willingness, confidence, acceptance, hesitancy, and actual uptake. The authors highlight that these outcomes correspond to different stages of decision-making, yet are frequently treated as interchangeable in empirical analyses.

To bring structure to this diversity, Ledderer et al. apply six meta-narratives of trust—attitudinal, cognitive, affective, contingent, contextual, and communicated—previously developed in climate science research. Attitudinal trust, defined as a general disposition toward scientific actors or institutions, appears in all 79 studies and dominates the field. Contingent trust, which treats trust as both shaped by and predictive of other variables such as political orientation or media use, is similarly ubiquitous. In contrast, cognitive trust (grounded in rational evaluation of scientific credibility) and affective trust (linked to emotions such as hope or fear) are comparatively rare, appearing in only a small minority of studies.

Contextual trust is present in most articles, typically through national comparisons or demographic analyses that situate trust within specific social and political environments. Communicated trust—focusing on how trust is constructed through communication processes and information channels—is identified in fewer than a quarter of the studies, despite the centrality of communication to pandemic response. This imbalance, the authors argue, reveals a literature that privileges measurable attitudes over relational, emotional, and communicative dimensions of trust.

Another important contribution of the review is its analysis of how trust is operationalized. Despite wide conceptual variation, methodological approaches are strikingly uniform. Most quantitative studies use single-item or short multi-item survey measures, often without distinguishing between dimensions such as competence, integrity, and benevolence. While this standardization facilitates comparability and policy relevance, it risks oversimplifying a complex construct. Qualitative and mixed-methods studies—though few—offer richer insights into deliberation, emotion, and social context, suggesting that current dominant methods capture only part of the trust phenomenon.

The authors also identify notable gaps. Trust is almost always framed instrumentally, as a means to achieve public health goals such as vaccine uptake, rather than as a reciprocal relationship between publics and institutions. Little attention is paid to scientists’ trust in the public, or to the mutual dynamics through which trust is built, eroded, or repaired. This asymmetry, the authors suggest, limits understanding of trust as a relational and ethical concept, not merely a behavioral predictor.

Critical opinion

This review makes a strong and original contribution by exposing the conceptual looseness underlying much trust-in-vaccination research and by offering a coherent framework to navigate it. Its meta-narrative approach is particularly valuable for interdisciplinary synthesis and reflexive critique. However, the analysis also reveals how deeply instrumentalized trust has become in public health research, often reduced to a variable to be optimized rather than a relationship to be understood. While the authors rightly acknowledge the pragmatic value of standardized surveys during crises, future research would benefit from greater theoretical rigor and methodological pluralism. Without deeper engagement with cognitive, affective, and communicative dimensions, policies risk treating trust as a technical problem rather than a fundamentally social one.

By Health Literacy Asia