Abstract
Public explanations of vaccine hesitancy often emphasize distrust of pharmaceutical companies as a primary driver of declining uptake. While such distrust is widespread, it does not adequately explain observed behavioral patterns. Survey evidence from Montgomery County, Pennsylvania (n=654) shows that distrust of pharmaceutical companies is high and broadly similar across political groups, yet vaccine uptake varies sharply.
This paper argues that vaccine behavior is better understood as a function of system legitimacy, defined as the perceived credibility, independence, and accountability of the institutions governing vaccine development, approval, and recommendation. Quantitative and qualitative evidence indicate a shift from product-level skepticism to system-level judgment. In some cases, skepticism coexists with continued participation. In others, it leads to selective engagement or complete disengagement from formal health institutions.
A pedagogical model is introduced in which behavior reflects the interaction of baseline distrust, system legitimacy, coercion sensitivity, and the availability of alternative authority. The findings suggest that restoring confidence in pharmaceutical companies alone is unlikely to address declining uptake. The central challenge lies in addressing broader fragmentation in the health information system.
1. Introduction
Debates over vaccine hesitancy have increasingly centered on the role of distrust in pharmaceutical companies. Concerns about profit motives, transparency, and influence over public health policy have been widely documented and are often assumed to translate directly into reduced vaccine uptake. Policy responses have followed accordingly, focusing on improving communication, increasing transparency, and countering misinformation. There is, however, growing reason to question whether this explanation is sufficient.
Distrust of pharmaceutical companies is high across all major political groupings and varies only modestly between them. Yet vaccine behavior diverges sharply. Some groups maintain relatively high levels of uptake despite skepticism, while others have sharply reduced participation, including in routine adult immunization such as influenza vaccination.
The relevant question is not whether distrust exists, but how it is interpreted and translated into action.
Vaccines are not encountered as isolated products. They are encountered as outcomes of a structured system involving scientific research, regulatory approval, public health recommendation, and, in some cases, mandates or strong social expectations. Trust in any given intervention is therefore mediated by trust in this broader institutional framework.
Where the system is still viewed as legitimate, skepticism can be accommodated within continued participation. Where it is not, skepticism may lead to reduced uptake or disengagement. In a subset of respondents, this process extends further, with individuals reporting a lack of confidence across the entire institutional chain — from federal public health agencies to physicians — and turning instead to alternative sources of authority.
2. Data and approach
The analysis is based on a survey of 654 respondents in Montgomery County, Pennsylvania, comprising 201 Republicans, 139 Independents, and 314 Democrats, as indicated by their party membership or designation in County-level voting records. The survey was conducted using channels developed in earlier work on vaccine attitudes and risk perception, including online surveys and face-to-face interviews.
The survey collected information on recent vaccine behavior, including COVID-19 vaccination within the past twelve months and influenza vaccination, along with broader measures of adult vaccination. It also captured reported trust in key institutions, including physicians and federal public health agencies. Additional questions addressed perceived risks, attitudes toward mandates and pandemic policies, and open-ended explanations of decision-making.
Trust in physicians and trust in public health agencies are used as proxies for system legitimacy, reflecting confidence in the institutions responsible for interpreting evidence and issuing recommendations. These measures are combined into a simple index to facilitate comparison across groups.
3. Pharmaceutical distrust
Distrust of pharmaceutical companies is a consistent feature of the survey data. Across all three political groupings, a large majority of respondents report skepticism toward industry. The proportions are 76.6 percent among Republicans, 74.8 percent among Independents, and 72.3 percent among Democrats.
| Republicans | 76.6% |
|---|---|
| Independents | 74.8% |
| Democrats | 72.3% |
Source: CGHA Survey Series, Montgomery County, Pennsylvania (n=654). A spread of roughly four percentage points across groups whose vaccine behavior differs sharply.
The narrowness of this spread is the central analytical problem. If distrust of industry were the operative driver of behavior, groups reporting nearly identical distrust should behave in nearly identical ways. They do not.
Institutional exit
THE SHIFT Distrust remains widespread but is increasingly directed beyond individual actors to encompass the structure of the system itself. Earlier work found that individuals often expressed skepticism while remaining engaged with the health system; distrust functioned as a background condition. The present findings indicate a shift in that relationship.Restoring confidence in pharmaceutical companies alone is therefore unlikely to address declining uptake. The central challenge lies in addressing broader fragmentation in the health information system — and in the credibility, independence, and accountability of the institutions that interpret evidence on the public’s behalf.
