The role of health systems in shaping vaccine decisions: Insights from Italy, Mexico, the United Kingdom, and the United States

Catherine Arsenault, Department of Global Health, The George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW #2, Washington 20037, DC, USA. Electronic address: catherine.arsenault@email.gwu.edu.
Sindhu Ravishankar, Department of Global Health, The George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW #2, Washington 20037, DC, USA. Electronic address: sindhu.ravishankar@gwu.edu.
Todd Lewis, Department of Global Health and Population, Harvard T.H. Chan School of Public Health; 677 Huntington Avenue, Boston 02115, MA, USA. Electronic address: t.lewis@wustl.edu.
Patricio Armeni, CERGAS SDA Bocconi School of Management, Bocconi University, Via Roberto Sarfatti, 10, 20136 Milano, MI, Italy. Electronic address: patrizio.armeni@unibocconi.it.
Kevin Croke, Department of Global Health and Population, Harvard T.H. Chan School of Public Health; 677 Huntington Avenue, Boston 02115, MA, USA. Electronic address: kcroke@hsph.harvard.edu.
Svetlana V. Doubova, Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Av. Cuauhtémoc 330, Doctores, Cuauhtémoc, 06720 Ciudad de México, CDMX, Mexico.
Martin McKee, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. Electronic address: Martin.McKee@lshtm.ac.uk.
Rosanna Tarricone, CERGAS SDA Bocconi School of Management, Bocconi University, Via Roberto Sarfatti, 10, 20136 Milano, MI, Italy; Department of Social and Political Science, Bocconi University, Via Roberto Sarfatti, 25, 20136 Milano, MI, Italy. Electronic address: rosanna.tarricone@unibocconi.it.
Margaret E. Kruk, Department of Global Health and Population, Harvard T.H. Chan School of Public Health; 677 Huntington Avenue, Boston 02115, MA, USA. Electronic address: mkruk@wustl.edu.

Document Type

Journal Article

Publication Date

4-16-2025

Journal

Vaccine

Volume

54

DOI

10.1016/j.vaccine.2025.127134

Keywords

Health systems; Quality of care; Trust; Vaccine confidence; Vaccine hesitancy

Abstract

BACKGROUND: The demographic drivers of vaccine uptake and confidence have been well-documented in diverse contexts. However, the role of health systems in improving vaccine uptake and confidence has been less discussed particularly in the post-pandemic period. METHODS: Using nationally representative surveys of adults conducted between December 2022 and April 2023 in Italy, Mexico, the United Kingdom (UK), and the United States (US), we examined demographic, health, and health system determinants of vaccine confidence and uptake of four vaccines for adult respondents or their children: COVID-19, influenza, human papillomavirus (HPV), and measles, mumps, and rubella (MMR). Logistic and linear regression models explored associations between predictors of interest and vaccine outcomes, with coefficients reported on the risk difference and risk ratio scales. FINDINGS: A total of 5180 respondents were surveyed, one-third of whom had at least one child aged 1-18 years. Having received at least three other preventive health services in the last year was associated with COVID-19 and Flu vaccination in all countries (Risk ratio (RR) 1.04-1.54) and with vaccine confidence in the US (RR 1.10). Having at least three health care visits in the last year and having a regular health provider were also associated with a higher likelihood of vaccine uptake and confidence in some countries. Being confident in one's ability to obtain and afford quality care (i.e. "health security") had a positive association with at least one outcome in all countries except Mexico (RR 1.07-1.36) and with children COVID vaccination in multi-country regression. Having a regular provider was associated with a higher probability of HPV vaccination for children. Health system engagement and health security showed stronger associations with Flu than COVID-19 vaccination and with vaccine uptake compared to vaccine confidence, although these associations varied across countries. Trust in scientists and trusting the national public health agency were also strongly correlated with several vaccine outcomes. INTERPRETATION: Our findings highlight the links between health system engagement, health security, and vaccination rates. Health system engagement may be particularly important to mitigate barriers to vaccination related to 'complacency' and 'convenience'.

Department

Global Health

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