Health Systems, Trust and Immunisation Governance Dynamics: Mixed-Methods Evidence from Zambia

Abstract

<title>Abstract</title> <p>Background: Vaccine uptake during public health emergencies reflects not only access but also institutional credibility and governance capacity. The COVID-19 vaccine rollout provided an opportunity to examine how trust, communication systems and health system performance shaped patterns of immunisation uptake in lower middle-income settings. This study analysed determinants of vaccine uptake among priority groups in Zambia through a health systems and governance lens. Methods: A concurrent mixed-methods study was conducted across five provinces in Zambia. Quantitative data were collected from 3,059 participants (including from the health sector, academia, religious groups, public service, defence forces and business sectors) using disproportionate stratified sampling. Binary logistic regression was used to examine determinants of receipt of at least one COVID-19 vaccine dose through staged modelling: demographics, institutional trust and information ecosystem variables. Institutional trust was operationalised as a composite index (Cronbach’s α = 0.84). Qualitative data from focus group discussions and key informant interviews were analysed thematically and mapped to the WHO determinants of vaccine hesitancy framework and a governance lens. Results: Overall, 69.2% of participants reported receiving at least one vaccine dose. Higher institutional trust was independently associated with vaccination in adjusted models, with participants in the high-trust category having more than twice the odds of uptake compared with those with low trust (AOR 2.32, 95% CI 1.83–2.95). Trust in one’s primary information source was also strongly associated with vaccination (AOR 2.20, 95% CI 1.76–2.76). Qualitative findings indicated that concerns regarding transparency, policy consistency and health worker confidence were associated with vaccination decisions, alongside perceptions of service reliability and communication coherence. Conclusion: COVID-19 vaccine uptake among priority groups in Zambia was strongly associated with trust in official health information and institutional credibility, interpreted here as proxy indicators of governance performance. Strengthening epidemic preparedness and routine immunisation systems requires sustained investment in transparent communication, workforce confidence and trust-building mechanisms as core components of health system resilience.</p>