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J Health Commun. Author manuscript; available in PMC 2022 May 16.
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Published in final edited form as:

J Health Commun. 2021 April 03; 26(4): 272–280. doi:10.1080/10810730.2021.1927259.

Development of a scale to measure trust in public health

authorities: Prevalence of trust and association with vaccination
Taylor A. Holroyd, PhD MSPH1,2, Rupali J. Limaye, PhD MPH MA1,2,3,4,5, Jennifer E. Gerber,
PhD MSc1, Rajiv N. Rimal, PhD MA3, Rashelle J. Musci, PhD MS6, Janesse Brewer, MPA
BA1, Andrea Sutherland, MD MPH MSc1,8, Madeleine Blunt, BSN1, Gail Geller, ScD
MHS3,7,8,9, Daniel A. Salmon, PhD MPH1,3,5
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1.Department of International Health, Johns Hopkins Bloomberg School of Public Health,

Baltimore, MD
2.International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD
3.Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD
4.Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
5.Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
6.Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
7.Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public
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Health, Baltimore, MD
8.Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
9.Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD

Abstract
Infectious disease outbreaks highlight the importance of trust in public health authorities to avoid
fear and improve adherence to recommendations. There is currently no established and validated
measure for trust in public health authorities. We aimed to develop and validate an instrument that
measures trust in public health authorities and to assess the association between trust in public
health authorities and vaccine attitudes. We developed 20 items to measure trust in public health
authorities. After implementing a survey in January 2020, we investigated relationships between
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the items, reduced the number of items, and identified latent constructs of the scale. We assessed
variability in trust and how trust was associated with vaccine attitudes, beliefs, and self-reported

Corresponding author: Taylor A. Holroyd, PhD MSPH, International Vaccine Access Center, Johns Hopkins Bloomberg School of
Public Health, tholroy1@alumni.jh.edu, (443) 955-2704, 415 N. Washington Street, Baltimore, MD 21231.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Statement
All authors have agreed on authorship, read and approved the manuscript, and given consent for submission and subsequent
publication of the manuscript. This study was ruled exempt by the Institutional Review Board at the Johns Hopkins Bloomberg School
of Public Health.
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vaccine acceptance. The pool was reduced to a 14-item trust in public health authorities scale and
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we found that this trust model was strongly associated with acceptance of vaccines. Our scale can
be used to examine the relationship between trust in public health authorities and adherence to
public health recommendations. The measure needs to be validated in other settings to determine
whether they are associated with other areas where the public question public health authority
recommendations.

Keywords
Vaccine hesitancy; Vaccine policy; Survey research; Child and adolescent health; Public health

INTRODUCTION
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The current COVID-19 pandemic highlights the importance of trust in public health
authorities to improve public adherence to evidence-based recommendations and minimize
unnecessary fear. Public trust in the United States government has decreased over the last
several decades, with only 17% of Americans trusting the government to do what is right
most of the time. This erosion of trust is particularly concerning from a public health
perspective, especially given challenges in measuring trust in public health. Measures of
trust in government, healthcare providers (Anderson and Dedrick 1990, Stecula, Kuru et al.
2020), health insurers (Zheng, Hall et al. 2002, Goold, Fessler et al. 2006), public health
after disasters (Eisenman, Williams et al. 2012), medical researchers (Geller, Bernhardt et al.
2005, Hall, Camacho et al. 2006, Yarborough, Fryer-Edwards et al. 2009), the United States
vaccine safety system (Frew, Murden et al. 2019), and the health system overall (Ozawa and
Sripad 2013) have been previously developed, and from these we can learn about aspects of
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public trust and how the public views different authorities. However, there is no established
and validated measure for trust in public health authorities specifically, such as local and
state health departments, the Centers for Disease Control and Prevention, the Food and Drug
Administration, and other government health agencies (U.S. Department of Health &
Human Services 2003). Trust in public health authorities can affect public attitudes and
behaviors, and ultimately have a substantial impact on health decisions and adherence to
health recommendations (Altman and Morgan 1983). Furthermore, the level of trust in
public health authorities across the United States population or subpopulations has not
previously been characterized, preventing us from fully understanding how trust in public
health authorities can impact health behaviors like vaccine uptake.

Public health authorities provide guidance and countermeasures to the public, but this
system is only effective if the public trusts the information provided and adheres to
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recommendations. Studies have demonstrated the importance of trust in government

authorities for effective risk communication (Peters, Covello et al. 1997), the importance of
trust in healthcare providers for adherence to clinical recommendations (Hevey 2007,
Dunbar-Jacob 2012, Orom, Underwood et al. 2018), and the interplay between trust in
government and trust in science (Wellcome Trust 2018). Specific trust in public health
authorities, however, has not been widely examined.

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Vaccines provide an excellent example of why trust in public health authorities and
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adherence to their recommendations are crucial. Declining confidence in immunization has

contributed to vaccine refusals, increased exemptions to school immunization requirements,
and outbreaks of vaccine-preventable diseases (Salmon, Haber et al. 1999, Omer, Pan et al.
2006, Omer, Enger et al. 2008, Glanz, McClure et al. 2009, Atwell, Van Otterloo et al. 2013,
Delamater, Leslie et al. 2017). In 2019, the World Health Organization declared vaccine
hesitancy one of the top ten threats to global health (World Health Organization 2019). Trust
in government was associated with vaccination intention during the 2009 H1N1 influenza
pandemic (Quinn, Parmer et al. 2013, Freimuth, Musa et al. 2014). Low trust in government
is associated with refusal of childhood vaccines (Salmon, Moulton et al. 2005) and
opposition to compulsory vaccination policies (Taylor-Clark, Blendon et al. 2005).

Measuring trust in public health authorities in a valid and reliable way is essential to
examine and improve adherence to public health authority recommendations. This study
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aimed to 1) develop and validate an instrument to comprehensively measure trust in public

health authorities (TiPHA scale), 2) characterize the level of trust in public health authorities
in the United States, and 3) evaluate whether trust in public health authorities is associated
with vaccine attitudes and acceptance.

MATERIALS AND METHODS

Item generation
In order to generate the item pool regarding trust in public health authorities, we first
reviewed existing literature relevant to trust in public health authorities from the domains of
trust in government (Taylor-Clark, Blendon et al. 2005, Lee, Whetten et al. 2016), risk
communication (Peters, Covello et al. 1997, Vaughan and Tinker 2009), and vaccine
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acceptance (National Vaccine Advisory Committee 2011, Quinn, Parmer et al. 2013,
Freimuth, Musa et al. 2014, National Vaccine Advisory Committee 2014). Based on existing
literature and in-depth interviews (Limaye, Oloko et al.), we initially identified ten crucial
content domains of trust: beneficence, efficiency, innovation, objectivity, competence,
equity, transparency, responsiveness, accuracy, and integrity. Using these ten domains, we
developed a 20-item pool related to trust in public health authorities (Table 1). Six items
were modified from studies by Salmon et al. and Lee et al. addressing issues of beneficence,
objectivity, equity, and integrity relating to trust in government (Salmon, Moulton et al.
2005, Lee, Whetten et al. 2016). The remaining 14 items were developed de novo based on
constructs identified in the literature. The item pool was reviewed by the research team to
ensure content validity and confirm that all identified domains were sufficiently covered.
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Study design and sampling

We conducted a panel survey among adults aged 18 and older in the United States in
January-February 2020. Participant recruitment was conducted by the web-based survey
panel company Qualtrics (Provo, UT). 1,925 participants completed the survey from panel
volunteers selected to match the demographic profile of the United States. This study was
ruled exempt by the Institutional Review Board at the Johns Hopkins School of Public
Health.

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Survey development
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The 20-item pool regarding trust in public health authorities (Table 1) included both
positively and negatively worded items to avoid affirmation bias (Devellis R.F. 2003).
Participants used a 4-point Likert scale (“Strongly agree”, “Agree”, “Disagree”, “Strongly
disagree”) to indicate how they felt “about public health authorities such as local and state
health departments, the Centers for Disease Control and Prevention (CDC), and Food and
Drug Administration (FDA)”.

Respondents identified their gender, age, education, household income, race or ethnic group,
whether they had children, and age of their youngest child. Different versions of 4-point
Likert scales were used to assess vaccine hesitancy, attitudes, beliefs and vaccine acceptance
among respondents without minor children (non-parents and parents with adult children over
age 18) (Gilkey, Magnus et al. 2014), respondents whose youngest child was aged 10 years
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and under (Opel, Taylor et al. 2011), and respondents whose youngest child was aged 11 to
17 years (Gilkey, Magnus et al. 2014).

The overall survey was pre-tested in 131 individuals from the same panel to ensure question
clarity and completeness of response options. A convenience sample of twenty pre-test
individuals were interviewed by phone to further ensure survey clarity. Changes made to the
overall survey instrument during pre-testing included re-wording of questions, addition of
response options, and removal of 20 questions.

Data analysis
We utilized factor analysis to investigate relationships between the trust items and identify
which items compose a scale measuring trust in public health authorities. Principal
components analysis with promax oblique rotation was conducted on the 20-item pool,
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assuming correlations between components. Eigenvalues were examined to identify the

number of factors accounting for a large proportion of variation in the items. A scree plot
was generated to confirm the number of factors. Only factors with a standard eigenvalue
cutoff >1.0 were included (Yeomans and Golder 1982). Exploratory factor analysis with
maximum likelihood estimation was conducted to examine the factor loadings and identify
whether any items with consistently low factor loadings or high cross-loadings could be
removed from the scale and subsequent analyses. We used a standard but stringent factor
loading cutoff of >0.7 (Opel, Taylor et al. 2011). The Cronbach α coefficient was calculated
to evaluate the internal consistency of the reduced scale and identified factors (Devellis R.F.
2003).

To assess the validity of the TiPHA scale, we utilized confirmatory factor analysis (CFA) to
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statistically evaluate the number of factors that represented the best and most parsimonious
fit for the overall data (Boelen, van den Hout et al. 2008, Atkinson, Rosenfeld et al. 2011,
Yen, Sousa et al. 2014). Several fit statistics were used to evaluate which model best
represents the data: root-mean-squared error of approximation (RMSEA), comparative fit
index (CFI), Tucker Lewis index (TLI), standardized root mean square residual (SRMR),
and chi-square. Models that represent a good fit of the data have RMSEA and SRMR values
≤0.08, CFI and TLI values >0.90, and a lower chi-square value compared to other

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models(Hu 1999). Stata version 14 (College Station, TX) and Mplus Version 8 (Los
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Angeles, CA) were used for all data analysis.

The prevalence of trust across the population and among subpopulations was evaluated using
descriptive statistics and Pearson’s chi-square test for independence. The sum of the 14
TiPHA scale items was calculated for each individual and dichotomized above and below
the median value to create a binary variable for reporting high or low trust in public health
authorities. We conducted multiple logistic regression to assess whether vaccine attitudes,
beliefs, and acceptance were associated with reported trust in public health authorities (Stata
version 14, College Station, TX), adjusting for participant demographic information,
including gender, income, education, race, age, region, and parent status. Respondents who
selected the “don’t know” option regarding specific vaccines were not included in analysis
for vaccine acceptance. Respondents who indicated they had accepted or planned to accept
vaccines were both counted as accepting vaccines.
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RESULTS
Participants
1,925 adults completed the survey. The majority of participants (64%) were the parent of at
least one child under age 18. We observed broad variability in participant sociodemographic
characteristics (Table 2); these characteristics are similar to the demographic profile of the
United States as enrollment quotas were used.

Survey item reduction

Principal components and exploratory factor analyses identified two factors that emerged
with eigenvalues much greater than one (6.80 and 4.39, respectively). A scree plot was
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generated to confirm that these two factors explained a significant proportion (56%) of
variability in the items. Upon examining the two-factor solution, we concluded that six items
could be removed from the scale based on low factor loadings <0.7. After removing these
items, we re-conducted the analyses and determined that the 14-item two-factor solution
most parsimoniously summarized the remaining data, accounting for 62% of variability in
trust in public health authorities (Table 3).

Trust in public health authorities was best conceptualized as two factors, beneficence and
competence. Factor 1, beneficence (eigenvalue 5.41) accounted for 64% of the variance and
contained eight items related to public health authorities helping the public and utilizing
resources well (Table 3). Factor 2, competence (eigenvalue 3.30) accounted for 36% of the
variance and contained six items related to public health authorities sharing information and
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solving problems. The items contained in the two factors are distinctive enough that they
comprehensively capture the spectrum of trust in public health authorities (Devellis R.F.
2003).

Reliability
We computed the Cronbach α coefficient to assess the internal consistency of the original
20-item pool, the shortened 14-item TiPHA scale, and each of the factor scales. The

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Cronbach α coefficient for the original 20-item pool was 0.89. The Cronbach α coefficient
for the shortened 14-item scale was 0.86. The α coefficients for the two factors individually
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were 0.92 for beneficence and 0.87 for competence.

Validity
The fit statistics indicate that two-factor model was a significant improvement over one-,
three, and four-factor models (Appendix A1). The two-factor model had a lower RMSEA
value (0.000), higher CFI and TLI values (0.987 and 0.985 respectively), lower SRMR value
(0.019), and a significant change in chi-square compared to one-, three-, and four-factor
models. Based on these results and in the interest of parsimony, the two-factor model was
selected as the best fit for the data. We found this two-factor structure was invariant across
age, education, and race characteristics. These findings provided strong evidence to support
a two-factor representation of trust in public health authorities and to establish construct
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validity of the 14-item TiPHA scale (Appendix A2).

Prevalence of trust in public health authorities

We found moderate variability in trust in public health authorities (Table 1). Most
participants agreed or strongly agreed with statements indicating trust, such as that public
health authorities base recommendations on the best available science (87%). A substantial
minority of participants agreed or strongly agreed with statements indicating distrust, like
that public health authorities waste money on health problems (30%). Concerningly, 48% of
participants agreed or strongly agreed that public health authorities sometimes hide
information from the public.

915 (48%) participants had low trust and 1,010 (52%) had high trust in public health
authorities. High trust participants were older, more often white, had higher educational
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levels and higher household incomes, while low trust participants were younger, more often
black or Hispanic, and reported lower education and lower household incomes (Table 2).
Among the participants who were parents, those with high trust were more likely to have an
adolescent or adult child, while those with low trust were more likely to have a child aged 10
and under.

Trust in public health authorities was associated with the odds of participants agreeing with
statements used to assess vaccine hesitancy (Table 4). Participants with high trust were more
likely to agree with positive statements about vaccines and less likely to agree with negative
statements. Among parents of children aged 10 and under, high trust in public health
authorities was associated with decreased odds of participants reporting that children get
more vaccines than are good for them (odds ratio [OR] 0.35, 95% confidence interval [CI]
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0.23–0.51), it is better for children to develop immunity by getting sick (OR 0.22, 95% CI
0.14–0.33), and it is better for children to get fewer vaccines simultaneously (OR 0.46, 95%
CI 0.32–0.68). Among parents of adolescents aged 11 to 17, high trust in public health
authorities was associated with increased odds of participants reporting that vaccines are
necessary to protect adolescent health (OR 12.88, 95% CI 4.71–35.20), vaccines do a good
job in preventing diseases (OR 14.01, 95% CI 5.19–37.85), and that unvaccinated teenagers
may contract a disease such as pertussis or human papillomavirus (OR 3.36, 95% CI 1.90–

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5.94). Among respondents without minority children, high trust in public health authorities
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was associated with increased odds of participants reporting that vaccines are necessary to
protect adult health (OR 4.24, 95% CI 2.60–6.91), vaccines do a good job in preventing
diseases (OR 8.10, 95% CI 4.60–14.25), and unvaccinated adults may contract and spread
influenza (OR 3.33, 95% CI 1.49–3.30).

In all sub-populations, participants with high trust in public health authorities were more
likely to agree with positive statements about vaccines (Table 5). Among parents of children
aged 10 and under, high trust was associated with increased odds of participants reporting
that they trust the information they receive from doctors about vaccines (OR 6.34, 95% CI
3.28–12.26), can openly discuss vaccine questions with their doctor or their child’s doctor
(OR 4.89, 95% CI 2.29–10.43), vaccines are very safe (OR 3.94, 95% CI 2.36–6.58), and
trust pharmaceutical companies to make safe and effective vaccines (OR 5.64, 95% CI 3.69–
8.60). Similar associations were observed among parents of adolescents aged 11 to 17 and
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among respondents without minor children (Table 5). Participants with high trust were also
more likely to report they trust vaccines that have been around for longer, but to a lesser
extent than the other key beliefs in all sub-populations.

Trust in public health authorities was highly associated with adherence to vaccine
recommendations. High trust was associated with influenza vaccine acceptance in the 2019–
20 flu season among respondents without minor children (OR 1.75, 95% CI 1.22–2.52), and
for children of respondents whose youngest child was under age 18 (OR 1.76, 95% CI 1.28–
2.42). Among all parents, high trust was associated with acceptance of diphtheria-tetanus-
acellular pertussis (OR 3.14, 95% CI 1.45–6.81) and varicella (OR 6.30, 95% CI 2.51–
15.83) vaccines for their child. High trust was also associated with acceptance of measles-
mumps-rubella vaccine among parents with children aged 10 years and under (OR 9.85,
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95% CI 2.20–44.00) and acceptance of meningococcal vaccine among parents with

adolescents aged 11 to 17 (OR 2.65, 95% CI 1.08–6.49).

DISCUSSION
Declining trust in government in general and the growing importance of maintaining trust in
public health authorities have emphasized the need for an instrument to systematically
measure trust in public health authorities and identify how to improve public adherence to
recommendations. We demonstrated that the 14-item TiPHA scale has good reliability and
validity in the nationally representative population. Two dimensions of trust in public health
authorities emerged (beneficence and competence) with good internal consistency. While
trust in public health authorities was generally high, a concerning proportion of participants
agreed with statements questioning the credibility of public health authorities. Trust in
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public health authorities was highly associated with vaccine attitudes, beliefs, and
acceptance.

Our scale is an important contribution to the literature on trust in public health authorities.
While previous trust literature has focused on disciplines outside of public health, little has
been explored about how to measure trust in public health authorities. The TiPHA scale
should be validated in additional populations, particularly among healthcare providers as

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they are important users of recommendations from public health authorities. These results
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provide very useful baseline data against which to measure the degree to which trust in
public health authorities changes or has changed since this survey, such as within the
COVID-19 context. Future studies should also explore the relationship between trust in
public health authorities and adherence to recommendations other than vaccines, such as
social distancing and handwashing during COVID-19.

This study has several limitations. It is possible that other survey questions inquiring about
vaccine intentions and behaviors may have impacted participant perceptions of trust in
public health authorities. The sample was comprised of participants with internet access who
were willing and able to complete an online panel survey, creating selection bias and
limiting generalizability. These data from a self-selected sample within a non-probability-
base panel cannot be used to make inferences about the US population. We must implement
the scale in additional populations to further establish scale reliability and validity. We may
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not have captured people with lower trust or interest in science and, subsequently lower trust
in public health authorities, and as such we may have underestimated the measured trust
constructs. The TiPHA scale does not identify varying trust in different public health
authorities; grouping public health authorities together may make it challenging for
participants to respond accurately, for instance if they feel differently about their local health
department versus the CDC.

This study establishes our understanding of the two-factor structure of trust in public health
authorities. The importance of beneficence and competence are particularly apparent in the
context of COVID-19. With the ongoing development and approval of COVID-19 vaccines,
this measure will allow us to assess whether trust or distrust in communication from public
health authorities have an impact on COVID-19 vaccine uptake. Further validation of our
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TiPHA scale in additional surveys will facilitate assessment of trust in public health
authorities over time. This innovative scale will help policymakers, providers, and public
health authorities to better understand public trust, effectively communicate with the public,
and improve adherence to recommendations. Further exploration of trust in public health
authorities among sub-populations with varying levels of trust will enable the development
of targeted interventions to address low trust and improve compliance with public health
authorities during both routine and emergency public health activities.

Acknowledgements
Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of
this article: This work was supported in part by National Human Genome Research Institute [grant number
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RM1HG009038].

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 Holroyd et al. Page 11

Table 1:

Initial 20-item pool concerning trust in public health authorities and frequency in study population
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Content domain Item Participants agreed or

strongly agreed, No. (%)

Beneficence a 1646 (86)

They do everything they should to protect the health of the population

a 803 (42)
They are partly responsible for the illegal drug problems in this country

Efficiency b 1576 (82)

They use resources well

b 568 (30)
They waste money on health problems

Innovation They keep trying the same things to help the public, even when they don’t work very well 942 (49)
c

d 1669 (87)
They come up with new ideas to solve health problems

Objectivity They provide the public with complete and accurate information about important health 1545 (80)
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a
issues

d 1668 (87)
They base recommendations on the best available science

Competence d 1366 (71)

They are not always able to help the health of the public

c 1652 (86)
They ensure the public is protected against diseases

Equity a 741 (39)

They are more concerned about some racial and ethnic groups than other groups

a 1475 (77)
They are concerned about all people, without caring about who has more or less money

Transparency c 1120 (58)

They sometimes hide information from the public

c 1579 (82)
They accurately inform the public of both health risks and benefits of medicines

Responsiveness b 626 (33)

They do not respond appropriately to emergencies and disasters
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b 1535 (80)
They quickly help the public with health problems

Accuracy d 651 (34)

They make unhelpful recommendations

c 840 (44)
They provide skewed information

Integrity a 541 (28)

They were responsible for creating HIV and AIDS

c 1648 (86)
They believe in what they recommend for the public

a
Source references[27, 29]
b
Novel item[28, 33]
c
Novel item[25, 26, 33]
d
Novel item[33]
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Table 2:

Demographic characteristics of survey respondents and reported level of trust in public health authorities
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Characteristic Entire sample (n=1,925), Participants with low trust (n Participants with high trust (n
No. (%) = 1037), No. (%) = 888), No. (%)

Age
18–24 years 157 (8) 101 (64) 56 (36)

25–34 years 534 (28) 328 (61) 206 (39)

35–44 years 358 (19) 188 (52) 170 (48)

45–54 years 303 (16) 140 (46) 163 (54)

55–64 years 259 (14) 78 (30) 181 (70)

65 years or older 310 (16) 89 (25) 231 (75)

Race
White 1403 (73) 796 (57) 607 (43)
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Black 278 (14) 170 (61) 108 (39)

American Indian / Native American 89 (5) 51 (57) 38 (43)

Asian 120 (6) 67 (56) 53 (44)

Native Hawaiian or Pacific Islander 25 (1) 15 (60) 10 (40)

Not reported 87 (5) 52 (60) 35 (40)

Ethnicity
Hispanic 354 (18) 197 (56) 157 (44)

Non-Hispanic 1564 (81) 713 (46) 851 (54)

Household income
Under $49,999 855 (44) 427 (50) 428 (50)

$50,000 – $99,999 508 (27) 233 (46) 275 (54)

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$100,000 – $149,999 236 (12) 118 (50) 118 (50)

$150,000 or more 290 (15) 116 (40) 174 (60)

Education
Some high school or graduate 893 (46) 459 (51) 434 (49)
Some college or college graduate 728 (38) 322 (44) 406 (56)

Post-graduate 277 (14) 114 (41) 163 (59)

Parent status
Not a parent 481 (25) 235 (49) 246 (51)

At least one child ≤10 years of age 724 (38) 387 (53) 337 (47)

At least one child 11–17 years of age 515 (27) 219 (42) 296 (58)

At least one child aged 18 or older 181 (9) 60 (33) 121 (67)

Not reported 24 (1) 14 (58) 10 (42)

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Participants with low and high trust were compared using Pearson’s chi-square test for independence. All characteristics had p-values <0.05
comparing low and high trust groups.

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Table 3:

Reduced 14-item Trust in Public Health Authorities scale and factor loadings for two-factor model
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Factors and items Factor loadings

Factor 1: Beneficence
They do everything they should to protect the health of the population 0.74

They keep trying the same things to help the public, even when they don’t work very well* 0.77

They base recommendations on the best available science 0.77

They are more concerned about some racial and ethnic groups than other groups* 0.78

They are concerned about all people, without caring about who has more or less money 0.74

They accurately inform the public of both health risks and benefits of medicines 0.77

They make unhelpful recommendations 0.73

They believe in what they recommend for the public 0.80

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Factor 2: Competence

They are partly responsible for the illegal drug problems in this country* 0.78

They use resources well 0.68

They waste money on health problems* 0.71

They come up with new ideas to solve health problems 0.73

They ensure the public is protected against diseases 0.71

They quickly help the public with health problems 0.74

*
Negatively worded items were reverse-coded in data analysis.
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Table 4:

Unadjusted and adjusted odds ratios of participants reporting vaccine hesitancy associated with high reported
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trust in public health authorities

Vaccine hesitancy statement Participants agreed or Unadjusted OR (95% CI) Adjusted OR (95% CI)
strongly agreed, No.
(%)
†
Parents of children aged 10 and under (n = 724 )

Children get more vaccines than are good for them. 264 (37) 0.34 (0.24–0.50)* 0.35 (0.23–0.51)*

It is better for children to develop immunity by getting 199 (28) 0.21 (0.14–0.32)* 0.22 (0.14–0.33)*
sick than by getting a vaccine.

It is better for children to get fewer vaccines at the 313 (43) 0.48 (0.34–0.69)* 0.46 (0.32–0.68)*
same time.

Parents of adolescents aged 11 to 17 (n = 515)

Vaccines are necessary to protect the health of 471 (92) 12.61 (4.88–32.56)* 12.88 (4.71–35.20)*
teenagers
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Vaccines do a good job in preventing the diseases they 468 (91) 13.81 (5.36–35.56)* 14.01 (5.19–37.85)*
are intended to prevent

If I do not vaccinate my child, he/she may get a 440 (85) 3.44 (2.04–5.80)* 3.36 (1.90–5.94)*
disease such as pertussis or human papillomavirus
(HPV) and cause other people to get sick

Respondents without minority children (n = 686)

Vaccines are necessary to protect the health of adults. 568 (83) 3.96 (2.56–6.12)* 4.24 (2.60–6.91)*

Vaccines do a good job in preventing the diseases they 572 (83) 7.80 (4.68–13.02)* 8.10 (4.60–14.25)*
are intended to prevent
If I do not get vaccinated, I may get influenza or the 512 (75) 2.98 (1.62–3.27)* 2.22 (1.49–3.30)*
flu and cause other people to get sick.

OR, odds ratio. CI, confidence interval. Odds ratios adjusted for age, education, income, race, region, and parent status.
†
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While 724 parents of children aged 10 and under participated in the survey, 215 did not receive these vaccine hesitancy questions due to a survey
error.
*
p < 0.01
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Table 5:

Unadjusted and adjusted odds ratios of participants agreeing with vaccine-related beliefs associated with high
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reported trust in public health authorities

Key immunization belief Participants agreed or Unadjusted OR (95% CI) Adjusted OR (95% CI)
strongly agreed, No. (%)

Parents of children aged 10 and under (n = 724)

I trust the information I receive from doctors about 621 (86) 6.29 (3.35–11.83)* 6.34 (3.28–12.26)*
vaccines

I can openly discuss my questions about vaccines with 656 (91) 4.94 (2.38–10.27)* 4.89 (2.29–10.43)*
my doctor.

Vaccines are very safe 611 (84) 3.67 (2.29–5.89)* 3.94 (2.36–6.58)*

I trust pharmaceutical companies to make very safe 535 (74) 5.95 (3.96–8.96)* 5.64 (3.69–8.60)*
and effective vaccines.

I am more likely to trust vaccines that have been 522 (72) 1.66 (1.19–2.31)* 1.70 (1.20–2.42)*
around for a while than newer vaccines.
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Parents of adolescents aged 11 to 17 (n = 515)

I trust the information I receive from doctors about 454 (88) 13.83 (5.36–35.68)* 14.48 (5.36–39.10)*
vaccines

I can openly discuss my questions about vaccines with 471 (92) 5.87 (2.35–14.70)* 6.03 (2.21–16.47)*
my doctor.

Vaccines are very safe 456 (89) 6.47 (3.34–12.53)* 6.83 (3.30–14.11)*

I trust pharmaceutical companies to make very safe 403 (78) 8.69 (5.21–14.48)* 10.25 (5.81–18.09)*
and effective vaccines.

I am more likely to trust vaccines that have been 368 (72) 2.05 (1.39–3.01)* 2.17 (1.43–3.29)*
around for a while than newer vaccines.

Respondents without minority children (n = 686)

I trust the information I receive from doctors about 561 (82) 5.01 (3.01–8.32)* 5.54 (3.14–9.77)*
vaccines
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I can openly discuss my questions about vaccines with 595 (87) 3.75 (1.98–7.08)* 3.91 (1.85–8.27)*
my doctor.

Vaccines are very safe 551 (80) 4.27 (2.82–6.47)* 4.97 (3.10–7.97)*

I trust pharmaceutical companies to make very safe 492 (72) 4.96 (3.44–7.14)* 6.00 (3.95–9.12)*
and effective vaccines.
I am more likely to trust vaccines that have been 439 (64) 1.10 (0.80–1.51) 1.14 (0.80–1.62)
around for a while than newer vaccines.

OR, odds ratio. CI, confidence interval. Odds ratios adjusted for age, education, income, race, region, and parent status.
*
p < 0.01
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