From Vaccine Skepticism to Institutional Distrust: The Post-Pandemic Shift

Background: Vaccine hesitancy has traditionally been understood as a multifactorial phenomenon shaped by individual beliefs, risk perceptions, and access barriers. However, the COVID-19 pandemic has fundamentally transformed the relationship between citizens, science, and public institutions, raising the question of whether vaccine hesitancy has evolved into a broader form of institutional distrust. Objective: This narrative review synthesizes evidence on vaccine confidence, trust dynamics, misinformation, and post-pandemic attitudes to propose a new conceptual framework, i.e., institutional hesitancy, that reframes vaccine acceptance within the wider context of institutional credibility, transparency, and legitimacy. Methods: We conducted a narrative synthesis of peer-reviewed literature, surveillance reports, and cross-national surveys published between 2015 and 2026, focusing on trust in science, governments, public health agencies, healthcare systems, and regulatory authorities as determinants of vaccination behavior. Results: The evidence consistently demonstrates that institutional trust is among the strongest predictors of vaccine acceptance, often surpassing traditional demographic and knowledge-based variables. The pandemic exposed and amplified pre-existing fractures in the relationship between citizens and institutions, creating a legacy of institutional skepticism that extends beyond COVID-19 vaccines to routine immunization programs, seasonal vaccination campaigns, and future pandemic preparedness. Traditional information-based approaches, which assume that knowledge deficits drive hesitancy, have proven insufficient when trust is compromised. Instead, rebuilding vaccine confidence requires sustained investment in institutional transparency, community engagement, and accountable governance. Conclusions: The post-pandemic era calls for a fundamental reconceptualization of vaccine hesitancy. We propose the institutional hesitancy framework as a complementary lens that shifts the analytical focus from individual knowledge deficits to relational dynamics between citizens and institutions. Addressing this challenge requires moving beyond communication campaigns toward long-term strategies that restore institutional trust and strengthen the resilience of public health systems.