The Association between Levels of Trust in the Healthcare
System and Influenza Vaccine Hesitancy among College
Students in Israel
Keren Dopelt 1,2, , Anuar Abudin 1, Sophie Yukther 1, Tatyana Shmukler 1 and Nadav Davidovitch 2
1 Department of Public Health, Ashkelon Academic College, Ashkelon 78211, Israel,
2 School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev,
Beer Sheva 84105, Israel; firstname.lastname@example.org
Abstract: Influenza is a contagious respiratory disease caused by the influenza virus. Vaccination
proves an effective approach to preventing influenza and minimizing the risk of experiencing asso-
ciated complications. However, the influenza vaccine coverage rate among Israeli college students
is low due to a sense of complacency, lack of knowledge, and vaccine hesitancy. The current study
examined the relationship between the level of trust in the healthcare system and influenza vaccine
hesitancy among college students in Israel. This cross-sectional study was conducted via an online
questionnaire in April–May 2023. In total, 610 students were surveyed, of whom 57% had been
vaccinated against influenza in the past; however, only 12% were vaccinated this year. Negative,
significant, and moderate relationships were found between the level of trust in the healthcare system
and influenza vaccine hesitancy. Students who had been vaccinated in the past had a higher level of
trust in the healthcare system and a lower level of vaccination hesitancy. The linear regression model
revealed that the variables of being a woman, not Jewish, vaccinated, and trusting the Ministry of
Health, family doctor, and health professionals were associated with a decrease in vaccine hesitancy.
These findings are in line with previous research in the field. Based on the present results, it may be
Citation: Dopelt, K.; Abudin, A.; advisable to develop intervention programs aimed at increasing confidence in the healthcare system
Yukther, S.; Shmukler, T.; and vaccinations by providing knowledge and addressing students’ concerns regarding vaccination.
Davidovitch, N. The Association
between Levels of Trust in the Keywords: trust in the healthcare system; influenza; vaccines; vaccine hesitancy; students; Israel
Healthcare System and Influenza
Vaccine Hesitancy among College
Students in Israel. Vaccines 2023, 11,
1728. https://doi.org/10.3390/ 1. Introduction
Vaccine hesitancy refers to delay in accepting or outright refusal of vaccines, even
Academic Editor: Pedro Plans-Rubió when vaccination services are readily available . This issue has been recognized by
Received: 21 October 2023 the World Health Organization  as a major health concern, and vaccine hesitancy is
Revised: 14 November 2023 listed among the top ten threats to public health. Influenza infections result in approxi-
Accepted: 18 November 2023 mately 3–5 million cases of severe illness and 290,000–650,000 respiratory-related deaths
Published: 19 November 2023 worldwide each year [3,4]. Influenza vaccination is one of the most efficient approaches
to reducing the health, societal, and economic impacts of influenza [5,6]. The Israeli Min-
istry of Health recommends receiving an influenza vaccine for every individual above six
months old, with an emphasis on the children and the elderly population. The vaccines are
Copyright: © 2023 by the authors. provided free of charge at clinics distributed in every neighborhood in Israel, ensuring very
Licensee MDPI, Basel, Switzerland. high accessibility to vaccines. Despite the seriousness of this illness and the availability
This article is an open access article
of safe vaccines, influenza vaccination rates continue to be low. This presents a global
distributed under the terms and
challenge and adds to the burden that this disease imposes on healthcare systems around
conditions of the Creative Commons
Attribution (CC BY) license (https:// the world . The healthcare system plays an essential role in encouraging vaccine uptake
creativecommons.org/licenses/by/ for influenza. Influenza vaccination is crucial for the general population, including student
4.0/). populations in close contact in classrooms and other social settings. Studies have reported
Vaccines 2023, 11, 1728. https://doi.org/10.3390/vaccines11111728 https://www.mdpi.com/journal/vaccines
Vaccines 2023, 11, 1728 2 of 11
low seasonal influenza vaccination rates among students, with coverage ranging from
12% to 30% . If the student population is not vaccinated against influenza, the global
population will not meet the World Health Organization (WHO) aim for approximately
75% coverage of influenza vaccination. While global healthcare systems face the need
to address vaccine hesitancy among the general public, particular emphasis needs to be
placed on university students in this regard. Influenza symptoms may persist for multiple
weeks, impacting students’ class attendance, academic achievements, social engagements,
and productivity . Additionally, influenza transmission rates within university settings
can be notably elevated due to the concentration of dozens of students in shared spaces .
Moreover, an influenza outbreak on campus holds the potential to extend its spread to the
broader community surrounding students, encompassing friends, family members, and
high-risk population groups .
Previous studies have explored trust in the healthcare system and trust in healthcare
providers when seeking to explain health-related behavior. These analyses have revealed
a positive correlation between trust in physicians and adherence to medical recommen-
dations, thereby leading to improved health outcomes . Conversely, lower levels of
trust are linked to reduced utilization of preventive health screenings and lower uptake of
the influenza vaccine [13–15]. The SAGE Working Group on Vaccine Hesitancy recognized
trust in the healthcare system and healthcare providers as pivotal determinants of vaccine
hesitancy [1,16]. Research has indicated higher levels of vaccine hesitancy regarding in-
fluenza, COVID-19, or HPV vaccines among specific demographic groups compared to
the general population. These groups include healthcare workers, minority communities,
and individuals with lower socioeconomic status [17–19]. Research has underscored the
significant impact that a doctor’s recommendation can have on a patient’s inclination
to receive vaccinations [20–22]. Conversely, individuals who opt not to get vaccinated
often cite a lack of trust in these institutions as a primary reason for refusing vaccines .
Groups with diminished trust in the public health system are approximately half as likely
to receive vaccinations compared to those with elevated levels of trust  (Gilles et al.,
2011). Moreover, healthcare professionals who themselves are hesitant about vaccinations
may not adequately address their patients’ vaccine concerns .
Trust in the public health organizations and experts who provide vaccine recom-
mendations is a significant factor influencing individuals’ decisions and beliefs regarding
vaccines [23,26]. The literature suggests that trust in the healthcare system is built on
healthcare professionals’ competence (skills and knowledge) and how the healthcare sys-
tem and its actors (medical staff) work to benefit the patient through acting with integrity,
maintaining individual privacy and medical confidentiality, and showing empathy and
respect . A healthcare system based on trust contributes to creating broader social
value, based on the premise that the healthcare system not only produces healthy outcomes
among the public and prioritizes improving the state of health in society but, as a social
institution, also establishes social norms shaping human behavior . In recent years, Is-
raelis have exhibited relatively low levels of public trust in the healthcare system compared
to other countries in the OECD, with only half of the Israeli public (52%) reporting that
they believed that they would receive the best treatment for a severe illness .
Low influenza vaccination rates among students are a worldwide occurrence .
While vaccine hesitancy has been extensively researched in the general adult population,
young individuals have not been a strategic focus of vaccination encouragement and public
health communication efforts from the perspective of the Israeli Health and Public Health
system. In general, students are young and tend to perceive themselves as healthy with
a low risk of falling ill despite the rapidity with which influenza can spread through
campuses. Given these concerns regarding the reluctance of students to be vaccinated, in
this study, we sought to explore their level of trust in the healthcare system and whether this
trust is associated with influenza vaccine hesitancy. The findings help understand the level
of trust in the healthcare system among students in Israel and its connection to influenza
vaccination hesitancy, aiding in the development of intervention programs accordingly.
Vaccines 2023, 11, 1728 3 of 11
2. Materials and Methods
2.1. Research Procedure
This descriptive, cross-sectional study was undertaken with students from Ashkelon
Academic College. In 2023, approximately 4200 students studied at this college in the
academic track. Approval for this study was obtained from Ashkelon Academic College
Ethics Committee (approval #42-2023). Data were obtained from all College departments.
The study ran from 2 April 2023 to 12 May 2023, concomitant with the end of the influenza
vaccination season in Israel. The survey questionnaire was programmed using Qualtrics
(Qualtrics, Provo, UT, USA) and was distributed to all students via email. One reminder to
fill out the questionnaire was sent via email three weeks following its initial distribution. A
total of 703 students responded, with 610 completing at least 90% of the questionnaire. This
represented a response rate of 87% of all respondents and 15% of the research population.
On average, it took 5 ± 1.44 min to complete the questionnaire. The introductory page of
the questionnaire explained the aims of this study and ensured anonymity. Completing
the questionnaire indicated the students’ voluntary agreement and informed consent to
participate. Students could stop responding at any time, and there was no obligation to
answer any specific question.
We used an online, closed, anonymous, self-completed questionnaire to collect the
data for this study. A professional translator translated the questionnaire from English into
Hebrew. The Hebrew-translated questionnaire was then administered to 10 students not
attending Ashkelon Academic College to verify the comprehensibility of the questions. The
questionnaire was revised based on their feedback. Moreover, the questionnaire underwent
content validation through assessment by an expert in public health and epidemiology and
an expert in infectious diseases.
The final questionnaire comprised the following components:
1. Demographic information: Gender, age, marital status, religion, department, and year
2. Vaccination history: This included questions drawn from Ryan et al. : Have you
ever been vaccinated against the flu? Have you been vaccinated against influenza
3. Vaccine hesitancy: This included six questions from Silva et al. . The respondents
were asked to indicate their degree of agreement with each statement in the ques-
tionnaire on a Likert scale ranging from 1 (not at all) to 5 (strongly agree) with the
option to answer “don’t know”. The average of the answers was calculated for each
participant after reversing the scales for questions 1 and 6 and dropping the “don’t
know” answers. A higher score was indicative of higher levels of vaccine hesitancy.
Cronbach’s α for reliability was 0.77.
4. Level of trust in the healthcare system: This included three questions from Jennings
et al.  measuring the level of trust in one’s doctor, the Ministry of Health, and
medical professionals. The response scale ranged from 1 (not at all) to 5 (strongly
agree). The variable was constructed by calculating the mean response for each
participant. The mean ranged from 1 to 5, with a higher score indicating a higher level
of trust in the healthcare system. Cronbach’s α for reliability was 0.82.
2.3. Data Analysis
The data were analyzed using SPSS 29.0 (IBM, Armonk, NY, USA). Relationships be-
tween the variables were examined using Pearson correlation analyses. Since the variables
met the criteria of normal distribution, differences between student groups were assessed
utilizing t-tests for independent samples and one-way analyses of variance (ANOVAs). To
predict the extent of vaccination hesitancy, a multiple linear regression model was used.
The model included variables that have been found to be associated with the dependent
Vaccines 2023, 11, 1728 4 of 11
variable in the univariate analyses. Significance in reported p-values relied on two-sided
tests and were considered significant when they fell below 0.05.
3.1. Participant Characteristics and Influenza Vaccination History
In total, 610 students participated in this study, of whom 60% were women, 53% were
in relationships, and 21% had children. Most participants were Jewish (83%). Nearly half
studied in the Faculty of Social Sciences (46%), 35% in Health Sciences, and 19% in Com-
puter Science and Management. The mean age of the respondents was 27.64 ± 7.20 years.
The survey population resembled the college’s population in terms of gender, age, and
faculties composition. More than half had been vaccinated in the past (57%; 61% when
excluding participants who could not remember). Among these participants, 12% were
vaccinated, 44% intended to get vaccinated, 8% were undecided, and 36% did not in-
tend to get vaccinated. No significant differences were found between the faculties with
respect to vaccination history. However, significant differences between faculties were
detected regarding vaccination in the study year (χ2 = 24.66, p < 0.001), with more students
in Health Sciences having been vaccinated or intending to be vaccinated (16% and 47%,
respectively) compared to Computer Science and Management students (14% and 52%,
respectively) or Social Sciences students (11% and 35%, respectively). The characteristics of
these participants and their influenza vaccination history are summarized in Table 1.
Table 1. The characteristics and influenza vaccination history of study participants.
Characteristics n %
Male 243 40
Female 367 60
In relationship 324 53
Have children 128 21
Jewish 509 83
Health Sciences 202 35
Social Sciences 262 46
Computers Science and Management 106 19
Year of studies
1st 310 51
2nd 198 32
3rd and 4th 102 17
Vaccinated against influenza in the past
Yes 351 57
No 223 37
Do not remember 36 6
Vaccinated this year against influenza:
Yes 76 12
Intend to vaccinate 269 44
Do not intend to vaccinate 217 36
Undecided 48 8
Vaccines 2023, 11, 1728 5 of 11
3.2. Level of Trust in the Healthcare System
The distribution of responses to statements that examined the level of trust in the
healthcare system is presented in Table 2 after combining categories as follows: answers 1
and 2 were incorporated into the category “weakly agree”, while answer 3 was classified as
“moderately agree”, and answers 4 and 5 were integrated into the category “strongly agree”.
Table 2. The distribution of responses to the questionnaire focused on the level of trust in the
healthcare system questionnaire.
Statement Weakly (%) Moderately (%) Strongly (%) Mean ± SD
I trust the Ministry of Health,
which works for the benefit of 46 32 22 2.67 ± 1.07
the entire population
I trust my family doctor’s
recommendations 13 30 57 3.55 ± 0.93
I trust the recommendations
of the health professionals 32 33 35 2.98 ± 1.08
To assess the level of trust in the healthcare system variable, the mean response for
each participant was calculated, with a computed value of 3.06 (SD = 0.88).
3.3. Influenza Vaccine Hesitancy
The distribution of responses to statements that examined influenza vaccine hesi-
tancy is presented in Table 3 after combining categories as follows: answers 1 and 2 were
combined into the category “weakly agree”, answer 3 remained “moderately agree”, and
answers 4 and 5 were integrated into the category “strongly agree”.
Table 3. Distribution of responses to the influenza vaccine hesitancy questionnaire.
Statement Weakly (%) Moderately (%) Strongly (%) Don’t Know (%) Mean ± SD 1
I am (not) worried about getting
influenza 40 19 36 5 3.01 ± 1.36
I am concerned about the
ineffectiveness of the 40 9 56 5 3.59 ± 1.61
I am concerned about the limited
information available about the 28 10 58 4 3.63 ± 1.62
I will only get the influenza shot if it
becomes mandatory 70 10 13 7 1.84 ± 1.28
I think the influenza shot is not safe 29 13 50 9 3.30 ± 1.52
I (do not) recommend family/friends
to get vaccinated against influenza 28 24 30 18 3.09 ± 1.37
1 The mean was calculated without including the “I don’t know” option. Opposite questions. The data are
presented in reverse rank order.
For the purposes of constructing the influenza vaccine hesitancy variable, we calcu-
lated the mean response for each participant when excluding the “I don’t know” responses
and reversing the scale for questions 1 and 6, yielding a mean value of 3.11 (SD = 0.70).
Vaccines 2023, 11, 1728 6 of 11
3.4. Relationships between the Level of Trust in the Healthcare System and Influenza
Negative, significant, and moderate relationships were found between the level of
trust in the Ministry of Health, one’s family doctor, health professionals, general trust in
the healthcare system, and influenza vaccine hesitancy (rp = −0.45, p < 0.001; rp = −0.21,
p < 0.001; rp = −0.44, p < 0.001; rp = −0.43, p < 0.001, respectively). In other words,
the higher the level of trust in the healthcare system, the lower the degree of influenza
3.5. The Relationship between Influenza Vaccination History and the Study Variables
Significant differences were found between students who had been vaccinated in the
past and students who had not been vaccinated with respect to their levels of trust in
the healthcare system (t = 3.89, p < 0.001) and vaccination hesitancy (t = 6.69, p < 0.001).
Specifically, students who had been vaccinated in the past exhibited a higher level of trust
in the healthcare system than unvaccinated students (3.17 vs. 2.87, respectively) and a
lower level of vaccination hesitancy (2.95 vs. 3.23, respectively).
3.6. Differences between Faculties
Significant differences were found between faculties in terms of level of trust in the
healthcare system (F(543) = 4.46, p < 0.05). Students in the Health Sciences faculty demon-
strated the highest level of trust, followed by students in Social Sciences and, finally,
students in Computer Science and Management (averages of 3.22, 3.01, and 2.92, respec-
tively). Scheffe post-hoc tests revealed that students in the Health Sciences faculty had
significantly higher knowledge levels than students in the two other faculties.
Furthermore, significant differences were found between the faculties with respect
to levels of influenza vaccine hesitancy (F(565) = 3.17, p < 0.05). Computer Science and
Management students had the highest hesitancy level, followed by students in Social
Sciences and, finally, Health Sciences (averages of 3.22, 3.10, and 3.00, respectively). Scheffe
post-hoc tests revealed that students in the Faculty of Computer Science and Management
exhibited significantly higher hesitancy levels than Health Science students.
3.7. Regression Model to Predict Influenza Vaccine Hesitancy
Table 4 presents the results of a linear regression model predicting influenza vaccine
hesitancy. The coefficients and p-values shed light on how each variable predicts vaccine
hesitancy. Being female, not Jewish, vaccinated, and trusting the Ministry of Health, the
family doctor, and health professionals were all found to be associated with lower vaccine
hesitancy. The best predictors of this lower vaccine hesitancy were the level of trust in the
Ministry of Health, the level of trust in health professionals’ recommendations, and the
incidence of being vaccinated in the past. The explained variance of the model was 30%
(p < 0.001).
Table 4. Linear regression model results for predicting influenza vaccine hesitancy.
Variable B β p
Gender (0—male; 1—female) −0.21 −0.12 0.001
Religion (0—Jewish; 1—not Jewish) 0.20 0.09 0.020
Vaccinated (0—no; 1—yes) −0.28 −0.16 <0.001
Trust in the Ministry of Health −0.23 −0.29 <0.001
Trust in the family doctor −0.10 −0.11 0.019
Trust in health professionals −0.22 −0.28 <0.001
Adjusted R Square 0.30, p < 0.001
F 39.43, p < 0.001
Vaccines 2023, 11, 1728 7 of 11
Our results revealed that trust in the Ministry of Health and the belief that it works
for the benefit of the entire population of Israel is low (average 2.67) among the college’s
students, while levels of trust in the recommendations of health professionals regarding
vaccines are higher but not satisfactory (average 2.98). Nevertheless, study participants
were found to generally trust their family doctor’s recommendations (average 3.55). Pre-
vious studies conducted in Western countries have also highlighted the disparity in trust
and satisfaction levels between local health services and the national healthcare system.
While trust and satisfaction rates often range from 80 to 90% at the local level, they decline
to approximately 50–60% at the national level. This emphasizes the greater trust that
individuals have in their local doctors compared to the national level [33–35].
Negative, significant, and moderate relationships were found between all the dimen-
sions of trust in the healthcare system and influenza vaccine hesitancy. The literature
indicates that public trust in healthcare professionals is crucial for the health system to
function efficiently. Trust is the primary factor influencing individuals’ vaccination de-
cisions [21,36]. Among other things, when making decisions, individuals must trust the
information they are being provided . In the context of vaccinations, decision-making
is associated with trust in government and public health professionals . In line with our
findings, studies have reported a negative correlation between an individual’s vaccine hesi-
tancy and their trust in the healthcare system and healthcare workers [38–40]. Physicians’
advocacy of vaccinations is recognized as one of the most influential factors affecting public
attitudes toward vaccinations [20–22]. Conversely, hesitancy and skepticism regarding
vaccinations can be linked, in part, to a diminished level of trust in physicians [23,41].
A cross-national study conducted during the COVID-19 pandemic found that when
trust levels in the healthcare system and the WHO were higher, vaccine hesitancy levels
were lower . A similar study conducted at the University of North Carolina found that
as students’ levels of trust in the healthcare system and other information sources rose,
their hesitancy levels declined . A survey distributed among students from the Central
University Center of Baia Mare (Romania) observed a significant correlation between high
levels of trust in institutions and the intention to vaccinate . The link between trust
in the healthcare system, attitudes towards vaccines, and vaccine hesitancy can also be
explained using the health belief model . According to this model, in order for a change
to be effected in a person’s behavior or, in this case, to induce a shift from vaccine hesitancy
to vaccine acceptance, the person must believe and have confidence that the action being
taken can indeed benefit them, meaning that, in this case, the vaccine can help them. The
more a given individual trusts the system, the more likely they are to believe that the
vaccine can benefit them.
The present results indicated that students who have been previously vaccinated ex-
hibit higher levels of trust in the healthcare system and lower levels of hesitancy compared
to students who have not been vaccinated. The theory of planned behavior  argues that
attitudes and social norms influence the behavior of a given individual. In other words,
those who have already been vaccinated likely hold more positive attitudes such that they
are less hesitant to vaccinate again. Additionally, it can be assumed that individuals who
have been vaccinated live in an environment where social norms emphasize trust in the
healthcare system and vaccines.
We also found that students from the Faculty of Health Sciences have the highest level
of trust and the lowest levels of vaccine hesitancy level compared to students from other
disciplines. Similar findings were also obtained in a study conducted at a university in
Saudi Arabia  and in Japan . Generally, health science students learn about the
healthcare system in greater depth than students from other disciplines and encounter it
during their internships. This results in higher levels of trust in this system among them
compared to students who come into contact with the health system only as patients. Health
science students also learn more about the mechanism of vaccines, and this knowledge
reduces vaccine hesitancy.
Vaccines 2023, 11, 1728 8 of 11
The linear regression model revealed an association between decreased vaccine hesi-
tancy and the variables of being a woman, not Jewish, vaccinated, and trusting the Ministry
of Health, family doctor, and health professionals. A study by Shon et al.  found
that more female students were vaccinated than male students, suggesting that among
students, males exhibit higher levels of vaccine hesitancy, as was found in the current
study. Also consistent with the results of the current study’s regression analysis are the
findings of other studies indicating that previously vaccinated students exhibit less vaccine
hesitancy [11,49,50]. With respect to religion, the current study’s findings align with those
from other studies, indicating that the Arab sector in Israel has less trust in state institutions,
including the healthcare system [21,51].
When delving into the association between trust and vaccine hesitancy, it is crucial to
acknowledge the erosion of public trust in governments, healthcare systems, and experts
on a global scale due to the influence of the COVID-19 pandemic . The pandemic
unleashed a flood of misinformation, famously termed an “Infodemic” , contributing
to the rise in vaccine hesitancy. Freiman  advocates for mitigating vaccine concerns and
fostering trust among the hesitant by actively engaging and imparting knowledge . It
is reasonable to anticipate that improving trust will streamline intricate decisions about
The present research effort was limited to students from a single college, potentially
affecting the ability to generalize these findings to students nationwide. Furthermore, most
participants had not been vaccinated against influenza in the study year, and a significant
portion expressed no intention of becoming vaccinated. This suggests a potential selection
bias, wherein students with greater vaccine hesitancy may have been more inclined to
participate in the survey.
Trust in the Ministry of Health, family doctors, and public health professionals are
important predictors of vaccine hesitancy. Physicians may be able to build on the trust
their patients have in them to address vaccine concerns and increase vaccination rates
against influenza. To persuade students to vaccinate, interventions centered on transferring
professional knowledge and allaying concerns about vaccinations can be conducted on
campuses in collaboration with the management of these institutions, the Ministry of Health,
and doctors from nearby hospitals or clinics. It is crucial to make it clear to students that
young people can also become seriously ill with influenza and that they are at high risk of
infection due to overcrowding in classrooms and other social settings. Lastly, steps to build
trust between various components of the healthcare system and the student population
should be taken, viewing these students as ambassadors for improving vaccination rates.
Author Contributions: Conceptualization, K.D., A.A., S.Y., T.S. and N.D.; methodology, K.D., A.A.,
S.Y., T.S. and N.D.; software, K.D.; validation, K.D., A.A., S.Y. and T.S.; formal analysis, K.D.; data
curation, A.A., S.Y. and T.S.; writing—original draft preparation, K.D.; writing—review and editing,
all authors; supervision, K.D. and N.D. All authors have read and agreed to the published version of
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved by the Ashkelon Academic College
Ethics Committee (approval #42-2023). All procedures were performed in accordance with the
Declaration of Helsinki. The questionnaire was anonymous and voluntary, and the information
gathered did not put the participants at risk in any form.
Informed Consent Statement: Informed consent was obtained from all participants. Filling out the
online questionnaire and sending it constituted consent to participate in the survey.
Vaccines 2023, 11, 1728 9 of 11
Data Availability Statement: The data presented in this study are available on request from the
Conflicts of Interest: The authors declare no conflict of interest.
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