The Cost of Distrust: Governance Perceptions, Risk, and COVID-19 Vaccine Uptake in Africa--Evidence from the Afrobarometer Survey

BackgroundThe stark heterogeneity in COVID-19 vaccine uptake across Africa cannot be fully explained by individual-level factors or access alone. This study investigates the crucial, yet underexplored, role of political and governance perceptions in shaping health behavior. We examine how citizen perceptions of governance, specifically institutional trust, perceived corruption, and satisfaction with health services, influence COVID-19 vaccination uptake in Africa. We further test whether perceived government preparedness, as a measure of institutional risk mitigation, mediates this relationship. MethodsWe analyzed cross-sectional data from 53,444 respondents across 39 African countries (Afrobarometer Round 9, 2021-2023). Using multilevel logistic regression and generalized structural equation modelling, we assessed associations while controlling for sociodemographic and accounting for country-level clustering. ResultsOur analysis reveals three key patterns. First, institutional trust has a non-linear relationship with vaccination. Respondents with "just a little" trust had[~] 28.6% uptake, compared to 23.1% for those with "a lot" of trust. Second, corruption perceptions exhibited a dose-response effect; a one-unit increase on the corruption scale was associated with a 1.8%-point reduction in vaccination probability (p<0.001). Third, we identified a complacency effect: a one-unit increase in perceived government preparedness was linked to 20.2% lower odds of vaccination (p<0.001). Substantial heterogeneity existed: the effect of institutional trust was twice as strong in urban areas (OR=1.050) than in rural areas (OR=1.025). Multilevel modelling showed that country-level factors accounted for 29% of the total variance in vaccination behavior. ConclusionGovernance perceptions are fundamental determinants of health behavior in Africa. The robust negative effect of corruption and the counterintuitive complacency effect underscore that building trustworthy, transparent governance is a public health imperative. However, communicating institutional capability requires careful framing to avoid undermining personal responsibility.