The relationship between trust and compliance in the Italian NHS: Results of the People's Voice Survey

Background Public health systems are assessed not only for outcomes but also for their ability to sustain legitimacy and trust. Trust supports long-term cooperation, while mandates can secure immediate adherence but risk eroding trust and weakening future willingness to comply. Italy illustrates this paradox, combining strong outcomes and extensive COVID-19 mandates with comparatively low public confidence. Objective To examine how trust, compliance, and intention to comply interact in the Italian health system, in the context of policies that rely on obligation rather than persuasion. Methods We analyzed data from the People’s Voice Survey conducted in Italy on a representative sample of 1001 adults. Outcomes were trust in the National Health Service, compliance with COVID-19 vaccination, and intention to comply with future directives. Determinants included perceptions of public influence, trust in scientists, vaccine attitudes, and past healthcare experiences, with education and income as moderators. Results Trust in the NHS was predicted by public influence, trust in scientists, and positive experiences, while negative experiences reduced it. Compliance was driven mainly by vaccine attitudes, with negative experiences lowering adherence. Intention to comply was associated with both general and policy-specific beliefs. Education moderated the role of trust in scientists, and income shaped the effect of experiences. Conclusions Trust sustains future cooperation, whereas reliance on obligation may erode it even in high-performing systems. Policies should foster transparency, responsiveness, and patient experience, and strengthen education as a stable foundation, since mandates ensure short-term adherence but not long-term cooperation.