"Vaccine hesitancy and acceptance in Latvia and Lithuania after the COVID-19 pandemic "

• Nearly half of respondents in Latvia and Lithuania report vaccine refusal preferences. • Trust in health authorities and prior COVID-19 vaccination predict acceptance. • Social restrictions had minor effects; voluntary approaches preferred. • Western vaccines are favoured over non-Western alternatives. • Gender and religion influence hesitancy differently by country. This study investigates vaccine hesitancy and acceptance in Latvia and Lithuania following the COVID-19 pandemic, contextualising current attitudes within historical and institutional frameworks, quantifying public preferences for vaccine features and policy measures, and identifying predictors of vaccine acceptance to inform future public health strategies. A cross-sectional survey using the VaxPref database was conducted with demographically balanced samples from Latvia ( n = 1109) and Lithuania ( n = 1010). A discrete choice experiment elicited preferences for vaccine characteristics and public health policies. Latent class analysis explored heterogeneity in vaccine acceptance, incorporating sociodemographic and attitudinal predictors such as trust in public health authorities and prior vaccination behaviour. Three classes emerged: Provaxers, Refusers, and Hesitants. Nearly half of respondents in both countries were Refusers, a marked increase from earlier surveys.Refusers were indifferent to vaccine attributes and strongly averse to vaccination, while Provaxers and Hesitants preferred higher vaccine effectiveness and Westernmanufactured vaccines. Trust public health authorities and prior COVID-19 vaccination were the strongest predictors of acceptance. Policy-related variables, such as social restrictions and mandates, had statistically significant but minor associations, with both countries preferring the absence of constraints. Gender and religious affiliation influenced hesitancy in a country-specific manner. Vaccine attitudes in Latvia and Lithuania are shaped more by trust public health authorities and prior behaviours than by traditional sociodemographic factors. The high proportion of systematic Refusers poses a significant challenge for pandemic preparedness, highlighting the need for targeted trust-building initiatives and contextspecific policies to improve vaccine uptake. Our study looked at why many people in Latvia and Lithuania are hesitant or refuse to get vaccinated, even after the COVID-19 pandemic. We found that nearly half of adults in both countries are strongly against vaccines, and this reluctance is not driven by age, education, or income. Instead, the main reasons are a lack of trust in public health authorities and past experiences with vaccination. While some people prefer vaccines that are more effective or made in Western countries, regulations such as societal limitations or mandates little affected their choices. To increase vaccine uptake in the future, context-specific approaches and trust-building are essential.