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Puerto Rico is experiencing a public health crisis driven by effects and processes of US colonialism in the archipelago, such as the exclusionary application of federal health policy, an exodus of health care professionals, and the long-term effects of unequal distribution of health care funding in the unincorporated territories. Compound effects of multiple disasters, including Hurricane María, repeated earthquakes, and the COVID-19 pandemic, as well as relentless privatization and fragmentation of the health care system, have led to very poor health outcomes. Puerto Rico's case clearly shows the negative effects of colonialism on public health. This article specifies what decolonization requires from a public health standpoint to promote health equity., (Copyright 2022 American Medical Association. All Rights Reserved.)

Background: Determinants of COVID-19 vaccine acceptance are complex; how perceptions of the effectiveness of science, healthcare and government impact personal COVID-19 vaccine acceptance is unclear, despite all three domains providing critical roles in development, funding and provision, and distribution of COVID-19 vaccine., Objective: To estimate impact of perception of science, healthcare systems, and government along with sociodemographic, psychosocial, and cultural characteristics on vaccine acceptance., Design: We conducted a global nested analytical cross-sectional study of how the perceptions of healthcare, government and science systems have impacted COVID-19 on vaccine acceptance., Setting: Global Facebook, Instagram and Amazon Mechanical Turk (mTurk) users from 173 countries., Participants: 7411 people aged 18 years or over, and able to read English, Spanish, Italian, or French., Measurements: We used Χ 2 analysis and logistic regression-derived adjusted Odds Ratios (aORs) and 95% CIs to evaluate the relationship between effectiveness perceptions and vaccine acceptance controlling for other factors. We used natural language processing and thematic analysis to analyse the role of vaccine-related narratives in open-ended explanations of effectiveness., Results: After controlling for confounding, attitude toward science was a strong predictor of vaccine acceptance, more so than other attitudes, demographic, psychosocial or COVID-19-related variables (aOR: 2.1; 95% CI: 1.8 to 2.5). The rationale for science effectiveness was dominated by vaccine narratives, which were uncommon in other domains., Limitations: This study did not include participants from countries where Facebook and Amazon mTurk are not available, and vaccine acceptance reflected intention rather than actual behaviour., Conclusions: As our findings show, vaccine-related issues dominate public perception of science's impact around COVID-19, and this perception of science relates strongly to the decision to obtain vaccination once available., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)