key: cord-0284351-npcy1q1n
authors: Smith, L. E.; Hodson, A. E.; Rubin, G. J.
title: Parental attitudes towards mandatory vaccination; a systematic review
date: 2021-02-26
journal: nan
DOI: 10.1101/2021.02.24.21250288
sha: cf1034bc76496ce6db1f41b93ad3db627a0d7541
doc_id: 284351
cord_uid: npcy1q1n

While mandatory vaccination schemes can increase vaccine uptake rates, they can also cause backlash among some parents. We conducted a systematic review investigating parental beliefs about vaccine mandates and factors associated with support for mandatory vaccination schemes. We searched Embase, Ovid MEDLINE, Global Health, APA PsycINFO and Web of Science from inception to 17th September 2020. Seventeen studies (five qualitative, twelve quantitative) were eligible for inclusion. We synthesised results of qualitative and quantitative studies separately. Studies were heterogeneous with regard to schemes investigated and factors investigated. Quantitative studies found little evidence for any factors being consistently associated with support for mandatory vaccination. Qualitative studies found that parents perceived mandatory vaccination schemes as an infringement of their rights and that they preferred universal, compared to targeted, schemes. To optimise engagement with existing child mandatory vaccination legislation, schemes should be designed with parental beliefs in mind.

While vaccines have substantially reduced morbidity and mortality for various diseases, [1] some parents choose not to vaccinate their child. In the UK, uptake of routine childhood vaccines has been decreasing for the last five years.

[2] Vaccine uptake has also been decreasing in the United States (US) and elsewhere globally. [3] One way of increasing uptake is make childhood vaccination mandatory. As of December 2018, 105 countries had a nationwide vaccine mandate in operation. [4] Other countries such as the US and Canada, do not have a nationwide mandate, but have mandates that vary on a regional basis. [5] [6] [7] Mandatory vaccine schemes tend to restrict access to child-care or schooling for children who are not vaccinated, or withhold state payments or benefits if children are not vaccinated. [4] In some circumstances, parents can apply for exemptions to vaccine mandates based on religious or personal beliefs, but the flexibility within policies varies widely. [4] Another way of promoting vaccination could be to offer financial incentives.

Making vaccinations mandatory tends to increase uptake. [8] However, there is substantial debate over the ethics of making vaccination mandatory.

[9] While mandatory vaccination may force people to overcome barriers to vaccination, such as having to make a primary care appointment, it may entrench negative perceptions of vaccination. [10] In some countries, the implementation of mandatory vaccination programs has led to increased anti-vaccination sentiments and negative vaccine messages in the media. [11, 12] In Germany, these negative sentiments impacted vaccination intentions for other recommended, but non-mandatory, vaccinations. [12] In the US, systematic differences in uptake of child vaccines still exists, with evidence of geographical clustering of vaccine exemptions. [13] There is no standard approach to mandatory vaccination programmes. [14] Approaches vary country to country by: which vaccines are mandatory; which age groups are included; and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 26, 2021. ; https://doi.org/10.1101/2021.02.24.21250288 doi: medRxiv preprint how flexible the mandate is (e.g. penalties, enforcement, ability to opt out, compensation for serious adverse events). Refusal is often allowed based on religious, moral, philosophical or personal reasons. To minimise backlash when implementing a new childhood vaccine mandate, and to optimise engagement with existing childhood mandatory vaccination legislation, schemes should be designed with parental beliefs in mind. One recent systematic review investigated parental beliefs towards mandatory vaccination, h but with major limitations. [15, 16] Another systematic review focused on acceptability, economic costs and incentives of specific schemes, but is now outdated having been conducted in 2013. [17] There are no recent, high quality reviews investigating parental beliefs and attitudes towards vaccine mandates for routine childhood vaccinations.

The aim of this study was to investigate parents' beliefs about vaccine mandates and factors associated with support for mandatory vaccination schemes.

We conducted a systematic review in accordance with PRISMA criteria [18] to investigate parents' beliefs and attitudes towards vaccine mandates and mandatory vaccination. We searched Embase, Ovid MEDLINE, Global Health and APA PsycINFO through OvidSP, and Web of Science. Our final search term combined terms related to: mandatory, compulsory, exemptions, or school entry requirements; vaccination or immunisation; beliefs, or attitudes; and children (see supplementary materials). Databases were searched from inception to 17 th September 2020. References and forward citations of included articles were also searched.

The following inclusion criteria were used:

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We extracted information about study design, inclusion criteria, participant characteristics, country of study, and attitudes towards vaccine mandates or mandatory vaccination. 6 study. To enable more detailed description of risk of bias in the study, we scored studies out of two on each of the five dimensions, resulting in a total score out of ten. To aid interpretation of results, studies were rated as poor quality if they scored five or under; moderate quality if they scored six or seven; and good quality if they scored eight or over.

LS and AH completed risk of bias ratings separately for all studies. Any discrepancies were solved through discussion and final scores were approved by both authors. Procedure LS came up with the search terms, carried out the search, screened papers, extracted data and completed risk of bias assessment. AH screened a random sample of 100 citations to full-text screening stage and completed risk of bias assessment. Guidance was provided by GJR.

Qualitative and quantitative data were synthesised separately. Quantitative data were narratively synthesised, considering risk of bias ratings. As studies were heterogeneous in the mandatory vaccination schemes and associated factors investigated, there was no scope to conduct a meta-analysis. Qualitative data were synthesised using meta-ethnography, [22] synthesising themes reported across studies included.

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The search identified 4,994 citations; after removing duplicates, 2,672 citations remained.

After title, abstract and full-text screening, seventeen citations remained. A further three citations were identified by reference searching and forward citation tracking. Thus, twenty citations, reporting on seventeen studies (twelve quantitative, five qualitative) met inclusion criteria (see Figure 1 ).

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 26, 2021. ; https://doi.org/10.1101/2021.02.24.21250288 doi: medRxiv preprint were only marked down for not reporting complete outcome data (including 95% confidence intervals for prevalence estimates) or fully accounting for confounders in the study design or analyses. Five quantitative studies scored six or seven.[17, 23, 31-35] These studies did not report complete outcome data, account for confounders in the study design or analysis, and participants were not representative of the target population or the outcome measure was not robust. Five quantitative studies scored particularly poorly (between three and five). [36] [37] [38] [39] [40] [41] These studies were poor across the different dimensions evaluated, but low scores were because participants were not representative of the target population, complete outcome data were not reported, confounders were not accounted for in the study design and analysis, and outcome variables were not robustly measured.

Ten studies used a cross-sectional design, one used a case-control design, and one study was a discrete choice experiment (see supplementary materials). Studies were conducted in the USA (n=5), Poland (n=2), Israel (n=2), England (n=1), Croatia (n=1), and Australia (n=1).

Studies investigated factors associated with support for various mandatory vaccination schemes, including: restricting access to childcare or schooling for children who are not vaccinated; removing religious and personal belief exemptions from childcare or school entry requirements; withholding state payments or benefits if children are not vaccinated; and mandatory vaccination generally. Support for mandatory vaccination schemes varied. One study found that 47% of rural Ohio Appalachian (US) parents who had not vaccinated their daughters for HPV believed they had the right to refuse vaccines that were require for their child's school,[35] while another found that 12% of US parents believed that children should be allowed to go to school even if they were not vaccinated.

[30] Support for religious belief exemptions (22%) was slightly higher . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) One Australian study found that parents who perceived a lower risk of measles for unvaccinated children were less likely to support the "no jab, no pay" scheme; there was no evidence for an association with needing the financial incentives to afford family expenses or having a child that attends childcare. [29] Qualitative studies Two studies, both conducted in the UK, used a focus group design. Three other studies (conducted in Australia, the USA and Hong Kong) used an interview design. Studies investigated parental beliefs about mandatory vaccination schemes which: offer financial incentives for vaccination; restrict access to childcare or schooling for children who are not vaccinated; remove religious and personal belief exemptions from childcare or school entry . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 26, 2021. ; requirements; withhold state payments or benefits if children are not vaccinated; and which restrict access to child-care or schooling and withhold state payments or benefits if children are not vaccinated.

Seven main themes were extracted from studies (see Table 1 

Dropping vaccination rates, such as those seen in the US, UK, and elsewhere,[2] and the recent COVID-19 pandemic have re-ignited discussion about mandatory vaccination. [42] . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 26, 2021. ; https://doi.org/10.1101/2021.02.24.21250288 doi: medRxiv preprint While introducing vaccine mandates increases uptake of vaccines, [8] they also have the potential to cause backlash. This may be particularly true for vaccine mandates that are considered to be more stringent. [4] When implementing mandatory childhood vaccination, parents' viewpoints should be considered, to ensure schemes are accepted and to minimise backlash. This review synthesised quantitative and qualitative studies investigating parental beliefs about mandatory vaccination and factors associated with support for vaccine mandates.

Perhaps unsurprisingly, all but one qualitative study found that parents thought schemes were an infringement of their right to choose whether to vaccinate their child. In a sample of parents who had not vaccinated their child, the introduction of a scheme withholding state benefits if children were not vaccinated strengthened their commitment to autonomy in making health decisions.

[24] Recent evidence shows that attitudes towards vaccinations are becoming more polarised.

[43] Another theme identified in this study was that parents thought they should not be penalised for not wanting to vaccinate their child due to safety concerns. A quantitative study found that support for religious belief exemptions (22%) was slightly higher than support for personal belief exemptions (17%) in US parents.

[34] Implementing vaccine mandates without considering parents' views on exemption policies could result in considerable backlash among some parents, however the purposive use of non-representative samples in the qualitative studies makes it impossible to identify the prevalence of these views.

Better insight into how many parents this might apply to can be found in quantitative studies.

These indicated that support for mandatory vaccination schemes in countries where one had been implemented was reasonably high, ranging between 73% and 88% of parents. Support for a mandatory vaccination scheme was much lower in one study (47%), [35] although this was in a sample of parents who had not vaccinated their daughters for HPV.

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Studies investigated support for different vaccine mandates in which unvaccinated children could not access schooling or childcare, parents did not receive state benefits, or in which parents received financial incentives, and for different aspects of vaccine mandates, such as support for specific exemption schemes. Due to the lack of a standard approach to mandatory vaccination, [14] it is difficult to quantify support for mandatory schemes generally. A more useful approach may be to identify parental preferences for different vaccination schemes.

One study included in the review did this, finding that parents preferred universal mandatory vaccination schemes compared to those which targeted parents who had not fully vaccinated . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 

While qualitative studies included in the review were generally of high quality, quantitative studies were of lower quality. In particular, quantitative studies often did not ensure their samples were representative of the target population or take potential confounders into account in the study design or analyses. Furthermore, outcome data was often not completely reported, and some studies used outcome measures which were not methodologically robust. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Studies were heterogeneous in terms of mandatory vaccination schemes investigated.

Parental concerns and beliefs about schemes mandating vaccination for schooling or childcare may be qualitatively different from schemes using financial incentives to promote vaccination. Few quantitative studies investigated the same predictive factors. This lack of replication meant that even where multiple studies found an association, evidence for that factor remained weak. We have based our interpretation and conclusions on factors that were supported by evidence from both quantitative and qualitative studies.

MeSH terms were not searched, therefore some studies which were eligible for inclusion could have been missed.

While mandatory vaccination schemes increase vaccine uptake rates, they have the potential to cause backlash in some parents. Results from qualitative studies indicated that mandatory vaccination schemes were perceived by some parents as an infringement of their rights.

Nevertheless, some parents also felt that schemes limiting access to schooling of unvaccinated children gave them "peace of mind." Parents preferred universal vaccination schemes, rather than targeted schemes, and particularly disliked schemes offering financial incentives for vaccination. However, these results should be interpreted with caution, taking into account the purposive use of non-representative samples. Quantitative studies reporting rates of endorsement of these views found that support for mandatory vaccination schemes was reasonably high (73% to 88%). Due to heterogeneity of quantitative studies, there was little evidence for factors consistently associated with support for mandatory vaccination.

Parental beliefs about vaccine mandates and factors associated with support for mandatory vaccination may shed light on how to implement schemes to maximise parental endorsement.

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World Health Organization. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Krok 

Giubilini A, Jain V. Should COVID-19 vaccines be mandatory? Two experts discuss.

2020. https://theconversation.com/should-covid-19-vaccines-be-mandatory-two-expertsdiscuss-150322. Accessed 3 December 2020.

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Lee CHJ, Sibley CG. Attitudes toward vaccinations are becoming more polarized in . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Mandat* 2. Compulsory 3.

Opt out 4. Obligatory 5. Legislation 6. Policy 7. Law 8.

School entry 9.

Day care entry 10.

Child care entry 11.

Exempt* 12.

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 13.

Vaccin* 14.

Immuni$* 15.

Innoculat . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 26, 2021. Focus groups: Financial incentives were thought of as inappropriate, displayed dismay that this type of incentive scheme would be under consideration. Universal incentives (offered to all regardless of vaccination status of child or socio-economic status of parent) was noted as positive, but a small financial incentive may not be attractive to more affluent parents. If financial reward were introduced, it would need to be a nationwide roll-out to ensure fairness for all parents from all backgrounds. Universal reward may encourage parents who do not prioritise vaccinations. Incentives might be seen positively in disadvantaged groups as a way of supplementing income from work / benefits. Concerns (from parents in more affluent areas) that financial incentives would create a divide between rich (who could afford not to vaccinate their child) and poor (who could not afford to disregard a payment). Targeting financial incentives only to parents of children who were not vaccinated would lead parents of vaccinated children who had fulfilled their 'obligations' as feeling penalised. Targeted financial incentives could lead people to play the system. Financial reward should not be a factor when deciding to immunise one's child. Financial incentives might be an inappropriate 9 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 26, 2021. use of resources when public services are being cut. Having immunisations free of charge on the NHS should be incentive enough. Would prefer to see public funds used to improve children's quality of life in a sustainable way. Quasi-mandatory schemes were seen as preferable to financial incentives, with many advantages. Perceived as fairer and more equitable. Agreed that unimmunised children should be excluded from interacting with other children in daycare or school settings. Introduction of quasi-mandatory scheme could facilitate the normalisation of immunisation behaviour, and to encourage parents who had not prioritised immunisation. Mandating immunisation for childcare / education would provide peace of mind for parents. Child's right to socialise / be educated should be respected. Refusing the child entry to daycare/school would punish the child and jeopardise their future rather than punishing the parent. Concern about their child being unable to attend school as a consequence of their immunisation decision (as parents could be prosecuted under legislation in place at the time for taking their child out of school during term time). Concern that introduction of quasi-mandatory scheme could be interpreted as removal of parents' choice, which parents felt was their right living in a democratic society. Implementation of quasi-mandatory scheme could mean that parents with the resources to do so could opt their child out of state education and home-school or pay for private tuition/daycare.

.

It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 26, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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) 542 (mean age 38.1 years, SD=6.3) Parents of children aged 6 years that attended School Health Services in Zagreb