key: cord-0723437-yzkwqpho
authors: Gagneux-Brunon, Amandine; Botelho-Nevers, Elisabeth; Bonneton, Marion; Peretti-Watel, Patrick; Verger, Pierre; Launay, Odile; Ward, Jeremy K.
title: Public opinion on a mandatory COVID-19 vaccination policy in France: a cross-sectional survey
date: 2021-11-10
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2021.10.016
sha: 60d2e5e2819d837c6a51e95da86fc85550ca4a95
doc_id: 723437
cord_uid: yzkwqpho

OBJECTIVES: Reaching the last pockets of unvaccinated people is challenging, and has led to the consideration of mandatory vaccination for coronavirus disease 2019 (COVID-19). Our aim was to assess attitudes toward mandatory COVID-19 vaccination in France before the announcement of—and factors associated with opposition to—this type of policy. METHODS: Between the 10th and 23rd May 2021, we conducted a cross-sectional online survey among a representative sample of the French population aged 18 and over, and a specific sample of the French senior population aged over 65. RESULTS: Among 3056 respondents, 1314 (43.0%) were in favour of mandatory COVID-19 vaccination, 1281 (41.9%) were opposed to such a policy, and 461 (15.1%) were undecided. Among opponents to mandatory COVID-19 vaccination for the general population, 385 (30.05%) were in favour of mandatory COVID-19 vaccination for healthcare workers (HCWs). In multivariate analysis, the age groups 18–24 and 25–34 years were significantly more opposed than the reference group (>75 years old) with respective adjusted odds ratio (aOR) and 95% confidence interval (95%CI) 4.67 (1.73–12.61) and 3.74 (1.57–8.93). Having no intention of getting COVID-19 vaccination was strongly associated with opposition to mandatory vaccination (aOR 10.67, 95%CI 6.41–17.76). In comparison with partisans of the centre, partisans of the far left and green parties were more likely to be opposed to mandatory COVID-19 vaccine, with respective aORs (95%CI) of 1.89 (1.06–3.38) and 2.08 (1.14–3.81). CONCLUSION: Attitudes toward mandatory COVID-19 vaccination are split in the French general population, and the debate might become politicized.

Coronavirus disease 2019 (COVID-19) has been responsible for more than 225 million cases and more than 4.6 million deaths worldwide up to the 14th September 2021 [1] . Vaccines were developed at "a pandemic speed" [2] . More than 5 billion COVID-19 vaccines had been administered worldwide by the end of August 2021 [3] . After 5e6 months of COVID-19 vaccination campaigns, many high-income countries have reached their coverage plateau (60% of the entire population) [3] . In France, all individuals over the age of 12 years have been eligible for COVID-19 vaccination since 1st June 2021. On 1st July 2021, 51% of the general French population (59.8% of the eligible population) had received a first dose of COVID-19 vaccine [4] .

As has been seen in the past with childhood immunizations, vaccinating a majority of the population is easier than reaching the last pockets of unvaccinated people, the unwilling or weakly motivated [5, 6] . Faced with this challenge in the past, many countries have resorted to various forms of vaccination mandates [7] . While recourse to constraint in its various forms can be effective in increasing vaccine coveragedparticularly by pushing those who wait and those who refuse to actdit also presents the risk of antagonizing part of the public, causing reactance and stimulating anti-vaccine movements [8] . Because the debate around mandatory COVID-19 vaccination is emerging in many countries, it is crucial to understand the conditions under which this policy could be widely accepted. France was among the most vaccine-hesitant countries in the world before the COVID-19 epidemic [9, 10] , and hesitancy toward COVID-19 vaccination has remained higher than in most neighbouring countries throughout the period [11] . Studying attitudes towards vaccine mandates in such a context can help to highlight the variety of factors influencing the acceptability of coercive measures, including preferences for political parties [12] , identifying target groups, and developing specific interventions to reduce reactance. Although healthcare workers (HCWs) were identified as a priority target group for COVID-19 vaccination, on 1st July only 60% of French HCWs had received a dose of COVID-19 vaccine [4] . To increase COVID-19 vaccine coverage in HCWs, COVID-19 vaccine mandates appeared as a solution. In France, the compulsory vaccination against hepatitis B led to a significant increase in vaccination coverage and reduced the differences between professional categories [13] .

In a survey carried out in May 2021, participants were asked for their opinion about COVID-19 vaccine mandates for the general population and for HCWs [14] . In this context, it seems interesting to assess opinions about mandatory vaccination prior to its implementation, and to identify factors associated with opposition to COVID-19 vaccination mandates in France.

Between 10th and 23rd May 2021, we conducted a crosssectional online survey among a sample of the French population aged 18 and over, with participants who were randomly selected from an existing online research panel of more than 750 000 nationally representative households of the general population (Bilendi SA®). A quota sampling method was applied to achieve a sample of 1514 respondents representative for the French adult population in terms of age, gender, occupation and population in the area of residence. In total 50 200 invitations were sent to reach this sample (response rate 3.1%). An additional sample of 1544 French residents 65 years of age selected from the same panel, representative of the general 'senior' population in terms of gender and age, was added because the survey also aimed to identify reasons for non-vaccination in the elderly. A total of 5700 additional persons over 65 years of age were invited to answer the survey to obtain this extra sample (response rate 27.1%). Prior information on the panellists was used to determine eligibility and to select a stratified random sample with oversampling of panellists over 65 years of age. To limit coverage biasddue to the fact that not all people use the internet, and, among users, that not all of them are willing to participate in web surveysdrandom sampling was stratified to match French official census statistics for gender, age, occupation (eight categories), population in the area of residence (five categories) and region (12 categories). In addition, a survey weight that takes into account gender, age, region and size of residence area was calculated and assigned to each response. The study design was approved by the ethical committee of the University Hospital Institute M editerran ee Infection (#2021e001).

In addition to background socioeconomic variables (gender, age, profession), we collected intention to vaccinate or history of COVID-19 vaccination, concerns about COVID-19, and opinion of vaccines in general. Respondents were asked to which French political party they felt the closest (among a quite comprehensive list of 17 parties), and responses were encoded into: far-left, green party, left, centre and right governmental parties, and far-right and feeling close to no party. Regarding mandatory COVID-19 vaccination, respondents were asked whether they think that vaccination against COVID should be mandatory for the entire population; the question was "Do you think that COVID-19 vaccination should be mandatory for all?". Respondents against mandatory COVID-19 vaccination were asked whether they think that COVID-19 vaccination should be mandatory for HCWs: "Do you think that COVID-19 vaccination should be mandatory for HCWs?". For both questions, the answers were yes, no or don't know.

Attitudes toward a mandatory COVID-19 vaccination for the general population were merged into a binary outcome: 'opposition to COVID-19 mandatory vaccine policy' equalled 1 if participants answered no, otherwise the value was 0. We chose this dichotomization, while we considered that undecided individuals will not be those who will strongly express their opposition. We first used bivariate analyses, and c 2 tests in cross-tabulations, and a bivariate logistic regression to investigate factors associated with opposition to mandatory COVID-19 vaccination, using respondents' socioeconomic background, concern about COVID-19, and political preferences as covariates. In a second part, we aimed to better describe the population of individuals reluctant about COVID-19 vaccination mandates for all, but in favour of mandatory COVID-19 vaccination for HCWs. In the regression model, we used bivariate analyses and a bivariate logistic regression to investigate factors associated with the attitude toward a COVID-19 vaccine mandate for HCWs in respondents opposed to a mandatory COVID-19 vaccine policy for all. In regression models, we used a forward stepwise selection method (entry threshold p < 0.2) to retain statistically significant covariates only.

A total of 3056 individuals answered the questionnaire (1455 men, 47.6%). Among the respondents, 1314 (43.0%) were in favour of mandatory COVID-19 vaccination, 1281 (41.9%) were opposed to such a policy, and 461 (15.1%) were undecided (Table 1) .

Opinions differed between age groups; 61.4% of the respondents aged 25e34 years were opposed to COVID-19, in contrast to 18.2% of individuals over the age of 75. Among the respondents who intended to get vaccinated or had already been vaccinated, 28.9% were opposed to mandatory COVID-19 vaccination.

The multivariate analysis confirmed that opinion toward a mandatory COVID-19 policy differed between age groups; younger individuals were more likely to be opposed to a mandatory COVID-19 vaccination (Table 2) . COVID-19 vaccination personal refusal was an important predictor of opposition to a mandatory COVID-19 vaccination (aOR 10.67, 95%CI 6.41e17.76). Differences in attitude to a mandatory COVID-19 vaccination were observed depending on political affiliation. Low trust in the government was also associated with reluctance to accept a mandatory COVID-19 vaccine policy (aOR 1.78, 95%CI 1.29e2.45). Respondents with an unfavourable opinion or no opinion about vaccination in general were also reluctant to accept a mandatory COVID-19 vaccine policy (aOR 2.81, 95%CI 1.85e4.27). Tables 3 and 4 .

In this survey we observed that the opinion of the general population on a mandatory COVID-19 vaccination policy was split, as 43% of the respondents were in favour, 15% were undecided, and 41.9% were opposed to it. Among the opponents to such a policy, around one third was in favour of mandatory COVID-19 vaccination for HCWs.

France is known as a 'vaccine-hesitant' country [9] , and may be a country reluctant to accept mandatory COVID-19 vaccination. The proportion of opponents to a mandatory COVID-19 vaccine in France is not far from the 51% proportion observed in a German study carried out in June and July 2020 [15] . We observed a higher proportion of opponents in France than in the USA and Greece (respectively 17.3% and 25.7%) [16, 17] . In Australia, 73% of the population said they would support the government requiring the coronavirus vaccine for activities such as travel, work, and study, and only 9% were clearly opposed to a mandatory COVID-19 vaccination [18] .

We observed that older age and a very high level of fear of COVID-19 were associated with support for a COVID-19 vaccination mandate for the general population. These factors were also identified in other European studies about COVID-19 vaccination mandates [15, 17] and were also associated with intention to get vaccinated [19, 20] . Intention to get vaccinated or vaccinated status were highly associated with support for mandatory COVID-19 vaccination, and it is not surprising to identify common determinants.

French reluctance to accept mandatory COVID-19 vaccination may in part be explained by some questions about mandatory vaccination. In December 2020, before the launch of the vaccine campaign, the President of the French Republic promised that the vaccine would not be made mandatory. On 12th July 2021, while the Delta variant spread in France, he announced mandatory COVID-19 vaccination for HCWs and other exposed professions and the 'COVID-19 passport' extension (complete vaccine schedule, or COVID-19 infection in the previous 6 months, or a negative severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) test in the previous 72 h) for the general population to attend public settings (such as restaurants, movie theatres, shopping centres, etc.). Since this announcement, 13 million French people have received their first dose of vaccine, and vaccine coverage reached 85.1% of the eligible population on 8th September 2021. At the time of writing, the movement against the 'COVID-19 passport', that protests every week, does not seem to be growing and is not supported by the majority of the French population. We observed that vaccinated individuals or those who intend to get vaccinated could be opposed to COVID-19 vaccination mandates. In the United Kingdom, vaccine passports would make a large minority of individuals no more nor less inclined to accept a COVID-19 vaccine, and individuals with definite intentions to get vaccinated were less inclined to get vaccinated if a vaccine passport was implemented [21] . It remains unclear whether 'COVID-19 passports' are more acceptable than mandatory COVID-19 vaccination for the general population. Indeed, mandatory COVID-19 vaccination for the general population is a highly politicized issue in the context of the 2022 presidential election campaign. We observed that lack of trust in the government during the pandemic and partisanship of far left and green parties were associated with a greater opposition to a mandatory COVID-19 vaccination policy. The influence of political identities on attitudes to vaccines has also been observed for the intention to get vaccinated against COVID-19 in France [12] . In the USA, Democrats (in Australia major party voters) were more likely to be in favour of mandatory COVID-19 vaccination than Republicans [16, 18] . In contrast, in Germany, political preferences do not seem to be associated with attitudes toward mandatory COVID-19 vaccination [15] . It has previously been observed that attitudes toward vaccine mandates were even more influenced by partisan orientations than vaccination intentions [22] . In addition, since 15th October, COVID-19 tests in asymptomatic individuals to obtain 'COVID-19 passports' are no longer free in France. This appears to be a back-door way of making vaccination almost compulsory. Mandatory COVID-19 vaccination would lead to an increase in vaccine coverage, as currently observed in French HCWs. COVID-19 vaccine coverage in HCWs was 62.4% on 12th July and reached 88.4% on 6th September. However, a COVID-19 vaccine mandate might be counterproductive, particularly if it is not acceptable for a great majority of the population [23] . Such a policy can have detrimental consequences: reduced uptake of other vaccines, a decrease in adherence to personal protective measures, enhancement of suspicion of both vaccines in general and public health authorities, and a reduction in autonomy in the decision-making. A detrimental effect of a mandatory COVID-19 vaccination policy is quite uncertain in France. Sant e Publique France has observed an increase in vaccine coverage of non-mandatory vaccines since the extension of mandatory vaccinations in infants, and a slight increase in the proportion of the French population favourable to vaccines in general [24] . After a period of reluctance, acceptability of mandatory COVID-19 vaccination will probably increase. In the past, the rate of favourable opinions toward mandatory childhood vaccines increased after the extension of the number of mandatory vaccines in 2018 [24] . Furthermore, in July 2021 in an opinion poll, 58% of the respondents were in favour of mandatory COVID-19 vaccination for all [25] . The COVID-19 passport could be considered as a form of COVID-19 vaccine mandate, and a majority of the French general population (58%) has a favourable opinion about the COVID-19 passport [26] . Our study suffers from several limitations. First, we can address the representativeness of participants in comparison with the French general population. Sample size is limited for the younger age groups; however, the observations have been weighted for age, gender, professional categories, and living areas. Older age and antecedents or intention to take up COVID-19 vaccination were great predictors of attitudes toward COVID-19 vaccination mandates. The survey was an internet-based survey, and so individuals without access to technologies or with disabilities are probably underrepresented in our sample. In addition, undecided respondents were not asked about their attitudes to a mandatory COVID-19 vaccination for HCWs. As we observed that one third of the opponents to COVID-19 vaccination mandates in the general population were in favour of specific mandates for HCWs, we cannot estimate the true proportion of the population in favour of mandatory COVID-19 vaccination for HCWs.

In conclusion, opinions toward COVID-19 vaccination mandates were split in France in May 2021. Mandatory COVID-19 vaccination is a highly political issue in the context of the next French presidential election. Despite the implementation of the COVID-19 passport and COVID-19 vaccination mandates for HCWs and COVID-exposed professionals, France seems to have hit the glass ceiling of COVID-19 vaccination coverage. In addition, disparities are observed between regions and French overseas territories. If another wave hits France in the autumn, and if a more comprehensive outreach programme is not put in place by then, the dilemma might well be: what would be less unacceptable: mandatory vaccination, or new containment measures?

Conception or design of the work: PV, AGB, JKW, EBN, OL and MB. Acquisition of the data: PV and JKW. Analysis: PV, JKW and AGB. Interpretation of data for the work: PV, OL, EBN, PPW and AGB.

EBN participated on a Data Safety Monitoring Board or Advisory Board for Pfizer and Janssen, but payment was made to her institution. Other authors did not declare any conflicts of interest. This research was carried out within the COVIREIVAC platform (intended for COVID-19 vaccine clinical research) and received financial support from Institut national de la sant e et de la recherche m edicale (INSERM), the Ministry of Health, and The Ministry of Higher Education and Research.

Johns Hopkins Coronavirus Resource Center. COVID-19 map

Developing COVID-19 vaccines at pandemic speed

COVID-19) VaccinationsdStatistics and Research. Our world in data

cartes, donn ees et graphiques. n.d

Childhood vaccination mandates: scope, sanctions, severity, selectivity, and salience

Adapting coercion: how three industrialized nations manufacture vaccination compliance

Manufacturing consent for vaccine mandates: a comparative case study of communication campaigns in France and Australia

Mandate vaccination with care

The state of vaccine confidence 2016: global insights through a 67-country survey

The state of vaccine confidence in the EU: 2018: the vaccine confidence project

Exploratory study of the global intent to accept COVID-19 vaccinations

The French public's attitudes to a future COVID-19 vaccine: the politicization of a public health issue

Num ero th ematique. Vaccinations et risque infectieux chez le personnel des etablissements de sant e

Enquête COVIREIVAC: les français et la vaccination

A7ais-et-la-vaccination

Attitudes on voluntary and mandatory vaccination against COVID-19: evidence from Germany

US public attitudes toward COVID-19 vaccine mandates

Mandatory vaccination support and intentions to get vaccinated for COVID-19: results from a nationally representative general population survey in October 2020 in Greece

Support for a COVID-19 vaccine mandate in the face of safety concerns and political affiliations: an Australian study

Intention to participate in a COVID-19 vaccine clinical trial and to get vaccinated against COVID-19 in France during the pandemic

A global survey of potential acceptance of a COVID-19 vaccine

The potential impact of vaccine passports on inclination to accept COVID-19 vaccinations in the United Kingdom: evidence from a large cross-sectional survey and modeling study

Vaccine risk perceptions and ad hoc risk communication: an empirical assessment

Reactance revisited: consequences of mandatory and scarce vaccination in the case of COVID-19

Bulletin de sant e publique vaccination

Covid-19: les Français majoritairement favorables a la vaccination obligatoire, selon notre sondage. Franceinfo

Enquête SLAVACO vague 2: passe sanitaire, obligation vaccinale et rappels

The authors would like to thank Cyril B erenger (Database manager, ORS PACA), S ebastien Cortaredona (Statistician, IRD), Lisa Fressard (Statistician, ORS PACA), Gwenaelle Maradan (Logistician, ORS PACA) and Alvaro Sanchez (Statistician) for their data collection and analysis, Glyn Thoiron for English editing and Delphine Grison for her help.