nature | Vaccine mandates do risk overly politicizing health policy, says MacDonald. But it is hard to accurately quantify the consequences such as social exclusion, loss of public trust or inequitable outcomes. Numerous other factors are at play, such as the way a government handled the pandemic overall, wider political campaigns against vaccination or mandates, or frustrations with the way that a mandate was implemented. Another crucial aspect of whether mandates are successful is the political skill and messaging used to introduce them.
Opposition to vaccines — and mandates — can also be a way of expressing displeasure with other aspects of civil society, says Heidi Larson, an anthropologist and founding director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine. “All of a sudden everyone who had an issue with government has an issue with vaccines,” she says. Oliu-Barton says that some mandates seem like a referendum: “Do you like the government? You can say, ’no’, by not getting a shot.”
Ward has tried to gauge how the French public reacted to vaccination policies by using questionnaires. When asked if they felt relief, anger or regret when they got vaccinated, respondents who were vaccinated in early 2021 said they mostly felt relief. But most of those vaccinated later, especially after the government imposed health-pass requirements, reported anger or regret6. In a later poll conducted in March this year, more than 60% of respondents said they had felt at least somewhat ‘constrained’ to get vaccinated. Ward’s future work will further dissect why and how.
In Germany, Katrin Schmelz, a psychologist at the University of Konstanz, has led a unique series of surveys that tracked the evolving views of nearly 2,000 German residents over the course of the pandemic7.
The questionnaire showed that only around 3% of the population consistently opposed vaccination if it was voluntary. By contrast, each survey revealed that around 16% of people opposed mandatory vaccination — crucially, however, it was not always the same 16% of respondents who felt this way. Roughly half of respondents changed their minds over time — and the shifting variables most closely tied to support for mandates were trust in government and belief in vaccine effectiveness.
“Mandates are an essential part of public health policies,” says Schmelz, but her work also suggests that it was a good decision to make vaccination a personal choice initially. Polling before vaccines were available showed that 73% of German adults were OK with getting vaccinated voluntarily8 — which corresponded almost exactly to the fraction who were vaccinated before mandates were introduced. Schmelz says she believes that a sense of moral autonomy motivated these people to help battle the virus, and that mandating vaccination earlier would probably have reduced this motivation. “People respond to feeling distrusted by lowering their effort,” she says.
A major concern is that if a substantial proportion of society has lost trust in public institutions, this will make public-health policies harder to implement — in particular, other ongoing vaccine programmes. “Sentiments around vaccines are hugely tied to trust in government,” says Larson. “What’s the knock-on effect of this COVID experience on routine vaccination?”
Deciphering those longer trends might take time. Larson is awaiting the results of the Vaccine Confidence Project’s latest survey of overall attitudes to vaccines, which she thinks will be an indicator of how views have shifted.
Like so many aspects of the pandemic, decisions about mandates and their implementation have occurred at speed — amid a constantly shifting crisis. The legal requirements now being studied were introduced in the summer of 2021, when anxieties about the pandemic still ran deep, and such measures were more palatable. Available vaccines also offered protection against infection, not just against serious illness. With people becoming less afraid of COVID-19 and vaccines offering less protection against infection by Omicron variants, plans this spring to introduce new nationwide mandates in Austria and Germany, for example, were rejected or never enforced.
As concerns about the pandemic wane in many countries, researchers fear that research fatigue is setting in, too, not least when it comes to analysing the complex behavioural responses of people to the virus and mitigation strategies. Yet behavioural science is an essential part of the response to this pandemic and future ones. “People are tired,” MacDonald says, “I think everybody wants this done.” But what she’s more tired of is seeing governments not learning the lessons of previous public-health emergencies. “We need this analysis done.”
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