Policy Feedback and the Politics of Childhood Vaccine Mandates: Conflict and Change in California, 2012-2019.

CONTEXT: In 2012, California instituted a new requirement for parents to consult with a clinician before receiving a personal belief exemption to its school entry vaccine mandate. In 2015, the state removed this exemption altogether. In 2019, legislators cracked down on medical exemptions to address their misuse by vaccine refusers and supportive clinicians. This paper explores these political conflicts using 'policy feedback theory,' arguing that personal belief exemptions informed the emergence and approaches of two coalitions whose conflict reshaped California's vaccination policies. METHODS: We analysed legal, policy, academic and media documents; interviewed ten key informants; and deductively analysed transcripts using NVivo 20 transcription software. FINDINGS: California's long-standing vaccination policy inadvertently disseminated two fundamentally incompatible social norms: vaccination is a choice; vaccination is not a choice. Over time, the culture and number of vaccine refusers grew, at least in part because the policy state-sanctioned the norm of vaccine refusal. CONCLUSIONS: The long-term consequences of California's 'mandate + PBE' policy - visible, public, and socially sanctioned vaccine refusal - undermined support for it over time, generating well-defined losses for a large group of people (the vaccinating public) and specifically for the parent activists whose experiences of personal grievance drove their mobilisation for change.

From speculative to real: community attitudes towards government COVID-19 vaccine mandates in Western Australia from May 2021 to April 2022.

Many governments employed mandates for COVID-19 vaccines, imposing consequences upon unvaccinated people. Attitudes towards these policies have generally been positive, but little is known about how discourses around them changed as the characteristics of the disease and the vaccinations evolved. Western Australia (WA) employed sweeping COVID-19 vaccine mandates for employment and public spaces whilst the state was closed off from the rest of the country and world, and mostly with no COVID-19 in the community. This article analyses WA public attitudes during the mandate policy lifecycle from speculative to real. Qualitative interview data from 151 adults were analysed in NVivo 20 via a novel chronological analysis anchored in key policy phases: no vaccine mandates, key worker vaccine mandates, vaccine mandates covering 75% of the workforce and public space mandates. Participants justified mandates as essential for border reopening and, less frequently, for goals such as protecting the health system. However, public discourse focusing on 'getting coverage rates up' may prove counter-productive for building support for vaccination; governments should reinforce end goals in public messaging (reducing suffering and saving lives) because such messaging is likely to be more meaningful to vaccination behaviour in the longer term.

COVID-19 vaccination of at-risk and marginalised groups: recentering the state in vaccine uptake.

Recent studies have used the World Health Organization's new Behavioural and Social Drivers (BeSD) framework to analyse vaccine uptake. However, this study of COVID-19 vaccination among marginalised population groups highlights the framework's limitations regarding the centrality of the state in shaping people's vaccination intentions in high income countries. We conducted interviews and focus groups with service providers and community members to explore COVID-19 vaccination amongst Western Australians experiencing homelessness and/or from other marginalised populations (such as people with substance use dependence). Analysing this data iteratively to emphasise the state's role and functions, we elaborate how trauma and mistrust of government drive thoughts, feelings, and social interactions regarding vaccination programs, which are mutually reinforcing and which inhibit individuals' willingness to engage. Government systems that leave some populations behind increase those populations' susceptibility to misinformation. Policies may generate new unintended problems: social service providers worried about vaccine advocacy damaging clients' trust, especially in the context of vaccine mandates. Reframing the state's responsibility for designing culturally and socially appropriate services, we outline how end-users and trusted providers can lead this process. We share a new framework, "Recentering the State in Vaccine Uptake," arising from our analyses.

Medical exemptions to mandatory vaccinations: The state of play in Australia and a pressure point to watch.

Australia's mandatory vaccination policies have historically allowed for non-medical exemptions (NMEs), but this changed in 2016 when the Federal Government discontinued NMEs for childhood vaccination requirements. Australian states introduced further mandatory vaccination policies during the COVID-19 pandemic for a range of occupations including healthcare workers (HCWs). There is global evidence to suggest that medical exemptions (MEs) increase following the discontinuation of NMEs; the new swathe of COVID-19 mandatory vaccination policies likely also placed further pressure on ME systems in many jurisdictions. This paper examines the state of play of mandatory vaccination and ME policies in Australia by outlining the structure and operation of these policies for childhood vaccines, then for COVID-19, with a case study of HCW mandates. Next, the paper explores HCWs' experiences in providing vaccine exemptions to patients (and MEs in particular). Finally, the paper synthesizes existing literature and reflects on the challenges of MEs as a pressure point for people who do not want to vaccinate and for the clinicians who care for them, proposing areas for future research and action.

Attitudes, perceptions, and experiences of Western Australians towards vaccine safety surveillance systems following COVID-19 vaccines: A qualitative descriptive study.

OBJECTIVE: Concerns regarding adverse events following immunisation are a barrier to vaccine uptake. Health professionals use vaccine safety surveillance systems (VSSSs) to monitor vaccines and inform the public of safety data. With little known about public attitudes, perceptions, and experiences with VSSS, we examined them in the context of COVID-19 vaccinations in Western Australia. METHODS: Researchers conducted 158 qualitative interviews between March 2021 and May 2022 within the broader [name redacted] project. Data regarding VSSS were coded in NVivo using the deductive and inductive methods. RESULTS: Despite some not knowing about VSSS, participants expected follow-up post COVID-19 vaccination. Vaccine hesitant or refusing participants knew about VSSS and regarded these systems positively. Additional considerations concerned the reliability of data collected by VSSS. CONCLUSION: Perceptions of VSSS signal a lack of understanding about how these systems work. Future studies should further explore the public's understanding of VSSS, whether VSSS improves vaccine confidence, and how governments can better communicate to the public about VSSS. IMPLICATIONS FOR PUBLIC HEALTH: Lack of understanding of how VSSS operate may be stymying attempts to build public vaccine confidence. Healthcare providers and governments could build public knowledge and understanding of VSSS to mitigate concerns of adverse events following immunisation.

Childhood vaccine refusal and what to do about it: a systematic review of the ethical literature.

BACKGROUND: Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature. METHODS: Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field of Research codes, and normative content was analysed using a framework analytical approach. RESULTS: Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled 'refusal arguments'); and (2) Whether strategies for dealing with those who reject vaccines are justifiable ('response arguments'). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent's will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom. CONCLUSIONS: This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy.

Making salient ethics arguments about vaccine mandates: A California case study.

Vaccine mandates can take many forms, and different kinds of mandates can implicate an array of values in diverse ways. It follows that good ethics arguments about particular vaccine mandates will attend to the details of individual policies. Furthermore, attention to particular mandate policies-and to attributes of the communities they aim to govern-can also illuminate which ethics arguments may be more salient in particular contexts. If ethicists want their arguments to make a difference in policy, they should attend to these kinds of empirical considerations. This paper focuses on the most common and contentious vaccine mandate reform in the contemporary United States: the elimination of nonmedical exemptions (NMEs) to school and daycare vaccine mandates. It highlights, in particular, debates about California's Senate Bill 277 (SB277), which was the first successful recent effort to eliminate NMEs in that country. We use media, secondary sources, and original interviews with policymakers and activists to identify and evaluate three ethics arguments offered by critics of SB277: parental freedom, informed consent, and children's rights to care and education. We then turn to one ethics argument often offered by advocates of SB277: harm prevention. We note, however, that three arguments for mandates that are common in the immunization ethics literature-fairness/free-riding, children's rights to vaccination, and utilitarianism-did not play a role in debates about SB277.

"Fighting the pandemic!" Western Australian pharmacists' perspectives on COVID-19 vaccines: A qualitative study.

BACKGROUND: In Western Australia, community pharmacists are authorized to administer a range of vaccines without a prescription. Since mid-July 2021, pharmacists can also administer Coronavirus Disease 2019 (COVID-19) vaccines. Little is known about how pharmacists think and feel about giving and receiving COVID-19 vaccines and how they discuss it with patients. AIM: This study aimed to explore Western Australian pharmacists' perceptions on being vaccinated with, administering, and communicating about COVID-19 vaccines. METHODS: Semi structured interviews were conducted with 20 pharmacists from metropolitan and regional areas of Western Australia across a two-week period in July and early August 2021. Interview transcripts were coded using NVivo 20 and data was thematically analyzed using the framework method. RESULTS: Most pharmacists (n = 16, 80 %) had received at least one dose of a COVID-19 vaccine. Some expressed difficulty accessing the vaccine while two unvaccinated pharmacists were hesitant to receive it due to concerns about vaccine development. The majority of pharmacists spoke positively about administering the vaccines, discussing perceived facilitators such as designated vaccination days but also perceived barriers such as inadequate financial reimbursement compared to other healthcare providers. Many pharmacists obtained their information from Australian government sources and training modules. Pharmacists were only passively promoting COVID-19 vaccines, with conversations mostly initiated by patients. Most pharmacists specified they would highlight the common side effects when administering the vaccine and would provide patients with written information. CONCLUSION: The majority of pharmacists were willing to administer and be vaccinated with COVID-19 vaccines. Since pharmacists play an important role in increasing vaccine uptake, governments should provide equitable reimbursement to pharmacists in line with other vaccinators such as General Practitioners. We welcome the recent resources produced by governments and pharmacy professional organizations to help pharmacists actively promote the vaccines since this work was undertaken.

West Australian parents' views on vaccinating their children against COVID-19: a qualitative study.

BACKGROUND: Australian children and adolescents were among the last local cohorts offered COVID-19 vaccines. Despite promising initial uptake, coverage subsequently plateaued, requiring further efforts to improve access and build parents' recognition of the importance of COVID-19 vaccination. We sought to understand West Australian (WA) parents' willingness to vaccinate their children to inform strategies for improving uptake at the time in which they were becoming eligible. METHODS: We undertook in-depth qualitative interviews with 30 parents of children aged 5-17 years from June - December 2021. During this period, children aged 12-15 years became eligible for vaccination; children aged 5-11 years became eligible shortly thereafter. Data were thematically analysed in NVivo. RESULTS: Most parents intended on vaccinating their children once eligible. Parents sought to protect their children, to protect the community, to resume travel, and to get back to "normal". They reflected that vaccination against key infectious threats is a routine activity in childhood. Some were concerned about the vaccine, particularly mRNA vaccines, being new technology or impacting fertility. "Wait-awhiles" wanted to see what other parents would do or were delaying until they felt that there was a higher risk of COVID-19 in WA. Most parents of younger children wanted their child to be vaccinated at the general practice clinic due to familiarity and convenience. Parents were particularly eager for clear and consistent messaging about vaccination of children and adolescents, including safety, importance, scientific evidence, and personal stories. CONCLUSION: For future pandemic vaccinations pertaining to children, governments and health officials need to address parents' concerns and meet their preferences for the delivery of the vaccine program to children and adolescents.

Eliminating nonmedical exemptions: a radical shift in how childhood vaccine mandates govern.

INTRODUCTION: Every state in the US has had school vaccine mandates for decades, and all except West Virginia and Mississippi offered nonmedical exemptions (NMEs) in addition to medical exemptions. Several states recently eliminated NMEs, and others have attempted to do so. These efforts are transforming America's immunization governance. AREAS COVERED: What we call the 'mandates & exemptions' regime of vaccination policy from the 1960s and 1970s functioned to orient parents toward vaccination, but did not coerce or punish them for not vaccinating. The article identifies how policy tweaks in the 2000s - including education requirements and other bureaucratic burdens - delivered enhancements to the 'mandates & exemptions' regime. Finally, the paper illustrates how the recent elimination of NMEs, first in California and then in other states, represents a radical transformation of America's vaccine mandates. EXPERT OPINION: Today's 'unencumbered vaccine mandates' (mandates without exemptions) directly govern and punish non-vaccination, unlike the 'mandates & exemption' regime that aimed to make it harder for parents to avoid vaccination. This kind of policy change introduces new problems for implementation and enforcement, especially within America's underfunded public health system, and in the context of post-COVID public health political conflicts.

Antibiotics online: digital pharmacy marketplaces and pastiche medicine.

The internet enables access to information and the purchasing of medical products of various quality and legality. Research and regulatory attention have focused on the trafficking of illicit substances, potential physical harms of pharmaceuticals, and possibilities like financial fraud. However, there is far less attention paid to antibiotics and other antimicrobials used to treat infections. With online pharmacies affording greater access, caution around antibiotic use is needed due to the increasing health risks of antimicrobial resistance (AMR). The COVID-19 pandemic has helped to normalise digital healthcare and contactless prescribing, amplifying the need for caution. Little is known of how antibiotics are consumed via digital pharmacy and implications for AMR prevention. To expand insight for AMR prevention policy in Australia and internationally, we use digital ethnographic methods to explore how digital pharmacies function in the context of health advice and policy related to AMR, commonly described as antimicrobial stewardship. We find that digital pharmacy marketplaces constitute 'pastiche medicine'. They curate access to pharmaceutical and information products that emulate biomedical authority combined with emphasis on the 'self-assembly' of healthcare. Pastiche medicine empowers the consumer but borrows biomedical expertise about antibiotics, untethering these goods from critical medicine information, and from AMR prevention strategies. We reflect on the implications of pastiche medicine for AMR policy, what the antibiotics case contributes to wider critical scholarship on digital pharmacy, and how medical humanities research might consider researching online consumption in future.

'I'm provax': Pro-vaccination personal histories and socialities of older Australians in the COVID-19 pandemic.

Vaccination scholarship often explores how social networks foster vaccine refusal and delay, revealing how social and institutional relations produce refusing or delaying parents and un- or under-vaccinated children. It is likewise critical to understand the development of pro-vaccination orientations by researching those who want to be vaccinated since such attitudes and associated practices underpin successful vaccination programmes. This article explores pro-vaccination sociality, personal histories and self-understandings during the COVID-19 pandemic in Australia. We draw upon 18 in-depth interviews with older Western Australians, documenting how they articulate 'provax' identities in opposition to those they depict as 'antivax' others. Provax identities were clearly anchored in and solidified through social relations and personal histories, as interviewees spoke of 'likeminded' friends and families who facilitated each other's vaccinations and referenced childhood experiences of epidemics and vaccinations. Access barriers relating to the vaccine programme drove interviewees to reimagine their provax status in light of not yet being vaccinated. Thus, interviewees' moral and ideological understandings of themselves and others were interrelated with supply-side constraints. We examine the development of self-proclaimed 'provaxxers' (in a context of limited access); how they imagine and enact boundaries between themselves and those they deem 'antivax'; and possibilities for public health research.

'COVID Is Coming, and I'm Bloody Scared': How Adults with Co-Morbidities' Threat Perceptions of COVID-19 Shape Their Vaccination Decisions.

Adults with comorbidities have faced a high risk from COVID-19 infection. However, Western Australia experienced relatively few infections and deaths from 2020 until early 2022 compared with other OECD countries, as hard border policies allowed for wide-scale vaccination before mass infections began. This research investigated the thoughts, feelings, risk perceptions, and practices of Western Australian adults with comorbidities aged 18-60 years in regard to COVID-19 disease and COVID-19 vaccines. We conducted 14 in-depth qualitative interviews between January and April 2022, just as the disease was starting to circulate. We coded results inductively and deductively, combining the Extended Parallel Process Model (EPPM) and vaccine belief models. Non-hesitant participants believed COVID-19 vaccines were safe and effective at mitigating COVID-19's threat and subsequently got vaccinated. Vaccine hesitant participants were less convinced the disease was severe or that they were susceptible to it; they also did not consider the vaccines to be sufficiently safe. Yet, for some hesitant participants, the exogenous force of mandates prompted vaccination. This work is important to understand how people's thoughts and feelings about their comorbidities and risks from COVID-19 influence vaccine uptake and how mandatory policies can affect uptake in this cohort.

Parents' COVID-19 vaccine intentions for children under 5 years: Brief reflections from a qualitative study.

AIM: Australian authorities made COVID-19 vaccines available for children aged under 5 years old with serious comorbidities in August 2022. There is presently no universal programme for young children, but crucial to any rollout's success is whether parents are motivated and able to vaccinate. By examining parents' vaccine intentions, this study aims to inform current and future COVID-19 vaccine roll-outs for children aged under 5 years. METHODS: As part of the mixed methods project 'Coronavax: Preparing Community and Government' we interviewed 18 Western Australian parents of young children about their intentions in late 2021. RESULTS: Two thirds intended to vaccinate if and when they could, with one third intending to delay for reasons including risk and safety perceptions, fears about side effects and influence from their social networks. However, even those choosing to delay were waiting rather than refusing. CONCLUSIONS: To improve uptake, targeted messaging should emphasise that COVID-19 can be a serious disease in young children, with such messaging drawing on the reputability and esteem of scientific and technical authorities. Such messaging should be oriented towards parents of children with serious comorbidities at the present time. It will be important to emphasise that government vaccine recommendations are based on supporting families to protect their children and keep them healthy.

School staff as vaccine advocates: Perspectives on vaccine mandates and the student registration process.

Recently, several states in the US have made it more difficult to receive nonmedical exemptions to school vaccine mandates in the hope of better orienting parents towards vaccination. However, little is known about how public-facing school staff implement and enforce mandate policies, including why or how often they steer parents towards nonmedical exemptions. This study focused on Michigan, which has recently added an additional burden for families seeking nonmedical exemptions. We used an anonymous online survey to assess Michigan public-school employees (n = 157) about their knowledge, attitudes, and behaviors regarding Michigan's school enrollment vaccine mandate policy. Our main conclusions are that frontline school staff are generally knowledgeable about vaccines and immunization policy, but are at best ambivalent about their role in immunization governance, believing that other agents should be responsible for ensuring that children are vaccinated. Furthermore, some respondents indicated low vaccine confidence, which was associated with increased ambivalence about, or opposition to, their role in immunization governance. As more jurisdictions within and beyond the US consider introducing or tightening childhood vaccine mandates, it is increasingly important to understand how these policies can be improved by attending to the attitudes and roles of relevant frontline actors.

COVID-19 vaccine knowledge, attitudes, and experiences of health care workers in Perth, Western Australia: A qualitative study.

INTRODUCTION: Health care workers (HCWs) faced an increased risk of Coronavirus Disease 2019 (COVID-19). Australia's COVID-19 vaccine rollout commenced in February 2021 to priority groups, including HCWs. Given their increased risk, as well as influence on patients' vaccine uptake, it was important that HCWs had a positive COVID-19 vaccination experience, as well as trusting the vaccine safety and efficacy data. METHODS: Semi-structured interviews were undertaken with 19 public- and privately-practicing HCWs in Western Australia between February-July 2021. Data were deductively analysed using NVivo 12 and guided by the Capability-Opportunity-Motivation-Behaviour model. RESULTS: 15/19 participants had received at least one COVID-19 vaccine. Participants were highly motivated, mostly to protect themselves and to get back to "normal", but also to protect patients. Many had a heightened awareness of COVID-19 severity due hearing from colleagues working in settings more impacted than Western Australia. Participants trusted the COVID-19 vaccine development and approval process; their histories of having to accept vaccines for work helped them to see COVID-19 vaccination as no different. Many recalled initially being unsure of how and when they'd be able to access the vaccine. Once they had this knowledge, half had difficulties with the booking process, and some were unable to access a clinic at a convenient location or time. Participants learnt about COVID-19 vaccination through government resources, health organisations, and their workplace, but few had seen any government campaigns for the wider public. Finally, most had discussed COVID-19 vaccination with their social network. CONCLUSION: HCWs in Western Australia demonstrated good knowledge about COVID-19 vaccination, with many reasons to vaccinate themselves and support the vaccination of others. Addressing the barriers identified in this study will be important for planning to vaccinate health workforces during future pandemics.

Consolidating a research agenda for vaccine mandates.

A workshop on mandatory vaccination was pitched to the World Public Health Congress in 2019 and the resultant special issue was pitched to Vaccine in 2020. During this project, the COVID-19 pandemic pushed vaccine policy to the forefront of global public health policy, and the imposition of vaccine mandates prompted a new wave of scholarship in the field. This introductory article employs the heuristic of Lasswell's (1956) policy cycle to synthesise the findings of the articles in the special issue. It considers the temporal lifetime of mandates and highlights findings regarding: the emergence of mandates as a policy option, public support and policy instrument design, what matters in the implementation of mandates, and what we can learn from evaluating them. The second half of the paper categorizes the included papers in terms of what aspects of mandates they study and the methods they employ to do so, in order to formulate a guide for future researchers of vaccine mandates. Scholars study either speculative or existing mandates - research can address several stages of the policy cycle or just one of them, ranging from attitudinal research to implementation studies and impact studies. Historical and contextual studies that take deep dives into a particular mandate are a much needed resource for studying emerging mandates, too, and scoping and framework- building work will undoubtedly be valuable in understanding and appreciating the wealth of knowledge production in this growing field. This special issue can serve as a roadmap for a consolidation of this interdisciplinary research agenda, and provide a helpful resource for decisionmakers at this historical juncture.