Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates

Document Type : Original Article


Political Science and International Relations, School of Social Sciences, University of Western Australia, Perth, WA, Australia


Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion – the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle.

To better understand the drivers of enhanced vaccine mandates, a crucial issue during the coronavirus disease 2019 (COVID-19) global rollout, this article engages with four case studies assembled from qualitative analysis of semistructured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents.

The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policy-makers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers.

In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.



Commentaries Published on this Paper


  •  Vaccines, Politics and Mandates: Can We See the Forest for the Trees?; Comment on “Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates”

        Abstract | PDF


  •  Vaccine Mandates in the COVID-19 Era: Changing Paradigm or Public Health Opportunity?; Comment on “Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates”

        Abstract | PDF


  • Coercion and Its Discontents: The Promise and Peril of Increasingly Restrictive of Vaccination Mandates; Comment on “Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates”

        Abstract | PDF


  • The Importance of Mapping Determinants, Attitudes and Beliefs of Vaccine Hesitancy in the Great Challenge of Compulsory Childhood Vaccination

        Abstract | PDF



  1. Attwell K, Navin MC, Lopalco PL, Jestin C, Reiter S, Omer SB. Recent vaccine mandates in the United States, Europe and Australia: a comparative study. Vaccine. 2018;36(48):7377-7384. doi:1016/j.vaccine.2018.10.019
  2. Attwell K, M CN. Childhood vaccination mandates: scope, sanctions, severity, selectivity, and salience. Milbank Q. 2019;97(4):978-1014. doi:1111/1468-0009.12417
  3. MacDonald NE, Harmon S, Dube E, et al. Mandatory infant & childhood immunization: rationales, issues and knowledge gaps. Vaccine. 2018;36(39):5811-5818. doi:1016/j.vaccine.2018.08.042
  4. Eibner C, Nowak SA. The Effect of Eliminating the Individual Mandate Penalty and the Role of Behavioral Factors. Commonwealth Fund; 2018.
  5. Peters BG. What is so wicked about wicked problems? A conceptual analysis and a research program. Policy Soc. 2017;36(3):385-396. doi:1080/14494035.2017.1361633
  6. Head BW. Forty years of wicked problems literature: forging closer links to policy studies. Policy Soc. 2019;38(2):180-197. doi:1080/14494035.2018.1488797
  7. Bedford H, Attwell K, Danchin M, Marshall H, Corben P, Leask J. Vaccine hesitancy, refusal and access barriers: the need for clarity in terminology. Vaccine. 2018;36(44):6556-6558. doi:1016/j.vaccine.2017.08.004
  8. Lehner L, Gribi J, Hoffmann K, Paul KT, Kutalek R. Beyond the "information deficit model" - understanding vaccine-hesitant attitudes of midwives in Austria: a qualitative study. BMC Public Health. 2021;21(1):1671. doi:1186/s12889-021-11710-y
  9. McCoy CA. Adapting coercion: how three industrialized nations manufacture vaccination compliance. J Health Polit Policy Law. 2019;44(6):823-854. doi:1215/03616878-7785775
  10. Nowak GJ, Gellin BG, MacDonald NE, Butler R. Addressing vaccine hesitancy: the potential value of commercial and social marketing principles and practices. Vaccine. 2015;33(34):4204-4211. doi:1016/j.vaccine.2015.04.039
  11. Omer SB, Allen K, Chang DH, et al. Exemptions from mandatory immunization after legally mandated parental counseling. Pediatrics. 2018;141(1):e20172364. doi:1542/peds.2017-2364
  12. Jones M, Buttenheim AM, Salmon D, Omer SB. Mandatory health care provider counseling for parents led to a decline in vaccine exemptions in California. Health Aff (Millwood). 2018;37(9):1494-1502. doi:1377/hlthaff.2018.0437
  13. Elliman D, Bedford H. Should the UK introduce compulsory vaccination? Lancet. 2013;381(9876):1434-1436. doi:1016/s0140-6736(13)60907-1
  14. Holzinger K, Knill C. Causes and conditions of cross-national policy convergence. J Eur Public Policy. 2005;12(5):775-796. doi:1080/13501760500161357
  15. Stone D. Transfer agents and global networks in the ‘transnationalization’ of policy. J Eur Public Policy. 2004;11(3):545-566. doi:1080/13501760410001694291
  16. Gilardi F, Füglister K, Luyet S. Learning from others: the diffusion of hospital financing reforms in OECD countries. Comp Polit Stud. 2009;42(4):549-573. doi:1177/0010414008327428
  17. Walkinshaw E. Mandatory vaccinations: the international landscape. CMAJ. 2011;183(16):E1167-1168. doi:1503/cmaj.109-3993
  18. Griffiths U, Mekki N. Perspectives on Mandatory Childhood Vaccination. UNICEF; 2020.
  19. Vaccination Acceptance Research Network (VARN). Vaccination Acceptance Research Network, Call for Action 2020. Accessed November 10, 2020.
  20. Attwell K, Dube E, Gagneur A, Omer SB, Suggs LS, Thomson A. Vaccine acceptance: science, policy, and practice in a 'post-fact' world. Vaccine. 2019;37(5):677-682. doi:1016/j.vaccine.2018.12.014
  21. Gravagna K, Becker A, Valeris-Chacin R, et al. Global assessment of national mandatory vaccination policies and consequences of non-compliance. Vaccine. 2020;38(49):7865-7873. doi:1016/j.vaccine.2020.09.063
  22. Mohanty S, Buttenheim AM, Joyce CM, Howa AC, Salmon D, Omer SB. California's Senate Bill 277: local health jurisdictions' experiences with the elimination of nonmedical vaccine exemptions. Am J Public Health. 2019;109(1):96-101. doi:2105/ajph.2018.304768
  23. 2019 Ward JK, Colgrove J, Verger P. Why France is making eight new vaccines mandatory. Vaccine. 2018;36(14):1801-1803.
  24. Vanderslott S. Exploring the meaning of pro-vaccine activism across two countries. Soc Sci Med. 2019;222:59-66. doi:1016/j.socscimed.2018.12.033
  25. World Health Organization (WHO). Ten Threats to Global Health in 2019. Geneva: WHO; 2019.
  26. Omer SB, Peterson D, Curran EA, Hinman A, Orenstein WA. Legislative challenges to school immunization mandates, 2009-2012. JAMA. 2014;311(6):620-621. doi:1001/jama.2013.282869
  27. Vis B, Van Kersbergen K. Towards an open functional approach to welfare state change: pressures, ideas, and blame avoidance. Public Adm. 2013;91(4):840-854. doi:1111/j.1467-9299.2012.02071.x
  28. Hannah A. Rethinking the ‘open functional’ approach: ideas, problem pressure and reform in the contemporary welfare state. Public Adm. 2018;96(3):528-543. doi:1111/padm.12414
  29. Green-Pedersen C, Wilkerson J. How agenda-setting attributes shape politics: basic dilemmas, problem attention and health politics developments in Denmark and the US. J Eur Public Policy. 2006;13(7):1039-1052. doi:1080/13501760600924092
  30. Kingdon JW. Agendas, Alternatives, and Public Policies. London: Scott Foresman & Company; 1984.
  31. Weaver RK. The politics of blame avoidance. J Public Policy. 1986;6(4):371-398. doi:1017/s0143814x00004219
  32. Baumgartner FR, Jones BD. Agendas and Instability in American Politics. Chicago: University of Chicago Press; 1993.
  33. Shanahan EA, McBeth MK, Hathaway PL, Arnell RJ. Conduit or contributor? The role of media in policy change theory. Policy Sci. 2008;41(2):115. doi:1007/s11077-008-9058-y
  34. Trump Administration Reverses Health Protections for Transgender People. The Guardian. June 12, 2020.
  35. Howlett M, Cashore B. The Dependent variable problem in the study of policy change: understanding policy change as a methodological problem. J Comp Policy Anal Res Pract. 2009;11(1):33-46. doi:1080/13876980802648144
  36. Bali AS, Hannah A. Policy styles in healthcare: understanding variations in health systems. In: Howlett M, Tosun J, eds. The Routledge Handbook of Policy Styles. Abingdon: Routledge; 2021
  37. Levin K, Cashore B, Bernstein S, Auld G. Overcoming the tragedy of super wicked problems: constraining our future selves to ameliorate global climate change. Policy Sci. 2012;45(2):123-152. doi:1007/s11077-012-9151-0
  38. Baekkeskov E, Rubin O, Munkholm L, Zaman W. Antimicrobial Resistance as a Global Health Crisis. Oxford: Oxford University Press; 2020.
  39. Barnett R, Barnett P. "If you want to sit on your butts you'll get nothing!" Community activism in response to threats of rural hospital closure in southern New Zealand. Health Place. 2003;9(2):59-71. doi:1016/s1353-8292(02)00019-9
  40. Jacobs AM, Weaver RK. When policies undo themselves: self-undermining feedback as a source of policy change. Governance. 2015;28(4):441-457. doi:1111/gove.12101
  41. Mello MM, Studdert DM, Parmet WE. Shifting vaccination politics--the end of personal-belief exemptions in California. N Engl J Med. 2015;373(9):785-787. doi:1056/NEJMp1508701
  42. Capurro G, Greenberg J, Dubé E, Driedger M. Measles, moral regulation and the social construction of risk: media narratives of “anti-vaxxers” and the 2015 Disneyland outbreak. Can J Sociol. 2018;43(1):25-47.
  43. Stephenson N, Chaukra S, Katz I, Heywood A. Newspaper coverage of childhood immunisation in Australia: a lens into conflicts within public health. Crit Public Health. 2018;28(4):472-483. doi:1080/09581596.2018.1446510
  44. Court J, Carter SM, Attwell K, Leask J, Wiley K. Labels matter: use and non-use of 'anti-vax' framing in Australian media discourse 2008-2018. Soc Sci Med. 2021;291:114502. doi:1016/j.socscimed.2021.114502
  45. Przeworski A, Teune A. The Logic of Comparative Social Inquiry. New York: Wiley-Interscience; 1970.
  46. Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health. 2001;91(4):645-648. doi:2105/ajph.91.4.645
  47. Falleti TG. Process tracing of extensive and intensive processes. New Political Econ. 2016;21(5):455-462. doi:1080/13563467.2015.1135550
  48. Signorelli C, Odone A, Cella P, Iannazzo S. Childhood vaccine coverage in Italy after the new law on mandatory immunization. Ann Ig. 2018;30(4 suppl 1):1-10. doi:7416/ai.2018.2227
  49. Lévy-Bruhl D, Desenclos JC, Quelet S, Bourdillon F. Extension of French vaccination mandates: from the recommendation of the Steering Committee of the Citizen Consultation on Vaccination to the law. Euro Surveill. 2018;23(17):18-00048. doi:2807/
  50. Mohanty S, Buttenheim AM, Joyce CM, Howa AC, Salmon D, Omer SB. Experiences with medical exemptions after a change in vaccine exemption policy in California. Pediatrics. 2018;142(5):e20181051. doi:1542/peds.2018-1051
  51. Signorelli C, Odone A, Cella P, Iannazzo S, D'Ancona F, Guerra R. Infant immunization coverage in Italy (2000-2016). Ann Ist Super Sanita. 2017;53(3):231-237. doi:4415/ann_17_03_09
  52. Gualano MR, Bert F, Voglino G, et al. Attitudes towards compulsory vaccination in Italy: results from the NAVIDAD multicentre study. Vaccine. 2018;36(23):3368-3374. doi:1016/j.vaccine.2018.04.029
  53. Attwell K, Seth R, Beard F, Hendry A, Lawrence D. Financial interventions to increase vaccine coverage. Pediatrics. 2020;146(6):e20200724. doi:1542/peds.2020-0724
  54. Burioni R, Odone A, Signorelli C. Lessons from Italy's policy shift on immunization. Nature. 2018;555(7694):30. doi:1038/d41586-018-02267-9
  55. Orsi A, Butera F, Piazza MF, et al. Analysis of a 3-months measles outbreak in western Liguria, Italy: are hospital safe and healthcare workers reliable? J Infect Public Health. 2020;13(4):619-624. doi:1016/j.jiph.2019.08.016
  56. Bernadou A, Astrugue C, Méchain M, et al. Measles outbreak linked to insufficient vaccination coverage in Nouvelle-Aquitaine region, France, October 2017 to July 2018. Euro Surveill. 2018;23(30):1800373. doi:2807/
  57. Attwell K, Harper T, Rizzi M, et al. Inaction, under-reaction action and incapacity: communication breakdown in Italy's vaccination governance. Policy Sci. 2021;54:457-475. doi:1007/s11077-021-09427-1
  58. Bonanni P, Bergamini M. Factors influencing vaccine uptake in Italy. Vaccine. 2001;20 Suppl 1:S8-12. doi:1016/s0264-410x(01)00284-5
  59. Moran NE, Gainotti S, Petrini C. From compulsory to voluntary immunisation: Italy's National Vaccination Plan (2005-7) and the ethical and organisational challenges facing public health policy-makers across Europe. J Med Ethics. 2008;34(9):669-674. doi:1136/jme.2007.022343
  60. Bonanni P, Ferro A, Guerra R, et al. Vaccine coverage in Italy and assessment of the 2012-2014 National Immunization Prevention Plan. Epidemiol Prev. 2015;39(4 Suppl 1):146-158.
  61. Rizzo C, Rota MC. Vaccines and Autism: The Procedure in Trani is Closed. EpiCentro; 2016.
  62. Rizzi M, Attwell K, Casigliani V, Taylor J, Quattrone F, Lopalco P. Legitimising a ‘zombie idea’: childhood vaccines and autism–the complex tale of two judgments on vaccine injury in Italy. Int J Law Context. 2021;17(4):548-568. doi:1017/s1744552321000586
  63. Signorelli C, Odone A, Conversano M, Bonanni P. Deaths after Fluad flu vaccine and the epidemic of panic in Italy. BMJ. 2015;350:h116. doi:1136/bmj.h116
  64. Gori D, Costantino C, Odone A, et al. The impact of mandatory vaccination law in Italy on MMR coverage rates in two of the largest Italian regions (Emilia-Romagna and Sicily): an effective strategy to contrast vaccine hesitancy. Vaccines (Basel). 2020;8(1):57. doi:3390/vaccines8010057
  65. D'Ancona F, D'Amario C, Maraglino F, Rezza G, Ricciardi W, Iannazzo S. Introduction of new and reinforcement of existing compulsory vaccinations in Italy: first evaluation of the impact on vaccination coverage in 2017. Euro Surveill. 2018;23(22):1800238. doi:2807/
  66. Ministry of Health. Vaccinations: State of the Art, False Myths and Perspectives. The Key Role of Prevention. Rome: Notebooks of the Ministry of Health; 2017.
  67. Signorelli C, Iannazzo S, Odone A. The imperative of vaccination put into practice. Lancet Infect Dis. 2018;18(1):26-27. doi:1016/s1473-3099(17)30696-5
  68. Senecat A. Refusal of Vaccination: Will the penalties be Increased [translated]. Le Monde. October 31, 2017. Accessed August 13, 2020.
  69. Ward JK. Rethinking the antivaccine movement concept: a case study of public criticism of the swine flu vaccine's safety in France. Soc Sci Med. 2016;159:48-57. doi:1016/j.socscimed.2016.05.003
  70. Hurel S. Rapport Sur La Politique Vaccinale. Paris: National Assembly; 2016.
  71. Ward JK, Cafiero F, Fretigny R, Colgrove J, Seror V. France's citizen consultation on vaccination and the challenges of participatory democracy in health. Soc Sci Med. 2019;220:73-80. doi:1016/j.socscimed.2018.10.032
  72. Larson HJ, de Figueiredo A, Xiahong Z, et al. the state of vaccine confidence 2016: global insights through a 67-country survey. EBioMedicine. 2016;12:295-301. doi:1016/j.ebiom.2016.08.042
  73. Lawrence GL, MacIntyre CR, Hull BP, McIntyre PB. Effectiveness of the linkage of child care and maternity payments to childhood immunisation. Vaccine. 2004;22(17-18):2345-2350. doi:1016/j.vaccine.2003.10.038
  74. Leask J, Danchin M. Imposing penalties for vaccine rejection requires strong scrutiny. J Paediatr Child Health. 2017;53(5):439-444. doi:1111/jpc.13472
  75. National Health Performance Authority. Healthy Communities: Immunisation Rates for Children in 2011-2012. Sydney: National Health Performance Authority; 2013.
  76. Hansen J. Mullumbimby Mum Fights to Boost Immunisation Rates in Byron Shire. The Sunday Telegraph; 2013.
  77. Sturgess K. Retreating to the Church of Anti-Vaccination. Skeptical Inquirer; 2013.
  78. Hansen J. Grieving Mother Toni McCaffery Was Vilified by Anti-Vaccination Bullies. The Sunday Telegraph; 2013.
  79. Hansen J. Grieving Parents Speak Out Against Anti-Vaccination Extremists. The Sunday Telegraph; 2013.
  80. Wood A, Hansen J, van den Broek L. Big Win for No Jab, No Play as NSW State Cabinet Approves Tough New Vaccination Laws. The Daily Telegraph; 2013.
  81. Government of Australia. Childcare and Early Childhood Learning, Productivity Commission Inquiry Report. Canberra: Commonwealth of Australia; 2014.
  82. Maiden S. Vaccinate your children or forget Government rebate for daycare. The Sunday Telegraph. Accessed June 22, 2020. Published 2015.
  83. Harvey C. Anti-Vaxers, You Are Baby Killers. The Daily Telegraph; 2015.
  84. Chambers G. Risky hippie hotbeds of anti-jab agitation: Steiner schools promote choice of parents to vaccinate children. The Daily Telegraph. 2015. Accessed October 27, 2015.
  85. Maiden S. Galaxy Poll: 86 per cent of Australians want childhood vaccination to be compulsory. The Daily Telegraph. 2015. Accessed June 22, 2020.
  86. Abbott T. Prime Minister Tony Abbott announces ‘no jab, no play and no pay’ policy for child vaccination. The Daily Telegraph. March 11, 2015.
  87. Parliament of Australia. Social Services Legislation Amendment (No Jab, No Pay) Bill. Vol 158. Australia: Parliament of Australia; 2015:7.
  88. Goldstein ND, Suder JS, Purtle J. Trends and characteristics of proposed and enacted state legislation on childhood vaccination exemption, 2011-2017. Am J Public Health. 2019;109(1):102-107. doi:2105/ajph.2018.304765
  89. Worden L, Ackley SF, Zipprich J, et al. Measles transmission during a large outbreak in California. Epidemics. 2020;30:100375. doi:1016/j.epidem.2019.100375
  90. California Medical Association. Senate Bill 277 clears Senate Judiciary Committee, 29 April 2015. Accessed July 8, 2020. Published 2015
  91. California Medical Association. I Heart Immunity campaign announces new wave of support for SB 277. Accessed August 5, 2020. Published 2015.
  92. California Department of Public Health. Shots for School. Accessed November 10, 2020. Published 2020.
  93. Abram S. As Measles Cases Near 60, California Health Officials Urge Vaccination. Redlands Daily Facts; 2015.
  94. Lin R-G, II. Schools Failing to Follow Up; Administrators Are Required to Ensure Kindergartners Are Immunized. Los Angeles Times; 2015.
  95. Los Angeles Times Staff. Look Up Your California Kindergarten’s Vaccination Rate. Los Angeles Times. January 23, 2015. Accessed September 21, 2020.
  96. Rosenhall L. Parents Lobby California Lawmakers from Both Sides of Vaccine Debate. The Sacramento Bee; 2015.
  97. American Academy of Pediatrics California. SB 277 (Pan & Allen) Elimination of CA Personal Belief Exemption for School-Entry Vaccines. United States: American Academy of Pediatrics California; 2015.
  98. Milken Institute School of Public Health. Understanding the Impact of Vaccines: A Conversation with the National Public Health Information Coalition, 18 September 2015. United States: Milken Institute School of Public Health at The George Washington University; 2015.
  99. Kossef A. California Senate Sends Mandatory Vaccines Bill to Governor. The Sacramento Bee; 2015.
  100. Attwell K, Ward JK, Tomkinson S. Manufacturing consent for vaccine mandates: a comparative case study of communication campaigns in France and Australia. Front Commun. 2020;6:598602. doi:3389/fcomm.2021.598602
  101. Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest. 2017;18(3):149-207. doi:1177/1529100618760521
  102. Smith DT, Attwell K, Evers U. Majority acceptance of vaccination and mandates across the political spectrum in Australia. Politics. 2020;40(2):189-206. doi:1177/0263395719859457
  103. Larson HJ. Politics and public trust shape vaccine risk perceptions. Nat Hum Behav. 2018;2(5):316. doi:1038/s41562-018-0331-6
  104. Delamater PL, Pingali SC, Buttenheim AM, Salmon DA, Klein NP, Omer SB. Elimination of nonmedical immunization exemptions in California and school-entry vaccine status. Pediatrics. 2019;143(6). doi:1542/peds.2018-3301
  105. Corderoy A, Harrison D. Federal Budget 2015: 'No Jab, No Pay' Tipped to Save $500 Million. Sydney Monring Herald; 2015.
  106. Crenna S, Osculati A, Visonà SD. Vaccination policy in Italy: an update. J Public Health Res. 2018;7(3):1523. doi:4081/jphr.2018.1523
  107. Mahoney J. Path dependence in historical sociology. Theory Soc. 2000;29(4):507-548.
  108. Peters BG, Pierre J, King DS. The politics of path dependency: political conflict in historical institutionalism. J Polit. 2005;67(4):1275-1300. doi:1111/j.1468-2508.2005.00360.x
  109. New York State. Governor Cuomo Signs Legislation Removing Non-Medical Exemptions from School Vaccination Requirements. Accessed May 20, 2020. Published 2019.
  110. An Act to Protect Maine Children and Students from Preventable Diseases by Repealing Certain Exemptions from the Laws Governing Immunization Requirements. 154 H.P. 586 - L.D. 798 (2019).
  111. Washington State Department of Health. MMR Vaccine Exemption Law Change 2019. Accessed February 25, 2020. Published 2019.
  112. Attwell K, Rizzi M, McKenzie L, et al. COVID-19 Vaccine Mandates: An Australian Attitudinal Study. Vaccine. 2021;S0264-410X(21)01530-9. doi:1016/j.vaccine.2021.11.056
  113. Biden J Jr. President Biden's COVID-19 Plan. Washington, DC: The White House; 2021.
  114. Health Do. COVID-19 Mandatory Vaccination- Employee Restrictions on Access to Health Care Facilities - Guidelines. Published 2021.
Volume 11, Issue 11
November 2022
Pages 2660-2671
  • Receive Date: 21 June 2021
  • Revise Date: 02 February 2022
  • Accept Date: 05 February 2022
  • First Publish Date: 06 February 2022