Vaccine 41 (2023) 7103–7115
Available online 17 October 20230264-410X/© 2023 Elsevier Ltd. All rights reserved.
U.S. public support and opposition to vaccination mandates in K-12
education in light of the COVID-19 pandemic
Simon F. Haeder
Department of Health Policy & Management, School of Public Health, Texas A&M University, TAMU 1266, 212 Adriance Lab Rd, College Station, TX 77843, United
States
A R T I C L E I N F O
Keywords:
Vaccines
Vaccination mandates
Vaccination uptake
A B S T R A C T
Background: Vaccination mandates have long been an effective tool in increasing vaccination rates and reducing
the potential for disease outbreaks. In the wake of COVID-19, opposition to mandates in the K-12 setting has
garnered more attention, and policymakers opposed to them have become more active. This study sought to
assess whether these efforts are supported by the U.S. public.
Methods: We fielded a large, national survey (N ˆ 16,461) from January to April of 2022 to assess U.S. public
opinion about seven specific vaccination mandates (diphtheria, tetanus, & pertussis (DTaP); polio; chickenpox;
measles, mumps, and rubella (MMR); hepatitis; human papillomavirus (HPV); and COVID-19) in K-12 educa-
tional settings.
Results: We found that Americans are overwhelmingly supportive of all vaccination mandates with support
ranging from a high 90 percent of respondents for DTaP, polio, chickenpox, and MMR to a low of 68 percent for
COVID-19. Individuals who deemed vaccines safe and important, those with trust in the National Institutes of
Health and the Food and Drug Administration, urban residents, and ethnic and racial minorities tended to be
consistently more supportive. Perceptions about vaccine effectiveness were positively associated with mandate
support in most cases, as was trust in medical doctors. Respondents who believed that vaccines cause autism,
those with better health and more trust in religious leaders tended to be consistently more opposed. Women were
generally more supportive of mandates except for HPV and COVID-19. Ideology and partisanship affected
opinion for COVID-19 as did trust in the Centers for Disease Control and Prevention. We found no effects for
income or education.
Conclusion: Vaccination mandates in K-12 have broad support among the American public, even in more
controversial cases such as HPV and COVID-19. Vocal opposition and growing interest by policymakers to limit
or undo vaccination mandates are not supported by the broader public.
1. Introduction
Vaccinations have been one of public health’s biggest achievement
[1]. However, the availability of a vaccine is not necessarily accompa-
nied by the widespread inoculation of target populations. This has
become painfully apparent in the wake of the COVID-19 pandemic [2,3].
Yet even before, growing rates of vaccination hesitancy had been
observed worldwide [4–7]. From a public health perspective, high
vaccination rates nonetheless remain an important goal because of the
reduced human and financial costs associated with widespread vacci-
nation adoption [1]. While several policy tools have the potential to
achieve this goal [8–10], vaccination requirements in educational set-
tings, also referred to as mandates, have proven to be particularly
effective [10–14]. Vaccination requirements are a particularly impor-
tant tool because adolescents have fewer preventive visits and are
generally hard to connect to preventive services like vaccinations [15].
Moreover, mandates may counteract growing vaccination hesitancy
[4–7]. Importantly, the benefits of increased vaccination rates may offer
important externalities in the form of lowering overall community
deaths [16], and here especially among seniors [17]. While K-12
educational settings have been the primary focus of policymakers’
attention, more limited mandates have also been implemented in day-
cares, colleges and universities, as well as certain workplace settings
[13,18–20].
Despite their proven effectiveness, states have long differed sub-
stantially on the extent that they choose to deploy this tool, as well as
E-mail address: sfhaeder@tamu.edu.
Contents lists available at ScienceDirect
Vaccine
journal homepage: www.elsevier.com/locate/vaccine
https://doi.org/10.1016/j.vaccine.2023.10.016
Received 25 May 2023; Received in revised form 6 October 2023; Accepted 7 October 2023
Vaccine 41 (2023) 7103–7115
7104
how forcefully they enforce it [21]. Reasons for this hesitancy can often
be found in policymakers’ reticence to interfere with parental rights in
addition to concerns about political backlash [11,21–23]. Even when
adopted, states often offer parents a way to circumvent the mandate
through medical, religious, or even philosophical exemptions [24,25].
However, controversies about vaccination requirements in schools have
intensified in the wake of the COVID-19 pandemic [10]. With anti-
vaccine sentiment on the rise, there are growing concerns that hesi-
tancy among both parents and policymakers related to COVID-19 vac-
cines may spillover into debates about other vaccination requirements
that have often been in place for a long time [26,27]. At least anec-
dotally, opposition among the general public has been on the rise
[28,29]. Moreover, policymakers have introduced more than 1,200 bills
in state legislatures to limit or eliminate vaccination mandates [30]. Are
these sentiments truly representational of the broader U.S. public? And
to do they apply to vaccination requirements across the board?
The analyses here seek to assess whether policymakers, and vocal
parents pushing for the reduction or elimination of vaccination man-
dates, are indeed representative of the broader American public. To do
so, we provide the first comprehensive assessment of U.S. public opinion
as related to vaccination requirements for seven vaccines in the K-12
setting as the U.S. emerges from the COVID-19 pandemic: diphtheria,
tetanus, & pertussis; polio; chickenpox; measles, mumps, and rubella;
hepatitis; human papillomavirus (HPV); and COVID-19. Below, we next
describe both data and methods. We then present the broad general
findings from the assessment of the seven vaccination mandates, as well
as indices combining the mandates, before exploring which particular
demographics were associated with opposition or support for vaccina-
tion mandates. Lastly, we offer some broader policy implications.
2. Material and methods
2.1. Data
In order to assess U.S. public opinion on K-12 vaccination re-
quirements, we developed an original survey that was administered
through Qualtrics. Respondents were recruited from Lucid’s large, on-
line, opt-in panel that is considered to be of high quality [31,32]. Lucid
provides incentives based on the amount of effort required and the
population being sampled. Overall, 53,517 individuals initiated the
survey, and 16,461 respondents completed it from January to April of
2022. To ensure data quality, three standard attention checks were
employed; these attention checks were the primary driver of respondent
attrition. Data were close to important national population benchmarks
on gender, race, income, and education (see Appendix). However, to
further improve fit we used weights based on the most recent version of
the U.S. Census Current Population Survey (see Appendix). This study
was determined to be exempt by the appropriate institutional review
board.
2.2. Methodological approach
Our analyses here used two major approaches. First, to assess and
compare overall support for the various vaccination requirements, we
utilized standard t tests. Second, to assess correlates of support and
opposition to the various vaccination mandates, we relied on ordinary
least squares (OLS) regression. This approach was appropriate here
because we were interested in the average support for vaccination
mandates. OLS results are also relatively straightforward in interpreta-
tion and allows for better comparison across the various models [33]. As
mentioned previously, data were weighted to improve the fit slightly.
Weighted and unweighted results closely resemble each other. Lastly,
we also estimated generalized ordered logit models for each vaccination
requirement [34]. These results were in line with the OLS estimates.
Because OLS results are much easier to interpret, especially with a large
number of regressions, we only present the OLS results here. Analyses
were conducted in Stata 17 and Stata 18.
2.3. Measures
2.3.1. Outcome measures
The main dependent variables for this analysis were derived from
answers to a number of analogous questions about respondents’ support
for various vaccination mandates for K-12 students. Importantly, we
asked respondents whether they thought that “K-12 students should be
required to be fully vaccinated against the following diseases to be
allowed to attend school.” We then asked them in random order about
requirements for vaccines against diphtheria, tetanus, & pertussis; polio;
chickenpox; measles, mumps, and rubella; hepatitis; human papillo-
mavirus (HPV); and COVID-19. For each disease, respondents where
offered a 4-point scale with options for “Definitely not,” “Probably not,”
“Probably yes,” and “Definitely yes.” We also generate a 13-point index
of the most commonly required vaccinations (diphtheria, tetanus, &
pertussis; polio; chickenpox; measles, mumps, and rubella) [25] and a
22-point index combining all seven mandates.
2.3.2. Explanatory measures
In order to assess correlates of support and opposition for various K-
12 vaccination mandates, we used a wide range of explanatory measures
consistent with the appropriate literatures. First, we included the
traditional three items that captures respondents attitudes toward vac-
cines [3] by asking respondents whether they deem vaccines safe,
effective, and important (4-point scales for each item). We also
measured respondents’ trust for various institutions including the
president, Congress, religious leaders, the Centers for Diseases Control
and Prevention (CDC), the National Institutes of Health (NIH), the Food
and Drug Administration (FDA), scientists, and medical doctors (4-point
scales for each item) [3]. Ideology has been a crucial factor shaping
perceptions towards vaccines [3,35–37]. We thus collected standard
information about respondents’ ideology using the traditional 7-point
scale with three options for liberals (Extreme Liberal, Liberal, Slight
Liberal), three options for conservatives (Extreme Conservative, Con-
servative, Slight Conservative), and one neutral option (Moderate;
Middle of the Road). Alternatively, we also created indicator variables
combining the three liberal options and the three conservative options,
respectively, with the neutral options as the omitted category. We also
include respondents level of education [6,38,39] as a 5-point scale (High
School Graduation or less, Some College, or College Graduation, with
graduate education serving as the reference category), income as a 6-
point scale [6,40], a dichotomous measure for female respondents
[41], whether underage children were living in the household [6], re-
spondents’ self-rated health status (a 5-point scale from poor to excel-
lent), and age, as well as its squared term to allow for non-linear effects
[42,43]. There is evidence that Americans from rural areas may be
particularly hesitant to vaccinate [44]. To determine whether re-
spondents lived in rural America, we asked respondents to self-
categorized into urban, suburban, or rural settings (we exclude subur-
ban as the reference category). Lastly, race and ethnicity may also play
important roles in shaping public opinion about vaccines [40]. Hence,
we included indicators for White, Asian, Black or Hispanic respondents.
3. Results
3.1. Overall support for vaccination requirements
As a first step, we analyzed overall support for vaccination mandates
for the 4-item index of the most commonly required vaccinations and
the 7-item index. Both items indicated high overall levels of support for
vaccination mandates. The 4-item index had a mean of 10.97 (95 % CI:
10.91–11.02) and the 7-item index had a mean of 17.40 (17.29–17.50).
At the individual mandate level, Fig. 1 displays the distribution of re-
sponses for the 7 distinct vaccine requirements. As already apparent
S.F. Haeder
Vaccine 41 (2023) 7103–7115
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from the index, Americans overwhelmingly supported vaccination re-
quirements for all seven mandates, with mean levels of support ranging
from a low of 2.98 for COVID-19 (95 % CI: 2.95–3.00) to a high of 3.54
for MMR (3.53–3.56) on a 4-point scale. Put differently, at least 2 in 3
Americans support requirements for each of the vaccines. Second, even
within these broad levels of support, Americans are clearly more in favor
of certain vaccine requirements than others (differences statistically
significant at p < 0.001). Support was particularly high for DTaP, polio,
chickenpox, and MMR. As mentioned above, these are the most
commonly required vaccination [25]. There was a slight drop for hep-
atitis vaccination requirements compared to previous four mandates,
and a more distinct reduction in support for HPV and COVID-19. Put
differently, roughly 90 percent of respondents supported vaccination
mandates for the four vaccines, dropping to 84 percent for hepatitis, 75
percent for HPV, and 68 percent for COVID-19. At the same time, the
strong opposition of 17 percent of respondents with regard to COVID-19
was also noteworthy.
3.2. State-level support for vaccination requirements
Next, we derived state-level estimates for vaccine mandate support.
The results for the 4-item index of mandates are displayed graphically in
Figs. 2 and 3. We also marked states in Fig. 2 by their support for Donald
Trump or Joseph Biden in the 2020 presidential election. Support
ranged from 11.67 (95 % CI: 11.37–11.97) in Maryland and 11.58 in
Nebraska (11.09–12.08) to 10.09 in North Dakota (8.20–11.98) and
10.09 in Montana (8.43–11.75), with Hawaii as the median (10.97,
10.14–11.81). States with the lowest levels of support were dispropor-
tionately Republican. Importantly, two states that have traditionally
been strict with regard to vaccination mandates, West Virginia and
Mississippi, ranked at the bottom of support. For the 7-item index (see
Appendix), support ranged from a high of 18.70 in Maryland
(18.10–19.31) and 18.46 in New York (18.11–18.80) to a low of 15.37 in
Wyoming (13.01–17.73) and 15.21 in Alaska (12.80–17.63), with a
median of 17.26 in New Mexico (15.97–18.55). West Virginia and
Mississippi, again, were in the bottom third. We also estimated state-
Fig. 1. Distribution of Support for Various Vaccination Mandates.
Fig. 2. State-level Support for Vaccination Mandates (4-item Index) Notes: Point estimates displayed with 95 % confidence bounds. Red columns indicate states
who voted for Donald Trump in the 2020 presidential election. Blue columns indicate states who voted for Joseph Biden in the 2020 presidential election. Range of
the index is 1 to 13. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
S.F. Haeder
Vaccine 41 (2023) 7103–7115
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level support across the 7 individual mandates. These findings were
relative consistent for all mandates (see Appendix). However, once
more, public opinion towards COVID-19 mandates stood out (see Fig. 4).
Unlike other mandates, point estimates showed consistent differences
between low and high support states. Estimates ranged from a high of
3.33 in New York (3.26–3.40) and 3.30 in Maryland (3.16–3.45) to a low
of 2.39 in Alaska (1.93–2.84) and 2.31 in Wyoming (1.76–2.86), with a
median of 2.94 in Oregon (2.76–3.12). Moreover, there were consistent
partisan patterns, with Republican states disproportionate at the bottom
and Democratic states at the top.
3.3. Correlates of support and opposition to vaccination requirements
While Americans were overwhelmingly supportive of vaccination
requirements in the K-12 settings, it is important to explore the distinct
correlates of support and opposition. First, we again assessed the 4-item
and 7-item indices (Table 1.) support was higher for individuals who
consider vaccines as safe (0.382, p-value < 0.001 & 0.907, p-value <
0.001), effective (0.257, p-value ˆ 0.001 & 0.291, p-value ˆ 0.019), and
important (1.023, p-value < 0.001 & 1.704, p-value < 0.001) while
support was lower for individuals who associated vaccines with autism
( 0.159, p-value < 0.001 & 0.298, p-value < 0.001). Trust in health
institutions was also a positive correlate of support including in the FDA
(0.169, p-value < 0.001 & 0.309, p-value < 0.001) and in the NIH
(0.202, p-value < 0.001 & 0.400, p-value < 0.001). Trust in the CDC was
statistically significant only for the 7-item index (0.443, p-value <
0.001), as was support for President Trump ( 0.655, p-value < 0.001)
and conservatism ( 0.259, p-value-0.032). Trust in doctors was only
significant in the 4-item index (0.213, p-value < 0.001). Trust in reli-
gious leaders was negatively associated with support ( 0.110, p-value
Fig. 3. State-level Support for Vaccination Mandates (4-item Index) Notes: Data breaks determined by ARCGIS Pro using national breaks (Jenks). Range of the
index is 1 to 13.
Fig. 4. State-level Support for COVID-19 Vaccination Mandate Notes: Point estimates displayed with 95 % confidence bounds. Red columns indicate states who
voted for Donald Trump in the 2020 presidential election. Blue columns indicate states who voted for Joseph Biden in the 2020 presidential election. Range of the
index is 1 to 13. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
S.F. Haeder
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Table 1
Correlates of support and opposition vaccination mandates.
(1) (2) (3) (4) (5) (6) (7) (8)
4-Item Index 7-Item Index
Trump Voter 0.141 0.245** 0.150 0.251** 0.655*** 0.853*** 0.656*** 0.851***
(0.076) (0.006) (0.062) (0.005) (0.000) (0.000) (0.000) (0.000)
Liberal 0.062 0.357*** 0.161 0.682***
(0.294) (0.000) (0.103) (0.000)
Conservative 0.027 0.004 0.259* 0.216
(0.705) (0.961) (0.032) (0.111)
Extremely Liberal 0.173* 0.561*** 0.491*** 1.187***
(0.025) (0.000) (0.000) (0.000)
Liberal 0.059 0.345*** 0.149 0.648***
(0.411) (0.000) (0.217) (0.000)
Slightly Liberal 0.030 0.216** 0.059 0.378**
(0.698) (0.010) (0.653) (0.008)
Slightly Conservative 0.095 0.031 0.271 0.162
(0.296) (0.757) (0.069) (0.326)
Conservative 0.095 0.055 0.438** 0.364*
(0.317) (0.603) (0.005) (0.040)
Extremely Conservative 0.220 0.116 0.099 0.078
(0.078) (0.402) (0.626) (0.730)
Vaccine Cause Autism 0.159*** 0.167*** 0.285*** 0.298***
(0.000) (0.000) (0.000) (0.000)
Vaccines Are Safe 0.382*** 0.376*** 0.907*** 0.894***
(0.000) (0.000) (0.000) (0.000)
Vaccines Are Effective 0.257*** 0.255*** 0.291* 0.287*
(0.001) (0.001) (0.019) (0.021)
Vaccines Are Important 1.023*** 1.028*** 1.697*** 1.704***
(0.000) (0.000) (0.000) (0.000)
Underage Children in Household 0.019 0.110 0.020 0.110 0.020 0.252* 0.023 0.256*
(0.769) (0.118) (0.756) (0.118) (0.847) (0.031) (0.824) (0.027)
Rural Resident 0.061 0.076 0.056 0.082 0.041 0.206 0.031 0.217
(0.323) (0.273) (0.366) (0.236) (0.683) (0.076) (0.758) (0.061)
Urban Resident 0.210*** 0.077 0.196** 0.062 0.462*** 0.221 0.430*** 0.187
(0.001) (0.251) (0.002) (0.361) (0.000) (0.051) (0.000) (0.101)
Health Level 0.094*** 0.122*** 0.100*** 0.128*** 0.177*** 0.222*** 0.187*** 0.231***
(0.001) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in Congress 0.101** 0.252*** 0.105** 0.256*** 0.150* 0.412*** 0.158* 0.421***
(0.009) (0.000) (0.007) (0.000) (0.019) (0.000) (0.013) (0.000)
Trust in President 0.052 0.004 0.056 0.001 0.099 0.188** 0.090 0.180**
(0.148) (0.920) (0.118) (0.987) (0.104) (0.007) (0.140) (0.009)
Trust in Religious Leader 0.110** 0.176*** 0.111** 0.175*** 0.216*** 0.325*** 0.212*** 0.319***
(0.001) (0.000) (0.001) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in Science 0.067 0.379*** 0.062 0.372*** 0.132 0.674*** 0.121 0.658***
(0.177) (0.000) (0.206) (0.000) (0.105) (0.000) (0.135) (0.000)
Trust in Doctors 0.213*** 0.444*** 0.209*** 0.442*** 0.151 0.561*** 0.145 0.559***
(0.000) (0.000) (0.000) (0.000) (0.051) (0.000) (0.060) (0.000)
Trust in CDC 0.068 0.303*** 0.069 0.301*** 0.443*** 0.856*** 0.448*** 0.855***
(0.138) (0.000) (0.130) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in NIH 0.202*** 0.291*** 0.207*** 0.295*** 0.400*** 0.543*** 0.407*** 0.548***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in FDA 0.169*** 0.253*** 0.172*** 0.255*** 0.309*** 0.469*** 0.313*** 0.471***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Religiosity 0.008 0.043* 0.011 0.044* 0.019 0.081* 0.023 0.082*
(0.677) (0.049) (0.570) (0.045) (0.572) (0.027) (0.495) (0.027)
Age 0.022** 0.028** 0.022* 0.028** 0.007 0.018 0.008 0.019
(0.010) (0.003) (0.010) (0.002) (0.604) (0.263) (0.586) (0.230)
Age Squared 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000
(0.126) (0.514) (0.135) (0.503) (0.669) (0.251) (0.662) (0.266)
Female 0.280*** 0.385*** 0.285*** 0.390*** 0.028 0.202* 0.040 0.213*
(0.000) (0.000) (0.000) (0.000) (0.733) (0.029) (0.628) (0.021)
High School or Less 0.126 0.149 0.118 0.153 0.352* 0.120 0.346* 0.119
(0.142) (0.118) (0.165) (0.107) (0.012) (0.448) (0.013) (0.453)
Some College 0.044 0.018 0.034 0.023 0.165 0.053 0.157 0.055
(0.555) (0.827) (0.646) (0.781) (0.176) (0.699) (0.195) (0.689)
College Graduate 0.055 0.022 0.062 0.029 0.033 0.019 0.039 0.014
(0.455) (0.782) (0.397) (0.716) (0.785) (0.887) (0.746) (0.920)
$15 to $24,999 0.070 0.098 0.067 0.095 0.074 0.113 0.064 0.102
(0.553) (0.440) (0.569) (0.456) (0.707) (0.594) (0.745) (0.630)
$25 to $34,999 0.055 0.023 0.055 0.022 0.193 0.057 0.196 0.063
(0.626) (0.852) (0.626) (0.857) (0.298) (0.784) (0.288) (0.763)
$35 to $49,999 0.031 0.182 0.032 0.184 0.093 0.261 0.095 0.263
(0.769) (0.108) (0.763) (0.105) (0.595) (0.167) (0.587) (0.163)
$50 to $74,999 0.016 0.254* 0.012 0.260* 0.184 0.277 0.178 0.286
(0.877) (0.024) (0.910) (0.020) (0.286) (0.147) (0.299) (0.133)
$75,000 and over 0.013 0.341** 0.017 0.346** 0.056 0.510** 0.052 0.517**
(continued on next page)
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ˆ 0.001 & 0.216, p-value < 0.001), but we found no such effect for
religiosity. Higher levels of health ( 0.094, p-value ˆ 0.001 & 0.177,
p-value < 0.001) were correlated with lower levels of support, as was
trust in Congress ( 0.101, p-value ˆ 0.009 & 0.150, p-value ˆ 0.019),
while urban respondents were more supportive (0.210, p-value ˆ 0.001
& 0.462, p-value < 0.001), as were Blacks (0.358, p-value ˆ 0.002 &
0.629, p-value ˆ 0.005) and Hispanics (0.430, p-value ˆ 0.002 & 0.820,
p-value < 0.001).
As a robustness check, we re-estimated the models excluding the four
variables assessing general attitudes towards vaccines (whether vaccines
safe, effective, and important, and whether they can cause autism).
Findings were generally consistent, but liberalism became a significant
predictor for both indices (0.357, p-value < 0.001 & 0.682, p-value <
0.001), while support for President Trump became a stronger predictor
( 0.245, p-value ˆ 0.006 & 0.854, p-value < 0.001). At the same time,
conservatism was no longer statistically significant. We also re-
estimated the models in both specifications replacing the dichotomous
indicators for ideology with the 7-point scale. Differences became
apparent for extreme liberals for the 4-item index (0.173, p-value ˆ
0.025 & 0.561, p-value < 0.001) and the 7-item index (0.491, p-value <
0.001 & 1.187, p-value < 0.001). Results were again analogous across
the other variables.
The results for the seven distinct vaccinations mandates are pre-
sented in Table 2. Findings were in line with the results presented for the
two indices. First, respondents who believed that vaccines were safe
(0.091–0.212, p-values < 0.001) and those who thought that vaccine
were important (0.207–0.268, p-values < 0.001) were consistently more
supportive of vaccination requirements. Belief in vaccine effectiveness
only correlated with mandate support in four cases (DTaP, polio,
chickenpox, and MMR, 0.052–0.076, p-values < 0.019); we found no
effect for hepatitis, HPV, or COVID-19. Substantively, these effects were
also consistently some of the largest predictors of support. Analogously,
we found that individuals who believed that vaccines cause autisms
were consistently opposed to vaccination requirements (0.031–0.048, p-
values < 0.002), with the exception of HPV.
Trust in institutions also proofed to be an important correlate. Spe-
cifically, trust in public health and medical institutions was associated
with stronger mandate support. These results were consistently signifi-
cant for both the FDA (0.030–0.059, p-values < 0.037) and the NIH
(0.039–0.071, p-values < 0.005), and, in four cases, for the CDC
(0.035–0.217, p-values < 0.009). Trust in the CDC was a particularly
strong predictor for support for COVID-19 vaccination mandates. Simi-
larly, trust in medical doctors was positively associated with support for
mandates in four cases (DTaP, polio, chickenpox, and MMR,
0.040–0.064, p-values < 0.005). Interestingly, the effect reversed for
COVID-19 ( 0.079, p-value < 0.001). Trust in scientists, however,
generally had no effect, with the exception of polio (0.038, p-value ˆ
0.001). In four cases, we found negative effects for trust in Congress
(polio chickenpox, MMR, and hepatitis, 0.024- 0.030, p-values <
0.038) but positive effects for those with higher trust in the president
with regard to HPV (0.031, p-value ˆ 0.020) and COVID-19 (0.129, p-
value < 0.001). Trust in religious leaders was consistently associated
with lower support for vaccination mandates ( 0.023- 0.048, p-
values < 0.024).
When it comes to politics and ideology, our findings were mixed.
Conservatism was only statistically significant for mandates for HPV
( 0.064, p-value ˆ 0.011) and COVID-19 ( 0.144, p-value < 0.001)
vaccinations, while in the case of liberalism this held only for COVID-19
(0.094, p-value < 0.001). The effects were relatively substantial for both
ends of the ideological spectrum with regard to COVID-19, however. At
the same time, respondents who voted for President Trump were
generally more opposed to mandates (0.046–0.245, p-values < 0.036),
with the exception of polio and MMR. Again, effects were substantial
when it comes to COVID-19 ( 0.245, p-value < 0.001). COVID-19
mandates also stood out with regard to urban and rural differences:
rural respondents were more likely to be opposed to COVID-19 vacci-
nation mandates ( 0.068, p-value ˆ 0.002) while urban residents were
more supportive (0.082, p-value < 0.001). Urban residents were also
more supportive of mandates in general (0.061–0.129, p-values <
0.003), with the exception of MMR. Similarly, we found effects for
COVID-19 mandates for parents with children in the household,
reducing support for a mandate ( 0.115, p-value < 0.001). We found
the opposite effect for hepatitis (0.058, p-value ˆ 0.003). Women were
generally more supportive of vaccination mandates (0.036–0.110, p-
values < 0.016), but held a more negative view for mandates related to
HPV ( 0.139, p-value < 0.001) and COVID-19 ( 0.126, p-value <
0.001). In addition, better health was consistently associated with
greater opposition to vaccination mandates ( 0.020- 0.035, p-values
< 0.032). Support for mandates tended to be inconsistent for increases in
age, and curvilinear. With regard to race and ethnicity, we found that
support for mandates was generally higher among Black (0.124, p-value
ˆ 0.005), Asian (0.181, p-value-0.001), and Hispanic respondents
(0.149, p-value-0.001). Lastly, we found no effect for religiosity and
only very limited effects for income and education.
Again, to assess the robustness of our results, we re-estimated the 7
models (Table 2) excluding the four variables assessing general attitudes
towards vaccines (whether vaccines safe, effective, and important, and
whether they can cause autism). Results in terms of statistical signifi-
cance and substantive effects are generally consistent. However, some
ideological and political variables became consistently significant across
the models. That is, liberals were consistently more supportive of all
mandates (0.067–0.179, p-values < 0.005). We did not find the
Table 1 (continued )
(1) (2) (3) (4) (5) (6) (7) (8)
4-Item Index 7-Item Index
(0.898) (0.002) (0.871) (0.002) (0.740) (0.006) (0.758) (0.005)
White 0.139 0.222 0.134 0.223 0.186 0.351 0.183 0.358
(0.246) (0.097) (0.265) (0.096) (0.319) (0.101) (0.327) (0.094)
Black 0.358* 0.121 0.371** 0.137 0.629** 0.226 0.656** 0.259
(0.010) (0.433) (0.008) (0.377) (0.005) (0.370) (0.003) (0.305)
Asian 0.075 0.318 0.090 0.343 0.394 0.851** 0.430 0.903**
(0.634) (0.073) (0.570) (0.053) (0.133) (0.004) (0.102) (0.002)
Hispanic 0.430** 0.487** 0.449** 0.510** 0.820*** 0.958*** 0.855*** 1.000***
(0.002) (0.002) (0.001) (0.001) (0.000) (0.000) (0.000) (0.000)
Constant 3.350*** 5.688*** 3.430*** 5.725*** 4.507*** 8.488*** 4.627*** 8.532***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Observations 15,851 15,948 15,838 15,935 15,700 15,795 15,687 15,782
R-squared 0.346 0.198 0.346 0.199 0.427 0.281 0.428 0.282
All results based on OLS regressions with weights.
p values in parentheses.
*** p < 0.001, ** p < 0.01, * p < 0.05.
“Moderate” is the omitted category for respondent ideology.
S.F. Haeder
Vaccine41(2023)7103–7115
7109
Table 2
Correlates of Support and Opposition to Various Vaccination Mandates.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
VARIABLES DTaP Polio Chickenpox MMR Hepatitis HPV COVID-19
Trump Voter 0.046* 0.073** 0.012 0.038 0.056* 0.084*** 0.027 0.057* 0.110*** 0.140*** 0.144*** 0.174*** 0.245*** 0.284***
(0.035) (0.003) (0.596) (0.126) (0.016) (0.001) (0.203) (0.017) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Liberal 0.016 0.092*** 0.025 0.099*** 0.014 0.083*** 0.002 0.077*** 0.000 0.071*** 0.006 0.067** 0.094*** 0.179***
(0.365) (0.000) (0.145) (0.000) (0.419) (0.000) (0.887) (0.000) (0.984) (0.001) (0.783) (0.004) (0.000) (0.000)
Conservative 0.006 0.002 0.021 0.013 0.004 0.010 0.010 0.003 0.031 0.024 0.064* 0.054* 0.144*** 0.140***
(0.785) (0.942) (0.332) (0.582) (0.835) (0.649) (0.616) (0.895) (0.188) (0.334) (0.011) (0.038) (0.000) (0.000)
Vaccine Cause Autism 0.048*** 0.031** 0.033*** 0.044*** 0.035** 0.014 0.076***
(0.000) (0.001) (0.001) (0.000) (0.001) (0.232) (0.000)
Vaccines Are Safe 0.091*** 0.099*** 0.093*** 0.098*** 0.135*** 0.153*** 0.212***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Vaccines Are Effective 0.076*** 0.075*** 0.052* 0.056** 0.032 0.004 0.013
(0.001) (0.001) (0.018) (0.010) (0.168) (0.873) (0.611)
Vaccines Are Important 0.254*** 0.251*** 0.249*** 0.268*** 0.243*** 0.207*** 0.229***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Underage Children in
Household
0.004 0.033 0.013 0.020 0.000 0.029 0.000 0.033 0.058** 0.025 0.004 0.023 0.115*** 0.161***
(0.847) (0.099) (0.470) (0.299) (0.990) (0.139) (0.995) (0.079) (0.003) (0.234) (0.862) (0.312) (0.000) (0.000)
Rural Resident 0.031 0.004 0.017 0.016 0.000 0.033 0.018 0.018 0.036 0.001 0.022 0.008 0.068** 0.111***
(0.081) (0.822) (0.327) (0.416) (0.981) (0.096) (0.274) (0.331) (0.067) (0.954) (0.308) (0.738) (0.002) (0.000)
Urban Resident 0.066*** 0.032 0.061*** 0.031 0.062*** 0.031 0.022 0.013 0.062** 0.029 0.129*** 0.103*** 0.082*** 0.036
(0.000) (0.104) (0.001) (0.104) (0.001) (0.106) (0.190) (0.473) (0.002) (0.174) (0.000) (0.000) (0.000) (0.120)
Health Level 0.021** 0.029*** 0.020** 0.028*** 0.029*** 0.036*** 0.024** 0.031*** 0.026** 0.033*** 0.035*** 0.039*** 0.020* 0.027**
(0.009) (0.001) (0.008) (0.001) (0.000) (0.000) (0.001) (0.000) (0.002) (0.000) (0.000) (0.000) (0.031) (0.008)
Trust in Congress 0.018 0.058*** 0.028* 0.066*** 0.024* 0.059*** 0.030** 0.068*** 0.027* 0.063*** 0.002 0.031* 0.004 0.049**
(0.116) (0.000) (0.014) (0.000) (0.037) (0.000) (0.004) (0.000) (0.037) (0.000) (0.913) (0.037) (0.795) (0.001)
Trust in President 0.010 0.005 0.020 0.005 0.003 0.015 0.022* 0.007 0.001 0.014 0.031* 0.042** 0.129*** 0.145***
(0.362) (0.682) (0.062) (0.655) (0.796) (0.184) (0.022) (0.489) (0.930) (0.288) (0.020) (0.003) (0.000) (0.000)
Trust in Religious Leader 0.033** 0.051*** 0.026* 0.042*** 0.023* 0.036*** 0.031** 0.047*** 0.032** 0.046*** 0.034** 0.044*** 0.048*** 0.066***
(0.001) (0.000) (0.012) (0.000) (0.023) (0.001) (0.001) (0.000) (0.005) (0.000) (0.005) (0.000) (0.000) (0.000)
Trust in Science 0.020 0.099*** 0.038* 0.115*** 0.000 0.072*** 0.010 0.089*** 0.015 0.089*** 0.024 0.087*** 0.028 0.115***
(0.200) (0.000) (0.014) (0.000) (0.997) (0.000) (0.435) (0.000) (0.342) (0.000) (0.153) (0.000) (0.100) (0.000)
Trust in Doctors 0.040** 0.102*** 0.048*** 0.108*** 0.064*** 0.118*** 0.061*** 0.120*** 0.021 0.080*** 0.006 0.054** 0.079*** 0.008
(0.004) (0.000) (0.001) (0.000) (0.000) (0.000) (0.000) (0.000) (0.169) (0.000) (0.735) (0.002) (0.000) (0.660)
Trust in CDC 0.008 0.068*** 0.007 0.065*** 0.035** 0.092*** 0.013 0.073*** 0.048** 0.106*** 0.095*** 0.146*** 0.217*** 0.283***
(0.546) (0.000) (0.625) (0.000) (0.008) (0.000) (0.314) (0.000) (0.002) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in NIH 0.070*** 0.092*** 0.043** 0.067*** 0.039** 0.060*** 0.046*** 0.070*** 0.060*** 0.081*** 0.060*** 0.077*** 0.071*** 0.095***
(0.000) (0.000) (0.004) (0.000) (0.004) (0.000) (0.001) (0.000) (0.000) (0.000) (0.001) (0.000) (0.000) (0.000)
Trust in FDA 0.030* 0.053*** 0.033* 0.054*** 0.059*** 0.078*** 0.050*** 0.070*** 0.054*** 0.075*** 0.054*** 0.074*** 0.036* 0.062***
(0.025) (0.000) (0.017) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.001) (0.000) (0.036) (0.000)
Religiosity 0.001 0.010 0.004 0.012 0.002 0.010 0.001 0.010 0.010 0.019** 0.008 0.015* 0.007 0.005
(0.831) (0.105) (0.530) (0.054) (0.746) (0.094) (0.892) (0.087) (0.118) (0.007) (0.280) (0.043) (0.293) (0.500)
Age 0.011*** 0.012*** 0.007** 0.009*** 0.001 0.000 0.007** 0.008** 0.005 0.006* 0.012*** 0.010** 0.007* 0.006
(0.000) (0.000) (0.004) (0.001) (0.661) (0.852) (0.005) (0.001) (0.100) (0.039) (0.000) (0.002) (0.031) (0.054)
Age Squared 0.000*** 0.000** 0.000 0.000 0.000 0.000* 0.000* 0.000 0.000* 0.000 0.000*** 0.000*** 0.000*** 0.000***
(0.000) (0.009) (0.063) (0.223) (0.090) (0.032) (0.022) (0.164) (0.046) (0.176) (0.000) (0.000) (0.000) (0.000)
Female 0.110*** 0.137*** 0.071*** 0.096*** 0.036* 0.061*** 0.065*** 0.093*** 0.015 0.040* 0.139*** 0.119*** 0.126*** 0.094***
(0.000) (0.000) (0.000) (0.000) (0.015) (0.000) (0.000) (0.000) (0.362) (0.019) (0.000) (0.000) (0.000) (0.000)
High School or Less 0.004 0.075** 0.016 0.054* 0.070** 0.004 0.027 0.042 0.073** 0.008 0.161*** 0.106** 0.007 0.088**
(0.888) (0.006) (0.500) (0.039) (0.006) (0.875) (0.241) (0.098) (0.009) (0.789) (0.000) (0.002) (0.811) (0.006)
Some College 0.008 0.024 0.003 0.018 0.031 0.015 0.010 0.006 0.052* 0.037 0.092** 0.080** 0.023 0.048
(0.706) (0.307) (0.899) (0.433) (0.172) (0.534) (0.627) (0.798) (0.037) (0.162) (0.001) (0.007) (0.358) (0.078)
College Graduate 0.004 0.005 0.036 0.028 0.014 0.007 0.012 0.002 0.011 0.001 0.014 0.021 0.020 0.027
(continued on next page)
S.F. H
aeder
Vaccine41(2023)7103–7115
7110
Table 2 (continued )
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
VARIABLES DTaP Polio Chickenpox MMR Hepatitis HPV COVID-19
(0.838) (0.838) (0.096) (0.227) (0.539) (0.780) (0.561) (0.931) (0.655) (0.960) (0.638) (0.472) (0.424) (0.314)
$15 to $24,999 0.020 0.028 0.023 0.032 0.014 0.006 0.010 0.016 0.022 0.013 0.021 0.017 0.023 0.034
(0.543) (0.423) (0.481) (0.362) (0.653) (0.854) (0.751) (0.632) (0.533) (0.721) (0.575) (0.655) (0.578) (0.420)
$25 to $34,999 0.003 0.016 0.021 0.000 0.041 0.024 0.020 0.001 0.052 0.031 0.102** 0.084* 0.003 0.031
(0.926) (0.641) (0.527) (0.999) (0.185) (0.479) (0.510) (0.982) (0.125) (0.394) (0.005) (0.024) (0.945) (0.461)
$35 to $49,999 0.011 0.043 0.010 0.044 0.031 0.018 0.012 0.041 0.028 0.024 0.078* 0.036 0.023 0.084*
(0.712) (0.186) (0.729) (0.169) (0.293) (0.559) (0.676) (0.176) (0.366) (0.458) (0.020) (0.291) (0.524) (0.029)
$50 to $74,999 0.013 0.056 0.005 0.074* 0.032 0.030 0.013 0.055 0.051 0.015 0.126*** 0.074* 0.016 0.061
(0.660) (0.084) (0.857) (0.019) (0.270) (0.334) (0.635) (0.069) (0.106) (0.659) (0.000) (0.039) (0.647) (0.118)
$75,000 and over 0.000 0.083** 0.020 0.103*** 0.026 0.052 0.012 0.072* 0.019 0.063 0.101** 0.033 0.038 0.135***
(0.992) (0.009) (0.489) (0.001) (0.358) (0.085) (0.658) (0.016) (0.553) (0.057) (0.003) (0.350) (0.305) (0.001)
White 0.054 0.076* 0.025 0.044 0.017 0.039 0.020 0.046 0.019 0.009 0.002 0.026 0.026 0.055
(0.103) (0.038) (0.438) (0.213) (0.617) (0.292) (0.544) (0.205) (0.591) (0.808) (0.954) (0.516) (0.479) (0.170)
Black 0.066 0.008 0.064 0.001 0.105** 0.052 0.096* 0.042 0.079 0.027 0.058 0.013 0.124** 0.056
(0.096) (0.851) (0.097) (0.983) (0.008) (0.226) (0.013) (0.327) (0.057) (0.545) (0.206) (0.789) (0.005) (0.243)
Asian 0.029 0.033 0.010 0.063 0.045 0.100* 0.025 0.087 0.020 0.080 0.062 0.116* 0.181*** 0.250***
(0.561) (0.549) (0.823) (0.215) (0.353) (0.048) (0.561) (0.061) (0.706) (0.152) (0.265) (0.047) (0.001) (0.000)
Hispanic 0.106** 0.120** 0.100** 0.110** 0.114** 0.132** 0.088* 0.111** 0.080 0.105* 0.128** 0.150** 0.149*** 0.176***
(0.007) (0.005) (0.009) (0.008) (0.005) (0.002) (0.019) (0.008) (0.051) (0.017) (0.005) (0.002) (0.001) (0.000)
Constant 1.424*** 1.996*** 1.562*** 2.181*** 1.707*** 2.271*** 1.702*** 2.281*** 1.604*** 2.172*** 1.739*** 2.276*** 0.842*** 1.399***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Observations 16,016 16,116 16,008 16,108 16,022 16,119 16,004 16,104 16,004 16,103 16,026 16,125 16,009 16,108
R-squared 0.298 0.175 0.286 0.161 0.277 0.171 0.308 0.166 0.256 0.159 0.253 0.194 0.489 0.411
All results based on OLS regressions with weights.
p values in parentheses.
*** p < 0.001, ** p < 0.01, * p < 0.05.
S.F. H
aeder
Vaccine41(2023)7103–7115
7111
Table 3
Correlates of Support and Opposition to Various Vaccination Mandates, Alternative Specification.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
DTaP Polio Chickenpox MMR Hepatitis HPV COVID-19
Trump Voter 0.048* 0.074** 0.012 0.038 0.061** 0.088*** 0.030 0.059* 0.108*** 0.138*** 0.140*** 0.170*** 0.243*** 0.280***
(0.030) (0.002) (0.597) (0.135) (0.010) (0.001) (0.168) (0.015) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Extremely Liberal 0.052* 0.150*** 0.029 0.128*** 0.069** 0.161*** 0.013 0.110*** 0.037 0.134*** 0.101** 0.184*** 0.179*** 0.291***
(0.028) (0.000) (0.229) (0.000) (0.003) (0.000) (0.582) (0.000) (0.176) (0.000) (0.001) (0.000) (0.000) (0.000)
Liberal 0.010 0.084*** 0.038 0.108*** 0.005 0.070** 0.001 0.073*** 0.003 0.065* 0.004 0.061* 0.092*** 0.172***
(0.633) (0.000) (0.069) (0.000) (0.819) (0.002) (0.971) (0.001) (0.899) (0.011) (0.889) (0.037) (0.000) (0.000)
Slightly Liberal 0.009 0.055* 0.003 0.065** 0.017 0.040 0.006 0.056* 0.021 0.038 0.052 0.002 0.044 0.115***
(0.685) (0.028) (0.901) (0.008) (0.499) (0.120) (0.799) (0.016) (0.433) (0.165) (0.094) (0.957) (0.127) (0.000)
Slightly Conservative 0.031 0.013 0.024 0.006 0.020 0.006 0.025 0.008 0.019 0.004 0.045 0.030 0.115*** 0.097**
(0.234) (0.634) (0.362) (0.844) (0.447) (0.832) (0.303) (0.760) (0.510) (0.891) (0.150) (0.355) (0.000) (0.004)
Conservative 0.034 0.022 0.051 0.039 0.002 0.012 0.016 0.005 0.073* 0.061 0.113*** 0.099** 0.163*** 0.153***
(0.226) (0.464) (0.073) (0.194) (0.932) (0.673) (0.516) (0.851) (0.018) (0.063) (0.000) (0.004) (0.000) (0.000)
Extremely Conservative 0.095** 0.069 0.038 0.016 0.051 0.028 0.030 0.006 0.031 0.008 0.004 0.021 0.168*** 0.204***
(0.005) (0.062) (0.289) (0.668) (0.142) (0.461) (0.354) (0.863) (0.426) (0.851) (0.931) (0.626) (0.000) (0.000)
Vaccine Cause Autism 0.051*** 0.032** 0.035*** 0.045*** 0.037*** 0.017 0.076***
(0.000) (0.001) (0.000) (0.000) (0.001) (0.157) (0.000)
Vaccines Are Safe 0.091*** 0.097*** 0.090*** 0.096*** 0.132*** 0.151*** 0.210***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Vaccines Are Effective 0.072*** 0.075*** 0.052* 0.057** 0.033 0.002 0.013
(0.001) (0.001) (0.016) (0.008) (0.160) (0.935) (0.629)
Vaccines Are Important 0.256*** 0.253*** 0.250*** 0.268*** 0.244*** 0.208*** 0.229***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Underage Children in
Household
0.003 0.034 0.014 0.020 0.001 0.029 0.000 0.033 0.057** 0.024 0.002 0.026 0.116*** 0.161***
(0.882) (0.086) (0.445) (0.312) (0.965) (0.143) (0.977) (0.083) (0.004) (0.249) (0.939) (0.264) (0.000) (0.000)
Rural Resident 0.029 0.006 0.017 0.017 0.001 0.035 0.017 0.019 0.035 0.000 0.020 0.010 0.069** 0.112***
(0.096) (0.751) (0.348) (0.387) (0.942) (0.078) (0.302) (0.300) (0.073) (0.996) (0.354) (0.665) (0.002) (0.000)
Urban Resident 0.061** 0.025 0.059** 0.029 0.058** 0.026 0.021 0.015 0.058** 0.024 0.120*** 0.093*** 0.077*** 0.031
(0.001) (0.195) (0.001) (0.136) (0.001) (0.172) (0.224) (0.418) (0.004) (0.257) (0.000) (0.000) (0.000) (0.173)
Health Level 0.023** 0.031*** 0.022** 0.029*** 0.031*** 0.037*** 0.024** 0.031*** 0.027** 0.034*** 0.037*** 0.041*** 0.021* 0.027**
(0.003) (0.000) (0.005) (0.001) (0.000) (0.000) (0.001) (0.000) (0.002) (0.000) (0.000) (0.000) (0.030) (0.008)
Trust in Congress 0.020 0.060*** 0.028* 0.067*** 0.025* 0.060*** 0.030** 0.069*** 0.028* 0.064*** 0.004 0.033* 0.004 0.049**
(0.084) (0.000) (0.013) (0.000) (0.028) (0.000) (0.004) (0.000) (0.032) (0.000) (0.800) (0.025) (0.757) (0.001)
Trust in President 0.011 0.004 0.022* 0.007 0.002 0.015 0.023* 0.008 0.001 0.012 0.029* 0.040** 0.128*** 0.145***
(0.331) (0.712) (0.042) (0.556) (0.835) (0.194) (0.016) (0.435) (0.942) (0.354) (0.031) (0.005) (0.000) (0.000)
Trust in Religious Leader 0.032** 0.050*** 0.026* 0.042*** 0.023* 0.036*** 0.032*** 0.047*** 0.031** 0.046*** 0.032** 0.042*** 0.046*** 0.064***
(0.001) (0.000) (0.010) (0.000) (0.021) (0.001) (0.001) (0.000) (0.006) (0.000) (0.008) (0.001) (0.000) (0.000)
Trust in Science 0.018 0.097*** 0.037* 0.113*** 0.001 0.070*** 0.010 0.088*** 0.014 0.088*** 0.021 0.084*** 0.025 0.111***
(0.238) (0.000) (0.017) (0.000) (0.926) (0.000) (0.439) (0.000) (0.376) (0.000) (0.202) (0.000) (0.133) (0.000)
Trust in Doctors 0.039** 0.101*** 0.047*** 0.108*** 0.063*** 0.117*** 0.060*** 0.120*** 0.020 0.079*** 0.005 0.054** 0.078*** 0.007
(0.005) (0.000) (0.001) (0.000) (0.000) (0.000) (0.000) (0.000) (0.187) (0.000) (0.769) (0.002) (0.000) (0.677)
Trust in CDC 0.009 0.068*** 0.007 0.064*** 0.035** 0.091*** 0.013 0.073*** 0.049** 0.107*** 0.097*** 0.147*** 0.217*** 0.282***
(0.492) (0.000) (0.648) (0.000) (0.007) (0.000) (0.304) (0.000) (0.002) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in NIH 0.072*** 0.094*** 0.045** 0.068*** 0.040** 0.061*** 0.047*** 0.070*** 0.060*** 0.081*** 0.061*** 0.078*** 0.072*** 0.095***
(0.000) (0.000) (0.003) (0.000) (0.003) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Trust in FDA 0.031* 0.053*** 0.034* 0.055*** 0.059*** 0.078*** 0.051*** 0.071*** 0.054*** 0.076*** 0.055*** 0.074*** 0.035* 0.061***
(0.020) (0.000) (0.014) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.001) (0.000) (0.038) (0.001)
Religiosity 0.003 0.011 0.004 0.012 0.003 0.011 0.001 0.010 0.011 0.019** 0.008 0.015* 0.008 0.004
(0.631) (0.074) (0.495) (0.059) (0.653) (0.085) (0.826) (0.091) (0.103) (0.007) (0.239) (0.039) (0.264) (0.620)
Age 0.011*** 0.012*** 0.007** 0.009*** 0.001 0.001 0.007** 0.008** 0.005 0.006* 0.012*** 0.010** 0.006* 0.006
(0.000) (0.000) (0.004) (0.001) (0.692) (0.785) (0.005) (0.001) (0.096) (0.034) (0.000) (0.002) (0.041) (0.078)
Age Squared 0.000*** 0.000* 0.000 0.000 0.000 0.000* 0.000* 0.000 0.000* 0.000 0.000*** 0.000*** 0.000*** 0.000***
(continued on next page)
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Table 3 (continued )
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
DTaP Polio Chickenpox MMR Hepatitis HPV COVID-19
(0.001) (0.010) (0.067) (0.217) (0.091) (0.036) (0.023) (0.157) (0.048) (0.169) (0.000) (0.000) (0.000) (0.000)
Female 0.113*** 0.140*** 0.071*** 0.096*** 0.037* 0.063*** 0.065*** 0.093*** 0.017 0.042* 0.135*** 0.116*** 0.124*** 0.093***
(0.000) (0.000) (0.000) (0.000) (0.012) (0.000) (0.000) (0.000) (0.304) (0.015) (0.000) (0.000) (0.000) (0.000)
High School or Less 0.009 0.079** 0.014 0.055* 0.069** 0.004 0.027 0.040 0.073** 0.009 0.162*** 0.107** 0.005 0.084**
(0.721) (0.004) (0.550) (0.035) (0.007) (0.871) (0.232) (0.110) (0.009) (0.758) (0.000) (0.001) (0.871) (0.009)
Some College 0.013 0.028 0.005 0.019 0.029 0.015 0.009 0.005 0.051* 0.037 0.093** 0.082** 0.020 0.043
(0.542) (0.234) (0.799) (0.399) (0.196) (0.545) (0.662) (0.813) (0.040) (0.155) (0.001) (0.006) (0.423) (0.113)
College Graduate 0.008 0.002 0.038 0.030 0.016 0.009 0.012 0.002 0.011 0.001 0.014 0.022 0.021 0.028
(0.720) (0.946) (0.078) (0.196) (0.484) (0.720) (0.557) (0.927) (0.657) (0.968) (0.619) (0.453) (0.408) (0.299)
$15 to $24,999 0.019 0.027 0.023 0.031 0.016 0.008 0.009 0.016 0.024 0.016 0.023 0.020 0.020 0.031
(0.566) (0.443) (0.483) (0.365) (0.620) (0.817) (0.769) (0.646) (0.491) (0.673) (0.524) (0.601) (0.621) (0.458)
$25 to $34,999 0.003 0.016 0.020 0.001 0.042 0.025 0.020 0.001 0.053 0.032 0.103** 0.086* 0.004 0.029
(0.915) (0.652) (0.544) (0.985) (0.176) (0.458) (0.513) (0.982) (0.118) (0.377) (0.004) (0.022) (0.914) (0.491)
$35 to $49,999 0.012 0.042 0.010 0.045 0.031 0.018 0.012 0.042 0.029 0.024 0.078* 0.036 0.023 0.084*
(0.682) (0.191) (0.729) (0.162) (0.291) (0.552) (0.682) (0.166) (0.346) (0.464) (0.020) (0.291) (0.520) (0.028)
$50 to $74,999 0.014 0.056 0.007 0.076* 0.030 0.032 0.012 0.057 0.051 0.016 0.126*** 0.073* 0.016 0.061
(0.640) (0.084) (0.810) (0.016) (0.292) (0.300) (0.679) (0.057) (0.109) (0.634) (0.000) (0.039) (0.655) (0.114)
$75,000 and over 0.000 0.084** 0.022 0.104*** 0.025 0.053 0.012 0.073* 0.019 0.064 0.101** 0.032 0.038 0.135***
(0.994) (0.008) (0.464) (0.001) (0.375) (0.077) (0.672) (0.014) (0.542) (0.055) (0.003) (0.359) (0.301) (0.000)
White 0.052 0.075* 0.025 0.045 0.016 0.039 0.019 0.046 0.019 0.011 0.002 0.028 0.028 0.059
(0.121) (0.040) (0.443) (0.198) (0.649) (0.294) (0.568) (0.201) (0.591) (0.776) (0.948) (0.494) (0.446) (0.141)
Black 0.069 0.011 0.068 0.006 0.108** 0.056 0.099* 0.045 0.085* 0.033 0.063 0.019 0.126** 0.060
(0.086) (0.802) (0.076) (0.888) (0.007) (0.195) (0.011) (0.287) (0.042) (0.457) (0.169) (0.696) (0.004) (0.214)
Asian 0.026 0.040 0.013 0.068 0.051 0.108* 0.026 0.092* 0.024 0.088 0.072 0.127* 0.189*** 0.260***
(0.613) (0.473) (0.782) (0.180) (0.296) (0.033) (0.532) (0.050) (0.642) (0.118) (0.199) (0.029) (0.000) (0.000)
Hispanic 0.112** 0.127** 0.105** 0.115** 0.119** 0.137** 0.090* 0.114** 0.085* 0.111* 0.136** 0.158*** 0.152*** 0.181***
(0.004) (0.003) (0.006) (0.005) (0.003) (0.001) (0.017) (0.006) (0.037) (0.011) (0.003) (0.001) (0.001) (0.000)
Constant 1.459*** 2.016*** 1.575*** 2.186*** 1.728*** 2.281*** 1.712*** 2.283*** 1.617*** 2.174*** 1.761*** 2.284*** 0.843*** 1.388***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Observations 16,003 16,103 15,995 16,095 16,009 16,106 15,991 16,091 15,991 16,090 16,013 16,112 15,996 16,095
R-squared 0.300 0.176 0.286 0.161 0.277 0.171 0.308 0.166 0.256 0.160 0.254 0.195 0.490 0.413
All results based on OLS regressions with weights.
p values in parentheses.
*** p < 0.001, ** p < 0.01, * p < 0.05, p < 0.10.
“Moderate” is the omitted category for respondent ideology.
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analogous effect among conservatives, indicating that conservatives did
not differ from moderates, with the exception of HPV ( 0.054, p-value
ˆ 0.038) and COVID-19 ( 0.140, p-value < 0.001). Lastly, we re-
estimated both types of models utilizing the full 7-point ideology scale
to parse out the potentially nuanced connection between ideology and
support for mandates (see Table 3). Across both specifications, but
particularly in the alternative specification without variables assessing
general attitudes towards vaccines, extreme liberals stand out as
particularly supportive of mandates (0.110–0.291, p-values < 0.001).
To a lesser degree, the same applies to liberals (0.061–0.172, p-values <
0.038). Once again, COVID-19 serves as an exception as liberalism and
conservative are consistent and strong indicators of support and oppo-
sition across all levels.
To further illustrate the effects of some of the important predictors of
support, we estimated three ideal types for the two indices and each of
the seven mandates using our original specifications. That is, we esti-
mated the predicted level of support of the mandates for a respondent
with “low support,” an individual who voted for Donald Trump, who
thought that vaccines could definitely cause autism, who thought vac-
cines were not all safe, effective, or important, lived outside an urban
area, was conservative, in excellent health, and had low trusts in doc-
tors, the NIH, the CDC, and the FDA. Conversely, we estimated the
predicted levels of support for an individual with the opposite charac-
teristics. We also estimated an ideal type at the mean of the data to
provide a reference point. The results are presented in Fig. 5. Clear
differences are apparent between the low and high supporter for both
indices and the seven individual mandates (p ˆ 0.000). With the
exception of HPV and COVID-19 the “high supporter” was close to the
highest level of support possible. “Low supporter” showed a bit more
diversity and alternated between 1.5 and 2.2 (on a 4-point scale).
However, “low supporters” dropped even further when it comes to
mandates for COVID-19 vaccinations. We note that the high-support
ideal type was consistently closer to the mean than the low-support
ideal type.
Analogously, we further illustrate the findings related to our more
nuanced analysis of the connection between ideology and support
mandates in Fig. 6. Here, we plot the predicted means for extreme lib-
erals, moderates, and extreme conservatives for the two indices and the
7 individual models with all other variables set to their means. As noted
above, differences are particularly apparent for COVID-19 as well as for
HPV.
4. Discussion
Public discourse about vaccinations and vaccination requirements
has been a political hot topic, albeit one with important public health
consequences [3,10]. Vocal opponents have stolen the proverbial spot-
light by aggressively and publicly expressing their opposition. Their
efforts have been amplified because they tend to gain significant media
attention [28,29]. Likeminded policymakers have welcomed the public
support for their opposition [29,30]. This study sought to shed light on
how prevalent anti-vaccination mandate sentiment is in the broader
American public for seven important vaccines. Importantly, it did so
with a very large, national survey that is of high quality. Overall, we
found considerable support for vaccination mandates across all seven
options presented to respondents as well as their indices. However, even
with high levels of overall important differences between the mandates
remained. Support markedly dropped, but remained high, when more
controversial vaccines were queried such as HPV, COVID-19, and, to a
lesser degree, hepatitis. Further work should explore whether this drop
in support is related to the length of time that these vaccines have been
approved or whether it is related to the type of disease. That is, re-
spondents may associate hepatitis and HPV with sexual or drug activity
and thus be less supportive. However, responses for COVID-19 partic-
ularly stood out from the remaining policies because of the importance
of political/ideological variables as well as the importance of trust in
various societal institutions. Moreover, a consistent minority of re-
spondents showed opposition to mandates of all kind. Our analyses also
indicated marked differences across the states.
The findings from these analyses are highly policy relevant. The
United States has experienced a significant drop in vaccination rates
during the pandemic, opening the door for substantial outbreaks of
preventable diseases that may inflict significant harm on individuals and
cause significant societal disruptions [45]. Increasing vaccination rates,
and thus reducing the potential for catastrophic outbreaks of diseases
like measles or mumps is an important public health priority. While
there are a number of tools available to policymakers to achieve this goal
[5,9,12,46–48], mandates have proven to be incredibly effective if
applied strictly and consistently. Moreover, they may further protect
historically underserved and marginalized populations, who struggle to
Fig. 5. Predicted Level of Support for Various Vaccine Mandates for Three Ideal Types Notes: “Low support” describes a respondent voting for Donald Trump,
who thinks that vaccines can definitely cause autism, who thinks vaccines are not all safe, effective, or important, lives outside an urban area, is conservative, in
excellent health, and has low trusts in doctors, the NIH, the CDC, and the FDA. “High support” describes a respondent with the opposite characteristics. We also
included an ideal type at the mean of the data for reference. Point estimates shown with 95 % confidence intervals.
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access medical services, and reduce health disparities [49,50]. Of
course, these efforts will not be without opposition. In most places, vocal
opponents portrayed in the news are not truly representative of the
American public. Indeed, the results presented here indicate that the
opposite is true. A silent, but overwhelming, majority of Americans
support vaccination requirements in K-12 settings. Policymakers eager
to improve public health should take these findings as encouragement
for their efforts and seek support from trusted sources like medical
providers, the NIH, and the FDA. Renewed efforts to inform the public
about the safety, necessity, and importance of vaccine are also crucial.
Moreover, the strongest form of opposition registered in our survey is
confined to <5 percent of respondents in four cases, and <9 percent in 6
cases. The only outlier is the mandate to vaccinate against COVID-19,
which saw strong opposition from 17 percent.
While the findings from this study are important, there are certain
limitations to it. First, general limitations of survey research apply. In
this case, reservations to online, opt-in panels are also relevant. More-
over, the survey is cross-sectional and thus only provides an assessment
of U.S. public opinion at one point in time. In addition, while the find-
ings are broadly representative of the U.S. as a whole, findings may not
hold for specific localities or states. There may also be a response bias
towards supporting vaccinations, overestimating public support. Some
state estimates also had large confidence bounds due to the limited
number of respondents. Lastly, we only asked respondents about seven
specific vaccination mandates. Our findings may not carry over to other
vaccines not analyzed here.
Funding
This work was supported by funding from the Interdisciplinary
Research Leaders Program, a national leadership development program
supported by the Robert Wood Johnson Foundation to equip teams of
researchers and community partners in applying research to solve real
community problems (Grant ID 76950).
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Data availability
Data will be made available on request.
Appendix A. Supplementary material
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.vaccine.2023.10.016.
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