Table 1.

Papers assessing knowledge, attitudes and believes towards vaccination programs.

	Country	Vaccine	Population Target	Sample	Evaluation Tool	Findings
Akmatov 2009 50	Kyrgyzstan	Childhood vaccinations	Children	Parents of first-year school children in the capital of Kyrgyzstan. N = 934	A questionnaire was developed for the purpose of the study and focused on the child’s vaccination status, attitudes and beliefs towards vaccinations, and source of information about vaccines.	15% of respondents were opposed to mandatory vaccination.
Akmatov 2018 22	Germany	Adult vaccinations	Adult population	Males and females between 15 and 69 years of age selected from the population registries. N = 1,698	Web- or paper-based questionnaire. The questionnaire on adult vaccinations was designed as a knowledge-attitude-practice (KAP) survey.	82% of the study participants supported mandatory vaccinations for specific population groups such as health care workers and 40% for all adults.
Greenberg 2017 24	Canada	Childhood vaccinations	Children 5 years old or younger	Parents with young children (5 and younger) regarding. N = 1,000	An online survey included 25 questions organized into 4 major categories: perceptions about vaccines and vaccination; views on the public debate about vaccines and vaccine-preventable disease; information seeking needs and practices, including media usage and trust in institutional sources; and communication strategies	44% agreed that vaccination should still be a matter of parental choice (49% disagreed, and 7% were unsure). When asked whether schools and day-care facilities should refuse children who are not vaccinated, except for those with medical exemptions, approximately 65% answered this question affirmatively.
Gualano 2018 23	Italy	Childhood Vaccination	Children	Pregnant women from 15 Italian cities. N = 1,820	A non-self-compiling paper questionnaire was used during the 25-minutes interview. The questionnaire was composed of seven sections for a total of 63 items.	Most women of the sample (81.6%) declared to be in favour of mandatory vaccinations, 13.8% were against them and 4.5% did not answer to the question.
Horn 2010 26	USA	Childhood vaccination (focusing on HPV)	Children	Parents with children 9 to 17 years old. N = 325	The survey was designed to be an anonymous self-administered survey. The 53-question survey was divided into 3 sections: demographic information, opinions on vaccines in general, and attitudes about the HPV vaccine.	The majority (89%) of parents support a mandatory vaccine program for their children. A minority of parents (43%) thought the HPV vaccine should be mandatory for their children.
Karageorgou 2014 27	Greece	Vaccine Preventable Disease (VPD). As of 2013, in Greece the Ministry of Health recommends the vaccination of HCWs against the following diseases: seasonal influenza, hepatitis A, hepatitis B, measles, mumps, rubella, varicella, tetanus, diphtheria, acellular pertussis (for HCWs in contact with patients), and the tetravalent meningococcal (A,C,W135,Y) vaccine for microbiologists only.	HCWs	Students of the Faculty of Healthcare Professions, Department of Nursing and Department of Medical Laboratories. N = 165	A standardized, self-reported, anonymous paper questionnaire.	Mandatory vaccination of HCWs was supported by 96.7% of the students.
Kennedy 2005 28	USA	Childhood Vaccination	Children	Parents with children aged <18 years living in the household. N = 1,540	Data from the 2002 HealthStyles survey was used for analysis. HealthStyles is an annual, mail panel survey of adults in the contiguous United States, as well as the District of Columbia	Parents who strongly agreed or agreed that children should be allowed to go to public school even if they are not vaccinated were categorized as opposed to compulsory vaccination (opposed parents). Parents who were neutral, disagreed, or strongly disagreed with the statement were considered supportive of compulsory vaccination (supportive parents). 12% of this weighted subsample was classified as opposed to compulsory vaccinations for school entry
Krok-Schoen 2018 29	USA	According to current recommendations by the Advisory Committee on Immunization Practices, adolescents should receive the tetanus, diphtheria toxoid, acellular pertussis, meningococcal vaccine, and human papillomavirus (HPV) vaccine at 11–12 years old.	Children	Parents of girls aged 9–17 from 12 counties in rural Ohio Appalachia enrolled in the Community Awareness, Resources and Education Project. N = 337	Telephone survey. During the initial phone call, the study was described, questions were answered, informed consent was obtained, and the baseline survey was administered. To assess beliefs about mandatory school vaccinations, participants were asked to respond to the statement, “Parents should have the right to refuse vaccines that are required for school for any reason.”	47% agreed with the statement that parents should have the right to refuse vaccines that are required for schools for any reason.
Kubli 2017 30	USA	Hepatitis B, influenza, measles, mumps, rubella (MMR), varicella, tetanus, diphtheria, pertussis (Tdap), meningococcal and human papilloma virus (HPV)	General Population	First year pharmacy students at the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. N = 85	A pre- and post-immunization course questionnaire. The questionnaire had forty-eight items.	The proportion of students believing immunizations should be a personal choice, not mandatory, did not change significantly from prior to taking the course (41.5%) and following the course (37.4%, p = 0.5572).
Little 2015 31	United Kingdom	Occupational Vaccination (annual flu and MMR)	HCWs	Clinical and non-clinical staff from eight randomly selected wards. N = 133	The survey comprised of twelve questions, eleven required simple multiple choice tick box responses and one required numerical ranking.	 70% supported the routine use of compulsory vaccination for staff working with vulnerable patients.
Macintosh 2014 32	USA	Occupational Vaccination (annual flu and MMR)	School Employees	A convenience sample of school district employees was invited to participate in the study. Both full- and part-time individuals employed by the rural school district were eligible. N = 835	The questionnaire was two pages and included 10 yes/no, 7 multiple choice, 2 open-ended, and 7 demographic questions.	Of those who responded about their beliefs regarding vaccination mandates for all school employees, 24.2% replied “no,” although almost half of participants believed school employees should have mandatory vaccination requirements. Another 30.1% were undecided about vaccination mandates for school employees.
Maltezou 2012 33	Greece	VPD: Completed and up-to-date vaccination was defined as follows: one shot for rubella, two shots for measles, mumps, varicella, or hepatitis A, and three shots for hepatitis B (all shots within the appropriate time schedule for each disease), and one booster shot against tetanus-diphtheria within the last 10 years.	HCWs	HCWs regardless of demographic or professional characteristics in four tertiary-care hospitals. N = 505	A standardized printed form to assess demographic and professional data, knowledge about recommended vaccines, attitudes towards mandatory vaccinations, and self-reported immunity against vaccine-preventable diseases.	63% stated that vaccination should be mandatory in general for all HCWs indiscriminately compared to 100% who stated that vaccination should be mandatory for HCWs who care for immunocompromised patients. Acceptance of a mandatory policy ranged significantly per disease, from 10.6% for mumps to 85.6% for hepatitis B.
Maltezou 2013 34	Greece	Mandatory occupational vaccinations. In Greece, the Ministry of Health recommends annual vaccination of all HCWs against hepatitis B and seasonal influenza and vaccination of paediatricians and infectious disease specialists against hepatitis A.	HCWs	HCWs were defined as all persons employed in a health care facility with or without involvement in direct patient care and regardless of employment status. They were selected in 185 primary health care centres in Greece. N = 2,055	A standardized, self-answered, anonymous questionnaire. The questionnaire elicited demographic and professional data, data on immunity against vaccine-preventable diseases, knowledge regarding recommended vaccines, and attitudes regarding mandatory vaccination for HCWs.	65.1% indicated that vaccinations should be mandatory; acceptance rates of mandatory vaccination differed by disease, ranging from 12.8% for pertussis to 87.3% for hepatitis B
Martinelli 2015 35	Italy	Mandatory childhood vaccination: diphtheria, tetanus, polio and hepatitis B.	Children	Family paediatrician working in Puglia. N = 502	A standardised, ad hoc and piloted phone questionnaire. The questionnaire included demographic and job information (gender, age, duration of professional career, number of children cared) and opinion on mandatory vaccinations.	14.3% would agree with the hypothesis of abrogation of mandatory vaccination.
Nicolay 2008 36	France	Adult Vaccination	General population	French population aged between 18 and 79 years. N = 4,112. General practitioners and paediatricians working or living in continental France. N = 1,285 General Practitioners and 742 paediatricians	National telephone survey. Two different questionnaires were administered by experienced interviewers. Common topics included immunization, practices and perceptions related to infectious risk in general, nosocomial infections, travellers’ tropical diseases, hygiene, hepatitis and zoonosis; the practitioners’ questionnaire also include questions on their patients’ perceptions. Eighteen questions referred either directly or indirectly to immunization in the practitioner questionnaire, and 16 in the general population questionnaire.	56.5% of the general population is in favour of mandatory vaccination. The percentage of GPs and paediatricians in favour of mandatory immunization is 42%.
Pelullo 2014 37	Italy	Mandatory childhood vaccination: diphtheria, tetanus, polio and hepatitis B.	Children	One parent of each child brought for the first, second or third dose of the hexavalent vaccine. When both parents were present at the centre, the workers interviewed only the mother. N = 1,039	A questionnaire was developed, aiming to investigate parents’ vaccination intentions.	955 (91.9%) stated that they would certainly (n = 721; 69.4%) or probably (n = 234; 22.5%) vaccinate their children if vaccination were not mandatory. On the other hand, 84 parents (8.1%) stated that they would certainly (n = 30; 2.9%) or probably not (n = 35; 3.4%) vaccinate their children or that they did not know what they would do (n = 19; 1.8%).
Perkins 2010 38	USA	HPV and Childhood vaccination	Vaccine-eligible girls aged 11–18 years	Parents or legal guardians of vaccine-eligible girls aged 11–18 years. N = 73	Interviews. Interview guides were designed to elicit demographic information, parental intention to vaccinate against HPV, and parents’ opinions about mandating routine childhood vaccines and HPV vaccine.	97.3% supported mandating childhood vaccinations for school entry.
Rebmann 2016 39	USA	A staff mandatory vaccination policy was defined as a policy requiring all staff except those with a medical contraindication to receive all Centers for Disease Control and Prevention (CDC) recommended vaccines.	Staff from children day-care agencies	Parents of children in day-care and childcare agency staff in the St Louis city and county region. In all, 23 childcare agencies assisted with subject recruitment. N = 354	The questionnaire was available online and in paper format. The questionnaire assessed attitudes regarding a proposed staff mandatory vaccination policy and/or agency certification program, including which exemptions should be allowed (18 items); perceptions related to staff vaccination (2 items); immunization status related to pertussis, hepatitis A, and seasonal influenza vaccine (3 items); and agency vaccine exemption policies (5 items).	80.0% reported that they would support a staff mandatory vaccination policy, and all groups (parents, staff, and administrators) were equally likely to support such a policy
Riccò 2017 40	Italy	Tetanus	Agricultural Workers	The target population included Aws. The sampling was performed through convenience, involving all consecutive participants to qualification courses and focusing on the occupational use of pesticides. The following excluding criteria were applied: an inadequate ability to understand the Italian language and age < 18 years. N = 707	The instrument used was a specifically designed structured questionnaire including a total of 22 items divided into four areas of inquiry: (1) Information about the interviewee. (2) Knowledge about vaccines. (3) Attitudes. (4) Practices	Attitude towards tetanus vaccination was somehow favourable in 79.5% of participants, and 72.7% correctly identified tetanus vaccination as mandatory for Agricultural Workers.
Seale 2009 41	Australia	Mandatory Occupational Vaccination. Vaccines encompassed within the directive include measles–mumps–rubella vaccine (MMR), varicella, hepatitis B vaccine, and diphtheria–tetanus- (acellular) pertussis vaccine (Tdap).	HCWs	Four groups were surveyed: Medical (staff specialists, registrars, medical students), Nursing (registered nurses, nurse unit managers, and enrolled nurses), Allied Health Personnel (physiotherapists, occupational therapists, psychologists) and Ancillary staff (domestic services, administration, computer specialists). N = 1,079	6 page survey that assessed: (1) demographic characteristics, professional designation; (2) awareness and understanding of the policy directive; (3) knowledge of specific vaccine inclusion; and (4) level/reasons for support/opposition. 894 paper survey were collected and further 185 questionnaires were submitted electronically.	After a brief description of the policy directive, 78% of staff supported it, 13.0% neither supported nor opposed it and 3.6% of staff opposed the directive. Only one ancillary staff member stated that they opposed the directive.
Seale 2011 42	Australia	Mandatory Occupational Vaccination. Vaccines encompassed within the directive include measles–mumps–rubella vaccine (MMR), varicella, hepatitis B vaccine, and diphtheria–tetanus- (acellular) pertussis vaccine (Tdap).	HCWs	10 wards from the original 40 (which had been included in Seale 2009) to contact for this second study, which included all the high risk wards (intensive care, neonatal, and emergency). The survey was sent to every staff member on the ward. N = 256	An anonymous self-completed paper-based questionnaire. We developed a four page survey that assessed (1) demographic characteristics and professional designation; (2) awareness and understanding of the policy directive; (3) level/reasons for support/opposition of the directive and how it was implemented; and (4) reasons for support/opposition for the possible inclusion of the influenza vaccine in the directive.	Eighty-five percent of respondents stated they were aware of a policy about staff vaccination. There was a significant change between the two surveys in regards to this question (OR: 0.27, 95%CI: 0.18–0.41, p = <0.001). The majority of respondents supported the directive, while four staff members were opposed to it. There was a significant increase in the number of respondents who supported the policy between the two surveys (OR: 0.47, 95% CI: 0.25–0.90, p = 0.01).
Tafuri 2009 43	Italy	Mandatory childhood vaccination: diphtheria, tetanus, polio and hepatitis B.	Children	All the employees of the Apulian Vaccination Services immediately before each employee began a 10-day training course on the updated management system of the vaccination registers. N = 302	A self-administered anonymous questionnaire. It reported demographic information, occupation, length of service in the vaccine clinic, the opinion on mandatory vaccination, the procedures for calling the parents to the clinic for the primary appointment and for the issuing of subsequent reminders, the conduct of the health worker when faced with parents who refuse vaccination for their child, and the importance the health worker gave to the computerisation of the vaccination registers.	Of those questioned, 4.4% (95% CI = 2–6.7) thought that mandatory vaccination should be abolished now, 21.2% (95% CI = 16.6–25.9) that it should be abolished gradually, while the majority of respondents, 74.4% (95% CI = 69.4–79.4), declared that it should be retained. The opinion that mandatory vaccination should be abolished was held by a higher proportion of doctors than by other health staff.

KAP: Kwnoledge, attitudes and practice; HPV: Human Papilloma Virus; VPD: Vaccine Preventable Disease; HCWs: Healthcare Workers; MMR: measles, mumps, rubella; Tdap: tetanus, diphtheria, pertussis; Aws: Agricultural Workers;