Attitudes towards mandatory vaccinations during the COVID-19 pandemic in Bulgaria

Abstract Background Vaccinations are an essential public health strategy to control preventable diseases. A much-discussed approach to increase coverage is mandatory vaccination; however, its legitimacy and effectiveness were put to question during the COVID-19 pandemic. As of March 1,2022, Bulgaria had one of Europe's lowest immunization coverage rates against COVID-19. Only 29.3% of Bulgarians had completed COVID-19 vaccination, compared to 71% in the EU and EEA, and the country ranked last in number of booster doses (9.9% vs 51.4 %). This study aims to investigate the public's attitudes toward proposed mandatory COVID-19 vaccination and toward the long-standing mandatory child immunization schedule in the context of the COVID-19 pandemic. Methods An online cross-sectional survey was conducted in April 2022 using a self-administered anonymous questionnaire to collect information on sociodemographic characteristics, vaccination status and attitudes toward mandatory vaccination to COVID-19 and the mandatory childhood immunization schedule. Results Out of 1433 reached respondents, 1200(84%) completed the survey. The largest relative share of respondents is between 35-44y-33.3%; 72.7% were women; mainly highly educated (50.8%), and vaccinated participants (59.3%). There is a significant and large difference between vaccinated and unvaccinated regarding the full support of mandatory COVID vaccinations (46.1% vs 1.8%), and regarding mandatory child vaccinations (77.9% vs 50.4%). Mandatory childhood vaccination schedules are supported by 88.7% of those in favor of obligatory COVID-19 vaccinations and 56% of those who oppose them (p < 0.001). Significance is preserved after adjustment for vaccination status. Conclusions Public health authorities need to develop well-organized vaccination campaigns in which accurate evidence-based information is adequately disseminated with respect to individuals’ autonomy. More research on the determinants of vaccination attitudes in Bulgaria is necessary. Key messages Mandatory vaccination programs should be proceeded by investigation of the social readiness for acceptance. Exploration of cultural specificities to influence vaccination decision is needed.


Background:
Vaccinations are an essential public health strategy to control preventable diseases. A much-discussed approach to increase coverage is mandatory vaccination; however, its legitimacy and effectiveness were put to question during the COVID-19 pandemic. As of March 1,2022, Bulgaria had one of Europe's lowest immunization coverage rates against COVID-19. Only 29.3% of Bulgarians had completed COVID-19 vaccination, compared to 71% in the EU and EEA, and the country ranked last in number of booster doses (9.9% vs 51.4 %). This study aims to investigate the public's attitudes toward proposed mandatory COVID-19 vaccination and toward the longstanding mandatory child immunization schedule in the context of the COVID-19 pandemic.

Methods:
An online cross-sectional survey was conducted in April 2022 using a self-administered anonymous questionnaire to collect information on sociodemographic characteristics, vaccination status and attitudes toward mandatory vaccination to COVID-19 and the mandatory childhood immunization schedule.

Results:
Out of 1433 reached respondents, 1200(84%) completed the survey. The largest relative share of respondents is between 35-44y-33.3%; 72.7% were women; mainly highly educated (50.8%), and vaccinated participants (59.3%). There is a significant and large difference between vaccinated and unvaccinated regarding the full support of mandatory COVID vaccinations (46.1% vs 1.8%), and regarding mandatory child vaccinations (77.9% vs 50.4%). Mandatory childhood vaccination schedules are supported by 88.7% of those in favor of obligatory COVID-19 vaccinations and 56% of those who oppose them (p < 0.001). Significance is preserved after adjustment for vaccination status.

Conclusions:
Public health authorities need to develop well-organized vaccination campaigns in which accurate evidence-based

Background:
Bulgaria faced significant COVID-19 morbidity and mortality rates, but many people underestimated the risk of transmission and severity of infection. Rising vaccine-related fear and misinformation exacerbated existing hesitancy and mass vaccination remained a challenge. This study aims to investigate the factors influencing COVID-19 vaccination uptake in Bulgaria.

Methods:
A cross-sectional study was conducted in April 2022 in a sample of 1,200 respondents. Data were collected via an online self-administered questionnaire, measuring perceived risk of COVID-19, vaccine attitudes, trust in health system, and sociodemographics. Results were analyzed using bivariate and multivariate statistical methods.

Results:
Bivariate analyses showed that the majority of vaccinated respondents (81.9%) expressed concern about infection, compared to 47.1% of non-vaccinated. Significant differences were related to perceived risk of COVID-19 vaccine: 61.0% of vaccinated assessed risk as small versus 7.4% of refusers. Nonvaccinated participants demonstrated distrust in vaccine benefits and lack of trust in health system, science and pharmaceutical companies. The multivariable regression revealed associations between age, income, vaccine perception, and vaccination uptake. The 45-54 and 55-64 age groups were less likely to refuse vaccination compared to the youngest age group (OR = 0.34, p = 0.009 and OR = 0.38, p = 0.036). Odds of refusing the COVID-19 vaccine decreased as income increased (OR = 0.33, p = 0.036). A high perceived risk of adverse effects increased the odds of vaccine refusal by 7.02 (p<.001).

Conclusions:
The lack of confidence in the vaccine safety and effectiveness, coupled with an underestimation of the coronavirus disease, formed a critical barrier to the vaccine uptake. The misinformation fueled vaccination fear. Public health campaigns should address vaccine-related concerns and promote vaccination adherence in more consistent manner targeting also the spread of fake news. Key messages: The lack of confidence became a crucial barrier for vaccination coverage in Bulgaria. Understanding driving factors for vaccine uptake is of utmost importance to design effective vaccination programs.