Article
Effectiveness of COVID-19 Vaccination Mandates and
Incentives in Europe
Lidia Kuznetsova 1, *, Elizabeth Diago-Navarro 1 , Rachel Mathu 2 and Antoni Trilla 1
Citation: Kuznetsova, L.; Diago-
Navarro, E.; Mathu, R.; Trilla, A.
Effectiveness of COVID-19
Vaccination Mandates and Incentives
in Europe. Vaccines 2022, 10, 1714.
https://doi.org/10.3390/
vaccines10101714
Academic Editor: Giuseppe La Torre
Received: 3 September 2022
Accepted: 10 October 2022
Published: 14 October 2022
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Attribution (CC BY) license (https://
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4.0/).
Vaccines 2022, 10, 1714. https://doi.org/10.3390/vaccines10101714
1 Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, Universitat de Barcelona,
08036 Barcelona, Spain
2 Columbia University Irving Medical Center, New York, NY 10032, USA
* Correspondence: lidia.kuznetsova@isglobal.org
Abstract: During 2021–2022 many countries in the European region of the World Health Organization
(WHO) adopted mandatory and incentive-based vaccination measures to stimulate immunization
against COVID-19. The measures ranged from positive incentive-based programs (i.e., cash incentives,
meal discounts, and lotteries) to introducing COVID-19 certificates and enforcing the universal
mandatory vaccination with fines. We assessed the effect of such interventions on COVID-19 vaccine
uptake in the population of eight countries within the region. An interrupted time series (ITS) analysis
was performed using an autoregressive integrated moving average (ARIMA) approach to account for
autocorrelation and seasonality. The results showed the immediate positive impact of vaccination
incentives on vaccine uptake in most cases, with the highest impact being cash incentives for the
population (1197 per million population per day). Discount incentives did not show any significant
impact. The introduction of COVID-19 certificates was associated with a significant immediate or
gradual increase in daily administered vaccine doses in all the countries included in the study, up
to 117,617 doses gained per million per month. The effect of mandatory vaccination for all or some
groups of the population varied from a continuous decrease in daily administered doses (332 per
million capita per day), no significant effect, or a delayed or temporary increase (1489 per million
capita per day).
Keywords: COVID-19; vaccination policy; mandatory vaccination; vaccine incentives; vaccine
uptake; Europe
1. Introduction
The COVID-19 pandemic showed that the significance of the topic of vaccines and
vaccination policies extends beyond the public health domain [1]. COVID-19 vaccination
policies have been implemented during a period of heightened global tension and a sys-
temic crisis, and some of them fueled political turbulence in a number of countries [2].
The choice of vaccination policy can make a profound effect on peoples’ life and soci-
ety [3,4]. Therefore, thorough selection and application of the correct vaccination policy is
of paramount importance [5]. This requires comprehensive evidence on what works and
what does not in different settings. Such knowledge should be translated into interventions
that maximize the benefits and minimize the harm for the population.
As the pandemic persists, vaccination policies will continue to play an important part
in mitigating the potential waves of COVID-19. Therefore, more evidence is needed on the
effectiveness and impact of past and current vaccination policies in addition to updated
vaccines [6]. Not only is the exploration on the impact of vaccination policies important for
evaluation of their efficacy, it aids in the development of new policies to prepare for future
public health crises [7]. The knowledge gained is not relegated solely to prevent the spread
of COVID-19, but can be used to prevent disease spread for other multi-country outbreaks
such as monkeypox, declared a Public Health Emergency of International Concern by the
https://www.mdpi.com/journal/vaccines
Vaccines 2022, 10, 1714 2 of 21

WHO, and hepatitis [8,9]. An increase in the incidence of vaccine-preventable diseases,

triggered by vaccine hesitancy and aggravated by disruptions of immunization services due
to the COVID-19 pandemic, are additional threats that may be mitigated with the addition
of evidence-based knowledge surrounding vaccine mandates and incentives [10,11].
There is a lack of comprehensive and systematic data regarding the effectiveness of
mandatory and incentive-based vaccination schemes; even when available, data are often
not adequately utilized or examined. During the COVID-19 pandemic, some countries
adopted unprecedented measures to increase vaccine uptake, such as lockdowns and
limited access to businesses for the unvaccinated. Despite some studies that explored the
impact of the implementation of country-level measures during the 2021 time period, such
as the introduction of COVID-19 vaccine certificates, more evidence is needed to understand
the impact of the whole range of interventions aimed at increasing vaccine uptake [12].
Focus drawn to understanding the effects of both announcement and enforcement of
interventions, when feasible, is considerable to understanding the full picture of vaccination
policies and implementation.
During 2021–2022, many countries in the European region of the WHO, which com-
prises 53 countries, adopted mandatory and incentive-based vaccination measures to
stimulate the immunization against COVID-19. The measures introduced in the countries
of the region range from positive incentive-based approaches (i.e., cash incentives, meal
discounts and lotteries) to introducing COVID-19 certificates or enforcing the universal
mandatory vaccination with fines.
This article addresses one of the most pressing social challenges of mandatory vac-
cination. The aim of the study is to assess the effect of mandatory and incentive-based
vaccination measures on vaccine uptake for COVID-19 in the population of the countries
within the WHO European region. The study focuses on eight countries (Austria, Greece,
Italy, Norway, Poland, Russia, Spain, and the United Kingdom) that introduced one or
more of such measures at a specific point during the 2021/2022 time period, and where
data were available pre- and post-intervention. The included countries have varied levels
of COVID-19 vaccine acceptance, from high (Norway, Spain, the UK) to low (Poland and
Russia) [13–15].

2. Methods
2.1. Policy Interventions
The interventions introduced between June 2021 and January 2022 in eight countries of
the WHO European region (Austria, Greece, Italy, Norway, Poland, Russia, Spain, and the
United Kingdom) were analyzed. The list of the analyzed policy interventions in each coun-
try is presented in Table 1. Wherever feasible—depending on data availability, availability
of information about the date of announcement and enforcement of measures, sufficient
time points between interventions—we assessed the effects of both the announcement and
enforcement of each intervention. For Greece, Poland, Russia, and the UK, the following
announcements/enforcements were analyzed: cash incentives, lotteries, municipalities
competitions, and discount vouchers. The impact of COVID-19 certificates was assessed
for Greece, Norway, Russia, and Spain. Lastly, the following interventions were studied
for Austria, Greece, Italy, and Russia: lockdown for the unvaccinated, mandates for adults
aged 50/60 and older, mandates for the employees, and the universal vaccine mandate.
Vaccines 2022, 10, 1714
Table 1. Summary of COVID-19 vaccination mandates and incentives in the selected countries.
Measure
Country Announced
Description
Introduction of a general
requirement for ‘3G’ proof
to enter the workplace.
The ‘3Gs’ are ‘geimpft,
genesen oder getestet’
Austria
(abbreviated as 3G as all
three words start with a G
in German) meaning
vaccinated, recovered or
tested.
Lockdown for the
unvaccinated.
Unvaccinated people in
15 November
Austria will be allowed to
leave their homes only for
work, food shopping or
emergencies.
Universal mandate with
fines announced. Those
over the age of 18 who
19 November
decline to take a jab face
penalty of up to 3600 EUR,
unless they are pregnant
or severely ill.
“Freedom pass”—150
EUR voucher offered to
Greece 28 June 2021
people 18–25 years old
who get vaccinated.
Financial incentives for
pharmacists and doctors
which include subsidies
for booked vaccination
appointments as well as
for in-home vaccinations.
3 of 21
Introduced Suspended Selected Sources
https://www.thelocal.at/2022
20 October 1 November 0223/austria-to-lift-3g-
March 2022
2021 2021 requirement-for-workplaces/
(accessed on 15 August 2022)
https://www.bbc.com/news/
world-europe-59343650
(accessed on 15 August 2022)
https:
//www.npr.org/sections/
15 November 19 November
coronavirus-live-updates/2021
2021 2021 2021
/11/15/1055839727/austria-
and-germany-impose-
restrictions-on-unvaccinated-
people-as-covid-cases-su
(accessed on 15 August 2022)
https://www.theguardian.
com/world/2022/mar/09
/austria-suspends-mandatory-
covid-vaccination-law
(accessed on 15 August 2022)
February 2022 March 2022
2021 https://www.bnnbloomberg.
ca/austria-suspends-vaccine-
mandate-as-omicron-
questions-policy-1.1734807
(accessed on 15 August 2022)
https://news.gtp.gr/2021/07/
23/greece-pushes-covid-19
-vaccination-new-incentives-
31 December laws/ (accessed on 15 August
20 July 2021
2021 2022)
https://emvolio.gov.gr/
freedompass-datapass
(accessed on 15 August 2022)
https://news.gtp.gr/2021/07/
23/greece-pushes-covid-19
23 July
23 July 2021 -vaccination-new-incentives-
2021
laws/ (accessed on 15 August
2022)
Vaccines 2022, 10, 1714
Table 1. Cont.
Measure
Country
Description
Those vaccinated against
COVID-19 have to present
their vaccination
certificates, while
unvaccinated people are
required to present a
negative COVID-19 test to
enter all shops, banks and
public indoor areas, as
well as outdoor
restaurants and cafes.
Exceptions were made for
food shops, pharmacies,
and places of worship.
Vaccination mandate for
all residents of Greece
over the age of 60. The
unvaccinated would be
fined 100 EUR for every
month they remain
unvaccinated.
Workers cannot access any
place of work in Italy
without a ‘Green Pass’,
which is issued if the
holder has been fully
vaccinated against
Italy
COVID-19, received a
negative result from a
rapid or antigen test in the
previous 48 h or recovered
from COVID-19 in the
previous six months.
4 of 21
Announced Introduced Suspended Selected Sources
https:
//abcnews.go.com/Health/
wireStory/greece-toughens-
restrictions-unvaccinated-
cases-spike-80927971 (accessed
on 15 August 2022)
https://www.reuters.com/
2 November 6 November world/europe/unvaccinated-
1 May 2022
2021 2021 greece-face-new-restrictions-
covid-cases-soar-2021-11-06/
(accessed on 15 August 2022)
https://news.gtp.gr/2022/04/
12/greece-suspend-covid-19
-vaccination-and-recovery-
certificates-next-month/
(accessed on 15 August 2022)
https://abcnews.go.com/
Health/wireStory/greece-
approves-mandatory-
vaccination-aged-60-81500213
(accessed on 15 August 2022)
1 December 17 January https://www.bbc.com/news/
15 April 2022
2021 2022 world-europe-59474808
(accessed on 15 August 2022)
https://greekcitytimes.com/20
22/04/15/over-60s-in-greece-
ends-as-of-today/ (accessed on
15 August 2022)
https://www.theguardian.
com/world/2021/oct/14
/italy-braced-for-unrest-as-
covid-pass-becomes-
mandatory-for-all-workers
(accessed on 15 August 2022)
https:
September 15 October //www.gazzettaufficiale.it/eli/
May 2022
2021 2021 id/2022/03/24/22G00034/sg
(accessed on 15 August 2022)
https://www.reuters.com/
world/europe/italy-readies-
law-make-covid-health-pass-
mandatory-all-workers-2021-0
9-16/ (accessed on 15 August
2022)
Vaccines 2022, 10, 1714
Table 1. Cont.
Measure
Country Announced
Description
Italy extends COVID-19
vaccine mandate to
everyone over 50. The fine 5 January 2022
for non-compliance is 100
EUR.
Domestic use of
COVID-19 certificates for
coastal cruises and events,
as well as authority for
Norway
municipalities to regulate,
e.g., opening of closed
businesses using
COVID-19 certificates.
Mandatory vaccination for
employees in a wide range
Russia of sectors, covering most
of employees in the
country.
Lotteries for the
vaccinated. Four draws of
total 2000 cash prizes,
100,000 RUB each.
Introduction of COVID-19
certificates in most
regions, nationwide
digital passes showing
proof of vaccination or
recent recovery from
COVID-19 to enter public
areas and events.
5 of 21
Introduced Suspended Selected Sources
https:
//www.reuters.com/world/
europe/italy-make-covid-jab-
mandatory-over-50s-tighten-
curbs-draft-2022-01-05/
(accessed on 15 August 2022)
https://www.normattiva.it/
5 January 2022 15 June 2022 uri-res/N2Ls?urn:nir:stato:
decreto.legge:2022-01-07;1
(accessed on 15 August 2022)
https://www.ilsole24ore.com/
art/in-arrivo-nuova-stretta-
anti-omicron-obbligo-vaccino-
gli-over-60-AEOd2T6 (accessed
on 15 August 2022)
https://www.regjeringen.no/
25 September no/dokumenter/prop.-10-l-20
20 June 2021
2021 212022/id2880813/?ch=5
(accessed on 15 August 2022)
https://abcnews.go.com/
Health/wireStory/russian-
regions-make-vaccines-
mandatory-workers-78334612
(accessed on 15 August 2022)
1 July 2021 May 2022 https://www.loc.gov/item/
global-legal-monitor/2021-06-
22/russian-federation-
unvaccinated-employees-can-
be-suspended-without-pay/
(accessed on 15 August 2022)
https://xn--80abehgib9bifaxh1
1 September 30 November
a8l.xn--p1ai/ (accessed on 15
2021 2021
August 2022)
https://www.themoscowtimes.
com/2021/11/02/russia-
22 October 8 November
March 2022 imposes-digital-covid-passes-
2021 2021
amid-virus-surge-a75461
(accessed on 15 August 2022)
Vaccines 2022, 10, 1714 6 of 21

Table 1. Cont.

Measure
Country
Description
Lottery for the vaccinated.
Every day from July 1,
every 500th participant to
receive a cash prize of
PLN200 (222 EUR) while
every 2000th person was
to win PLN500 and every
week for three months
until the end of September,
the government gave
several automobiles, five
prizes of 50,000 PLN and
Poland 720 electric scooters. The
government engaged
municipalities all over
Poland by launching a
competition with
numerous financial prizes.
The commune with the
highest percentage of the
vaccinated will receive 2
million PLN. The first 500
municipalities that will
vaccinate 67 percent will
receive 100,000 PLN.
Introduction of COVID-19
certificates in 10 regions
and 2 cities. Required in
Spain bars, restaurants, nursing
homes, health
establishments as well as
to access events.
Food, clothes,
United transportation and leisure
Kingdom discounts and vouchers
for the vaccinated.
Announced Introduced Suspended Selected Sources
https://www.intellinews.com/
poland-kicks-off-covid-19
-vaccination-lottery-214644/?
source=poland (accessed on 15
August 2022)https:
//www.gov.pl/web/loteria/
30 September
1 July 2021 zasady-i-regulamin2 (accessed
2021 (lottery)
on 15 August 2022)
https://www.gov.pl/web/
szczepimysie/do-wygarnia-
zdrowie-i-miliony-zlotych-
ruszaja-konkursy-dla-gmin
(accessed on 15 August 2022)
https://elpais.com/sociedad/
2021-11-26/certificado-covid-
que-comunidades-han-
aprobado-su-uso-y-para-que-
actividades.html (accessed on
22 November 6 December 15 August 2022)
2021 2021 https://www.abc.es/sociedad/
abci-estas-son-comunidades-
necesitar-pasaporte-covid-
navidad-nsv-202112171646
_noticia.html (accessed on 15
August 2022)
https://abcnews.go.com/
Health/wireStory/pizza-shots-
uk-targets-young-vaccine-
incentives-79200767 (accessed
1 August 2021 1 August 2021
on 15 August 2022)
https://www.bbc.com/news/
uk-58044088 (accessed on 15
August 2022)

2.2. Data Sources

Data on daily administered COVID-19 vaccine doses were sourced from Our World in
Data, which utilized governmental reports to inform their database [16]. Additionally, we
consulted official governmental sources in cases of missing data or in the case of Russia,
where Our World in Data did not use official data provided by the Russian government,
but the data from alternative sources. Furthermore, we referred to the European Centre for
Disease Prevention and Control COVID-19 Vaccine Tracker for data for specific age groups
for the relevant interventions in the European Union countries [17]. The dates of policy
Vaccines 2022, 10, 1714 7 of 21

interventions were obtained from official governmental documents, local and international
news outlets.

2.3. Population
The study focuses on the population of eight countries of the WHO European region
that introduced one or more of mandatory or incentive-based measures at a specific point
in time, and where sufficient data were available before and after the introduction of
the measures and on exact dates of introduction of the interventions, necessary for an
ITS analysis with daily data. The rationale for our choice was to include countries that
represent different levels of the COVID-19 vaccine acceptance. The included countries
had the following levels of acceptance of the COVID-19 vaccine: high (Norway, Spain,
UK), medium (Austria, Greece, Italy), and low (Poland, Russia) [13–15]. We also took into
consideration whether the countries and interventions had been already assessed in other
available studies, to avoid duplication.

2.4. Outcome
The primary outcome of this analysis was the change in the number of daily adminis-
tered doses following the interventions. Outcomes could be broken down into categories.
An instantaneous impact is defined as an impact that occurs in the same period in which
the policy is introduced, and the impact in the days following the introduction of the
policy, that is, the dynamic effect of the impact. We also report the change in the number
of administered vaccine doses per million capita, to facilitate the comparison between the
interventions and countries. Through conducting a counterfactual analysis, we report the
values of daily administered doses in the absence of interventions, and number of doses
gained (or missed) due to the implementation of interventions.

2.5. Statistical Analysis

An Interrupted Time Series, a quasi-experimental method, was used to carry out this
analysis. ITS analyses have increasingly been applied to evaluate the impact of large-scale
health interventions. The choice of this method was based on its suitability for the dataset,
which satisfied the following conditions: clear differentiation of the pre-intervention pe-
riod and the post-intervention period and sufficient number of datapoints. In their ITS
regression tutorial Bernal et al. argue that ITS works best with short-term outcomes that are
expected to change either relatively quickly after an intervention is implemented or after
a clearly defined lag [18]. According to Schaffer et al., the ITS method is suitable for the
evaluation of ‘natural experiments’ implemented in real-world settings and is becoming
widely used with the increasing availability and quality of routine data spanning before
and after interventions [19]. The ITS analysis has been conducted through the following
steps: (1) proposing an impact model, that is assuming whether the change following the
intervention is immediate or gradual and whether there will be a lag period before any ef-
fect is expected. (2) Conducting descriptive analysis, consisting of initial summary statistics
and plots to explore the data. (3) Carrying out regression analysis. Such analysis can be per-
formed through segmented regression, which requires a linear or easily modelled trend and
independently distributed residuals. Segmented regression was not suitable for out data,
due to the difficulty in modelling the autocorrelation structure. Therefore, we used ARIMA
approach to account for autocorrelation and seasonality. (4) Addressing methodological
issues, such as seasonality, autocorrelation and confounders. (5) Model checking [18].
When the assumption of constant variance was not met for the ARIMA model, other mod-
els were explored. These included autoregressive conditional heteroskedasticity (ARCH)
and generalized autoregressive conditional heteroskedasticity (GARCH) models [20]. For
Norway, the use of the autoregressive distributed lagged model (ARDL) was explored, as
ARIMA models failed to provide a good fit for the data.
Furthermore, we conducted a counterfactual analysis to obtain the values predicted
by the ARIMA model in absence of the intervention compared with the observed values.
Vaccines 2022, 10, 1714 8 of 21

To do this, we built additional ARIMA models for the periods up to the time before the
intervention, with the forecasts representing what would happen if no intervention had
been put into place.
To develop the models, the general to particular approach was applied. This consisted
of starting from a dynamic model with a large lag structure (12, 24, or 30 days), and then
eliminating the non-significant lags until a nested model with all significant variables was
identified. The intervention variables were entered as predictors into the model, and if
statistically significant, this induced a positive or negative change in the intercept of the
model.
Stationarity was tested by Dickey–Fuller test, and autocorrelation by the Ljung–Box
test. Autocorrelation, nonstationarity, and seasonality were handled through differencing in
the ARIMA model. To check the stability of the models, the calculation of the inverse values
of the roots of the autoregressive polynomial was performed. To conduct the statistical
analysis, Eviews (version 12; IHS Markit, London, UK) and SPSS software (version 28.0;
IBM Corp., Armonk, NY, USA) were utilized.

3. Results
The data were analysed by country and type of implemented measure.

3.1. Austria
The sample consisted of 161 observations for the period 1 September 2021–8 February
2022. The mean number of daily doses in the sample was 44,984, while 50 percent of the
observations were below 32,736 doses. The maximum number of doses was 112,599, and
the minimum number of doses was 12,932.
The purpose of the ARIMA model was to determine the impact of the following
intervention variables: announcement of the employee vaccine mandate (am1), enforcement
of the employee vaccine mandate (m1force), introduction of lockdown for the unvaccinated
(m2) and announcement of the universal vaccine mandate with fines (am3). Figure 1 shows
the time series with the intervention time points.
The ARIMA model shows that the only intervention variable affecting the doses vari-
able was am3, the universal vaccine mandate with fines, which was statistically significant
at any significance level (p-value < 0.000). The announcement of the universal vaccine
mandate (am3) acted as a leading indicator, that is, it impacted doses administered one day
after the announcement. This announcement on 19 November 2021 had a negative impact
on doses and was associated with a reduction from on intervention period to the next
by 3010 doses (95% CI: −3592–2428). The introduction of mandatory vaccination for the
employees (am1) did not produce an immediate effect but likely produced an anticipatory
and/or delayed effect. This is in line with the data on vaccine coverage among different
age groups (17). The observed effect can also be linked to the data reporting issues for
Austria. In order to produce a complete series of daily figures and account for missing data
Our World in Data, the data source utilized, used a rolling 7-day average window, possibly
hiding some of the significant effects of the assessed interventions [21]. As for the lockdown
for the unvaccinated, which was in force for only 4 days, the lack of any significant effect
can be linked to the short duration of the intervention. Finally, the negative effect of the
introduction of the universal vaccine mandate (am3) is likely to be due to the substitution
on 19 November 2021 of the lockdown for the unvaccinated (m2) (announced just 5 days
before on 15 November) with vaccine mandate for everybody with the fines applied from
the next year and the immediate lockdown for everybody. These quick changes resulted in
the unvaccinated losing the motivation to vaccinate, which was likely tied to the general
confusion felt among the Austrian population due to rapidly changing measures and policy
unpredictability [22]. As a result, it is likely that many preferred to adopt the “wait and see
approach”. These findings are in line with the results of an initial comparison of vaccination
policies and vaccine uptake between Austria and Germany in November to December
2021 [23].
Vaccines
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Figure 2 shows the forecast of the evolution of doses in the absence of the introduc-was likely
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Vaccines 2022, 10, 1714 11 of 21

Figure 2 shows the forecast of the evolution of doses in the absence of the introduction
Vaccines 2022, 10, x FOR PEER REVIEW 12 of 24
of COVID-19 certificates (m3) based on an ARIMA model. It illustrates a substantial impact
of the introduction of COVID-19 certificates (m3) on vaccine coverage in the country. The
figure also shows the forecast of the evolution of the daily doses in the absence of entry
country.
into The
force of thefigure alsomandate
vaccine shows the
forforecast
adults of the60
aged evolution of (m4force),
and older the daily doses
basedinon
theARIMA
ab-
sence of entry into force of the vaccine mandate for adults aged 60 and older (m4force),
model. The measure (m4force) entered into force in the final stage of the mass vaccination
based on ARIMA model. The measure (m4force) entered into force in the final stage of the
campaign, which was not accounted for in the forecast, and did not induce any increase
mass vaccination campaign, which was not accounted for in the forecast, and did not in-
in the administered doses, as there were very few individuals left in the population to be
duce any increase in the administered doses, as there were very few individuals left in the
vaccinated. This intervention was clearly aimed at the few people who resisted vaccination
population to be vaccinated. This intervention was clearly aimed at the few people who
the most.
resisted vaccination the most.
3.3. Italy
3.3. Italy
The sample of 181 observations covered the period 1 September 2021–28 February
The sample of 181 observations covered the period 1 September 2021–28 February
2022. The average number of daily doses in the sample was 312,657, while 50 percent of the
2022. The average number of daily doses in the sample was 312,657, while 50 percent of
observations
the observations werewere
under the daily
under dosedose
the daily levellevel
of 248,011. TheThe
of 248,011. maximum
maximum number
number of doses
of
was 665,777, while the minimum number was
doses was 665,777, while the minimum number was 114,725.114,725.
The
Themain
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determine the impact of
the impact of interven-
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tion variables, specifically, the entry into force of the “Green pass” mandate for employees(m1)
Vaccines 2022, specifically,
10, x FOR PEER the
REVIEWentry into force of the “Green pass” mandate for employees
Vaccines2022,
Vaccines 10,xxFOR
2022,10, FORPEER
PEERREVIEW
and
REVIEW
(m1)theand
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entry intoofforce
the vaccine mandate
of the vaccine for adults
mandate aged 50
for adults and50older
aged (m2). 9(m2).
and older 9 ofof 24
Figure 24 3
shows the time series with the intervention time points.
Figure 3 shows the time series with the intervention time points.

Figure 1. Daily new vaccinations in Austria before and after the policy changes and pr
Figure3.3.Daily
Dailynew
newvaccinations
vaccinations in Italy
in Austria
Italy before
before and
andafter
after the
thepolicy changes andandpredicted values
Figure
Figure
Figure1.1.Daily
Dailynewnewvaccinations in
in absence
vaccinations before
beforeand
of intervention
in Austria after
andbased onpolicy
afterthe
the policy changes
policychanges
ARIMA model.and
changes
predicted
andpredicted
values of empl
values
Announcement
predicted values
in absence
in absence of intervention
of of
intervention based
based on ARIMA models. Introduction of “Green pass” mandate
in
inabsence
absence ofintervention
intervention basedon
based
mandate ononARIMA
ARIMAmodels.
ARIMA
(am1) model.
model. Employees Introduction
Announcement of of
mandate in force
Announcement “Green pass”vaccine
ofemployees
(m1force)
employees mandate
vaccineLockdown for
for employees (m1) Introduction of vaccine mandate for adults aged 50 forandunvaccinated
older (m2)
formandate
mandate(am1)
employees (m1)
(am1) Employees
(m2)
Introduction
Employees mandate in
inforce
ofAnnouncement
vaccine
mandate (m1force)
mandate
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for adults
(m1force) Lockdown
mandate
aged 50with
Lockdown andfines
older
for (am3)
(m2)
unvaccinated Predicted
(m2) Predicted values in absence
Announcement of of entry into force of the(am3)
vaccine mandate for adults aged 50
(m2) values
Predicted Announcement
in absence of ofuniversal
sence
entryof into mandate
announcement
universal mandate
force of with
with
the fines
ofvaccine
the universal
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mandatevaccine
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mandate
Predicted
adults aged values
(am3).
values
50 in
and ab-
inolder.
ab-
and older.
sence
senceof
ofannouncement
announcementof
ofthe
theuniversal
universalvaccine
vaccinemandate
mandate(am3).
(am3).
According to the estimated Themodel,
ARIMA model
only shows
thevaccine
vaccine that the onlyfor
mandate intervention
adults variable
aged 50 and affecting th
According
The ARIMA to model
the estimated
shows model,
that the only
only the
intervention mandate
variable for adultsthe
affecting aged 50 and
doses var-
older The
(m2) ARIMA
had model iable
shows was am3,
that the the
onlyuniversal
interventionvaccine mandate
variable with
affecting fines,
the Thisisis in statisti
which
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older
iable (m2)
was hada asignificant
am3, significant
the
impact
universalimpact on
vaccineonthe
the number
number
mandate
of
with
administered
of fines,
administered
which
vaccinedoses.
vaccine
was
doses.This
statistically signifi-
line iable
with was am3,
the data the
on vaccinecant
universal at any
vaccine
coverage significance
mandate
among level
with
different (p-value
fines, <
which
age age 0.000).
groups was The announcement
statistically
(17).(17).
TheThe model signifi-
shows of the univ
incant
lineatwith
any the data
significance onlevel
vaccine coverage
(p-value among
<<0.000). The different
announcement groups
of the universal model
vaccine
that cant at any
m2 impactedsignificance mandate
level
with lags. (am3)
(p-value
Inlags.
fact,In
once acted
0.000). as
Thea leading indicator,
announcement of that
the is, it
universal impacted
vaccine doses admi
shows
mandatethat m2 impacted with fact,m2 came
once into effect
m2 came on 5 January
into effect 2022,2022,
on 5 January the impact
the
mandate(am3)
(am3)acted
actedas aaleading
asday indicator,
after the
leading that
thatis,
announcement.
indicator, is,ititThis
impacted doses
dosesadministered
announcement
impacted administered one
on 19 Novemberone 2021 ha
impact
day on theannouncement.
number of doses took place fromon the following period, inducing an
dayafter
afterthe impact
the announcement. This
on announcement
This doses on19
and was associated
announcement 19 November 2021
2021 had
hadafrom
with a reduction
November a negative
on intervention p
negative
impact
impactonondoses
dosesand
andwas
was associated
next by 3010with
associated doses
with aareduction
(95% from
fromononintervention
CI: −3592–2428).
reduction period
periodto
The introduction
intervention ofthe
to mandatory va
the
next
nextby
by3010
3010doses
doses(95% CI:
(95%the −3592–2428).
CI:employees
−3592–2428). The
(am1) introduction
Thedid not produce
introduction of
ofmandatory
an immediate
mandatory vaccination
effect butfor
vaccination likely produc
for
the
theemployees
employees(am1)
(am1)did
did not
notproduce
patory and/or an
produce animmediate
delayed effect.effect
immediate but
This is
effect inlikely
but line produced
with
likely the data
produced an antici-
anon vaccine coverag
antici-
patory and/or delayed effect. This is in line with the data on vaccine coverage among dif-
Vaccines 2022, 10, 1714 12 of 21

on the number of doses took place from the following period, inducing an interperiod drop
of 43,357 (95% CI: −53,057–33,659) doses, to two periods beyond the effective date where
there was a change in the trend. This change resulted in an increase of 89,728 (95% CI:
76,848–102,610) doses from period to period. The direction of the trend was maintained for
one more period, but with a smaller interperiod growth of 17,919 (95% CI: 8321–27,518)
doses. Four periods after the entry into force of m2, the measure’s previous trend was
reversed, implying an interperiod drop of 76,621 (95% CI: −86,530–66,712) doses. Further,
the impact of m2 on daily dose-behavior was negative, indicating an interperiod decrease
of 12,330 doses on the fifth period.
A substantial increase in the number of administered doses in the period between the
end of November and Christmas holidays can be attributed to the mass administration
of the third dose of the vaccine, as well as the start of the vaccination of 5–11-year-old
children [25,26].
Figure 3 shows the forecast of the evolution of the daily doses in the absence of entry
into force of the vaccine mandate for adults aged 50 and older (m2), using an ARIMA
model. The forecast assumes an infinite number of people to vaccinate. The discrepancy
between the observed values and long-term forecast has similarities to the projected Greece
forecast where the vaccine mandate for adults aged 60 and older is introduced during the
final period of the mass vaccination campaign with few people left to vaccinate.
Several published studies have analyzed COVID-19 vaccination mandates in
Italy [12,27,28]. However, their focus was on the effect of the introduction of COVID-
19 certificates in Italy in July 2021, which was not a period covered by our data. The
results indicated that this intervention was associated with a significant increase in admin-
istered first doses of COVID-19 vaccine in Italy. Our findings provide insights on further
developments in the vaccination campaign in Italy.

3.4. Norway
The sample of 182 observations spanned the period 2 June 2021–30 November 2021.
The mean number of daily doses was 32,630, and the number of doses in which 50 percent
of the observations fell below was 35,443. The maximum number of doses was 69,114,
while the minimum was 4762.
As the attempted ARIMA models did not appropriately fit the data, we estimated
an autoregressive distributed lagged model, where the dependent variable entered as a
significant lagged explanatory variable until period 7. It was necessary to introduce four
dummy variables during the sample period (7 July 2021, 31 August 2021, 1 September
2021 and 22 September 2021) to pick up outlier effects. These dummy variables were
associated with a decrease in doses of 7.11%, 3.55%, 9.01%, and 12.05%, respectively. The
outliers are related to summer holidays and COVID-19 vaccination calendar in Norway.
The vaccination calendar is important to note during the period of our sample as it coincides
with the earlier stages of the mass vaccination campaign in Norway, where the numbers of
daily doses were dependent on vaccination appointments offered to people of certain age
groups [29].
The purpose of the ARDL model was to determine the impact of a single intervention
variable, which was entry into force of the COVID-19 certificates (m1). Figure 4 shows the
time series with the intervention time point.
The entry into force of COVID-19 certificates was on 20 June 2021 and remained in
force until 25 September 2021. According to the estimated ARDL model, once the measure
came into effect it had a positive impact after four days, with an approximate increase of
1308 doses from one period to the next, and a negative impact of 1399 doses on the fifth
day after coming into effect. Further, the effect is negative, with a drop from one period
to another of 90 doses (1308.2 + (−1398.64)). This period overlaps with the availability of
vaccinations for the 45–54 age group, according to the vaccination calendar. From August
2021 COVID-19 vaccine became available for everybody over 18 years old in Norway,
and the summer holidays in ended the same month, which is reflected in the spike of the
Vaccines 2022, 10, 1714 13 of 21

Vaccines 2022, 10, x FOR PEER REVIEW

Vaccines 2022, 10, x FOR PEER REVIEW 14 of 24
vaccine uptake curve [29]. Therefore, the introduction of COVID-19 certificates in Norway
was likely to produce moderate supporting effect to motivate people to vaccinate.

Figure 1. Daily new vaccinations in Austria before and after the policy changes and pr
Figure4.4.Daily
Figure Dailynew
newvaccinations
vaccinations in Norway
Norway
in absence before
beforeand
and
of intervention after
afterthe
based policy
the
on change.
policy
ARIMA change.
model. Introduction of emp
Announcement
Introduction of COVID
of COVID certificates (m1). certificates
mandate (am1) (m1). Employees mandate in force (m1force) Lockdown for
(m2) Announcement of universal mandate with fines (am3) Predicte
3.5. Poland
The entry into force sence of announcement
of COVID-19 of the
certificates universal
was vaccine
on 20 June mandate
2021 (am3).
and remained in
force
Theuntil 25 September
sample comprised 2021.
122According
observations to the forestimated
the period ARDL1 June model,
2021–30onceSeptember
the measure2021.
came into effect it had a positiveTheimpact
ARIMA aftermodelfour shows
days, that the
with an only intervention
approximate increasevariable
of affecting th
An average number of 145,891 daily doses were observed in the dataset, while 50 percent
iable was am3, the universal vaccine mandate with fines, which was statist
of1308 dosesfell
the data from one period
below 99,022 to the next,
daily doses. and The a negative impact of 1399
strong discrepancy doses on
between thethemean fifthand
day after comingthe into cant at any
effect. Further, significance
the effect level (p-value
is dataset.
negative,The < 0.000).
withhighest
a dropdoseThe announcement
fromlevel
one period of the univ
median suggests existence of outliers in this observed
to another mandate (am3) acted as a leading indicator, that is, it impacted doses admi
was 341,329,ofwhile
90 doses (1308.2dose
the lowest + (−1398.64)).
level wasThis period overlaps with the availability of
19,980.
day after the announcement. This announcement
vaccinations for the 45–54 age group, according to the vaccination calendar. From August on 19 November 2021 ha
An ARIMA GARCH model was developed to determine the impact of the intervention
2021 COVID-19 vaccine became impactavailable
on dosesfor and was associated
everybody over 18with years a old
reduction
in Norway, from and on intervention
variable “introduction of nationalnext by lottery and municipality competitions” (m1). Figure 5
the summer holidays in ended the3010
samedosesmonth, (95% CI: −3592–2428).
which is reflected inThe theintroduction
spike of the vac- of mandatory va
shows the time series withthe theemployees
intervention (am1) time didpoint.
not produce ancertificates
immediatein effect but likely produc
cine uptake curve [29]. Therefore, the introduction of COVID-19 Norway
When the measure came patory into forcedelayed
and/or on 1 July 2021, it is
had a positive theimpact
data onwith an coverag
was likely to produce moderate supporting effecteffect. This
to motivate in line
people with
to vaccinate. vaccine
interperiod increase of 25,196 doses. One period after the measure’s entry
ferent age groups (17). The observed effect can also be linked to the data rep into force, the
trend shifted and resulted for
3.5. Poland in aAustria.
decrease In of
order 24,368 doses from
to produce periodseries
a complete to period.
of daily Further,
figuresthe and accoun
measure produces an interperiod increase of 827 doses (25,196.74 + ( − 24,368.91)).
The sample comprised 122 observations for the period 1 June 2021–30 September 7-day aver
data Our World in Data, the data source utilized, used a rolling
It was necessary to introduce dummy variables on the dates 24ofJune 2021, 26interventions
June
2021. An average numberpossibly of 145,891 hiding
daily somedoses of were
the significant
observedeffects the assessed
in the dataset, while 50 [2
2021, 3 July 2021 and 11 July 2021
lockdown to pick
for the up irregularities
unvaccinated, in
which the dependent
was in force variable.
for only 4 These
days, the lack o
percent of the data fell below 99,022 daily doses. The strong discrepancy between the
irregularities were a drop of 12.47%,
icant effect an
can increase
be linked of 8.46%,
to the a
shortfall
mean and median suggests the existence of outliers in this dataset. The highest dose level of 10.65%
duration of and
the an increase
intervention. Finally,
ofobserved
5.61%, respectively.
was 341,329, whileThe variations
effect
theoflowest can
dosebelevel
the introduction explained
of the
was by the vaccination
universal
19,980. vaccine mandate schedule (am3) andis likely to
logistical reasons, such as substitution
closure of on 19
vaccinationNovember points 2021
An ARIMA GARCH model was developed to determine the impact of the interven-[30].of the lockdown for the unvaccinated (m2)
The intervention had just
an 5 days
immediate before on
temporary 15 November)
positive
tion variable “introduction of national lottery and municipality competitions” (m1). Fig- with
effect vaccine
on the mandate
number for
of everybody
daily w
administered vaccine applied
doses. To ourfrom the
knowledge,
ure 5 shows the time series with the intervention time point.next year
there and
are the
no immediate
published lockdown
studies for
evaluating everybody.
changes however,
this initiative specific to Poland; resulted inthere the unvaccinated
are studies losing the motivation
that examined to vaccinate,
the effect of whi
incentives on vaccine coverage tied to in theother
general confusion
countries felt as
such among the Austrian
the USA. population
Our findings are due
in to rapid
line with the conclusion derived measures byandthesepolicy unpredictability
researchers, reporting [22].
anAs a result,
increase in itCOVID-19
is likely that many
adopt the “wait and see approach”. These
vaccinated rates after the implementation of conditional cash lotteries in Ohio [31]. Despite findings are in line with the result
Vaccines 2022, 10, 1714 14 of 21

the
Vaccines abundance
2022, of REVIEW
10, x FOR PEER COVID-19 vaccines in Poland, there was an overall decrease in the
Vaccines 2022, 10, x FOR PEER REVIEW 15 of 24 the
weeks after the implementation of the intervention due to vaccine hesitancy among
population [30]. The summer holidays season also contributed to the general reduction [32].

Figure 1. Daily new vaccinations in Austria before and after the policy changes and predi
Figure5.5.Daily
Figure Dailynew
newvaccinations
vaccinations in
inPoland
in absence Poland before
before and
of intervention afteronthe
based policymodel.
policy
ARIMA change.
change. Start of nationalof employ
Announcement
Start of national lottery and
mandate municipality
(am1)
lottery and municipality competitions (m1). competitions
Employees (m1).
mandate in force (m1force) Lockdown for un
(m2) Announcement of universal mandate with fines (am3) Predicted v
3.6. Russia
When the measuresence
cameof into
announcement
force on 1ofJuly
the universal vaccine
2021, it had mandateimpact
a positive (am3). with an
interperiod
The sample increase of 25,196
consisted of 255doses. One period
observations forafter the measure’s
the period entry intoFebruary
1 June 2021–10 force, the2022.
The average number of daily doses was 502,514, with a median of 484,198 dailyvariable
trend shifted and resulted The
in a ARIMA model
decrease of shows
24,368 doses thatfromthe only
period intervention
to period. doses. affecting
Further, The the
the measure produces iable was
an interperiod am3, the
increase universal vaccine mandate with fines, which was statistica
maximum number of doses was 1,020,075 andofthe 827minimum
doses (25,196.74 number + (−24,368.91)).
of doses was 66,419.
cant at any significance level (p-value <dates
0.000).24The announcement of the univers
The purpose of the ARIMA model was to determine the impactJune
It was necessary to introduce dummy variables on the 2021, 26 Junevari-
of intervention
2021,namely:
3 July 2021 mandate
and 11 July of 2021 (am3)
to pick upacted as a leading
irregularities indicator,
in the(m1),
dependentthat is, it impactedThese for adminis
doses
ables, introduction employee vaccine mandates launchvariable.
of the lottery
irregularities day after the announcement. This announcement on 19 November 2021 had a
the vaccinatedwere (m2),a drop of 12.47%, an
announcement ofincrease of 8.46%, a of
the introduction fallCOVID-19
of 10.65% and an increase
certificates (am3)
of 5.61%, respectively. impact
The on doses
variations and was
can be explained associated by thewith a reduction
vaccination from on intervention per
and entry into force of next
COVID-19
by 3010 certificates
doses (95% (m3force).
CI: −3592–2428). Figure The showsschedule
6 introduction the timeof
and
series
mandatory vacci
logistical reasons, such as closure of vaccination points [30].
with the intervention time the points
employees and (am1)
the forecast
did notofpositive
the evolution
produce of the daily
an immediate effectdoses
but in theproduced
likely
The intervention had an immediate temporary effect on the number of daily
absence of the announcement patoryTo of COVID-19
and/or delayedcertificates
effect. (am3), basedwithon the ARIMA model.
administered vaccine doses. our knowledge, thereThis are nois in line
published the
studies data on vaccine
evaluating coverage a
We made the forecast for am3age
ferent as it was statistically
groups (17). The significant,
observed effect and
can the
also dataset
be linked contained
to the data report
this initiative specific to Poland; however, there are studies that examined the effect of
appropriate number of pre- and
for Austria. post-intervention
In order to producedatapoints
a complete to develop
series an ARIMA
of dailyare figures model.
incentives on vaccine coverage in other countries such as the USA. Our findings in lineand account fo
According to the estimated data Our ARIMA
World inmodel,
Data, the thedataintervention
source associated
utilized, with the entry
with the conclusion derived by these researchers, reporting an increase in used
COVID-19 a rollingvac-7-day average
into force of COVID-19 certificates
possibly hiding some
cinated rates after the implementation (m3force) was not significant.
of the significant
of conditional effectsin
cash lotteries The
of Ohio entry
the assessed into force of
interventions
[31]. Despite [21].
employee vaccineofmandate
the abundance (m1)
lockdown
COVID-19 on
for 1the
vaccines July
in 2021 had
unvaccinated,
Poland, anwhich
there immediate
was was in but
an overall force negative
for onlyimpact
decrease the on
4indays, the lack of a
the number
weeks afterofthe
doses; stimulating
icant effectofacan
implementation drop
the be from
linkedone
intervention period
to thedueshort toduration
another
to vaccine bythe
of
hesitancy 43,429amongdoses.
intervention.the On Finally, the
the other hand,
population [30].theThe
launch
summer of of
effect thethelottery program
introduction
holidays season of (m2)
also the in the period
universal
contributed to the1general
vaccine September
mandate 2021ishad
(am3)
reduction likely to be
an[32].
immediate positive impact, substitution on 19 November
increasing the number 2021ofofdoses
the lockdown
interperiod for the by unvaccinated
9766 doses. (m2) (a
The announcement of the just entry
5 daysinto beforeforce onof 15COVID-19
November)certificates
with vaccine mandate
(am3) on 22for everybody with
October
2021
3.6.had an immediate applied
Russia and lagged from the next
impact on theyearbehavior
and theofimmediate
doses. Thelockdown immediate forimpact
everybody. Th
was negative, changes resulted in the unvaccinated losing the motivation to vaccinate, which
The sample consisted of 255 observations for the period 1 June 2021–10 February the
with a fall from one period to another in the order of 42,718 doses. In
period after the tied to the the
announcement, general
impact confusion
was felt among
positive with theanAustrian
interperiod population
increase dueofto rapidly
2022. The average number of daily doses was 502,514, with a median of 484,198 daily
43,775 measures andanpolicy unpredictability [22]. Asdoses.
a result, it is likely that many pr
doses.doses. Further, am3
The maximum numberimplied
of doses interperiod
was 1,020,075 increase
and theofminimum
1056 number of doses
adopt the “wait and see approach”. These findings are in line with the results o
was 66,419.
 the vaccinated (m2), announcement of the introduction of COVID-19 certificates (am3)
and entry into force of COVID-19 certificates (m3force). Figure 6 shows the time series
with the intervention time points and the forecast of the evolution of the daily doses in
the absence of the announcement of COVID-19 certificates (am3), based on the ARIMA
model. We made the forecast for am3 as it was statistically significant, and the dataset
nes
Vaccines Vaccines
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2022, 2022,
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m1

Figure
Figure 6. 6.Daily
Dailynew
newvaccinations
vaccinations in in Russia
Russia before
before and
andafter
afterthe
thepolicy
policychanges
changes andand
predicted values
predicted values
Figure 1. Daily Figure
1. Figure 1.1.absence
Daily
newinvaccinations
Daily newinvaccinations
new vaccinations
Austria in
before
in Austria
andon before
after
Austria andpolicy
theinpolicy
before and after the
changes
after the policy
and changes
andpredicted
policy changes andpredicted
predicted
values
the and values
Figure Daily new vaccinations
Figure 1.in Austria
Daily
intervention new before
based and
vaccinationsafter
ARIMA the
Austria
models. changes
before and
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policy
Introduction of values
values
changes and predicted values
employees
in absence inin absence
absence
of intervention
in absence in of
absence of intervention
intervention
ofbased
intervention on ARIMA
intervention based
based on
model. ARIMA
ARIMA
on model.
ARIMA models.
model.
Announcement
model. Introduction
Announcement
of(m2)
employees
Announcement of employees
of employees
vaccine
of employees vaccine
vaccine
vaccine mandate
vaccine in based
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(m1) ARIMA
intervention based
Lottery onthe
for Announcement
ARIMA model.
vaccinated of employees vaccine
Announcement of employees
Announcement of vaccine
mandate (am1)
mandate mandate
(m1)
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(am1) Lottery
Employees
Employees
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for
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(m2)
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Announcement
Lockdown
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Lockdown
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for
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the introduction of COVID certificates (am3) COVID certificates in force (m3force)
(m2)
(m2) (m2) Announcement
(m2) Announcement
certificates Announcement
of universal
Announcement
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(m2) of universalofuniversal
COVIDuniversal
mandate
of with
mandate
Announcement mandate
fines
mandate
with
certificates (am3)
fines
of the with
with
(am3) fines
fines
inannouncement
force
universal (am3)
Predicted
(am3)
(m3force)
mandate values
Predicted
with fines Predicted
values
Predicted
(am3) values
in ab-invalues
Predicted values
ab- inab-
in
in ab-
absence
Predicted of in ab-
values
Predicted values in absence of of COVID certificates.
sencesence sence
of announcement
sence of
of
of announcement announcement
of the
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of the of
of the
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(am3). (am3).
(am3).
of the universal vaccine mandate (am3).
the announcement COVID certificates.

The ARIMA
The ARIMA The
model
The ARIMA
ARIMA
model
Even shows
though model
showsthat
model
The theshows
shows
that
ARIMA only that
that
the modelonly the
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the onlyintervention
only
intervention
shows intervention
variable
that variable
thethe affecting
only variable
variable
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theaffecting
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the var-
doses
variable the
the doses
doses
var- affecting var-the doses var-
var-
According tothethe analysis
estimated showed
ARIMA an
model,immediate negative
intervention effect
associated of the
with introduction
the entry
iableiable
was was
am3, iable was am3, the universal vaccine mandate with fines, which was statistically signifi-
ofthe
iable
am3, the
into universal
wasthe am3,
employee
force ofthe
universal
iable vaccine
universal
was vaccine mandate
am3,
vaccine
COVID-19 vaccine
mandate
the
mandate, with
universal
certificates fines,
mandate
with
thevaccine
(m3force) which
fines,with
interventionwhich
was was
fines,
mandate notwasstatistically
whichwith
produced
significant. was
statistically
fines, signifi-
statistically
aThe signifi-
which
positive
entry was signifi-
statistically
delayed
into of signifi-
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 Vaccines 2022, 10, 1714 16 of 21

were found was 146,011. The minimum number of doses observed was 2724, while the
maximum number of doses was 670,109.
The main purpose in estimating the ARIMA model was to determine the impact of
Vaccines
the predictor variables: 2022, 10, x FOR of
announcement PEER
theREVIEW
introduction of COVID-19 certificates (m1)
Vaccines 2022, 10, x FOR PEER REVIEW 9 of 24 18 of 24
and entry into force of COVID-19 certificates (m2). Figure 7 shows the time series with the
intervention time points.

Figure 1. Daily new vaccinations in Austria before and aft

Daily new vaccinations in Austria before and Figure
after Dailychanges
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and predicted in Spain before and after the introduction of COVID oncertificates.
Figure 7. Daily new vaccinations in values in absence
Spain before and after of intervention
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of COVID ARIMA model.
e of intervention based on ARIMA model. Announcement
Announcement
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Announcement of universal mandate with fines (am3) Predicted values in ab- sence of announcement of the universal vaccine mandate
announcement of the universal vaccine mandate (am3). Regarding
Regarding the impact
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ARIMA model shows that the only intervention
COVID-19 variable affecting
certificates (22 the doses
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2021), the impact was positive,
COVID-19 certificates (22 November 2021), the impact was positive, producing an in-mandate with
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r the announcement. This announcement on 19
announcement, November 2021 had
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intervention
of 51,641period to the next by 3010 doses (95% CI: −3592–2428). The intro
ofnumber
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3010 doses (95% CI: −3592–2428). The introduction of mandatory
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of 61,287 and/or
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However, is in
in line with the
the regulation came effect, inducing a decrease of 61,287 on average. However,
nd/or delayed effect. This is in line with thethedata on vaccine coverage among dif- ferent age groups (17). The observed effect can also
in thethreethreedays days following
following thetheintroduction
introduction the impact
the impactof theofmeasure
the measure becamebecame positive. An
positive.
ge groups (17). The observed effect can alsoincrease
be linked to
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49,711, data reporting
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103,764 doses were for Austria.
seen on on In
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daysproduce
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An increase 49,711, 58,830, and 103,764 doses were seen three days following
ria. In order to produce a complete series ofintroduction,
daily figuresrespectively.
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r World in Data, the data source utilized,introduction,
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window, alsobebeinterpreted
interpretedasasa acumulative
cumulative increase
increase of about
of about
212,306doses dosesover overthisthis three-day
three-day period. Estimates possibly hiding some of the significant effects of the
212,306
hiding some of the significant effects of the assessed interventions [21]. As for period.
the Estimatesshow show that
that thethepositive
positive impact
impactof theof the
regulation’sentry entry into
into force
force waswas greater lockdown for the unvaccinated, which was in force
n for the unvaccinated, which was in force regulation’s
for only 4 days, the lack of any greater than
signif- thanitsitsannouncement;
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however, thethe
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positive
impactofofthe theimplemented
implemented regulationregulation acted icant effect can be linked to the short duration of t
ect can be linked to the short duration of impact
the intervention. Finally, the negative actedas asaaleading
leadingindicator.
indicator.
effect
Two additive outliers were found on 12 October 2021 and 26 December 2021 that of the introduction of the universal vaccine m
the introduction of the universal vaccine mandate Two (am3)additive is outliers
likely to be were
due tofound
the on 12 October 2021 and
substitution on 19
26 December
November 2021
2021
of
that
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negatively impacted the dose variable, causing decreases of 16,295 and 14,139 doses, re-
tion on 19 November 2021 of the lockdown negatively
for the impacted (m2)
unvaccinated the dose variable, causingjust
(announced decreases
5 days of 16,295
before on and
15 14,139 doses,
November) with vaccine m
spectively. These outliers coincide with holidays in Spain. A transitory outlier was also
ys before on 15 November) with vaccinerespectively.
mandate
identifiedfor
These outliers
on everybody
16 December with coincide
2021thecausing
fineswith holidays in Spain.
applied
a positive impact, from A the
increasing
transitory
nextnumber
the
outlier
year and was also
the immediate
of doses lo
from the next year and the immediate identified
lockdown on
for 16everybody.
December These 2021 causing
quick a positivechanges
by 41,090. This increase corresponds to the start of the vaccination in
impact,resulted
increasing
of the
the number
5–11unvaccinated
of
year old chil-
doses
losing the mot
resulted in the unvaccinated losing the motivation
dren; thetoestimated
vaccinate,decay which was was
factor likely0.445 [40]. tied to the general confusion felt among the Austria
he general confusion felt among the Austrian population due to rapidly changing
The positive effect of the introduction of COVID-19 measures and policy
certificates on the unpredictability
number of ad-[22]. As a res
s and policy unpredictability [22]. As a result, it is likely
ministered doses thatin many
Spain preferred
is evident.toThe regulation adopt
wasthe “wait and
introduced inseetheapproach”.
context of the These findings
e “wait and see approach”. These findings are in line with the results of an initial
 Vaccines 2022, 10, 1714 17 of 21

by 41,090. This increase corresponds to the start of the vaccination of 5–11 year old children;
the estimated decay factor was 0.445 [40].
Vaccines 2022, 10, x FOR PEER REVIEW 19 of 24
The positive effect of the introduction of COVID-19 certificates on the number of
administered doses in Spain is evident. The regulation was introduced in the context of
the preparation for Christmas holidays and the spread of Omicron variant. Furthermore,
topreparation
facilitate theforvaccination,
Christmas holidays and the spread
the authorities set upofadditional
Omicron variant. Furthermore,
vaccination points intothis
facilitate the vaccination, the authorities set up additional vaccination
period [41]. COVID-19 certificates increased vaccination numbers beyond the points in this period
regions
[41]. COVID-19 certificates increased vaccination numbers beyond the regions
where they were introduced due to increased travel of the population during the holiday where they
were introduced due to increased travel of the population during the holiday season [42].
season [42]. A number of other countries implemented COVID-19 certificates, and several
A number of other countries implemented COVID-19 certificates, and several studies an-
studies analyzing these measures implemented in summer 2021 have been published.
alyzing these measures implemented in summer 2021 have been published. Our findings
Our findings are in line with the results delivered by these studies, reporting a signifi-
are in line with the results delivered by these studies, reporting a significant increase in
cant increase in COVID-19 vaccine uptake in Canada, France, Germany, Israel, Italy, and
COVID-19 vaccine uptake in Canada, France, Germany, Israel, Italy, and Switzerland
Switzerland
[12,27,28].
[12,27,28].

3.8. United Kingdom

3.8. United Kingdom
The sample consisted of 92 observations for the period 1 July 2021–30 September
The sample consisted of 92 observations for the period 1 July 2021–30 September
2021. The mean number of daily doses in the sample was 180,283, with 50 percent of the
2021. The mean number of daily doses in the sample was 180,283, with 50 percent of the
observations
observationsfalling
falling below
below 200,182. Themaximum
200,182. The maximumnumber
number of of doses
doses in in
thethe sample
sample waswas
327,284, while the minimum number was 63,283
327,284, while the minimum number was 63,283 doses. doses.
AnAnARIMA
ARIMAARCHARCH model was developed
model was developedtotodetermine
determine the
the impact
impact of the
of the intervention
intervention
s 2022, 10, x FOR PEER REVIEW variable
variable“introduction
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discounts and vouchersfor
forthe
thevaccinated”
vaccinated”
9 of 24 (m1)
(m1) on on
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number
ofof
doses
dosesadministered.
administered. Figure
Figure 88 shows thetime
shows the timeseries
serieswith
withthe
the intervention
intervention time
time point.
point.

Figure 1. Daily newFigure Daily

8. 8.
Figure
vaccinations innew
Daily vaccinations
new
Austria before andinafter
vaccinations the
in United Kingdom
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Kingdom
changes and after
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and vouchers
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forARIMA for the vaccinated.
the vaccinated.
model. Introduction
AnnouncementIntroduction of discounts
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vaccine for the
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mandate in force (m1force) Lockdown for unvaccinated
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sence of announcement of the universal vaccine mandate (am3).
According to the ARIMA ARCH model, the intervention variable impacts the number
According
of doses to the
one period ARIMA
after ARCH
its entry intomodel,
force onthe1intervention
August 2021. variable impacts
However, thisthe num-was
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However, this impact
statistically significant (p = 0.1345), which is higher than the standard significance levels
iable was am3, thewasuniversal vaccine mandate
not statistically with
significant (p =fines, which
0.1345), wasisstatistically
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the standard significance
cant at any significance level (p-value < 0.000). The announcement of the universal vaccine
mandate (am3) acted as a leading indicator, that is, it impacted doses administered one
day after the announcement. This announcement on 19 November 2021 had a negative
impact on doses and was associated with a reduction from on intervention period to the
Vaccines 2022, 10, 1714 18 of 21

of 1%, 5% or 10%. Regardless, the effect on the number of doses is negative, inducing a fall
of 2558 doses period to period.
It was necessary to introduce dummy variables on the dates 5 July 2021, 31 August
2021 and 7 September 2021. These dates correspond to outliers were doses decreased by
1.99%, 2.31%, and 4.73%, respectively. It is likely that these drops are related to seasonal
holidays. The increase in vaccinations at the end of September 2021 coincides with the start
of a COVID-19 booster vaccine program in the country [43].
The lack of a significant effect of the introduction of discounts and vouchers on the
number of vaccinations is in line with the data on vaccine coverage in the age group
targeted by the intervention designed to boost the vaccine uptake among adults under
30 [44].
Table 2 summarizes the results that proved to be statistically significant.

Table 2. Change in number of daily administered doses before and after the policy interventions, that
proved to be statistically significant.

Gain in Number of
Change in Number of Daily Doses Over a Time
Type of
Intervention Time Period Administered Doses Total (95% Period (Based on
Change
CI)/Per Million Capita Counterfactual
Analysis)
Announcement of cash
incentive (“Freedom pass” Pulse Immediate 12,354 (11,755–12,954)/1197
in Greece)
Financial incentives for
pharmacists and doctors Pulse Immediate 1546 (1215–1878)/150
(Greece)
Lottery and municipalities
Pulse Immediate 25,196 (15,023–35,371)/667
competition (Poland)
Lottery (Russia) Pulse Immediate 9766 (4003–15,530)/67
Introduction of COVID-19
Step Over 1 month 1500 (1284–1716)/145 immediately 830,956
certificates (Greece)
Introduction of COVID-19 −42,718 (−78,256–7180)/−293 and
Pulse and step Over 1 month 17,149,679
certificates (Russia) 43,775 (8201–79,349)/300 immediately
Introduction of COVID-19
Pulse Over 3 days 212,306/4544
certificates (Spain)
Introduction of COVID-19 1308 (228–2388)/237 on day 4
Gradual step 5 days
certificates (Norway) −1399 (−2482–315)/−254 on day 5
Introduction of employee Over 1,5 −43,429 (−78,063–8797)/−298
Pulse
vaccine mandate (Russia) months immediately
Announcement of the −1,696,266
−3010 (−3592–2428)/−332
universal vaccine mandate Step Over 1 month (“missed” doses due to
immediately
(Austria) the policy change)
Introduction of the vaccine
mandate for adults aged 60 Step Immediate −1932 (−2066–1798)/−187
and older (Greece)
−43,358 (−53,057–33,659)/−720 on
day 1
Introduction of vaccine
89,729 (76,849–102,610)/1489 on day 2
mandate for adults 50 and Pulse and step Over 4 days
17,920 (8321–27,518)/297 on day 3
older (Italy)
−76,621 (−86,530–66,712)/−1272 on
day 4
Vaccines 2022, 10, 1714 19 of 21

4. Conclusions
We examined the effect of mandatory and incentive-based vaccination measures on
vaccine uptake for COVID-19 in the population of eight countries within the WHO Euro-
pean region. Our findings show the immediate positive impact of vaccination incentives on
vaccine uptake in most cases, with the highest impact of cash incentives for the population
seen in Greece (1197 per million population per day). Discounts incentives did not show
any significant impact. The introduction of COVID-19 certificates was associated with a sig-
nificant immediate (Spain) or gradual increase (Greece) in daily administered vaccine doses
in all the countries included in the study, up to 117,617 doses gained per million per month
seen in Russia. The effect of mandatory vaccination for all or some groups of the population
varied from a continuous decrease in daily administered doses (Austria—332 per million
capita per day), no significant effect, delayed or temporary increase (Italy—1489 per million
capita/day). Our study provides new insights on the effectiveness of vaccine interventions
that had not previously been assessed. The impact of both incentive and mandate inter-
ventions are of great interest to various stakeholders including researchers, policy makers,
and the general population. The study has several limitations: it does not account for
changes in the required vaccine doses over time, differences in the countries’ information
campaigns aimed at increasing the vaccine uptake and differences in the degree of ethical
concerns regarding mandatory vaccination, which was beyond the scope of this study. It is
important to note that these findings should be applied with caution, especially in policy
making. Interventions producing a significant effect on the vaccine uptake may come at a
cost, both direct financial and indirect. Further research is needed in many additional areas
and disciplines to have a complete understanding of the impact of mandates, other than its
direct impact on doses. This includes evaluating the costs of implementation of vaccine
incentives and mandates, assessing individuals’ willingness to trust authorities or vaccines,
as well as the effect on civil liberties and collateral effects such as forging the evidence
of immunization status. The COVID-19 pandemic has highlighted many inadequacies in
public health response, but has also been a demonstration of ingenuity. It is obvious that
high level of vaccine hesitancy is reflected in lower vaccine uptake. At the same time, we
did not find clear difference in the effectiveness of the interventions among the countries
with different levels of the vaccine acceptance. Yet, vaccination policies have varied impact
depending on context and setting. This in itself is an important outcome because it gives
countries the tools to learn from their own policies, as well as the policies of like nations.
Moving forward, long-term programs such as scientific outreach activities should be ongo-
ing to provide people with objective and transparent information and education regarding
vaccinations in order to improve the outcomes of emergency public health initiatives in the
future.

Author Contributions: Conceptualization and methodology, L.K., E.D.-N., A.T., and R.M.; formal
analysis and investigation, L.K., E.D.-N., and R.M.; writing—original draft preparation, L.K. and
R.M.; writing—review and editing, E.D.-N., R.M., L.K., and A.T.; supervision, A.T. and E.D.-N. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Publicly available datasets were analyzed in this study. This data can
be found here: [https://ourworldindata.org/coronavirus, accessed on 3 September 2022].
Conflicts of Interest: The authors declare no conflict of interest.
Vaccines 2022, 10, 1714 20 of 21

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