Australia’s “no jab, no pay” policy has been associated with a drop in the number of children catching up on their first dose of the measles, mumps and rubella vaccine, suggesting the policy has had little impact on those who reject vaccination science. However, the policy was associated with more children catching up on their second dose of the vaccine and on their diphtheria–tetanus–pertussis vaccine, especially in lower socioeconomic status areas, the study published in the Medical Journal of Australia on Monday found. The no jab, no pay policy, introduced from January 2016, meant family and childcare payments would be withheld from people who claimed to be “conscientious objectors” to vaccination. To examine the impact of the policy, researchers from the National Centre for Immunisation Research and Surveillance and the University of Sydney analysed data from the Australian immunisation register for catch-up vaccinations of children aged five to under seven. They examined data from between January 2013 and December 2014, before the policy was introduced, to establish a baseline. They then compared that with data from the same age group during the first two years of the policy to December 2017, and examined data from children aged seven to under 10 and young people aged 10 to under 20 after the policy was introduced. “The proportion of children aged five to less than seven years who received catch-up MMR1 [first dose measles, mumps and rubella vaccine] vaccination was 13.6% (4,719 of 34,793 unvaccinated children) during the baseline period and 12.9% (4,169 of 32,321 unvaccinated children) during the ‘no jab, no pay’ period,” the study found. “Of 407,332 incompletely vaccinated adolescents aged 10 to less than 20 years, 71,502 (17.6%) received catch-up MMR2 [second dose measles, mumps and rubella vaccine] during the first two years of ‘no jab, no pay’. This increased overall coverage for this age group from 86.6% to 89.0%. MMR2 catch-up activity in this age group was greater in the lowest socioeconomic status areas than in the highest socioeconomic status areas (29.1% v 7.6%), and also for Indigenous than for non-Indigenous Australians (35.8% v 17.1%).” State-specific “no jab, no play” policies, adopted by four of eight jurisdictions by January 2020 and which permit children to attend childcare only if they are fully vaccinated “should not have affected our findings as they target children under five years of age”, the study stated. The associate director of the National Centre for Immunisation Research and Surveillance, Dr Frank Beard, led the study and said the findings suggested that while monetary sanctions were effective in promoting catch-up vaccination, their impact varied with socioeconomic disadvantage. He said this did not mean disadvantaged groups were vaccine refusers, given many of them had received their first dose of MMR1 and of diphtheria–tetanus–pertussis vaccine. More likely, issues such as access or language barriers might have been a more important factor in not receiving ongoing doses. Withholding family and childcare tax benefits would also affect this group more, prompting them to catch up under the policy, he said. Previous research had found wealthier parents appeared more likely to register a vaccine objection compared with more financially disadvantaged families. “This study found there was just no major change to that vaccine-objector group with the ‘no jab, no pay’ policy,” Beard said. “But on the positive side, a substantial number of people did catch up vaccination which led to modest increases in overall vaccine coverage. It was always thought by experts that the policy might have little impact on vaccine refusers. This study certainly provides evidence to support that.” Prof Julie Leask, an expert on vaccination attitudes and behaviour from the University of Sydney, said the policy simply served as a prompt for people already happy to vaccinate their children – but did not work on those who actively rejected vaccines. “We did in-depth interviews with this group for up to two hours, and we have done a number of studies with these vaccine-refusal groups now, and what we hear from them is that when you take away choice it causes a psychological reaction and it’s an anger towards having one’s choice removed,” Leask said. “That caused people to dig down more, and we saw that coming through in this study with parents continuing not to vaccinate despite the policy, and in fact it suggests some who were on the fence said, ‘That’s it, if they force me I won’t do it at all.’ ” Leask was concerned that by removing the conscientious objector exemption, which required people to have a signed note from their doctor or nurse, it removed an opportunity for healthcare providers to engage with those who refused vaccinations. “At least there was more of a chance of engagement with mainstream medical services which would continue to give parents opportunities to review their decision,” she said. “Another aspect often ignored in thinking about no jab no pay is that it means significant financial hardship for a minority of families who are vaccine refusers and that doesn’t just impact the parents, it means the kids are missing out too.”