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 Preventive Medicine 145 (2021) 106406

Contents lists available at ScienceDirect

Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Removing conscientious objection: The impact of ‘No Jab No Pay’ and ‘No
Jab No Play’ vaccine policies in Australia
Ang Li a, b, *, Mathew Toll c, d
a
Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
b
Sydney Health Economics Collaborative, Sydney Local Health District, Camperdown, NSW, Australia
c
Department of Sociology and Social Policy, School of Social and Political Science, Faculty of Arts and Social Science, The University of Sydney, Camperdown, NSW,
Australia
d
LCT Centre for Knowledge Building, Faculty of Arts and Social Science, The University of Sydney, Camperdown, NSW, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Vaccine refusal and hesitancy pose a significant public health threat to communities. Public health authorities
Immunisation coverage have been developing a range of strategies to improve childhood vaccination coverage. This study examines the
Conscientious objection effect of removing conscientious objection on immunisation coverage for one, two and five year olds in Australia.
Vaccine refusal
Conscientious objection was removed from immunisation requirement exemptions for receipt of family assis­
Vaccine hesitancy
tance payments (national No Jab No Pay) and enrolment in childcare (state No Jab No Play). The impact of these
Non-medical exemptions
Vaccination policy national and state-level policies is evaluated using quarterly coverage data from the Australian Immunisation
Financial sanctions Register linked with regional data from the Australian Bureau of Statistics at the statistical area level between
Childcare entry requirements 2014 and 2018. Results suggest that there have been overall improvements in coverage associated with No Jab
Immunisation mandates No Pay, and states that implemented additional No Jab No Play and tightened documentation requirement
Interrupted time series policies tended to show more significant increases. However, policy responses were heterogeneous. The
improvement in coverage was largest in areas with greater socioeconomic disadvantage, lower median income,
more benefit dependency, and higher pre-policy baseline coverage. Overall, while immunisation coverage has
increased post removal of conscientious objection, the policies have disproportionally affected lower income
families whereas socioeconomically advantaged areas with lower baseline coverage were less responsive. More
effective strategies require investigation of differential policy effects on vaccine hesitancy, refusal and access
barriers, and diagnosis of causes for unresponsiveness and under-vaccination in areas with persistently low
coverage, to better address areas with persistent non-compliance with accordant interventions.

1. Introduction effective vaccination policies to sustain high immunisation coverage.

Vaccination is among the most effective presentative measures
against infectious diseases (Andre et al., 2008). Having a sufficient
proportion of the population immunised is required to protect the
community through sustained control of vaccine preventable diseases.
Although the majority of Australian children are immunised, main­
taining high immunisation coverage is imperative to prevent trans­
mission of serious diseases and reduce the risk of local outbreaks
(Australian Institute of Health and Welfare, 2017). Australia’s national
target for childhood coverage is 95%.
With the emergence of global anti-vaccination movements and
recent increases in measles cases in Australia, it is important to have
Since the introduction of the National Immunisation Program (NIP) in
1997, childhood immunisation coverage has had substantial increases in
Australia. NIP provided free vaccines for eligible people, introduced
school-entry immunisation requirements, and offered parental financial
incentives for immunisation. Under the NIP, receipt of the Child Care
Benefit (CCB) and Family tax Benefit (FTB) part A supplement was
linked with childhood immunisation status (Ward et al., 2013).1
During the period when conscientious objection on philosophical or
religious grounds was a valid exemption from immunisation re­
quirements for family assistance payments and childcare enrolment, the
percentage of children with conscientious objection recorded an in­
crease from 0.23% in 1999 to 1.34% in 2015 (Department of Health,

* Corresponding author at: Faculty of Medicine and Health, Level 2 Charles Perkins Centre D17, The University of Sydney, NSW 2006, Australia.
E-mail address: a.li@sydney.edu.au (A. Li).
1
The CCB replaced previous the Childcare Assistance Rebate and Childcare Cash Rebate in 2000, and the FTB Part A supplement replaced Maternity Immunisation
Allowance that discontinued 2012.

https://doi.org/10.1016/j.ypmed.2020.106406
Received 18 May 2020; Received in revised form 22 December 2020; Accepted 29 December 2020
Available online 1 January 2021
0091-7435/© 2020 Elsevier Inc. All rights reserved.
A. Li and M. Toll
2018). Targeting vaccine objection, the Australian government intro­
duced the No Jab No Pay legislation, implemented in January 2016, that
abolished conscientious objection exemptions from immunisation re­
quirements, which was linked to the eligibility for the CCB, Child Care
Rebate (CCR) and FTB-A supplement (Parliament of Australia, 2015-
16).2 Only parents of children who are fully immunised on the childhood
schedule (see Department of Health (2019b)), on a recognised catch-up
schedule, or with approved medical exemptions (e.g. medical contra­
indications and natural immunity) can receive these payments.
Several state governments augmented the financial penalties with
childcare enrolment restrictions under No Jab No Play that applied to
approved and licensed childcare centres. In January 2016, Victoria
(VIC) prohibited enrolment of unvaccinated children in early childhood
services unless they had medical exemptions or on a 16-week grace
period for vulnerable families. Meanwhile, Queensland (QLD) allowed
childhood services discretion not to enrol unvaccinated children. New
South Wales (NSW), which previously required children to be fully
immunised or hold an approved exemption to be enrolled in childcare
services since January 2014, removed the exemption in January 2018.3
Legislation in the remaining states and territories has been less stringent.
A timeline of relevant immunisation policies is displayed in Fig. 1.
Evidence on the effectiveness of mandatory immunisation policies on
childhood vaccination uptake is limited and mixed (Dubé et al., 2015;
Omer et al., 2009; Sadaf et al., 2013; Hull et al., 2020). There is scarce
evidence on the effectiveness of mandatory immunisation in childcare
centres and for countries other than the United States (Lee and Robinson,
2016). Many previous Australian studies lack baseline measurement or
control groups (Ward et al., 2012). Adoption of punitive mandates can
have unintended negative effects (Leask and Danchin, 2017). Removal of
conscientious objection can lead to an increase in numbers of medical
exemption claims (MacDonald et al., 2018), reduced equity in childcare
access (Beard et al., 2017), and failure to target under-vaccinated groups
not registered as objectors (Leask and Danchin, 2017). Australia has
consistent geographic clustering of vaccine objection (Beard et al., 2016),
2
These payments altogether could add up to $AU 15,000 a year (Leask and
Danchin, 2017). The government expected savings of AU$508.3 millions over
five years (Parliament of Australia, 2015-16). Within the 6 month of the
introduction of the No Jab No Pay, 5738 children whose parents were receiving
childcare payments and claiming vaccination objection had their children
vaccinated; and 148,000 previously under-vaccinated children were up-to-date
with their vaccination (Commonwealth of Australia, 2016).
3 6
During 2016–18, an interim vaccination objection form from parents could
still be accepted for childcare enrolment.
2
Preventive Medicine 145 (2021) 106406
Fig. 1. Main immunisation policies around financial
penalties and childcare enrolment.
Notes: The No Jab No Pay policy abolishes the con­
scientious objection from immunisation requirements
for eligibility of certain government payments. The
No Jab No Play policy prevents children who are not
immunised from enrolling in childcare centres, not
allowing conscientious objection as valid exemption.
Documentation requirements are to provide a state­
ment of immunisation status for childcare enrolment.
NSW, VIC, QLD, SA, WA, ACT and TAS are states and
territories in Australia. Source: Respective Public
Health Acts, Public Health Regulations, and Health
Amendment Acts across different years in each state
and territory; and National Centre for Immunisation
Research and Surveillance (2019).
which increases risks of outbreaks with unvaccinated clusters in informal
childcare arrangements (Leask and Danchin, 2017).
The current study aims to examine the effectiveness of removing
conscientious objection that affects government rebates and childcare
enrolment on immunisation coverage in Australia. In specific, non-
medical exemptions were removed for government payments (national
No Jab No Pay) and childcare enrolment (state No Jab No Play). The impact
of these national and state-level policies, largely targeting vaccine refusal,
is evaluated using coverage data from the Australian Immunisation Reg­
ister (AIR) linked with regional data from the Australian Bureau of Sta­
tistics (ABS) at the statistical area level 3 (SA3). The study considers
coverage rates for the vaccines on the NIP Schedule including Diphtheria,
tetanus, pertussis (DTP), Polio, Haemophilus influenzae type b (HIB),
Hepatitis B (HEP), Measles, mumps, rubella (MMR), Pneumococcal,
Meningococcal, Varicella, and full vaccination at one, two and five years of
age.4 Policy response heterogeneity is also examined by area socioeco­
nomic status, median income, numbers of FBT-A recipients and baseline
pre-policy coverage, due to potential effect modifying factors (Beard et al.,
2016; Beard et al., 2017; Leask and Danchin, 2017; Toll and Li, 2020).
2. Method
Data on childhood immunisation coverage are from the AIR for the
period 2014–2018.5,6 The AIR is a national register that records vaccines
given to all ages in Australia. Children enrolled in Medicare are regis­
tered on the AIR, which constitutes a nearly complete population
(Department of Health, 2007). The data contain quarterly vaccination
rates at the SA3 level at the milestone ages of one (12–15 months), two
(24–27 months) and five (60–63 months), for DTP, Polio, HIB, HEP,
MMR, Pneumococcal, Meningococcal, Varicella and full vaccination.
4
Based on the NIP Schedule, DTP, Polio, HIB, HEP, Pneumococcal and fully
immunised (Pneumococcal included in December 2013) are assessed at one
year of age. DTP, Polio, HIB, HEP, MMR, Meningococcal, Varicella and fully
immunised (Meningococcal, and MMR dose 2 and Varicella dose 1 included in
December 2014, and DTP dose 4 included in March 2017) are assessed at two
years of age. DTP, Polio, MMR and fully immunised (MMR removed in
December 2017) are assessed at five years of age.
5
The Australian Childhood Immunisation Register (ACIR) that recorded
vaccinations given to children under the age of 7 was expanded to become the
Australian Immunisation Register (AIR) that records vaccinations given to
people of all ages in September 2016.
Data involve only information publicly available and therefore no ethics
review was required.
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table 1
Summary statistics for immunisation coverage and regional characteristics, 2014–18.
2014 2015 2016 2017 2018

Mean SD Mean SD Mean SD Mean SD Mean SD

DTP 1 year olds 0.917 0.031 0.930 0.028 0.943 0.024 0.947 0.024 0.945 0.025
DTP 2 year olds 0.952 0.022 0.954 0.022 0.961 0.020 0.927 0.029 0.931 0.028
DTP 5 year olds 0.927 0.030 0.931 0.030 0.938 0.028 0.944 0.028 0.947 0.026
Polio 1 year olds 0.917 0.031 0.930 0.028 0.942 0.024 0.946 0.025 0.945 0.025
Polio 2 year olds 0.952 0.022 0.954 0.022 0.961 0.020 0.964 0.020 0.965 0.020
Polio 5 year olds 0.927 0.030 0.931 0.030 0.938 0.028 0.944 0.027 0.947 0.026
HIB 1 year olds 0.916 0.031 0.929 0.028 0.940 0.025 0.945 0.025 0.943 0.025
HIB 2 year olds 0.941 0.026 0.945 0.025 0.953 0.022 0.954 0.023 0.956 0.023
HEP 1 year olds 0.914 0.031 0.929 0.028 0.942 0.024 0.947 0.025 0.944 0.025
HEP 2 year olds 0.948 0.024 0.951 0.024 0.959 0.021 0.963 0.021 0.964 0.021
MMR 2 year olds 0.934 0.035 0.912 0.031 0.930 0.027 0.935 0.027 0.934 0.028
MMR 5 year olds 0.926 0.030 0.931 0.030 0.939 0.029 0.956 0.025
Pneumococcal 2 year olds 0.914 0.031 0.927 0.028 0.940 0.025 0.943 0.025 0.950 0.027
Meningococcal 2 year olds 0.934 0.027 0.942 0.027 0.951 0.023 0.954 0.023 0.955 0.023
Varicella 2 year olds 0.902 0.034 0.913 0.030 0.929 0.027 0.929 0.027 0.926 0.029
Fully 1 year olds 0.909 0.032 0.923 0.029 0.935 0.026 0.940 0.026 0.939 0.026
Fully 2 year olds 0.916 0.038 0.894 0.036 0.915 0.030 0.906 0.032 0.909 0.032
Fully 5 year olds 0.922 0.031 0.926 0.031 0.931 0.030 0.939 0.029 0.946 0.026
Median age 38.573 4.584 38.707 4.699 38.848 4.826 38.997 4.884 38.848 4.791
Total fertility rate 1.965 0.329 1.916 0.324 1.876 0.311 1.864 0.311 1.885 0.313
IRSAD 999.246 68.382 999.342 68.633 999.320 68.559 999.362 68.454 999.474 68.550
Gini coefficient 0.463 0.051 0.461 0.048 0.463 0.048 0.463 0.049 0.462 0.048
Working age population (%) 65.789 4.581 65.523 4.665 65.193 4.797 64.940 4.868 65.226 4.773
Population density (,000) 2.502 6.461 2.540 6.546 2.595 6.655 1.016 1.415 1.041 1.448
Median income (,000) 49.517 8.200 49.953 8.229 50.167 8.070 48.275 7.900 47.884 7.784
No. FTB A (,000) 4.950 3.617 4.863 3.610 4.799 3.611 4.676 3.589 4.504 3.516
No. FTB B (,000) 4.282 3.139 4.241 3.158 3.947 3.034 3.695 2.878 3.571 2.828
No. people w/insurance (,000) 23.048 15.136 24.202 15.891 24.768 16.303 23.988 15.769 24.491 16.091
No. jobs for females (,000) 27.559 16.313 27.778 16.599 27.982 16.981 27.754 16.618 27.883 16.784
No. jobs for males (,000) 30.181 18.199 30.312 18.448 30.361 18.822 30.265 18.470 30.340 18.625
No. observations 3749 3759 3761 3760 3757
No. SA3s 319 319 321 320 321

Notes: There were a few changes in the antigens assessed for the coverage calculation at milestone ages (Department of Health, 2019a). In December 2013, Pneumococcal
for children aged 12–15 months was included. In December 2014, Meningococcal and dose 2 MMR and dose 1 varicella (MMRV) for children aged 24–27 months were
included. In March 2017, dose 4 DTP for children aged 24–27 months was included. In December 2017, dose 2 MMR for children aged 60–63 months was removed.

There were 358 SA3 regions covering Australia in 2016. SA3s
generally have a population between 30,000 to 130,000 people, closely
align with Local Government Areas, and represent areas with district
identity and similar socioeconomic characteristics (ABS, 2016a). Non-
spatial SA3s that cannot be mapped in each state or territory are
recorded with one coverage rate in each state or territory at each age
group without identification codes. These non-mapped SA3s are not
included in the main study but used for robustness checks. Coverage
rates for SA3s with fewer than 50 individuals, around 20 SA3s per
quarter per age group, were supressed and not included in the study.
Data on regional characteristics at the SA3 level were obtained from the
ABS and included variables for population, economy, income, educa­
tion, employment, health, and family.7 The regional data from the ABS
were matched with the coverage data from the AIR using SA3 identifi­
cation for SA3s with more than 50 individuals.
The analytical approach is based on an interrupted time series (ITS)
framework. ITS approaches account for pre-intervention trends and are
well-suited to studies of population-level interventions occurring at a
defined time point. A before and after or ITS method was applied to
compare changes in vaccination coverage before and after No Jab No
Pay. A difference-in-difference (DID) or controlled ITS method was
applied to compare the difference in the changes of vaccination
coverage across states and territories with state-level immunisation
policies of different degrees of stringency, that is, before and after No Jab
No Play and tightened documentation requirement policies.
7
Most measures used in the study are available from 2014 to 2018 and some
are only available until 2017, including median income, Gini coefficient, the
number of jobs, and the number of private insurance holders. These variables
are extrapolated to 2018 using a simple moving average method.
Generalised linear models with a binomial distribution and a logit
link function were used to explore the association of immunisation
coverage at each age group with policy indicators, adjusting for regional
sociodemographic characteristics, states and territories indicators,
quarter indicators, and national and state time trends. Standard errors
were adjusted for unspecified heteroscedasticity and within-SA3 corre­
lation over time. The specification is as follows:
(
Coverageijt = f Post year1t + Post year2t + Post year3t + Post year1t
/ /
× state territoryj + Post year2t × state territoryj + Post year3t
/ / /
× state territoryj + state territoryj × Tt + state territoryj
/
× Tt2 + Tt + Tt2 + state territoryj + quartert + Xijt
)
The unit of analysis is at the state-SA3-quarter level. The dependent
variables are childhood vaccination coverage rates of DTP, Polio, HEP,
HIB, Pneumococcal, Meningococcal, MMR, Varicella and full vaccination
for one, two- and five-year olds at SA3 i, state or territory j, and quarter t.
Linear and quadratic time terms control for secular trends shown in the
coverage rates at the national and state or territory level over time. State
or territory indicators control for time-invariant unobserved factors
common within states or territories, and quarter fixed affects account for
any seasonal variations. Estimates are expressed as average marginal
effects (AMEs). A series of robustness checks were performed on sample
selection and model specification (see Appendix B).
Several coefficients are of interest for policy evaluation. The co­
efficients on Post year1t, Post year2t, and Post year3t measure the change
in the level of coverage post-implementation of No Jab No Pay at the
national level in 2016, 2017 and 2018 compared to pre-policy
(2014–2015). The coefficients on Post year1t × state/territoryj, Post
year2t × state/territoryj, and Post year3t × state/territoryj measure the

3
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

difference in the change of coverage after implementation of national

and state policies between states and territories.
The regional sociodemographic covariates (Xijt) include proportions
of working age population aged 15–64, median age of usual residents,
total fertility rates, population density, median total income, Gini co­
efficient, numbers of FTB-A and FTB-B cases, numbers of jobs for males
and females, numbers of taxpayers with private health insurance, and
the Index of Relative Socio-economic Advantage and Disadvantage
(IRSAD) quintiles.8 IRSAD summarises information on income, educa­
tion, occupation, and dwelling conditions of people and households
within an area (ABS, 2016b).
Heterogeneity analyses were also performed according to potential
policy effect modifying variables. The model specification included in­
teractions of policy indicators (post year dummies and their interactions
with state dummies) and indicators for area socioeconomics, median
income, numbers of FBT-A recipients, and baseline coverage in 2014.

3. Results

3.1. Summary of coverage rates

The sample mean and standard deviation of SA3-level immunisation

coverage rates for one, two and five age groups and regional covariates
from 2014 to 2018 are reported in Table 1. The coverage rates have been
high across the country and have improved over time. There are sig­
nificant variations at the SA3-level with the full immunisation coverage
in 2014 ranging from 76.9% to 100%, 73.6% to 100%, and 77.5% to
100% for one, two and five years olds, although the variation in local
coverage rates has decreased over time. Regional factors reveal the
general social trends in Australia.
Fig. 2 shows changes in quarterly coverage rates for each state and
territory over time by age groups. Quarterly coverage rates are calculated
as the weighted mean of coverage rates at each quarter, in each state or
territory, and for each age group. Coverage for one year olds shows
different rates of change before and after 2016, coverage for two year olds
has been increasing at a decreasing rate since September–December 2014,
and coverage for five year olds was more linear over time. Coverage rates
in ACT and VIC were among the highest across the country.
Tables 2, 3 and 4 present the main policy effect estimates from
generalised linear models for the effect of No Jab No Pay, No Jab No Play,
and tightened documentation requirement policies related to removal of
conscientious objection on childhood vaccination coverage for various
vaccines at one (Table 2), two (Table 3) and five (Table 4) years of age,
respectively. The results for other covariates (see Table A2, A3 and A4),
overall policy effects at the national level (Table A1), and robustness
checks (Table B1) are reported in the Appendix. At the national level, there
have been significant increases in coverage, with the increase for one and
two years olds showing stabilisation in the third year post No Jab No Pay
and the increase for five years olds being more persistent (Table A1).

3.2. Vaccine coverage among one-year-old cohorts

Controlling for national and state time trends and state fixed effects,
compared to pre policy, No Jab No Pay and No Pay No Play in January 2016
were associated with increases in coverage across vaccines in VIC and QLD Fig. 2. Coverage rates of full vaccination among states and territories by age
by 2–4 percentage points, with QLD showing more significant increases. groups, 2014–18.
No Jab No Pay in January 2016 led to an increase in coverage in NSW by Notes: NSW, VIC, QLD, SA, WA, ACT and TAS are eight states and territories in
around 2 percentage points in 2016, 2.7 percentage points in 2017, and Australia. In December 2014, Meningococcal and dose 2 MMR and dose 1
varicella (MMRV) were included in the definition of fully immunised for the 2-
years-olds, and in March 2017, dose 4 DTP was included in the definition of
8
Logarithmic transformations are conducted for population density, median fully immunised for the 2-years-olds. These changes explained the drops in the
income, the number of FTB cases, the number of private insurance holders, and 2-year-olds coverage rates (Department of Health, 2019a).
the number of female and male jobs to adjust for the large scale across obser­
vations. The log of population density is constructed as the log of population
density plus one to adjust for less-than-one values. Median income is inflated to
2018 dollars using the Consumer Price Index from the ABS.

4
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table 2
Effects of immunisation policies on coverage for one year olds.
DTP Polio HIB HEP Pneumo Fully

VIC Post y1 vs pre 0.023** 0.022** 0.015 0.023** 0.053*** 0.013

(0.010) (0.010) (0.010) (0.010) (0.012) (0.010)
Post y2 vs pre 0.027** 0.025** 0.019 0.026** 0.051*** 0.015
(0.012) (0.012) (0.012) (0.012) (0.014) (0.012)
Post y3 vs pre 0.019 0.017 0.011 0.016 0.035** 0.004
(0.015) (0.015) (0.015) (0.016) (0.017) (0.016)
QLD Post y1 vs pre 0.033*** 0.032*** 0.025** 0.032*** 0.069*** 0.024**
(0.011) (0.011) (0.011) (0.011) (0.014) (0.011)
Post y2 vs pre 0.037*** 0.036*** 0.029** 0.034*** 0.067*** 0.026**
(0.013) (0.013) (0.013) (0.012) (0.015) (0.013)
Post y3 vs pre 0.036** 0.035** 0.028** 0.032** 0.062*** 0.026*
(0.015) (0.015) (0.014) (0.014) (0.017) (0.014)
NSW Post y1 vs pre 0.025** 0.024** 0.017* 0.025** 0.077*** 0.018*
(0.010) (0.010) (0.010) (0.010) (0.015) (0.011)
Post y2 vs pre 0.029** 0.028** 0.022* 0.029** 0.086*** 0.027**
(0.012) (0.012) (0.011) (0.011) (0.016) (0.012)
Post y3 vs pre 0.030** 0.029** 0.024* 0.029** 0.089*** 0.031**
(0.013) (0.013) (0.012) (0.012) (0.017) (0.013)
WA Post y1 vs pre 0.032** 0.030** 0.021 0.028** 0.069*** 0.018
(0.014) (0.014) (0.013) (0.013) (0.016) (0.013)
Post y2 vs pre 0.039** 0.038** 0.029* 0.036** 0.067*** 0.027*
(0.016) (0.016) (0.015) (0.016) (0.018) (0.015)
Post y3 vs pre 0.049*** 0.048*** 0.039** 0.045** 0.070*** 0.038**
(0.018) (0.018) (0.017) (0.018) (0.021) (0.017)
SA Post y1 vs pre 0.017* 0.016* 0.010 0.017* 0.048*** 0.009
(0.009) (0.009) (0.009) (0.009) (0.011) (0.010)
Post y2 vs pre 0.016 0.015 0.008 0.017 0.041*** 0.007
(0.012) (0.012) (0.012) (0.011) (0.013) (0.012)
Post y3 vs pre 0.007 0.007 − 0.002 0.004 0.026 − 0.001
(0.016) (0.016) (0.016) (0.016) (0.017) (0.016)
TAS Post y1 vs pre 0.021* 0.020 0.012 0.019 0.052*** 0.012
(0.012) (0.013) (0.012) (0.012) (0.015) (0.012)
Post y2 vs pre 0.013 0.011 0.003 0.009 0.043** 0.004
(0.015) (0.016) (0.015) (0.015) (0.018) (0.016)
Post y3 vs pre − 0.005 − 0.008 − 0.017 − 0.016 0.020 − 0.017
(0.023) (0.023) (0.023) (0.023) (0.026) (0.025)
NT Post y1 vs pre 0.032*** 0.030** 0.020* 0.014 0.057*** 0.016
(0.012) (0.012) (0.011) (0.011) (0.013) (0.010)
Post y2 vs pre 0.034* 0.032* 0.020 0.019 0.051*** 0.014
(0.018) (0.018) (0.019) (0.019) (0.020) (0.019)
Post y3 vs pre 0.027 0.023 0.009 0.012 0.038 0.003
(0.026) (0.025) (0.029) (0.032) (0.026) (0.026)
ACT Post y1 vs pre 0.017** 0.015* 0.012 0.018** 0.044*** 0.013
(0.008) (0.008) (0.008) (0.008) (0.010) (0.009)
Post y2 vs pre 0.009 0.008 0.001 0.011 0.033** − 0.001
(0.014) (0.014) (0.015) (0.015) (0.014) (0.017)
Post y3 vs pre 0.004 0.003 − 0.007 0.004 0.023 − 0.009
(0.022) (0.022) (0.027) (0.023) (0.021) (0.027)
Other covariates Yes Yes Yes Yes Yes Yes
States, quarters, trends Yes Yes Yes Yes Yes Yes

Notes: Generalised linear models with a logit link are estimated. AMEs and robust standard errors are reported. AMEs times 100% give percentage points. Significant at
***1%, **5% and *10%.

with the additional No Jab No Play in January 2018, around 3 percentage
points in 2018. No Jab No Pay and tightened documentation requirements
in 2016 led to a 2.7% increase in 2017 and a 3.8% increase in 2018 in full
vaccination for WA.9 Increases in other states have been less significant.
Coverage rates have significant upward time trends at the national
level that explains some of the increase in the coverage for one year olds
over time (coefficients not shown). The increasing time trends likely
reflect implementation of a series of government vaccination strategies
following the NIP such as state campaigns, reminder systems, financial
incentives for providers and parents, and broadened awareness of
vaccination among parents.
3.3. Vaccine coverage among two-years-old cohorts
Following No Jab No Pay and No Pay No Play in 2016, QLD had
significant increases in coverage in Polio, HIB and HEP by 0.7–0.9% in
2016 and 1.0–1.2% in 2017, more significant than the increases in VIC.
No Jab No Pay in 2016 was associated with increased coverage by
around 0.7% in 2016 and 1.2% in 2017 in NSW, and together with No
Jab No Play, by around 1.5% in 2018.10
3.4. Vaccine coverage among five-years-old cohorts
No Jab No Pay and No Jab No Play in QLD led to an increase in the full
vaccination by 0.8% in 2016, 2.5% in 2017, and 3.0% in 2018. These
two policies in VIC led to an increase in the full vaccination by 0.3%
(insignificant), 0.8% and 1.4% in 2016, 2017 and 2018 respectively. No
Jab No Pay was associated with a 0.3% (insignificant) increase in 2016
and a 0.7% increase in full vaccination for NSW, and the additional No

9
Note the increase in Pneumococcal was partially the artefact of its inclusion
for the coverage definition in December 2013.
10
Note that there were some changes in the coverage definition in DTP in
March 2017 and MMR, Varicella and Meningococcal in December 2014.

5
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table 3
Effects of immunisation policies on coverage for two years olds.
DTP Polio HIB HEP MMR Meningo Varicella Fully

VIC Post y1 vs pre 0.003 0.004* 0.005** 0.003 0.027*** 0.015** 0.031*** 0.026***
(0.002) (0.002) (0.002) (0.002) (0.004) (0.006) (0.008) (0.004)
Post y2 vs pre − 0.036*** 0.005 0.002 0.003 0.034*** 0.014* 0.028*** 0.016***
(0.004) (0.003) (0.004) (0.004) (0.005) (0.008) (0.010) (0.005)
Post y3 vs pre − 0.038*** 0.005 0.001 0.003 0.027*** 0.015 0.023* 0.003
(0.007) (0.005) (0.006) (0.005) (0.007) (0.010) (0.012) (0.009)
QLD Post y1 vs pre 0.008*** 0.007*** 0.009*** 0.007*** 0.035*** 0.021*** 0.040*** 0.033***
(0.002) (0.002) (0.002) (0.002) (0.004) (0.007) (0.008) (0.003)
Post y2 vs pre − 0.018*** 0.011*** 0.012*** 0.010*** 0.045*** 0.026*** 0.041*** 0.032***
(0.004) (0.004) (0.004) (0.004) (0.005) (0.008) (0.010) (0.005)
Post y3 vs pre − 0.018*** 0.008 0.009 0.008 0.041*** 0.023** 0.037*** 0.023***
(0.007) (0.006) (0.006) (0.006) (0.007) (0.010) (0.013) (0.008)
NSW Post y1 vs pre 0.006*** 0.007*** 0.006** 0.007*** 0.030*** 0.019*** 0.031*** 0.024***
(0.002) (0.002) (0.002) (0.002) (0.004) (0.007) (0.007) (0.003)
Post y2 vs pre − 0.030*** 0.011*** 0.006 0.012*** 0.039*** 0.023*** 0.028*** 0.010*
(0.004) (0.004) (0.004) (0.003) (0.006) (0.008) (0.010) (0.006)
Post y3 vs pre − 0.027*** 0.014*** 0.009 0.016*** 0.039*** 0.023** 0.025** − 0.001
(0.007) (0.005) (0.006) (0.005) (0.008) (0.010) (0.012) (0.009)
WA Post y1 vs pre 0.004 0.006 0.006 0.003 0.030*** 0.032*** 0.034*** 0.032***
(0.003) (0.004) (0.004) (0.004) (0.005) (0.009) (0.009) (0.005)
Post y2 vs pre − 0.052*** 0.007 0.009 0.006 0.036*** 0.037*** 0.031*** 0.021***
(0.006) (0.006) (0.007) (0.006) (0.007) (0.012) (0.012) (0.007)
Post y3 vs pre − 0.047*** 0.010 0.014 0.007 0.033*** 0.038*** 0.026* 0.014
(0.010) (0.010) (0.010) (0.010) (0.011) (0.014) (0.015) (0.011)
SA Post y1 vs pre 0.002 0.001 0.003 0.002 0.033*** 0.021*** 0.030*** 0.043***
(0.003) (0.004) (0.004) (0.004) (0.005) (0.007) (0.008) (0.006)
Post y2 vs pre − 0.048*** − 0.002 − 0.007 − 0.003 0.029*** 0.018* 0.017 0.021**
(0.008) (0.007) (0.007) (0.006) (0.008) (0.010) (0.011) (0.010)
Post y3 vs pre − 0.054*** − 0.012 − 0.018* − 0.013 0.018* 0.014 0.007 0.003
(0.012) (0.012) (0.010) (0.011) (0.011) (0.013) (0.015) (0.015)
TAS Post y1 vs pre − 0.001 0.002 0.012** 0.002 0.038*** 0.016* 0.034** 0.038***
(0.005) (0.005) (0.005) (0.005) (0.010) (0.008) (0.014) (0.010)
Post y2 vs pre − 0.049*** − 0.001 0.006 − 0.003 0.041*** 0.011 0.027 0.024*
(0.008) (0.005) (0.006) (0.005) (0.011) (0.012) (0.018) (0.013)
Post y3 vs pre − 0.075*** − 0.011 − 0.011 − 0.014 0.019 − 0.009 − 0.003 − 0.013
(0.024) (0.011) (0.012) (0.012) (0.021) (0.018) (0.030) (0.023)
NT Post y1 vs pre 0.010* 0.010* 0.016** 0.007* 0.042*** 0.019 0.056*** 0.039***
(0.005) (0.005) (0.008) (0.004) (0.011) (0.013) (0.020) (0.012)
Post y2 vs pre − 0.046*** 0.007 0.017** − 0.002 0.053*** 0.021 0.067** 0.030
(0.012) (0.008) (0.009) (0.006) (0.014) (0.014) (0.028) (0.020)
Post y3 vs pre − 0.067*** − 0.001 0.017 − 0.014 0.046*** 0.019 0.074** 0.012
(0.020) (0.016) (0.013) (0.013) (0.016) (0.020) (0.032) (0.027)
ACT Post y1 vs pre 0.002 0.003 0.002 0.004 0.025*** 0.012 0.027** 0.023***
(0.004) (0.007) (0.007) (0.008) (0.006) (0.011) (0.011) (0.006)
Post y2 vs pre − 0.033*** 0.001 − 0.005 0.003 0.035*** 0.014 0.040** 0.029**
(0.011) (0.016) (0.016) (0.017) (0.013) (0.018) (0.018) (0.013)
Post y3 vs pre − 0.051* − 0.006 − 0.025 − 0.006 0.016 0.010 0.038* 0.008
(0.030) (0.030) (0.040) (0.033) (0.023) (0.024) (0.022) (0.024)
Other covariates Yes Yes Yes Yes Yes Yes Yes Yes
States, quarters, trends Yes Yes Yes Yes Yes Yes Yes Yes

Notes: Generalised linear models with a logit link are estimated. AMEs and robust standard errors are reported. AMEs times 100% give percentage points. Significant at
***1%, **5% and *10%.

Jab No Play was associated with a 1.2% increase in 2018.11No Jab No Pay
and tightened documentation requirements in SA and WA brought about
2–3% increases in coverage. In particular, the increase in full vaccina­
tion was largely driven by the improvement in MMR. Significant in­
creases in coverage were not observed in the remaining states.
3.5. Regional factors associated with full vaccination coverage
The proportion of working age population, median age of usual
residents, population density and Gini coefficient were negatively
associated with the full vaccination coverage, while the number of
taxpayers who report having private health insurance was positively
correlated with full vaccination coverage (see Tables A2-4). Moreover,
vaccination coverage significantly decreased as area socioeconomic
status increased for one, two and five years olds.
11
MMR was not assessed at five years old since December 2017.
3.6. Response heterogeneity
Considering the concentration of recorded objection in more
advantaged areas (Beard et al., 2016), the greater effects of the policies
on lower-income families (Leask and Danchin, 2017), and the persistent
geographic clusters of recorded objection (Beard et al., 2017), the policy
response likely varied. The policy response heterogeneity was therefore
examined according to area socioeconomics, median income, numbers
of FBT-A recipients, and baseline coverage.
Fig. 3 panel (a) examines the overall policy effects on the full vacci­
nation coverage by area socioeconomic status measured by the IRSAD.
The increase in coverage associated with the policies was smallest in the
highest IRSAD quintile (most affluent and educated) for one and five
years olds, and in the second IRSAD quintile for two year olds.12 Overall,
12
Note that the mean of full vaccination coverage rates was highest in the
second quintile. The difference in coverage changes across the quintiles are not
significant for one year olds.

6
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table 4 reported in Fig. 3 panel (c).15No Jab No Pay policy linked childhood
Effects of immunisation policies on coverage for five years olds. immunisation to FTB-A supplements (2016–17) and FTB-A (2018-cur­
DTP Polio MMR Fully rent). Thus, there may be an interaction effect between the policy and
the number of FBT-A cases on coverage. It shows that the effect of the
VIC Post y1 vs pre 0.004 0.005* 0.003 0.003
(0.003) (0.003) (0.003) (0.003) policies increased as more people on FTB-A were in the area for one, two
Post y2 vs pre 0.007* 0.007* 0.016*** 0.008* and five year old cohorts.
(0.004) (0.004) (0.004) (0.004) Fig. 3 panel (d) presents the policy responses separately for SA3s
Post y3 vs pre 0.009* 0.009** 0.014*** with baseline pre-policy annual coverage in 2014 below and above 90%.
(0.005) (0.005) (0.005)
QLD Post y1 vs pre 0.010*** 0.010*** 0.008** 0.008**
The largest proportion of low baseline coverage occurred in the highest
(0.003) (0.003) (0.004) (0.004) quintile of the IRSAD, followed by the fourth, third, first, and second
Post y2 vs pre 0.022*** 0.021*** 0.034*** 0.025*** quintiles. The increase in areas with baseline coverage above 90% was
(0.004) (0.004) (0.004) (0.004) larger than that in areas with baseline coverage below 90%, and the
Post y3 vs pre 0.022*** 0.023*** 0.030***
positive policy effects mostly occurred in areas with higher baseline
(0.005) (0.005) (0.005)
NSW Post y1 vs pre 0.003 0.003 0.002 0.003 coverage. That is, the increase in immunisation coverage has been
(0.003) (0.003) (0.003) (0.003) largely driven by SA3s with relatively higher baseline coverage, which
Post y2 vs pre 0.004 0.003 0.014*** 0.007* tend to be socioeconomically disadvantaged areas.
(0.004) (0.004) (0.004) (0.004)
Post y3 vs pre 0.005 0.004 0.012***
(0.005) (0.005) (0.004)
4. Discussion
WA Post y1 vs pre − 0.000 − 0.001 0.003 0.001
(0.004) (0.004) (0.005) (0.004) The present study examines the associated impact of removing con­
Post y2 vs pre − 0.001 − 0.001 0.019*** 0.004 scientious objection exemptions from children vaccination requirements
(0.006) (0.006) (0.006) (0.006)
for access to family assistance payments (No Jab No Pay in 2016),
Post y3 vs pre 0.002 0.001 0.011
(0.008) (0.008) (0.008) enrolment in childcare (No Jab No Play in VIC and QLD in 2016 and NSW
SA Post y1 vs pre 0.013*** 0.013*** 0.017*** 0.014*** in 2018), and tightened documentation requirements for childcare
(0.005) (0.005) (0.006) (0.005) enrolment (WA in 2016 and SA in 2017). Overall, the results indicate that
Post y2 vs pre 0.015** 0.014** 0.033*** 0.019*** removing philosophical or religious exemptions was associated with in­
(0.006) (0.006) (0.006) (0.006)
Post y3 vs pre 0.018** 0.017** 0.027***
creases in the vaccination coverage at one (approx. 2–4%), two (approx.
(0.008) (0.008) (0.008) 1–1.5%) and five (approx. 1–3.5%) years of age. There have been overall
TAS Post y1 vs pre 0.006 0.005 0.006 0.003 improvements in coverage associated with No Jab No Pay, and states that
(0.005) (0.006) (0.006) (0.006) implemented additional No Jab No Play and tightened documentation
Post y2 vs pre 0.001 − 0.000 0.006 − 0.001
requirement policies tended to show more significant increases.
(0.009) (0.009) (0.007) (0.010)
Post y3 vs pre 0.002 0.000 0.006 Similar to the order of magnitude in this study, studies in the United
(0.009) (0.010) (0.010) States examining the removal of nonmedical exemptions from school
NT Post y1 vs pre − 0.023* − 0.024* − 0.019 − 0.024* entry requirements in California found an increase of nearly 3% in
(0.013) (0.013) (0.015) (0.014) kindergartener vaccination coverage in the first year, and a slight
Post y2 vs pre − 0.029** − 0.032** − 0.009 − 0.023*
(0.012) (0.013) (0.018) (0.013)
decrease of 0.45% in the second year (Bednarczyk et al., 2019; Delam­
Post y3 vs pre − 0.059* − 0.064** − 0.044* ater et al., 2019). The stabilisation of post-implementation trends has
(0.031) (0.032) (0.026) also observed for the one and two years olds. The increase in the
ACT Post y1 vs pre − 0.001 − 0.001 − 0.001 − 0.004 coverage of five years olds was more persistent and largely driven by
(0.007) (0.008) (0.008) (0.007)
MMR, which has been one of the most controversial vaccines since a
Post y2 vs pre 0.003 0.003 0.017 0.005
(0.013) (0.014) (0.012) (0.012) fraudulent study linked MMR with autism.
Post y3 vs pre − 0.004 − 0.000 0.000 However, the policy response was heterogenous. The changes in
(0.022) (0.021) (0.019) immunisation coverage post removal of conscientious objection was
Other covariates Yes Yes Yes Yes greatest in areas that were more socioeconomically disadvantaged, more
States, quarters, trends Yes Yes Yes Yes
government benefit dependent, with lower median income, and with
Notes: Generalised linear models with a logit link are estimated. AMEs and higher baseline coverage. The policies disproportionally affected lower
robust standard errors are reported. AMEs times 100% give percentage points. income families who were less likely to be vaccine objectors (Leask and
Significant at ***1%, **5% and *10%. Danchin, 2017) and have less means to arrange other informal childcare
coverage rates were less responsive in more socioeconomically advan­ (Helps et al., 2018; Leask and Danchin, 2017). Contrastingly, the
taged areas. improvement in immunisation coverage was smallest in more socio­
Fig. 3 panel (b) shows the policy effects on the full vaccination economically advantaged areas with lower baseline coverage. Smaller
coverage by logarithmised SA3-level median total income.13 Consistent improvement in these areas indicates that low immunisation coverage
with the findings for IRSAD gradients, the policy effects generally has been persistent at some local areas.
decreased as the level of median income increased. While the increase in Non-immunising parents are broadly comprised of refusing and hes­
coverage following removal of conscientious objection was around 3 itant parents who tend to be socioeconomically advantaged and accept­
percentage points for areas with the lowest median income, the increase ing parents who experience access barriers (Pearce et al., 2015; Toll and
was nearly zero for areas with the highest median income.14 Similarly, Li, 2020). The results imply that the areas with large proportions of
the policy effects were insignificant in affluent areas. motivated or persistent vaccine objectors who are affluent tend to have
Policy effect estimates by the number of FTB-A recipients are more persistently low vaccination and be less responsive to the elimina­
tion of conscientious objection. However, the areas with largely accept­
ing parents whose access issues have not been improved by the policies
will also have smaller responsiveness, depending on the size of the policy
13
The mean median income is $AU 49,517 with a range of 34,457-92,416. nudge relative to the barriers they face. These results imply that targeted
14
Note that most policy estimates show significance for two and five years
olds.
15
The mean number of FTB-A recipients is 4950 with a range of 591–19,450.

7
A. Li and M. Toll
Fig. 3. Effects of immunisation policies on full vaccination coverage rates by subgroups.
Notes: Generalised linear models with a logit link for full immunisation at 1, 2 and 5 years olds are estimated. AMEs on the overall post policy indicators are
displayed. AMEs times 100% give percentage points.
strategies, accordant with different causes of under-vaccination, at the
national or local area level might be needed to reach persistent non-
compliers and reduce risks of local outbreaks.
The study contributes to the literature on the effectiveness of
mandatory immunisation policies, including financial sanctions and
childcare entry requirements. Australia is among the first few jurisdic­
tions implementing regulations that remove non-medical exemptions to
childhood immunisation requirements. With more countries moving
towards implementing vaccination mandates, evidence from Australia
can assist effective policy designs to achieve high vaccination coverage.
Currently, there is a paucity of evidence on mandatory immunisation in
high-income regions with relatively high baseline rates (MacDonald
et al., 2018). A recent systematic review identifies a gap in studies
around immunisation mandates for childcare entry (Lee and Robinson,
2016).
This study provides empirical evidence on the effectiveness of
removing conscientious objection exemptions from vaccination re­
quirements linked to receipt of family assistance payments and/or child­
care enrolment. The investigation of vaccination coverage was conducted
for a range of scheduled vaccines at one, two and five years of age across
areas implemented with the policies. One of the key caveats is that the
variation in policy effects needs to be considered when implementing
mandatory immunisation programs. Given vulnerable families often sup­
port vaccination (MacDonald et al., 2018) and many areas with low
coverage have been persistent, future immunisation programs can be more
16
In the robustness checks, results for Varicella and MMR using only data after 2015 confirm similar findings (see Appendix B).
8
Preventive Medicine 145 (2021) 106406
effective if efforts are put in place to diagnose causes of under-vaccination
in areas with low coverage and small policy responses, and tailor accordant
interventions for for groups or areas with persistent non-compliance.
The study has a few limitations. First, ITS approaches assume that
pre-existing trends continue unchanged without the intervention. The
availability of counterfactual controls for No Jab No Pay would provide
more robust causality inference. Second, while the specification controls
for national and state-level time trends and state and quarter fixed ef­
fects, there might be some time-varying smaller-scale effects such as
client reminder and recall systems, home visits, and campaigns that
cannot be separated out from the main policy effects. Third, the study
did not assess the effectiveness of the policies separately for parents who
are refusing, hesitant, or facing access barriers that require individual-
level data, which would inform more targeted strategies to improve
coverage. Fourth, there have been changes in coverage definitions, such
as the inclusion of Pneumococcal in December 2013, DTP in March
2017, and MMR and Varicella in December 2014. For these vaccines, the
coverage changes post definition revision are mixed with policy effects,
although the results using only post definition period and findings for
other vaccines are similar.16
5. Conclusion
There has been an improvement in immunisation coverage with
implementation of vaccine mandates that remove conscientious
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

objection from vaccination requirements for government payments and refusal and access barriers, and a diagnosis of causes for lack of response
childcare enrolment. Australia has a high childhood vaccination rate, and under-vaccination in areas with persistently low coverage.
compared globally, but community immunity is contingent on high
coverage to reduce transmission risks of vaccine-preventable diseases.
Results suggest removing conscientious objection is a policy lever that Declaration of Competing Interest
improves vaccine coverage. However, more effective strategies require
an investigation of differential policy effects on vaccine hesitancy, None.

Appendix A

Table A1
Effects of immunisation policies on coverage rates at the national level.

One year olds

DTP Polio HIB HEP Pneumo Fully

Post y1 vs pre 0.026** 0.025** 0.018* 0.025** 0.065*** 0.017*

(0.010) (0.010) (0.010) (0.010) (0.013) (0.010)
Post y2 vs pre 0.029** 0.028** 0.022* 0.028** 0.065*** 0.021*
(0.012) (0.012) (0.012) (0.011) (0.014) (0.012)
Post y3 vs pre 0.027** 0.026** 0.019 0.024* 0.059*** 0.019
(0.013) (0.013) (0.013) (0.013) (0.015) (0.013)

Two years olds

DTP Polio HIB HEP MMR Meningo Varicella Fully

Post y1 vs pre 0.005*** 0.005*** 0.007*** 0.005*** 0.031*** 0.020*** 0.034*** 0.030***
(0.002) (0.002) (0.002) (0.002) (0.003) (0.006) (0.007) (0.003)
Post y2 vs pre − 0.033*** 0.008*** 0.006* 0.007** 0.039*** 0.022*** 0.032*** 0.020***
(0.003) (0.003) (0.003) (0.003) (0.004) (0.008) (0.009) (0.005)
Post y3 vs pre − 0.034*** 0.006 0.004 0.006 0.033*** 0.020** 0.026** 0.008
(0.005) (0.004) (0.005) (0.004) (0.006) (0.009) (0.011) (0.007)

Five years olds

DTP Polio MMR Fully

Post y1 vs pre 0.005** 0.005** 0.005* 0.004*

(0.002) (0.002) (0.002) (0.002)
Post y2 vs pre 0.009*** 0.008*** 0.021*** 0.011***
(0.003) (0.003) (0.003) (0.003)
Post y3 vs pre 0.009** 0.009** 0.017***
(0.004) (0.004) (0.004)
Other covariates Yes Yes Yes Yes Yes Yes Yes Yes
States, quarters, trends Yes Yes Yes Yes Yes Yes Yes Yes
Notes: Generalised linear models with a logit link for full immunisation at 1, 2 and 5 years olds are estimated. AMEs on the overall post policy indicators are displayed.
AMEs times 100% give percentage points.

Table A2
Effects of immunisation policies on coverage rates for one year olds.

DTP Polio HIB HEP Pneumo Fully

VIC Post y1 vs pre 0.023** 0.022** 0.015 0.023** 0.053*** 0.013

(0.010) (0.010) (0.010) (0.010) (0.012) (0.010)
Post y2 vs pre 0.027** 0.025** 0.019 0.026** 0.051*** 0.015
(0.012) (0.012) (0.012) (0.012) (0.014) (0.012)
Post y3 vs pre 0.019 0.017 0.011 0.016 0.035** 0.004
(0.015) (0.015) (0.015) (0.016) (0.017) (0.016)
QLD Post y1 vs pre 0.033*** 0.032*** 0.025** 0.032*** 0.069*** 0.024**
(0.011) (0.011) (0.011) (0.011) (0.014) (0.011)
Post y2 vs pre 0.037*** 0.036*** 0.029** 0.034*** 0.067*** 0.026**
(0.013) (0.013) (0.013) (0.012) (0.015) (0.013)
Post y3 vs pre 0.036** 0.035** 0.028** 0.032** 0.062*** 0.026*
(0.015) (0.015) (0.014) (0.014) (0.017) (0.014)
NSW Post y1 vs pre 0.025** 0.024** 0.017* 0.025** 0.077*** 0.018*
(0.010) (0.010) (0.010) (0.010) (0.015) (0.011)
Post y2 vs pre 0.029** 0.028** 0.022* 0.029** 0.086*** 0.027**
(0.012) (0.012) (0.011) (0.011) (0.016) (0.012)
Post y3 vs pre 0.030** 0.029** 0.024* 0.029** 0.089*** 0.031**
(0.013) (0.013) (0.012) (0.012) (0.017) (0.013)
WA Post y1 vs pre 0.032** 0.030** 0.021 0.028** 0.069*** 0.018
(continued on next page)

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A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table A2 (continued )
DTP Polio HIB HEP Pneumo Fully

(0.014) (0.014) (0.013) (0.013) (0.016) (0.013)

Post y2 vs pre 0.039** 0.038** 0.029* 0.036** 0.067*** 0.027*
(0.016) (0.016) (0.015) (0.016) (0.018) (0.015)
Post y3 vs pre 0.049*** 0.048*** 0.039** 0.045** 0.070*** 0.038**
(0.018) (0.018) (0.017) (0.018) (0.021) (0.017)
SA Post y1 vs pre 0.017* 0.016* 0.010 0.017* 0.048*** 0.009
(0.009) (0.009) (0.009) (0.009) (0.011) (0.010)
Post y2 vs pre 0.016 0.015 0.008 0.017 0.041*** 0.007
(0.012) (0.012) (0.012) (0.011) (0.013) (0.012)
Post y3 vs pre 0.007 0.007 − 0.002 0.004 0.026 − 0.001
(0.016) (0.016) (0.016) (0.016) (0.017) (0.016)
TAS Post y1 vs pre 0.021* 0.020 0.012 0.019 0.052*** 0.012
(0.012) (0.013) (0.012) (0.012) (0.015) (0.012)
Post y2 vs pre 0.013 0.011 0.003 0.009 0.043** 0.004
(0.015) (0.016) (0.015) (0.015) (0.018) (0.016)
Post y3 vs pre − 0.005 − 0.008 − 0.017 − 0.016 0.020 − 0.017
(0.023) (0.023) (0.023) (0.023) (0.026) (0.025)
NT Post y1 vs pre 0.032*** 0.030** 0.020* 0.014 0.057*** 0.016
(0.012) (0.012) (0.011) (0.011) (0.013) (0.010)
Post y2 vs pre 0.034* 0.032* 0.020 0.019 0.051*** 0.014
(0.018) (0.018) (0.019) (0.019) (0.020) (0.019)
Post y3 vs pre 0.027 0.023 0.009 0.012 0.038 0.003
(0.026) (0.025) (0.029) (0.032) (0.026) (0.026)
ACT Post y1 vs pre 0.017** 0.015* 0.012 0.018** 0.044*** 0.013
(0.008) (0.008) (0.008) (0.008) (0.010) (0.009)
Post y2 vs pre 0.009 0.008 0.001 0.011 0.033** − 0.001
(0.014) (0.014) (0.015) (0.015) (0.014) (0.017)
Post y3 vs pre 0.004 0.003 − 0.007 0.004 0.023 − 0.009
(0.022) (0.022) (0.027) (0.023) (0.021) (0.027)
Working age population % − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002***
(0.001) (0.001) (0.001) (0.001) (0.001) (0.001)
Median age − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Total fertility rate − 0.006 − 0.006 − 0.005 − 0.005 − 0.005 − 0.003
(0.006) (0.006) (0.006) (0.006) (0.006) (0.006)
Log population density − 0.001*** − 0.001*** − 0.002*** − 0.002*** − 0.002*** − 0.002***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000)
Log median total income 0.009 0.009 0.013 0.009 0.015 0.015
(0.012) (0.012) (0.013) (0.012) (0.012) (0.013)
IRSAD Q2 − 0.004 − 0.004 − 0.004 − 0.004 − 0.004 − 0.003
(0.003) (0.003) (0.003) (0.003) (0.003) (0.003)
IRSAD Q3 − 0.012*** − 0.012*** − 0.012*** − 0.013*** − 0.012*** − 0.012***
(0.004) (0.004) (0.004) (0.004) (0.004) (0.004)
IRSAD Q4 − 0.013*** − 0.013*** − 0.014*** − 0.014*** − 0.014*** − 0.015***
(0.004) (0.004) (0.004) (0.004) (0.004) (0.005)
IRSAD highest quintile − 0.014** − 0.014** − 0.014** − 0.016*** − 0.015** − 0.017***
(0.006) (0.006) (0.006) (0.006) (0.006) (0.006)
Gini coefficient − 0.207*** − 0.206*** − 0.212*** − 0.211*** − 0.222*** − 0.241***
(0.037) (0.037) (0.037) (0.039) (0.038) (0.039)
Log no. people on FTB-A 0.005 0.005 0.002 0.003 − 0.001 − 0.001
(0.021) (0.021) (0.021) (0.021) (0.021) (0.022)
Log no. people on FTB-B − 0.026 − 0.026 − 0.024 − 0.023 − 0.021 − 0.022
(0.020) (0.020) (0.020) (0.020) (0.020) (0.021)
Log no. insurance holders 0.029*** 0.029*** 0.027*** 0.028*** 0.025*** 0.026***
(0.008) (0.008) (0.008) (0.008) (0.008) (0.008)
Log no. jobs for females − 0.007 − 0.007 − 0.001 − 0.007 0.001 0.006
(0.018) (0.019) (0.019) (0.020) (0.019) (0.020)
Log no. jobs for males − 0.002 − 0.002 − 0.005 − 0.002 − 0.005 − 0.009
(0.018) (0.018) (0.018) (0.019) (0.019) (0.020)
Notes: Generalised linear models with a logit link are estimated. AME and robust standard error are reported. Significant at ***1%, **5% and *10%. The models with
and without allowing different slopes before and after 2016 had similar results.

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A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table A3
Effects of immunisation policies on coverage rates for two years olds.

DTP Polio HIB HEP MMR Meningo Varicella Fully

VIC Post y1 vs pre 0.003 0.004* 0.005** 0.003 0.027*** 0.015** 0.031*** 0.026***
(0.002) (0.002) (0.002) (0.002) (0.004) (0.006) (0.008) (0.004)
Post y2 vs pre − 0.036*** 0.005 0.002 0.003 0.034*** 0.014* 0.028*** 0.016***
(0.004) (0.003) (0.004) (0.004) (0.005) (0.008) (0.010) (0.005)
Post y3 vs pre − 0.038*** 0.005 0.001 0.003 0.027*** 0.015 0.023* 0.003
(0.007) (0.005) (0.006) (0.005) (0.007) (0.010) (0.012) (0.009)
QLD Post y1 vs pre 0.008*** 0.007*** 0.009*** 0.007*** 0.035*** 0.021*** 0.040*** 0.033***
(0.002) (0.002) (0.002) (0.002) (0.004) (0.007) (0.008) (0.003)
Post y2 vs pre − 0.018*** 0.011*** 0.012*** 0.010*** 0.045*** 0.026*** 0.041*** 0.032***
(0.004) (0.004) (0.004) (0.004) (0.005) (0.008) (0.010) (0.005)
Post y3 vs pre − 0.018*** 0.008 0.009 0.008 0.041*** 0.023** 0.037*** 0.023***
(0.007) (0.006) (0.006) (0.006) (0.007) (0.010) (0.013) (0.008)
NSW Post y1 vs pre 0.006*** 0.007*** 0.006** 0.007*** 0.030*** 0.019*** 0.031*** 0.024***
(0.002) (0.002) (0.002) (0.002) (0.004) (0.007) (0.007) (0.003)
Post y2 vs pre − 0.030*** 0.011*** 0.006 0.012*** 0.039*** 0.023*** 0.028*** 0.010*
(0.004) (0.004) (0.004) (0.003) (0.006) (0.008) (0.010) (0.006)
Post y3 vs pre − 0.027*** 0.014*** 0.009 0.016*** 0.039*** 0.023** 0.025** − 0.001
(0.007) (0.005) (0.006) (0.005) (0.008) (0.010) (0.012) (0.009)
WA Post y1 vs pre 0.004 0.006 0.006 0.003 0.030*** 0.032*** 0.034*** 0.032***
(0.003) (0.004) (0.004) (0.004) (0.005) (0.009) (0.009) (0.005)
Post y2 vs pre − 0.052*** 0.007 0.009 0.006 0.036*** 0.037*** 0.031*** 0.021***
(0.006) (0.006) (0.007) (0.006) (0.007) (0.012) (0.012) (0.007)
Post y3 vs pre − 0.047*** 0.010 0.014 0.007 0.033*** 0.038*** 0.026* 0.014
(0.010) (0.010) (0.010) (0.010) (0.011) (0.014) (0.015) (0.011)
SA Post y1 vs pre 0.002 0.001 0.003 0.002 0.033*** 0.021*** 0.030*** 0.043***
(0.003) (0.004) (0.004) (0.004) (0.005) (0.007) (0.008) (0.006)
Post y2 vs pre − 0.048*** − 0.002 − 0.007 − 0.003 0.029*** 0.018* 0.017 0.021**
(0.008) (0.007) (0.007) (0.006) (0.008) (0.010) (0.011) (0.010)
Post y3 vs pre − 0.054*** − 0.012 − 0.018* − 0.013 0.018* 0.014 0.007 0.003
(0.012) (0.012) (0.010) (0.011) (0.011) (0.013) (0.015) (0.015)
TAS Post y1 vs pre − 0.001 0.002 0.012** 0.002 0.038*** 0.016* 0.034** 0.038***
(0.005) (0.005) (0.005) (0.005) (0.010) (0.008) (0.014) (0.010)
Post y2 vs pre − 0.049*** − 0.001 0.006 − 0.003 0.041*** 0.011 0.027 0.024*
(0.008) (0.005) (0.006) (0.005) (0.011) (0.012) (0.018) (0.013)
Post y3 vs pre − 0.075*** − 0.011 − 0.011 − 0.014 0.019 − 0.009 − 0.003 − 0.013
(0.024) (0.011) (0.012) (0.012) (0.021) (0.018) (0.030) (0.023)
NT Post y1 vs pre 0.010* 0.010* 0.016** 0.007* 0.042*** 0.019 0.056*** 0.039***
(0.005) (0.005) (0.008) (0.004) (0.011) (0.013) (0.020) (0.012)
Post y2 vs pre − 0.046*** 0.007 0.017** − 0.002 0.053*** 0.021 0.067** 0.030
(0.012) (0.008) (0.009) (0.006) (0.014) (0.014) (0.028) (0.020)
Post y3 vs pre − 0.067*** − 0.001 0.017 − 0.014 0.046*** 0.019 0.074** 0.012
(0.020) (0.016) (0.013) (0.013) (0.016) (0.020) (0.032) (0.027)
ACT Post y1 vs pre 0.002 0.003 0.002 0.004 0.025*** 0.012 0.027** 0.023***
(0.004) (0.007) (0.007) (0.008) (0.006) (0.011) (0.011) (0.006)
Post y2 vs pre − 0.033*** 0.001 − 0.005 0.003 0.035*** 0.014 0.040** 0.029**
(0.011) (0.016) (0.016) (0.017) (0.013) (0.018) (0.018) (0.013)
Post y3 vs pre − 0.051* − 0.006 − 0.025 − 0.006 0.016 0.010 0.038* 0.008
(0.030) (0.030) (0.040) (0.033) (0.023) (0.024) (0.022) (0.024)
Working age pop % − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.003***
(0.001) (0.000) (0.001) (0.000) (0.001) (0.001) (0.001) (0.001)
Median age − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.001)
Total fertility rate 0.001 0.002 0.006 0.002 0.003 0.007 0.001 0.007
(0.005) (0.005) (0.005) (0.005) (0.006) (0.006) (0.006) (0.007)
Log population density − 0.002*** − 0.001*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.002*** − 0.003***
(0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.000) (0.001)
Log median income 0.004 0.020** 0.011 0.020** − 0.002 0.012 − 0.004 − 0.002
(0.011) (0.009) (0.011) (0.010) (0.013) (0.010) (0.013) (0.014)
IRSAD Q2 − 0.005** − 0.005*** − 0.006*** − 0.006*** − 0.005* − 0.006*** − 0.004 − 0.005
(0.002) (0.002) (0.002) (0.002) (0.003) (0.002) (0.003) (0.003)
IRSAD Q3 − 0.013*** − 0.013*** − 0.014*** − 0.014*** − 0.014*** − 0.016*** − 0.013*** − 0.013***
(0.003) (0.003) (0.003) (0.003) (0.004) (0.003) (0.004) (0.004)
IRSAD Q4 − 0.015*** − 0.015*** − 0.017*** − 0.016*** − 0.017*** − 0.019*** − 0.015*** − 0.018***
(0.004) (0.003) (0.004) (0.004) (0.005) (0.004) (0.005) (0.005)
IRSAD highest quintile − 0.018*** − 0.017*** − 0.019*** − 0.019*** − 0.018*** − 0.022*** − 0.015** − 0.019***
(continued on next page)

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A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table A3 (continued )
DTP Polio HIB HEP MMR Meningo Varicella Fully

(0.006) (0.005) (0.005) (0.005) (0.006) (0.005) (0.006) (0.007)

Gini coefficient − 0.212*** − 0.153*** − 0.207*** − 0.163*** − 0.284*** − 0.202*** − 0.277*** − 0.338***
(0.033) (0.029) (0.034) (0.031) (0.038) (0.036) (0.038) (0.040)
Log no. FTB A − 0.021 − 0.016 − 0.029 − 0.007 − 0.023 − 0.031* − 0.016 − 0.016
(0.019) (0.017) (0.018) (0.017) (0.022) (0.018) (0.022) (0.024)
Log no. FTB B − 0.002 0.000 0.007 − 0.008 − 0.003 0.010 − 0.008 − 0.017
(0.018) (0.016) (0.017) (0.016) (0.021) (0.017) (0.020) (0.022)
Log no. insurance 0.022*** 0.014** 0.018*** 0.015** 0.029*** 0.021*** 0.034*** 0.032***
(0.007) (0.006) (0.007) (0.006) (0.008) (0.007) (0.009) (0.009)
Log no. jobs, females − 0.001 0.001 0.011 − 0.005 0.002 0.017 − 0.007 0.015
(0.016) (0.015) (0.017) (0.016) (0.020) (0.018) (0.019) (0.021)
Log no. jobs, males 0.001 − 0.001 − 0.008 0.004 − 0.006 − 0.019 − 0.004 − 0.015
(0.016) (0.015) (0.017) (0.016) (0.019) (0.018) (0.019) (0.021)
Notes: Generalised linear models with a logit link are estimated. AMEs and robust standard errors are reported. Significant at ***1% **5% and *10%.

Table A4
Effects of immunisation policies on coverage rates for five years olds.

DTP Polio MMR Fully

VIC Post y1 vs pre 0.004 0.005* 0.003 0.003

(0.003) (0.003) (0.003) (0.003)
Post y2 vs pre 0.007* 0.007* 0.016*** 0.008*
(0.004) (0.004) (0.004) (0.004)
Post y3 vs pre 0.009* 0.009** 0.014***
(0.005) (0.005) (0.005)
QLD Post y1 vs pre 0.010*** 0.010*** 0.008** 0.008**
(0.003) (0.003) (0.004) (0.004)
Post y2 vs pre 0.022*** 0.021*** 0.034*** 0.025***
(0.004) (0.004) (0.004) (0.004)
Post y3 vs pre 0.022*** 0.023*** 0.030***
(0.005) (0.005) (0.005)
NSW Post y1 vs pre 0.003 0.003 0.002 0.003
(0.003) (0.003) (0.003) (0.003)
Post y2 vs pre 0.004 0.003 0.014*** 0.007*
(0.004) (0.004) (0.004) (0.004)
Post y3 vs pre 0.005 0.004 0.012***
(0.005) (0.005) (0.004)
WA Post y1 vs pre − 0.000 − 0.001 0.003 0.001
(0.004) (0.004) (0.005) (0.004)
Post y2 vs pre − 0.001 − 0.001 0.019*** 0.004
(0.006) (0.006) (0.006) (0.006)
Post y3 vs pre 0.002 0.001 0.011
(0.008) (0.008) (0.008)
SA Post y1 vs pre 0.013*** 0.013*** 0.017*** 0.014***
(0.005) (0.005) (0.006) (0.005)
Post y2 vs pre 0.015** 0.014** 0.033*** 0.019***
(0.006) (0.006) (0.006) (0.006)
Post y3 vs pre 0.018** 0.017** 0.027***
(0.008) (0.008) (0.008)
TAS Post y1 vs pre 0.006 0.005 0.006 0.003
(0.005) (0.006) (0.006) (0.006)
Post y2 vs pre 0.001 − 0.000 0.006 − 0.001
(0.009) (0.009) (0.007) (0.010)
Post y3 vs pre 0.002 0.000 0.006
(0.009) (0.010) (0.010)
NT Post y1 vs pre − 0.023* − 0.024* − 0.019 − 0.024*
(0.013) (0.013) (0.015) (0.014)
Post y2 vs pre − 0.029** − 0.032** − 0.009 − 0.023*
(0.012) (0.013) (0.018) (0.013)
Post y3 vs pre − 0.059* − 0.064** − 0.044*
(0.031) (0.032) (0.026)
ACT Post y1 vs pre − 0.001 − 0.001 − 0.001 − 0.004
(0.007) (0.008) (0.008) (0.007)
Post y2 vs pre 0.003 0.003 0.017 0.005
(continued on next page)

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A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table A4 (continued )
DTP Polio MMR Fully

(0.013) (0.014) (0.012) (0.012)

Post y3 vs pre − 0.004 − 0.000 0.000
(0.022) (0.021) (0.019)
Working age pop % − 0.003*** − 0.003*** − 0.002*** − 0.003***
(0.001) (0.001) (0.001) (0.001)
Median age − 0.002*** − 0.003*** − 0.002*** − 0.002***
(0.000) (0.000) (0.000) (0.000)
Total fertility rate − 0.001 − 0.001 0.003 0.001
(0.007) (0.007) (0.007) (0.007)
Log population density − 0.002*** − 0.002*** − 0.002*** − 0.003***
(0.001) (0.001) (0.001) (0.001)
Log median income 0.003 0.002 0.009 0.004
(0.013) (0.013) (0.015) (0.014)
IRSAD Q2 − 0.004 − 0.004 − 0.003 − 0.004
(0.003) (0.003) (0.003) (0.003)
IRSAD Q3 − 0.014*** − 0.014*** − 0.015*** − 0.014***
(0.004) (0.004) (0.004) (0.004)
IRSAD Q4 − 0.017*** − 0.017*** − 0.018*** − 0.017***
(0.005) (0.005) (0.005) (0.005)
IRSAD highest quintile − 0.019*** − 0.019*** − 0.022*** − 0.020***
(0.007) (0.007) (0.007) (0.007)
Gini coefficient − 0.248*** − 0.243*** − 0.230*** − 0.260***
(0.044) (0.044) (0.045) (0.046)
Log no. FTB A − 0.032 − 0.028 − 0.016 − 0.029
(0.024) (0.024) (0.026) (0.024)
Log no. FTB B 0.013 0.010 − 0.003 0.009
(0.022) (0.022) (0.024) (0.022)
Log no. insurance 0.024*** 0.025*** 0.023*** 0.024***
(0.009) (0.009) (0.009) (0.009)
Log no. jobs, females − 0.017 − 0.019 − 0.015 − 0.008
(0.023) (0.023) (0.024) (0.025)
Log no. jobs, males 0.008 0.009 0.008 0.002
(0.022) (0.022) (0.023) (0.024)
Notes: Generalised linear models with a logit link are estimated. AMEs and robust standard errors are reported. Significant at ***1%, **5% and *10%. The
models with and without quadratic trends had similar results.

Appendix B

A series of sensitivity checks are performed to check the robustness of the model specification (Table B1). First, the estimation is applied to a sample
containing non-mapped SA3s (column (1)). For this specification, regional variables are not included because these SA3s with no identification codes
cannot be matched with the ABS data. Second, the estimation is limited to a sample of SA3s observed consistently for 20 quarters from January 2014 to
December 2018 to check the influence of areas with small population (column (2)). Third, the interaction between post-policy indicators, state or
territory indicators, and linear trends are included to allow for changes in trends during post-implementation period for different states and territories
(column (3)). Fourth, state or territory-level time trends are replaced with SA3-level time trends to allow time trends to vary for different SA3s (column
(4)). Fifth, a fixed effect regression is modelled to remove time-invariant unobserved heterogeneity among SA3s (column (5)). Estimations using these
specifications produce similar results.
Sixth, the coverage for MMR at two years of age is modelled using the data starting from January 2015 and April 2015 respectively, after the
coverage measure amendment in September–December 2014, to obviate the effect of definition changes (column (6)). The estimates are slightly
smaller using April 2015 and onwards. Seventh, weights derived from the synthetic control method are applied to states and territories at different age
groups to test the effect of No Jab No Play in VIC (column (7)), NSW (column (8)) and QLD (column (9)) using counterfactual controls with similar pre-
intervention characteristics. This approach allows identification of a combination of control units that most closely resembles implemented units. SA,
WA, TAS, NT and ACT without No Jab No Play in place are adopted as the donor pool for the evaluation of No Jab No Play for VIC and QLD in 2016 and
for NSW in 2018. Regional factors, age-appropriate population, and coverage rates over the pre-intervention period are used as predictor variables.
Similarly, the results show that NSW, VIC and QLD have extended policy effects at five years of age. An estimation using NT as the control unit for
tightened documentation requirements in WA and SA shows that there is no significant difference between WA or SA and NT, except that SA has larger
increases than NT for the five-year-old cohorts (results not shown).

13
 A. Li and M. Toll
Table B1
Robustness checks on effects of immunisation policies on full vaccination coverage rates.

(1) (2) (3) (4)

1 year 2 years 5 years 1 year 2 years 5 years 1 year 2 years 5 years 1 year 2 years 5 years

Post y1 vs pre NSW 0.017* 0.022*** 0.002 0.017 0.022*** 0.004 − 0.002 0.005*** 0.002 0.019* 0.022*** 0.001
(0.010) (0.003) (0.002) (0.011) (0.003) (0.003) (0.002) (0.001) (0.003) (0.011) (0.003) (0.002)
VIC 0.010 0.024*** 0.000 0.010 0.025*** 0.003 − 0.004* 0.006*** 0.002 0.013 0.024*** 0.000
(0.009) (0.003) (0.002) (0.009) (0.004) (0.003) (0.002) (0.001) (0.004) (0.010) (0.004) (0.003)
QLD 0.021** 0.030*** 0.005* 0.023** 0.032*** 0.009*** 0.002 0.007*** 0.007 0.024** 0.032*** 0.006
(0.010) (0.003) (0.003) (0.010) (0.003) (0.003) (0.003) (0.001) (0.004) (0.010) (0.003) (0.003)
SA 0.007 0.039*** 0.012** 0.005 0.042*** 0.013** − 0.008 0.015*** 0.011 0.009 0.041*** 0.012**
(0.009) (0.006) (0.005) (0.010) (0.006) (0.005) (0.006) (0.001) (0.007) (0.009) (0.006) (0.005)
WA 0.014 0.030*** − 0.003 0.014 0.029*** 0.001 − 0.008*** 0.007*** − 0.001 0.018 0.030*** − 0.003
(0.011) (0.003) (0.003) (0.012) (0.005) (0.004) (0.003) (0.002) (0.004) (0.013) (0.005) (0.004)
TAS 0.007 0.037*** 0.001 0.006 0.039*** 0.006 − 0.003 0.015*** 0.006 0.014 0.036*** 0.002
(0.012) (0.011) (0.006) (0.013) (0.007) (0.004) (0.008) (0.003) (0.005) (0.012) (0.009) (0.006)
NT 0.012 0.036*** − 0.026* 0.019* 0.042*** − 0.035*** − 0.006 0.006*** − 0.038* 0.018* 0.039*** − 0.026
(0.010) (0.010) (0.015) (0.011) (0.012) (0.012) (0.008) (0.002) (0.021) (0.010) (0.011) (0.017)
ACT 0.011 0.020*** − 0.009 0.014 0.017*** − 0.004 0.003 0.005 − 0.004 0.013 0.020*** − 0.008
(0.009) (0.006) (0.006) (0.010) (0.005) (0.007) (0.005) (0.004) (0.009) (0.009) (0.005) (0.007)
Post y2 vs pre NSW 0.024** 0.008 0.003 0.025** 0.007 0.007* 0.005* 0.003** − 0.012 0.027** 0.007 0.005
(0.011) (0.005) (0.003) (0.012) (0.005) (0.004) (0.003) (0.001) (0.008) (0.012) (0.005) (0.004)
VIC 0.012 0.013*** 0.004 0.011 0.014** 0.008* 0.007** 0.004*** − 0.032** 0.015 0.011** 0.005
(0.011) (0.005) (0.004) (0.011) (0.005) (0.004) (0.003) (0.001) (0.014) (0.012) (0.005) (0.004)
QLD 0.021* 0.027*** 0.021*** 0.024* 0.029*** 0.025*** 0.010*** 0.006*** 0.027*** 0.026** 0.028*** 0.022***
(0.012) (0.005) (0.004) (0.013) (0.006) (0.004) (0.004) (0.001) (0.005) (0.012) (0.005) (0.004)
14

SA 0.005 0.015 0.015*** 0.004 0.020** 0.019*** 0.006 0.009*** 0.012 0.008 0.015 0.016**
(0.011) (0.010) (0.006) (0.012) (0.010) (0.007) (0.004) (0.002) (0.011) (0.012) (0.010) (0.006)
WA 0.019 0.017*** − 0.006 0.021 0.018** 0.004 − 0.000 0.004** − 0.033** 0.027* 0.016** − 0.000
(0.014) (0.006) (0.005) (0.015) (0.007) (0.006) (0.005) (0.002) (0.016) (0.015) (0.007) (0.006)
TAS − 0.003 0.019 − 0.004 0.000 0.023* 0.006 − 0.012 0.014*** − 0.054** 0.007 0.017 − 0.002
(0.016) (0.013) (0.010) (0.017) (0.012) (0.009) (0.024) (0.002) (0.025) (0.016) (0.012) (0.009)
NT 0.008 0.022 − 0.028** 0.029 0.030 − 0.038** 0.007 − 0.002 − 0.089 0.022 0.025 − 0.024
(0.018) (0.018) (0.014) (0.021) (0.023) (0.019) (0.009) (0.006) (0.070) (0.018) (0.020) (0.017)
ACT − 0.006 0.025* − 0.006 0.006 0.015* 0.005 0.005 0.009 − 0.052* − 0.000 0.023* 0.001
(0.018) (0.013) (0.012) (0.017) (0.009) (0.012) (0.006) (0.006) (0.030) (0.017) (0.012) (0.012)
Post y3 vs pre NSW 0.027** − 0.005 0.007* 0.028** − 0.005 0.013*** 0.023*** 0.013*** 0.022*** 0.030** − 0.007 0.011***
(0.012) (0.009) (0.004) (0.013) (0.009) (0.004) (0.002) (0.002) (0.007) (0.013) (0.009) (0.004)
VIC − 0.002 − 0.003 0.009** − 0.004 0.001 0.015*** 0.005 0.015*** 0.020*** 0.002 − 0.004 0.012**
(0.015) (0.009) (0.004) (0.014) (0.009) (0.005) (0.007) (0.002) (0.007) (0.015) (0.009) (0.005)
QLD 0.020 0.016* 0.024*** 0.024* 0.020** 0.030*** 0.018*** 0.017*** 0.019* 0.025* 0.017** 0.028***
(0.014) (0.009) (0.005) (0.014) (0.008) (0.005) (0.005) (0.001) (0.011) (0.014) (0.008) (0.005)
SA − 0.004 − 0.008 0.021*** − 0.001 0.004 0.027*** 0.014** 0.024*** 0.013 − 0.003 − 0.005 0.024***
(0.015) (0.016) (0.008) (0.016) (0.015) (0.008) (0.006) (0.003) (0.021) (0.016) (0.016) (0.008)

Preventive Medicine 145 (2021) 106406

WA 0.024 0.004 − 0.003 0.032* 0.009 0.011 0.022*** 0.019*** 0.014 0.036** 0.008 0.007
(0.016) (0.011) (0.008) (0.017) (0.011) (0.008) (0.005) (0.002) (0.016) (0.017) (0.011) (0.008)
TAS − 0.027 − 0.024 0.002 − 0.016 − 0.011 0.009 0.008 0.021*** 0.025 − 0.013 − 0.025 0.005
(0.025) (0.024) (0.011) (0.029) (0.027) (0.008) (0.029) (0.002) (0.015) (0.025) (0.025) (0.010)
NT − 0.008 − 0.001 − 0.053* 0.033 0.016 − 0.060*** 0.020*** 0.012* − 0.227 0.014 0.006 − 0.046
(0.027) (0.027) (0.029) (0.022) (0.031) (0.019) (0.005) (0.006) (0.157) (0.024) (0.027) (0.033)
ACT − 0.017 − 0.000 − 0.018 0.007 − 0.012 0.001 0.017*** 0.010 0.024 − 0.010 − 0.002 − 0.003
(0.030) (0.025) (0.023) (0.023) (0.023) (0.019) (0.003) (0.011) (0.020) (0.027) (0.024) (0.019)
Covariates Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
A. Li and M. Toll Preventive Medicine 145 (2021) 106406

Table B1
Robustness checks on effects of immunisation policies on full vaccination coverage rates (cont.)

(5) (6) (7) (8) (9)

1 year 2 years 5 years Jan 2015- Apr 2015- 1 year 2 years 5 years 1 year 2 years 5 years 1 year 2 years 5 years

Post y1 vs pre NSW 0.022** 0.024*** 0.004* 0.032*** 0.019*** 0.020 0.025*** 0.004
(0.009) (0.003) (0.003) (0.006) (0.005) (0.014) (0.004) (0.003)
VIC 0.018* 0.025*** 0.002 0.028*** 0.017** 0.026 0.024*** 0.005
(0.010) (0.004) (0.003) (0.009) (0.008) (0.016) (0.005) (0.004)
QLD 0.027*** 0.033*** 0.007** 0.035*** 0.018** 0.012 0.032*** 0.003
(0.009) (0.003) (0.003) (0.010) (0.009) (0.014) (0.004) (0.004)
SA 0.012 0.047*** 0.013** 0.025** 0.007 0.022 0.043*** 0.017*** 0.010 0.044*** 0.014*** − 0.001 0.042*** 0.010*
(0.010) (0.006) (0.005) (0.011) (0.009) (0.015) (0.006) (0.006) (0.012) (0.006) (0.005) (0.013) (0.006) (0.006)
WA 0.019* 0.031*** − 0.002 0.034*** 0.023* 0.035* 0.032*** 0.006 0.019 0.034*** 0.001 0.003 0.028*** − 0.007
(0.010) (0.004) (0.004) (0.013) (0.013) (0.021) (0.006) (0.006) (0.017) (0.006) (0.004) (0.016) (0.006) (0.004)
TAS 0.016 0.042*** 0.003 0.032* 0.023 0.024 0.038*** 0.005 0.013 0.040*** 0.004 0.002 0.038*** − 0.000
(0.013) (0.012) (0.007) (0.018) (0.016) (0.017) (0.011) (0.006) (0.015) (0.011) (0.006) (0.015) (0.011) (0.006)
NT 0.017* 0.038*** − 0.027 0.063*** 0.066** 0.031* 0.041*** − 0.024* 0.019 0.043*** − 0.025* 0.005 0.037*** − 0.029**
(0.009) (0.012) (0.017) (0.024) (0.026) (0.016) (0.012) (0.013) (0.013) (0.014) (0.015) (0.013) (0.012) (0.012)
ACT 0.024** 0.023*** − 0.003 0.050* 0.048* 0.024* 0.022*** − 0.001 0.015 0.026*** − 0.003 0.003 0.020*** − 0.011
(0.011) (0.005) (0.007) (0.027) (0.026) (0.014) (0.007) (0.008) (0.011) (0.007) (0.008) (0.011) (0.007) (0.008)
Post y2 vs pre NSW 0.035*** 0.009 0.010 0.056*** 0.034*** 0.026 0.012* 0.008*
(0.012) (0.007) (0.006) (0.010) (0.010) (0.016) (0.007) (0.004)
VIC 0.024* 0.013* 0.006 0.048*** 0.027** 0.027 0.013* 0.011**
(0.013) (0.007) (0.006) (0.013) (0.013) (0.019) (0.007) (0.005)
QLD 0.033*** 0.030*** 0.023*** 0.059*** 0.031** 0.013 0.031*** 0.019***
(0.013) (0.007) (0.005) (0.015) (0.014) (0.016) (0.007) (0.005)
SA 0.016 0.019* 0.018** 0.031* − 0.001 0.020 0.019* 0.023*** 0.006 0.023** 0.019*** − 0.006 0.020* 0.012*
(0.013) (0.011) (0.008) (0.016) (0.014) (0.018) (0.011) (0.007) (0.015) (0.011) (0.007) (0.016) (0.011) (0.007)
WA 0.032** 0.015* 0.000 0.058*** 0.037* 0.044* 0.020** 0.009 0.027 0.025*** 0.005 0.011 0.018** − 0.006
(0.014) (0.008) (0.008) (0.018) (0.019) (0.024) (0.009) (0.007) (0.020) (0.008) (0.007) (0.019) (0.009) (0.007)
TAS 0.013 0.021* − 0.002 0.045** 0.030 0.017 0.023* 0.003 0.004 0.026** 0.000 − 0.009 0.023* − 0.006
(0.016) (0.013) (0.011) (0.021) (0.021) (0.021) (0.013) (0.010) (0.019) (0.013) (0.010) (0.019) (0.013) (0.010)
NT 0.022 0.019 − 0.025 0.090*** 0.090*** 0.028 0.034 − 0.024* 0.015 0.037 − 0.024* 0.002 0.029 − 0.030**
(0.017) (0.024) (0.016) (0.025) (0.029) (0.025) (0.022) (0.013) (0.021) (0.023) (0.014) (0.021) (0.020) (0.012)
ACT 0.016 0.028** 0.006 0.075* 0.069* 0.011 0.027* 0.008 − 0.001 0.031** 0.006 − 0.014 0.026* − 0.005
(0.019) (0.013) (0.013) (0.041) (0.038) (0.020) (0.014) (0.013) (0.019) (0.014) (0.012) (0.020) (0.014) (0.013)
Post y3 vs pre NSW 0.042*** − 0.004 0.015* 0.077*** 0.047*** 0.026 − 0.000 0.013***
(0.014) (0.010) (0.008) (0.013) (0.014) (0.017) (0.011) (0.005)
VIC 0.017 − 0.001 0.011 0.062*** 0.034** 0.014 0.001 0.018***
(0.016) (0.011) (0.008) (0.015) (0.016) (0.023) (0.012) (0.006)
QLD 0.035** 0.020* 0.029*** 0.077*** 0.041** 0.011 0.023** 0.022***
(0.015) (0.010) (0.007) (0.017) (0.017) (0.018) (0.010) (0.006)
SA 0.010 − 0.000 0.024** 0.047** 0.008 0.010 0.001 0.031*** − 0.007 0.005 0.028*** − 0.017 0.003 0.018**
(0.016) (0.016) (0.011) (0.018) (0.018) (0.021) (0.018) (0.009) (0.019) (0.016) (0.008) (0.020) (0.017) (0.009)
WA 0.044** 0.005 0.005 0.080*** 0.049** 0.052** 0.013 0.018* 0.034 0.017 0.013 0.020 0.011 − 0.001
(0.018) (0.012) (0.010) (0.022) (0.023) (0.026) (0.014) (0.009) (0.021) (0.012) (0.008) (0.021) (0.013) (0.009)
TAS 0.000 − 0.017 0.002 0.050* 0.024 − 0.005 − 0.013 0.010 − 0.022 − 0.011 0.008 − 0.035 − 0.012 − 0.001
(0.021) (0.020) (0.013) (0.029) (0.032) (0.031) (0.023) (0.010) (0.029) (0.023) (0.011) (0.031) (0.024) (0.011)
NT 0.009 − 0.005 − 0.042* 0.104*** 0.093*** 0.017 0.015 − 0.046* 0.003 0.019 − 0.046 − 0.014 0.011 − 0.058**
(0.022) (0.031) (0.023) (0.026) (0.030) (0.031) (0.029) (0.027) (0.028) (0.030) (0.028) (0.029) (0.028) (0.025)
ACT 0.012 0.007 0.004 0.073 0.057 0.001 0.006 0.006 − 0.014 0.010 0.002 − 0.024 0.006 − 0.010
(0.027) (0.023) (0.020) (0.047) (0.045) (0.030) (0.025) (0.020) (0.030) (0.025) (0.019) (0.032) (0.025) (0.020)
Covariates Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Notes: Generalised linear models with a logit link are estimated. AMEs and robust standard errors are reported. AMEs times 100% give percentage points. Significant at
***1%, **5% and *10%.

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Title: Sonnets and madrigals of Michelangelo Buonarroti

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1900

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 S ON N E T S A N D
M A D R I GA L S
OF M I C H E L A N GE L O
B U ON A R R OT I
S O NNE T S A ND MADRIG A L S
O F MICHEL ANG EL O
BU O NA RRO T I

RE NDE RED INTO ENG L ISH

V ERSE BY WIL L IAM
WEL L S NEWEL L

WI T H ITAL IAN T EXT

I NT RO DU CT I O N
AN D N O T ES

H O U G H TO N
MIFFLIN AND
C O M PA N Y
MDCCCC
Copyright 1900 by William Wells Newell
All rights reserved
 CONTENTS
Michelangelo as Poet Page i
Sonnets ” 1
Epigrams ” 26
Madrigals ” 28
Notes ” 59
Index of First Lines ” 105
MICHELANGELO AS
POET
 MICHELANGELO AS
POET
MICHELANGELO, who considered himself as primarily sculptor,
afterwards painter, disclaimed the character of poet by profession.
He was nevertheless prolific in verse; the pieces which survive, in
number more than two hundred, probably represent only a small part
of his activity in this direction. These compositions are not to be
considered merely as the amusement of leisure, the byplay of fancy;
they represent continued meditation, frequent reworking, careful
balancing of words; he worked on a sonnet or a madrigal in the
same manner as on a statue, conceived with ardent imagination,
undertaken with creative energy, pursued under the pressure of a
superabundance of ideas, occasionally abandoned in dissatisfaction,
but at other times elaborated to that final excellence which exceeds
as well as includes all merits of the sketch, and, as he himself said,
constitutes a rebirth of the idea into the realm of eternity. In the
sculptor’s time, the custom of literary society allowed and
encouraged interchange of verses. If the repute of the writer or the
attraction of the rhymes commanded interest, these might be copied,
reach an expanding circle, and achieve celebrity. In such manner,
partly through the agency of Michelangelo himself, the sonnets of
Vittoria Colonna came into circulation, and obtained an acceptance
ending in a printed edition. But the artist did not thus arrange his own
rhymes, does not appear even to have kept copies; written on stray
leaves, included in letters, they remained as loose memoranda, or
were suffered altogether to disappear. The fame of the author
secured attention for anything to which he chose to set his hand; the
verses were copied and collected, and even gathered into the form
of books; one such manuscript gleaning he revised with his own
hand. The sonnets became known, the songs were set to music, and
the recognition of their merit induced a contemporary author, in the
seventy-first year of the poet’s life, to deliver before the Florentine
Academy a lecture on a single sonnet.
Diffusion through the printing-press, however, the poems did not
attain. Not until sixty years after the death of their author did a grand-
nephew, also called Michelangelo Buonarroti, edit the verse of his
kinsman; in this task he had regard to supposed literary proprieties,
conventionalizing the language and sentiment of lines which seemed
harsh or impolite, supplying endings for incomplete compositions,
and in general doing his best to deprive the verse of an originality
which the age was not inclined to tolerate. The recast was accepted
as authentic, and in this mutilated form the poetry remained
accessible. Fortunately the originals survived, partly in the
handwriting of the author, and in 1863 were edited by Guasti. The
publication added to the repute of the compositions, and the sonnets
especially have become endeared to many English readers.
The long neglect of Michelangelo’s poetry was owing to the
intellectual deficiencies of the succeeding generation. In spite of the
partial approbation of his contemporaries, it is likely that these were
not much more appreciative, and that their approval was rendered
rather to the fame of the maker than to the merits of the work. The
complication of the thought, frequently requiring to be thought out
word for word, demanded a mental effort beyond the capacity of
literati whose ideal was the simplicity and triviality of Petrarchian
imitators. Varchi assuredly had no genuine comprehension of the
sonnet to which he devoted three hours of his auditors’ patience;
Berni, who affirmed that Michelangelo wrote things, while other
authors used words, to judge by his own compositions could scarce
have been more sensible of the artist’s emotional depth. The
sculptor, who bitterly expressed his consciousness that for the
highest elements of his genius his world had no eyes, must have felt
a similar lack of sympathy with his poetical conceptions. Here he
stood on less safe ground; unacquainted with classic literature,
unable correctly to write a Latin phrase, he must have known, to use
his own metaphor, that while he himself might value plain homespun,
the multitude admired the stuffs of silk and gold that went to the
making of a tailors’ man. It is likely that the resulting intellectual
loneliness assumed the form of modesty, and that Michelangelo took
small pains to preserve his poetry because he set on it no great
value.

The verse, essentially lyric, owed its inspiration to experience. A

complete record would have constituted a biography more intimate
than any other. But such memorial does not exist; of early
productions few survive; the extant poems, for the most part, appear
to have been composed after the sixtieth year of their author.
The series begins with a sonnet written in 1506, when
Michelangelo was thirty-one years of age. The sculptor had been
called to Rome by pope Julius, who conceived that the only way to
ensure an adequately magnificent mausoleum was to prepare it
during his own lifetime. A splendid design was made for the
monument destined to prove the embarrassment of Michelangelo’s
career; but the pope was persuaded that it was not worth while to
waste his means in marbles, and in the spring of 1506 the artist fled
to Florence. In that city he may have penned the sonnet in which
Julius is blamed for giving ear to the voice of Echo (misreporting
calumniators) instead of holding the balance even and the sword
erect (in the character of a sculptured Justice). The writer adds a
bitter complaint of the injustice of fate, which sends merit to pluck the
fruit of a withered bough. Another sonnet of the period seems to
have been written in Rome; the subscription reads: “Your
Michelangelo, in Turkey.” The piece contains an indictment against
the papal court, at that time occupied with plans for military
advancement, where the eucharistic cup is changed into helmet, and
cross into lance; for safety’s sake, let Christ keep aloof from a city
where his blood would be sold dropwise. Work there is none, and the
Medusa-like pope turns the artist to stone; if poverty is beloved by
heaven, the servants of heaven, under the opposite banner, are
doing their best to destroy that other life. In 1509, a sonnet
addressed to Giovanni of Pistoia describes the sufferings endured in
executing the frescoes of the Sistine chapel. We are shown
Michelangelo bent double on his platform, the paint oozing on his
face, his eyes blurred and squinting, his fancy occupied with
conjecture of the effect produced on spectators standing below.
Allusion is made to hostile critics; the writer bids his friend maintain
the honor of one who does not profess to be a painter. While looking
upward to the vault retained in the memory of many persons as the
most holy spot in Europe, it is well to recollect the sufferings of the
artist, who in an unaccustomed field of labor achieved a triumph
such as no other decorator has obtained. A fourth sonnet, addressed
to the same Giovanni, reveals the flaming irritability of a temper
prone to exaggerate slights, especially from a Pistoian, presumably
insensible to the preëminence of Florence, “that precious joy.”
With this group can be certainly classed only one sonnet of a
different character (No. XX). This was penned on a letter of
December, 1507, addressed to Michelangelo at Bologna, where he
was then leading a miserable life, engaged on the statue of Julius;
this work, on which he wasted three years, was finally melted into a
cannon, in order that the enemies of the pope might fire at the latter
by means of his own likeness. The verse is a spontaneous and
passionate outburst of admiration for a beautiful girl. With this piece
might be associated two or three undated compositions of similar
nature, which serve to show the error of the supposition that the
artist was insensible to feminine attractions. It may be affirmed that
the reverse was the case, and that the thoughtful temper of the
extant poetry is due solely to the sobering influences of time.
The verse which might have exhibited the transition from early to
later manhood has not been preserved; during twenty years survive
no compositions of which the date is assured. Subsequently to that
time, assistance is derived from the fortunate accident that several of
the sonnets were written on dated letters. It is true that this indication
is far from furnishing secure testimony. Even at the present day,
when paper is so easily obtained, I have known a writer of rhyme
who was in the habit of using the backs of old letters. That
Michelangelo sometimes did the same thing appears to be
demonstrated by the existence of a sonnet (No. L), which, though
written on the back of a letter of 1532, professes to be composed in
extreme old age. The evidence, therefore, is of value only when
supported by the character of the piece. Nor is internal testimony
entirely to be depended on. It is to be remembered that all makers of
verse remodel former work, complete imperfect essays, put into form
reminiscences which essentially belong to an earlier stage of feeling.
Attempts to classify the productions must follow a subjective
opinion, very apt to err. Nevertheless something may be
accomplished in this direction.
The nephew states that two sonnets (Nos. XXIV and XXV) were
found on a leaf containing a memorandum of 1529. Extant is another
sonnet, certainly written on a page having an entry of that year.
These three sonnets seem to breathe the same atmosphere; the
emotion is sustained by a direct impulse, the verse is apparently
inspired by a sentiment too lyric to be unhappy; the employment of
theologic metaphor and Platonic fancy is still subsidiary to emotion.
Allowing for the imaginative indulgence of feeling common to lyrical
poets, it seems nevertheless possible to perceive a basis of personal
experience. With these pieces may be associated a number of
sonnets and madrigals, among the most beautiful productions of the
author, which may conjecturally be assigned to the period before his
permanent Roman residence, or at any rate may be supposed to
represent the impressions of such time. As compared with the work
which may with confidence be dated as produced within the ensuing
decade, these correspond to an earlier manner. Wanting the
direct and impetuous passion of the few youthful verses, they
nevertheless show a spiritual conception of sexual attachment, not
yet resolved into religious aspiration. They suggest that the
inflammable and gentle-hearted artist passed through a series of
inclinations, none of which terminated in a permanent alliance.
At the end of 1534, near his sixtieth year, Michelangelo came to
live in Rome; and to that city, three years later, Vittoria Colonna
came for a long visit, in the twelfth year of her widowhood, and the
forty-seventh of her life. An acquaintance may have been
established in the course of previous years, when the lady visited
Rome, or possibly even at a prior time. Whatever was the date of the
first encounter, allusions in the poems seem to imply that the
meeting produced a deep impression on the mind of the artist
(Madrigals LIV, LXXII). At all events, the relations of the two grew
into a friendship, hardly to be termed intimacy. Only a very few of the
poems are known to have been addressed to Vittoria; but the veiled
references of several pieces, and the tone of the poetry, appear to
justify the opinion that admiration for this friend was the important
influence that affected the character of the verse written during the
ten years before her death in 1547.
In Rome, the Marchioness of Pescara made her home in the
convent of San Silvestro, where she reigned as queen of an
intelligent circle. A charming and welcome glimpse of this society is
furnished by Francis of Holland, who professes to relate three
conversations, held on as many Sunday mornings, in which the
sculptor took a chief part. It is not difficult to imagine the calmness
and coolness of the place, the serious and placid beauty of the
celebrated lady, the figure of Michelangelo, the innocent devices by
which the sympathetic Vittoria contrived to educe his vehement
outbursts on artistic questions, the devout listening of the stranger,
hanging on the chief artist of Italy with the attention of a reporter who
means to put all into a book. So far as the conversation represents a
symposium on matters of art, no doubt the account is to be taken as
in good measure the method adopted by Francis to put before the
world his own ideas; but among the remarks are many so consonant
to the character of the sculptor that it is impossible to doubt the
essential correctness of the narration. In the language of
Michelangelo speaks haughty reserve, the consciousness of
superiority, accompanied by a sense that his most precious qualities
exceeded the comprehension of a world which rendered credit less
to the real man than to the fashionable artist, and whose attention
expressed not so much gratitude for illumination as desire of
becoming associated with what society held in respect.
 All students who have had occasion to concern themselves with
the biography of Vittoria Colonna have become impressed with the
excellence of her character. After the loss of a husband to whom she
had been united in extreme youth, she declared her intention of
forming no new ties; and it must have been an exceptional purity
which the censorious and corrupt world could associate with no
breath of scandal. She had been accounted the most beautiful
woman in Italy, of that golden-haired and broadbrowed type
recognized as favorite; but her intelligence, rather than personal
attractions or social position, had made her seclusion in Ischia a
place of pilgrimage for men of letters. The attraction she possessed
for the lonely, reserved, and proud artist is a testimony that to her
belonged especially the inexplicable attraction of a sympathetic
nature. Such disposition is a sufficient explanation of her devotion to
the memory of a husband who appears to have been essentially a
condottiere of the time, a soldier who made personal interest his
chief consideration. She may also be credited with a sound judgment
and pure ethical purpose in the practical affairs of life.
Yet to allow that Vittoria Colonna was good and lovable does not
make it necessary to worship her as a tenth muse, according to the
partial judgment of her contemporaries. Unfortunately, time has
spared her verses, respecting which may be repeated advice
bestowed by Mrs. Browning in regard to another female author, by
no means to indulge in the perusal, inasmuch as they seem to
disprove the presence of a talent which she nevertheless probably
possessed. In the case commented on by the modern writer, the
genius absent in the books is revealed in the correspondence; but
epistolary composition was not the forte of the Marchioness of
Pescara, whose communications, regarded as pabulum for a hungry
heart, are as jejune as can be conceived. Neither is she to be
credited with originality in her attitude toward political or religious
problems. It does not appear that she quarreled with the
principles of the polite banditti of her own family; nor was she able to
attain even an elementary notion of Italian patriotism. She has been
set down as a reformer in religion; but such tendency went no further
than a sincere affection toward the person of the founder of
Christianity, a piety in no way inconsistent with ritual devotion. When
it came to the dividing of the ways, she had no thought other than to
follow the beaten track. Nor in the world of ideas did she possess
greater independence; with all her esteem for Michelangelo as artist
and man, it is not likely that she was able to estimate the sources of
his supremacy, any more than to foresee a time when her name
would have interest for the world only as associated with that of the
sculptor. It may be believed that a mind capable of taking pleasure in
the commonplaces of her rhyme could never have appreciated the
essential merits of the mystic verse which she inspired. Here, also,
Michelangelo was destined to remain uncomprehended. Vittoria
presented him with her own poems, neatly written out and bound,
but never seems to have taken the pains to gather those of the artist.
Intellectually, therefore, her limitations were many; but she was
endowed with qualities more attractive, a gentle sympathy, a noble
kindness, a person and expression representative of that ideal
excellence which the sculptor could appreciate only as embodied in
human form.
While earlier writers of biography were inclined to exaggerate the
effect on Michelangelo of his acquaintance with Vittoria Colonna,
later authors, as I think, have fallen into the opposite error. To
Vittoria, indeed, whose thoughts, when not taken up with devotional
exercises, were occupied with the affairs of her family or of the
church, such amity could occupy only a subordinate place. One of
her letters to Michelangelo may be taken as a polite repression of
excessive interest. But on the other side, the poetry of the artist is a
clear, almost a painful expression of his own state of mind. We are
shown, in the mirror of his own verse, a sensitive, self-contained,
solitary nature, aware that he is out of place in a world for which he
lacks essential graces and in which he is respected for his least
worthy qualities. That under such circumstances he should value the
kindness of the only woman with whom he could intelligently
converse, that he should feel the attraction of eyes from which
seemed to descend starry influences, that he should suffer from the
sense of inadequacy and transitoriness, from the difference of
fortune and the lapse of years, the contrasts of imagination and
possibility, was only, as he would have said, to manifest attribute in
act, to suffer the natural pain incident to sensitive character.