The Ethicality of Mandatory COVID-19 Vaccinations in Uganda: A Qualitative Study

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Approximately 2.8 billion doses of COVID-19 vaccines were administered worldwide. Some studies have suggested that vaccination is the most effective strategy for mitigating COVID-19. However, due to vaccine hesitancy, many people end up shunning vaccinations. The parliamentary committee on health in Uganda proposed making coronavirus vaccinations mandatory and as a result, the Public Health Act was amended in 2022 making vaccinations of immunizable diseases mandatory. There has not been a scientific study to explore the views of healthcare workers, bioethicists, and the general public on the ethicality of mandatory COVID-19 vaccinations in Uganda. Methods This was a cross-section sectional study that employed in-depth interviews and focus group discussions. The study was conducted in Mulago National Referral Hospital, Makerere University, College of Health Sciences, Wandegeya, and Mulago areas. Fifteen participants were purposively selected based on their expertise for in-depth interviews and four groups of twenty-four members for focus group discussions. Data were transcribed verbatim and analyzed. The coding was both deductive and inductive. NVivo software 12 was used to support data analysis and illustrative quotes were extracted. Results The participants shared their perspective on the ethicality surrounding mandatory COVID-19 vaccinations. Opinions were divided: 21 participants supported the mandates, 5 expressed reservations, and 13 opposed them. Supporters argued that requiring vaccination helped reduce infection rates and that the overall benefits outweighed any potential risks. Those with reservations felt that, while mandates were necessary in principle, there were significant practical concerns, controversies, and shortcomings in their implementation. Opponents contended that such mandates infringed upon their personal autonomy. Conclusion This inquiry into the ethicality of mandatory COVID-19 vaccinations raised mixed views among the stakeholders, and implementors of vaccination programs should have put this in mind. Clinical Trial number: Not Applicable Ethicality Vaccine Mandates Bioethicists Healthcare workers General Public Introduction Coronavirus disease 2019, known as COVID-19 was an extremely expanding pandemic caused by a novel human coronavirus; severe acute respiratory syndrome-corona (Abdel Wahed et al., 2020 ). The coronavirus disease-2019 pandemic was a major global health crisis of the 21st century. About 2.3% of the world’s population was infected by the severe acute respiratory coronavirus-2 and more than 3.3 million people died (Bongomin et al., 2021 ). Approximately 2.8 billion doses of COVID-19 were administered, and 40.5 million have been administered each day globally. About 22.2% of the world population received at least one dose of the COVID-19 vaccine (Wong et al., 2021 ). The COVID-19 pandemic continued to cause devastating effects globally on economies as well as social aspects of life, some of these happened due to control strategies such as lockdowns (Kitonsa et al., 2021 ). Some studies suggested that vaccination was the most effective strategy for mitigating COVID-19 and restoring society's function. As the pandemic evolved with no certainty of a herd immunity threshold, universal vaccination of at-risk populations was desirable (Hagan et al., 2021 ). A common factor in COVID-19 vaccine allocation plans to date was the prioritization of healthcare personnel who are faced with a high risk of infection and transmission. At-risk populations included all frontline workers namely; physicians, nurses, physicians’ assistants, laboratory technicians, students on rotation, administrative staff, cleaning personnel, and security staff (Gur-Arie et al., 2021 ). By 2021, seven COVID-19 vaccines had been rolled out globally. Six hundred and forty-nine million doses have been administered globally, at a rate of 16.6 million doses per day (Bradfield & Giubilini, 2021 ). Africa lagged behind the rest of the world in rolling out the COVID-19 vaccine. Through COVAX, the global initiative to ensure rapid and equitable access to COVID-19 vaccines for all countries regardless of income level, Africa was guaranteed vaccines for 20% of its population, how, ever this was not enough for the continent, which was aiming to vaccinate at least 60% of its population (Adepoju, 2021 ). Despite their claim of proven efficacy in saving lives, as well as containing and eradicating the disease, vaccines were surrounded by controversy which include fear of possible side effects like infertility, the speed with which clinical trials were conducted (Carrasco-Polaino et al., 2021 ). COVID-19 vaccinations were hindered by vaccine hesitancy, which was an internationally prevalent phenomenon (Feleszko et al., 2021 ). Vaccine hesitancy was believed to be the main impediment that made COVID-19 vaccine mandates necessary. COVID-19 mandatory vaccination policies were put in place in different parts of the world (Savulescu, 2021 ). The Italian Republic provided for mandatory COVID-19 vaccinations for health professionals by Degree –Law of 1 April 2021 no 44, to guarantee public health and adequate safety conditions (Frati et al., 2021 ). Article 4 of the same Decree imposed vaccine mandates on HCWs in both public and private institutions and failure to comply would result in lawsuits (Vinceti, 2021 ). COVID-19 vaccine mandates in Ghana took two forms that is to say direct targeted mandatory vaccination and indirect mass mandatory vaccination. Consequently, a directive by the Ghana Health Service mandated all travelers coming into and leaving the country be fully vaccinated. Additionally, persons visiting certain public spaces, including beaches, restaurants, nightclubs, sports stadiums, the Ministry of Health, and other government agencies, had to show proof of vaccination. These directives were guided by Ghana’s Public Health Act section 22 which allowed the minister of health, by executive instrument, to order compulsory vaccination “generally or concerning a particular district, area or place or concerning a particular class or classes of persons.” Noncompliance was punishable by fine, three-month imprisonment, or both (Addadzi-Koom, 2022 ). Uganda’s Public Health (Amendment) Act 2022 legally equipped the government of Uganda to deal with emerging public health threats and emergencies. The Law provides for mandatory vaccination as a public health measure to protect the vulnerable. The Act also spells doomsday for vaccine skeptics and prescribes UGX 1 Million (Approx. 270 USD) penalty or half a year jail term for anyone convicted for spreading misleading statement of information regarding use of the vaccines (MOH, 2023). However, if such a law was to be implemented and optimize its intended goal, it should be widely supported by the key stakeholders in health care. There were no empirical ethical analysis of how the public thinks of the mandates and why (Attwell et al., 2021). Although attitudes towards mandatory vaccination have been investigated by several studies (Gualano et al., 2019), in Uganda, there has not been any scientific study to explore the views of stakeholders on a policy mandating COVID-19 vaccination. Therefore, this study aimed at exploring the views of health care workers, bioethicists and general public on the ethicality of mandatory COVID-19 vaccinations. Methods Study Design and setting This was a cross-sectional study using a qualitative method of data collection. The study was conducted in Mulago National Referral Hospital, Makerere University, college of Health Sciences, Wandegeya, and Mulago areas in Kampala District. Doctors were got from the Directorate of Internal Medicine in Mulago National Referral Hospital. Bioethicists were got from the College of Health Sciences at Makerere University. Research participants from the general public were got from Wandegeya and Mulago areas in Kampala District. Ten doctors were purposively selected for interviews based on their roles in the hospital. They were five male doctors and five female doctors. Selection was based on age, gender, field of specialty, and level of education. Purposive sampling ensures the identification and selection of individuals or groups of individuals that are especially knowledgeable about or experienced with a phenomenon of interest (Palinkas et al., 2015 ). For this study, a list of potential participants including their designations was obtained from the hospital administration to identify members who were then selected for interviews. Five bioethicists were purposively selected for interviews based on their roles and position in the University. Selection was based on experience. Use of relatively small samples in qualitative research helps us to obtain enough in-depth data from individuals to be able to capture variations in the individual’s perspectives and experiences related to the research question (Kielmann, 2012 ). For this study, a list of potential participants was provided by Bioethics Centre at Makerere University to identify members who were then selected for interviews. Four FGDs were purposively selected for the discussions. They were two FGDs for females and two FGDs for males per area. One FGD for females and one FGD for males from each area. Each FGD had six participants, totaling twenty-four participants. For this study, participants were identified by mobilizers from the areas of study, and the selection of these FGDs was based on age, sex, and level of education. Focus group discussions generate information on collective views, and are useful in generating a rich understanding of participants' experiences and beliefs (Gill et al., 2008 ). Data collection Data was collected through in-depth interviews (IDIs) and Focus Group Discussions (FGDs). English version of the guides has been uploaded as supplementary files. The guides consisted of open-ended questions that explored participants’ views on the ethicality of mandatory COVID-19 vaccinations. Open-ended questions allowed the easy flow of the discussions and provided participants with a platform to share their thoughts and opinions on mandatory COVID-19 vaccinations. The in-depth interview and FGD guides were pre-tested before data collection to ensure that the questions were clear and appropriate. The tools comprised questions on demographic information, age, gender, field of specialty, and level of education. In-depth interviews were used to explore the views of healthcare workers and bioethicists on the ethicality of mandatory COVID-19 vaccinations, and an interview guide was used. Participants gave written informed consent before the interviews. In-depth interviews provided an opportunity for a detailed investigation of each individual’s view about his or her experience and detailed coverage of the subject under study through one-on-one interaction. Focus Group Discussions were used to explore the views of the general public on the ethicality of mandatory COVID-19 vaccinations and a focus group discussion guide was used. Participants gave written informed consent before the discussions. Focus group discussions helped to bring out majority and minority perceptions, opinions, views, and experiences within the groups. FGDs provided a platform for a discussion and exploration of peoples’ views collectively. Data analysis All audio-recorded interviews were transcribed verbatim and checked for accuracy before analysis. Coding began once the data was fully transcribed. Data were categorized and organized in a theme and sub-themes which emerged from the coding process. The coding was done both inductively and deductively. Data verification was done by confirming codes across all transcripts and cross-checking with the recorded data. NVivo 12 was used to support data analysis and results were presented as narratives and quotes. Results Thirty-nine individuals participated in the study, of which 20 were male and 19 were female. Participants’ demographic information is summarized as shown in Table 1. One major theme and five themes were generated from the findings are summarized in Table 2. Table 1: Demographic characteristics of the participants Table 2: Emerged themes and subthemes Approval of mandatory COVID-19 vaccinations Most respondents were positive about COVID-19 vaccine mandates highlighting that the benefits outweighed the risks for example mandates reduced COVID-19 severity. They noted that it was a public health emergency and there was no time to negotiate. In addition, they highlighted that it could have costed the government more in terms of resources if mandates were not in place implying those who could have not been vaccinated would continue to spread the virus. They further stated that vaccine mandates increased vaccine uptake among health care workers which helped in reducing more COVID-19 cases and infections. On this subject, the respondents had the following to say. “I think it is the right approach because the benefits outweigh the risks. Those who get COVID will continue to spread it and this costs the government and society a lot of money which could have been prevented by vaccination. COVID-19 was a public health emergency and there was no time for negotiating. IDI- D8 “Well, we all know that people are always defiant. If the government had not brought the vaccine mandates, COVID-19 cases would have been much. Also, if people had an option of not taking the vaccines, they would not have been vaccinated, and we would have died in large numbers”. FGD 2- 3 Reser vations about mandatory COVID-19 vaccinations Most respondents emphasized that the vaccines were brought to the public without proper investigation highlighting that in the past, vaccines were developed in a thorough process, and by the time they came out, people had confidence in them. They further stated that the vaccines were developed faster than expected and hence bringing trial vaccines into circulation. But some respondents had confidence in vaccines since WHO handled the distribution which they believed could risk its reputation for giving out dangerous vaccines. For this reason, in the opinion of the majority of the respondents, it was difficult to ascertain the safety of the COVID vaccines, implying potential reservations about the ethicality of the COVID-19 vaccination mandate. This attitude was captured in the following quotations. “My honest feeling is ...these vaccines didn’t go through all the research process. Most vaccines in the past took a long to come out and we could have confidence that they have been through a thorough process. But for the case of COVID, the disease had just started and within a few months, they had already got the vaccine. So, they brought a trial vaccine into circulation”. IDI-D5 “Initially, I was a bit skeptical but one thing that gave me some confidence was the distribution of vaccines by WHO. I felt they cannot risk their reputation to give out something dangerous”. IDI-D8 Disapproval of mandatory COVID-19 vaccinations Some respondents felt that it was not right and not necessary to force COVID-19 vaccinations. They highlighted that mandatory COVID-19 vaccinations did not stop further reinfections despite their enforcement and therefore stated that the government had to explore other options besides mandates to mitigate the pandemic. They further stated that enforcing mandates deprived people of their right to self-determination. In addition, the respondents felt that the authorities had an obligation to explain to people the side effects, adverse events resulting from the COVID-19 vaccines as well as encouraging people to voluntarily vaccinate. This attitude was captured in the following quotations. “I don’t think it is right to force anyone to receive a vaccine. We also need to understand that enforcing mandates does not stop reinfections, the government had to explore other options”. IDI- D3 “Because of these forceful vaccinations, we got terrible side effects for example some men developed erectile dysfunction, and this affected our marriages. This increased domestic violence in families”. FGD 3- 6 Ethical issues in mandatory COVID-19 vaccinations Some respondents supported vaccine mandates in principle but highlighted that in practice it was doubtful, full of controversies, and had gaps. Most respondents noted highlighted that vaccine mandates were a good strategy, but the authorities did not give adequate information concerning these vaccines to the public. They noted that the authorities had to inform the public that the vaccines were trial vaccines, had not been fully approved, and were given on a compassionate basis. They further noted that the authorities did not clearly outline safety issues as they should have earlier. On this issue, the following quote was captured. “Mandating was okay, but the public was not given adequate information. It should have been clearer that these vaccines are trial vaccines and that they were being given on what we call a compassionate basis and that they had not been approved to be effective. Safety issues were not well outlined”. IDI-B5 On the other hand, some respondents noted that there was an infringement of individual rights in mandating COVID-19 vaccinations which greatly affected the principle of autonomy. They noted that forcing vaccinations was a clear violation of individual rights because people were not given a chance to decide on their own. However, some supported infringement of rights stating that the end justified the means because, in the long run, harm was minimized. On this issue, the respondents had the following to say. “It is well known that individuals have rights, and we saw there was a clear violation of these Individual rights, people were not given a chance to decide on their own”. IDI-B3 “It was necessary to limit liberties of individuals because the major aim was to protect people from harm. We all know the end always justifies the means”. IDI-B4 Worries about mandatory COVID-19 vaccinations A few of the respondents from the general public supported vaccine mandates in principle but were apprehensive. They noted that there was a lack of conclusive evidence on the safety and efficacy of the vaccines which questioned the mandates. They further noted that these vaccine mandates were political and that there was a motive for making them mandatory for example they stated that the authorities were looking for accountability for the Western world. On this issue, the respondents said the following. “I was not convinced with these mandates because there was a lack of adequate and conclusive evidence on the safety and efficacy of the vaccines in question. We didn’t understand how the government could mandate COVID-19 vaccinations without necessary evidence regarding safety. FGD 1- 4 “Vaccine mandates were political. Authorities wanted to account for the vaccines and funds got from the Western world. There must have been a motive to this otherwise this government cannot do something out of the blue”. FGD 4- 4 Discussion The findings show that the majority supported mandatory COVID-19 vaccinations. These respondents supported COVID-19 vaccination mandates because they increased vaccine uptake and minimized infection rates in healthcare settings. A similar study highlighted that COVID-19 vaccination mandates significantly decreased transmission among healthcare workers. Another study highlighted that a vaccine mandate was the most effective and least risky method to prevent disease spread (Sween et al., 2022 ). The findings greatly fulfilled the principles of non-maleficence and beneficence because mandatory COVID-19 vaccinations not only protected HCWs but also protected the health of patients, they attend to and hence minimization of harm. The findings show a strong debate on the infringement of individual rights. Interference with the right to autonomy raised split views amongst respondents where the majority supported infringement of individual rights on grounds of prevention of harm while some respondents highlighted that infringement on individual rights was a clear violation of the principle of autonomy. According to (Rodger et al, 2022), the COVID-19 vaccine mandate is a ‘minor infringement’ that is justified to protect others’ health. Another similar study highlighted that autonomy is paramount for individuals to make any decision related to COVID-19 vaccinations (Olick et al., 2021 ). Some respondents noted that vaccine mandates were clearly against the rights of the people and these rights are inherent regardless of race, sex, or any other status. Among these rights include liberty, freedom of opinion, and expression. According to international human rights documents like UDHR, these rights are fundamental and are supposed to be protected. However, civil liberties are not absolute and can be justifiably limited. This idea is commonly enshrined in law and constitutions, where there is a limitation to the rights of the individual for the interests of society. Arguing that vaccine mandates infringe on civil liberties is not enough to conclude they are necessarily ethically wrong. Further, vaccine mandates would advance civil liberties because they protect the most vulnerable like children (Smith & Emanuel, 2023 ). According to the Constitution of Uganda, Article 110 under a state of emergency, the President may take measures that are required to secure public safety (Uganda, 1995 ). The government had an obligation to prevent harm which justifies the suspension of the right to self-determination. From this view, vaccine mandates were a strong justification and evidence that in the measure, the government would achieve the calculated goal of public safety. With this, one would expect the public to be receptive to government initiatives in curbing the COVID-19 pandemic. One of the issues that came out clearly from the majority of the respondents was that the lack of conclusive evidence on the efficacy and safety of the vaccines worsened the case for mandatory vaccines. This is similar to a study on Public opinion of a mandatory COVID-19 vaccination policy in France in which a percentage of the general population highlighted the unclear safety profile of the COVID-19 vaccines (Gagneux-Brunon et al., 2022 ). The majority of the respondents highlighted that mandates were unethical given the insufficient evidence to back the safety of the vaccines. It is for this reason that the respondents linked some of the side effects which included erectile dysfunction and blood clots to vaccine inefficacy. Notwithstanding the opinion of the respondents, it was quite hard to determine whether the side effects were a result of vaccine mandates or not. Further, the principle of non-maleficence would oppose a mandate if a coerced vaccine in question has no sufficient evidence of its safety which would imply serious implications. Therefore, in such circumstances of unprecedented vaccination, the policy mandating COVID-19 vaccinations was premature, and this explained anti-COVID-19 vaccine movements from the public. Although it was justifiable to coerce vaccinations, Ministry of Health had an obligation to provide sufficient evidence given the risks. People are more likely to adhere to a policy that sufficiently addresses their concerns and would not jeopardize their health. Other emerging issues The study finding shows convergence and divergence in view amongst the health care workers, bioethicists and the general public. Most of them supported mandatory COVID-19 vaccinations highlighting that it was beneficial, convenient and feasible to the entire public. They highlighted that the policy reduced more infections and deaths. This is similar to (Mtimkulu-Eyde et al., 2022 ) that pointed that mandatory vaccination was a viable, reasonable, and ethical policy position to mitigate the pandemic. However, there was also divergence in views. Most health care workers highlighted that mandatory COVID-19 vaccinations were a violation of their autonomy. This is similar to the study conducted in United States which showed that many health care workers disagreed with mandatory vaccinations against COVID-19 since they felt it was an infringement of their autonomy (Rao et al., 2022 ). However, bioethicists opposed this view and highlighted that it was necessary to infringe on people’s autonomy on the basis of preventing harm to the majority. A similar study highlighted there is nothing tyrannical about mandating vaccination for everyone. Allowing and giving some people, the choice to remain unvaccinated severely threatens the safety of other people, which makes the availability of that choice both unfair and dangerous for those who are especially vulnerable and who may not have other options to protect themselves (Wynia et al., 2021 ). The Public Health Act amended in 2022 provide for penalties for misleading information about the vaccines. Given that the community was still divided on the efficacy and safety of COVID-vaccines, how would misinformation about the vaccines be ascertained? WHO recommended a non-fault compensation scheme to be in place if mandatory vaccinations were to be introduced. No-Fault Compensation Program was the first international vaccine injury compensation mechanism intended to provide no-fault compensation to eligible individuals who suffer serious adverse events after receiving a COVID-19 vaccine distributed through the COVAX Facility (Frati et al., 2022 ). In comparison with Uganda’s amended Public Health Act 2022, there was no compensation mechanism put in place for injuries arising from mandatory vaccinations like serious adverse events and hence the Ministry of Health was not liable, which violated the principle of justice which call for fair share of benefits and burdens. The absence of a reparation clause in the amended Public Health Act made the policy unfair and questioned by the public. Conclusion In light of the mixed perspectives identified among stakeholders, it is evident that the implementation of mandatory COVID-19 vaccination programmes should be approached with careful consideration of these divergent views. Programme implementors ought to remain mindful of the ethical complexities and the need for inclusive dialogue when designing and enforcing such policies, ensuring that concerns regarding autonomy, practical challenges, and the broader ethical landscape are adequately addressed. Strengths and limitations to the Study This study’s strengths include a clear focus on public health ethics issues, offering valuable insight into the ethical considerations surrounding mandatory COVID-19 vaccinations. While the findings may not be broadly generalisable to all stakeholders in Uganda, they nonetheless provide a representative snapshot of perspectives on the ethicality of these measures. In this regard, the study establishes a useful benchmark for subsequent research and scholarly inquiry both within Uganda and further afield. Nevertheless, certain limitations exist, such as the risk of potential biases and differing interpretations of essential terms. Furthermore, although the views of some stakeholders were incorporated, the coverage was not comprehensive. Declarations Ethical approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. All procedures performed involving human participants were in accordance with the 1964 Helsinki Declaration. Ethical approval for this study was obtained from the Makerere University School of Biomedical Sciences Research Ethics Committee (Reference No. SBS-2022-206). The research was conducted in accordance with the ethical guidelines and regulations of the Committee. Written informed consent was obtained from the participants. All participants’ personal information obtained was kept confidential. Participation in this study was voluntary, and participants were free to withdraw from the study at any time. All participants were monetarily compensated. Consent for Publication Not applicable Competing interests The authors declare that they have no competing interests Funding This research was funded by the SUSTAIN-scholarship program at Makerere University, College of Health Sciences. It should however be noted that all the views expressed in this article are views of the authors and do not in any way represent the views of the funders. Author Contribution The manuscript is a part of SN’s final year Master of Health Sciences in Bioethics thesis supervised by FN and JB. SN carried out the study, did the data analysis and interpretation of the results and wrote the first draft of the manuscript. FN and JB guided the writing of the manuscript. SN, FN and JB participated in reviewing, editing and drafting the final manuscript. The final version of the manuscript was read and approved by all authors. Acknowledgments The authors thank the SUSTAIN scholarship program at Makerere University for supporting SN’s training in bioethics and funding this study. We sincerely appreciate the respondents for their involvement and the study sites for their invaluable support in facilitating this research. Data Availability The datasets generated during the current study are not publicly available due to ethical restrictions but are available from the corresponding author upon reasonable request. References Abdel Wahed WY, Hefzy EM, Ahmed MI, Hamed NS. Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. J Community Health. 2020;45(6):1242–51. Addadzi-Koom ME. No Jab, No Entry: A Constitutional and Human Rights Perspective on Vaccine Mandates in Ghana. Health Hum Rights. 2022;24(2):47–58. Adepoju P. Africa prepares for COVID-19 vaccines. Lancet Microbe. 2021;2(2):e59. Bongomin F, Olum R, Andia-Biraro I, Nakwagala FN, Hassan KH, Nassozi DR, Kaddumukasa M, Byakika-Kibwika P, Kiguli S, Kirenga BJ. COVID-19 vaccine acceptance among high-risk populations in Uganda. Therapeutic Adv Infect Disease. 2021;8:20499361211024376. Bradfield OM, Giubilini A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. J Med Ethics. Carrasco-Polaino R, Martín-Cárdaba M-Á, Villar-Cirujano E. Citizen participation in Twitter: Anti-vaccine controversies in times of COVID-19. Comunicar. 2021;29(69):21–31. Feleszko W, Lewulis P, Czarnecki A, Waszkiewicz P. Flattening the curve of COVID-19 vaccine rejection—an international overview. Vaccines. 2021;9(1):44. Frati P, Di Fazio N, La Russa R, Santoro P, Delogu G, Fineschi V. No-Fault Compensation and Anti-COVID-19 Compulsory Vaccination: The Italian Context in a Broad View. Vaccines. 2022;10(5):635. Frati P, La Russa R, Di Fazio N, Del Fante Z, Delogu G, Fineschi V. Compulsory vaccination for healthcare workers in Italy for the prevention of SARS-CoV-2 infection. Vaccines. 2021;9(9):966. Gagneux-Brunon A, Botelho-Nevers E, Bonneton M, Peretti-Watel P, Verger P, Launay O, Ward JK. Public opinion on a mandatory COVID-19 vaccination policy in France: a cross-sectional survey. Clin Microbiol Infect. 2022;28(3):433–9. Gill P, Stewart K, Treasure E, Chadwick B. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J. 2008;204(6):291–5. Gur-Arie R, Jamrozik E, Kingori P. No jab, no job? Ethical issues in mandatory COVID-19 vaccination of healthcare personnel. BMJ Global Health. 2021;6(2):e004877. Hagan K, Forman R, Mossialos E, Ndebele P, Hyder AA, Nasir K. (2021). COVID-19 vaccine mandate for healthcare workers in the United States: a social justice policy. Expert Rev Vaccines, 1–9. Kielmann K. Introduction to qualitative research methodology: a training manual. Norwich: In: University of East Anglia; 2012. p. NR4. Kitonsa J, Kamacooko O, Bahemuka UM, Kibengo F, Kakande A, Wajja A, Basajja V, Lumala A, Ssemwanga E, Asaba R. Willingness to participate in COVID-19 vaccine trials; a survey among a population of healthcare workers in Uganda. PLoS ONE. 2021;16(5):e0251992. Mtimkulu-Eyde L, Denholm J, Narain A, Fatima R, Sagili KD, Perumal R, Padayatchi N. Mandatory COVID-19 Vaccination: Lessons from Tuberculosis and HIV. Health Hum Rights. 2022;24(1):85. Olick RS, Shaw J, Yang YT. (2021). Ethical issues in mandating COVID-19 vaccination for health care personnel. Mayo Clinic Proceedings. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm policy mental health mental health Serv Res. 2015;42:533–44. Rao R, Koehler A, Beckett K, Sengupta S. COVID-19 vaccine mandates for healthcare professionals in the United States. Vaccines. 2022;10(9):1425. Savulescu J. Good reasons to vaccinate: mandatory or payment for risk? J Med Ethics. 2021;47(2):78–85. Smith MJ, Emanuel EJ. Learning from five bad arguments against mandatory vaccination. Vaccine. 2023;41(21):3301–4. Sween L, Ekeoduru R, Mann D. Ethics and Pitfalls of Vaccine Mandates. ASA Monit. 2022;86(2):24–5. Uganda. Constitution of the Republic of Uganda. Uganda Print. and Publishing Corporation; 1995. Vinceti SR. (2021). COVID-19 Compulsory Vaccination of Healthcare Workers and the Italian Constitution. Annali di Igiene, Medicina Preventiva e di Comunità . Wong M, Wong EL, Cheung AW, Huang J, Lai CK, Yeoh EK, Chan PK. COVID-19 vaccine hesitancy in a city with free choice and sufficient doses. Vaccines. 2021;9(11):1250. Wynia MK, Harter TD, Eberl JT. Why a universal COVID-19 vaccine mandate is ethical today. Health Affairs Forefront; 2021. Additional Declarations No competing interests reported. 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expanding pandemic caused by a novel human coronavirus; severe acute respiratory syndrome-corona (Abdel Wahed et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The coronavirus disease-2019 pandemic was a major global health crisis of the 21st century. About 2.3% of the world\u0026rsquo;s population was infected by the severe acute respiratory coronavirus-2 and more than 3.3\u0026nbsp;million people died (Bongomin et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Approximately 2.8\u0026nbsp;billion doses of COVID-19 were administered, and 40.5\u0026nbsp;million have been administered each day globally. About 22.2% of the world population received at least one dose of the COVID-19 vaccine (Wong et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The COVID-19 pandemic continued to cause devastating effects globally on economies as well as social aspects of life, some of these happened due to control strategies such as lockdowns (Kitonsa et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome studies suggested that vaccination was the most effective strategy for mitigating COVID-19 and restoring society's function. As the pandemic evolved with no certainty of a herd immunity threshold, universal vaccination of at-risk populations was desirable (Hagan et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A common factor in COVID-19 vaccine allocation plans to date was the prioritization of healthcare personnel who are faced with a high risk of infection and transmission. At-risk populations included all frontline workers namely; physicians, nurses, physicians\u0026rsquo; assistants, laboratory technicians, students on rotation, administrative staff, cleaning personnel, and security staff (Gur-Arie et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBy 2021, seven COVID-19 vaccines had been rolled out globally. Six hundred and forty-nine million doses have been administered globally, at a rate of 16.6\u0026nbsp;million doses per day (Bradfield \u0026amp; Giubilini, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Africa lagged behind the rest of the world in rolling out the COVID-19 vaccine. Through COVAX, the global initiative to ensure rapid and equitable access to COVID-19 vaccines for all countries regardless of income level, Africa was guaranteed vaccines for 20% of its population, how, ever this was not enough for the continent, which was aiming to vaccinate at least 60% of its population (Adepoju, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Despite their claim of proven efficacy in saving lives, as well as containing and eradicating the disease, vaccines were surrounded by controversy which include fear of possible side effects like infertility, the speed with which clinical trials were conducted (Carrasco-Polaino et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). COVID-19 vaccinations were hindered by vaccine hesitancy, which was an internationally prevalent phenomenon (Feleszko et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Vaccine hesitancy was believed to be the main impediment that made COVID-19 vaccine mandates necessary.\u003c/p\u003e \u003cp\u003eCOVID-19 mandatory vaccination policies were put in place in different parts of the world (Savulescu, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The Italian Republic provided for mandatory COVID-19 vaccinations for health professionals by Degree \u0026ndash;Law of 1 April 2021 no 44, to guarantee public health and adequate safety conditions (Frati et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Article 4 of the same Decree imposed vaccine mandates on HCWs in both public and private institutions and failure to comply would result in lawsuits (Vinceti, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCOVID-19 vaccine mandates in Ghana took two forms that is to say direct targeted mandatory vaccination and indirect mass mandatory vaccination. Consequently, a directive by the Ghana Health Service mandated all travelers coming into and leaving the country be fully vaccinated. Additionally, persons visiting certain public spaces, including beaches, restaurants, nightclubs, sports stadiums, the Ministry of Health, and other government agencies, had to show proof of vaccination. These directives were guided by Ghana\u0026rsquo;s Public Health Act section 22 which allowed the minister of health, by executive instrument, to order compulsory vaccination \u0026ldquo;generally or concerning a particular district, area or place or concerning a particular class or classes of persons.\u0026rdquo; Noncompliance was punishable by fine, three-month imprisonment, or both (Addadzi-Koom, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUganda\u0026rsquo;s Public Health (Amendment) Act 2022 legally equipped the government of Uganda to deal with emerging public health threats and emergencies. The Law provides for mandatory vaccination as a public health measure to protect the vulnerable. The Act also spells doomsday for vaccine skeptics and prescribes UGX 1\u0026nbsp;Million (Approx. 270 USD) penalty or half a year jail term for anyone convicted for spreading misleading statement of information regarding use of the vaccines (MOH, 2023). However, if such a law was to be implemented and optimize its intended goal, it should be widely supported by the key stakeholders in health care. There were no empirical ethical analysis of how the public thinks of the mandates and why (Attwell et al., 2021). Although attitudes towards mandatory vaccination have been investigated by several studies (Gualano et al., 2019), in Uganda, there has not been any scientific study to explore the views of stakeholders on a policy mandating COVID-19 vaccination. Therefore, this study aimed at exploring the views of health care workers, bioethicists and general public on the ethicality of mandatory COVID-19 vaccinations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and setting\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional study using a qualitative method of data collection. The study was conducted in Mulago National Referral Hospital, Makerere University, college of Health Sciences, Wandegeya, and Mulago areas in Kampala District. Doctors were got from the Directorate of Internal Medicine in Mulago National Referral Hospital. Bioethicists were got from the College of Health Sciences at Makerere University. Research participants from the general public were got from Wandegeya and Mulago areas in Kampala District. Ten doctors were purposively selected for interviews based on their roles in the hospital. They were five male doctors and five female doctors. Selection was based on age, gender, field of specialty, and level of education. Purposive sampling ensures the identification and selection of individuals or groups of individuals that are especially knowledgeable about or experienced with a phenomenon of interest (Palinkas et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). For this study, a list of potential participants including their designations was obtained from the hospital administration to identify members who were then selected for interviews. Five bioethicists were purposively selected for interviews based on their roles and position in the University. Selection was based on experience. Use of relatively small samples in qualitative research helps us to obtain enough in-depth data from individuals to be able to capture variations in the individual\u0026rsquo;s perspectives and experiences related to the research question (Kielmann, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). For this study, a list of potential participants was provided by Bioethics Centre at Makerere University to identify members who were then selected for interviews. Four FGDs were purposively selected for the discussions. They were two FGDs for females and two FGDs for males per area. One FGD for females and one FGD for males from each area. Each FGD had six participants, totaling twenty-four participants. For this study, participants were identified by mobilizers from the areas of study, and the selection of these FGDs was based on age, sex, and level of education. Focus group discussions generate information on collective views, and are useful in generating a rich understanding of participants' experiences and beliefs (Gill et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData was collected through in-depth interviews (IDIs) and Focus Group Discussions (FGDs). English version of the guides has been uploaded as supplementary files. The guides consisted of open-ended questions that explored participants\u0026rsquo; views on the ethicality of mandatory COVID-19 vaccinations. Open-ended questions allowed the easy flow of the discussions and provided participants with a platform to share their thoughts and opinions on mandatory COVID-19 vaccinations. The in-depth interview and FGD guides were pre-tested before data collection to ensure that the questions were clear and appropriate. The tools comprised questions on demographic information, age, gender, field of specialty, and level of education.\u003c/p\u003e \u003cp\u003eIn-depth interviews were used to explore the views of healthcare workers and bioethicists on the ethicality of mandatory COVID-19 vaccinations, and an interview guide was used. Participants gave written informed consent before the interviews. In-depth interviews provided an opportunity for a detailed investigation of each individual\u0026rsquo;s view about his or her experience and detailed coverage of the subject under study through one-on-one interaction. Focus Group Discussions were used to explore the views of the general public on the ethicality of mandatory COVID-19 vaccinations and a focus group discussion guide was used. Participants gave written informed consent before the discussions. Focus group discussions helped to bring out majority and minority perceptions, opinions, views, and experiences within the groups. FGDs provided a platform for a discussion and exploration of peoples\u0026rsquo; views collectively.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll audio-recorded interviews were transcribed verbatim and checked for accuracy before analysis. Coding began once the data was fully transcribed. Data were categorized and organized in a theme and sub-themes which emerged from the coding process. The coding was done both inductively and deductively. Data verification was done by confirming codes across all transcripts and cross-checking with the recorded data. NVivo 12 was used to support data analysis and results were presented as narratives and quotes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-nine individuals participated in the study, of which 20 were male and 19 were female. Participants\u0026rsquo; demographic information is summarized as shown in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne major theme and five themes were generated from the findings are summarized in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic characteristics of the participants \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Emerged themes and subthemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Approval of mandatory COVID-19 vaccinations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents were positive about COVID-19 vaccine mandates highlighting that the benefits outweighed the risks for example mandates reduced COVID-19 severity. They noted that it was a public health emergency and there was no time to negotiate. In addition, they highlighted that it could have costed the government more in terms of resources if mandates were not in place implying those who could have not been vaccinated would continue to spread the virus. They further stated that vaccine mandates increased vaccine uptake among health care workers which helped in reducing more COVID-19 cases and infections. On this subject, the respondents had the following to say.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it is the right approach because the benefits outweigh the risks. Those who get COVID will continue to spread it and this costs the government and society a lot of money which could have been prevented by vaccination. COVID-19 was a public health emergency and there was no time for negotiating. IDI- D8\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, we all know that people are always defiant. If the government had not brought the vaccine mandates, COVID-19 cases would have been much. Also, if people had an option of not taking the vaccines, they would not have been vaccinated, and we would have died in large numbers\u0026rdquo;. FGD 2- 3\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReser\u003c/strong\u003e\u003cstrong\u003evations about mandatory COVID-19 vaccinations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents emphasized that the vaccines were brought to the public without proper investigation highlighting that in the past, vaccines were developed in a thorough process, and by the time they came out, people had confidence in them. They further stated that the vaccines were developed faster than expected and hence bringing trial vaccines into circulation. But some respondents had confidence in vaccines since WHO handled the distribution which they believed could risk its reputation for giving out dangerous vaccines. \u0026nbsp;For this reason, in the opinion of the majority of the respondents, it was difficult to ascertain the safety of the COVID vaccines, implying potential reservations about the ethicality of the COVID-19 vaccination mandate. This attitude was captured in the following quotations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My honest feeling is ...these vaccines didn\u0026rsquo;t go through all the research process. \u0026nbsp; \u0026nbsp;Most vaccines in the past took a long to come out and we could have confidence that they have been through a thorough process. But for the case of COVID, the disease had just started and within a few months, they had already got the vaccine. So, they brought a trial vaccine into circulation\u0026rdquo;. IDI-D5\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Initially, I was a bit skeptical but one thing that gave me some confidence was the distribution of vaccines by WHO. I felt they cannot risk their reputation to give out something dangerous\u0026rdquo;. IDI-D8\u003c/em\u003e\u003c/p\u003e\n\u003cp id=\"_Toc141267674\"\u003e\u003cstrong\u003eDisapproval of mandatory COVID-19 vaccinations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome respondents felt that it was not right and not necessary to force COVID-19 vaccinations. They highlighted that mandatory COVID-19 vaccinations did not stop further reinfections despite their enforcement and therefore stated that the government had to explore other options besides mandates to mitigate the pandemic. They further stated that enforcing mandates deprived people of their right to self-determination. In addition, the respondents felt that the authorities had an obligation to explain to people the side effects, adverse events resulting from the COVID-19 vaccines as well as encouraging people to voluntarily vaccinate. This attitude was captured in the following quotations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t think it is right to force anyone to receive a vaccine. We also need to understand that enforcing mandates does not stop reinfections, the government had to explore other options\u0026rdquo;. IDI- D3\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because of these forceful vaccinations, we got terrible side effects for example some men developed erectile dysfunction, and this affected our marriages. This increased domestic violence in families\u0026rdquo;. FGD 3- 6\u003c/em\u003e\u003c/p\u003e\n\u003cp id=\"_Toc141267677\"\u003e\u003cstrong\u003eEthical issues in mandatory COVID-19 vaccinations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome respondents supported vaccine mandates in principle but highlighted that in practice it was doubtful, full of controversies, and had gaps. Most respondents noted highlighted that vaccine mandates were a good strategy, but the authorities did not give adequate information concerning these vaccines to the public. They noted that the authorities had to inform the public that the vaccines were trial vaccines, had not been fully approved, and were given on a compassionate basis. They further noted that the authorities did not clearly outline safety issues as they should have earlier. On this issue, the following quote was captured.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Mandating was okay, but the public was not given adequate information. It should have been clearer that these vaccines are trial vaccines and that they were being given on what we call a compassionate basis and that they had not been approved to be effective. Safety issues were not well outlined\u0026rdquo;. IDI-B5\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, some respondents noted that there was an infringement of individual rights in mandating COVID-19 vaccinations which greatly affected the principle of autonomy. They noted that forcing vaccinations was a clear violation of individual rights because people were not given a chance to decide on their own. However, some supported infringement of rights stating that the end justified the means because, in the long run, harm was minimized. On this issue, the respondents had the following to say.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It is well known that individuals have rights, and we saw there was a clear violation of these Individual rights, people were not given a chance to decide on their own\u0026rdquo;. IDI-B3\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It was necessary to limit liberties of individuals because the major aim was to protect people from harm. We all know the end always justifies the means\u0026rdquo;. IDI-B4\u003c/em\u003e\u003c/p\u003e\n\u003cp id=\"_Toc141267680\"\u003e\u003cstrong\u003eWorries about mandatory COVID-19 vaccinations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA few of the respondents from the general public supported vaccine mandates in principle but were apprehensive. They noted that there was a lack of conclusive evidence on the safety and efficacy of the vaccines which questioned the mandates. They further noted that these vaccine mandates were political and that there was a motive for making them mandatory for example they stated that the authorities were looking for accountability for the Western world. On this issue, the respondents said the following.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was not convinced with these mandates because there was a lack of adequate and conclusive evidence on the safety and efficacy of the vaccines in question. We didn\u0026rsquo;t understand how the government could mandate COVID-19 vaccinations without necessary evidence regarding safety. FGD 1- 4\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Vaccine mandates were political. Authorities wanted to account for the vaccines and funds got from the Western world. There must have been a motive to this otherwise this government cannot do something out of the blue\u0026rdquo;. FGD 4- 4\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings show that the majority supported mandatory COVID-19 vaccinations. These respondents supported COVID-19 vaccination mandates because they increased vaccine uptake and minimized infection rates in healthcare settings. A similar study highlighted that COVID-19 vaccination mandates significantly decreased transmission among healthcare workers. Another study highlighted that a vaccine mandate was the most effective and least risky method to prevent disease spread (Sween et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The findings greatly fulfilled the principles of non-maleficence and beneficence because mandatory COVID-19 vaccinations not only protected HCWs but also protected the health of patients, they attend to and hence minimization of harm.\u003c/p\u003e \u003cp\u003eThe findings show a strong debate on the infringement of individual rights. Interference with the right to autonomy raised split views amongst respondents where the majority supported infringement of individual rights on grounds of prevention of harm while some respondents highlighted that infringement on individual rights was a clear violation of the principle of autonomy. According to (Rodger et al, 2022), the COVID-19 vaccine mandate is a \u0026lsquo;minor infringement\u0026rsquo; that is justified to protect others\u0026rsquo; health. Another similar study highlighted that autonomy is paramount for individuals to make any decision related to COVID-19 vaccinations (Olick et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Some respondents noted that vaccine mandates were clearly against the rights of the people and these rights are inherent regardless of race, sex, or any other status. Among these rights include liberty, freedom of opinion, and expression. According to international human rights documents like UDHR, these rights are fundamental and are supposed to be protected. However, civil liberties are not absolute and can be justifiably limited. This idea is commonly enshrined in law and constitutions, where there is a limitation to the rights of the individual for the interests of society. Arguing that vaccine mandates infringe on civil liberties is not enough to conclude they are necessarily ethically wrong. Further, vaccine mandates would advance civil liberties because they protect the most vulnerable like children (Smith \u0026amp; Emanuel, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). According to the Constitution of Uganda, Article 110 under a state of emergency, the President may take measures that are required to secure public safety (Uganda, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). The government had an obligation to prevent harm which justifies the suspension of the right to self-determination. From this view, vaccine mandates were a strong justification and evidence that in the measure, the government would achieve the calculated goal of public safety. With this, one would expect the public to be receptive to government initiatives in curbing the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eOne of the issues that came out clearly from the majority of the respondents was that the lack of conclusive evidence on the efficacy and safety of the vaccines worsened the case for mandatory vaccines. This is similar to a study on Public opinion of a mandatory COVID-19 vaccination policy in France in which a percentage of the general population highlighted the unclear safety profile of the COVID-19 vaccines (Gagneux-Brunon et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The majority of the respondents highlighted that mandates were unethical given the insufficient evidence to back the safety of the vaccines. It is for this reason that the respondents linked some of the side effects which included erectile dysfunction and blood clots to vaccine inefficacy. Notwithstanding the opinion of the respondents, it was quite hard to determine whether the side effects were a result of vaccine mandates or not. Further, the principle of non-maleficence would oppose a mandate if a coerced vaccine in question has no sufficient evidence of its safety which would imply serious implications. Therefore, in such circumstances of unprecedented vaccination, the policy mandating COVID-19 vaccinations was premature, and this explained anti-COVID-19 vaccine movements from the public. Although it was justifiable to coerce vaccinations, Ministry of Health had an obligation to provide sufficient evidence given the risks. People are more likely to adhere to a policy that sufficiently addresses their concerns and would not jeopardize their health.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eOther emerging issues\u003c/h2\u003e \u003cp\u003eThe study finding shows convergence and divergence in view amongst the health care workers, bioethicists and the general public. Most of them supported mandatory COVID-19 vaccinations highlighting that it was beneficial, convenient and feasible to the entire public. They highlighted that the policy reduced more infections and deaths. This is similar to (Mtimkulu-Eyde et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) that pointed that mandatory vaccination was a viable, reasonable, and ethical policy position to mitigate the pandemic. However, there was also divergence in views. Most health care workers highlighted that mandatory COVID-19 vaccinations were a violation of their autonomy. This is similar to the study conducted in United States which showed that many health care workers disagreed with mandatory vaccinations against COVID-19 since they felt it was an infringement of their autonomy (Rao et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, bioethicists opposed this view and highlighted that it was necessary to infringe on people\u0026rsquo;s autonomy on the basis of preventing harm to the majority. A similar study highlighted there is nothing tyrannical about mandating vaccination for everyone. Allowing and giving some people, the choice to remain unvaccinated severely threatens the safety of other people, which makes the availability of that choice both unfair and dangerous for those who are especially vulnerable and who may not have other options to protect themselves (Wynia et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Public Health Act amended in 2022 provide for penalties for misleading information about the vaccines. Given that the community was still divided on the efficacy and safety of COVID-vaccines, how would misinformation about the vaccines be ascertained?\u003c/p\u003e \u003cp\u003eWHO recommended a non-fault compensation scheme to be in place if mandatory vaccinations were to be introduced. No-Fault Compensation Program was the first international vaccine injury compensation mechanism intended to provide no-fault compensation to eligible individuals who suffer serious adverse events after receiving a COVID-19 vaccine distributed through the COVAX Facility (Frati et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In comparison with Uganda\u0026rsquo;s amended Public Health Act 2022, there was no compensation mechanism put in place for injuries arising from mandatory vaccinations like serious adverse events and hence the Ministry of Health was not liable, which violated the principle of justice which call for fair share of benefits and burdens. The absence of a reparation clause in the amended Public Health Act made the policy unfair and questioned by the public.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eIn light of the mixed perspectives identified among stakeholders, it is evident that the implementation of mandatory COVID-19 vaccination programmes should be approached with careful consideration of these divergent views. Programme implementors ought to remain mindful of the ethical complexities and the need for inclusive dialogue when designing and enforcing such policies, ensuring that concerns regarding autonomy, practical challenges, and the broader ethical landscape are adequately addressed.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations to the Study\u003c/h2\u003e \u003cp\u003e This study\u0026rsquo;s strengths include a clear focus on public health ethics issues, offering valuable insight into the ethical considerations surrounding mandatory COVID-19 vaccinations. While the findings may not be broadly generalisable to all stakeholders in Uganda, they nonetheless provide a representative snapshot of perspectives on the ethicality of these measures. In this regard, the study establishes a useful benchmark for subsequent research and scholarly inquiry both within Uganda and further afield. Nevertheless, certain limitations exist, such as the risk of potential biases and differing interpretations of essential terms. Furthermore, although the views of some stakeholders were incorporated, the coverage was not comprehensive.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki. All procedures performed involving human participants were in accordance with the 1964 Helsinki Declaration.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003efor this study was obtained from the Makerere University School of Biomedical Sciences Research Ethics Committee (Reference No. SBS-2022-206). The research was conducted in accordance with the ethical guidelines and regulations of the Committee. Written informed consent was obtained from the participants. All participants\u0026rsquo; personal information obtained was kept confidential. Participation in this study was voluntary, and participants were free to withdraw from the study at any time. All participants were monetarily compensated.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for Publication\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was funded by the SUSTAIN-scholarship program at Makerere University, College of Health Sciences. It should however be noted that all the views expressed in this article are views of the authors and do not in any way represent the views of the funders.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe manuscript is a part of SN\u0026rsquo;s final year Master of Health Sciences in Bioethics thesis supervised by FN and JB. SN carried out the study, did the data analysis and interpretation of the results and wrote the first draft of the manuscript. FN and JB guided the writing of the manuscript. SN, FN and JB participated in reviewing, editing and drafting the final manuscript. The final version of the manuscript was read and approved by all authors.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe authors thank the SUSTAIN scholarship program at Makerere University for supporting SN\u0026rsquo;s training in bioethics and funding this study. We sincerely appreciate the respondents for their involvement and the study sites for their invaluable support in facilitating this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated during the current study are not publicly available due to ethical restrictions but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbdel Wahed WY, Hefzy EM, Ahmed MI, Hamed NS. Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. J Community Health. 2020;45(6):1242\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddadzi-Koom ME. No Jab, No Entry: A Constitutional and Human Rights Perspective on Vaccine Mandates in Ghana. Health Hum Rights. 2022;24(2):47\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdepoju P. Africa prepares for COVID-19 vaccines. Lancet Microbe. 2021;2(2):e59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBongomin F, Olum R, Andia-Biraro I, Nakwagala FN, Hassan KH, Nassozi DR, Kaddumukasa M, Byakika-Kibwika P, Kiguli S, Kirenga BJ. COVID-19 vaccine acceptance among high-risk populations in Uganda. Therapeutic Adv Infect Disease. 2021;8:20499361211024376.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradfield OM, Giubilini A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. J Med Ethics.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarrasco-Polaino R, Mart\u0026iacute;n-C\u0026aacute;rdaba M-\u0026Aacute;, Villar-Cirujano E. Citizen participation in Twitter: Anti-vaccine controversies in times of COVID-19. Comunicar. 2021;29(69):21\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeleszko W, Lewulis P, Czarnecki A, Waszkiewicz P. Flattening the curve of COVID-19 vaccine rejection\u0026mdash;an international overview. Vaccines. 2021;9(1):44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrati P, Di Fazio N, La Russa R, Santoro P, Delogu G, Fineschi V. No-Fault Compensation and Anti-COVID-19 Compulsory Vaccination: The Italian Context in a Broad View. Vaccines. 2022;10(5):635.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrati P, La Russa R, Di Fazio N, Del Fante Z, Delogu G, Fineschi V. Compulsory vaccination for healthcare workers in Italy for the prevention of SARS-CoV-2 infection. Vaccines. 2021;9(9):966.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagneux-Brunon A, Botelho-Nevers E, Bonneton M, Peretti-Watel P, Verger P, Launay O, Ward JK. Public opinion on a mandatory COVID-19 vaccination policy in France: a cross-sectional survey. Clin Microbiol Infect. 2022;28(3):433\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGill P, Stewart K, Treasure E, Chadwick B. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J. 2008;204(6):291\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGur-Arie R, Jamrozik E, Kingori P. No jab, no job? Ethical issues in mandatory COVID-19 vaccination of healthcare personnel. BMJ Global Health. 2021;6(2):e004877.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHagan K, Forman R, Mossialos E, Ndebele P, Hyder AA, Nasir K. (2021). COVID-19 vaccine mandate for healthcare workers in the United States: a social justice policy. Expert Rev Vaccines, 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKielmann K. Introduction to qualitative research methodology: a training manual. Norwich: In: University of East Anglia; 2012. p. NR4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitonsa J, Kamacooko O, Bahemuka UM, Kibengo F, Kakande A, Wajja A, Basajja V, Lumala A, Ssemwanga E, Asaba R. Willingness to participate in COVID-19 vaccine trials; a survey among a population of healthcare workers in Uganda. PLoS ONE. 2021;16(5):e0251992.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMtimkulu-Eyde L, Denholm J, Narain A, Fatima R, Sagili KD, Perumal R, Padayatchi N. Mandatory COVID-19 Vaccination: Lessons from Tuberculosis and HIV. Health Hum Rights. 2022;24(1):85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlick RS, Shaw J, Yang YT. (2021). Ethical issues in mandating COVID-19 vaccination for health care personnel. Mayo Clinic Proceedings.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm policy mental health mental health Serv Res. 2015;42:533\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao R, Koehler A, Beckett K, Sengupta S. COVID-19 vaccine mandates for healthcare professionals in the United States. Vaccines. 2022;10(9):1425.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSavulescu J. Good reasons to vaccinate: mandatory or payment for risk? J Med Ethics. 2021;47(2):78\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith MJ, Emanuel EJ. Learning from five bad arguments against mandatory vaccination. Vaccine. 2023;41(21):3301\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSween L, Ekeoduru R, Mann D. Ethics and Pitfalls of Vaccine Mandates. ASA Monit. 2022;86(2):24\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUganda. Constitution of the Republic of Uganda. Uganda Print. and Publishing Corporation; 1995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVinceti SR. (2021). COVID-19 Compulsory Vaccination of Healthcare Workers and the Italian Constitution. \u003cem\u003eAnnali di Igiene, Medicina Preventiva e di Comunit\u0026agrave;\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong M, Wong EL, Cheung AW, Huang J, Lai CK, Yeoh EK, Chan PK. COVID-19 vaccine hesitancy in a city with free choice and sufficient doses. Vaccines. 2021;9(11):1250.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWynia MK, Harter TD, Eberl JT. Why a universal COVID-19 vaccine mandate is ethical today. Health Affairs Forefront; 2021.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ethicality, Vaccine Mandates, Bioethicists, Healthcare workers, General Public","lastPublishedDoi":"10.21203/rs.3.rs-8404180/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8404180/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCOVID-19 spread globally and caused greater than 3.9\u0026nbsp;million deaths worldwide. Approximately 2.8\u0026nbsp;billion doses of COVID-19 vaccines were administered worldwide. Some studies have suggested that vaccination is the most effective strategy for mitigating COVID-19. However, due to vaccine hesitancy, many people end up shunning vaccinations. The parliamentary committee on health in Uganda proposed making coronavirus vaccinations mandatory and as a result, the Public Health Act was amended in 2022 making vaccinations of immunizable diseases mandatory. There has not been a scientific study to explore the views of healthcare workers, bioethicists, and the general public on the ethicality of mandatory COVID-19 vaccinations in Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-section sectional study that employed in-depth interviews and focus group discussions. The study was conducted in Mulago National Referral Hospital, Makerere University, College of Health Sciences, Wandegeya, and Mulago areas. Fifteen participants were purposively selected based on their expertise for in-depth interviews and four groups of twenty-four members for focus group discussions. Data were transcribed verbatim and analyzed. The coding was both deductive and inductive. NVivo software 12 was used to support data analysis and illustrative quotes were extracted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants shared their perspective on the ethicality surrounding mandatory COVID-19 vaccinations. Opinions were divided: 21 participants supported the mandates, 5 expressed reservations, and 13 opposed them. Supporters argued that requiring vaccination helped reduce infection rates and that the overall benefits outweighed any potential risks. Those with reservations felt that, while mandates were necessary in principle, there were significant practical concerns, controversies, and shortcomings in their implementation. Opponents contended that such mandates infringed upon their personal autonomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis inquiry into the ethicality of mandatory COVID-19 vaccinations raised mixed views among the stakeholders, and implementors of vaccination programs should have put this in mind.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial number: \u003c/strong\u003eNot Applicable\u003c/p\u003e","manuscriptTitle":"The Ethicality of Mandatory COVID-19 Vaccinations in Uganda: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 12:18:25","doi":"10.21203/rs.3.rs-8404180/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-30T07:14:03+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"200776750892684952150207745288044759916","date":"2026-01-30T07:06:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165834691923529578939342033485483776657","date":"2026-01-29T15:17:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T06:01:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301909416207927528970497127186371754346","date":"2026-01-28T15:39:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180378880099143565907005750309381956263","date":"2026-01-28T13:33:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63751148027800309854452526217938107400","date":"2026-01-26T14:42:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175820572381320378706513420102982979052","date":"2026-01-26T14:09:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28784961082391736400335514891869896017","date":"2026-01-22T13:28:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285139306198018803018221074076696624600","date":"2026-01-22T10:25:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63836952948644530788168249839413310528","date":"2026-01-21T06:30:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174025110734784772890711504208585706488","date":"2026-01-20T08:47:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182867080370014376071007672408251410139","date":"2026-01-19T20:25:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T17:28:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129714951664837025745767687966472997233","date":"2026-01-16T22:36:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-15T13:22:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-15T08:21:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-29T09:04:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-26T14:03:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2025-12-26T13:56:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3b77510-8045-4a77-8869-bec02a13c3a1","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T14:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 12:18:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8404180","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8404180","identity":"rs-8404180","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}