The attitudes of psychiatric patients towards COVID-19 vaccination in China: a cross-sectional study

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) emerged in December 2019. The COVID-19 pandemic has become a global health catastrophe, causing over 120 million confirmed cases and 2 million deaths worldwide [1].

Although many countries imposed strict restrictions to contain the virus, serious challenges still remained with regards to its highly infectious characteristics. Early in the pandemic, no clinical approved effective drugs was available [2]. Non-pharmaceutical interventions (e.g.. social distancing) were effective [3], however, implementing those interventions for a long term would cause damaging sociological [4] and psychological consequences [5]. Thus, developing a vaccine against COVID-19 appeared to be the most effective strategy to stop repeated outbreak [6].

National institutions and vaccine companies responded rapidly to this critical need. On 31st December 2020, the World Health Organization (WHO) approved a COVID-19 vaccine from Pfizer/BioTech for emergency use [7], and several other candidates were undergoing different phases of clinical trials [8]. Despite the scientific community and related industries working hard to create a vaccine against COVID-19, the mutations of the coronavirus genome might present difficulties with vaccine development [9], and the efficacy and safety of the vaccine remained a concern [10].

Although vaccines have been approved for emergency use in certain high risk groups [11], and a lot of efforts were made to improve their efficacy, the roll out of mass vaccination against COVID-19 would be complicated. To ensure a successful implementation of vaccine, our government planned to prioritize recipient groups and provide the COVID-19 vaccines for free. Also, national-level strategies have been made to guide and navigate through the vaccine roll-out process. While other nations are still combating the virus, China is now recovering; this might lead to public presumption that vaccination was unnecessary. In China, there are routinely offered vaccines/Category 1 free of charge to every child under the age of 14. While all of these vaccines are free, there are other vaccines/Category 2 vaccines for children and adults that are self-funded. Category 2 vaccines such as flu vaccine are taken up according to self-risk assessment. Self-perceived low risk of certain infectious diseases attributes to low vaccination adherence [12, 13], which explained why some optional and self-paid vaccines, still presented with deficient coverage. For example, only 10.5% of Chinese adults have been vaccinated against influenza [14]; this compared to 37 to 95% of adults in the United States [15]. Moreover, past incidents of expired or improperly stored vaccines have driven fervent debate amongst the public [16]. These factors also contributed to hesitation towards vaccination, especially in certain vulnerable groups, such as psychiatric patients. It has been established that during the pandemic, psychiatric patients have been associated with an increased risk of COVID-19 mortality and severity [17, 18]. Vaccination for COVID-19 is of paramount importance, and published studies urged governments to prioritize vaccination for psychiatric patients [19‐22]. It is critical to evaluate the vaccination intention amongst this vulnerable group. Thus, in the present study, we aimed to investigate the attitudes of psychiatric patients with regards to COVID-19 vaccination and the potential factors that might influence acceptance for vaccination. These insights would offer empirical evidence to increase vaccination uptake and help the government to generate appropriate vaccination strategies.

According to our survey, 78.7% of our participants said they would be willing to get vaccinated or would agree to vaccinate for who they were cared for, while 21.3% would refuse the vaccine. Most of them (71.3%) refused the vaccine for concerning its safety. In terms of preferences, participants would prefer a free vaccination, which was developed and funded by Chinese government. Participants would also prefer to be vaccinated in hospitals. Among those who intended to get vaccinated, factors influencing their vaccination acceptance were high vaccine coverage amongst community residents or their relatives and friends, the possibility of pandemic resurgence and the perceptions of vaccines as a solution to the pandemic.

The high acceptance of the COVID-19 vaccine amongst participants implied that their need for vaccines was evident. Since the COVID-19 outbreak, the Non-pharmaceutical interventions disrupted work and daily life across the population. As reported in the study, 77.7% of our participants agreed their daily routine was influenced at a fair level or above. As China recovered from the pandemic after the lockdown was lifted, only 13.0% of our participants considered that they had a high risk of being infected. Their reduced self-perceived risk of COVID-19 infection might lead to less compliance with restrictions measures (e.g., wearing masks) [23]. Given that therapeutics for COVID-19 have yet to be discovered, and the public’s adherence to restriction measures was weaken, a vaccine was needed to assure that normal life would continue and to prevent further waves of infection [13]. Chinese scientists have ramped up together to develop vaccines for COVID-19 at the earliest stage of the pandemic [24, 25]. Our research showed preference of Chinese state-developed vaccine. This contradicted other research findings where imported vaccines were more popular [26]. However, there is no indication of distrust towards any non-Chinese state-developed vaccines. There were several contributors for people’s preference: firstly, drastic measures such as national lockdown and its successful outcome had gained huge confidence for the Chinese government from its people; as a result, people trusted the government would push for an effective vaccine however difficult. Secondly, as Chinese government responded promptly to the pandemic and it was under controlled after national lockdown, there was more information gathered and more time and resources for Chinese scientists to develop a vaccine. Finally, daily update on new cases, as well as development of vaccines were reported everyday on special national news programme. Information is made available in all traditional media: newspaper, TV and radio as well as online social media platform: WeChat news, Tencent News, Weibo et al.

However, translating the willingness for vaccination into actual action is essential, yet complicated. Over the last decade, trust in vaccines has been increasingly challenged by vaccine scandals, such as the Hepatitis B vaccine crisis of 2014 [16, 27], and anti-vaccination sentiments [28]. In line with reduced trust, the vaccination dropped [29]. 21.3% of the participants said they would reject the vaccination, and the uncertainty about vaccine safety was our participants’ main reason to refuse the vaccine. They might worry that the medicine they or their family members already took would interact with the vaccine, as the current knowledge about this newly-launched vaccine was scarce and the proof of its immunogenicity and safety was short-term at present [30]. In this situation, providing timely and transparent information would help to reduce distrust in vaccination and convincing doubters to become vaccinated amongst this group. Furthermore, continued investigations into the efficacy and safety of the vaccine were required. Adverse events in ongoing research should be disseminated to the public with clear interpretation, or else negativity would become rumors that compounded vaccine hesitancy. After all, 63.9% in our study stated that negative news would reduce their possibility of receiving vaccination.

Our study revealed the vaccine coverage of community residents or friends and relatives around our participants was one of the factors that influenced the vaccination utility. An individual follows a morally neutral perception of what the majority of individual are doing is called descriptive social norms. According to previous study, social norms could either support or hinder vaccination goals [31] and norms-base strategies might increase vaccination intention [32]. Public health messaging should update vaccination coverage to encourage psychiatric patients to receive vaccination. Our study also found that participants’ vaccination intention related to the possible resurgence of the COVID-19 pandemic and the thought that the vaccine is the most powerful weapon with which to combat the virus. Under the current circumstance, it seemed likely that COVID-19 would co-exist with us and become a flu-like seasonal disease [30]. As a result, the number of newly infected COVID-19 cases should be released timely to remind the participants that the pandemic was under control but far from over, getting infected was possible. The importance of vaccine as an effective measure to prevent themselves from serious illness and hospitalization, and control the virus should be stressed in tailored communication. Our results showed that the influencing factors underlying vaccination acceptance between psychiatric patients and the general public, might be different [33]. Utilizing evidence-based communication strategies is essential, if we are to achieve an adequate vaccination rate.

In our study, we focused on psychiatric patients, aiming to evaluate their attitude towards COVID-19 vaccination, which provided information for the acceptance of COVID-19 vaccination by this vulnerable group. By considering the vaccine distrust and dividing subjects based on vaccine acceptance, our study revealed influencing factors that contributed to the participants’ decision-making process with regards to vaccination, such as the vaccine coverage of their surrounding people. The investigation of barriers and preference of vaccination was useful when government needed to generate effective immunization strategies for this group. However, this study has several limitations. First, a modest sample size of 408 participants was enrolled from the same hospital. Therefore, our findings may not adequately reflect trends seen throughout the whole targeted population. Second, the study conducted before a COVID-19 vaccine was available to the public. The results may differ when a vaccine was ready for the immunization program. Finally, family caregivers were recruited for those patients who were incapable of making medical decisions, whose opinion might not be the same as the patients they looked after. Future studies should enroll a larger sample size from different hospitals after a vaccine approved to be used. More research could be done to investigate family caregivers’ role in supporting the psychiatric patients’ acceptance of COVID-19 vaccination.

To conclude, this study reflected a high level of acceptance of COVID-19 vaccination amongst our psychiatric patients. For those who would decline vaccination, vaccine safety was their main concern. It is important to remind the public that vaccination plays a crucial part in containing COVID-19. Timely information including new COVID-19 cases in the regions and up-to-date vaccinated number of people amongst community can help to increase vaccination uptake. Improving health literacy of vaccine safety is crucial to ease concerns amongst this vulnerable group.