Attitudes Toward COVID-19 Vaccination Among Behavioral Health Service Clients

Recruitment and data collection for this study took place in August and September 2021. Fifty adult clients receiving services at a CMHC in Texas were recruited to participate in interviews. Front desk staff at the CMHC were asked to identify clients visiting the facility who met the following criteria: documented level of care (determined by the statewide standardized assessment to triage appropriate service packages) of three or four, indicating a serious mental illness diagnosis and functional impairment; and sufficient cognitive capability to understand interview questions. Participants were compensated with a $20 gift card for a local grocery store. Interviews were conducted at the CMHC by trained University of Texas at Austin researchers. Interviews lasted between 10 and 20 minutes and contained questions such as, “Where did you get your information on the COVID-19 vaccine from?” and “Why did you decide to get or not get the COVID-19 vaccine?” Participants were asked to answer close-ended demographic questions, and information on their psychiatric diagnoses was obtained from administrative records. Four researchers independently coded transcripts from interview audio recordings with Microsoft Excel software and then manually analyzed the transcripts by using thematic analysis. This study was approved by the institutional review board at the University of Texas at Austin.

As shown in Table 1, 82% of participants had a primary diagnosis of a serious mental illness. The remaining 16% of participants (one value was missing) had a primary diagnosis of opioid use disorder. More than two-thirds of participants (68%) reported having received at least one COVID-19 vaccine dose. Participants had a mean±SD age of 49±12 years and were predominantly male (58%); 44% identified as White, and 38% were unhoused.

The desire to protect oneself or others was the most common motivation for receiving the COVID-19 vaccine, reported by 29 of 34 (85%) vaccinated participants (i.e., participants who reported receiving at least one COVID-19 vaccine dose). Several participants identified fears related to specific adverse outcomes of contracting COVID-19, including risk for death or long-term health consequences, as the reason for their decision to get vaccinated. One vaccinated participant stated, “I don’t want to die. I don’t want to make anyone else sick, either” (participant 37).

Participants described several factors that contributed to their perceptions of the risk to themselves or others associated with COVID-19. Some indicated that they considered themselves to be vulnerable because of underlying health conditions or their age or because they had vulnerable family members. As one participant explained, “[Being] immunocompromised with underlying medical conditions made [the decision to get vaccinated] a no-brainer” (participant 21). Seeing other people get sick with or die of COVID-19 also caused some participants to become fearful of contracting the illness: “I wasn’t hiding, I was going out and doing stuff. I hadn’t had any problems, but then just that one time. Like, my friend ended up in the hospital over it, and I had been spending time hanging out with him. It’s all good until it’s not good” (participant 25).

Conversations with health care professionals played a role in six participants’ decision to get vaccinated. These participants indicated that their physician or other health care staff explained why it made sense for them to receive the vaccine: “I talked to the pharmacist and she explained, ‘You are one of the people . . . in that past group of people with [a] low immune system [and with] these problems, these illnesses, and it’s really important’” (participant 48).

Despite the potential of advice from health care professionals to influence decision making, 18 participants stated that their health care providers did not discuss the COVID-19 vaccine with them. A participant who was not yet vaccinated explained that there was “no specific reason I didn’t get it; if they [CMHC] put the Moderna in front of me, I’d probably say yes” (participant 20).

Participants who were not motivated by concerns about contracting or spreading COVID-19 cited practical reasons for getting vaccinated, including being required to do so to visit with vulnerable family members in a nursing home or by the regulations of a residential facility.

Concerns about the vaccine were common among both vaccinated and unvaccinated participants, even among those who indicated that they are generally in favor of vaccines. Some form of concern was noted by nearly half (46%, N=23) of participants, including 11 of 34 (32%) vaccinated participants. Many vaccinated and unvaccinated participants had heard and believed inaccurate information related to COVID-19 vaccination, such as the vaccine itself causing death, leading some to fear getting the vaccine. One participant stated, “China made it. They’re just trying to kill us. . . . So, I just started feeding into that. And I was like, ‘Well, what if the vaccines that they made . . . have something for us?’” (participant 44).

Others were concerned about what they perceived to be a rapid vaccine development process, lack of U.S. Food and Drug Administration approval, and risk for side effects; for example, one vaccinated individual described being “unsure about the whole thing as far as the rush to create [a vaccine] and the efficacy of it” (participant 2). In particular, several participants indicated that the fact that vaccinated people could still contract COVID-19 made them question the vaccine’s effectiveness. Because of these concerns, some participants noted that they had waited or were continuing to wait to see what happened with people who got vaccinated before deciding to do so themselves: “[I] did want to make sure people weren’t dying. So [I] waited, like, a month and then saw that it was fine” (participant 3).

Among participants who experienced uncertainty about the vaccine, family, friends, and other trusted individuals such as faith leaders often played a key role in participants’ vaccination decision making. In some cases, this social influence reinforced participants’ concerns about vaccination, leading them to forgo receiving the vaccine:

Like, you hear that people [are] trying to put chips in your bodies or putting things in your body where they can track you and all this stuff . . . my dad’s like, “You better not get that shot.” You know, my family’s like, “Don’t do it.” I . . . already had thought that whenever I thought of the shot, but [this belief is reinforced] when I have my family and then other people say, “No, don’t do it.” (participant 16)

For others, conversations with family members helped them to overcome their concerns and led them to get vaccinated:

I said, “Mom [referring to a grandmother], on Facebook they’re saying no [referring to antivaccine posts].” And she’s like, “Well, let me educate you on it.” She was like, “You live with old people, you have kids at home. You need to get vaccinated, baby.” And that made me want to get vaccinated because of the stuff she told me. (participant 11)

Many participants were exposed to a mix of opinions in their social networks; moreover, in some cases they had to navigate opposition to their vaccine choice by friends, family, and acquaintances.

Circumstances that made it easy to get vaccinated facilitated COVID-19 vaccine uptake, even among people who were initially hesitant. Being offered the vaccine by a current health care provider or other service provider or at locations where people already were going (e.g., church or parks) increased convenience and led some participants to get vaccinated. Convenience of vaccination location was particularly important for participants with limited transportation access. Finally, cost was also an important factor for multiple participants: “They told me they were offering the service [referring to vaccination] for free today if I wanted. . . . So, they’re offering it as an opportunity. . . . I would say that the price is definitely important” (participant 2).

In this report, we examined COVID-19 vaccine–related decision making among individuals with serious mental illness or substance use disorders. Most participants had received at least one COVID-19 vaccine dose. Participants who got vaccinated were most commonly motivated by a desire to protect themselves or others. Factors that contributed to this motivation were perceived vulnerability due to health status or age, knowing others who became sick with or died of COVID-19, or discussing the vaccine with a health care provider. Convenience of vaccination location and access to free vaccination also facilitated vaccine uptake. Both vaccinated and unvaccinated participants reported concerns about the vaccine, ranging from its efficacy to conspiracy-based beliefs. Social connections played an important role in reinforcing or overcoming these concerns.

These findings highlight an opportunity for improved access to information from trusted sources, including health care providers. Many participants reported that their health care providers had not addressed COVID-19 vaccination in their visits. In light of the complex (and sometimes conflicting) nature of information about vaccines and the outsized influence of social connections described by study participants, trusted members of the behavioral health care team could have an important role in vaccine outreach to those living with behavioral health conditions. For example, in a pilot intervention study in which clinicians at a CMHC were trained to communicate with outpatient clients about COVID-19 vaccination, vaccine uptake at the CMHC exceeded the statewide uptake rate (13).

This study has a few limitations. First, vaccination status was self-reported, and interviews were conducted in a clinic setting, which poses the risk of social desirability bias. Second, we used a convenience sample recruited by the clinic’s receptionists. Third, for the purpose of this study, we were only provided information about participants’ primary diagnosis and not a comprehensive list of all diagnoses in their record. Fourth, we cannot rule out the potential for bias regarding which individuals opted to participate in the study and which individuals declined. Finally, because interviews of participants took place at a CMHC where they were already receiving service, the sample consisted of individuals engaged with health care services. Study findings may not generalize to individuals not currently engaged with health care services.

This study provides insight into considerations for tailoring COVID-19 vaccination (or other vaccination) outreach and education to individuals living with serious mental illness or substance use disorder. Fear, uncertainty, and conflicting information were common themes across participant interviews. Less than half of participants reported having conversations about the COVID-19 vaccine with a health care provider, and many reported that their vaccination decisions were influenced by friends and family members. In future studies, researchers could test the effectiveness of strategies to increase COVID-19 vaccine or other vaccine uptake in this population, including tactics to better engage the behavioral health care team in vaccine education. In addition, greater insight into potential differences in COVID-19 vaccine uptake and attitudes between subpopulations of individuals with behavioral health conditions is needed to effectively tailor such strategies.