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COVID-19 vaccine attitudes among mental health professionals in the WHO’s global clinical practice network [1]

['Cary S. Kogan', 'School Of Psychology', 'University Of Ottawa', 'Ottawa', 'Ontario', 'Dan J. Stein', 'Department Of Psychiatry', 'Neuroscience Institute', 'Samrc Research Unit On Risk', 'Resilience In Mental Disorders']

Date: 2024-07 

Abstract Although COVID-19 vaccines have demonstrated efficacy, there is variability in health professionals’ attitudes towards these agents. Factors associated with mental health professionals’ attitudes towards COVID-19 vaccination are not well understood. We investigated these factors by administering a newly developed measure, the COVID-19 Vaccine Attitudes Questionnaire (C-VAQ), to members of the World Health Organization’s Global Clinical Practice Network (GCPN) of mental health professionals. 1,931 GCPN members representing all world regions participated between July 28 and September 7, 2021. Mental health professionals’ attitudes towards COVID-19 vaccination were assessed in one of five languages (Chinese, English, French, Japanese, Russian, or Spanish) using the C-VAQ. Internal consistency, factor structure, and predictive validity of the C-VAQ were examined, and a multiple-linear regression model was employed to assess C-VAQ score predictors, including sociodemographic variables (age, gender, WHO region, country income level, profession, and years of professional experience) as well as country mortality rate and the stringency of each country’s response to COVID-19. The C-VAQ demonstrated good internal consistency and external validity. Items loaded on to a single factor. Having received a COVID-19 vaccine, higher country mortality rate, and higher stringency index was significantly associated with more positive vaccine attitudes. Lower age, residing in a low-and-middle income country, and living in Asia were all was significantly associated with less positive vaccine attitudes. The C-VAQ scores were negatively correlated with the number of concerns about the COVID-19 vaccination. The C-VAQ was useful in demonstrating the extent to which additional work is needed to improve mental health professionals’ attitudes towards COVID-19 vaccines globally. Relatively poorer attitudes toward vaccination among some mental health clinicians around the world suggests the need for broad, multi-pronged interventions.

Citation: Kogan CS, Stein DJ, Garcia-Pacheco JA, Rebello TJ, Montoya MI, Robles R, et al. (2024) COVID-19 vaccine attitudes among mental health professionals in the WHO’s global clinical practice network. PLOS Ment Health 1(1): e0000018. https://doi.org/10.1371/journal.pmen.0000018 Editor: Ansar Abbas, Hamdard University - Islamabad Campus, PAKISTAN Received: January 8, 2024; Accepted: May 6, 2024; Published: June 26, 2024 Copyright: © 2024 Kogan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: Anonymized, group-level data can be provided, but not individual participant underlying results given that Global Clinical Practice Network (GCPN) members did not consent to having their data shared publicly. A data dictionary of available variables will be provided. Any requests will be reviewed by the GCPN research committee, including the corresponding author, and require a proposal outline and a signed data access agreement. Requests should be made to gcpn@cugmhp.org. Funding: This work was supported by the Canadian Institutes of Health Research – Institute of Neurosciences, Mental Health and Addiction (VR4-172750) to CSK, GMR and KD. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have read the journal’s policy and have the following competing interests: Wolfgang Gaebel, MD and Oye Gureje, MD, PhD are members of LINF, Lundbeck International Neuroscience Foundation and Dan J. Stein, MD, PhD has in the past 3 years received research grants and/or consultancy honoraria from Johnson & Johnson, Lundbeck, Servier and Takeda. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Introduction Despite the paramount importance of vaccines for improving global health, vaccine hesitancy has a long history, and persists worldwide [1]. Given the deleterious effects of the COVID-19 pandemic to individuals and society, and the positive impact of COVID-19 vaccination, it is particularly crucial to understand those factors that affected COVID-19 vaccine acceptance and hesitancy among different groups including mental health professionals. A recent systematic review of 51 studies found that vaccine hesitancy and avoidance were highly prevalent, not only in the general public, but also among health care workers, emphasizing the need to further investigate obstacles to vaccine uptake, and to develop appropriate evidence-based interventions [2]. Attitudes are causally linked to health intentions and behaviour with a medium effect size [3], emphasizing the importance of measuring these cognitions and considering them for targets of interventions intended to increase vaccination rates. Therefore, the availability of a self-report measure of COVID-19 vaccine knowledge and attitudes could be useful in achieving this important public health goal. COVID-19 negatively impacts physical and mental health, and given the important role of health care workers, including mental health professionals, in providing interventions and in vaccine advocacy, it is particularly important to understand vaccine attitudes in this group. A recent scoping review of vaccine intentions in health care workers identified 26 papers and emphasized a range of concerns about vaccine safety and efficacy [4]. Our current understanding of predictors of vaccine hesitancy in health care workers is limited, with even fewer data available about vaccine hesitancy in mental health professionals [4]. The importance of attitudes toward vaccines in this group is underscored by evidence that individuals with serious mental illness may be at heightened risk of infection and increased mortality [5]. Furthermore, protection of an already fragile and understaffed mental health workforce is a priority [6]. The World Health Organization’s Global Practice Network (GCPN) is comprised of more than 16000 mental health professionals representing a diverse range of geographic regions and settings, and provides a unique opportunity to investigate professional’s knowledge and attitudes from a global perspective. We aimed to investigate these professionals’ knowledge about and attitudes toward vaccination by administering a new 8-item measure, the COVID-19 Vaccine Attitudes Questionnaire (C-VAQ), to members of the GCPN. We investigated whether sociodemographic variables, vaccination status, as well as country mortality rate and stringency index at the time of data collection predicted C-VAQ scores.

Discussion The main findings of this study were: 1) a newly constructed measure of vaccine attitudes, the Vaccine Acceptance Quetionnaire (C-VAQ), has good internal consistency, with items loading on to a single factor, 2) having received a COVID-19 vaccine was significantly associated with higher C-VAQ scores, whereas having concerns about COVID-19 vaccination was significantly associated with lower C-VAQ scores; 3) younger age, residing in a low-and-middle income country, and living in an Asian country were all significantly associated with lower C-VAQ scores; and 4) increased COVID-19 mortality rate and higher stringency index were significantly associated with higher C-VAQ scores. Our finding that having received a COVID-19 vaccine was significantly associated with higher C-VAQ scores provides some external validation of the measure. The measure also demonstrates some convergent validity as demonstrated by the significant negative association between C-VAQ scores and the number of concerns endorsed by participants about COVID-19 vaccination. It is also consistent with findings from experimental studies that demonstrate that changes in attitudes predict changes in health behaviours [3]. A considerably longer questionnaire assessing COVID-19 attitudes also yielded only one factor and had similar internal consistency to the C-VAQ [11]. The C-VAQ, which was translated into Chinese, English, French, Japanese, Russian, and Spanish for the present study adds to the literature a new relatively short measure that can be used by governments, organizations and researchers to efficiently measure vaccine attitudes. Previous work has demonstrated that a range of sociodemographic factors may be associated with greater vaccine hesitancy in both health care workers and the general population [2]. It is not surprising that such sociodemographic predictors are also apparent among the attitudes of mental health clinicians toward vaccination. Nevertheless, it is important to note that there may be significant regional variation in such findings [18]. For example, within the general population, Solís Arce et al. (2021) [19] found that those living in low- and middle-income countries were more accepting of COVID-19 vaccines, particularly if guidance comes from health care workers. In the present study, we found evidence for the opposite effect such that mental health clinicians living in low- and middle-income countries as well as in Asian countries, particularly Japan, expressed more negative attitudes toward COVID-19 vaccination. This finding highlights the importance of interventions to address these beliefs in these regions. Further work must be done to understand why mental health professionals living in low- and middle-income countries, but not the general population [19], hold more negative vaccine attitudes. It is noteworthy that higher country mortality rate and stringency index were significantly associated with higher C-VAQ scores. While environmental factors associated with vaccine attitudes may include exposure to myths about vaccines, these findings suggest that real threat from the pandemic may act to encourage positive attitudes toward vaccines. However, we cannot rule out the possibility that countries with high stringency and COVID-19 death rates had stronger programs to encourage vaccination, particularly among health professionals. A 5A model (addressing vaccine acceptability, accessibility, affordability, awareness, and activation–or nudges to use vaccine) may be useful in understanding vaccine uptake among adults [20], and in developing multi-prong interventions that address individual, organizational, and societal factors to improve such uptake [21,22]. The C-VAQ was found to possess excellent internal consistency with items loading on to a single factor. Our results suggest that the C-VAQ is a useful measure that can be used internationally to measure COVID-19 vaccine attitudes. Previous work on COVID-19 vaccine beliefs has often used a simple yes/no approach, focusing on intent to obtain vaccination [4,21]. A Likert-like measure of acceptability and hesitancy may allow for a more detailed assessment of inter-individual variations and so for more nuanced statistical analyses. A longer scale may allow assessment of different factors that contribute to vaccine attitudes, but this must be weighed against respondent burden. Future research on the C-VAQ’s sensitivity to change among international samples would be useful in the context of evaluating programs that aim to increase vaccine uptake among health care professionals. A number of limitations deserve emphasis. First, member of the GCPN generously volunteer their time to participate in a range of research studies, and may not be systematically representative of mental health professionals. Nevertheless, the GCPN does provide access to a broad range of professionals working in diverse geographic regions and settings. Second, the design of this study does not allow determination of causality. Further work is needed to assess the precise nature of the relationships between attitudes towards COVID-19 vaccination, behavior with regards to vaccination, and social and political context. The development of the C-VAQ occurred during 2020–21 as part of an urgent call by the World Health Organization’s Global Research Roadmap [23] and funding agencies (the present study was funded by a special COVID-19 fund by the Canadian Institutes for Health Research) to address the pandemic. Furthermore, the data collection occurred at the height of the pandemic when public health measures and restrictions were in place across various countries. Variables not considered in the present report may have had a significant influence on the acceptance of vaccinations by mental health professionals at that time. While, such public measures are currently significantly less restrictive in many countries, our findings may have relevance to future pandemics. Finally, the present study examined internal consistency, factor structure, and predictive validity of the C-VAQ. Future research should validate the C-VAQ, in particular assessing convergent and divergent validity of this new measure. The availability of this measure in the published literature in advance of a future pandemic is useful. Investigating the generalizability of this brief and practical measure to other public health vaccination programs would also be beneficial. The study also has a number of notable strengths. The study includes a large sample size of GCPN members from across all five WHO regions including clinicians working in LAMICs. The multilingual nature of the study allowed for a broader participation of clinicians. Finally, the study provides the field with a brief, publicly available, free measure that can be easily administered to assess COVID-19 vaccine attitudes.

Conclusion Employment of the C-VAQ in the World Health Organization’s CGPN was useful in demonstrating the extent to which additional work is needed to improve mental health clinician’s attitudes towards COVID-19 vaccines around the world. Lack of vaccination in this group (7.1% of professionals reported not being vaccinated) is particularly worrisome in light of evidence that individuals with serious mental illness may be heightened risk of infection and increased mortality [5]. Furthermore, protection of an already fragile mental health workforce is a priority particulary with evidence of growing prevalence of mental health conditions during the pandemic (e.g., [24]). While increased intervention efforts may be particularly pertinent for a number of sociodemographic groupings, relatively high levels of vaccine hesitancy in clinicians and communities around the world also suggest the need for broad, multi-pronged interventions that address negative attitudes among large numbers of individuals in future pandemics.

Acknowledgments We are grateful to the GCPN members for participating in the study.

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[1] Url: https://journals.plos.org/mentalhealth/article?id=10.1371/journal.pmen.0000018

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