Skip to main content Accessibility help
×
Home
Hostname: page-component-544b6db54f-n9d2k Total loading time: 1.062 Render date: 2021-10-22T17:38:15.630Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Attitudes toward COVID-19 vaccination and willingness to pay: comparison of people with and without mental disorders in China

Published online by Cambridge University Press:  11 August 2021

Fengyi Hao
Affiliation:
Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, China; Mental Health Center, West China Hospital, Sichuan University, China; Translational Neuroscience Center, West China Hospital, Sichuan University, China; State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China; and Department of Psychiatry, The First People's Hospital of Chongqing Liang Jiang New Area, China
Bokun Wang
Affiliation:
Modern Service Industry Bureau, Chongqing Liangjiang New Area Administration Committee, China
Wanqiu Tan
Affiliation:
Department of Psychiatry, National University of Singapore (Chongqing) Research Institute, China
Syeda Fabeha Husain
Affiliation:
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Roger S. McIntyre
Affiliation:
Mood Disorders Psychopharmacology Unit, University Health Network, Ontario, Canada
Xiangdong Tang
Affiliation:
Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, China; Mental Health Center, West China Hospital, Sichuan University, China; Translational Neuroscience Center, West China Hospital, Sichuan University, China; and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, China
Ling Zhang
Affiliation:
Department of Psychiatry, The First People's Hospital of Chongqing Liang Jiang New Area, China
Xiaofan Han
Affiliation:
Department of Psychiatry, The First People's Hospital of Chongqing Liang Jiang New Area, China
Li Jiang
Affiliation:
Department of Psychiatry, The First People's Hospital of Chongqing Liang Jiang New Area, China
Nicholas W. S. Chew
Affiliation:
Department of Medicine, National University Health System, Singapore
Benjamin Yong-Qiang Tan
Affiliation:
Department of Medicine, National University Health System, Singapore
Bach Tran
Affiliation:
Institute for Preventive Medicine and Public Health, Hanoi Medical University, Vietnam; and Bloomberg School of Public Health, Johns Hopkins University, Maryland, USA
Zhisong Zhang
Affiliation:
Faculty of Education, Huaibei Normal University, China
Gia Linh Vu
Affiliation:
Institute for Global Health Innovations and Faculty of Medicine, Duy Tan University, Vietnam
Giang Thu Vu
Affiliation:
Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Vietnam
Roger Ho*
Affiliation:
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; and Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
Cyrus S. Ho
Affiliation:
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Vijay K. Sharma
Affiliation:
Division of Neurology, Department of Medicine, National University Health System, Singapore; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
*
Correspondence: Roger Ho. Email: pcmrhcm@nus.edu.sg
Rights & Permissions[Opens in a new window]

Abstract

Background

Acceptance and willingness to pay for the COVID-19 vaccine are unknown.

Aims

We compared attitudes toward COVID-19 vaccination in people suffering from depression or anxiety disorder and people without mental disorders, and their willingness to pay for it.

Method

Adults with depression or anxiety disorder (n = 79) and healthy controls (n = 134) living in Chongqing, China, completed a cross-sectional study between 13 and 26 January 2021. We used a validated survey to assess eight aspects related to attitudes toward the COVID-19 vaccines. Psychiatric symptoms were assessed by the 21-item Depression, Anxiety and Stress Scale.

Results

Seventy-six people with depression or anxiety disorder (96.2%) and 134 healthy controls (100%) reported willingness to receive the COVID-19 vaccine. A significantly higher proportion of people with depression or anxiety disorder (64.5%) were more willing to pay for the COVID-19 vaccine than healthy controls (38.1%) (P ≤ 0.001). After multivariate adjustment, severity of depression and anxiety was significantly associated with willingness to pay for COVID-19 vaccination among psychiatric patients (P = 0.048). Non-healthcare workers (P = 0.039), health insurance (P = 0.003), living with children (P = 0.006) and internalised stigma (P = 0.002) were significant factors associated with willingness to pay for COVID-19 vaccine in healthy controls.

Conclusions

To conclude, psychiatric patients in Chongqing, China, showed high acceptance and willingness to pay for the COVID-19 vaccine. Factors associated with willingness to pay for the COVID-19 vaccine differed between psychiatric patients and healthy controls.

Type
Papers
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press on behalf of the Royal College of Psychiatrists

As of 31 March 2021, 130 million confirmed cases of COVID-19 infection and 2.8 million deaths have been reported by the World Health Organization.1 Although some people infected with COVID-19 remain asymptomatic, most patients present with fever and respiratory (sore throat, cough, nasal congestion, anosmia), gastrointestinal (nausea, vomiting) or neurological symptoms (headache), as well as myalgia and malaise.Reference Gregorevic, Maier, Miranda, Loveland, Miller and Buising2 Reported long-term effects of COVID-19 infection include attention deficit, dyspnoea, fatigue, hair loss and headache.Reference Lopez-Leon, Wegman-Ostrosky, Perelman, Sepulveda, Rebolledo and Cuapio3 The fatality rate for COVID-19 is 1.4%.4

The COVID-19 vaccine

Vaccination offers a crucial opportunity for reducing COVID-19 transmission and is a critical initiative to resolving the COVID-19 pandemic.Reference Alexander, Moran, Gaya, Raine, Hart and Kennedy5 Despite various prevailing concerns, the benefits of vaccination against COVID-19 are believed to outweigh the risks of vaccine-related side-effects, including pain and swelling at the injection site, malaise, headache, dizziness and fever.Reference Desai, Gainor, Hegde, Schram, Curigiliano and Pal6,Reference Gee, Marquez, Su, Calvert, Liu and Myers7 As of 20 March 2021, a total of 75 million COVID-19 vaccine doses have been administered.1 Nevertheless, several European countries, including Germany, France and Italy, temporarily paused the administration of several brands of the COVID-19 vaccines because of reports of thrombosis in some vaccine recipients.Reference Oldenburg, Klamroth, Langer, Albisetti, von Auer and Ay8 Extraordinary media attention, political discussion and public discourse may promote vaccine hesitancy among general public,Reference Sallam, Dababseh, Eid, Al-Mahzoum, Al-Haidar and Taim9 and create a major public health problem during the current pandemic, leading to a huge setback to the success of the mass immunisation programme.Reference Tran, Boggiano, Nguyen, Latkin, Nguyen and Tran10 Therefore, perception of vaccine safety is an important research topic for the COVID-19 pandemic.Reference Ehde, Roberts, Herring and Alschuler11

The impact of the COVID-19 pandemic on mental health

The COVID-19 pandemic has led to unprecedented hazards to mental health globally.Reference Xiong, Lipsitz, Nasri, Lui, Gill and Phan12 Research has confirmed the severe negative psychological impact of strict lockdown measures on people with depression or anxiety disorder.Reference Hao, Tan, Jiang, Zhang, Zhao and Zou13,Reference McIntyre and Lee14 People with mental disorders reported higher levels of anxiety or depression compared with people without such conditions. One reason for worsening of mental disorders is the lack of access to mental health services during the pandemic.Reference Hao, Tan, Jiang, Zhang, Zhao and Zou13 Heightened levels of anxiety, depression and insomnia could affect perception toward COVID-19 vaccination, and excessive worries could result in vaccine hesitancy. Several studies have assessed the attitude of people with mental disorders toward vaccines for various conditions. Cotugno et al reported that the overall acceptance rate of influenza vaccine in people hospitalised for psychiatric illnesses was 26%.Reference Cotugno, Morrow, Cooper, Cabie and Cohn15 Carney et al reported that the acceptance rates for hepatitis B, pneumococcal and influenza vaccines were 11, 30 and 45%, respectively.Reference Carney, Allen and Doebbeling16 On the contrary, higher levels of education and perceived risk of contracting COVID-19 were associated with increased willingness to receive the COVID-19 vaccine by people suffering from multiple sclerosis.Reference Ehde, Roberts, Herring and Alschuler11 These differences in willingness to receive the COVID-19 vaccine have been studied scarcely. One study among people with substance use disorder found the lack of trust and readiness as potential barriers for COVID-19 vaccination.Reference Mellis, Kelly, Potenza and Hulsey17 Other studies focused on confidence and knowledge in COVID-19 vaccines among healthcare workers.Reference Kasozi, Laudisoit, Osuwat, Batiha, Al Omairi and Aigbogun18 To the best of our knowledge, no study has assessed the willingness to pay for COVID-19 vaccination among people with mental disorders, including depression or anxiety disorder. In China, there are about 130 million people who suffer from mild to severe mental disorders, and 80% of them experience discrimination, thus providing a suitable population for evaluating such associations and differences.Reference Zhang, Sun, Jatchavala, Koh, Chia and Bose19

The aims of this study

The central government of China ensures that the COVID-19 vaccines are affordable for all Chinese residents. Several places rolled out free vaccinations to key and high-risk groups, including Chongqing, Guangdong, Zhejiang and Shandong provinces. In other parts of China, people paid $35 for each shot in Wuhan20 and $60 for each shot in Yiwu.Reference Devonshire-Ellis21 We used a sample of adults who suffer from depression or anxiety disorder with matched healthy controls just before the launch of the COVID-19 vaccination programme in Chongqing, a major city in China with a population of more than 30 million people. This study compared attitudes toward the pandemic and vaccines, concerns about the vaccine, perceived risk of contracting COVID-19, internalised stigma of COVID-19 infection, trust in health authorities and willingness to pay for the COVID-19 vaccine among people with depression or anxiety disorder and healthy controls. The null hypothesis was that there would be no difference in the aforementioned parameters between the two groups.

Method

Study design and participants

We recruited consecutive patients for the first visit or follow-up appointment in all psychiatric clinics of five hospitals in Chongqing, China, from 13 to 26 January 2021, shortly before the launch of the COVID-19 vaccination programme in the region. Four hospitals are general hospitals and one hospital is a psychiatric hospital. All hospitals are public hospitals run by the city and provincial health authorities. A hard copy of questionnaire was administered after obtaining a written consent from participants. A group of age-, gender- and education-matched healthy controls were recruited through posters on the noticeboards of the hospitals and word of mouth in Chongqing between 15 and 27 January 2021. All procedures involved in this study complied with the ethical standards of the relevant national and institutional committees on human experimentation and the Declaration of Helsinki. The study was approved by Ethics Review Committee of The First People's Hospital of Chongqing Liang Jiang New Area (approval number 2021-01-006).

Inclusion and exclusion criteria

All people with depression or anxiety disorder were aged ≥18 years with psychiatrist-diagnosed major depressive disorder (single episode or recurrent episodes) or anxiety disorders including generalised anxiety disorder and panic disorder, based on the ICD-10 criteria (codes F32, F33 and F41, respectively). Healthy controls were aged ≥18 years with no history of psychiatric illnesses.

Measures

This study used the National University of Singapore COVID-19 vaccine questionnaire that was developed and validated in the Asia-Pacific regions, including China, India, Indonesia, Bhutan, Singapore and Vietnam.Reference Chew, Cheong, Kong, Phua, Ngiam and Tan22 Participants indicated their responses in eight aspects. The first aspect was participant's willingness to receive the vaccine. This was assessed by a single item: ‘I would be willing to receive the COVID-19 vaccine if it was safe, available and recommended’. Willingness to receive the COVID-19 vaccine was dichotomised (1, willing; 0, not willing). The second aspect was perception of the COVID-19 pandemic and vaccine. A total of three items assessed the perception of pandemic and the vaccine. The third aspect was participant's concerns of the vaccine. This was subdivided into three components: (a) physical harm index (five items) assessing the participant's perception of the anticipated harm by the vaccine, (b) financial concerns related to the vaccine (one item) and (c) other concerns (four items). The fourth aspect was the COVID-19 risk profile. This included nine items assessing the direct impact of COVID-19 infection on their personal, family and social life.

The fifth aspect was internalised stigma of COVID-19 infection. The internalised stigma of COVID-19 infection questionnaire was adapted from the Perceived External Stigma of the Ebola-related Stigma Questionnaire,Reference Overholt, Wohl, Fischer, Westreich, Tozay and Reeves23 and was assessed by three items: ‘I would feel stigmatised if I contracted COVID-19’, ‘I am worried that others may refuse to have contact with me If I were to receive the vaccine’ and ‘I am worried that others may think that I have COVID-19 if I were to receive the vaccine’. This assessed participants’ internalised stigma of receiving the COVID-19 vaccine. The sixth aspect was a pro-socialness scale, evaluating participants’ pro-socialness stance on the COVID-19 vaccine, including social responsibility of vaccination and agreement to receive other vaccines (e.g. influenza vaccines).

The seventh aspect was public trust of health authorities. This evaluated the extent of the public's trust in the healthcare and government sector during the pandemic. Five items encompassing various components of the public's trust (including participants’ overall perception of trust in health authorities and perception of authorities’ competency, fairness, honesty and confidentiality). A Likert scale was used to assess participants’ responses (1, strongly agree; 2, agree; 3, neutral; 4, disagree; 5, strongly disagree). Consistent with previous literature using the vaccine willingness scale, items with the same index were collapsed into a composite score for analysis in the logistic model.Reference Jenkins, Torugsa, Markowitz, Mason, Jamroentana and Brown24 The eighth aspect was related to participants’ willingness to pay for the vaccination.

Mental health status was assessed with the 21-item Depression, Anxiety and Stress Scale (DASS-21). The DASS-21 was demonstrated to be a reliable and valid measure in assessing mental health in the Chinese population and people with depression or anxiety disorder during the COVID-19 pandemic.Reference Hao, Tan, Jiang, Zhang, Zhao and Zou13,Reference Tan, Hao, McIntyre, Jiang, Jiang and Zhang25 Based on previous COVID-19 research, the Cronbach's alpha for the subscales of the Chinese version of DASS-21 was >0.8, indicating high internal consistency in assessing stress, depression and anxiety in the Chinese population.Reference Wang, Chudzicka-Czupała, Tee, Núñez, Tripp and Fardin26

Statistical analysis

The effect of psychiatric diagnosis on continuous and categorical variables was determined with the Student's t-test and Pearson's χ²-test, respectively. Variables included demographic characteristics, socioeconomic status, occupation, medical history and subsections of the questionnaire. Associations between questionnaire measures and willingness to pay for the vaccine were determined with univariate binary logistic regression analysis. Questionnaire measures that were associated with willingness to pay for the vaccine on univariate analysis were included in a subsequent multivariable binary logistic regression model. The dependent variable was willingness to pay for the vaccine, and covariates were healthcare worker status, ownership of private health insurance, presence of children or dependents, presence of medical condition, perceived risk index, physical harm index, financial concern, personal risk profile, internalised stigma, pro-socialness index, public trust in health authorities and DASS-21 score. All tests were two-tailed, with a significance level of P ≤ 0.05. Data are expressed as mean (s.d.). Statistical analysis was performed with SPSS Statistics version 26 for Windows (IBM Corporation).

Results

A total of 90 people with mental disorders were approached; 7 people refused and 8 did not complete the questionnaire. The response rate for people with depression or anxiety disorder was 83.33% (n = 75). Out of 162 healthy controls, 28 refused to participate after obtaining more information on the study. The response rate for healthy controls was 82.71% (n = 134). Table 1 summarises the characteristics of participants. Of the 213 participants included in the final analyses, there were 79 people with mental disorders and 134 healthy controls. Out of 79 people with mental disorders, 56 people suffered from F33 major depressive disorder and 23 people suffered from F41 anxiety disorder.

Table 1 Characteristics of people with depression or anxiety disorder and healthy controls (N = 213)

P ≤ 0.05 indicated in bold. DASS-21, 21-item Depression, Anxiety and Stress Scale.

a. Student's t-test.

b. Pearson's χ²-test.

c. Complete data was not obtained (occupation: healthy controls, n = 134; people with depression or anxiety disorder, n = 78; employed during the COVID-19 pandemic: healthy controls, n = 133; people with depression or anxiety disorder, n = 79.)

There were no significant differences in age, gender, marital status, smoking status, housing ownership of private health insurance and education level between people with depression or anxiety disorder and healthy controls (P > 0.05). The participants were predominantly young adults (mean age of people with depression or anxiety disorder, 33.8±14.3 years; mean age of healthy controls, 35.7±13.4 years), female (people with depression or anxiety disorder, 69.6%; healthy controls, 67.9%), non-smokers (people with depression or anxiety disorder, 75.9%; healthy controls, 79.1%) and university educated (people with depression or anxiety disorder, 70.9%, healthy controls, 65.7%). There were significantly more healthy controls who were employed during the COVID-19 pandemic than people with depression or anxiety disorder (76.8 v. 53.8%, P = 0.027), but people with depression or anxiety disorder had significantly higher income than healthy controls (≥$35 000 per year, 29.1 v. 11.2%; P ≤ 0.001). There were significantly more people with depression or anxiety disorder who had chronic medical conditions (46.8 v. 15.7%, P ≤ 0.001) and were on long-term medication (54.4 v. 9.7%, P ≤ 0.001). People with depression or anxiety disorder had significantly higher DASS-21 scores (14.2 v. 2.6, P ≤ 0.001).

Supplementary Table 1 available at https://doi.org/10.1192/bjo.2021.979 compares the responses for each question in the questionnaire. The acceptance rate for the COVID-19 vaccine was 100% for healthy controls and 96.2% for people with depression or anxiety disorder. Healthy controls had a significantly higher acceptance rate (P = 0.023). Significantly higher proportion of people with depression or anxiety disorder were concerned about having to sign informed consent documents than healthy controls (27.8 v. 24.6%, P = 0.021). More healthy controls were worried about the cost or inability to afford the COVID-19 vaccine than people with depression or anxiety disorder (9 v. 1.3%, P = 0.049), and more healthy controls expected the COVID-19 vaccine to be free of charge (61.9 v. 35.4%, P ≤ 0.001). In contrast, more people with depression or anxiety disorder (13.9%) were willing to pay >$250 for the COVID-19 vaccine than healthy controls (5.2%, P ≤ 0.001), whereas more healthy controls expected the COVID-19 vaccine to be provided at no cost (61.9 v. 35.4%, P ≤ 0.001). A significantly higher proportion of people with depression or anxiety disorder strongly felt that the public healthcare system was effective (53.2 v. 39.6%, P = 0.039) than healthy controls. There were no differences between people with depression or anxiety disorder and healthy controls in other questions, including stigma after contracting of COVID-19, safety concerns over vaccines, willingness to receive other vaccines, outlook of vaccine leading to normal life and intention to travel (P > 0.05).

Table 2 compares the scores of eight subscales of the COVID-19 vaccine questionnaire between people with depression or anxiety disorder and healthy controls. People with depression or anxiety disorder were more likely to pay for the COVID-19 vaccine (64.6 v. 38.1%, P ≤ 0.001) and showed significantly higher levels of physical harm concerns (14.7 v. 13.8%, P = 0.027) and financial concerns regarding the COVID-19 vaccine (5.6% v. 4.6%, P ≤ 0.001). People with depression or anxiety disorder reported higher score in the personal risk profile (0.8 v. 0, P ≤ 0.001) and family risk (0.4 v. 0.2, P = 0.047), compared with healthy controls. There were no significant differences between people with depression or anxiety disorder and healthy controls in the perception of the COVID-19 vaccines and other concerns associated with risk of contracting COVID-19, overall perceived risk index, internalised stigma of potential COVID-19 infection, pro-socialness stance on the vaccine and trust in health authorities between people with depression or anxiety disorder and healthy controls (P > 0.05).

Table 2 Comparison of subscale scores between people with depression or anxiety disorder and healthy controls (N = 213)

P ≤ 0.05 indicated in bold.

a. Pearson's χ²-test.

b. Student's t-test.

Table 3 shows the univariate and multivariate logistic regression between willingness to pay for the COVID-19 vaccine and independent variables among people with depression or anxiety disorder. Personal risk profile of contracting COVID-19 (P = 0.047) and DASS-21 scores (P = 0.014) were independently associated with higher willingness to pay for the COVID-19 vaccine. After multivariate adjustment, higher DASS-21 score was significantly associated with willingness to pay for COVID-19 vaccination (P = 0.048). The regression model captured 13.9% variance in willingness to pay for the COVID-19 vaccine.

Table 3 Univariate and multivariate logistic analysis of willingness to pay for COVID-19 vaccination among people with depression or anxiety disorder (n = 79)

Healthcare workers, those with private health insurance, those with children or dependents, those with a medical condition and those who were willing to pay for the vaccine were coded ‘1’ and were the reference category (last). DASS-21, 21-item Depression, Anxiety and Stress Scale.

Table 4 shows the univariate and multivariate logistic regression between willingness to pay for the COVID-19 vaccine and independent variables among healthy controls. Non-healthcare worker status (P ≤ 0.001), private health insurance (P ≤ 0.001), living with children or dependents (P ≤ 0.001), physical harm index (P ≤ 0.001), personal risk profile of contracting COVID-19 (P ≤ 0.049), internalised stigma of COVID-19 infection (P ≤ 0.001), pro-socialness index (P = 0.004) and DASS-21 scores (P ≤ 0.001) were independently associated with higher willingness to pay for the COVID-19 vaccine. After multivariate adjustment, non-healthcare worker status (P = 0.039), private health insurance (P = 0.003), living with children or dependents (P = 0.006) and internalised stigma of COVID-19 infection (P = 0.002) were significantly associated with willingness to pay for COVID-19 vaccination. The regression model captured 30.6% variance in willingness to pay for the COVID-19 vaccine.

Table 4 Univariate and multivariable binomial logistic regression of willingness to pay for COVID-19 vaccination among healthy controls (n = 134)

Healthcare workers, those with private health insurance, those with children or dependents, those with a medical condition and those who were willing to pay for the vaccine were coded ‘1’ and were the reference category (last). DASS-21, 21-item Depression, Anxiety and Stress Scale.

Discussion

The key finding of this study is that people with and without mental disorders showed a high acceptance rate for the COVID-19 vaccine in Chongqing, China. The higher willingness to pay for the vaccine by people with depression or anxiety disorder is a novel finding. Factors associated with willingness to pay for COVID-19 vaccination differed between people with and without mental disorders. For people with depression or anxiety disorder, high DASS-21 score was associated with willingness to pay for the COVID-19 vaccine. In contrast, non-healthcare worker status, having private health insurance, living with children or dependents and internalised stigma of COVID-19 infection were associated with willingness to pay for the COVID-19 vaccine in healthy controls. Our findings provide health authorities with information regarding the attitudes of people with depression or anxiety disorder regarding COVID-19 vaccination. The high acceptance rate among people with depression or anxiety disorder and healthy controls is encouraging for the aim of achieving herd immunity.

The high proportion of willingness to receive the COVID-19 vaccine in people with depression or anxiety disorder is similar to our observation among healthcare workers across Asia.Reference Chew, Cheong, Kong, Phua, Ngiam and Tan22 Interestingly, the willingness to receive vaccination in our study is higher than recent studies conducted in the general population in China (84.8–91.3%),Reference Leng, Maitland, Wang, Nicholas, Liu and Wang27,Reference Wang, Jing, Lai, Zhang, Lyu and Knoll28 as well as among multiple sclerosis patients in the USA (66%).Reference Ehde, Roberts, Herring and Alschuler11 Similarly, the acceptance rate for the healthy controls in this study is higher than general population in the USA (67%) and Japan (65.7%).Reference Malik, McFadden, Elharake and Omer29,Reference Yoda and Katsuyama30 Importantly, our study was conducted before the launch of the COVID-19 vaccination programme in Chongqing, China, in contrast to the prior USA study conducted in 2020, when the COVID-19 vaccine was hypothetical.Reference Ehde, Roberts, Herring and Alschuler11 By January 2021, China had made progress in developing several COVID-19 vaccines,Reference Wu, Hu, Xu, Chen, Yang and Jiang31 and about 64% of Chinese had even expressed a preference for a China-made vaccine over foreign-made vaccine.Reference Lin, Hu, Zhao, Alias, Danaee and Wong32 By 20 March 2021, China had administered 75 million doses of COVID-19 vaccines.33 Since vaccine willingness might change over time as more data is accumulated about the safety and efficacy of the vaccine, further study may be required to monitor the trend worldwide.

The other explanation for the high COVID-19 vaccine acceptance rate in our study is the high confidence in the public healthcare system and recommendations from the Chinese Government. In our study, only 3.7% of healthy controls and 3.8% of people with depression or anxiety disorder expressed disagreement or strong disagreement that the COVID-19 vaccine was safe. This is in contrast to a study in France in which 25% of the adult participants refused to take the COVID-19 vaccine, citing concerns over its safety.Reference Ward, Alleaume and Peretti-Watel34 Furthermore, the high acceptance rate in our study could be because Chinese people are more collectivistic, attached to social conformity and responsive to administrative collective orders such as wearing face masks during the current pandemic.Reference Wang, Chudzicka-Czupała, Grabowski, Pan, Adamus and Wan35 A similar attitude was responsible for the high acceptance rate noted among Asian Americans among all racial and ethnic groups in a recent study in the USA,Reference Malik, McFadden, Elharake and Omer29 which might explain the better containment of the current pandemic in some Asia countries.

Previous studies found that education levels and perceived risk of COVID-19 infection were associated with willingness to receive the COVID-19 vaccine.Reference Ehde, Roberts, Herring and Alschuler11,Reference Leng, Maitland, Wang, Nicholas, Liu and Wang27 Our study found that internalised stigma was significantly associated with willingness to pay for COVID-19 vaccination, after multivariate adjustment in healthy controls. Our finding has important implications for the community and supports the previous postulation that demographics, health status and source of COVID-19 information do not completely explain willingness to pay for the COVID-19 vaccine.Reference Ehde, Roberts, Herring and Alschuler11 Physician- or pharmacist-led programmes for vaccine education and immunisation counselling might further address the benefits and risk of vaccination, the potential interaction with medications, the differences between somatic complaints and vaccine side-effects, and improve compliance. Interestingly, for healthy controls, internalised stigma associated with COVID-19 infection was a motivator, not a barrier, to paying for the vaccine and thereby reducing the risk of contracting COVID-19. This is in contrast to a previous study in which the stigma associated with an infectious disease increased vaccine hesitancy and resistance.Reference Bologna, Stamidis, Paige, Solomon, Bisrat and Kisanga36 For people with depression or anxiety disorder, high DASS-21 score was the only factor associated with willingness to pay for the COVID-19 vaccine, after adjustment for other factors. Psychiatric patients might be more depressed and anxious during the pandemic, and this might explain their keenness for vaccination.

Although this study found that a third of people with depression or anxiety disorder, and two-thirds of healthy controls, preferred to receive free COVID-19 vaccines, there was a significantly higher proportion of people with depression or anxiety disorder who were willing to pay for the COVID-19 vaccine and had fewer financial concerns. There could be several explanations for this finding. First, depression and anxiety disorders are mild psychiatric conditions and have less impact on occupational function and willingness to pay for the COVID-19 vaccine. In this study, about 53.8% of people with depression or anxiety disorder and 76.8% of healthy controls were employed. Second, the proportion of healthcare workers was higher in healthy controls (45.5%) compared with people with depression or anxiety disorder (5.1%). Among healthy controls, non-healthcare worker status was a significant factor associated with willingness to pay for the COVID-19 vaccine. We performed further analysis by comparing annual incomes of people with depression or anxiety disorder, healthy controls who were healthcare workers and healthy controls who were not healthcare workers. In this study, 28% of people with depression or anxiety disorder, 15.1% of healthy controls who were not healthcare workers and 6.6% of healthy controls who were healthcare workers reported an annual income ≥$35 000, and the differences were significant (P = 0.005). The Chinese government has maintained its pricing power over healthcare services and salaries.37 As a result, China's healthcare workers are underpaid compared with other professions. Furthermore, healthcare workers might expect the vaccine to be free of charge, which could affect their willingness to pay for COVID-19 vaccine. Our finding is different when compared with a recent study that reported that median willingness to pay for the COVID-19 vaccine was $28 in China.Reference Lin, Hu, Zhao, Alias, Danaee and Wong32 In our study, >25% of people with depression or anxiety disorder and healthy controls were willing to pay $50 for the COVID-19 vaccine. More than 5% of people with depression or anxiety disorder and healthy controls were willing to pay $250 for the COVID-19 vaccine.

Our findings need to be interpreted in context of the economic status of Chongqing, where this study was conducted. The gross domestic product of Chongqing in 2020 was 2 500 279 billion yuan ($380.925 billion), ranking fifth among all cities in China. As a result, some people with depression or anxiety disorder and healthy controls were able to afford to pay for the COVID-19 vaccine. The Chinese healthcare system has a vibrant private sector and patients may engage both public and private health services. Many Chinese with mental disorders pay for their psychiatric treatment as part of the chronic disease management, which might explain why people with depression or anxiety disorder in our study were more willing pay for the COVID-19 vaccine compared with healthy controls, who were willing to pay if covered by health insurance. Our findings may not apply to other cities with a lower gross domestic product, and further research in other countries is required.

Limitations

Although this study is among the first to report the willingness to pay for the COVID-19 vaccine in people with depression or anxiety disorder, some limitations need to be acknowledged. First, we studied people without psychosis, and mainly focused on people suffering from depression or anxiety disorder. These patients might have better occupational potential and higher socioeconomic status than people with psychotic illnesses (e.g. schizophrenia), although people with depression or anxiety disorder are prone to cognitive bias that may affect perception of the COVID-19 vaccines.Reference Salali and Uysal38 Furthermore, patients with psychosis experience higher levels of stigma compared with those without psychosis.Reference Zhang, Sun, Jatchavala, Koh, Chia and Bose19 Our findings could not be generalised to people suffering from severe mental disorders (e.g. schizophrenia) that result in severe financial difficulty, as well as those with low educational background. Furthermore, we measured anxiety and depression symptoms in general, and we did not assess the potential effects of COVID-19-related anxiety as a specific cause of vaccination willingness.

Second, our study participants were from one city in China, and the findings may not be generalized to the rest of China and other countries. Third, the regression model captured 30.6% variance in willingness to pay for the COVID-19 vaccine in people with depression or anxiety disorder, suggesting that other factors were not assessed in this study. Nevertheless, the percentage of variance is higher than previous studies on willingness to receive the COVID-19 vaccine.Reference Ehde, Roberts, Herring and Alschuler11 Fourth, the study design was cross-sectional and could not demonstrate causal relationship between independent variables and willingness to pay for the COVID-19 vaccines. Fifth, the study was based on self-administered questionnaires, where the responses could be affected by recall and reporting bias.

To conclude, >95% of people with depression or anxiety disorder and healthy controls were willing to receive the COVID-19 vaccine in Chongqing, China. People with depression or anxiety disorder were more willing to pay for the COVID-19 vaccine than healthy controls. Severity of depression and anxiety was the most important factor associated with willingness to pay for the COVID-19 vaccine in people with depression or anxiety disorder. In contrast, non-healthcare worker status, ownership of private insurance, living with children and adolescents and internalised stigma associated with COVID-19 infection were the most important factors associated with willingness to pay for the COVID-19 vaccine in healthy controls. As people with mental disorders are keen to accept the COVID-19 vaccine, health authorities should offer vaccination as soon as possible.

Supplementary material

Supplementary material is available online at http://doi.org/10.1192/bjo.2021.979

Data availability

The data that support the findings of this study are available on request from the corresponding author, R.H.. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

Author contributions

F.H., B.W., W.T. and R.H. conceived of the study. N.W.S.C., B.Y.-Q.T. and V.K.H. designed the methodology. S.F.H. and R.H. conducted data validation. F.H., B.W. and Z.Z. were responsible for resources. L.Z., X.H. and L.J. were responsible for data curation. R.H., S.F.H., F.H. and W.T. conducted formal analysis. F.H., W.T., C.S.H. and R.H. were responsible for original draft preparation. R.S.M., B.T., G.L.V., G.T.V. and V.K.S. reviewed and edited the manuscript. S.F.H. was resposible for visualisation. R.H., R.S.M., B.T. and V.K.S. supervised the study. Z.Z. and X.T. handled project administration. All authors have read and agreed to the published version of the manuscript.

Funding

This project is funded by Chongqing Municipal Science & Technology Commission and Municipal Health Commission Joint Medical Research Project (grant 2021MSXM228), Chongqing Science and Technology Dissemination and Popularization Project (grant cstc2019kpzx-kphdA0014), NUS iHeathtech Other Operating Expenses (grant R-722-000-004-731), NUS Department of Psychological Medicine Other Operating Expenses (grant R-177-000-003-001) and Anhui Province University excellent top talent cultivation funding project (project number GXGWFX2018032).

Declaration of interest

None.

References

World Health Organization (WHO). WHO Coronavirus Disease (COVID-19) Dashboard. WHO, 2021 (https://covid19.who.int/).Google Scholar
Gregorevic, K, Maier, A, Miranda, R, Loveland, P, Miller, K, Buising, K, et al. Presenting symptoms of COVID-19 and clinical outcomes in hospitalised older adults. Intern Med J 2021; 51(6): 861–7.CrossRefGoogle ScholarPubMed
Lopez-Leon, S, Wegman-Ostrosky, T, Perelman, C, Sepulveda, R, Rebolledo, P, Cuapio, A, et al. More than 50 long-term effects of COVID-19: a systematic review and meta-analysis. MedRxiv [Preprint] 2021. Available from: https://www.medrxiv.org/content/10.1101/2021.01.27.21250617v2 [refd 6 July 2021].Google ScholarPubMed
Worldometer. COVID-19 Coronavirus Pandemic. Worldometer, 2020 (https://www.worldometers.info/coronavirus/).Google Scholar
Alexander, JL, Moran, GW, Gaya, DR, Raine, T, Hart, A, Kennedy, NA, et al. SARS-CoV-2 vaccination for patients with inflammatory bowel disease: a British Society of Gastroenterology Inflammatory Bowel Disease Section and IBD Clinical Research Group position statement. Lancet Gastroenterol Hepatol 2021; 6(3): 218–24.CrossRefGoogle ScholarPubMed
Desai, A, Gainor, JF, Hegde, A, Schram, AM, Curigiliano, G, Pal, S, et al. COVID-19 vaccine guidance for patients with cancer participating in oncology clinical trials. Nat Rev Clin Oncol 2021; 18(5): 313–9.CrossRefGoogle ScholarPubMed
Gee, J, Marquez, P, Su, J, Calvert, GM, Liu, R, Myers, T, et al. First month of COVID-19 vaccine safety monitoring - United States, December 14, 2020–January 13, 2021. MMWR Morb Mortal Wkly Rep 2021; 70(8): 283–8.CrossRefGoogle ScholarPubMed
Oldenburg, J, Klamroth, R, Langer, F, Albisetti, M, von Auer, C, Ay, C, et al. Diagnosis and management of vaccine-related thrombosis following AstraZeneca COVID-19 vaccination: guidance statement from the GTH. Hamostaseologie 2021; 41(3): 184–9.Google ScholarPubMed
Sallam, M, Dababseh, D, Eid, H, Al-Mahzoum, K, Al-Haidar, A, Taim, D, et al. High ates of COVID-19 vaccine hesitancy and its association with conspiracy beliefs: a study in Jordan and Kuwait among other Arab countries. Vaccines 2021; 9(1): 42.CrossRefGoogle Scholar
Tran, BX, Boggiano, VL, Nguyen, LH, Latkin, CA, Nguyen, HLT, Tran, TT, et al. Media representation of vaccine side effects and its impact on utilization of vaccination services in Vietnam. Patient Prefer Adherence 2018; 12: 1717–28.CrossRefGoogle ScholarPubMed
Ehde, DM, Roberts, MK, Herring, TE, Alschuler, KN. Willingness to obtain COVID-19 vaccination in adults with multiple sclerosis in the United States. Mult Scler Relat Disord 2021; 49: 102788.CrossRefGoogle ScholarPubMed
Xiong, J, Lipsitz, O, Nasri, F, Lui, LMW, Gill, H, Phan, L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277: 5564.CrossRefGoogle ScholarPubMed
Hao, F, Tan, W, Jiang, L, Zhang, L, Zhao, X, Zou, Y, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun 2020; 87: 100–6.CrossRefGoogle ScholarPubMed
McIntyre, RS, Lee, Y. Preventing suicide in the context of the COVID-19 pandemic. World Psychiatry 2020; 19(2): 250–1.CrossRefGoogle ScholarPubMed
Cotugno, S, Morrow, G, Cooper, C, Cabie, M, Cohn, S. Impact of pharmacist intervention on influenza vaccine assessment and documentation in hospitalized psychiatric patients. Am J Health Syst Pharm 2017; 74(23 suppl 4): S90–4.CrossRefGoogle ScholarPubMed
Carney, CP, Allen, J, Doebbeling, BN. Receipt of clinical preventive medical services among psychiatric patients. Psychiatr Serv 2002; 53(8): 1028–30.CrossRefGoogle ScholarPubMed
Mellis, AM, Kelly, BC, Potenza, MN, Hulsey, JN. Trust in a COVID-19 vaccine among people with substance use disorders. Drug Alcohol Depend 2021; 220: 108519.CrossRefGoogle Scholar
Kasozi, KI, Laudisoit, A, Osuwat, LO, Batiha, GE-S, Al Omairi, NE, Aigbogun, E, et al. A descriptive-multivariate analysis of community knowledge, confidence, and trust in COVID-19 clinical trials among healthcare workers in Uganda. Vaccines 2021; 9(3): 253.CrossRefGoogle ScholarPubMed
Zhang, Z, Sun, K, Jatchavala, C, Koh, J, Chia, Y, Bose, J, et al. Overview of stigma against psychiatric illnesses and advancements of anti-stigma activities in six Asian societies. Int J Environ Res Public Health 2019; 17(1): 280.CrossRefGoogle ScholarPubMed
Global Times. China to Eventually Make COVID-19 Vaccines Free to Public as a ‘Premise’. Global Times, 2020 (https://www.globaltimes.cn/page/202012/1211519.shtml).Google Scholar
Devonshire-Ellis, C. China's COVID-19 Vaccine Development and Availability. China Briefing, 2020 (https://www.china-briefing.com/news/chinas-covid-19-vaccine-development-and-availability/).Google Scholar
Chew, NWS, Cheong, C, Kong, G, Phua, K, Ngiam, JN, Tan, BYQ, et al. An Asia-Pacific study on healthcare worker's perception and willingness to receive COVID-19 vaccination. Int J Infect Dis 2021; 106: 5260.CrossRefGoogle Scholar
Overholt, L, Wohl, DA, Fischer, WA, Westreich, D, Tozay, S, Reeves, E, et al. Stigma and Ebola survivorship in Liberia: results from a longitudinal cohort study. PLoS One 2018; 13(11): e0206595.CrossRefGoogle ScholarPubMed
Jenkins, RA, Torugsa, K, Markowitz, LE, Mason, CJ, Jamroentana, V, Brown, AE, et al. Willingness to participate in HIV-1 vaccine trials among young Thai men. Sex Transm Infect 2000; 76(5): 386–92.CrossRefGoogle ScholarPubMed
Tan, W, Hao, F, McIntyre, RS, Jiang, L, Jiang, X, Zhang, L, et al. Is returning to work during the COVID-19 pandemic stressful? A study on immediate mental health status and psychoneuroimmunity prevention measures of Chinese workforce. Brain Behav Immun 2020; 87: 8492.CrossRefGoogle Scholar
Wang, C, Chudzicka-Czupała, A, Tee, ML, Núñez, MIL, Tripp, C, Fardin, MA, et al. A chain mediation model on COVID-19 symptoms and mental health outcomes in Americans, Asians and Europeans. Sci Rep 2021; 11(1): 6481.CrossRefGoogle ScholarPubMed
Leng, A, Maitland, E, Wang, S, Nicholas, S, Liu, R, Wang, J. Individual preferences for COVID-19 vaccination in China. Vaccine 2021; 39(2): 247–54.CrossRefGoogle ScholarPubMed
Wang, J, Jing, R, Lai, X, Zhang, H, Lyu, Y, Knoll, MD, et al. Acceptance of COVID-19 vaccination during the COVID-19 pandemic in China. Vaccines (Basel) 2020; 8(3): 482.Google ScholarPubMed
Malik, AA, McFadden, SM, Elharake, J, Omer, SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine 2020; 26: 100495.CrossRefGoogle ScholarPubMed
Yoda, T, Katsuyama, H. Willingness to receive COVID-19 vaccination in Japan. Vaccines 2021; 9(1): 48.CrossRefGoogle ScholarPubMed
Wu, Z, Hu, Y, Xu, M, Chen, Z, Yang, W, Jiang, Z, et al. Safety, tolerability, and immunogenicity of an inactivated SARS-CoV-2 vaccine (CoronaVac) in healthy adults aged 60 years and older: a randomised, double-blind, placebo-controlled, phase 1/2 clinical trial. Lancet Infect Dis 2021; 21(6): 803–12.CrossRefGoogle ScholarPubMed
Lin, Y, Hu, Z, Zhao, Q, Alias, H, Danaee, M, Wong, LP. Understanding COVID-19 vaccine demand and hesitancy: a nationwide online survey in China. PLoS Negl Trop Dis 2020; 14(12): e0008961.CrossRefGoogle ScholarPubMed
Reuters Staff. China Steps Up COVID-19 Vaccination, Considers Differentiated Visa Policies. Reuters, 2021 (https://www.reuters.com/article/us-health-coronavirus-china-vaccine-idUSKBN2BD0A8).Google Scholar
Ward, JK, Alleaume, C, Peretti-Watel, P. The French public's attitudes to a future COVID-19 vaccine: the politicization of a public health issue. Soc Sci Med 2020; 265: 113414.CrossRefGoogle ScholarPubMed
Wang, C, Chudzicka-Czupała, A, Grabowski, D, Pan, R, Adamus, K, Wan, X, et al. The association between physical and mental health and face mask use during the COVID-19 pandemic: a comparison of two countries with different views and practices. Front Psychiatry 2020; 11: 901.Google ScholarPubMed
Bologna, L, Stamidis, KV, Paige, S, Solomon, R, Bisrat, F, Kisanga, A, et al. Why communities should be the focus to reduce stigma attached to COVID-19. Am J Trop Med Hyg 2021; 104(1): 3944.CrossRefGoogle ScholarPubMed
Wang Y. Protecting China's Healthcare Workers during COVID-19. BMJ Group, 2020 (https://blogs.bmj.com/covid-19/2020/03/31/protecting-chinas-healthcare-workers-during-covid-19/).Google Scholar
Salali, GD, Uysal, MS. COVID-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the UK and Turkey. Psychol Med [Epub ahead of print] 19 Oct 2020. Available from: https://doi.org/10.1017/S0033291720004067.CrossRefGoogle ScholarPubMed
Figure 0

Table 1 Characteristics of people with depression or anxiety disorder and healthy controls (N = 213)

Figure 1

Table 2 Comparison of subscale scores between people with depression or anxiety disorder and healthy controls (N = 213)

Figure 2

Table 3 Univariate and multivariate logistic analysis of willingness to pay for COVID-19 vaccination among people with depression or anxiety disorder (n = 79)

Figure 3

Table 4 Univariate and multivariable binomial logistic regression of willingness to pay for COVID-19 vaccination among healthy controls (n = 134)

Supplementary material: File

Hao et al. supplementary material

Hao et al. supplementary material

Download Hao et al. supplementary material(File)
File 68 KB
Submit a response

eLetters

No eLetters have been published for this article.
You have Access
Open access

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Attitudes toward COVID-19 vaccination and willingness to pay: comparison of people with and without mental disorders in China
Available formats
×

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Attitudes toward COVID-19 vaccination and willingness to pay: comparison of people with and without mental disorders in China
Available formats
×

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Attitudes toward COVID-19 vaccination and willingness to pay: comparison of people with and without mental disorders in China
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *