Covid-19 vaccination hesitancy

Dear Editor

I am very happy to respond to John Stone and Noel Thomas to clarify what motivational interviewing is, and how it can be entirely compatible with supporting patients to make informed decisions that feel right for them.

Simply trying to persuade or browbeat people into changing their behaviour to improve their health (for example to lose weight, do more exercise, or stop smoking), however well intentioned, feels uncomfortably doctor - rather than patient - centred and often doesn’t work very well. In the vaccine hesitancy field for example, confronting people with facts designed to correct misunderstandings has not met with much success, and might even backfire (Nyhan et al 2014). There are a few limited interventions that do seem to make a difference (Briss et al, 2000).

The great strength of motivational interviewing is that it does not seek to persuade or coerce patients into having the vaccine. It offers a different approach, where the practitioner comes “alongside” the patient, tries to understand their views, and offers rather than imposes information that might help them weigh up the risks and benefits for themselves, and make a decision that makes sense to them. It is absolutely not a technique for making people do what they might not otherwise want to do. Rather, the patient is encouraged to examine the pros and cons of change and to make an informed decision that they think could lead to improvement in their health and wellbeing.

Motivational interviewing has been the subject of over 1600 randomised controlled trials (Stephen Rollnick, personal communication). Recently this has been explored in the vaccine hesitancy field (Gagneur, 2020) and one recent study in a paediatric setting found an increase in vaccine uptake as a result (Gagneur, 2018).

References
Nyhan et al, 2014: https://pediatrics.aappublications.org/content/133/4/e835

Briss et al, 2000: Briss PA, Rodewald LE, Hinman AR, Shefer AM, Strikas RA, Bernier RR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med. 2000;18:97–140.

Gagneur 2020: Gagneur A. Motivational interviewing: A powerful tool to address vaccine hesitancy. Can Commun Dis Rep 2020;46(4):93–7. https://doi.org/10.14745/ccdr.v46i04a06

Gagneur et al 2018: Gagneur A, Lemaître T, Gosselin V, Farrands A, Carrier N, Petit G, Valiquette L, De Wals P. A postpartum vaccination promotion intervention using motivational interviewing techniques improves short-term vaccine coverage: PromoVac study. BMC Public Health 2018 Jun;18(1):811. DOI PubMed

Dear Editor

I read the latest intervention in this correspondence (from Graham Easton) with despair [1,2,3]. I do not see how trust can exist if a doctor has the role of persuader in the same way that a dealer or agent might try to sell a car or a property, or that they would meet their ethical obligation to inform the patient not only of the advantages of the product but also it’s risks. I do not want to visit my doctor and have moral pressure put on me to do something I do not want, or be embarrassed, and this is surely an invidious position for the professional. It should not be a test of wills in which the doctor is trained to overcome resistance by subtle means.

[1] Mohammad S Razai, Umar A R Chaudhry, Katja Doerholt, Linda Bauld, Azeem Majeed, ‘Covid-19 vaccination hesitancy’,
BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1138 (Published 20 May 2021)

[2] Responses to Razai, Chauhry, Doerholt, Bauld and Majeed, https://www.bmj.com/content/373/bmj.n1138/rapid-responses

[3] Graham P Easton, ‘ Resisting the “righting reflex” in Covid Vaccine hesitancy conversations ’, 8 June 2021, https://www.bmj.com/content/373/bmj.n1138/rr-29

Dear Editor

I find it interesting that Razai et al take an eminence based position over an evidence based position that the vaccine hesitant population seem to suffer the misfortune of being less well educated than those supporting a full roll out of a Covid 19 vaccine.



“Higher vaccine hesitancy is also reported among women (women 21%, men 15%), younger age groups (28% in 25-34 years, versus 14% in 55-64 years), and in people with a lower education level (24% in secondary school graduates; 13% in university graduates).These data follow a historical trend in the UK of lower uptake of pneumococcal, influenza, rotavirus, and shingles vaccines among socioeconomically disadvantaged individuals and ethnic minorities.”



One only has to scroll through many of the responses available on this site to observe that many well respected doctors, scientists, clinicians and well read members of the public can point out that obvious discrepancies associated with glowing press releases that permeate the media. 

If basic pre-requisites of long term trial data and safety is not available, and we ignore the primary data that Covid 19 is a) not a threat to a large amount of the population and b) children simply are not susceptible to Covid unless like their adult counterparts have some level of metabolic inflexibility. Are you, despite your high level of education just simply falling prey to biological reductionism?

The current VAERS data is unlike anything that has been seen from other interventions, and quite likely that the proposed cure could be creating artefacts that are just not being considered.

Even in these modern times, the suggestion that a high level degree offers anything more than the capacity to tick boxes and follow algorithms, compared to someone with less credentials, is as myopic as some of the endpoints and efficacy rates proposed by the studies employed to date. If you can’t question and critique, it’s not science, and it’s certainly not settled.

Yours Sincerely



Keith Littlewood


BSc, MSc (Phd Student).

Dear Editor,

India is severely affected by the COVID-19 pandemic. India has a massive population with mental illness. As per the National Mental Health Survey 2015-16, the lifetime prevalence and current prevalence of mental illnesses in India were 13.67% and 10.56%, respectively [1, 2]. If it is projected to the total population of India (approximately 1370 million), then about 187 million Indians are having some form of mental illness during their lifetime, and 145 million have any mental illness currently.
Evidence supports that patients with mental illness are at higher risk of getting infected with COVID-19 [3]. As per the available evidence, if a person has any mental illness in the previous year, then the relative risk of having COVID-19 infection is 1.65 folds [4]. Therefore, considering the increased risk for COVID-19, it has been recommended that persons with mental illness (particularly those with severe mental illness) need to be vaccinated on a priority basis [3, 5].
However, there exist certain challenges and controversies regarding the inclusion of all patients with mental illnesses in the vaccination process. To enlist, some are:
1. Certain mental illnesses like depression and schizophrenia reduce the immune response to vaccines leading to inadequate production of antibodies, which may give insufficient protection to the patient even after vaccination.
2. Patients with lifetime psychiatric disorders in the phase of remission may not get the priority for vaccination.
3. Hesitation and fear among the public receive vaccination due to fear of side effects and doubt about the efficacy [6].
4. Reluctance and lack of motivation among the patients with mental illnesses to get vaccines for COVID-19.
5. It has been suggested that patients with mental illness with a certificate for the illness will be given vaccination [7]. However, in a country like India, most patients with mental illnesses do not have certificates of their mental illness due to their unawareness and stigma of getting labeled. So, this directive is likely to deprive many persons from getting the vaccination on a priority basis.
For the equitable distribution of COVID-19 vaccines, it has been recommended that in phase 2, the patients with severe mental illnesses, developmental and intellectual disabilities need to be vaccinated [8]. This recommendation was meant for patients who are staying in group homes or shelter homes. However, there is no concrete recommendation for the patients with mental illness who remain in the community at their homes. Priority should also be given to the patients who are currently or recently been symptomatic. They pose a higher risk of getting infected with COVID-19 as they may not be able to take adequate preventive measures against COVID-19.
Similarly, those with multiple psychiatric illnesses or with severe disability or dysfunction should get priority over those who have moderate to no disability. As certification is a big challenge in a country like India, there is a need to consider the valid prescription from recent consultation as a substitute for an illness certificate to get vaccinated. However, in India, only a small fraction of patients with mental illness are able to avail consultation for their illness due to lockdown and shifting of consultation mode to the digital platform. To overcome this difficulty, the patients with mental illness may be encouraged to consult and liaison with the district mental health program to get a valid prescription. Similarly, consulting mental health professionals should be encouraged to sensitize the patients and their caregivers for COVID-19 vaccination.

References
[1] Gururaj G, Varghese M, Benegal V, et al. National mental health survey of India, 2015-16: Summary. Bengaluru: National Institute of Mental Health and Neurosciences.
[2] Gautham MS, Gururaj G, Varghese M, et al. The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. International Journal of Social Psychiatry 2020; 66: 361–372.
[3] Mazereel V, Assche KV, Detraux J, et al. COVID-19 vaccination for people with severe mental illness: why, what, and how? The Lancet Psychiatry 2021; 8: 444–450.
[4] Taquet M, Luciano S, Geddes JR, et al. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. The Lancet Psychiatry 2021; 8: 130–140.
[5] Stip E, Javaid S, Amiri L. People with mental illness should be included in COVID-19 vaccination. The Lancet Psychiatry 2021; 8: 275–276.
[6] Razai MS, Chaudhry UAR, Doerholt K, et al. Covid-19 vaccination hesitancy. BMJ 2021; 373: n1138.
[7] The Hindu. HC notice to Centre on plea for vaccine for people suffering from mental illness. The Hindu, March 16, 2021, https://www.thehindu.com/news/national/hc-notice-to-centre-on-plea-for-v... (March 16, 2021, accessed May 29, 2021).
[8] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Board on Health Sciences Policy; Committee on Equitable Allocation of Vaccine for the Novel Coronavirus. Framework for Equitable Allocation of COVID-19 Vaccine. Washington (DC): National Academies Press (US), http://www.ncbi.nlm.nih.gov/books/NBK562672/ (2020, accessed May 29, 2021).

Authors:
 Sujita Kumar Kar*#, Department of Psychiatry, King George's Medical University, Lucknow 226003, India. E-mail: drsujita@gmail.com
 Amit Singh#, Department of Psychiatry, King George's Medical University, Lucknow 226003, India. E-mail: amitsingh0612@gmail.com

*Correspondence
E-mail: drsujita@gmail.com, ORCID ID: https://orcid.org/0000-0003-1107-3021
#Contributed equally as first author.
Conflict of interest: None.
Funding: None
Acknowledgment: None