Assiut Scientific Nursing Journal

http://asnj.journals.ekb.eg http://www.arabimpactfactor.com
DOI: 10.21608/ASNJ.2023.174740.1454 http://olddrji.lbp.world/indexedJournals.aspx
https://vlibrary.emro.who.int/journals/assiut-scientific-nursing-journal
Relationship between Psychiatric Patients' Awareness about COVID-19 and Their
Attitudes toward its Vaccine
Shymaa Mohammed Sayed Hassan1, Amal Abd Elaal Mohamed Ali2 & Ghada Ahmed Ghazi Mohamed3
1.
Lecturer of Psychiatric and Mental Health Nursing, Faculty of Nursing, Assiut University, Egypt.
2.
Lecturer of Psychiatric Nursing and Mental Health, Faculty of Nursing, South Valley University, Egypt.
3.
Assistant Professor of Psychiatric Nursing and Mental Health, Faculty of Nursing, Alexandria University, Egypt.

Abstract
Psychiatric patients are at higher risk of dying from COVID-19, making the concern of vaccination willingness
crucial. Aim: This research aimed to assess the relationship between psychiatric patients' awareness of COVID-19
and their attitude toward its vaccine. Design: A descriptive-correlational design was used. Setting: The research was
done at an outpatient clinic and inpatient psychiatric department of the neuropsychiatric and neurosurgery hospital at
Assiut University Hospital. Sample: Included 186 psychiatric inpatients and 278 psychiatric outpatients. Tools:
three tools were used; Tool (1): Structured interviewing questionnaire, Tool (2): Coronavirus (COVID-19)
Awareness Scale, and Tool (3): Attitudes toward COVID-19 vaccines. Results: The research subjects have the
highest mean score and SD of coronavirus concern (12.2±3.3), followed by exaggerated perception (5.2±2.1) and the
lowest mean score is related to immunity perception (2.7±1.2). The mean rank of coronavirus concern is higher
among outpatients than inpatients and there is a significant relation between outpatient and coronavirus concern (p-
value= 0.000). Conclusion: Psychiatric patients who have coronavirus concerns and have information about the
virus have the wiliness to be vaccinated more those patients who have not aware of the pandemic of coronavirus.
Also, it can be concluded that outpatients are more aware of COVID-19 as they are in more contact with mass media
than inpatients. Recommendations: Implementation of educational programs about the effects and importance of
vaccines against COVID-19.

Keywords: Attitude, Awareness, COVID-19, Vaccine& Psychiatric patients.

Introduction: loneliness, sadness, stress, and insomnia indicates that

Coronavirus disease (COVID-19) is a viral illness COVID-19 lowers the immune system (Suhas, 2021).
that has spread over the world and is a significant A person with a mental illness may decline the
topic of public health research. It continues to be a vaccine due to a lack of understanding, expense,
problem for many nations. Numerous attempts have accessibility issues, immunization-related anxieties,
been taken to stop the spread of the virus, but only and a lack of health education from their primary care
vaccination can stop the pandemic and contain it providers. Additionally, individuals with paranoid
(Bilsin & Kocamaz, 2022). delusions may not believe in vaccinations and worry
Vaccines are efficient therapies that can reduce the about interactions with psychoactive drugs (Miles et
high burden of disease on a global scale. However, a al., 2019).
significant issue for public health agencies is a public The coronavirus disease 2019 has brought significant
reluctance to get vaccines (El-Elimat et al., 2021). pressure on nurses as they are the frontline of care.
Patients who are mentally ill have the risk of both Patient care responsibilities fall mostly on the
contracting COVID-19 and developing a more serious shoulders of nurses. The demands on nurses have
condition. They frequently have more comorbid increased and public health decision-making has
conditions such as diabetes, respiratory illness, received more attention. Despite criticism, nurses and
obesity, and cardiovascular disease. All of these other healthcare professionals have remained society's
characteristics raise the chance of getting COVID-19, leaders in advising the public during the epidemic
the quarantine, and resulting in societal changes in (Riedel et al., 2021).
particular. It's critical to comprehend COVID-19
vaccine reluctance if you want to encourage people Significance of the study:
with mental health issues to receive vaccines Many public health initiatives have been advocated as
(Payberah et al., 2022). a result of COVID-19 diseases. Less attention has
Due to COVID-19, patients with severe mental illness been paid to its effects on a population at risk who
die more frequently than the normal population. The suffers from serious mental illness. Due to cognitive
correlation between COVID-19 and elevated levels of impairment brought on by their condition, people who

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Print Issn: 2314-8845 Online Issn: 2682-3799
Assiut Scientific Nursing Journal Hassan et al.,

are mentally ill may find it difficult to absorb Sample size:

information overload when it arises. High rates of A current study was carried out on 468 psychiatric
smoking and increased medical co-morbidities like patients (188 psychiatric inpatients and 280
diabetes mellitus and systemic hypertension lead to psychiatric outpatients). The sample was computed
an increase in the problem and risk of spreading using the equation given below:
diseases in the hospitals for mental illnesses. These n = [DEFF*N p (1-p)]/ [(d2/Z21-α/2*(N-1) + p*(1-p)]
factors, along with a lack of awareness of risk and DEFF (Design effect) = 1
diminished efforts regarding personal protection (i.e., N (population) = 368 psychiatric inpatients and 1030
social distance, hand-washing, and home isolation) psychiatric outpatients
also contribute to the problem (Muruganandam et p (Hypothesized %) = 50%+/-5
al., 2020). So, the relationship between psychiatric d (tolerated margin of error) = 0.05
patients' awareness of COVID-19 and their attitude Z (level of confidence) = 1.96
toward its vaccine is very important in restricting of α (Alpha)= 0.05
COVID -19 pandemic. N (psychiatric inpatients) = [1*368*50%+/-5 (1-
Aim of the Study: 50%+/-5)/ [(0.05)2/ (1.96)21-0.05*(368-1) + 50%+/-5
This research aimed to assess the relationship (1-50%+/-5)]
between psychiatric patients' awareness of COVID-19 N (psychiatric inpatients) = 188 psychiatric
and their attitude toward its vaccine. inpatients
Research questions: N (psychiatric outpatients) = [1*1030*50%+/-5 (1-
1. What is the degree of awareness regarding 50%+/-5)/ [(0.05)2/ (1.96)21-0.05*(1030-1) + 50%+/-
COVID-19 and attitudes toward its vaccines 5 (1-50%+/-5)]
among psychiatric patients? N (psychiatric outpatients) = 280 psychiatric out
2. Is there a difference between psychiatric patients
inpatients and outpatients regarding awareness of Tools of the study:
COVID-19 and attitudes toward its vaccines? Tool (1): Self-administered questionnaire included
two parts:
Subjects and Methods: Part I: Included personal characteristics such as
Research Design: A descriptive correlational design name, age, residence, educational level, and
was used in this research. occupation.
Setting: The research was done at a psychiatric Part II: Included clinical characteristics related to
outpatient clinic and inpatient department of the diagnosis, and the date of admission to the hospital
neuropsychiatric and neurosurgery hospital at Assiut (one week, two weeks, three weeks, and four weeks
University. The hospital offers services for Assiut city ago).
and most of the bordering governorates and is the Tool (2): Corona Virus (COVID-19) Awareness
largest hospital in Upper Egypt (Assiut, Sohage, Scale:
Qena, and Aswan). The hospital's psychiatry and The Corona Virus Awareness Scale-10 (CAS-10)
neurology departments are spread across 10 floors; consists of a 10-item was developed by (Landa-
they are located on the first and second levels of the Blanco et al., 2021) in the English language and
building, respectively. The hospital's bottom floor translated into the Arabic language by the researcher.
houses clinics for neurology, neurosurgery, and The CAS-10 features a 5-point Likert-type response
psychiatry. The female inpatient psychiatric unit is set (0–4). This scale assesses the degree of awareness
located on the second floor, the male inpatient about Corona Virus (COVID-19). The three subscales
psychiatric unit is located on the third floor and the are Coronavirus concern, which is defined as being
addiction department is located on the fourth floor. concerned about contracting COVID-19 and includes
Subjects: Non-probability (Purposive) sample was the following items: 1, 2, 4, 6, and 10; Exaggerated
applied in this research. A current study was carried Perception, which contains three items (3, 8, and 9),
out on psychiatric patients. They were included in the relates to the idea that governments and the media are
study based on the following criteria: overreacting to the COVID-19 issue, whereas
Inclusion criteria: Immunity Perception, which has two items (5 and 7),
- Accept to participate in the study. refers to the idea that COVID-19 infection is unlikely.
- Diagnosed with any psychiatric disorders. The raw scores for the related elements are averaged
- Age range between (15 to 60 years). to create each factor's mean (without reverse coding).
Exclusion criteria: A higher Corona Virus Concern score (which
- Psychiatric patients with mental retardation. exclusively comprises positively oriented items)
- Psychiatric patients with an organic brain disorder. denotes a greater Corona Virus Awareness when item
- Psychiatric patients with medical illnesses. orientation is taken into account. Low Corona Virus

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Assiut Scientific Nursing Journal Hassan et al.,

Awareness is indicated by high scores on the outpatients) to assess the clarity and applicability of
Exaggerated Perception and Immunity Perception the tools. No changes were made to the tools. So, they
subscales. Cronbach's alpha for the CAS-10 is 0.762, were added to the total sample.
which is regarded as satisfactory (Landa-Blanco et Procedure:
al., 2021). Two phases of the actual fieldwork, which lasted six
Tool (3): Attitudes toward COVID-19 vaccines: - months from November 2021 to April 2022, were
An attitude toward COVID-19 vaccines was involved:
developed by El-Elimat et al., (2021) in the English The preparatory phase:
language and translated into the Arabic language by The researchers reviewed past and currently available
the researcher. This scale assesses the degree of literature relevant to the study topic to acquire in-
attitudes toward COVID-19 vaccines. The attitudes depth theoretical knowledge of the various aspects of
towards COVID-19 vaccines section consists of six the problem then they prepared the tools for the study.
statements on a five-point Likert scale (5 = strongly The implementation phase:
agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 =  Following the evaluation of the study's proposal by
strongly disagree), as well as questions on reluctance the nursing faculty's ethical and scientific
and worries about COVID-19 vaccines. The committee, to obtain formal approval to conduct the
Cronbach's alpha for the items in this area was 0.6, study, the Dean of the Nursing Faculty at Assiut
which denotes high reliability. The researcher University wrote a letter to the Manager of the
modified the scale and made several changes to this Neuropsychiatric and Neurosurgery Hospital at
scale, including the addition of item number seven Assiut University Hospital.
and a word change in item number five from (Most  After receiving formal approval to carry out the
individuals will refuse to take the COVID-19 study. Each psychiatric inpatient and outpatient
vaccination once it is approved in Jordan) to (How were questioned individually by the researchers,
much you agree to take a vaccine for the call from who also gave a brief explanation of the study's
COVID-19?) (Most people will refuse to take the goals and obtained her oral agreement to participate.
COVID-19 vaccine once licensed in Egypt). Three days a week, the researchers visited with
Tools validity: patients in the inpatient psychiatric unit. Each day,
Five professionals with advanced degrees in about two to three sheets were completed. Each
psychiatric and mental health nursing evaluated the interview lasted between 25 and 35 minutes,
research tools for validity. As required, the depending on the patient's schedule.
adjustments were completed.  Also the researchers visited with psychiatric
Tools reliability: outpatients on two additional days each week and
Cronbach's Alpha was utilized to assess the reliability completed five to six sheets each day. According to
of the tools; it was (0.78) for Coronavirus (COVID- the out-patients working hours and each interview
19) Awareness Scale & (0.74) for Attitudes toward lasted around 20 to 30 minutes.
COVID-19 vaccines after modification of the scales. Statistical analysis:
Ethical and legal considerations: SPSS version 22 was used for data entry and analysis
Before starting the study, ethical approval was (Statistical Package for Social Science). Numbers,
obtained from the scientific research ethical percentages, means and standard deviations were
committee of the faculty of Nursing, Assiut used to show the data. To compare qualitative
University number 320 (26-10-2021). The manager of variables, the Chi-square test was employed.
the neuropsychiatric and neurosurgical hospital at Quantitative differences across groups were
Assiut University Hospital granted formal approval. compared using the independent samples t-test. In the
Before data collection, psychiatric patients were told instance of non-parametric data, Spearman correlation
of the study's purpose and nature, which didn't was used to assess the correlation between
include any injury or pain, and oral consent was quantitative variables. The P-value is considered
obtained before any data were collected. Additionally, statistically significant when P < 0.05.
they received assurances that the data was private and
would only be used for research. The study's
participants were made aware that participation was
optional and that they had the choice to discontinue at
any time. They were also advised that the data
collected would be kept anonymous and confidential.
Pilot study:
Pilot research was conducted on 10% of the total
sample (19 psychiatric inpatients and 28 psychiatric

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Assiut Scientific Nursing Journal Hassan et al.,

Results:

Table (1): Personal characteristics of the studied psychiatric patients (n=468)

Studied psychiatric patients
Personal characteristics (n=468)
Number %
Age (years)
Less than 20 years 21 4.5
20 to less than 30 yrs 174 37.2
30 to less than 40 yrs 167 35.7
40 yrs to less than 50 yrs 81 17.3
50 to 60 yrs 25 5.3
Min-Max 15-60
Mean± SD 32.4±9.4
Sex
Male 281 60.0
Female 187 40.0
Educational level
Illiterate 121 25.9
Read and write 31 6.6
Primary 47 10.0
Preparatory 44 9.4
Secondary 190 40.6
University 35 7.5
Working Status
Not working & Students 353 75.4
Working (Employee) 37 7.90
Private workers 78 16.70

Table (2): Clinical characteristics of the studied psychiatric patients

Studied psychiatric patients
Clinical characteristics (n=468)
Number %
Groups
Inpatients 188 40.2
Outpatients 280 59.8
Diagnosis
Bipolar disorder 238 50.9
Schizophrenia 176 37.6
Depression 54 11.5
Admission (N= 188)
1 week 57 30.3
2 weeks 75 40.0
3 weeks 37 19.7
4 weeks 19 10.0

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Figure (1): Mean and SD of awareness's subscales among psychiatric patients (n=468)

Figure (2): Attitude toward COVID-19 vaccines among psychiatric patients (n=468)

Table (3): Mean rank of awareness subscales and groups of patients (n=468)
Awareness Mann-Whitney U Test
Groups
subscales N Mean Rank U p-value
Corona virus Inpatient 188 197.15
19299.0 0.000**
Concern Outpatient 280 259.58
Exaggerated Inpatient 188 281.42
17499.5 0.000**
perception Outpatient 280 203.00
Immunity Inpatient 188 289.60
15960.5 0.000**
perception Outpatient 280 197.50
* Statistically significant difference (p<0.05) ** Highly statistically significant difference (p<0.01)

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Table (4): Correlation between awareness's subscales score and attitude toward COVID-19 vaccines
scale items score among psychiatric patients (n=468):
Psychiatric Patients' Awareness
Corona virus Exaggerated Immunity
Attitude toward COVID-19 vaccines
Concern perception perception
r p r p r p
It is important to get a vaccine to protect the
.581 .000 -.228 .000 -360 .000
people from COVID-19
Pharmaceutical companies are going to
develop safe and effective COVID-19 .610 .000 -.272 .000 -341 .000
vaccines.
COVID-19 vaccines made in Europe or
America are safer than those made in other .036 .441 -.063 .171 -050 .282
world countries
Side effects will prevent me from taking a
-.069 .134 .183 .000 .230 .000
vaccine for the prevention of COVID-19.
Most people will refuse to take the COVID-
-.146 .002 .111 .016 .237 .000
19 vaccine once licensed in Egypt
The government will make the vaccine .000
.253 -.103-* .026 -187-** .000
available for all citizens for free.
How much you agree to take a vaccine for .000
.530** -.231-** .000 -347-** .000
the call from COVID-19
** )Correlation is significant at the 0.01 level) *(Correlation is significant at the 0.05 level)

Table (1): Shows the personal data of the studied (p-value= 0.000). Also, there are significant relations
participants. As regards age, 37.2% of the studied between exaggerated perception, immunity
participants in the age group ranged from 20 to less perception, and the inpatient group (p-value=0.000)
than 30 yrs. The mean age of the studied participants for both.
was 32.4±9.4; 60% of the studied participants were Table (4): Shows that, the correlation between
males; 40.6% of the participant had secondary awareness subscales and attitudes toward COVID-19
education level; and about three-quarters of the vaccines among psychiatric patients. Patients who
studied participant weren't working (75.4%). reported that the vaccine is very important, they were
Table (2): Illustrates the clinical characteristics of the known that companies will develop a safe vaccine
studied participants, more than half of the studied and patients whose point of view that European and
participants (59.8%) were in psychiatric outpatients' American COVID-19 vaccinations are safer than
clinics and about half of the patients (50.9%) are those produced in other nations are positively and
diagnosed with bipolar disorders' patients. According significantly correlated with coronavirus concerns.
to the period of admission, 40.0% of the studied On the other hand, attitude toward COVID-19
participants spent 2 weeks in the hospital. vaccines is negatively and significantly correlated
Figure (1) demonstrates that the study's participants with exaggerated immunity perception. Patients who
have the highest mean score and SD of coronavirus understand that side effects will prohibit them from
concern (12.2±3.3), followed by exaggerated receiving a COVID-19 vaccination are positively and
perception (5.2±2.1), and the lowest mean score is significantly correlated with exaggerated immunity
immunity perception (2.7±1.2). perception. Patients who saw that when the COVID-
Figure (2): Shows the attitude toward COVID-19 19 vaccine was licensed in Egypt, people would
vaccines, the majority of research participants agreed refuse to get it, and the government would provide it
or strongly agreed that the government should free of charge to all residents, had a negative and
provide the vaccination free of charge to all citizens. significant correlation with inflated immunity
Additionally, they stated that vaccination is crucial perception.
for protecting against COVID-19, with respective
percentages of 88.9% and 85.9%. Discussion:
Table (3): Shows that; the mean rank of coronavirus This research aimed to assess the relationship
concern is higher among the outpatient group than the between psychiatric patients' awareness of covid-19
inpatient one and there is a significant relation and their attitude toward its vaccine. Recently, there
between the outpatient group and coronavirus concern is evidence that individuals with mental illness should

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Assiut Scientific Nursing Journal Hassan et al.,

be prioritized for COVID-9 vaccinations because the Patients who perceived side effects would avoid
hospitalization and mortality rates are increasing receiving the COVID-19 vaccination. Patients who
more than the general population. the attitude toward were apprehensive about drug side effects may not be
vaccination is considered the main barrier and may ready to get the vaccination, which may account for
reduce vaccine uptake in this population (Fond et al., this finding.
2021).
According to current results; the coronavirus concern Conclusion:
has a higher mean score rather than other subscales of Based on the obtained results, it can be concluded that
awareness. Such findings are consistent with those of psychiatric patients who have coronavirus concerns
(Dalky et al., 2021) who studied the assessment of and have information about the virus are willing to be
the awareness, perception, attitudes, and preparedness vaccinated more than patients who didn't aware of the
of healthcare professionals potentially exposed to pandemic of coronavirus. Also, outpatients were more
COVID-19 in the United Arab Emirates and found aware of COVID-19 as they were in more contact
that most patients had the appropriate amount of with mass media than those inpatients.
awareness regarding the COVID-19 epidemic.
Understanding the symptoms is important for Recommendations:
managing and preventing the spread of COVID-19 The following suggestions are made in light of the
because it enables the hospital to identify the hazard findings of this research:
and take the appropriate measures. 1. Implementation of psycho-educational programs
The present study showed that a high percentage of about COVID-19 as ways of transmission,
psychiatric patients agreed to have the COVID-19 symptoms, and complications of the disease.
vaccine. It can be explained by psychiatric patients 2. Implementation of educational programs about the
saying that they were hearing from their parents, effects and importance of vaccines against the
relatives, and neighbors that persons who did not take virus.
the vaccination would die and the mass media was
showing high proportions of deaths due to the References:
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discovered that the majority of patients with serious Covid-19 and attitudes toward vaccination in
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individuals who delayed getting vaccinated were sectional study. Journal of Pediatric Nursing, 65,
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than that of the inpatient. Also, another study showed attitudes, and preparedness of health-care
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many reasons for low awareness such as social Multidisciplinary Healthcare, 14(1): 91-102.
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