Context Following approval from the Lambeth Directorate of South London and Maudsley (SLaM) NHS Foundation Trust, we investigated COVID-19 vaccination rates in a sample of patients with SMI from a psychosis community service in South London (n=236).

Issue/Challenge The COVID-19 pandemic has disproportionately affected patients with severe mental illness (SMI). Evidence indicates that patients with schizophrenia are more vulnerable to COVID-19 and have a higher morbidity and mortality. There are reduced vaccination rates in these patients, and they should be prioritised for vaccination.

Assessment of issue and analysis of its causes

An initial audit was performed, and COVID-19 vaccination recorded. Patients with missing information were called and asked if they had the vaccine; reasons for refusal were recorded. As an intervention, patients were subsequently encouraged to book an appointment or discuss options with their care coordinators. After the intervention, a re-audit was performed. Chi-squared statistical analysis was performed to establish if there was a significant difference between the number of patients who had been vaccinated before and after the intervention. Patients with inaccessible GP records, or discharged, were considered to be unvaccinated. Findings from the study were reported at the Trust special interest forum, made up of staff, directors, patients, and advocates.

Impact This research helps us to understand the complexity of vaccine hesitancy, highlighting the requirement for tailor-made strategies. Special consideration is needed for patients with SMI symptomology and barriers to healthcare may reduce vaccine uptake. Despite our intervention, more needs to be done to overcome vaccine hesitancy.

Intervention There was no statistical significance (p=0.1509) between the number of patients who received a vaccine before and after intervention. Before the intervention, 143 patients (60.6%) had received at least one vaccine. 24 patients (10.2%) received only one dose, and 77 (32.8%) were yet to receive a vaccine.

After intervention, 33.1% of patients still remained unvaccinated, compared to the national figure of 6.6%.

Results can be reproduced with any cohort, using the same method of calling patients and accessing GP records to determine vaccination status.

Involvement of stakeholders, such as patients, carers or family members:

Prior to initiation of the study, stakeholders in the Trust special interest forum were approached to consider interventions to improve vaccine uptake. A feedback meeting was held, made up of clinical staff, directors, patients, and advocates.

Key Messages Vaccines are a cost-effective way of preventing communicable disease, but there is limited research on the perceptions of receiving vaccines in patients with SMI.

Patients taking antipsychotic medications, particularly clozapine, may have a weaker immune system due to potential myelosuppression. In our sample, 33 patients were taking clozapine; 23 were vaccinated with at least one dose, and 10 were not vaccinated. Many were unsure of the interactions or side effects vaccines could have, thereby reducing vaccine uptake. Research indicates these patients have worse prognosis compared to patients with SMI, thus a focussed approach should be taken in addressing this vulnerable cohort.

Lessons learnt Our findings indicate a focussed education programme aimed at patients with SMI about the benefits of vaccination is essential to overcome vaccine hesitancy. Many of our patients decided against vaccination due to cultural background and ethnicity. Studies have shown low uptake in Black/African/Caribbean ethnic groups, with 49.3% of our patients falling into this category. The reasons behind these inequalities include general mistrust in institutions and access barriers. For patients of minority communities, vaccination sites in community centres or places of worship have proven to be effective, offering familiarity and support from peers and family members. This should be something we consider when encouraging patients to receive vaccination.

Measurement of improvement Measuring the effect of improvement involved re-auditing the cohort and seeing if patients had gone onto receive vaccines after phoning them up to enquire.

Strategy for improvement A lack of knowledge and awareness, and minimal recommendations from the care team are some reasons for hesitancy. Misinformation, conspiracy theories and social media propaganda, can drive people towards refusal. Patients with SMI are faced with social disadvantage of healthcare inequality, lower levels of education and less access to accurate information. Paranoia and amotivation may also be driving refusal of treatment. Identifying reasons for refusal can help create tailor-made strategies for improving vaccine uptake. Patients should be well-informed about benefits of vaccination, and their healthcare team should be knowledgeable about the different vaccines, their efficacy and side effects.