Suspicion and other feelings about COVID-19 vaccines and mask-wearing among individuals recovering from substance addiction

Abstract

Objective

This study presents findings about vaccination willingness or resistance and mask-wearing among individuals recovering from a substance use disorder during the COVID-19 pandemic period.

Study design

Content analysis.

Method

Fifty individuals were interviewed. Interviews were transcribed verbatim, and then coded using Atlas Ti qualitative analysis software. A content analysis was conducted, eliciting recurring themes and overarching COVID-19 health behavior dimensions for getting (or not) vaccinated and wearing a mask.

Results

While most subjects were willing to get vaccinated and wear mask, a small minority were not. Both formal (mandates) and informal (pressure from others) mechanisms played a role in getting participants to mask-up and get vaccinated, even when they did not want to. Concern for others motivated some individuals to both get vaccinated and wear a mask. Fear and ambivalence emerged as emotional themes, as did suspicion particularly among vaccine-refusing subjects. Reasons for not getting vaccinated included lack of trust in the government, as well as the vaccine-development process.

Conclusions

The results suggest that many COVID-19 prevention initiatives have gone right in terms of reaching individuals recovering from substance addiction. Public health officials may consider alternative ways of reaching individuals whose frame of reference regarding vaccines, public health, and government outreach is one of suspicion and distrust of facts. Future research should examine sources of health and medical information, and how these contribute to individuals’ vaccination hesitancy.

1. Introduction

As some individuals’ reluctance to do the one thing that could have helped end the pandemic sooner rather than later – getting vaccinated and consistently wearing masks – remains an unfortunate and vexing issue [1,2], this study contributes to the knowledge base about the reasons for vaccine hesitancy and mask-wearing resistance among an already vulnerable population – individuals with a substance use disorder. The rise of new strains of the COVID-19 virus [3] could re-introduce masking requirements, despite rising vaccination levels among the population. There are immunocompromised individuals [4] who prefer to remain isolated, even after getting vaccinated. While vaccine hesitancy among vulnerable populations has been studied globally in countries such as South Africa [5] and India [6,7], it is less researched in the United States. Scholarship on the impact of COVID-19 on individuals who use substances is in the very early stages.

2. Literature review

2.1. Substance use disorder and the COVID-19 pandemic

The COVID-19 pandemic upended all areas of life. Activities that would normally be undertaken indoors – work, events, school – shifted to remote participation; or in-person, socially distanced, masked-up events. This includes attendance at substance use recovery meetings such as 12-step fellowships like Alcoholics Anonymous and Narcotics Anonymous, and meetings with a drug counselor. Some psychology and public health literature [[8], [9], [10], [11], [12]] frames the pandemic as a major trauma-inducing experience that has harmed individuals mentally and emotionally.

Research to date shows that people with a substance use disorder faced risks [13] of contracting severe COVID-19 as compared to individuals that did not use substances. Substance-using individuals also face greater physical and mental health issues [13] in general including HIV, anxiety and mood disorders, and overdose; and other problems such as homelessness, incarceration, and financial struggles. Because COVID-19 is a respiratory illness, substance users who smoked (cigarettes, marijuana) and/or vape may have been particularly susceptible to infection [14]. Because of strains on the U.S. healthcare system stemming from COVID treatment, individuals recovering from substance use who contracted COVID-19 may have experienced obstacles to getting treatment [15,16]. Treatment can be achieved, however, with medical staff that have a solid connection to their patients, and strong communication skills [17].

Recovering individuals faced challenges presented by social distancing measures [14]. Relapse among individuals recovering from substance use disorder has been observed [1] during the COVID-19 era. Economic and social shifts caused by COVID-19 adversely impacted access to treatment for substance abusing individuals, worsening their addictions [18,19]. A South Africa-based study [20] revealed that some recovering people engaged in substitution of preferred substances (alcohol, cigarettes) for other addictions (pornography). Another study [21] of mental health among Italian substance abusing individuals during the COVID-19 lockdown period found evidence of depression, anxiety and post-traumatic stress disorder.

2.2. Vaccine hesitancy

A reluctance to get vaccinated against illnesses predates the arrival of COVID-19. As early as 1720, a smallpox inoculation was declared by some as counter to God's will [22]. Prior research finds diverse reasons for vaccine hesitancy, including mistrust of institutions that develop and provide vaccines [23], religious belief systems [24,25], and a perception that vaccine risks outweigh their benefits [26]. A 2022 review [27] of 31 published papers found a variety of factors contributed to vaccine hesitancy including demographic factors (age, sex), lack of trust in the government and public health figures, and concern about the speed of the COVID-19 vaccines' development. Another review [28] of published research similarly found that common reasons for resistance to getting vaccinated against COVID-19 included a belief that the vaccines were produced too quickly, or were ineffective; a belief in already being immunized against the virus; or an individual being opposed to vaccines (any vaccine) generally. Socio-demographic characteristics (e.g., race, ethnicity, gender, having children at home, rural residency, political affiliation) also play a role in acceptance of or resistance to getting vaccinated [29]. A 2023 study [30] found that vaccine-skeptical subjects held a variety of false beliefs (medical, technological) about vaccines, including denial of the COVID-19 virus itself. As Sallam [31] and others [32] observed, myriad factors (e.g., psychological [33], cultural [34]) must be considered in trying to counter vaccine resistance.

2.3. Resistance to wearing a mask

Reducing the spread of COVID-19 through the wearing of face masks is an established and effective strategy [35]. Despite this, some individuals resisted state and local mandates to mask up, for a variety of reasons. Some remained unconvinced of masks' abilities to prevent the virus' transmission [36]. Political orientation [37] and a view of government mandates to wear a mask as threatening to personal freedoms played a role for some individuals [38], as did general mistrust of authority (e.g., the government) [39]. Demographic factors such as gender and age also played a role. Specifically, prior research has found that men were more resistant to wearing a mask than are women [40], both because they viewed mask-wearing as unmanly and because they saw themselves as less likely to catch COVID-19. Other research [41] determined that older individuals were more concerned with the risks of contracting COVID-19, as opposed to younger individuals who were less concerned about COVID-19 risk. Individuals from a collectivist culture (e.g., valuing the community good over one's own desires) were also more likely to wear a mask [37,40], viewing it as a civic obligation to protect others. Finally, recent research [42] has identified variables such as understanding about disease and effectiveness of protection methods as impacting an individual's willingness to mask up.

3. Method

The principal investigator interviewed 50 individuals recovering from a substance(s) use disorder, recruited from different socio-economic areas throughout a rural state in the New England region of the United States. Two-third of the state's residents (under one million people) live in rural areas [43]. Individuals recovering from substance use disorders in rural areas can face unique challenges [44] including needing to travel far to access treatment, and limited substance use counselors and peer support availability [45].

3.1. Recruitment

Approval from the university's institutional review board (IRB) was obtained prior to subject recruitment beginning. To recruit subjects, the PI visited and announced the study at 12-step meetings of the Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) fellowships that were designated as open to the public, meaning that an attendee does not need to be in recovery themselves to attend. The PI initially selected 12-step meetings in a city with a population around 44,000, the largest city in the state (recruitment location #1); a town with a lower socio-economic status (recruitment location #2, population around 8300); and an affluent, suburban town (recruitment location #3, population around 5200). Twelve-step meeting times and locations were obtained through two apps that were downloaded to the PI's phone. The PI also asked subjects if they knew anyone else with whom the PI might speak [46]. Subjects were offered a $20 Amazon gift card as an incentive to participate in the interview.

3.2. Subjects

Of the 50 subjects, 29 were male, 18 were female, and 3 individuals self-identified as transgender or gender fluid. All but two were White, in keeping with the largely White population of the state. (Of the three non-White subjects, one female was Hispanic, one male was Native American and one male was African American.) The mean age range was 40's, although subjects ranged from being in their 20's to being in their 70's. The youngest individual was 21 years old. It should be noted that participants were not initially asked their age since it was not directly relevant to the study's focus. Midway through the project the study's funder requested demographic information including subject age. The PI then retroactively added approximate age ranges for participants, and for consistency continued to record estimated the age range unless a participant proactively stated their exact age.

Thirty percent of the sample (n = 15) indicated that they attend NA exclusively; 40 % of individuals said they attend AA exclusively; and 20 % indicated that they attend both 12-step fellowships. Ten percent of the sample had other mechanisms (e.g., therapy, church) for supporting their recovery. Eight percent of the sample indicated that they currently or in the past participated in medication-assisted treatment, such as using doctor-prescribed suboxone to ease addiction to an opioid (heroin, fentanyl).

3.3. Interview protocol

Subjects were asked a variety of questions about a range of topics (e.g., substances used in the past, status of their recovery pre- and during the pandemic, relapse). For the purposes of this article, findings from responses to the questions about getting vaccinated and mask-wearing are presented. Subjects' interviews were recorded and subsequently transcribed using an outside transcription firm. Three student research assistants independently performed the initial coding of the qualitative data (i.e., words and phrases) in the transcripts, and for interrater reliability checked each other's coding. The PI subsequently checked the research assistants' coding.

3.4. Data, coding and analyses

The transcripts were reviewed, and subject answers to open-ended questions were coded using a code list created based on the interview protocol, and coded using Atlas Ti [47] qualitative analysis software which has been used in other qualitative public health research [48,49]. Coding from a code list is an initial step in conducting a content analysis [50] of responses to open-ended questions (e.g., “How do you feel about vaccines?”). Content analysis is a method of analyzing written communication, such as interview transcripts [51]. The researcher tags sections of text (sentences and paragraphs) with content-relevant codes [52] in the software program. Once all text has been appropriately coded, the researcher then performs a search in Atlas for all so-coded text, beginning the content analysis process.

The broad code list for the qualitative data (words and phrases) were as follows: vaccines, vaccines-feelings about, masks, masks-feelings about. The process for creating the broad codes was deductive, using questions in the interview protocols to create the broad codes. Once all the verbatim text from the interview transcripts was coded with the broad codes, coded text about vaccines was reviewed and then categorized into eight recurrent themes and two COVID health behavior dimensions: willingness to get vaccinated and boosted (see Table 1); and emotions and thoughts around getting vaccinated (see Table 2). The process used to create the recurrent themes was inductive, emerging from the qualitative data collected. The process was then repeated for mask-wearing, which produced eleven recurrent themes and three COVID health behavior dimensions (see Table 3) pertaining to mask-related behavior.

Table 1.

Was the subject vaccinated against COVID-19?

Got vaccinated?	Number	Percent
Yes	43	86.0
No	7	14.0

Table 2.

Common themes about vaccines across the interviews.

COVID health behavior dimensions	Willingness to get vaccinated and boosted			Emotions and thoughts around getting vaccinated
Recurrent themes	Got vaxxed	Got boosted	Unwilling to get vaxxed/boosted	Concern for others	Fear	Felt forced to get vax-xed	Ambiva-lence	Suspicious of vaccines
Sum	49	22	13	5	7	4	5	12

Table 3.

Common themes about masks across the interviews.

COVID health behavior dimen-sions	Willingness to wear a mask			Physical feelings about masks		Thoughts and emotions around masking
Recurrent themes	Yes	No	Change over time	Physi-cally unpleasant	Dis-like	Safe-ty	Con-cern for others	Be-lief that masks work	Skepti-cal that masks work	Anger at others for not mask-ing	Social pres-sure to mask
Sum	68	10	2	10	25	12	10	10	8	5	13

4. Results

4.1. Getting vaccinated against COVID-19

Forty-three subjects had been vaccinated, while seven individuals had not been vaccinated.

Willingness to get vaccinated and having been vaccinated was the most commonly mentioned theme among subjects (n = 49 mentions). As one subject explained, “I'm got my vaccine, I'm pro-vaccine.” A willingness to get the booster vaccines was also a recurring theme (n = 22 mentions), as indicated in statements like “I get my booster shot. What would I fight that for? It's free. And it helps us.” Referencing other types of vaccines, one subject made the analogy of other contagious diseases, explaining “I'm vaccinated. Whenever I talk to people about this, I said, you know, I really liked my life without polio.” From the non-vaccinated subjects, unwillingness to get vaccinated-themed comments emerged, including “I was very afraid that the government was going to somehow force us to get the vaccine, me and my family, to the point that I wanted to run and hide with my children.”

As a reason to get vaccinated, participants voiced concern for others, including family and loved ones. “I only did it [got vaccinated] for my mom ’cause I didn't want her to catch it [COVID-19]”. “I did it so I could be around my family.” Regardless of their willingness to get vaccinated, participants also discussed fear of vaccines. One participant described anxiety about the fast pace of the vaccines' development: “the nervousness of ‘is it [the vaccine] effective’, is it, you know, good, ‘has it been rushed’ kind of thing.” Others worried about vaccine side effects. “Even though this is a prescribed shot, or whatever it is, we still don't know. Like, I'm hearing people having breathing problems, heart problems. My roommate had it and he's been sick ever since he had it.” “I heard a lot of people having a lot of aches and pains, and a lot of repercussions after.” “I have a very sensitive system, and I just don't trust -- I don't take medication. Like, any time I can, I'll take natural supplements. I go to a naturopath.”

On the flip side of the coin, some participants expressed emotional ambivalence (“don't care”) about both getting vaccinated and the pandemic in general. “I'm certainly due for a booster at some point. Just haven't really justified it because I haven't been out very much … Doing more remote work than anything, so just haven't had the immediate, urgent need to go to it.” Some participants' ambivalence seemed rooted in skepticism about the pandemic's seriousness, claiming to not know of anyone who had actually died from COVID-19. “I never personally investigated or spoke to somebody who watched their loved one die from it [COVID-19] … as far as I could see, I was like, it's being a little bit exaggerated.” “The same amount of people died in 2017 that died in 2021. I mean, there's a thing on the Internet called the death clock, and you can look up the past years, and it hasn't increased.” “I just think it's another cold, the immune system needs to learn how to fight it off.”

Feeling forced to get vaccinated emerged as a theme, evident in statements like “the state essentially putting a gun to your head to do it. They were like, you can work here, but you have to be vaccinated, no choice.” “I never wanted to do it [get vaccinated], but it's one of the requirements of the house.” In other words, due to work or housing requirements participants reluctantly agreed to get vaccinated. The theme of suspicion of the vaccines (“just don't trust it”) emerged among both vaccinated and unvaccinated subjects. For the individuals who had not been vaccinated, the reasons for not getting the vaccine included lack of trust in the government, as well as the process for developing the vaccines. These sentiments are reflected in comments such as “The COVID-19 shot is not a vaccine. It is not a vaccine. It is actually gene therapy. It is -- from a research standpoint, the research studies are completely flawed. I don't trust any research study that gets rid of the control group.” “It was really pushed, and there's this big propaganda campaign around it, so I don't trust it at all.” “The vaccinated, they actually are literally radioactively emitting Bluetooth signals." “The things [vaccines] haven't been tested, usually they test those things for 10 years.”

4.2. Wearing a mask during the COVID-19 pandemic

Willingness to wear a mask was the most common recurrent theme (n = 68 mentions; “I still wear a mask at work”). As for complete unwillingness to wear a mask, there were far fewer outright statements to that effect. Some statements reflected a change in participants' willingness to wear a mask as pandemic wore on. “I did it [wear a mask] in the beginning [of the pandemic], but like I said, as time went on, I was less afraid.” Another participant explained that “in the beginning I thought they [masks] were necessary, and considerate, and two years later I think I was just so depressed that I really just wasn't thinking about it anymore, I just stopped, I just checked out of the pandemic, and checked out of masks.”

On the one hand, some participants expressed their belief that masks work to keep people safe. “It definitely made me feel a lot safer to go out, and especially going to work, it definitely made me feel safer when I was wearing a mask and my co-workers were masked up.” “The best example was wearing a mask is like wearing pants and peeing yourself. Like, if you were to pee and you weren't wearing pants, it would be really rude if you were around a bunch of friends. But if you're wearing a mask, it's like wearing pants where you're only affecting yourself.”

On the other hand, as with participants' skepticism about vaccines' effectiveness and the process through which vaccines were rapidly developed, some individuals expressed skepticism that masks worked to keep people safe. “I feel like it [masks] really doesn't save much of anything.” “I think it's a bunch of hogwash. I don't think it's healthy for you breathing in that air.” “But like in the house … we're all walking around wearing masks. We share a kitchen. We share food. We share a sofa. Like, this is stupid, dude. There were some times when I was like a mask isn't going to do anything, you know?” “They'd give me a bank-issued mask, and, like, the bag clearly says, like, ‘Not for medical purpose.’ And then I say, ‘Well, then, what are we doing?’”

Similar to having concern for others as a reason to get vaccinated, some participants willing to wear a mask cited safety and concern for others (e.g., children, senior citizens, family members) as driving reasons for why they wore a mask. As one interviewee expressed, “I'm not a big fan of it [wearing masks] … but I saw the necessity of it. Who cares about how I feel? I don't want the old people to die.” Another indicated, “I feel like wearing a mask is the best thing you can do to prevent giving what you have to somebody else.” And “I don't want to ever be the person who's like oh, I -- like go to get tested because you were with me.” In other words, individuals balanced their personal feelings against a sense of responsibility for others, i.e., collectivist sense. Others were willing to wear a mask despite not liking to wear masks or finding it physically unpleasant to do so. As one subject explained, “I didn't enjoy wearing masks, but I didn't hate it either.” “Behind my ears it hurt so bad.” “I really had trouble hearing.” “It was really harder for me to breathe.”

Thirteen comments referenced social pressure to wear a mask (e.g., in a store, at work, at the doctor's office). As one participant explained, “You would get chastised if you walked into a local store and didn't have one on. So rather than deal with everybody, you know, shitting on you, you just put it on, suck it up. It was awful.” “I know a lot of people felt more comfortable with everybody wearing one.” “Getting mad that the bus drivers wouldn't let us on without a mask.” “I remember going into Shaw's [grocery store] a couple times and I didn't have a mask, and like, this, the guy would like, chase me around, ‘You need to wear this.’ I didn't give him a hard time, I should have worn one to begin with.” “When the governor lifted the mask mandate, and I would go into like, Walgreens, I had people come up and like, kind of harass me, telling me, the manager was like, you need to put a mask on, we have a policy. I'm like, you know, I'm not wearing that, you know? They refused to like, cash me out, so I just money on the counter and took my stuff anyway.”

Some participants expressed anger or disappointment at others for not wearing masks. “I was disappointed at times when I thought I could start going back to [12-step recovery] meetings and I would walk in and nobody would be wearing a mask … I don't know what's with us alcoholics but sometimes we think we're bulletproof.” “At first, I was furious with people who wouldn't wear masks, because I felt like they were killing people.” “I wore them religiously and I got really angry at people who didn't.”

5. Discussion

People with a substance use disorder are vulnerable and may have had a heightened risk of catching COVID-19. Results from a content analysis of interviews with 50 individuals show that while most subjects were willing to get vaccinated and wear masks, a small minority were not. The reasons to get vaccinated and wear masks included a belief that vaccines and masks were effective in stopping the spread of the virus, and concern for others such as older family members. In some cases, participants' collectivist beliefs – valuing the good of family and the community – superseded their personal feelings (e.g., dislike) about vaccines and masks. This finding reflects the results of others’ work [37,40] about collectivist beliefs. Vaccine and mask mandates for work and housing contributed to some participants reluctantly getting vaccinated and wearing a mask, suggesting that formal social mechanisms (mandates) are effective. Informal social control – pressure and negative comments from others – to mask up also played a role, as expressed by participants who were subjected to pressure from others, and participants who discussed their anger at others for not masking up.

Regardless of their willingness to get vaccinated, participants discussed fear of vaccines and the side effects, including the rapid pace at which vaccines were developed. Some participants were skeptical about both vaccines' and masks' effectiveness in keeping people safe. Some individuals voiced their belief that vaccines make people sick. Finally, some participants remained ambivalent about the pandemic's seriousness, stating they knew of no actual person who had died from COVID-19 and suggesting the danger of the virus was being exaggerated.

It is worth considering the strong feelings of suspicion – of vaccines, of the scientific methods used to develop the vaccines, and of the government – that emerged particularly from the subjects who refused to get vaccinated. Some of the comments suggest that the interviewees may not get their information from reputable sources, and/or have a conspiratorial bent to their views (i.e., the vaccines are gene therapy, kill everyone who gets one, or emit Bluetooth signals). Even so, these are still individuals that public health workers need to reach and care for, as they may have heightened risk for catching the virus (or any virus) and ending up in the hospital. This underscores the importance of making sure that even conspiracy-minded, government-suspicious individuals have access to accurate, clear information. It is worth considering how to best message the benefits of getting vaccinated to individuals who hold such views.

The findings of this study echo those of prior research, which have found that some individuals were skeptical of the rapid speed with which COVID-19 vaccines were produced [27,28]. The present findings about skepticism of the seriousness of the virus also echo other research [30] that the COVID-19 virus was not a real thing. Participants’ comments about being willing to put their own fears about masks and vaccines aside, and place the good of others ahead of their own feelings, supports other work [37,40] about collectivist beliefs. Where the present study adds to the literature is the findings about the role that both formal (mandates) and informal (pressure from others) mechanisms played in getting participants to play their part in keeping others safe.

With regards to the vaccine-refusers, given that the theme of suspicion (of vaccines, of the government) emerged strongly, in hindsight it would have been useful to know from where these individuals obtained their information about COVID-19 vaccines. There is a plethora of virus and vaccine misinformation available on social media (e.g., Facebook, Twitter), which has been linked [53] to declining vaccination rates. It could be useful to know how much of these types of misinformation the subjects consumed, and from where (e.g., Facebook, Reddit, 4chan). However, questions along these lines were not included in the interview protocol, a limitation of the study.

Limitations aside, the study's findings contribute to an intractable obstacle to tackling the COVID-19 virus and other future pandemics. As the number of people dying from COVID-19 has shrunk, and social distancing requirements and mask mandates have lifted, many people now experience pandemic-fatigue and may opt to skip the latest booster shot [54]. Researchers need to remain vigilant in studying the reasons behind resistance to getting vaccinated and wearing a mask, in anticipation of the next pandemic. Research findings must inform future public health messaging and improve on what was done, and not done, during the COVID-19 pandemic. The simple ‘presentation of the facts’ method does not work well with individuals suspicious of the source of the facts (government). As others [55] have noted, communication methods around personal safety during a pandemic should be multi-faceted, including appealing to emotions in addition to providing facts. Creating narratives that elicit emotional responses and providing examples relevant to individuals' community and social circle are two examples of approaches that may spark positive change [55] in behaviors like wearing masks and getting vaccinated in the future. Future research should investigate which communication methods are most effective in increasing individuals' pro-health behaviors, and consider the sources of information (newspapers, podcasts, social media) from which people get their medical information.

Author statements

Approval from the author's Institutional Review Board was obtained prior to any subjects were recruited and interviewed. Subjects received, read, signed and returned an informed consent form prior to being interviewed.

This study is supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number [P20GM103449] to the Vermont Biomedical Research Network (VBRN). Its contents are solely the responsibility of the author and do not necessarily represent the official views of NIGMS, NIH or VBRN.

The author has no competing interests in conducting this study.

Author's contribution

The corresponding author, Dr. Hassett-Walker, the study's PI, is responsible for all the analyses and writing presented in this paper.

Funding

This study is supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number P20GM103449 to the Vermont Biomedical Research Network (VBRN). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIGMS, NIH or VBRN.

Conflict of interest statement

The author of this manuscript has no conflicts of interest.