Within the context of increasing mental distress noted since the beginning of the pandemic, this study uses the 5Cs framework to analyse the role that depressive symptoms play in driving vaccine
behaviour in South Africa. The study further explores pathways of this association through vaccine distrust, risk perception and efficacy. Multivariate regression analysis taking into account endogeneity concerns reveal that vaccine distrust is the most important predictor of vaccine hesitancy. There is little evidence of significant association of either pre-pandemic mental distress or current depressive symptoms with vaccine hesitancy in a fully specified model. However, significant indirect effect of depressive symptoms on vaccine hesitancy is found via vaccine distrust and risk perception.

The findings indicate that individuals at high risk of depression are more concerned regarding the safety of vaccines, which in turn feeds into vaccine hesitancy. On the other hand, depressive
symptoms have an opposite effect via risk perception. Risk perception is a negative predictor of vaccine hesitancy; therefore, the enhanced risk perception leads to lower vaccine hesitancy. This
study has established that the indirect effects are highly relevant and need to considered closely while analysing the relationship between mental distress and vaccine behaviour. Lastly, the study also found significant feedback effect of mental distress with vaccine distrust as well as risk perception. Therefore, improved vaccine trust can lead to not just increased vaccine acceptance and reduced risk perception; but also, better mental health.