Coronavirus (COVID-19) Highest Risk (formerly Shielding) List end: equality and fairer Scotland impact assessment

4. Impact - Protected characteristics

4.1 This policy will directly affect those individuals who are currently on the Covid Highest Risk List. (HRL). The following table assesses any differential impact (positive or negative) of the decision on each of the protected characteristics^[5] and any possible inequality of outcomes due to socio-economic differences.

Age: Older People

Background

There is clear evidence that age is the highest risk factor for COVID-19^[6], which is reflected in the statistics for the Highest Risk List where 81% are 50 years or older, and 51% are 65 years or over.

The highest level of vaccination rates within the population are also amongst those aged 50 or over^[7].

Differential Impact

There is strong evidence to show that vaccines are offering significant protection to people on the HRL from becoming severely ill, including older people^[8]. Clinicians are therefore of the view that removing the HRL will not significantly increase the risk for older people.

However, this change may cause anxiety for some older people on the HRL which could impact on their confidence about using services, public transport and indoor public places^[9].

Conversely, there are also potential benefits to this change in policy as some older people on the Highest Risk List may now feel less anxious and less restricted as they go about their daily lives^[10].

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life.

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[11].

Age: Children and Young People

Background

There were 1,369 children and young people under 16 on the Highest Risk List as at 4 April 2022^[12].

57% (2,567) of children and young people were removed from the HRL during the summer of 2020. This was because the evidence indicated that children and young people with long term health conditions were very unlikely to suffer severe illness or outcomes when infected with COVID-19.

Children and young people aged 12 to 15 in particular clinical risk groups, became eligible for vaccination in July 2021, with other risk groups added in September 2021; all will now have been offered two doses as a primary course or, in the case of children who are severely immunosuppressed, three doses as a primary course. In addition, children aged 5 to 11 in particular clinical risk groups have been eligible to receive their primary course since January 2022.

Differential Impact

There is strong evidence to show that vaccines are offering significant protection to people on the HRL from becoming severely ill, including children and young people^[13]. Clinicians are therefore of the view that removing the HRL will not significantly increase the risk for children and young people, including those who are immuno-suppressed or immuno-compromised.

There are potential positive impacts to removing these restrictions so that everyone, including children and young people on the HRL, can feel less restricted in how they go about their daily lives^[14].

However, this change in policy may cause anxiety for some of the children and young people on the HRL and/or their parents/guardians which could impact on their confidence about using services, public transport and indoor public places^[15].

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[16].

Sex

Background

After adjusting for age, COVID-related deaths for men were 1.4 times more likely than for women.^[17] During 2021, the number of deaths due to COVID-19 continued to be higher in men compared to women^[18].

COVID-19 admissions to hospital have been higher for men in the age groups 45 to 64 and above.

Total vaccination coverage rates among men have been slightly higher than for women in the age bracket 55 to 59 and above, and lower (by up to 9.6% in the 18 to 29 age group – 45.4% compared to 55%) in age groups 50 to 54 and below^[19].

Women up to the age group of 50 to 54 have higher levels of total vaccination coverage than for males, with those 18 to 29 showing the biggest difference – 55% to 45.4%. Above that group, the rate for males is slightly higher^[20].

As at 4 April 2022, 56% (98,353) of those on the HRL were women and 44% (77,905) were men.

A YouGov poll for the Scottish Government found that in February 2022, 46% of women and 38% of men agreed that they were worried about the effect of the ongoing pandemic on their mental health^[21].

Differential Impact

There is strong evidence to show that vaccines are offering significant protection to people on the HRL from becoming severely ill^[22]. Clinicians are therefore of the view that ending the HRL will not significantly increase the risk for men or women.

However, the ending of the HRL may lead to anxiety amongst a higher proportion of women as there are more women on the HRL^[23]. This could compound the general level of anxieties about the effect of the ongoing pandemic on their mental health which are generally higher in women. However, given that men are at higher risk of dying from COVID-19, and older men have a higher risk of admission to hospital after contracting the virus, higher levels of anxiety may be felt by men as a result of this change in policy.

There are also potential benefits for men and women as a result of this policy, given that some may feel less restricted as they go about their daily lives as a result of being removed from list^[24].

As women have experienced an increased burden in relation to unpaid caring during the pandemic^[25], which is likely to include care for older people and children on the HRL, this change in policy may support a decrease in the levels of unpaid care they provide due to HRL individuals feeling less restricted in how they go about their daily lives. For example, children and young people attending school and no longer having to be home-schooled due to COVID-restrictions. However, women remain the greatest unpaid caregivers.

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting to a more normal way of life.

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[26].

Race

Background

After accounting for age, sex, area-level deprivation and urban rural classification, of deaths occurring in Scotland involving COVID-19 (between 12 March 2020 and 30 September 2021), people with Pakistani ethnicity were: 3.7 times as likely compared to the White Scottish ethnic group; 3 times as likely for Other Asian^[27]; and 1.7 times as likely for Chinese ethnicity.^[28]

Vaccine uptake has been lower among certain ethnic minorities, including Caribbean or Black, African and South Asian^[29].

Of those individuals who are currently on the highest risk list some will be from minority ethnic communities but we do not have figures to confirm numbers on vaccine uptake amongst individuals from minority ethnic communities on the HRL.

Differential Impact

There is strong evidence to show that vaccines are offering significant protection to people on the HRL from becoming severely ill^[30]. Clinicians are therefore of the view that removing the HRL will not significantly increase the risk for minority ethnic people.

For members of some minority ethnic communities who are on the HRL, the removal of the list may cause them greater anxiety given the higher proportion of deaths amongst some ethnic minorities especially if they live in communities where there is lower vaccine uptake. This could lead to decisions on self-shielding and/or to restrict activities and interactions, which would impact on quality of life and mental health and wellbeing.

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[31].

There are also potential benefits for individuals of minority ethnic communities on the Highest Risk List who may feel less restricted as they go about their daily lives as a result of this policy^[32].

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life.

Religion and Faith

Background

We do not have figures on the religion and faith of individuals on the HRL, however, a substantial proportion of attendees of places of worship are of an older demographic and are therefore more likely to be on the HRL.

Differential Impact

This change in policy may bring a potential benefit to people on the Highest Risk List with a religion or faith as they may have fewer reservations about attending places of worship after being removed from the list.

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[33].

Disability

Background

COVID has a disproportionate impact on the health of disabled people: 93% of people who had died from COVID-19 up until June 2021 had at least one pre-existing condition.^[34] Some evidence (although not peer-reviewed) also suggests that people with learning disabilities may be twice as likely to become infected with COVID-19 and three times more likely to die than the general population.^{[35, 36]}

Disabled people may be more likely to be immunocompromised, or otherwise suffer more intense/fatal symptoms from COVID.^[37]

ONS has also found the negative social impacts of the pandemic have been greater for disabled people. Among people who indicated that their wellbeing had been affected by COVID-19, 46% of disabled people said the pandemic had a negative impact on their mental health^[38]. This compares with 29% for non-disabled people. The pandemic also impacted on access to services for disabled people and the level of care that they received. The move to putting services online for disabled people may have impacted adversely for those who were digitally excluded^[39].

The CMO regularly wrote to those on the HRL to communicate any changes in advice. Letters are available to be translated into any format and language needed. On each occasion, we produce 60 different variants of the letters, translated into 'Easy Read', large print, BSL, alongside several languages such as Urdu, Cantonese and Mandarin. An SMS service was also available for individuals on the HRL to receive key messages and updates.

Of those individuals who are currently on the highest risk list, some will be disabled but we do not currently hold data to confirm how many.

Data on vaccination uptake rates for disabled people is not currently collected.

Differential Impact

There is strong evidence which shows that vaccines are offering significant protection to people on the HRL from becoming severely ill, including those who are immunosuppressed or immunocompromised^[40]. In addition, we have seen significant improvement in outcomes since vaccination, and this is also seen, although to a lesser extent, within people who are immunosuppressed or immunocompromised.

Clinicians are therefore of the view that removing the HRL will not significantly increase the risk for disabled people.

However, given that COVID has had a disproportionate impact on the health of disabled people, and the negative social impacts of the pandemic have been greater for disabled people, the removal of list may cause a higher level of anxiety for some disabled people on the HRL. This could lead to decisions around self-shielding or restricting activities and interactions, which would impact on their quality of life as well as their mental health and wellbeing.

Conversely this policy could have potential benefits by making some disabled people on the Highest Risk List feel less restricted as they go about their daily lives, including accessing services which were previously only available online.

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life^[41].

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[42].

Sexual Orientation

Background

During the COVID-19 pandemic, loneliness and isolation have been an issue particularly for LGBTi people of all ages.^[43] Age UK also reported that older LGBTi people are especially vulnerable to loneliness as they are more likely to be single, live alone, and have less contact with relatives.^[44]

Of those individuals who are currently on the highest risk list some may identify as LGBTi but we don't know how many.

Differential Impact

This policy could have potential benefits by making some LGBTi individuals on the HRL feel less restricted as they go about their daily lives, which could address the higher level of loneliness and isolation reported by this group during the pandemic.

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life^[45].

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[46].

Marriage and Civil Partnership

Differential Impact

It is not considered that the removal of the HRL will have a specific differential impact on people in relation to this protected characteristic.

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[47].

Pregnancy and Maternity

Background

Pregnancy itself was not considered as a Highest Risk List condition, however there may have been individuals on the Highest Risk List due to other comorbidities, who were also pregnant.

In terms of direct harm to health from the virus, evidence suggests that pregnant women are no more likely to get COVID-19 than adults without health conditions, but that they may be at increased risk of becoming severely unwell compared to non-pregnant women, particularly in the third trimester.^[48]

Studies have also shown that there are higher rates of admission to intensive care units for pregnant women with COVID-19 compared to non-pregnant women with COVID-19. It is important to note that this may be because clinicians are more likely to take a more cautious approach when deciding whether to admit someone to the intensive care unit when a woman is pregnant^[49].

Vaccine uptake among pregnant women remains consistently below that of the general female population^[50].

There was initially much reluctance among people who were pregnant to receive vaccinations because of mixed reports of side-effects, however clinicians and advisers are clear it is safe to get the vaccine if you are pregnant. This was confirmed in the Royal College of Obstetricians and Gynaecologist's Coronavirus (COVID-19) Infections in Pregnancy report^[51], published March 2022.

It remains a key priority to ensure all pregnant women have the most up-to-date information. As such Public Health Scotland have developed a leaflet setting out important information about the COVID-19 vaccination and pregnancy, including information on fertility and breastfeeding. All health boards have copies of this leaflet to distribute to pregnant women in their care, in addition to the information on Public Health Scotland's website and information from the Royal College of Obstetricians and Gynaecologists.

Health professionals across the country have access to learning resources about COVID vaccination in pregnancy which are continually reviewed and updated. Bespoke vaccination teams are present in many maternity units to provide on the spot vaccination.

There is currently no data available on the number of pregnant women on the HRL.

Differential Impact

The removal of the HRL may cause a higher level of anxiety amongst pregnant women on the list given the evidence that suggests they may be at increased risk of becoming severely unwell compared to non-pregnant women, particularly in the third trimester, and that they are less likely to have been vaccinated.^[52]

This could lead to decisions around self-shielding or restricting activities and interactions, which would impact on their quality of life as well as their mental health and wellbeing.

Conversely this policy could have potential benefits by making some pregnant women on the Highest Risk List feel less restricted as they go about their daily lives.

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life^[53].

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[54].

Gender Reassignment

Background

As of May 2018, around 0.5% of the population of Scotland (24,000 people) were estimated to be transgender.^[55] Trans people suffer disproportionately from mental health conditions. A systematic review concluded that they were twice as likely as the general population to take their own lives, and that a lack of health care access adds particular pressure onto trans communities.^[56]

There is currently no data available on the number of trans people on the HRL.

Differential Impact

Given that trans people suffer disproportionately from mental health conditions, the removal of the HRL, could lead to greater anxiety for some trans individuals on the HRL and compound those mental health.

Conversely this policy could have potential benefits by improving the mental health of some trans people on the Highest Risk List though making them feel less restricted in going about their daily lives.

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life^[57].

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[58].

Socio-economic disadvantage

Background

The evidence suggests that people in the most deprived areas are over twice as likely to die with Covid-19 than those in the least deprived areas^[59].

In addition, of those individuals who are on the HRL, as of 4 April 2022, almost half (48% or 84,957) live in the two most deprived Scottish Index of Multiple Deprivation quintiles^[60].

Differential Impact

There is strong evidence to show that vaccines are offering significant protection to people on the HRL from becoming severely ill. Clinicians are therefore of the view that removing the HRL will not significantly increase the risk for individuals on the list including those from deprived areas.

However, the removal of the HRL may cause a higher level of anxiety for some people on the list who live in the most deprived areas, given the higher likelihood of dying from Covid amongst this group. In addition, recent research suggests that a much higher proportion of individuals on the HRL from socio-economic vulnerable households (61% compared to 28% from less socio-economic vulnerable households) still try to minimise all physical contact with people from other households^[61]. Furthermore, the same research showed that the following concerns were more common amongst those with socio-economic vulnerability: negative impacts of being on HRL; the likelihood of ongoing worries; and feeling less supported.

A higher level of anxiety amongst this group could affect their decision to self-shield or restrict activities and interactions, which would impact on their quality of life as well as their mental health and wellbeing.

In relation to employment, the same research showed that:

• 63% reported an ongoing negative impact on their employment from the initial shielding period
• 42% reported flexibility from their employer as a positive impact of being on the HRL
• 77% said they had received the advice and support they needed
• 60% have looked at the SG advice on workplace safety, which has influenced some of their actions
• 31% still try to minimise all physical contacts (less than 36% across all respondents)
• 9% think support to help them return to work or find a new job would be helpful
• 46% consider it very or quite problematic that they are no longer advised not to go into the workplace
• 52% agree it is safe to go into the workplace

It is estimated 60% of working age people on the Highest Risk List are employed in jobs that cannot be easily done from home.

There are therefore also potential benefits for people on the Highest Risk List from more deprived socio-economic backgrounds who may feel less restricted as they go about their daily lives as a result of this policy, including returning to the workplace.

Understanding that their risk has now reduced may help people to feel more confident and less vulnerable about adapting a more normal way of life.

Vaccination has progressed extremely well overall for the Highest Risk List population with approximately 96% of highest risk individuals now having received two doses, and around 91% having received a third dose or booster^[62].