Test and Protect: equality and Fairer Scotland Duty impact assessment

8. Summary of Key Findings

Test and Protect is anticipated to have a positive impact across all groups in society by reducing transmission of Covid-19 reducing deaths and serious illness caused by the virus. It is a fundamental part of the Scottish Government's strategy to mitigate the severe impacts of Covid-19 on public health.

However, the interventions and services delivered as part of Test and Protect may have a range of differential impacts across different equalities groups. This EQIA provides a summary of these considerations and mitigation actions taken to reduce any negative impacts anticipated as a result of Test and Protect.

Whilst there is a broad range of impacts related to a wide range of measures delivered as part of Test and Protect, there are clear themes related to certain equalities groups including:

• that public messaging and guidance must be accessible for people for whom English is not their first language, for people who have lower levels of digital literacy and for disabled people who require information in Easy Read and British Sign Language Formats;
• that building trust in the Test and Protect service in the general population, but also in relation to some equalities groups including Black and Minority Ethnic communities, is key to ensuring that people are confident in engaging with Test and Protect;
• the impact of self-isolation has a much greater impact on specific groups of people who may share a protected characteristic or socio-economic profile including people in low-income households and older people; and
• ease of access to testing may be divergent across rural and urban areas, and those equality groups who are less likely to have access to a car.

Whilst the detail of this paper sets out a range of specific measures that attempt to address specific impacts, there are some key mitigating actions that run across the Test and Protect programme that are intended to minimise any negative impacts of the policy on a range of equality groups including:

• ensuring guidance and public messaging is provided in a range of languages and formats to take account of levels of digital literacy, language needs and communication preferences to best ensure that information is equally accessible across a wide range of equality groups;
• a significant package of practical and financial support for people self-isolating, where needed, to minimise the impact of self-isolation requirements on people in low-income households and older people;
• ensuring a broad range of communication support and interpretation services across testing, contact tracing and isolation support services so that Test and Protect is able to meet the communication needs and preferences of people accessing these services;
• expansions to the testing programme to ensure that it is both as accessible as possible to people in rural and remote areas and specific targeted testing to increase uptake of testing within low-income households and black and minority ethnic communities;
• the delivery of home testing to reduce the impacts on people who may not be able to afford to travel to a testing site, or for disabled people and people with mobility needs who may not wish to travel to a testing centre.

Testing

Guidance on those eligible for a test, how to get tested and the different types of test available is published on the Scottish Government website.[7] This is updated in line with changes and refinements in our approach to testing. Communications relating to testing have been designed to be accessible to people with lower literacy levels in English, speakers of a foreign language and people with a visual impairment.

In designing the policy and delivery model for testing as part of Test and Protect, we have considered the needs of different groups with protected characteristics and those from lower income households who may not have access to a car, a number of different testing routes are available:

• Regional Testing Sites - these are large drive-through sites that are situated at fixed locations and can be accessed by car – of which there are 8 Scotland;
• Mobile Testing Units - these are hybrid drive-through and walk-through sites that move location to provide access to testing over a wide geographical area and where it is most needed;
• Walk-through Test Sites - these testing sites provide tests to people who do not have access to a car. These sites can be accessed by foot, bike, wheel or scoot. These sites should not be accessed by public transport.
• Home Test Kits - Anyone who is not able to get to a test site for any reason is able to order a home test kit. This will be delivered to their door and they can either return it using Royal Mail priority post boxes or through a pre-paid courier service.
• Satellite channel - bespoke testing channels have been setup to improve access to testing in certain groups or geographies, this includes remote and rural areas to improve geographic access for drive-through and walk-through testing and university students in student halls if they cannot access a test through national channels.
• Local Health Board testing access – testing for vulnerable individuals who are unable to access the national testing systems can be organised by Health Boards at local centres or at home.
• Targeted Community Testing – the development of specific local test sites with signposting and wraparound support to increase the take-up of testing by harder to reach groups.

Age

Older people

Older people are confirmed as having coronavirus at a higher rate than younger people - as at 07 March 2021, people aged 75-84 were confirmed as having coronavirus at a rate of 3,118 people per 100,000 population, and for those aged 85 and over, the rate was 7,003 people per 100,000 population. This is compared to a rate of 4,089 people per 100,000 population for people aged 45-64.[8] As of 28 February, just under three quarters (74%) of all deaths involving Covid-19 were of people aged 75 or over. [9] There are a higher ratio of women to men in older age groups, reflecting women's longer life expectancy. For example, women make up 65% of people aged 85+ in Scotland.[10][11] Measures that may help limit the spread of coronavirus are designed to positively affect the entire population, but may particularly benefit older individuals.

During engagement with stakeholders earlier in the pandemic, questions were raised around the ability of some groups to physically access testing sites, including older people; disabled people and single parents. Stakeholders raised that for some older people, particularly those who are frail, there will have reduced access to transport to access testing which may mean they are disproportionately impacted.[12]

In relation to home test kits, it was thought that some older people and disabled people could find it difficult to understand instructions and administer home test correctly. An increased proportion of older people may also experience fine motor difficulties for example following a stroke or living with Parkinson's disease which may impact on their ability to utilise home testing kits effectively.[13] Home test results being sent to mobile phones may also exclude some older people.

Access to the internet in order to book a test was also seen as a potential issue that would disproportionately affect older people. Older people are less likely to have internet access and even if they do they are less likely to use it. 36% of households where all adults are over 65 do not have home internet access, with only 57% of those with access using it regularly. 60% of households where all adults are over 80 do not have internet access, with 72% not using it regularly. Only 29% of adults aged 75 and over use a smartphone to access the internet.[14]

A range of actions have been taken to mitigate these impacts including:

• the development a non-digital route to book a test through a telephone service, with no need to access the internet required and to receive test results through the telephone with no access to email required. This positively impacts on those who do not have access to the internet or broadband.
• expansion of our testing offer to ensure it is accessible to people of all ages and in a variety settings, for example walk through test sites, home test kits and testing arranged through local health boards mean people can get tested within their local area or at home, with or without assistance.
• raising public awareness of availability of testing, and advice on when and how to book a test, through a range of channels in addition to social media including as part of the daily briefing given by the First Minister and through television and non-digital media channels.

Young people

Whilst accessing to testing is anticipated to have a broadly positive impact on young people, a number of actions have been identified and delivered to maximise the positive impact of testing on this cohort including:

• following engagement with clinicians, extending testing eligibility from Summer 2020 to include children under 5 years of age;
• the delivery of Local Test Sites from early Autumn 2020 which are accessible by people who do not have a car or do not have a registered address in Scotland. This ensured that people under the legal age for driving, and young people who do not have a driving licence, have been able to easily access testing where required.
• in early 2021, the design and delivery of testing in schools and early learning and childcare establishments to minimise transmission of Covid-19 in young people and those who work in educational establishments.

Disability

According to the 2019 Scottish Health Survey, 32% of men and 37% of women in Scotland reported living with a limiting long-term condition. For people aged 75 and over, 58% had a limiting long-term condition.[15] 1 in 5 Scots identify as disabled and more than a quarter of working age people acquire an impairment.[16]

Coronavirus particularly affects those with a pre-existing medical condition.[17] Disabled people are more likely, either due to a disability or because they have a disability, to have a long term condition that puts them at risk of experiencing severe ill-health from contracting Covid-19 than the general population.. Therefore, measures which limit the spread of coronavirus would be positive for these individuals. However, disabled people may be more negatively impacted by certain restrictions, such as self-isolation, which could mean these measures could have a negative impact on this group. It is important to note, however, that many disabled people do not have underlying health conditions that put them at a higher risk of poor outcomes from infection with COVID-19.[18]

Our policy position is that the testing system needs to be fully accessible for disabled people. However, stakeholders raised concerns about the inaccessibility of test centres to anyone without a car or unable to drive as public transport is not an option for anyone with symptoms; this will disproportionately affect people with learning disability, dementia or mental health issues and particularly those living in remote and rural locations. Various routes to testing have been implemented in order to mitigate the risk of barriers to testing for those with protected characteristic, including disabled people.

For some people, there was concern that the process of testing may be experienced as intrusive and could trigger difficult reactions. It was felt that increasing awareness of the potential intrusiveness of the testing process among frontline delivery staff might mitigate this risk.

It was also noted that some people with autistic spectrum disorders and other conditions may struggle with the busyness of testing centres and as we head into the winter months, with the possibility of increased cases and demand on test centres.

The Mental Welfare Commission has received a number of calls through their advice line from people about testing. In relation to testing kits there is a need to have clear instructions in an easily understood format. Sensitivity to home testing kits can also be difficult for disabled people either to be undertaken themselves or by a carer, particularly when they do not understand why. Each kit comes with comprehensive instructions to guide you through how to administer the swab yourself. Test kits come with further instructions and a short video to take people through the process step by step.

In addition to engagement with the Scottish Consortium for Learning Disabilities at the inception of this EQIA summary document, engagement with Autism and Learning Disabilities policy division has been undertaken to consider the impact on testing on living with a disability. We will continue to refine our approach to ensure we are getting it right for those who may face barriers to accessing or administering tests.

A number of mitigating actions have been delivered in relation to the impact of testing policy on disabled people including:

• accessible communications regarding testing, and easy-read leaflets and guidance, to ensure that communications and guidance are provided in a format that is most likely to meet the needs of people with learning disabilities and autism.
• the delivery of Local Test Sites which are accessible for people who do not have access to a car including people who have lower levels of mobility and do not drive..
• testing of the health and social care workforce to ensure that people providing support to people with disabilities and long-term conditions, and people receiving care and support, are less likely to contract Covid-19.
• raising public awareness of the support available for people self-isolating to ensure that disabled people and people with long-term conditions are not discouraged from accessing testing because of concern about the challenges they may experience in self-isolating if they test positive.

Sex

Measures that may help limit the spread of coronavirus are designed to positively affect the entire population regardless of sex by reducing the risk of infection. However, based on the currently available data, limiting the spread may particularly benefit men, in respect of reducing ICU admissions and the age-standardised death rate, and limiting the spread – and any reductions in the overall numbers of deaths – may particularly benefit women over the age of 85.[19]

Women, who are less likely to have access to a car, may also experience barriers in accessing drive-through testing leaving them disproportionately impacted.[20] The use of Scotland's public transport system is highly gendered[21]. Women are less likely to drive and be more reliant on bus than men[22] and also tend to make more complex and frequent journeys due to caring responsibilities and working patterns.

A number of aspects of the testing programme are expected to mitigate some of these impacts, particularly in relation to access to testing, including:

• delivery of test sites in accessible locations across the length and breadth of Scotland that can be accessed on foot.[23]
• ensuring availability of home-test kits
• testing of the health and social care workforce which is predominantly female (c.85% - Scottish Social Services Council Report on Workforce Data 2019)

Ethnicity

Analysis by National Records of Scotland (NRS) in July found that deaths among people in the South Asian community were almost twice as likely to have involved Covid-19, compared to deaths in the White ethnic community, after accounting for age group, sex, area-level deprivation and urban rural classification.* NRS noted they did not have sufficient evidence to say that deaths among people in the Chinese community were more likely to involve Covid-19. Due to the low number of completed records for deaths involving Covid-19 in other minority ethnic groups, NRS also stated they were not able to carry out analysis of the relative likelihood that deaths involved Covid-19.[24]

NRS published an updated analysis in November, after linking deceased individuals to the 2011 census and manually contacting informants of the deceased whose ethnicity was still missing even after census linkage. The conclusions of the analysis with more complete ethnicity data confirmed the findings from the earlier July report.[25]

Public Health Scotland (PHS) also published updated analysis in December of the risk of serious health outcomes due to COVID-19 by ethnicity (that is, those requiring hospitalisation or intensive care or dying within 28 days following a positive swab test result)[26]People from the South Asian community were about twice as likely in risk of admission to hospital or die as a result from COVID-19, and this increased risk was not explained by differences in deprivation, residential care home status and diabetic status.[27] [28] The latest PHS analysis also demonstrated there is an increased risk of hospitalisation due to COVID-19 among those from the Caribbean or Black community.

Similarly, analysis from Public Health England in June showed that death rates from Covid-19 were highest among people in the Black and Asian ethnic groups.[29]

In the case of testing engagement with external stakeholders suggests that there is potentially perceived stigma attached to being tested depending on a person's cultural background.

Early feedback suggested that with the online booking system being the primary route to testing, it was felt that this excludes people who do not fully understand written English and/or who do not have internet access. Feedback also suggests that the information provided as part of this portal is complex and people have to read through a lot of guidance and click through a number of links before they can book a test. This could create a barrier to those with lower literacy levels.

A number of mitigating actions taken to address some of these issues include:

• translation of public health leaflets and information into a wide range of languages to ensure information is accessible.
• the implementation of a phone translation service as part of the phone based test booking route
• the delivery of the Targeted Community Testing Programme aiming to increase take-up of testing by harder to reach groups including people from BAME communities.

Gypsy / Travellers

Gypsy/Travellers in Scotland, compared to the population as a whole, are more likely to report a long-term health problem or disability and were more likely to report bad or very bad general health.[30] Reducing the spread of coronavirus through Test and Protect should therefore have a positive impact on protecting these communities from health harms.

However, research shows that those from Gypsy / Traveller communities may have lower levels of literacy which could create a barrier to understanding advice and information on access to testing.[31]

To mitigate this potential impact:

• guidance is available in an Easy Read format for people with lower literacy levels and for people for whom English is a second language.

Religion or belief

Regular engagement with stakeholders from faith groups and from organisations representing people with a range of religious and cultural backgrounds suggest that whilst testing is anticipated to have a broadly positive impact on people with a wide range of religious and cultural backgrounds, concerns have been raised about potential trust in public agencies.

• Targeted Community Testing is anticipated to increase access to testing by hard to reach groups including, potentially, people from a range of different faiths and cultural backgrounds.
• Third sector stakeholders are supporting with engagement with their organisational members and marketing materials have been designed in such a way as to promote the confidentiality of the Test and Protect system and provided in a range of languages.

Socio-economic disadvantage

Whilst the testing programme is anticipated to have a positive impact on people experiencing socio-economic disadvantage a range of impacts and concerns have been considered in the development of testing policy.

A number of concerns about access to testing for low-income households have been raised throughout the pandemic including:

• that people in low-income households may be more reluctant to engage with testing because of concern that if they are required to self-isolate, they may experience a significant drop in income.
• that people in low-income households are more likely to use public transport rather than have access to a car making it more difficult to access to testing
• that this group of people are less likely to have high levels of digital literacy and access to the internet

As the testing programme has evolved, a number of actions have been delivered that are anticipated to have mitigated some of these issues including:

• the introduction of the Self-Isolation Support Grant, a £500 payment to people on low-incomes who are required to self-isolate and promotion of this grant – ensuring that people in low-income households are not dissuaded from accessing testing due to concerns that they won't be able to afford to self-isolate
• a broad range of testing services including Mobile Testing Units (MTUs), Local Test Sites and Home Test Kits to ensure that appropriate channels and access to testing are available for people who do not have access to a car
• in addition to the digital portal, a phone test booking service for people who cannot access the internet
• the delivery of Targeted Community Testing in areas where a higher proportion of the population is anticipated to live in low-income households, with the aim of increasing take up of testing by harder to reach groups.

Rurality

Access to test sites may be more challenging for people living in rural areas, particularly for people who not have access to a car. For people on low incomes, the cost of travelling potentially long distances to a test centre may be a barrier to accessing testing services.

The development of testing services has been undertaken with the intent to address concerns about rural access to testing including:

• the delivery of a number of Local Test Sites in rural areas to provide walk-through testing for people in rural areas who do not have access to a car
• the deployment of mobile testing units in rural and remote areas to ensure these communities are more able to access testing
• from December 2020 ensuring availability of postal home testing kits to all mainland areas including remote and rural areas

Contact tracing

Proactive work was undertaken in the form of extensive public communications issued to reassure people about the breadth of the Test and Protect process, across the different pillars, including relating to contact tracing. This included the nationwide door drop which issued in late June 2020 to every household in Scotland, setting out how the process operates (further information below). This document was made available in many languages to ensure maximum accessibility. A further door drop distributed in January 2021 included updated content for the public about the Test and Protect system, contact tracing and self-isolation, including signposting to the Local Self-Isolation Assistance Service and Self-Isolation Support Grant.

Scripts utilised by contact tracers when speaking with people who have tested positive, and their close contacts, have been designed to ensure accessibility for people with a diverse range of language and other needs – including those with protected characteristics – and to provide the relevant information and intelligence to inform the contact tracing process. The approach used by Test and Protect draws on the expertise of existing local health protection teams within NHS Boards, used to dealing with infectious disease outbreaks, often within communities affected by specific inequalities considerations.

Public Health Scotland (PHS) undertook a separate EQIA on contact tracing and it is available online.[32] We will share the findings from this impact assessment with PHS to inform the continued delivery of contact tracing in Scotland.

Age

Whilst the contact tracing system is anticipated to have a positive impact on people of all age ranges, aspects of the system have been identified where there may be a differential impact on people from different age ranges.

Feedback from public health officials suggests that older people may be more likely to be concerned that a call from a contact tracer is fraudulent. Conversely, older people are at greater risk of fraudulent phone calls purporting to be from contact tracers.

The standard process for some aspects of the contact tracing system requires engagement with text messaging and this may be more challenging for some older people to engage with. Similarly, higher numbers of older people may not have a high level of digital literacy or access to the internet and 'digital only' or 'digital by design' services may exclude a proportion of this cohort of people.

To ensure that the contact tracing service takes account of these impacts:

• all people contact traced have the option of giving a landline number and doing so will prevent them from having to engage with text messaging or emails as part of the service
• all Boards have in place measures to allow call verification, as does the National Contact Tracing Centre, and all calls from Test and Protect come from an 0800 number to ensure transparency and confidence in the system.
• Proactive communications has also been issued in the form of social media campaigns, press releases and updates at the televised Daily Briefing events to reassure members of the public about what to expect from a call from a contact tracer.

Young people

Evidence from outbreak management in education settings has found that the contact tracing process may have a disproportionate impact on young people who feel peer pressure not to disclose information about who they have been in contact with due to a feeling of telling on their friends. Some young people also may not want to provide information that will result in their parents having to self-isolate meaning that they will not be able to go work.

We engaged with two panels of young people run by Young Scot, YSHealth and Technology Enabled Care, to understand the needs of young people engaging with both the testing and contact tracing process, and providing information which has formed web content housed within Young Scot's coronavirus information hub.

Disability

Contact tracing is predominantly a phone based service and as a result there are a number of potential impacts for deaf people and people who do not find a standard phone call an accessible form of communication[33]

For contact tracing staff, the Mental Welfare Commission suggested that specific training is provided to support telephone calls to those who may experiencing poor mental health or have a learning disability to maximise the opportunity to engage and inform the person and, where appropriate, carers/relatives.

The service has embedded a range of communication tools to ensure that it is accessible for people with disabilities including:

• a callback service for people who require an interpreter, including for people who communicate using British Sign Language
• the ability to access information in text messages, email or by phone to suit the communication preferences of the person engaging with the service
• Through the contact tracing programme's workforce education stream and existing territorial health board resources, continuous development and upskilling of staff is integral to the service, including in relation to ensuring supportive and inclusive communication for a variety of audiences.

Sexual orientation and Gender Reassignment

The UK Government Equalities Office LGBT Survey 2017 found that 24% of all respondents were not open about identifying as LGBTQIA+ with any family members that they lived with (excluding partners).[34] For some people, it is likely that concerns around levels of anonymity in the contact tracing system may discourage them from either engaging with the system at all or, if they do, declaring certain close contacts.

In line with data protection rules and the Caldecott principles, the contact tracing system is entirely confidential and individuals are reassured that their personal information will not be shared with close contacts, employers or others without prior consent, helping built trust with individuals concerned about disclosing personal contacts generally.

Public messaging relating to contact tracing makes clear that it is entirely anonymous, that the information is not shared or passed to other agencies and that its sole purpose is the protection of public health.

Ethnicity

One of the factors driving transmission of Covid-19 is the level of household occupation because household contacts are required to self-isolate where one member of the household tests positive. Census data suggests that there is divergence across different ethnic groups in relation to the average number of people resident in a household. Scotland's 2011 census found that the 'White: Polish' ethnic group had the highest rate of overcrowded households (30 per cent), followed by 'Bangladeshi' and 'African' households (both 28 per cent). This compares with 8% for 'White: Scottish' and 6% for 'White: Other British'.[35]

Whilst the impacts of contact tracing on all ethnic groups are broadly positive, there is a specific concern that people in higher density households are more likely to be asked to self-isolate because with more people resident within a household, they have a higher chance of a member of the household testing positive.

Furthermore, the report by Public Health England noted that Black, Asian and Minority Ethnic people may be at an increased risk of acquiring coronavirus due to factors such as overcrowded households.[36]

In addition, where household numbers exceed those allowed by a landlord, people engaging with contact tracing may be reluctant to share details of close contacts for fear of it impacting their lease.

Similarly there is a significant intersection between different ethnic groups and residency status. It is likely that people who do not have a settled residency status within the United Kingdom may be more reluctant to engage with the contact tracing system, particularly if they are concerned about a potential impact on their right to remain.

A number of mitigating actions are anticipated to reduce the potential negative impacts of contact tracing policy across different ethnic groups including:

• public messaging in a range of formats, languages and across a number of different media channels that makes clear that information provided to contact tracers is confidential and is not passed to, for instance, Police Scotland.
• delivery of a range of isolation support services, including extension in eligibility of the Self-Isolation Support Grant for people with no recourse to public funds, to ensure that people in larger households are more confident to declare close contacts due to awareness of support available to members of their household where they are required to self-isolate

Socio-economic disadvantage

For those in precarious or low income jobs there may be a greater sense of fear of job loss, loss of earnings, stigma, and not wanting fellow friends/colleagues to be impacted. There may therefore be perceived barriers to participating in the contact tracing process which may have a disproportionately negative impact on those on low incomes.

To reduce concern about engaging with contact tracing because of the impact of having to self-isolate, a range of actions have been delivered including:

• the self-isolation support grant for low income workers who will lose income when self-isolating
• The provision of practical support including access to food, medication and any referral to third parties

Self-isolation

Research by University College London indicates that there is a high level of compliance with public health guidance, and shows that 62%[37] of symptomatic people and 80% of close contacts comply with the need to self-isolate[38]. Only 13% of symptomatic people do not self-isolate at all, 16% only self-isolate for 1-5 days and 9% self-isolate for 6-9 days. This has increased significantly from early research in Summer 2020 prior to the commencement of a range of isolation support measures in Scotland and across the other nations of the United Kingdom.

It is anticipated that most people asked to self-isolate because they have tested positive, or have been a close contact of a positive case, should be able to do so effectively on their own, or with the help of family, friends and neighbours. Whilst robust estimates of the proportion of people who may require support to isolate are challenging to quantify, only a small proportion (7%)[39] of people are likely to require additional support. This was higher among men than women (9% and 5% respectively, who were less likely to have a support network that could help them whilst self-isolating.

However, whilst this is a relatively small proportion of the population, a much larger proportion of people may face financial challenges that could be exacerbated by the requirement to isolate.[40]

Research by King's College London[41] published in Summer 2020 indicates that men, younger people, those with young children and key workers were less likely to adhere to Covid-19 guidance generally. Lower socio-economic status and greater hardship during the pandemic were also associated with lower adherence. Results suggested that adherence could be improved by practical support and financial reimbursement to reduce the burden incurred by self-isolation. Our approach to services and support therefore follow this evidence that removing barriers to self-isolation compliance is key to ensuring people are able to comply. Targeted messaging and policies to men, younger age groups, and key workers about the COVID-19 symptoms and the importance of a Test, Trace, Isolate and Support system to contain the spread of the virus could also improve engagement.

A recent survey by the Scottish Government[42], published 29 January 2021 asked which boundaries people experiences or expected to experience to comply to self-isolation guidance. The 457 respondents represented both people with and without self-isolation experience. The main barriers to self-isolation were identified as follows:

• access to food (difficulty accessing only shopping and delivery slots; needing a support network nearby to help with food shopping),
• living arrangements (people in small or crowded housing might not be able to keep distance from other household members),
• financial situation: people both worried about being able to afford food and pay bills as well as the wider impact of a reduced or uncertain income.
• Caring responsibilities: people with caring responsibilities noted difficulties, especially around understanding guidance and adapting to keep others safe.

We have noted that these barriers around self-isolation seem to be present in several risk categories. We have therefore tried to create mitigating actions that will target the wider population.

We recognise that isolation may be more challenging for people with protected characteristics or a socio-economic disadvantage, and additional support will be necessary to ensure people can isolate safely and remove any barriers to compliance.

The National Assistance Helpline, referred to in Scottish Government guidance and Test and Protect marketing assets, supports people who do not have other community or family support available by joining them up with local services. There is a textphone number available and we have added into our guidance that deaf and deafblind BSL users can contact the national helpline number via contact Scotland-BSL, a Scottish Government service that connects BSL users throughout Scotland through an online BSL interpreting video relay service (VRS).[43]

The support offered by local authorities is be different across the country and depends on the need identified and local capability and capacity. In general though this will include as a minimum access to essential food and medicine, emotional and social support. Some support interventions may fall within existing statutory provision, for example on financial hardship or homelessness, and local authority teams have access to refer into relevant local services.

Qualitative research published by Scottish Government[44] detailed the range of assistance, which Local Authorities have identified, that people report needing when calling the National Assistance Helpline. Most local authorities report food and medicine being the main requests, followed by befriending and financial assistance. Many needs are interlinked: financial issues and inability to obtain food, for example. Local Authorities provide help as required, wherever reasonable.

Local Authorities also report that not all callers know what they need when they call and it might take a conversation to get to the wider picture of need, particularly for wellbeing or isolation issues. However, some callers do know what they want or need, and may also know what support is available through the Local Authority; these calls have tended to be much shorter and more direct.

In order to mitigate for the above needs among the population, and in order to ensure that no one falls through the net if they do not themselves proactively call the pre-existing helpline to access support, the First Minister announced on 22 September that we would be changing the approach from a self-referral model to proactive support model. In partnership with Local Authorities, we launched, on 12 October, the Local Self-Isolation Assistance Service which proactively get support to the people self-isolating who are likely to need it after they are asked by contact tracers to self-isolate. This will have a positive impact on those with protected characteristics and on lower incomes who may have a greater need for support to self-isolate safely and effectively.

Age

The need for isolation support may be greater for older people who may be disproportionately impacted due to limited social networks; family support; lower incomes or a lack of awareness / use of digital support. Older people are less likely to be involved in digital economy and who may still rely on paying bills by more traditional means could potentially to be cut off from utilities if they cannot pay bills and do not have family support to do this for them.

A number of measures have been delivered to mitigate some of the potential negative impacts of self-isolation on people of different age ranges including:

• ensuring that support can be accessed through the National Assistance Helpline phone number and that it is provided in a non-digital way by phone to ensure that people with lower levels of digital literacy, including some older people, are able to access the service.
• the Local Self-Isolation Assistance Service pro-actively triages the isolation support needs of people who have been contact traced and consent to receive the service and local authorities have given examples of supporting older people with a wide range of activities including re-establishing their household energy supply
• the support services available have been promoted through a range of media channels including television, radio and print media to ensure that people who do not have access to the internet are aware of the support that can be provided.

Disability

The ability to understand the instruction to isolate and of impact of isolation may disproportionately impact on those with a learning disability or dementia. These individuals and their carers are more likely to have a low income which will mean they experience problems with very practical issues if they are isolating for example accessing food and basic supplies.[45] In addition people with learning disabilities are more likely to require information to be provided in alternative formats such as Easy Read.

The Mental Welfare Commission noted that mental health issues could be made worse during a period of self-isolation, with those who were already becoming increasingly anxious and distressed during lockdown experiencing more symptoms if they have to self-isolate again.

A number of aspects of the support offer are intended to mitigate some of these issues including:

• that local authorities delivering the National Assistance Helpline and the Local Self-Isolation Assistance also provide care and support through adult social care and social work services and are therefore able to triage people's needs accordingly where people in their area are required to self-isolate
• the National Assistance Helpline and Local Self-Isolation Assistance Service provided referrals and engagement with local statutory and voluntary sector services ensure that where people have additional support needs who are self-isolating, relevant non-Covid specific services can be accessed
• we have ensured that much of the public health advice related to Covid-19 and to self-isolation has been provided in a range of formats including Easy Read versions.

Sex

Evidence indicates that women spend far more time providing childcare than men. 1 in 4 women across all age groups took part in childcare on a given day in 2014-15 (24%), compared to 15% of men.[46]

It has also been clear that parents of children required to self-isolate as close contacts, whilst not required to self-isolate themselves, have had to take an absence from work to look after a child required to self-isolate. It is recognised that this has a significant financial impact on people on low-incomes who are unable to work from home and that provision of childcare is much more likely to be provided by woman and is therefore more likely to negatively impact woman.

As set out above, given that men are almost twice as likely to have no support network than woman (9% and 5% respectively) the isolation support offer is anticipated to have a positive impact on men.

We've undertaken a range of measures to try to mitigate some of these impacts including:

• expansion of the Self-Isolation Support Grant to provide eligibility to parents and carers on low-incomes who are required to take time off work to look after a child self-isolating despite not being required to isolate themselves
• we have ensured the Scottish Government's Covid-19 webpage provides guidance/links in relation to topics such as: help if you additional support; support if you are feeling anxious or depressed; domestic abuse support; information for older people; and guidance for households (referred to below as the Scottish Government's Covid-19 guidance) including for people self-isolating
• campaigns to reassure those experiencing domestic violence of the support available and public messaging setting out that that people should not delay in seeking help during pandemic including signposting to relevant support services and Police Scotland, including for people self-isolating

Ethnicity

At the inception of this exercise, some health boards noted the importance of a culturally sensitive approach and accessible support to isolate for black and minority ethnic communities. One Board reported that only at the end of the isolation period did women approach them for more bespoke help, such as assistance in purchasing sanitary products, advice and support in relation to domestic abuse concerns.

To address these concerns the support services available have provided, from October:

• access, referral or signposting to a range of local voluntary sector services including third sector services supporting people from a range of cultural backgrounds
• to address feedback that some people from black and minority ethnic communities are more likely to be reluctant to engage with public agencies pro-actively, the Local Self-Isolation Assistance now provides a pro-active call service to ensure that people self-isolating who consent to receive the service receive a call from their local authority rather than being required to phone to ask for support
• local authorities provide a range of language services to meet the communication needs of people self-isolating who require support

Religion and Belief

Whilst self-isolation support is likely to have a broadly positive impact across people of all faiths and beliefs, some specific measures related to isolation support have been implemented to ensure that these services meet the needs of a broad range of religious beliefs and cultural backgrounds including:

• ensuring that access to food provided as part of the National Assistance Helpline and Local Self-Isolation Assistance services is appropriate for the dietary and religious requirements of people who are using these services
• providing self-isolation guidance in a wide range of languages to ensure that people from a wide range of cultural backgrounds are able to access public health advice in the language that is most appropriate

Socio-economic disadvantage

The disproportionate impact on people who are at socio-economic disadvantage who instructed to self-isolate under Test and Protect has been a common theme in feedback from stakeholders throughout the pandemic.

The types of employment that many people in low-income households undertake means they are less likely to be able to work from home. As a result they're more likely to be required to self-isolate by coming into contact with people who have tested positive and more likely to experience a loss of income if they are required to self-isolate.

90% of the top 50% of earners in the country can work from home, whilst 90% of the bottom 50% cannot do so.[47] This means that the impact of being asked to self-isolate on an individual's income will vary substantially depending on the sector they work in and the terms of their employment. People who are able to work from home are not likely to see any reduction in their income as a result of being asked to self-isolate. The Resolution Foundation Briefing: Doing What it Takes, suggests that this may impact on women workers more than men workers.[48][49] This may also have a disproportionate impact on minority ethic and younger workers working on temporary / zero hours contracts in precarious jobs.

People who work in jobs that require them to attend their workplace may see a significant reduction in income – from the wages they expected to receive for the period they are self-isolating to either nothing, or to Statutory Sick Pay, which for most people will be a lot less than they would have been paid. This is compounded by the fact that workers who cannot work from home could be at higher risk of exposure to the virus and therefore may face the prospect of having the isolate multiple times.

This means some people might decide to avoid testing due to the risk of having to self-isolate. In addition, less supportive employers may coerce or encourage their employees to return to work while they should be self-isolating.

The Consensus Statement from the Multidisciplinary Task and Finish Group on Mass Testing (TFMS), established to advise SAGE on the benefits and challenges of mass testing, has recommended that to promote self-isolation and mitigate impacts on inequalities as part of the UK government's strategy of 'mass testing' for COVID-19 will require:

'.a universal response to receipt of a positive test result [that] may need structured financial and social support both to promote self-isolation and mitigate impacts on inequalities. This should include (i) proactive provision of information and social and clinical support, (ii) sufficient supplies of food, (iii) employment protection, (iv) financial assistance and (v) accommodation where necessary.'

Amongst its key observations, the TFMS advises that mass testing can only lead to decreased transmission if individuals with a positive test rapidly undertake effective isolation. However, it highlights that self-reported ability to self-isolate or quarantine is three times lower in those with incomes less than £20,000 or savings less than £100, a finding echoed in accounts during the current pandemic of those in low paid employment unable to self-isolate for financial reasons.

Recognising that nobody should be forced to choose between self-isolating for the collective good and paying their rent and feeding their families, the First Minister announced a £500 financial support grant for people self-isolating. This is focused on lower-paid workers, those in precarious employment, or otherwise at economic risk. The Self-Isolation Support Grant (SISG) scheme, which was rolled out from 12 October, is being delivered though the Scottish Welfare Fund which is administered by local authorities. This has been agreed with CoSLA and we are working with councils on delivering the scheme. Evidence to support this comes from the Resolution Foundation Doing What it Takes report.[50]

Recognising the extensive impact on low-income households of having to self-isolate, sometimes on repeated occasions, a range of measures have been introduced by the Scottish Government including:

• from October 2020 the delivery of the Self-Isolation Support Grant for people required to self-isolate who are on a low-income and face a loss in income as a result of self-isolating
• increasing the availability of funding for crisis grants in Summer 2020 as part of provision of additional financial support for people experiencing financial hardship as a result of Covid-19
• from October 2020 the delivery of the Local Self-Isolation Assistance Service which provides a range of practical support which includes access food both in relation to physical access and in relation to affordability – the service also provides signposting to a range of other services in different areas including relating to finance and to Scottish Welfare Fund teams administering crisis grants, where appropriate
• from December 2020, the extension of the Self-Isolation Support Grant for parents of a child who is required to self-isolate, where they fulfil the other eligibility criteria of the grant
• from February 2021 the extension of the Self-Isolation Support Grant to include workers in receipt of Council tax Reduction, workers with caring responsibilities for someone over the age of 16 and workers who earn the Real Living wage or less
• extending the claim period for the grant from 10 days to 28 days recognising that financial hardship related to the isolation period may only become evident at the end of a pay period
• the Cabinet Secretary for Economy issued a joint statement with the Scottish Trade Union Congress (STUC), the Institue of Directors (IoD), COSLA and the Scottish Council for Voluntary Organisations (SCVO) setting out a shared commitment to putting Fair Work at the heart of the economic recover including within the statement that employers should support workers to follow Covid guidance including in relation to self-isolation
• revised guidance issued in December 2020 to make clear the Scottish Government's position that employers should support employees self-isolating
• from 2 March, particularly for people in insecure employment, an option for people contact traced to receive a notification from Test and Protect they can share with their employer which evidences that they have been asked by public health officials to self-isolate

Test & Protect Communications & Marketing

A common theme which has emerged from engagement with stakeholders and equalities group throughout policy development is the importance of accessible and inclusive Test and Protect guidance and communication. The Scottish Government recognises the importance of this in ensuring that public health advice and messaging is accessible, and therefore more likely to be followed, by the broadest section of the population possible.

As part of this, a campaign ran in October/November 2020 which promoted the public ask around self-isolation, with the ambition of boosting compliance as well as raising awareness. This media activity was seen by 87.31% of all adults in Scotland at least three times, and outperformed all targets around raising awareness of self-isolation, booking and taking a test if symptomatic, and self-isolating if requested by Test and Protect following identification as a close contact. In addition a new campaign was launched in February 20201 to further boost people's awareness of the ask to self-isolate and the available support.

Each element of Test and Protect requires the public to engage in challenging new behaviours, so engaging meaningfully around these via communications is essential. Due to the complex nature of the task, a number of key strategic principles have been developed to guide communications on Test & Protect. They are shown in summary below.

• Access for all: We need to ensure that everyone in Scotland and those arriving into Scotland are aware of Test & Protect and can use the service if they need to or are asked to. Amongst other things, this will involve providing on and offline touchpoints. This includes ensuring materials are accessible and working with stakeholders to continue to share key messages with Minority Ethnic communities.
• Keeping communications simple: Citizens currently have reduced 'bandwidth' or processing capability due to the stresses of coronavirus – and thus to ensure clarity within this context, we need to keep communications simple and straightforward.
• Part of a larger whole: Communications on Test & Protectwill run alongside messages and campaigns around changes to restrictions and protection (FACTS) and that must be borne in mind when planning and implementing communications.
• Different voices: Due to the large variety of experiences that people have had during coronavirus, it will be valuable for communications activity to connect meaningfully with as many different groups of people and communities as possible.
• Compliance and behavioural insights: It is essential for the success of this campaign that people comply with the asks and we will enrol findings from the field of behavioural insights to do this.
• Optimisation: This project is doing something entirely new, making asks of citizens which have not been made before. Whilst we will use insights to inform our communications, we will also need to test and learn, optimising as we progress and responding to feedback from those delivering the programme. The delivery of the Test & Protect programme is also likely to change over time, so we may need to adapt future communications to reflect this.

Age

Data suggests older people are less likely to be digitally literate with the primary source of Test and Protect information online it was felt that older people, and some other groups with protected characteristics could be at a disadvantaged. Some older people may face barriers to understanding how Test and Protect works and what it intends to do as much of the information is online and refers to e-mails / text messages.

To try to ensure people of all age groups are able to access public messaging and advice relating to Test and protect:

• public media campaigns have been delivered across a range of media channels including television, radio and print
• hard copy leaflets have been provided on a range of aspects of Test and Protect including large scale door drop leaflet campaigns
• all services provided under the Test and Protect banner are provided with a non-digital route to ensure that people with lower digital literacy are able to access services

Disability

There is a clear need for availability of accessible information in a range of formats for each of pillar of the Test and Protect strategy. Testing can be unpleasant and intrusive and ensuring that people with reduced capacity to understand the nature and purpose of the test is important to reduce any distress and ensure cooperation. From the Mental Welfare Commission's local intelligence gathering (undertaken regularly by practitioners at the Commission), some areas have developed accessible information about Covid-19, including information and signage at test centres, particularly for people with a learning disability. They see the production of information nationally, in various accessible formats as a priority.

To ensure public messaging and guidance is accessible to disabled people:

• information in British Sign Language and Easy Read formats is available
• contact tracing and local authority support services use a range of communication services including British Sign Language interpretation to meet the needs of a broad range of people
• a wide range of information is provided in an Easy Read format to ensure that people with learning disabilities and autism who require that format can access the relevant public health information

Maternity / pregnancy

The Royal College of Obstetricians and Gynaecologists states that people who are pregnant do not appear to be more susceptible to coronavirus than the general population, although are generally more susceptible to infection generally[51]. If a pregnant woman contracts coronavirus during their pregnancy it is likely that they will not be more seriously unwell than other healthy adults, and that they will experience only mild or moderate cold/flu-like symptoms.[52] However, pregnant women are listed in the group of people who are at higher risk of developing severe illness with coronavirus. [53] Additional consideration should also be given to pregnant women who might have specific concerns about how Test and Protect information relates to them.

Ethnicity

People from minority ethnic groups may be disproportionately impacted in relation to the communications around Test and Protect if they are not provided in a language and format that is appropriate.

To this end, a range of actions have been undertaken including:

• recognising the challenges in ensuring that dynamic messaging remained up to date and the lead in time required for translation services, working in partnership with relevant stakeholders and translation services to ensure that accurate up to date information is available for people for whom English is not their first language
• consulting with public and third sector partners to understand language and accessibility requirements, and working collaboratively to create and disseminate this information about Test & Protect.
• Test & Protect Door Drop alternative languages/formats were also produced with the and translated into Arabic, Bengali, Farsi, Gaelic, Hindi, Hungarian, Latvian, Lithuanian, Kurdish Sorani, Polish, Punjabi, Romanian, Russian, Simplified Chinese, Slovakian, Traditional Chinese, Urdu, Easy Read, Audio, BSL, Large Print Format and Braille.[54]
• We have expanded the translations to include the following Test & Protect sections on nhsinform.scot/coronavirus:
  • Test and Protect
  • Coronavirus (COVID-19): Testing
  • Coronavirus (COVID-19): Contact Tracing
  • Coronavirus (COVID-19): Overseas Visitors: Testing and treating overseas
    visitors, asylum seekers and refugees
• To support the launch of the Protect Scotland App back in September, the NHS Translations Group shared launch information, highlighting accessible and translated information to their stakeholders. A separate interim EQIA on the proximity app is available in the Scottish Government website.[55]
• Work has been undertaken with policy areas across Scottish Government and Scottish Public Health Network (ScotPHN) to create a bespoke, printed Easy Read Version of Door Drop created specifically for the Gypsy/Traveller community, to be distributed by COSLA to Gypsy/Traveller sites.

Refugees and asylum seekers

A particular focus on the needs of refugees and asylum seekers and ensuring that information is made available to them through the networks - both statutory and third sector - may help to reduce inequalities within these communities.

A consultation exercise in December 2020 showed that local Authorities work together with volunteering organisations to meet the needs of this group and provides support to people within this community who are asked to self-isolate. We have ensured our guidance is available in easy read text and is translated into a wide variety of languages.

Additional support for language insights and further dissemination of information to vulnerable groups was provided by the Equality and Human Rights Manager, NHS Greater Glasgow & Clyde.

We are working across government, NHS Scotland and third sector partners to spread the message of available formats, with our outreach reaching 400+ organisations, which include: Scottish Refugee Council, NHS Lothian Minority Ethnic Inclusion Service (MEHIS), Refuweegee, Ubuntu Women's Shelter, British Red Cross, Bridges Programmes, Inclusion Scotland, Scottish Independent Living Coalition (SILC), Progress in Dialogue and Article 12. This was welcomed by a range of equalities groups.

Consultative activities related to communications and engagement

NHS Inform Translations Group – Public Health Scotland, NHS 24, NHSGGC and NHS Lothian

SG Marketing is currently working in partnership with NHS 24, NHS Lothian, NHSGGC and Public Health Scotland to translate key coronavirus sections of NHS Inform into multiple languages/formats. This group was established in early April and continues to meet fortnightly. The group works together to translate key coronavirus-related content on NHS Inform into the following languages: Arabic, Bengali, Chinese (simplified), Hindi, Polish, Punjabi, Romanian, Slovak, Spanish, Urdu, BSL, Easy Read and Audio. Consideration of languages/content is regularly discussed, and activities are updated according to recommendations.

Scottish Public Health Network (ScotPHN) Gypsy/Traveller Community

We have been working in partnership with the Scottish Public Health Network who have supported us to adapt Test & Protect information to make this more accessible to the Gypsy/Traveller community:

• Key considerations for the Gypsy/Traveller community include: traditional mail drop may not reach their homes; no broadband access in many households; low use of data on smartphones due to cost for Pay As You Go contracts; and the low literacy levels.
• Following past success with video explanations/testimonials featuring people from within the community, we created a Test & Protect Door Drop video, and we are currently creating a video for the Protect Scotland App.
• Co-created 3000 x Gypsy/Traveller Test & Protect Assets, including 2 x Easy Read leaflets bespoke for the Gypsy/Traveller community - delivered by hand to site managers in community through ScotPHN and COSLA.
• Scottish Government Marketing continues to work on Test & Protect alongside the Gypsy/Traveller community, and is currently working with a Health Inequalities Public Health Practitioner, COSLA and members of the community to create Easy Read and Video assets for the Protect Scotland App.

Minority Ethnic Carers of People Project (MECOPP)

Since early June the Scottish Government has also been working with Minority Ethnic Carers of People (MECOPP) - a charity that works with elderly ME communities where there is limited literacy in English, and potentially also in their mother tongue. Additional materials were created to address a need was identified for further information for this audience.

While Test & Protect information was available in Easy Read and audio, which could help some individuals with low literacy levels in English understand the process, it was identified that a video version of Test & Protect infographics with accompanying voiceovers were also required. These were created in Chinese, Arabic and Urdu.

MECOPP created additional languages of the Test & Protect Step by Step video, which was included in the Phase 3 Stakeholder Toolkit launched on 13 July, and these translated videos were shared with internal and external stakeholders.

The Protect Scotland App launch information was shared with MECOPP in September, highlighting accessible and translated information to their stakeholders. For the Protect Scotland App, MECOPP has agreed to share our Explainer video translated assets, and will also create additional translated versions based on the needs highlighted within their communities.

BEMIS

BEMIS has partnered with Scottish Government Marketing on Parent Club and Test & Protect activities, and have provided input and distribution channels for campaign assets and messaging. There are plans in place for further collaboration with BEMIS for the Protect Scotland App, and BEMIS has confirmed they will collaborate in the development of supporting materials and share this information across their main networks and membership across Scotland. This will include:

• Sharing resources through MEMO and MEMO plus publications
• Facilitate awareness sessions and training workshops with EM groups across Scotland
• Incorporate messaging into the Ethnic Minority National Resilience Network (EMNRN) which has been established in response to COVID19.

Additionally, in August Scottish Government Marketing presented inclusive communications activities to the Ethnic Minority National Resilience Network (EMNRN) which were established in response to the Covid 19. This group has over 84 member organisations from across Scotland.

Minority Ethnic health Inclusion Service, NHS Lothian (MEHIS)

In June, MEHIS highlighted the need for Test & Protect information for the Bangladeshi community. SG Marketing worked to create the Bengali versions of the Test & Protect Door Drop and FACTS poster for this community, and translated materials were shared by MEHIS.

RNIB

Scottish Government Marketing partnered with RNIB to produce, print and distribute Braille versions of the Test &Protect Door Drop towards in June. RNIB handles these requests, which are signposted to via gov.scot. A press release on the availability of Braille formats of Test and Protect information was published on 10 July.

Additional Partnership Translations (In-kind)

Easy Read Information

The Autism and Learning Disabilities Policy Team has been working closely with Scottish Government marketing to produce all key content in Easy Read format.

Test and Protect Translated Video Infographics

We have partnered with Minority Ethnic Carers of People (MECOPP), who work with ME communities where there is limited literacy in both English as well as their own language.

The Test & Protect Infographic Video that outlines the process was then translated by MECOPP and alternative voiceovers were created in specific ME languages that they have identified as key to their audiences: Chinese, Arabic, Polish and Urdu.[56]