COVID-19 and flu vaccination 2022 to 2023: equality impact assessment

Equality Impact Assessment: COVID-19 & Flu 2022-2023 Vaccination Programme

About this document

1. Section 149 of the Equality Act 2010 places a duty (known as the public sector equality duty, or PSED) on public authorities to have due regard to the need to eliminate discrimination, advance equality of opportunity and promote good relations betw2een people who share a protected characteristic and those who do not.

2. The Scottish Government introduced Regulations, (the Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012) which set out specific duties to enable better delivery of the PSED. Regulation 5 (5) of the Specific Duties requires that a listed authority must make such arrangements as it considers appropriate to review and, where necessary, revise any policy or practice that it applies in the exercise of its functions to ensure that, in exercising those functions, it complies with the equality duty.

3. The Scottish Government is mindful of the three needs of the Public Sector Equality Duty (PSED): eliminate unlawful discrimination, harassment and victimisation; advance equality of opportunity between people who share a protected characteristic and those who do not; and foster good relations between people who share a protected characteristic and those who do not. Where any negative impacts have been identified, we have sought to mitigate/eliminate these. We are also mindful that the equality duty is not just about negating or mitigating negative impacts, as we also have a positive duty to promote equality. We have sought to do this through provisions contained in the Regulations, or by current support and guidance available.

4. Therefore this Equality Impact Assessment has been carried out to ensure that the Flu and COVID-19 Vaccination Policy considers the needs above.

5. The vaccination programme is continually developing and responding to emerging clinical advice, and therefore this EQIA represents the position at Winter 2022. Given the impact of the COVID-19 vaccination programme on the population of Scotland, it is vital that inclusion and equality are firmly embedded at its heart. This approach is central to all aspects of work on the programme in order to reach everyone and ensure that no one is left behind, both for individual health and our collective community wellbeing.

6. This document details the policy aims and approach, the evidence reviewed and stakeholders consulted in development of this EQIA, an impact assessment for each of the protected characteristics, learning and next steps.

7. A key document that has been important helping us analyse the impact of the programme on inequalities to date is the ‘Extended flu and COVID-19 vaccination health inequalities impact assessment (HIIA)’^[1] by Programme partners Public Health Scotland.

COVID-19 and Flu Vaccine Policy Aims

8. The Joint Committee on Vaccination and Immunisation (JCVI) is an independent scientific advisory body charged with providing recommendations to all Governments within the UK, including on the safety and efficacy of vaccines. The advice provided by the JCVI and UK Chief Medical Officers (CMO) supports the government in the development of a vaccine strategy for the procurement and delivery of a vaccine programme to the population.

9. The safety of all vaccines and medicines is monitored by the Medicines and Healthcare Products Regulatory Agency (MHRA) on a UK wide basis.

10. COVID-19 and flu vaccines are a critical part of suppressing the viruses to the lowest possible level, in order to save lives, protect health and wellbeing, reduce health inequalities and maintain quality of life. The vaccines produce an immune response that we know reduces severity of illness, hospitalisation and death from the virus. It therefore makes a significant contribution to reducing the impact of the wider economic, educational attainment and work impacts of the pandemic on people, families and communities.

11. The COVID-19 pandemic has produced disproportionate impacts across a range of outcomes for a number of groups, including households on low incomes or in poverty, low paid workers, children and young people, older people, disabled people, certain minority ethnic communities and women^[2]. These groups and intersections between them have been considered in development of the policy approach and delivery.

12. Immunisation programmes are designed to help protect the population from serious vaccine-preventable diseases. The JCVI advises that the primary objective for this campaign is to augment immunity in those at higher risk from COVID-19 and flu, thereby optimise protection against severe illness, specifically hospitalisation and death, over winter 2022/23^[3]. The vaccination of health and social care workers is also advised, in order to optimise the benefits to the NHS arising from vaccine-induced protection against flu as well as Omicron symptomatic illness and transmission^[4].

13. Our aim is to deliver our vaccination programmes in a way that ensures no-one is excluded, in particular those most at risk from COVID-19 and flu. The offer of COVID-19 vaccination will remain open to those newly eligible, or those who have not yet taken up the offer of a vaccine, for both the initial programme and the booster programme. This offer will be reviewed regularly in line with JCVI guidance and the COVID-19 Green Book Chapter. The flu vaccination offer will end on 31 March 2023. The above is retrospective of the COVID-19 vaccination programme in 2022.

14. The COVID-19 and flu vaccination programme contributes to the delivery of the Scottish Government’s National Performance Framework Outcomes 3 and 10:

• 3. Ensure healthy lives and promote well-being for all, at all ages;
• 10. Reduce inequality within, and among countries.

15. The approach being taken focusses on ensuring that everyone who is eligible has the relevant information to make an informed choice about taking up the offer of vaccination against flu and COVID-19 this winter. Through delivery we aim to:

• Protect people in Scotland most at risk of harm from COVID-19 and flu through timely vaccination of flu and COVID-19 boosters;
• Ensure the programme is person centred and informed by those most at risk of inequalities in access to or uptake of vaccination.
• Support protection and recovery from COVID-19, minimising the need for non-pharmaceutical interventions;
• Reduce the pressure on the NHS; and
• Increase uptake rates for those most at risk of flu and COVID-19.

16. The complexity and pace of the COVID-19 vaccination programme has been unprecedented and progress has been remarkable. With the reduction in testing and removal of societal restrictions, vaccination remains our best route out of the pandemic. Whilst we continue to promote non-pharmaceutical interventions such as good hygiene practice and look at ways to protect society in future through Covid Ready Society, vaccination remains our best tool against severe illness. We continue to strongly encourage everyone who has not already done so to come forward and get fully vaccinated.

17. For detail on earlier parts of the programme, please refer to the Flu and COVID-19 vaccination programme - autumn/winter 2021-2022: equality impact assessment, published 29 October 2021.

18. On 15 July the JCVI announced that a Winter COVID-19 booster dose be offered to the following groups, to protect those most vulnerable to severe illness, hospitalisation and death, whose protection may have waned over time:

• Frontline Health and Social Care Workers
• Residents & Staff in care homes for older adults
• Persons aged 50 and above
• Person aged 5-49 in a clinical risk group
• Persons aged 5-49 who are household contacts of the immunosuppressed
• Carers aged 16-49

19. The CMO letter of 5 May 2022 confirmed Scotland’s flu cohorts for Winter 2022. Flu vaccination is being offered to the same extended cohorts that were agreed in 2021:

• Frontline Health and Social Care Workers
• Non-frontline NHS staff
• Residents & Staff in care homes for older adults
• Persons aged 50 and above
• Person aged 5-49 in a clinical risk group
• Persons aged 5-49 who are household contacts of the immunosuppressed
• Carers & young carers
• Children aged 6 months to 2 years with an eligible health condition
• All children aged 2 to 5 years (not yet at school)
• All primary and secondary school pupils
• Nursery, primary and secondary school teachers and pupil-facing support staff in local authority or independent settings
• Prison population, prison officers and support staff who deliver direct front-facing detention services

20. The COVID-19 and flu vaccination programme has a potential impact on almost everyone in Scotland. The scope of this equality impact assessment, therefore, is extended beyond the list of protected characteristics to include wider socio-economic considerations: including people living in remote, rural areas and island communities; in areas of multiple deprivation; prisoners; migrant workers; those with substance misuse issues, and those who sell or exchange sex.

21. As the COVID-19 Vaccination Programme progressed through the younger cohorts, the Scottish Government completed a Children’s Rights and Wellbeing Impact Assessment (CRWIA) covering the period up to spring 2022. This is currently in the process of publication. A new CRWIA for the Winter 2022 Programme has also been produced.

Approach

22. Evidence^[5] from the UK, and the JCVI advice, indicates that the risk of poorer outcomes from COVID-19 infection and flu increase dramatically with age in both healthy adults and in adults with underlying health conditions. Those over the age of 65 years have the highest risk, with the risk increasing with age. Additionally, the JCVI and WHO consider frontline health and social care workers who provide care to people at highest risk of severe illness a high priority for vaccination.

23. Scottish Government’s overall approach is set out in more detail in these published plans:

• COVID-19 Vaccine Deployment Plan January 2021
• COVID-19): vaccine deployment plan 2021
• COVID-19: vaccine deployment plan: update - July 2021
• COVID-19: Scotland's autumn/winter vaccination strategy 2021
• Scotland's autumn and winter vaccination strategy: progress report and accelerated delivery plans - December 2021
• COVID-19 Vaccine Deployment Plan September 2022

Impact Assessment for Winter 2022

Age

24. The vaccination programme approach is guided by JCVI advice on prevention of severe illness and mortality and the functioning of health and social care systems. This prioritises people primarily due to their age and other clinical risk factors.

25. Data analysis continues to show that COVID-19 disproportionately affects those in older age groups. Older people undergo hospital admissions with COVID-19 at a higher rate than younger people. As of 3 October 2022, people aged 75-84 were admitted to hospital with COVID-19 at a rate of 2,957 admissions per 100,000 population, and for those aged 85 and over, the rate was 4,954 admissions per 100,000 population. This compared to a rate of 908 admissions per 100,000 population for people aged 45-64^[6]. As of 2 October 2022, more than two thirds (70%) of all deaths involving COVID-19 were in people aged 75 or over^[7]. There is a higher ratio of women to men in older age groups, reflecting women’s longer life expectancy. For example, women make up 64% of people aged 85+ in Scotland^[8].

26. In terms of COVID-19 vaccination uptake, those in the older age brackets are more likely to receive their vaccination.

* Table correct as of 12 September 2022

Those most at risk as a result of their age have been offered vaccination early throughout the various phases of the programme and have again been prioritised as part of the Winter 2022 programme. Evidence shows that younger people with no underlying health conditions are less at risk from severe illness, hospitalisation and death from COVID-19. Those under the age of 50, with no underlying health conditions, are not being offered a COVID-19 booster vaccination this winter, and the 50-64 age bracket are the last group to be offered a vaccine as part of this winter campaign.

27. Primary schools in Scotland have successfully supported the flu immunisation programme since 2014. Flu can be serious and life-threatening, even for healthy children. The aim is to reduce the risk of children and young people spreading flu to friends and family and to help prevent the flu virus adding additional strain on our NHS services through the winter. To support this aim, the flu eligible groups were expanded in 2021 and remain in place for the Winter 2022 programme. The flu vaccination programme is available to:

• Children aged 2 to 5 years and not yet at school (children must be aged two years or above on 1 September 2022 to be eligible);
• Primary school children (primary 1 to primary 7);
• Secondary school pupils (years 1 to 6);
• Home educated children of primary and secondary school age.

28. Lower vaccine uptake in younger age groups may be driven by their perceived lower risk from COVID-19 and flu, with a considerable clinical focus on those in older age groups or those with underlying health conditions. Communications and marketing materials continue to highlight the benefits of vaccination across all age groups, such that individuals can make an informed choice on vaccination when it is offered to them.

29. We have continued to use analysis and feedback from previous parts of the programme to inform and improve how we appoint people. Digital preference and literacy tends to decrease with age, so we have appointed all those aged 65 and over and sent them this appointment via letter. We have retained the National Vaccination Helpline for those who are more comfortable talking to someone, rather than rescheduling online. We have also attempted, where possible, to offer a range of appointment venues and types to cater for older individuals such as housebound vaccinations and local venues, including community pharmacies.

Disability

30. Around a third of adults living in Scotland reported a limiting longstanding health condition or illness in the 2017 Scottish Health survey, with 29% of men and 34% of women in Scotland reported living with a limiting long-term condition. For people aged 75 and over, 56% had a limiting long-term condition^[9]. 1 in 5 Scots identify as disabled and more than a quarter of working age people report having an impairment^[10].

31. There is significant evidence of the negative impact that the COVID-19 pandemic has had on disabled people. A study by YouGov and the BBC among people in the UK living with disabilities in 2020, found that almost half (47%) were unable to socialise, a third (36%) were unable to access medical appointments because of COVID-19 and just over a quarter (27%) were unable to carry out essentials such as food shopping^[11]. We know that the COVID-19 pandemic has produced disproportionate impacts across a range of outcomes for a number of groups, including households on low incomes or in poverty, low paid workers, children and young people, older people, disabled people, minority ethnic groups and women. Several of these groups can intersect, resulting in a magnification of the negative impacts experienced. 

32. Given the considerable proportion of the Scottish population that lives with disability and the significant impact of the COVID-19 pandemic, access to the individual and public health benefits of vaccination are important. People who are clinically extremely vulnerable or have particular health conditions are eligible for a flu and COVID-19 vaccine as part of Winter 2022 and are called after the 65+ age group. This does not, however, include all people with disabilities and not everyone with pre-existing medical conditions is disabled.

33. Earlier in the programme, the JCVI gave specific advice on those with learning disabilities^[12]. This was subsequently augmented by additional guidance for vaccination of people with learning disabilities in Scotland^[13]. The JCVI advice and Green Book definition of those with a learning disability was widened in August 2022 to include all those on the learning disability register^[14]. Scotland does not specifically operate a learning disability register and the reference mainly relates to the register in England. In England, anyone with a learning disability can request that their GP add them to the list, regardless of severity. In identifying those who are eligible in Scotland, we have applied the same criteria to our own data.

34. Programme delivery continues to seek to address specific issues that are more likely to affect disabled people, for example:

• accessible vaccination venues, e.g. for people who use wheelchairs or have sight loss;
• proximity to a suitable vaccination centre;
• availability of transport assistance;
• availability of information in accessible formats and languages including British Sign Language (BSL);
• elimination of other communication barriers;
• the provision of quieter spaces, allowing more time for appointments, smaller clinics and appropriately trained staff to support the needs of people with Learning Disabilities, Autism Spectrum Disorder (ASD), Sensory Impairments and mental health conditions;
• consideration of the needs of people with mobility impairments or mental health conditions who may be unable to leave their home to attend an appointment;
• provision for the needs of people who may require to attend the vaccination appointment with support (paid/unpaid carer, family member, friend, interpreter, guide support etc.);
• access to digital and non-digital information and services; and
• consideration of the needs of those who may be experiencing anxiety or needle phobia at their appointment.
• Learning and engagement with stakeholders throughout the programme has led to a commitment of embedding more of the above measures and making translation and transport information easy to access. The collection of disability data to support the design and monitoring of Scotland’s public health approach to immunisation is also being considered.

Sex / Gender

35. Data analysis continues to show that COVID-19 disproportionately affects men in terms of hospital admissions and mortality rates. As of 3 October 2022, men were admitted to hospital with COVID-19 at a rate of 981 admissions per 100,000 population, and for women the rate was 876 per 100,000. As of 2 October 2022, 52% of deaths involving COVID-19 have occurred in men versus 48% in women. This percentage varies by age, with a higher percentage of deaths occurring in males in the 15-44, 45-64, 65-74 and 75-84 age categories (56%, 61%, 59% and 55% respectively), but a lower percentage than females in those aged 85 and over (43% for males and 57% for females)^[15].

36. Consideration has been given through the programme to the location, appointment timings and travel to vaccination clinics to ensure people with different working and caring responsibilities are not excluded. Information has also been updated to make it clear that individuals can bring their children or people they care for to their appointment. Our digital booking portal and the National Vaccination Helpline has continued to evolve, making it as easy as possible for people to change the time, date and location of their appointment.

37. As the programme has progressed and we have moved out of lockdown, the type, number and location of clinics has changed depending on the eligibility of individuals for vaccination. With a smaller group of people being eligible for vaccination in Winter 2022 than the previous year, and the fact that many venues have now returned to their original use, the model has pivoted away from mass vaccination sites towards small to medium community clinics. There are over 400 sites in use across Scotland for this programme. These smaller style venues tend to be the preference for many with additional barriers. Health Boards are operating a flexible model that includes scheduled clinics and drop-ins, depending on previous demand and uptake in local areas. Improvements to the scheduling system ensure that people will be booked into the clinic closest to their home address, irrespective of Health Board boundaries, with the option to rebook to other venues such as those nearest to their place of work, or where is most convenient for them.

38. Vaccination uptake data has continued to be monitored. Data suggests that uptake of the COVID-19 vaccine does not vary greatly by sex, with both female and males showing 75-80% uptake. As we descend in age groups, uptake among men is lower than women between the ages of 16 and 39 for doses one, two and three (data correct as per the PHS Dashboard^[16], as of 13 September 2022).

Pregnancy and Maternity

39. In December 2021, data from the UKOSS and MBRRACE-UK studies indicated that clinical outcomes following COVID-19 in pregnant women had worsened over the course of the pandemic, and the majority of pregnant women admitted to hospital with COVID-19 were unvaccinated. Women who are pregnant are considered to be in a clinical risk group within the COVID-19 vaccination programme. Unvaccinated women who become pregnant are strongly encouraged by the JCVI to come forward for vaccination. Women who are pregnant and have previously been vaccinated will be offered a booster dose as part of the Winter 2022 programme. They are also eligible for the flu vaccination.

40. In order to maximise uptake and protection for pregnant women as part of the Winter 2022 programme, the preferred approach to the vaccination is for co-administration of both flu and COVID-19 vaccines by midwifery teams at existing appointments. The Chief Midwife of Scotland has endorsed this approach and where possible Health Boards are asked to offer co-administration with seasonal flu within their local arrangements, where practicable.

41. There has been some evidence of disinformation campaigns and women not coming forward for vaccination due to concerns around fertility. Specific advice to address these concerns has therefore been included in the following resources:

• PHS: Vaccines in pregnancy | Ready Steady Baby!
• PHS: Royal College of Obstetricians and Gynaecologists (RCOG): Vaccination | RCOG
• People should be given the PHS and RCOG leaflets by maternity services before they attend for vaccination and encouraged to read both leaflets. Both PHS and RCOG leaflets highlight that the vaccine is safe at any stage of pregnancy or fertility treatment. Additionally, the RCOG leaflet notes that some women may choose to delay their vaccine until after the first 12 weeks – reflecting that some women may wish to limit all risk during the first trimester of pregnancy. A range of new resources have been produced, including posters and social media assets. Pregnancy vaccine resources - Publications - Public Health Scotland

42. Figures from the COVID-19 in Pregnancy in Scotland (COPS) study reveal that, between December 2020 and July 2022, 30.8% of pregnant women received at least one COVID-19 vaccination dose.^[17] As a comparator against the population, as of 1 August 2022, 95.0% of the population aged 12 and over had received at least one COVID-19 vaccination dose^[18]. However, updated statistics from PHS’s COVID-19 Statistical Report September 2022 shows that of the 3,631 women who delivered their baby or babies (in the case of a multiple pregnancy) in July 2022 2,842 (78%) of the women had received at least one dose of COVID-19 vaccination prior to delivery, with 2,636 (73%) of the women having received at least two and 1,733 (48%) having received three or more doses which shows that the number of women being vaccinated had steadily risen since July 2022 ^[19].

Sexual Orientation and Trans Gender

43. No differential impacts have been identified; however many Health Boards have worked pro-actively with LGBTIQ+ organisations to ensure local arrangements are accessible and welcoming to this population and to address any issues of trust.

44. Scottish Government worked with the Scottish Trans Alliance to ensure that trans people are receiving the correct information about the programme and prepared a frequently asked questions document to support people with the self-registration systems. We are also supporting call handlers on the National Vaccination Helpline to provide the appropriate information to ensure trans callers are treated with dignity and respect.

Race and Ethnicity

45. The PHS Health Inequalities Impact Assessment (HIIA) and PHS FVCV programme evaluation report June 2022: ‘Factors affecting uptake of the COVID-19 vaccine: Learning from the flu and COVID-19 vaccination’^[20] identified a number of potential issues affecting access to vaccination and uptake relating to race and ethnicity. This included lack of trust in organisations promoting the vaccine; lack of available information which is culturally and linguistically appropriate; lack of flexibility in vaccine appointments and perceived harms from vaccine promoted via social media (especially in the Polish community).

46. The programme approach has been to consider these issues and to constantly adapt to intelligence and data regarding uptake in consultation with third sector and community groups. Initial activity included:

• Informed consent materials are available in 25 different languages on NHS Inform and in accessible formats such as Easy Read, BSL and audio;
• QR codes on all vaccination appointment letters which direct individuals to this information so they are fully informed ahead of their vaccine;
• Ongoing stakeholder relationships have helped shape our marketing activities and better reach communities via their trusted voices, such as community leaders and influencers;
• Close working with BEMIS, the national umbrella body supporting the development of the Ethnic Minorities Voluntary Sector in Scotland;
• Development of the COVID-19 Vaccine NHS Scotland Explainer Video was informed by third sector and community partners. It provides key facts about the COVID-19 vaccines for those who may have questions or concerns, or for those more likely to have been exposed to myths or misinformation. It is available in 19 languages and a range of formats;
• NHS Inform have also started to pilot direct page translations, beginning with Polish;
• Local Health Boards have continued to work with relevant communities, understanding concerns and making vaccine accessible at locations suitable to those communities.

47. PHS began publication of vaccination uptake broken down by ethnicity and deprivation on 24 March 2021 and was included periodically in the weekly COVID-19 statistical reports^[21]. For Winter 2022, PHS will provide a breakdown of vaccination uptake data by ethnicity and deprivation at two points in the programme. This in-depth analysis will assist Scottish Government and Health Boards in monitoring the impact of Boards inclusivity plans and how they can more effectively target resources to reduce health inequalities amongst particular groups and geographical areas.

48. Data reveals that from the beginning of the programme, uptake among African, Black, Caribbean, Polish and Gypsy/traveller communities has been significantly lower than the general population, with individuals from these communities almost a third less likely to take up the offer of vaccination.

49. This has been a catalyst for specific national and local level activity to understand the real time concerns or constraints of ethnic minority groups and seek to address them. PHS also facilitated ‘Inclusion Sharing Sessions’ for Health Boards where they were able to share information about approaches that had worked well with particular groups and communities. One session was specifically around the work with Polish and Gypsy Traveller communities. Some of the resulting activity that has been built into Health Boards inclusion plans for Winter 2022 including but not limited to the following:

• Polish Community:
  • PHS, NHS Inform and Health Boards offer materials in multiple languages and formats, including Polish with NHS Inform having developed a Polish page translation facility.
  • Health Boards operate a range of different interpreter services on helplines and at vaccination centres.
  • Boards with Polish communities created links earlier in the programme, that they are using to disseminate information on the Winter 2022 programme.
  • NHS Tayside’s communications go out in multiple local languages, including Polish. They have also developed links with local Polish businesses, local churches and faith communities, who help the Boards refine and target their messaging.
  • NHS Highland also have good links to the Polish faith community and work with the Polish Society to encourage uptake. They also surveyed this community for previous parts of the programme, to help target and develop messaging.
  • Some Boards, including NHS Lanarkshire have links with Feniks, a grass-roots charity that supports Central Eastern Europeans communities in Scotland.
• Gypsy / Traveller Communities:
  • NHS Highland offer vaccination at traveller sites throughout the Highlands. They also developed a tailored flyer designed with the Minority Ethnic Carer of People Project (MECOPP) and promote a YouTube video for this community on their website.
  • NHS Lothian have targeted outreach activity at known large traveller sites, encouraging people to book via the portal or helpline, or sometimes giving vaccination at sites via their Health and Social Care Partnership (HSCP) Teams. They have also partnered with MECOPP and Streetwork.
  • Several Boards, including NHS Greater Glasgow & Clyde, are using support from the Scottish Ambulance Service (SAS) to offer vaccinations within traveller sites, with support from community leaders.
• African, Black and Caribbean Communities:
  • Boards have made good links with local community and faith leaders and produced materials in a range of different languages, where needed.
  • Some Boards enlisted the help of local clinicians from these communities to produce videos or social media posts explaining the benefits of vaccination and dispelling certain myths that were prevalent within certain African communities.
  • We also continue to work closely with various research projects, recently contributing to ‘Scotland African Voices: COVID-19 Vaccine Debate’ film by Dr Adekola from the University of Glasgow.

50. Working with the Expert Reference Group (ERG) on COVID and Ethnicity it was agreed that data on ethnicity would be requested from people as part of future vaccination programmes.

51. The COVID-19 and Flu programme commenced the collection of ethnicity data of adults in November 2021 through the ‘Vaccine Management Tool’ (VMT) that was created as part of the Covid-19 response, for recording Covid-19 and flu vaccinations. Previously ethnicity data was linked to vaccination through other datasets, which meant the data was not always complete or reliable. This information is used for statistics, research and public health planning. The Census 2022 categories are used for this collection in line with the ERG recommendations. The ethnicity question is a mandatory field and includes an option for people to select ‘prefer not to say/don’t know’. If someone wishes to record their ethnicity as a group not listed, then they can do this through the write-in option. The data is collected once through either the online booking portal, national vaccination helpline or at point of vaccination.

52. For Winter 2022, collection of this data has been expanded to include all those of secondary school age. Guidance and training for vaccinators around approaching these questions is available on the online TURAS platform and the Winter 2022 CMO letter reiterated our commitment to collecting this data and its importance in monitoring and improving health inequalities.

53. At the National Vaccine Inclusive Steering Group, convened by the Scottish Government’s Vaccine Inclusion Team, available data is shared with stakeholders and their feedback continues to inform policy and approach. The group’s membership includes, among others, representatives of Health Boards, faith groups, third and community sector. The group advises on inclusive policy and delivery and is a forum for a range of partners to share practice and learning.

Religion or Belief

54. The PHS HIIA identified vaccine ingredient information and the potential to hold vaccination clinics in places of worship as two important aspects of confidence of the programme among religious groups.

55. From the programme outset, SG and PHS have engaged with faith leaders and representatives asking for support to promote the vaccination programme within communities as well as seek their advice on any adaptations to delivery that should be made to enable people to receive and take up their offer of vaccination. A number of faith leaders have publicly endorsed the vaccination programme.

56. Through partnerships built between Scottish Government, Public Health Scotland, local health boards and faith leaders:

Vaccinations continue to be offered in places of worship during the Winter 2022 programme, including Glasgow Central Mosque, local parish churches and numerous village halls and community centres, attached to places of worship;

PHS has produced information on vaccine ingredients Coronavirus (COVID-19) vaccine leaflets | NHS inform

An updated fatwa has been shared from trusted Muslim faith leaders to address childhood flu vaccine concerns for Winter 2022.

Deprivation

57. The recent PHS uptake report found lower uptake in Scotland’s more deprived communities. As of 3 May 2022, 81.2% of those aged 12 and over in the least deprived areas had received their second dose of vaccine for COVID-19 as compared to 69.4% in the most deprived areas. For dose 3 across those aged 16 and over, this figure is 76.2% and 56.1% respectively.

58. The evaluation report showed that those in the most deprived areas were only around half as likely to take up one for more doses of the COVID-19 vaccine, when compared to those in the least deprived areas. The report recommended further research to fully explore the factors contributing to this. Boards have implemented strategies throughout the COVID-19 programme to try and reduce this inequality, based upon the recognised factors that can limit uptake.

59. Various PHS reports, including ‘Factors affecting uptake of the COVID-19 vaccine: Learning from the flu and COVID-19 vaccination’ and ‘Evaluation of the COVID-19 vaccination programme 2020/22 report’ identify access to venues and digital access as potential issues affecting people living in areas of multiple, social and economic deprivation.

60. One factor identified was transport costs. Many Boards have offered local transport options for people that cannot afford travel and have located clinics in areas of deprivation for ease of access. They continue to utilise mobile outreach units to offer pop-up clinics in targeted locations of deprivation and poor uptake.

61. Childcare was recognised as a potential barrier and for Winter 2022 the invite letter made it clear that children can accompany adults to their vaccination appointments.

62. Digital provision and literacy were further identified as a potential barrier. To mitigate this, all those eligible were sent a letter in the post, with the option to rebook via the online portal, or via the National Vaccination Helpline for those who preferred non-digital options. A vaccination information leaflet to support informed consent was also included, such that individuals did not need to go online to receive further information about the vaccination offer.

63. The demographics and age within the most deprived communities in Scotland is significantly different from that within the most affluent communities. This plays out in a marked difference in life expectancy, with the onset of ‘diseases of old age’ occurring around 15 years earlier. Therefore, an age-based approach may disadvantage people from the most deprived neighbourhoods.^[22] JCVI advice allows for local flexibility to mitigate health inequalities.

64. More in-depth PHS data on uptake in relation to Scottish Index of Multiple Deprivation (SIMD) will allow Boards and Scottish Government to further analyse inequality in uptake and to target health and communications research. Examples of Boards proactive work to encourage uptake in areas of high SIMD include:

• Following on from an initial pilot undertaken in the spring 2022 campaign, NHS Tayside provided additional winter booster clinics in 2 community centres in deprived areas of Dundee for those aged over 75. These clinics reduced the number of domiciliary visits and increased uptake in these areas by providing easier access for those with reduced mobility or otherwise unable to travel into the city centre to attend our main central clinic. In Angus and Perth & Kinross NHS Tayside also provided a greater number and spread of rural weekend clinics, including in more deprived areas. The same Dundee and outlying community venues have also been utilised to deliver COVID-19 vaccinations to eligible children's cohorts. Additionally, the Tayside routine children's programme, including pre-school flu, is well established in a wide range and distribution of health and other venues throughout the region, many based in areas of higher deprivation.
• Multiple Boards have used spare call capacity at the National Contact Centre to proactively call individuals in areas of high SIMD to remind then to attend their appointment, resulting in increased uptake and decreased “did not attend” (DNA) rates.
• NHS West Lothian had good success with targeted pop-up clinics in areas of high SIMD.
• NHS Ayrshire & Arran spent time visiting food banks and speaking to users and building trust, before bringing their outreach bus for vaccination sessions.
• The SG National Comms Team have been working with Deep Dive GPs in areas of high deprivation to help promote vaccination in these areas for Winter 2022 and for future immunisations.

Substance Misuse & Homelessness

65. In March 2021, the JCVI advised that people experiencing homelessness, including those sleeping rough, should be prioritised for the COVID-19 vaccine. Subsequently, NHS Boards were encouraged through the programme CMO letter, to use their local judgement to vaccinate people experiencing homelessness, in temporary accommodation and rough sleeping. A significant proportion of these individuals will have underlying chronic medical conditions and are at high risk of both flu and COVID-19 related complications. This approach had the support of the Scottish Government.

66. The same CMO letter, with Scottish Government support, stated that Boards could use the same principle for those experiencing drug and alcohol misuse, as they too are likely to have underlying chronic medical conditions and are at increased risk of both COVID-19 and flu.

67. This policy continues for Winter 2022 and Health Boards continue to work with substance misuse health teams, general practices for the homeless, local authority teams and third sector providers to identify eligible individuals and direct them towards vaccination opportunities.

68. Some specific initiatives include work from Boards who are offering vaccination to those with substance misuse issues via pharmacies that provide opiate replacement therapies. NHS Forth Valley have good links with the 55 community pharmacies in the Board providing flu vaccination, who can then refer eligible people to COVID-19 vaccination sites. NHS Tayside also offers drop-in clinics in harm reduction sites in their major urban centres.

Other Factors Impacting on Equality

69. Progress on the COVID-19 vaccination programme has been unprecedented and every opportunity has been made to take a national collective approach and improve the offer to the public, for example, the introduction of digital systems in addition to letters and phone line. In addition to the above impact assessments, specific approaches have been taken to ensure that the following eligible groups are not excluded from the programme as a consequence of their particular circumstances.

Prisoners

70. For previous phases of the programme, Scottish Government and PHS created tailored resources on informed consent for prisoners. A prisoner ‘door-drop’ letter from clinicians was sent to each prisoner with accompanying leaflets outlining what to expect after vaccination and information about vaccine safety. The SG National Clinical Director attended HMP Barlinnie for a Q&A session with prisoners which was available via prison radio and TV. Prisoners due to be released were given leaflets in liberation packs encouraging them to receive second doses in the community and information on how they can do this.

71. For Winter 2022 all prisoners are eligible for flu vaccination, with those aged over 50 or those who have underlying health conditions also eligible for a COVID-19 vaccine. Different Boards have different arrangements in place with individual prisons. Some are delivering the vaccination programme through outreach teams that visit the prison, whereas others are being delivered in-house by prison healthcare teams. PHS produced updated tailored leaflets to support informed consent and provide information on what to expect after your vaccination for the prison population for the Winter 2022 programme. Leaflets have been delivered to every prison in Scotland based on their population size.

Refugees and asylum seekers

72. PHS co-produced the COVID-19 vaccine videos ‘Statement of Facts’ in partnership with the Scottish Refugee Council with films of community representatives reading vaccine information in their own languages. Clear messaging and reassurance are provided to undocumented migrants that NHS Scotland does not pass personal details to the Home Office for the purpose of immigration enforcement and that immigration checks are not required to access vaccination. The ‘Statement of Facts’ has been updated during 2022 to support the Winter 2022 Programme, with animations being created in a range of languages, developed in partnership with the Scottish Refugee Council.

73. Health Boards with refugee and asylum seeker populations are partnering with local authority refugee and resettlement teams and third sector organisations to reach out to these individuals. There are a range of materials in associated languages. NHS Highland also conducted some specific survey work with their Syrian refugee population.

Afghan Relocation and Assistance Policy

74. A number of people from Afghanistan have arrived in Scotland under the Afghan Relocation and Assistance Policy (ARAP) scheme. This was an emergency response to the situation in Afghanistan, whereby people who worked for British institutions, particularly the military, were offered relocation to the UK because of the risks they faced as a result of their service to the UK. Although many of the people coming to the UK speak good English, this is not universal, particularly among family members. COVID-19 vaccine information is available on NHS Inform in the two main languages used in Afghanistan, Dari and Pashto. Various Health Boards have established links with colleagues in primary care, local authorities and HSCPs to support development of pathways for eligible members of Afghan resettled families.

Ukrainian refugees

75. Scotland is a super sponsor for those fleeing the conflict in Ukraine. PHS have developed assets and materials in Ukrainian that have been distributed to resettlement teams. They have also been distributed to the two cruise ships docked in Edinburgh that are housing some of those displaced by the war in Ukraine. NHS Lothian are working with the refugee and resettlement teams to facilitate vaccination for this community.

Impact Monitoring and Mitigation

What might prevent the desired outcomes being achieved?

• Achieving the desired short and long term aims of the policy is dependent on the effectiveness of the COVID-19 and Flu vaccines that are produced and distributed to the people of Scotland. There are multiple dependencies which may prevent such an outcome. These are, but not limited to:
• vaccine efficacy and/or immunogenicity in different age and risk groups;
• the safety of administration in different age and risk groups;
• the effect of the vaccine on acquisition of infection and transmission;
• the transmission dynamics of the SARS-CoV-2 virus in the UK population;
• the epidemiological, microbiological, and clinical characteristics of COVID-19, in particular, emerging variants and the effect of the vaccine on these variants and any vaccine escape;
• secure supply of effective vaccines, including the impact of challenges with development, manufacture and logistics which may be affected by geopolitical issues;
• the storage, transportation and pack down of available COVID-19 and Flu vaccines
• the lack of single dose COVID-19 vials which would facilitate opportunistic vaccination for example in primary care and community pharmacy settings; and
• inequitable access to and uptake of the vaccine across the Scottish population.