Flu and COVID-19 vaccination programme - autumn/winter 2021-2022: equality impact assessment

Annex B: Development of this EQIA

Evidence reviewed

108. Public Health Scotland (PHS) carried out a Health Inequalities Impact Assessment (HIIA) in November 2020^[29]. The HIIA identified how population groups could be differentially impacted by the COVID-19 population vaccination programme. Complex factors such as race, ethnicity, age, religion, disability and socio-economic differences interact at a structural, community and individual level to impact people differently. The groups considered in this work included:

• Age - older people; middle years; early years; children and young people
• Disability - physical, sensory and learning impairment; mental health conditions; long-term medical conditions
• Gender reassignment - people undergoing gender reassignment
• Marriage and civil partnerships - people who are married, unmarried or in a civil partnership
• Pregnancy and maternity - women before and after childbirth; breastfeeding
• Race and ethnicity - minority ethnic people; non-English speakers; gypsy/travellers; migrant workers
• Religion or belief - people with different religions or beliefs, or none
• Sex - men; women; experience of gender-based violence
• Sexual orientation - lesbian; gay; bisexual; heterosexual
• Looked after (including accommodated) children and young people
• Carers - paid/unpaid, family members
• People experiencing homelessness - including those rough sleeping staying temporarily with friends/family; in hostels, B&Bs
• Involvement in the criminal justice system - offenders in prison / on probation, ex-offenders
• Substances misuse / people experiencing alcohol or drug dependence
• Staff - full/part time; voluntary; delivering/accessing services
• Low income
• Low literacy / health literacy - includes poor understanding of health and health services as well as poor written language skills
• Living in deprived areas
• Living in remote, rural and island locations
• Discrimination/stigma
• Refugees and asylum seekers

109. The HIIA made a number of recommendations that aimed to improve impacts on health and enhance actions to reduce health inequalities, avoid discrimination and take action to improve equality and enhance human rights. Recommendations covered topics including communications, information materials, invitations, appointments, partners, promoting uptake, advice to professionals, and data and research. This assessment has helped to inform the development of this EQIA, the national COVID-19 and flu vaccination programmes, and the work of health boards at a local level in planning and delivery.

110. PHS carried out research over summer 2021 to refresh the HIIA drawing on the experiences and lessons learned during Tranche 1. A revised HIIA is expected to be published in October 2021.

111. Further evidence of the need for tailored approaches has also come from:

• Voluntary Health Scotland (VHS)
• UK research suggests 72% Black or Black British and 42% of Pakistani and Bangladeshi respondents reported being unlikely/very unlikely to be vaccinated.^[30]
• A University of Cambridge study showed that vaccine hesitancy was associated with younger age, women, lower income and ethnicity.^[31]
• Research from SAGE has shown that barriers to vaccination among minority ethnic groups include perception of risk, confidence in vaccine, distrust, lack of communication from community leaders, access issues, inconvenience, and socio-demographic context.^[32]
• The four nations Chief Medical Officers meeting of 2 February agreed there is a need to improve vaccine uptake in Minority Ethnic communities.
• COVID-19 Vaccine Deployment for Marginalised Groups in Scotland, The Scottish Deep End Project, April 2021.^[33]
• The Coronavirus (COVID-19) Vaccine Deployment Plans – update- March 2021. ^{[34] [35]}
• Public Health Scotland equalities statistical report^[36] and Supporting data ^[37]
• A survey of over 7,000 frontline health and social care workers' in Scotland found that those who had decided not to take up the vaccine were proportionately more likely to be young, female and social care workers. Reasons for not being vaccinated centred around worry about long- and short-term side effects; lack of belief of the danger of the virus for them; and issues surrounding pregnancy and fertility.^[38]

112. An update to COVID-19: Scotland's Strategic Framework (first published on 23 October 2020) was published in February 2021^[39], in which the Scottish Government re-confirmed its strategic intent to "suppress the virus to the lowest possible level and keep it there, while we strive to return to a more normal life for as many people as possible." It described six key tools for achieving this: including 'The quickest practical roll-out of vaccinations, in line with advice from the Joint Committee on Vaccination and Immunisation (JCVI)'

113. In the latest Coronavirus (COVID-19): Scotland's Strategic Framework update – June 2021^[40], the First Minister, Nicola Sturgeon said

'We have come a long way in the battle against COVID-19. Progress has been achieved through extraordinary developments in science, in healthcare and in the sacrifices that we have all made together. In particular, the success of our vaccination programme has been above and beyond expectations. However, the virus is still out there, it is still mutating and it is still harmful. So we must all follow through with our second dose of the vaccine to make sure of the best possible level of protection'.

114. Immunisation policy in Scotland is set by the Scottish Ministers, guided by advice of the JCVI, SAGE, Public Health Scotland and the Chief Medical Officer^[41].

Stakeholders engaged

115. Public Health Scotland undertook extensive stakeholder engagement as part of developing the Extended Flu and COVID-19 Vaccination Health Inequalities Impact Assessment (HIIA) November 2020. Scottish Government took part in the engagement exercise in order inform policy making and this EQIA. Scottish Government officials also engaged directly with:

• Older People's Strategic Action Forum
• Disabled Person's Organisations
• Ethnic Minority Resilience Network
• Radio Awaz
• BEMIS
• MECOPP
• Gypsy travellers
• Carers groups
• Trade unions
• Faith community partners group

116. Many of the members of these groups covered intersections, for example LGBTI+ older people; ethnic minority carers.

117. To ensure a strong voice for equalities groups and representatives, and provide greater leadership to inclusion and equalities as part of the Flu and COVID-19 vaccination programme, a National Vaccine Inclusive Steering Group was established in March 2021. Its purpose is to provide feedback, challenge, ideas and to advise on planning, communications and delivery of the programme. Membership includes faith, community and third sector organisations; umbrella bodies such as Voluntary Health Scotland; health professionals including GPs working in practices in deprived areas, PHS, NHS boards, Scottish Ambulance Service; relevant SG policies; and minority ethnic communities. Membership of the steering group includes representatives from:

• SG Expert Reference Group on COVID and Ethnicity
• Public Health Scotland
• Health Boards
• Local authority/COSLA
• Chief Officer representatives
• General Practice, including from GPs working in practices in deprived areas
• BEMIS
• The African Council
• Scottish Refugee Council
• Members of SG Faith and Belief stakeholder group
• Health and Social Care Alliance
• Glasgow Disability Alliance
• Community Justice Scotland
• Coalition of Care and Support Providers Scotland
• Scottish Government policy teams

118. Members of the National Vaccine Inclusive Steering Group and Vaccination Programme Board were consulted on a draft of this EQIA.