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

Other Factors Impacting On Equality

Age

44. 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 because of their age and other clinical risk factors.

45. Older people are confirmed as having coronavirus at a higher rate than younger people - as at 16 August 2020, people aged 75-84 were confirmed as having coronavirus at a rate of 766 people per 100,000 population, and for those aged 85 and over, the rate was 2,214 people per 100,000 population. This is compared to a rate of 418 people per 100,000 population for people aged 45-64^[9]. As of 09 August 2020, more than three quarters (77%) of all deaths involving COVID-19 were of people aged 75 or over^[10]. 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^[11]. Measures that may help limit the spread of coronavirus are designed to positively affect the entire population, but may particularly benefit older individuals.

46. Those most at risk as a result of their age have been offered vaccination first. The impact on younger people is that they are the last to be offered vaccination. Lockdown measures have had the highest impact on young people. JCVI advised that implementation of the COVID-19 vaccine programme should aim to achieve high vaccine uptake and that an age-based programme would likely result in faster delivery and better uptake than an alternative model.

47. Primary schools in Scotland have successfully supported the flu immunisation programme since 2014. Flu can be serious and life-threatening, even for healthy children. This year the programme is being extended to secondary school pupils to reduce the risk of children and young people spreading flu to friends and family and to help prevent the flu virus putting extra strain on our NHS services this winter.

The flu vaccination programme is now available for:

• children aged 2 to 5 years and not yet at school (children must be aged two years or above on 1 September 2021 to be eligible);
• primary school children (primary 1 to primary 7);
• secondary school pupils (years 1 to 6);
• NHSScotland recommends that children and young people get the flu vaccine this year.

Disability

48. Around a third of adults reported a limiting longstanding health condition or illness in the 2017 Scottish Health survey. Twenty-nine percent 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^[12]. 1 in 5 Scots identify as disabled and more than a quarter of working age people acquire an impairment^[13].

49. There is significant evidence of the negative impact COVID-19 pandemic has had on disabled people. The Office for National Statistics published Coronavirus and the social impacts on disabled people in Great Britain: February 2021^[14]. The Glasgow Disability Alliance published 'Supercharged – A Human Catastrophe'^[15] which sets out the impacts on poverty and food security, digital exclusion, isolation, mental and physical health inequalities and social care issues. 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. Overlap between these groups mean that impacts may be magnified for some people.^[16]

50. Given the considerable proportion of the Scottish population that is disabled 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 prioritised for early vaccination in this policy. This means that disabled people with a pre-existing medical condition^[17] likely to experience more severe ill-health from contracting COVID-19 than the general population have been prioritised by this policy. However this is not all disabled people and not everyone with pre-existing medical conditions is disabled.

51. The JCVI gave specific advice on learning disability^[18]. This was subsequently augmented by additional guidance for vaccination of people with learning disabilities in Scotland^[19]. In addition the Flu Vaccine, COVID-19 Vaccine Health Inequalities Impact Assessment (HIIA), developed by Public Health Scotland in November 2020, includes potential impacts for disabled people including physical, sensory and learning disability; mental health conditions; and long-term medical conditions and advises on service design and delivery mitigations.

52. Programme delivery seeks 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 passenger assistance;
• availability of information available in accessible formats and languages;
• availability of information about how to access appointments in BSL;
• elimination of other communication barriers;
• the provision of quieter spaces, allowing more time for appointments, smaller clinics and appropriate staff training to support the needs of people with Learning Disabilities, Autism, 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 a 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 at their appointment.

53. Learning and engagement with stakeholders during Tranche 1 has led to a commitment in Tranche 2 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

54. While more men died from COVID-19, women's well-being was more negatively affected than men's during the first year of the pandemic. In general, men and women's experiences of life in lockdown tended to differ. Women were more likely to be furloughed, and to spend significantly less time working from home, and more time on unpaid household work and childcare. However, when looking at mortality from the coronavirus, more men died from COVID-19 than women. (Pre-pandemic annual mortality rates for all causes were already higher for men than women in England and Wales)^[20]

55. Consideration has been given through the programme to the location, timings and travel of vaccination clinics to ensure people with different working and caring responsibilities are not excluded. Information has also been updated to make clear it is ok to bring people you care for to your appointment. A digital and phone rebooking service was developed to enable people to change the time, date and location of their appointment. As the programme has progressed more drop in clinics have also been available at sports grounds, shopping centres and workplaces.

56. Vaccination uptake data is monitored. This has shown that as we move down the age groups uptake among men is lower than women. The programme seeks to address this with additional bespoke communication and delivery methods aimed specifically at men for example in partnership with Scottish Football Association and local football teams.

57. Health boards have responded to local data and intelligence regarding uptake changing the time and location of clinics, engaging with third sector and community groups to reach people experiencing homelessness or women involved in commercial sexual exploitation, for example. They have also engaged with larger employers to reach particular parts of the population.

58. Data and intelligence are being monitored and differing impacts on men or women responded to as they arise with learning built into future approaches.

Pregnancy and Maternity

59. Pregnant women are offered flu vaccine. The JCVI has advised that all pregnant women should be offered the COVID-19 vaccine at the same time as people of the same age or risk group. The vaccine can be given at any stage during pregnancy. All pregnant women are being called for vaccination in line with age and clinical risk. There is emerging evidence that some women are not coming forward for vaccination due to concerns around fertility. Fertility advice is therefore included in these resources.

• PHS supplies copies of the PHS COVID-19 Vaccine Important Information about pregnancy and breastfeeding leaflet
• Royal College of Obstetricians and Gynaecologists (RCOG) information leaflet and decision aid is issued to all maternity and vaccination clinics.
• The PHS leaflet is available in a range of languages and alternative formats, including British Sign Language, Audio, Easy Read, Large Print, etc.

60. People should be given the PHS and RCOG leaflets from maternity services before they attend for vaccination and are encouraged to read both leaflets. Both PHS and RCOG leaflets say the vaccine is safe at any stage of pregnancy or fertility treatment. RCOG leaflet notes in addition that some women may choose to delay their vaccine until after the first 12 weeks - this reflects the issue that some women may take less risks in first trimester of pregnancy. A range of new resources have been produced, including posters and social media assets.

Pregnancy, breastfeeding and the coronavirus vaccine | The coronavirus (COVID-19) vaccine (nhsinform.scot)

61. JCVI will review data as they emerge and consider further advice at the appropriate time on booster vaccinations for women who are pregnant without any other clinical risk factors.

Sexual Orientation

62. No differential impacts have been identified. However many health boards are working pro-actively with LGBTIQ+ organisations to ensure local arrangements are accessible and welcoming to this population and to address any issues of trust.

63. SG 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 phone-line so they have the appropriate information to ensure trans callers are treated with dignity and respect.

Race and Ethnicity

64. The HIIA identified a number of potential issues affecting access to vaccination and uptake relating to race and ethnicity. For example different cultural and historical approaches to vaccines, availability of accurate information in different languages and that is culturally sensitive, differences in GP registration, access to digital resources, and being comfortable attending particular venues.

65. 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:
• a QR code on all vaccination appointment letters which takes people 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.
• £80,000 SG funding to organisations working with minority ethnic communities to help inform and promote the programme. Activities undertaken include the facilitation of focus groups, provision of translations, hosting awareness-raising events and the development of tailored resources for certain communities.
• 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.

66. PHS began publication of vaccination uptake broken down by ethnicity and deprivation on 24 March and this is now included periodically in the weekly COVID-19 statistical reports they produce. This has shown uptake among African, Black, Caribbean and Polish communities has been significantly lower than the general population. As at 28 September 2021, in those aged 18 and over, dose 1 vaccine uptake is highest in White ethnic groups (89%) and lowest in the Caribbean or Black ethnic groups (68%). For dose 2 this is 84% and 60% respectively. For dose 2 the lowest uptake is in African ethnic groups (59%).^[21]

67. This has been a catalyst for specific national and local level activity to understand the real time concerns or constraints of particular ethnic minority groups and seek to address them. Some of the resulting activity includes:

• The Cabinet Secretary for Health & Social Care, Humza Yousaf MSP, met with the Ethnic Minority National Resilience Network (EMNRN) on 10 June 2021 to listen and give support to minority ethnic communities.
• Strengthened relationships with the African Council to better understand the needs of their communities and how best to support them through COVID-19.
• Jambo! Radio Q&A/Interview SG National Clinical Director to discuss the COVID-19 concerns of those with African and Caribbean Heritage.
• Local partnerships have led to vaccinations clinics in mosques, African churches and community centres, gurdwaras and venues used by the Chinese community.
• Eastern European charity based in Edinburgh, Feniks, hosted a Q+A session with SG National Clinical Director for the Polish community. The session focussed on issues and concerns relating to the vaccine and the session was streamed on Facebook and Zoom and has been made available to re-watch.

68. Working with the Expert Reference Group on COVID and Ethnicity it has now been agreed that data on ethnicity will be requested from people as part of future vaccination programmes starting during Tranche 2.

69. The National Vaccine Inclusive Steering Group, available data and stakeholder relationships continue to shape the policy and approach.

Religion or Belief

70. The HIIA identified ingredient information and the potential to hold vaccination clinics in places of worship.

71. From the programme outset, SG and PHS have engaged with faith leaders and representatives asking for support to promote the vaccination programme and 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.

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

• vaccinations have taken place in places of worship;
• A Ramadan film was developed in partnership with the British Islamic Medical Association and PHS to reassure Muslims concerned about getting the vaccine while observing Ramadan;
• PHS has produced information on vaccine ingredients;
• The explainer video was developed with engagement from a number of stakeholders including faith groups.

73. The National Vaccine Inclusive Steering Group, available data and stakeholder relationships continue to shape the policy and approach.

Deprivation

74. The HIIA identified access to venues and digital access as potential issues affecting people living in deprived communities. PHS equalities data also found lower uptake in Scotland's more deprived communities. As at 28 September 2021, 84% of those aged 18 and over in the less deprived areas had received their first dose of vaccine for COVID-19 compared to 76% in more deprived areas. For dose 2 this figure is 80% and 69%. though at time of writing the Tranche 1 programme is still live.^[22]

75. Health boards have responded by ensuring access to vaccination clinics and pop up clinics are within familiar local settings in deprived communities. Decisions on where to locate these and hours of opening have often been made with local authorities and local communities.

76. Biological age in the most deprived communities is significantly different from in the most affluent communities. This plays out in a marked difference in life expectancy and the fact that onset of 'diseases of old age' is around 15 years earlier. Therefore an age based approach may disadvantage people from the most deprived neighbourhoods.^[23] JCVI advice allows for local flexibility to mitigate health inequalities.

Remote Rural/Island Communities

77. We considered whether there might be a need for a separate Island Communities Impact Assessment, however, this was not deemed necessary after January 2021 when the decision was taken to vaccinate people in the JCVI cohorts on islands en masse. This decision was based on the low numbers of residents, difficulties in logistics and vaccine characteristics making it more sensible to vaccinate all residents in one visit rather than in phases. Island communities have had high uptake and constantly adapted approaches to reach everyone possible.

Relationship Status

78. Gender based violence (GBV) and control may involve limitation of internet access or control of a person's mail. Coercive control is one factor of GBV which may have an impact on the women's or men's ability to leave the house to attend a vaccination clinic. Qualitative research by the Scottish Government on the experience of individuals and families experiencing domestic abuse found that in some cases, victims and their children were at greater risk due to the increased time spent in isolation with the perpetrator. This research took place over the initial 8 weeks of the COVID-19 'lockdown'. Many services involved in the research reported that the impact and risk of domestic abuse is magnified by lockdown^[24].

79. Mitigating measures are in place to help support those affected by domestic abuse. The Scottish Government's COVID-19 guidance has been updated to reflect these exemptions and provides information on domestic abuse support^[25] while Ready Scotland's additional support page^[26] also provides links to support for anyone experiencing domestic abuse, forced marriage or anyone affected by sexual violence. Engagement with organisations that support women affected by commercial sexual exploitation have advised on how best to include people in the vaccination programme. This advice has been shared with local health boards.

Other Factors Impacting on Equality

80. 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

81. 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 now have leaflets in liberation packs encouraging them to receive second dose in the community and information on how they can do this. PHS has published data on prison vaccine uptake showing it is close to the population as a whole.

Migrant seasonal agricultural workers and seafarers

82. We agreed with health boards that an assertive outreach model will be used to offer vaccinations to this group. The majority of seasonal agricultural workers are within 4 health board areas (Grampian, Highland, Tayside and Fife) and we have shared details of the farms and expected numbers of workers to support outreach. As most will not be registered with a GP, we have agreed that vaccines can be administered and details recorded so CHI numbers can be retrospectively produced.

83. Various approaches have been tried to reach seafarers from a range of countries who are often living on their vessels and sporadically on and off land. Health and Social Care Partnerships worked with local Fishermen's Missions to hold clinics providing translators and transport for those attending.

Refugees and asylum seekers

84. PHS co-produced COVID-19 vaccine 'Statement of Facts' in partnership with the Scottish Refugee Council with films of community representatives reading them in their own languages circulated. Clear messaging and reassurance is 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.

Afghan Relocation and Assistance Policy

85. A number of people from Afghanistan will be arriving in Scotland under the Afghan Relocation and Assistance Policy (ARAP) scheme. This is an emergency response to the deteriorating situation in Afghanistan, whereby people who worked for British institutions, particularly the military, are being offered relocation to the UK because of the risks they now face 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 health information available on NHS Inform in the two main languages used in Afghanistan Dari and Pashto.