Coronavirus (COVID-19) and flu vaccination programme: user journeys and experiences

1. Introduction and Methods

This report presents the findings from qualitative research into user journeys and experiences of the Covid-19 and flu vaccination programmes in Scotland for groups who may face additional barriers during 2021/22. The research was carried out by Ipsos Scotland on behalf of the Scottish Government.

This research sits alongside the wider evaluation of both vaccination programmes led by Public Health Scotland (PHS). The project adds to the current evidence base on uptake and experiences by providing evidence on a defined set of groups and is intended to inform policy and the practical rollout of all future vaccinations from early 2023, to help ensure that inclusion is kept at the heart of Scotland's Vaccination and Immunisation Programme.

Background to the 2020/21 vaccination programme

In January 2021 the Scottish Government in collaboration with PHS established a Covid-19 vaccination programme as part of its response to the pandemic.^[1] In Autumn/Winter 2022, this was expanded to include both Covid-19 and flu vaccinations, and from early 2023 onwards the Scottish Vaccination and Immunisation Programme will be rolled out and this will cover all vaccinations in Scotland.

As of 25 May 2022, 91.8% of the Scottish population aged 18 and over have received their first dose, 88.8% have received their second dose and 78.3% have received a third dose/booster.^[2]

While the overall vaccine uptake rate in Scotland is high, a minority remain unvaccinated (8.2% as of 25 May 2022) and there is evidence that this proportion is higher among certain groups in society. In September 2021, an Audit Scotland briefing showed that a lower proportion of younger people, those living in the most deprived areas and people from some minority ethnic groups had been vaccinated.^[3]

Since the beginning of the Covid-19 pandemic Scotland also developed its flu vaccination programme to take account of the risks of concurrent infection of both Covid-19 and flu, as well as the extra pressures on health and social care services due to the pandemic. The flu vaccination programme is seasonal and takes place in the Autumn/Winter of each year and is routinely offered to: children aged 2 to 5, primary school aged children living with a health condition, young carers, pregnant women, those aged 65 and over, adults living with a health condition, unpaid carers, and healthcare workers. In Autumn/Winter 2021/22, where possible, those eligible were offered the option to receive both the flu and Covid-19 vaccine on the same day.^[4]

As of the 1^st February 2022, flu vaccination uptake among eligible adults in Scotland was again higher than previous years, with 90% of those aged 65 years and over having received it.^[5]

Research aims

Broad aims

The purpose of this research was to understand experiences of the Scottish vaccination programme (Covid-19 and flu) among people who may face additional barriers to vaccination in Scotland. The project aimed to address a gap in the current evidence base on uptake and experiences by providing up-to-date evidence on the chosen target groups. The findings are intended to support the Scottish Government, Public Health Scotland and NHS Health Boards to continue to ensure that the vaccination programme is as accessible as possible as Scotland develops its long-term plan for providing vaccinations across the country from early 2023.

The two broad aims of this research were to provide rich, qualitative data on:

• The user journeys of a specified set of key groupings within the population, taking into account highly practical experiences of vaccination, and providing information that can aid in planning and support for future vaccine rollout
• The wider experiences of vaccination, specifically why people decided to engage with or disengage from the vaccination programme.

Key research areas

Specifically, the research explored the following key areas:

• How individuals heard about the programme and the information sources used to make decisions about vaccination;
• What and/or who influenced this decision-making;
• The practical considerations taken into account to allow, or that prevented, take-up of vaccination;
• End-to-end experiences of getting vaccinated, from booking an appointment through to receiving the vaccine, and views on the support available (e.g. national and/or local helplines);
• Side-effects experienced by those taking up a vaccination and any impact of these on subsequent decision-making;
• Motivations to engaging with the vaccination programme or not;
• Impact - if any - of the introduction of Covid Status Certification, sometimes known as 'vaccine passports' or 'vaccine certificates' (domestic and international); and
• Likelihood of taking up future offers of a vaccine (Covid-19 or flu) and what - if anything - would encourage or improve engagement in future.

Methods

Overview

This research was qualitative in nature. Data was gathered from 81 participants using semi-structured depth interviews lasting one hour each (on two occasions two participants took part in a joint interview together which took slightly longer). Due to restrictions on face-to-face research at the time of fieldwork, all interviews were conducted via telephone or videocall and took place between 11 March and 3 May 2022. The interviews were structured by discussion guides (Annex A – available via 'Supporting Documents' on the Scottish Government website), with separate guides used for those who had engaged with the vaccination programme and those who had not.

A Research Advisory Group (RAG) was set up by the Scottish Government to oversee project progress and to advise as necessary. The RAG consisted of representatives from relevant Scottish Government analytical and policy areas, Public Health Scotland, NHS Health Boards, CEMVO Scotland, Glasgow Disability Alliance, MECOPP, the National Parent Forum of Scotland, Poverty Alliance, and the Scottish Youth Parliament. The research team worked closely with both the Scottish Government and RAG members on the design of research materials as well as on the presentation of findings in the final report. The RAG also supported the choice of key recruitment groups, alongside the PHS data, and with recruitment to the project.

Recruitment

A multi-pronged recruitment strategy was used to provide coverage across a range of population groups. Participants were invited to take part in the research in the following ways:

1. Via a professional research recruitment agency. This was carried out by telephone and involved a professional recruiter using a recruitment script written by the research team. This included information explaining the purpose of the research and what taking part would involve, as well as a list of screener questions. It was explained that participation was entirely voluntary and that participants could change their mind about taking part at any stage.

2. Through gatekeeper organisations. This was done on an opt-in basis, whereby gatekeepers shared an information sheet with details about the research with the people they supported and who would be eligible to take part. The information sheet included instructions on how to get in touch with the research team for those who were interested in taking part. This approach helped to ensure participants could give fully informed consent by giving them time and space to engage with information about the research and decide whether or not to take part. Participants were informed that they could ask further questions by contacting a member of the research team directly. Information sheets were also provided in Easy Read format to communicate key information in a simple and accessible way for those who may have difficulties reading. A screener call was then carried out by a project team member using the recruitment script when individuals got in touch.

3. From Ipsos' Parents Omnibus Survey recontact database. A small number of participants who had taken part in the Parents Omnibus Survey and had agreed to be recontacted about further research were identified as being part of particular groups of interest. They were then called by a member of the research team and recruited in the same way described above.

All participants received £40 via BACS transfer or a high street voucher as a token of thanks for giving up their time to take part in an interview.

Sampling and recruitment

All participants were adults living in Scotland during the vaccination programme and were members of groups who may face additional barriers to Covid-19 vaccination. Recruitment was based on target quotas to ensure the sample included sufficient numbers of those in particular groups of interest. Quotas were divided into two tiers, with every participant having to satisfy at least one 'Tier 1' quota in order to be eligible to take part.

Tier 1 quotas included:

• those who had a disability or long-term health condition;
• members of specific ethnic minority communities, specifically those who identified as African, Black or Caribbean , Gypsy/Travellers, Pakistani or Polish; or
• those living in a deprived area, which was defined as postcodes falling into the first or second quintiles of the Scottish Index of Multiple Deprivation (SIMD).

Towards the end of the fieldwork period, Tier 1 quotas were flexed in order to boost numbers of participants who were less engaged in the vaccination programme. The quotas were flexed to allow anyone aged under 40 to take part in the research if they had never engaged with the vaccination programme or they had only received one Covid-19 vaccination. Only four participants fell into this category.

Further 'Tier 2' quotas were set on age, parental or unpaid care responsibilities, rurality, being pregnant during the vaccination programme and low digital skills.

Eligibility for inclusion in the research was also based on participants' attitudes towards getting a future Covid-19 vaccination and their views on vaccines in general. Since this research focuses on identifying barriers that can be reduced through targeted interventions, participants were screened out if there was no possibility that they would ever engage in the vaccination programme. This was determined in the initial screener call and applied specifically to those participants who said they were "certain not to get vaccinated" against Covid-19 or were "strongly opposed to vaccinations" in general.

Table 1 shows a breakdown of the demographics and other characteristics of interest within the sample. It should be noted that there was a high level of intersectionality between groups covered in the Tier 1 quotas listed above.

Use of COM-B

A behavioural science approach was used to ensure that the full range of influences and experiences of vaccine user journeys were explored. The COM-B behavioural framework^[8] was used to help structure the design, conduct and analysis of interviews.

COM-B facilitates interpretation of what is driving a given behaviour and the identification of related evidence-based interventions. It holds that for any behaviour to occur, a person must have the:

• Capability: Including the physical capability (for example, the skill, strength, stamina) and the psychological capability (knowledge or psychological skills to engage in the necessary mental processes)
• Opportunity: Including physical opportunity (as afforded by environmental factors such as time, resources, locations, cues) and social opportunity (as afforded by interpersonal influences, social cues and cultural norms that may influence the way we think)
• Motivation: Including reflective motivation (self-conscious intentions and evaluations) and automatic motivations (for example, emotional desires, impulses, inhibitions etc.)

Applying this behavioural framework provided for a rich understanding of the enablers and barriers to vaccination.

Approach to analysis

A systematic and thematic approach was taken to analysis. Interviews were summarised into thematic matrices developed by the research team and reviewed in line with the COM-B framework to identify the full range of motivations and barriers to getting a Covid-19 or flu vaccination. The data was then subject to further analysis to identify similarities or differences within different subgroups.

Scope and limitations

The value of qualitative research lies in its ability to provide rich, in-depth information, in this case on why people have or have not engaged with the vaccination programme. However, it is important to note that the prevalence of particular experiences in the wider population, or specific sub-groups, cannot be quantified. Therefore, this report avoids quantifying language, like 'most' or 'a few'.

It is important to consider the timing of this research and take into account any contextual factors which may have impacted views of the current or future vaccination programme. This research was undertaken during the spring of 2022. Significant changes in Government's response to the Covid-19 pandemic were taking place during this time and are likely to have impacted on how participants responded to the research.

With a high rate of Covid-19 vaccination achieved across most of society and a decrease in infection rates and mortality, several measures enacted during the peak of the pandemic were relaxed or removed. These included the relaxation of domestic Covid Status Certification on the 28th of February, moving from mandatory to voluntary use and the end of all international travel restrictions for people travelling into Scotland from the 18th of March.^{[9] [10]}

Throughout April there was a winding down of testing, with free Covid-19 tests ending for most groups by the start of May.^[11] The legal requirement to wear face coverings in shops, hospitality venues and on public transport in Scotland came to an end on 18 April and self-isolation guidance was replaced with 'stay at home' advice from 1 May.^[12]

The Highest Risk List (formerly known as the Shielding List), a list of people regarded as most vulnerable to serious Covid-19 health outcomes, was formally ended on the 31st May. This was in recognition of both the high rates of vaccination achieved, and the introduction of new and effective treatments for Covid-19.^[13] During Spring 2022 there was an ongoing offer of Covid-19 vaccines for anyone who had not yet been vaccinated. This included offering a first vaccine for 5-11 year olds, and second booster people in certain high risk groups.^{[14] [15]}

These policy developments reflected a new phase of the pandemic, moving beyond measures like Covid Status Certification. The inclusion of questions on these measures in this research remains important, allowing effective evaluation and ultimately informing future policy.

Another factor impacting on fieldwork was the news coverage about parties and gatherings held at Westminster during lockdown. This had been going on since the story first broke in November 2021 and was mentioned by participants during interviews, particularly in relation to their current trust in government.

It is also important to bear in mind that not all participants received a first dose or subsequent doses at the same point in time. For example, those in younger age groups became eligible for a Covid-19 vaccine at a later date.

Figure 1 shows a timeline of some key contextual events throughout the vaccination programme.

Figure 1 – A timeline of key events

• 8^th of December 2020 – the first Covid-19 vaccinations are given in Scotland.
• 25^th of February 2021 – the Scottish Government announce the Covid-19 vaccine has been given to a third (33.4%) of those eligible – more than 1.5 million people.
• 11^th of March 2021 – Denmark is one of the first countries to suspend all AstraZeneca vaccinations amid blood clot concerns.
• 15^th of March 2021 – JCVI advise that adults aged under 30 without underlying conditions should be offered an alternative to AstraZeneca vaccine when available.
• 1^st of October 2021 – The Covid status Certification scheme comes into effect in Scotland meaning people will have to show proof of their vaccination status to enter some events and higher risk venues.
• 30^th of November 2021 – The Daily Mirror reports that some 10 Downing Street staff held gatherings during lockdown in the 2020 Christmas season.
• 16^th of February 2022 – Scotland becomes the UK's second constituent country to an announce plans to offer Covid-19 vaccines to children aged 5 to 11.
• 25^th May of 2022 – Public Health Scotland figures show that 91.8% of the Scottish population aged 18 and over have received their first dose, 88.8% have received their second dose, and 78.3% have received their third dose/booster.

Report structure and conventions

Quotes from participants are included throughout the report to illustrate points. Pen portraits and user journey maps are also used to give a sense of individual participants' experiences over time. Key characteristics are also included alongside quotes, pen portraits and user journey maps to further contextualise these views and experiences. To protect anonymity, participants depicted in pen portraits are identified using pseudonyms.

The remainder of this report is structured as follows:

• Chapter 2: Getting a first Covid-19 vaccination. This chapter describes the range of information sources used and participants' motivations and barriers to engaging with the Covid-19 vaccination programme. It also looks at their experiences of receiving a first Covid-19 vaccination, including practical considerations.
• Chapter 3: Getting a second or third Covid-19 vaccination examines the information sources used, motivations and barriers to getting a second or third vaccination, and experiences of doing so, including practical considerations.
• Chapter 4: Getting a flu vaccination considers how accessing information, motivations and barriers to engagement, and experiences differ for the flu and Covid-19 vaccination programmes.
• Chapter 5: Views on children getting vaccinated against Covid-19 and the flu examines parents' views and experiences of children receiving either or both vaccinations.
• Chapter 6: Future considerations. This chapter looks at the likelihood of engagement in future offers of the Covid-19 vaccination and the flu vaccination, as well as suggested improvements for a future vaccination programme in Scotland.
• Chapter 7: Conclusions. This chapter brings together the learnings from across the previous chapters under the domains of the COM-B model of behaviour. It considers each domain in order of influence on engagement with the current vaccination programme.