Vaccinating fairly in an unequal society: addressing health inequalities in the UK’s vaccine rollout
News last week that the UK has vaccinated more people than it has had confirmed cases of COVID-19 offered hope to many during a bleak January of national lockdown. However, the vaccine rollout will be effective at protecting populations only if the most at-risk groups have access to the vaccine. On an international level, access to COVID-19 vaccines is a critical issue, both with regards to affordability and rapid access to supplies. This particularly affects lower and middle income countries. Ensuring fair and just global access will act not only to prevent unnecessary deaths but also to reduce viral spread. Indeed, initiatives such as the COVAX alliance are working towards global equitable access. However, even in a high income country, such as the UK, equitable access to vaccines is not guaranteed. An emerging problem is that populations that have most adversely been affected by the COVID-19 pandemic, such as BAME populations and low-income groups, are the same groups that currently run the risk of lower vaccination rates. Understanding their concerns, and addressing the underlying causes of lower vaccination rates in these more vulnerable populations is essential to the UK’s vaccination programme’s success.
Higher vaccine distrust levels in at-risk groups
The coronavirus pandemic has highlighted and worsened many pre-existing structural inequalities, from food poverty to the digital divide, and these inequalities often manifest as differing health outcomes within populations. Since March 2020, mortality rates from COVID-19 have been higher in low-income groups, thought to be caused by various factors, ranging from higher rates of pre-existing comorbidities to working in sectors with a higher risk of viral exposure. Although the Joint Committee on Vaccination and Immunisation’s interim report (1) did identify people in areas of higher socioeconomic deprivation as a risk group, the final list of priority groups for vaccination did not have any mention of deprivation level. In addition to the lack of vaccine prioritisation for low-income groups, a survey from December 2020 found that people in low-income groups were more likely to be uncertain about or refuse a COVID-19 vaccination (2). A similar trend of higher COVID-19 mortality rates, lack of vaccine prioritisation and community distrust in vaccines has also been seen in BAME populations (3, 4). Both low-income groups and BAME populations have been documented to have poorer health outcomes and so an ineffective vaccine rollout risks a further widening of these health disparities.
Causes of vaccine uncertainty
Mistrust in COVID-19 vaccines appears to stem from uncertainty of the benefits of vaccination and fears of side-effects. Misinformation propagated via social media networks has stoked these fears. Groups with lower levels of education and poorer knowledge of COVID-19 were found to show higher levels of vaccine mistrust (2). The development of accessible health information resources is therefore essential to address these uncertainties and such resources would need to be targeted towards at-risk groups to improve confidence in vaccine efficacy and safety. Furthermore, the importance of community engagement cannot be understated, as cultural and religious attitudes are vital in addressing concerns around vaccine safety. This work can range from grassroots approaches such as community leaders championing vaccine uptake, to more technological solutions such as social media campaigns, to more standard approaches such as focus groups to address local concerns.
Access to vaccines and logistical barriers
While some people may plan to refuse COVID-19 vaccines, many others are simply unsure and ensuring vaccination accessibility can act to increase vaccine uptake in this group. A key issue is the location of vaccination appointments. Vaccination hubs have been established throughout the country and although centres may aid the distribution and storage of vaccines, people are invited to these hubs from significant distances away; presenting a challenge for those without independent means of transport. Those dependent on public transport may be dissuaded by reduced services and worries around the risk of infection and similarly disadvantaged are low-income groups, who may be financially unable to cover transport costs and loss of wages. There has also been little consideration for those with reduced mobility, such as those with physical disabilities and elderly populations. Further, the unfamiliar environment of vaccination hubs may discourage those already fearful of vaccinations (5). Solutions may come from offering vaccinations at more local and already trusted venues, such as GP surgeries. In addition, implementing a schedule that accounts for those with restricted hours, like shift workers, could dramatically improve vaccine uptake, especially in vulnerable populations. Barriers may also be faced in a lack of digital literacy or digital access, not to mention language barriers. These challenges are more likely to be the case in the same communities who have not been considered in existing plans. It is clear that working with community leaders and charities will be key to supporting and engaging these groups for vaccination.
Ensuring equal access to vaccination
A multifaceted approach is required to ensure parity in vaccination rates between vulnerable populations and the general population. Community engagement to shift attitudes in favour of COVID-19 vaccines must be expanded alongside targeted efforts to improve accessibility for disadvantaged and at-risk groups. Some people have also called for low-income groups, alongside BAME groups and prison populations, to be identified as priority groups for vaccination. Even if this is not implemented, demographic vaccination data must be transparently collected and, critically, made openly accessible so that groups with lower vaccination rates can be identified and targeted.
The rollout of the vaccine will be most effective when it retains a focus on vulnerable populations. Work to tackle health inequalities should form a key component of post-pandemic policy too. Despite the popular desire for a return to normalcy, it is important that society builds back fairer, not just build back better. This sentiment is echoed by the Marmot Review (6), chaired by Michael Marmot, a key advocate for action against health inequalities. Marmot has long emphasised the need for wider changes to be made to reduce the structural inequalities. It is these inequalities that lie at the root of the increased mortality rates as well as lower rates of vaccine uptake in vulnerable and disadvantaged groups. For example, BAME populations have historically had lower rates of seasonal flu vaccine uptake and lower rates of cancer screening. This is thought to be caused by a range of factors including previous negative experiences of discrimination within healthcare settings, general distrust of public institutions and cultural or religious concerns (7). To tackle these wider issues, health information needs to be developed and targeted towards specific groups and more community engagement and support is needed to improve access to healthcare services for marginalised groups.
More about the Author: Anya Webber
Anya is a Biochemistry master’s student interested in public health and the public understanding of science.
Joint Committee on Vaccination and Immunisation’s interim report on priority groups for vaccination https://www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-25-september-2020/jcvi-updated-interim-advice-on-priority-groups-for-covid-19-vaccination#vaccine-priority-groups-interim-advice
Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications, Paul et al, 2020 https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext
New poll finds BAME groups less likely to want COVID vaccine https://www.rsph.org.uk/about-us/news/new-poll-finds-bame-groups-less-likely-to-want-covid-vaccine.html
How the UK’s Covid-19 vaccination programme is failing to address racial disparities https://www.newstatesman.com/politics/health/2021/01/how-uk-s-covid-19-vaccination-programme-failing-address-racial-disparities
Keeping vaccinations local https://www.bmj.com/content/372/bmj.n145
Health equity in England: The Marmot Review Ten Years On https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on
Barriers to effective uptake of cancer screening among black and minority ethnic groups, Thomas et al, 2013 https://pubmed.ncbi.nlm.nih.gov/16471043/