Local listening: fears and concerns about Covid-19 vaccination

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As the vaccination programme for Covid-19 begins, there finally seems to be light at the end of a long and difficult tunnel. Huge effort is being put into organising the infrastructure and staff required for rollout to ensure the benefits of vaccination are seen at a population level. While still not certain, estimates suggest that around two-thirds of people will need to be vaccinated to reach population immunity. Alongside the operational efforts to ensure the supply of vaccines, a great deal of work is being done on the demand side. How many people will agree to be vaccinated? Are some groups more likely to agree than others and what can be done to encourage uptake?

A recent study published in Nature, which surveyed 13,426 people in 19 countries, found that 71.5 per cent of participants reported that they would be very likely or somewhat likely to get a Covid-19 vaccine. The figure for the United Kingdom was in line with the overall average (71.48 per cent). Similarly, other polling asking similar questions shows that roughly 7 out of 10 people say they are likely to get vaccinated once vaccines are available to them. This level of uptake should achieve the required level of population immunity.

The risk is that the pre-existing health inequalities exposed and worsened by Covid-19 are further exacerbated by the vaccine rollout. 

However, when you start to look behind those averages it is clear there are issues with uptake that could further exacerbate health inequalities that have already been magnified to devastating effect by Covid-19. The data suggests that many of the groups in society who have already been disproportionately affected by Covid-19 are those who are least likely to say they will be vaccinated. Rates of Covid-19 infection, severe disease and mortality have been highest among deprived and ethnic minority communities amplifying health inequalities that existed before the pandemic. Yet, polling suggests there is significantly more vaccine hesitancy among ethnic minorities. Similarly a multi-methods study in England of parents’ and guardians' views on the acceptability of a future Covid-19 vaccine for themselves and their children showed that ethnicity and household income were predictors of Covid-19 vaccine refusal with survey participants from lower-income households more likely to say they would reject a Covid-19 vaccine. The risk is that the pre-existing health inequalities exposed and worsened by Covid-19 are further exacerbated by the vaccine rollout.

What is driving this and what can be done about it? The figures only take us so far, we need the insight and stories behind the numbers. The numbers tell us that deprivation and ethnicity are important variables when it comes to uptake but clearly caution is needed when it comes to generalising what lies behind the data. Local understanding of the context and issues is needed to understand community variation. The insight is already there locally and held by many people who are already working with deprived and ethnically diverse communities. I spoke to a few colleagues who work with people in areas already disproportionately affected by Covid-19 to explore what might be happening.  

They told me that a range of different concerns will need to be addressed. Some groups are concerned that vaccines would not have been tested on people who represented their communities leading to wider concerns about its safety. There are concerns around some of the companies behind the vaccines. A view that people who do not get the vaccine will not be allowed to travel and that this is therefore a way of the state controlling the movement of certain communities. There are concerns about whether vaccines would be allowed on religious grounds. These and many other concerns are travelling quickly through social media and gaining traction, with WhatsApp being a key channel. Polling data suggests that those who say they get a great deal of information on Covid-19 from WhatsApp are less likely to get vaccinated.

Colleagues told me that underlying all this is the concept of trust in the system and government, something that is in short supply in many of these communities and something that has been further eroded during the pandemic. The Nature study reinforces how important trust is when it comes to potential uptake of vaccines. Respondents who said that they trusted their government were more likely to accept a vaccine than those who said they did not.  

[T]here need to be safe spaces for these conversations and routes for the system to hear them and determine what it means for delivering the vaccination programme.

These and many other stories I heard need to be listened to, they represent deep-seated concerns that need to be understood, worked with and acted on. Do I know if this data is representative and generalisable? No. Does it need to be listened to? Yes. Rather than being dismissed as misinformation, there need to be safe spaces for these conversations and routes for the system to hear them and determine what it means for delivering the vaccination programme. One of the often-heard challenges around patient and public engagement is that ‘We don’t have the time to do it, we need to get on with delivery.’ Their answer to this is that the engagement is already happening, but health and care services need to work with those who are already having these conversations at a local level. 

This work needs to be undertaken by people who already have strong connections with their communities, work in partnership with them and hold their trust. The messenger is as important as the message and it is clear that a one-size-fits-all approach will not work. Work like the Community Voices initiative in north-west London, which provides a platform for these conversations, and the health champion work taking place in Newham, which recognises the need for partnership working with local people and communities, are examples of more locally targeted approaches.  

It is the type of local working that has been advocated for by The King’s Fund and many others for some time now. It is the approach already being taken by areas, like Wigan, that recognises that for services to be effective they need to build on and work with the strengths and assets of local individuals and communities to improve outcomes. This is a way of working that can bring in left-behind areas and communities from already deprived areas where the economic toll of Covid-19 will be greatest, reinforcing inequalities and the impact of the disease. There is a risk that the vaccine rollout further widens the gap but equally a chance that some of this can be addressed by learning from and acting on what communities are saying. The first step is to listen.  

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