Coronavirus (COVID-19) vaccine barriers and incentives to uptake: literature review

Covid-19 vaccine uptake in Scotland

Between the launch of the vaccination campaign (8 December 2020) and the end of April 2022, over 12 million doses have been administered in Scotland, including 4.39 million first doses, 4.1 million second doses and 3.47 million third doses. This corresponds to 90.3%, 85.8% and 72.6% of those aged 12+ respectively^[2]. Fourth doses are currently being deployed. However, due to the timing of the search for this review, the figures used throughout refer to doses 1-3 only.

Despite the overall success of the roll-out, equality data show lower uptake in some of Scotland's communities. Data covering ethnicity, age, the Scottish Index of Multiple Deprivation (SIMD), sex differences, the prison population and those in contact with drug services are available at a national level from Public Health Scotland (PHS).

As of 3 May 2022, aged 12+ uptake of the first dose of a Covid-19 vaccine by ethnicity was 88.6% in White ethnic groups, 80.1% in Asian ethnic minorities, 74.4% in mixed or multiple ethnic groups, 73.4% in African communities and 70% in Caribbean or Black populations. This compares with the following percentages for aged 12+ second doses: 84.5% in White ethnic groups, 73.6% in Asian ethnic minorities, 66.3% in mixed or multiple ethnic groups, 64.4% in African communities, and 62.1% in Caribbean or Black populations. Uptake of third doses for those aged 16+ has been lower in all ethnic groups, although the variation for ethnic minorities has been considerably higher: 75.4% in White ethnic groups, 60% in Asian ethnic minorities, 53% in mixed or multiple ethnic groups, 45.8% in Caribbean and Black populations, and 41.7% in African communities^[3]. Analysis of available sub-groups shows how uptake of third doses is particularly low in Caribbean and Black (45.8%), Arab, Arab Scottish or Arab British (43.7%), African, African Scottish or African British (42.8%), White Polish (36.7%), Other African (28.3%) and White Gypsy/traveller (24%) populations^[4]. It has to be noted that there have also been some positive changes in recent months: between August 2021 and January 2022 uptake for older adults in minority ethnic groups (particularly African) has increased^[5].

Together with ethnicity, there are significant differences in uptake between SIMD deciles. At the beginning of May 2022, just 56.1% of those living in the most deprived decile had received their third dose, compared to 76.2% of those in the least deprived areas. This is similar to the pattern for dose 2, given the administration of a third dose is dependent on it^[6].

Uptake also varies by age group. While uptake of first doses at the end of April 2022 is high in all age groups (ranging from 100% in those aged 75-79 to 77.9% in those aged 18-29), there has been a gradual decline with second and third doses (100% vs 71.3% and 100% vs 51.4% respectively). This drop-off becomes substantial in the under 30s for second doses, and it is pronounced in all the under 60s for third doses^[7].

Sex differences exist, with lower uptake of first doses among men who are under 40. The gap between sexes becomes more evident for second and third doses which see increasingly lower vaccine acceptance in men under 50 compared to women^[8]. An exception is represented by pregnant women, who report levels of uptake below that in the general female population. Between 8 December 2020 and 31 October 2021, just 32.3% of women giving birth in October had received two doses of a Covid-19 vaccine, compared to 77.4% of all women of reproductive age (18-44 year-olds). Uptake was lowest in the youngest age group (≤20 years) and in those in the most deprived SIMD quintiles^[9]. Data from PHS also showed that being of Black, Caribbean, or African ethnicity negatively affected uptake in pregnant women^[10].

Records on adults in prison show that by mid-April 2022 uptake of first doses matched that of control groups in the general population (73%). On the other hand, uptake of second and third doses was slightly lower (64% and 43% respectively, compared to 68% and 48% among the general population matched controls). Furthermore, uptake of all doses among the prison adult population in the most deprived SIMD quintiles exceeded that recorded in control groups^[11].

Finally, despite progress, vaccine uptake in those prescribed opioid agonist therapy remained significantly lower compared to the general population matched controls (61% vs 76% for first doses and 42% vs 68% for second doses at 24 August 2021)^[12].

Though these data are as robust as possible, they do present some limitations due to the difficulty in clearly identifying the unvaccinated population. Statistics are based on those who have been assigned a CHI number. However, some may have left Scotland without informing their GP practice and some may have arrived and not registered yet. Others may have received their vaccines abroad despite being registered. There may also be some individuals who are not eligible for dose 2 or 3 yet, depending on when they received dose 1 or 2.