Vaccination Programme : Autumn/Winter 2021-2022 Flu and COVID-19 : Equality Impact Assessment Results
Title of Policy
Autumn/Winter 2021-2022 Flu & COVID-19 Vaccination Programme
Summary of aims and desired outcomes of Policy
Immunisation programmes are designed to help protect the population from serious vaccine-preventable diseases. The complexity and pace of the COVID-19 vaccination programme has been unprecedented and progress has been remarkable.
Since December 2021 Scottish Government has aimed to offer and deliver COVID-19 vaccination to all adults, 16 and 17 year olds and specific at risk 12-15 year olds in Scotland between December 2020 and September 2021, guided by advice from the Joint Committee on Vaccinations and Immunisations (JCVI) and availability of vaccine. A universial offer for all 12-15 year olds was made September 2021. A third does is also offered to people who are severly immunosuppressed. Our aim has been to deliver this in a way that ensures no-one is unintentionally excluded, in particular those most at risk from COVID-19. (Tranche1)
Flu and COVID-19 Vaccination Programme autumn/winter 2021-22 (Tranche 2) aim is to offer and deliver flu vaccination and COVID-19 booster vaccine to eligible groups guided by JCVI advice, ensuring that no-one is excluded and in particular those most at risk from COVID-19. The JCVI's final advice on a Flu and Covid-19 booster programme was received on 14 September.
The offer of COVID-19 vaccination will remain open to those newly eligible or those who have not yet taken up the offer of a vaccine for the initial programme (Tranche 1) and the Booster Programme (Tranche 2). This offer will remain under regular review.
Directorate: Division: team
Directorate for Vaccines Strategy and Policy: Vaccine Strategy Division: Vaccinations Inclusion and Equalities Unit
Section 149 of the Equality Act 2010 places a duty (known as the public sector equality duty, or PSED) on public authorities to have due regard to the need to eliminate discrimination, advance equality of opportunity and promote good relations between people who share a protected characteristic and those who do not.
The Scottish Government is mindful of the three needs of the Public Sector Equality Duty (PSED) - eliminate unlawful discrimination, harassment and victimisation, advance equality of opportunity between people who share a protected characteristic and those who do not, and foster good relations between people who share a protected characteristic and those who do not. Where any negative impacts have been identified, we have sought to mitigate/eliminate these. We are also mindful that the equality duty is not just about negating or mitigating negative impacts, as we also have a positive duty to promote equality. We have sought to do this through provisions contained in the Act's Regulations, or by current support and guidance available.
The COVID-19 pandemic has had a significant impact on the population of Scotland, that impact has been greater in some equalities groups. Inclusion and equality must be firmly embedded in the COVID-19 vaccination prgoramme in order to reach everyone and ensure that no one is left behind, both for individual health and our collective community wellbeing.
For the autumn/winter 2021-22 Flu and COVID-19 vaccination programme, the JCVI issued its full advice on 14 September. Their statement clarifies that they regard the primary objective of a 2021 COVID-19 booster programme to be to reduce the occurrence of serious COVID-19 disease, which is consistent with the principles guiding their advice during Tranche 1 COVID-19 vaccination programme. The JCVI makes clear that it is not its intention that the 2021 COVID-19 booster vaccine programme should disrupt or delay deployment of the annual influenza vaccination programme which is already well established. Both of these are important for individual and public health, especially over winter 2021 to 2022. Where operationally expedient, COVID-19 and influenza vaccines may be co-administered (given at the same time).
A free flu vaccination will be available for:
- over 50s
- people with underlying health conditions which put them at risk
- pregnant women
- children aged 2-5
- health and social care staff
- unpaid and young carers
- all primary and secondary school age children, (given in school setting)
- independent NHS contractors, (GP, dental and optometry practices, community pharmacists), laboratory staff (working on Covid-19 testing) including support staff
- teachers, nursery teachers and support staff in close contact with pupils
- prison staff and support staff and inmates
COVID-19 booster vaccinations will be offered to:
- all adults aged 50 years or over
- frontline health and social care workers
- all those aged 16 to 49 years with underlying health conditions that put them at higher risk of severe COVID-19 (as set out in the green book), and adult carers
- adult household contacts (aged 16 or over) of immunosuppressed individuals
This policy forms part of Scottish Government's long term planning, and response to the COVID-19 global pandemic. Immunisation programmes are designed to help protect the population from serious vaccine-preventable diseases. The complexity and pace of the COVID-19 vaccination programme has been unprecedented and progress has been remarkable.
COVID-19 vaccines are a critical part of suppressing the virus to the lowest possible level, in order to save lives, protect health and wellbeing, reduce health inequalities and maintain quality of life. The vaccines produce an immune response that we know reduces severity of illness from the virus. It therefore makes a significant contribution to reducing the impact of the wider economic, educational attainment and work impacts of the pandemic on people, families and communities.
The Scope of the EQIA
The Flu and COVID-19 Vaccination Programme potentially affects everyone in Scotland with an initial focus on the whole adult population with children coming into scope as scientific evidence of risk and benefit becomes available. Therefore the scope of this equality impact assessment is extended beyond the list of protected characteristics to include wider socio-economic considerations.
The impact of the policy and mitigations have been considered for the following characteristics:
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.
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 . As of 09 August 2020, more than three quarters (77%) of all deaths involving COVID-19 were of people aged 75 or over. 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 . Measures that may help limit the spread of coronavirus are designed to positively affect the entire population, but may particularly benefit older individuals.
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.
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;
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 . 1 in 5 Scots identify as disabled and more than a quarter of working age people acquire an impairment .
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 . The Glasgow Disability Alliance published 'Supercharged – A Human Catastrophe' 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.
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 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.
The JCVI gave specific advice on learning disability. In addition the Health Inequalities Impact Assessment (HIIA) produced by Public Health Scotland (PHS) 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.
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.
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.
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 were already higher for men than women in England and Wales)
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.
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.
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.
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
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.
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)
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.
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.
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
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.
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.
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 and 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%).
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.
- Jambo! Radio Q&A/Interview SG National Clinical Director to discuss the Covid 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.
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.
The National Vaccine Inclusive Steering Group, available data and stakeholder relationships continue to shape the policy and approach.
Religion or Belief
The HIIA identified ingredient information and the potential to use places of worship for vaccination clinics.
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.
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 Public Health Scotland 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.
The National Vaccine Inclusive Steering Group, available data and stakeholder relationships continue to shape the policy and approach.
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.
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.
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 . JCVI advice allows for local flexibility to mitigate health inequalities.
Remote Rural/Island Communities
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.
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 .
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 while Ready Scotland's additional support page 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
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.
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
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.
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
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
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.
Recommendations and Conclusion
The Scottish Government has assessed the potential impact of its vaccination policy on equal opportunities and has determined it does not unlawfully directly discriminate with respect to any of the protected characteristics (including age, disability, sex, pregnancy and maternity, gender reassignment, sexual orientation, race, religion or belief, marriage or civil partnership). Where provision might potentially indirectly impact on equality, the Scottish Government considers the impacts are justified and a proportionate means of achieving the legitimate aim of supporting the Government's continued response to the public health emergency caused by the coronavirus pandemic. The Scottish Government remains committed to keeping the policy under review.
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