The COVID-19 pandemic, via rate of infection, deaths and vaccine uptake has exposed the existing health inequalities that are embedded in society. It is thus pivotal that we use this increased awareness to act now to reduce these inequalities and improve health outcomes for the entire population.
According to Public Health England, health inequalities are “systematic, avoidable and unjust differences in health and wellbeing between different groups of people”[1]. These groups of people can be broken down into four distinct yet overlapping categories: protected characteristics under the Equality Act, geographic deprivation, being a member of a vulnerable group and socioeconomic groups[2]. What drives these inequalities are the wider determinants of health, differences in health behaviours, psychosocial factors, and unequal access to health services.
Albeit evident that COVID-19 has had a profound impact on all aspects of society, the virus has disproportionately impacted those from an ethnic minority background. A Public Health England Report in 2020 confirmed that people of Bangladeshi ethnicity had approximately twice the risk of mortality in comparison to white British people. Those with a Pakistani, Chinese, Indian, Other Asian, Black Caribbean and Other Black ethnicity had between a 10% – 50% increased risk of death than those who identify as white British[3].
The government’s ‘Final report on progress to address COVID-19 health inequalities’, published on 03 December 2021, highlights the reasons why ethnic minority groups have a higher risk of COVID-19 infection. The principal factors outlined include occupation (frontline, NHS workers), living in multigenerational households, and wider determinants of health such as living in areas of deprivation which are densely populated with poor air quality[4]. Such insight has been paramount in shaping the government’s response to COVID-19 to best protect all members of society. For example, Bangladeshi and Pakistani ethnic groups had a much higher risk of dying from COVID-19 in the second wave of the pandemic. As a result, specific measures were put in place to protect individuals from South Asian groups such as implementing measures to protect taxi drivers, of whom over 50% are from an ethnic minority background[5].
Although ethnicity was not initially considered to be a risk factor, scientists from Oxford University have since discovered that 60% of people with South Asian ancestry carry a gene responsible for doubling the risk of respiratory failure from COVID-19[6]. This breakthrough provided an explanation for the higher mortality rates and hospitalisations from this group. However, this also highlighted the importance of implementing a successful vaccination programme in order to protect ethnic minorities from risk of infection.
Bola Owolabi, Director of the Health Inequalities Improvement Team at NHS England and NHS Improvement, believes that using data is the answer to improve health inequalities[7]. According to January 2021 uptake data, whilst 82% of over-80s had received their first vaccine, the uptake among Pakistanis was only 45% and for black Africans, a mere 38%[8]. Such data facilitates the identification of specific parts of the population which have had a low vaccine uptake, enabling the government to reconsider its approach to improve vaccination rates.
Fast forward 11 months and we continue to identify similar trends. At the start of December 2021, 90% of all white British people aged 50-54 had been vaccinated with a first dose, in comparison to 62% of those from the Caribbean ethnic group and 74% of those of African heritage[9]. Differences such as the case outlined above are found across all age groups eligible for the vaccine, yet the size of the difference fluctuates. It is therefore important to understand why this is the case and what can be done to continue to improve the rates of vaccine uptake among ethnic minority groups.
An article written by Shaun Treweek, Professor of Health Services Research at the University of Aberdeen, highlighted the three principal barriers which are preventing ethnic minorities from getting vaccinated[10].
Firstly, there is a general lack of trust in organisations promoting the COVID-19 vaccine among those from ethnic minority groups. A survey carried out by the London School of Economics on attitudes towards the COVID-19 vaccine supports this. The survey highlighted that previous negative experiences with the NHS and government have facilitated a feeling of distrust amongst individuals from an ethnic minority background[11]. Secondly, there appears to be a lack of linguistically and culturally sensitive information regarding the COVID-19 vaccine. Discussions surrounding the benefits and risks associated with the vaccine can be overly technical and ignorant of an individual’s cultural values and beliefs. Thirdly, a more practical barrier presents itself in terms of non-suitable timings of appointments as well as a difficulty accessing vaccination centres.
To overcome these barriers, the principal answer lies in communication. The vaccination programme must be promoted by messengers that are trusted by the target population. Messages should be tailored, which not only involves information being translated into different languages, but also the use of culturally appropriate jargon and the provision of answers to particular questions that members from specific communities may have. There should also be added flexibility in regard to the location of vaccination centres and an increased use of ‘pop-ups’ at places where the target population regularly frequent and feel comfortable accessing.
The government has already adopted some of these strategies, for instance producing videos with faith leaders from the Bangladeshi community to improve vaccination rates amongst individuals from the Bangladeshi group. Furthermore, a webinar performed by Dr Binita Kane, a respiratory consultant and co-founder of South Asian Heritage Month, provided targeted information regarding the COVID-19 vaccine in order to bolster vaccination uptake rates amongst individuals from Indian ethnic groups[12]. To breakdown the accessibility barrier, places of worship and schools have been used as vaccination centres. Mobile vaccination buses have also been used to reach some of the UK’s most deprived areas to ensure as many people as possible, no matter what their individual circumstances, can be vaccinated[13].
There has been a history of failure by organisations such as the NHS and government to engage with ethnic minority groups[14]. Therefore, as Prime Minister Boris Johnson urges everyone to receive a booster vaccine in response to the new Omicron variant, measures such as those outlined above must be sustained and continuously improved to help stop the spread of COVID-19 and reduce hospitalisations. Members of ethnic minority groups should be involved in designing such strategies so that they can contribute their lived experience in a successful implementation programme.
The COVID-19 pandemic has taught us that a ‘one size fits all approach’ is an ineffective way to tackle health inequalities. The increased use of data to drive decisions visibly highlights why ethnic minorities should not be treated as a homogenous group and it is acknowledgement of this that will enable the improvement of health outcomes. As we enter our third year in a COVID-19 world, we must now look to use what we have learnt to improve inequalities in other areas of health such as pregnancy and birth.
Footnotes
[1] Public Health England (2021) Health Equity Assessment Tool (HEAT): executive summary. Available at: https://www.gov.uk/government/publications/health-equity-assessment-tool-heat/health-equity-assessment-tool-heat-executive-summary#fn:2 (Accessed: 28 December 2021).
[2] Ibid.
[3]Public Health England (2020) Disparities in the risk and outcomes of COVID-19. Available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf (Accessed: 29 December 2021).
[4]HM Government (2021) Final report on progress to address COVID-19 health inequalities. Available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1038338/2021-12-03_Final_COVID-19_disparities_report___updated_3_Dec.pdf (Accessed: 29 December 2021)
[5] Ibid.
[6] University of Oxford (2021) Researchers uncover gene that doubles risk of death from COVID-19. Available at: https://www.ox.ac.uk/news/2021-11-05-researchers-uncover-gene-doubles-risk-death-covid-19 (Accessed: 29 December 2021).
[7] Brown, S. (2021) ‘Levelling Up’, Healthcare Finance, 06 December. Available at: https://www.hfma.org.uk/docs/default-source/default-document-library/12-17_dec21_inequals-final.pdf?sfvrsn=1c6775e7_0 (Accessed: 29 December 2021).
[8] Ibid.
[9] Treweek, S. (2021) ‘Three ways to improve the uptake of COVID vaccines by ethnic minority groups in the UK’, The Conversation, 15 December. Available at: https://theconversation.com/three-ways-to-improve-the-uptake-of-covid-vaccines-by-ethnic-minority-groups-in-the-uk-173438 (Accessed: 30 December 2021).
[10] Ibid.
[11] Asaria, M., Costa-Font, J., and Akaichi, F. (2021) ‘Why some ethnic groups are more likely to refuse the COVID vaccine (and what we could do about it)’, LSE Blogs, 21 October. Available at: https://blogs.lse.ac.uk/covid19/2021/10/21/why-some-ethnic-groups-are-more-likely-to-refuse-the-covid-vaccine-and-what-we-could-do-about-it/ (Accessed: 29 December 2021).
[12]HM Government (2021) Final report on progress to address COVID-19 health inequalities. Available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1038338/2021-12-03_Final_COVID-19_disparities_report___updated_3_Dec.pdf (Accessed: 29 December 2021)
[13] ITV News (2021). Coronavirus: Vaccine bus will bring jab to minority ethnic communities. Available at: https://www.itv.com/news/anglia/2021-03-09/coronavirus-vaccine-bus-will-bring-jab-to-minority-ethnic-communities (Accessed: 30 December 2021).
[14]Collaboration for Change (2021) Collaboration for Change: Promoting vaccine uptake. Available at: https://www.collaborationforchange.co.uk/_files/ugd/642bdf_ec6a0b72c8d54c9399f39854038f044c.pdf (Accessed: 30 December 2021).
