The definition of ‘hesitant’ is ‘tentative, unsure and slow in acting or speaking’.
Vaccine hesitancy is a spectrum, with people being hesitant for a variety of reasons. This hesitancy may be born from rational and irrational reasons. This must not be confused with ‘anti-vax’ sentiments, related to people who do not support vaccinations because they do not believe the COVID-19 virus is real.
We are living through a pandemic. Day by day our understanding of the world around us shifts and changes. We are more global (because of social media and this unique pandemic that is affecting every country), at the same time we are more local (because we are limited in our physical movement and social interactions).
As we get better at monitoring the effect of the virus on people linked to their characteristics, we can see more clearly health inequalities in all their horrible glory – with death being the ultimate end. The greater numbers of men, ethnic minorities, older people, disabled people and people living in deprived areas who are dying day by day.
This has made everyone more conscious of their own ‘diversity’ their uniqueness, which may make them more susceptible to the virus. Originally, this virus was deemed to be the great leveller – with the belief that everyone no matter who you are would be affected in the same way. We now know this is not true. Instead, it has exacerbated inequalities that already existed.
In this context, when the light at the end of the tunnel started to shine, and the vaccines became more than a theoretic discussion, with clear plans to roll out at the end of November 2020, why would people who are dying in greater numbers be hesitant to be protected and not want to be prioritised.
Consider the answers to these questions:
- Why would learning disabled people not want the vaccine?
- Why would people from ethnic minority backgrounds not want the vaccine?
- Why would younger women not want the vaccine?
- Why would people from certain religions not want the vaccine?
People from marginalised groups; for example, people who are disabled and those who are lesbian, gay, bisexual and trans have historically negative experiences of health care and are therefore less trusting of their medical professionals.
With learning disabled people being 6 times more likely to die than the general population during the first wave of the pandemic it is essential that communications about vaccine are made accessible and understandable to this group. Even before the pandemic people with learning disabled were dying on average 16 years earlier than people without learning disabilities.
People from ethnic minority groups have also had historically differential treatment and outcomes from their healthcare, eg, black women are five times as likely to die in childbirth compared to white women. Women and ethnic minority people have often been underrepresented in clinical trials and there are relatively recent examples of clinical trials have taken place in countries in Africa without informed consent.
Counterintuitively, the discussions in the media about the prioritisation of people from ethnic minority groups could make them more suspicious that they are going to be test subjects again.
Several recent surveys have shown stark differences by ethnic groups in who would take-up the COVID-19 vaccine. One showed that 57% of respondents from Black, Asian and minority ethnic backgrounds would accept the vaccine compared to 79% of White respondents. Recent research about the reasons behind vaccine hesitancy for ethnic minority groups point to factors such as; low confidence in the vaccine, distrust, access barriers, inconvenience, socio-demographics and lack of communication from trusted providers.
A podcast on The Guardian’s Today in Focus explores the topics behind fears about the vaccine in ethnic minority communities. The solutions suggested are that health messages and vaccine distribution strategies should be sensitive to local communities and that ‘evaluation of interventions is essential to identify strategies that work well and strategies that are less effective’ to ‘build confidence in the fairness, safety and efficacy of the vaccines’.
For ethnic minority groups in particular these differences are a significant concern given the devastatingly disproportionate impact the virus has had on people from ethnic minority backgrounds and the need to monitor if vaccines are being taken up in equal measures by all ethnic groups, a recent study has shown that Black people over the age of 80 were half as likely as their white peers to been vaccinated against COVID by 13 January.
A BMJ article explores how essential cultural competence in COVID-19 vaccine rollout will be; for example recognising that ethnic minority adults are disproportionately represented among low paid, frontline workers, many of whom works shifts, so vaccination should be available at times most appropriate to their working patterns.
We must not forget that healthcare workers are people too and these differences are reflected in the vaccination rates for workers.
Recent stats from a trust that will not be named showed: 89% of White British staff; 77% of Asian/British Asian staff; and 44% of Black African/Caribbean/Black British staff had been vaccinated. The Workplace Race Equality Standard reports show the effect of structural discrimination in the NHS with: racial abuse from colleagues, disproportionately high disciplinaries and lack of progression for healthcare workers from some ethnic minority backgrounds. In this context, for some people from these groups, confidence that their employers have their best interest at heart could be very low. Particularly considering the ongoing difficulties with protection of ethnic minority doctors.
There have also been concerns raised based on faith, as to whether the vaccines available and in production will be acceptable to certain faiths in regard to their ingredients.
Organisations in different faith communities, such as the British Islamic Medical Association have produced statements to inform their communities about the currently available vaccines (Pfizer Biotech and Oxford Astra Zeneca).
According to a poll of 56,000 people a quarter of women of aged 18-34 said they would not take the Covid-19 vaccines due concerns about the vaccine’s effect on fertility and pregnancy.
Changing government advice has led to some women of childbearing age being confused on whether they should be taking the vaccine. In addition, a recent report has explored the ongoing impact of pregnant women being been excluded from clinical trials in the past.
The common theme for reasons why people have vaccine hesitancy in all these groups is trust, or lack thereof.
In addition, it is important to recognise that social media and methods of communication can be very varied for different groups who are more likely to trust information sources that are closer to them, such as family, friends and local organisations. The misinformation is often provided in a far more accessible form than the official information.
For example, via short video messages forwarded on social media platforms between friends. Therefore, information from government should be available in as equally accessible format in order that people have all the information available to make informed choices.
It is on the responsibility of the authorities to make the information clear and accessible, for whoever the intended recipient is and for whatever reason. One size fits all is not an acceptable communication strategy to the entire population of the UK.
Practically, hesitancy is difficult to deal with during a mass vaccination programme. It takes time and consideration for delicate, tailored communication with buckets of empathy.
Our doctors and healthcare professionals are under immense pressure and have little time, resources or energy to give that extra something, which would be needed to bring everyone along on the vaccine journey. There is no simple answer to a complex problem, and the BMA have called for a more sophisticated approach to vaccinations.
We have to get this right. The alternative is unacceptable, the possibility that the vaccines (light at the end of the tunnel), further exacerbates inequalities because their roll-out doesn’t effectively engage with different groups is a scary future that we must do all that we can to avoid. Building trust and communicating clearly is the answer to this conundrum and we have more information about how to do this here.
Aishnine Benjamin is head of equality inclusion and culture