With last month’s news that the UK is now one of the most pro-vaccination countries in the world, what’s behind the hesitancy of some communities and what can be done to tackle this?
In December, a study by the Royal Society for Public Health revealed that only 57% of those from a Black, Asian or minority ethnic background were likely to accept a Covid-19 vaccine. Confidence in the vaccine was lowest in those with Asian heritage (55%).
I’ve written before on the disproportionate effect that Covid-19 is having on BAME communities and concluded that there was no evidence for anything except for discrimination as to why. We know that most racial health inequalities can be boiled down to inequality within our society. Why then, given that black and brown people in the UK are so much more likely to be negatively affected by Covid-19, might they be so averse to taking a vaccine?
Clinical trials by pharmaceutical companies in times past rankle with many who have African heritage. Many in countries like Burkina Faso, Nigeria and Chad rail against Polio vaccination because they believe that the jabs contain HIV-causing components and many Nigerians will not take part in clinical trials due to the meningitis scandal in Kano in the 1990s, after 11 children died and many more were injured. That illegal, clinical trial forever marred Pfizer’s name within Nigerian communities, as the tests for the new antibiotic Trovan led to a lawsuit around informed consent.
Other medical scandals in the continent involve forced sexual reassignment to stamp out homosexuality in the military in South Africa in the 70s and HIV/AIDs testing without full informed consent, again in the 90s. So it’s no wonder those communities have a real distrust for the medical model, given such a chequered (and recent) past.
More recently, however, Nigeria was blighted by an outbreak of Polio actually caused by vaccination. In 2007, around 70 children caught Polio from children who had already been vaccinated because the vaccinated children “excreted a mutated form of the virus, which infected others who were not immunised”, according to Reuters. WHO spokeswoman Sona Bari told the news outlet that the mutations were rare but this vaccine-derived Polio had also previously affected parts of Cambodia, Myanmar and Indonesia. It was especially problematic in communities where immunisation programmes did not reach adequate levels in the most vulnerable.
In 2019, the WHO highlighted 10 threats to global health as part of its 5-year strategic plan – the 13th General Programme of Work. Amongst such prescient threats as the risk of a global flu pandemic and “Ebola and other high-threat pathogens”, they highlighted vaccine hesitancy as a huge threat to global health improvements. Predicting that 1.5 million deaths per year “could be avoided if global coverage of vaccinations improved”, the WHO also declared that its vaccines advisory group “identified complacency, inconvenience […] and lack of confidence [as] key reasons underlying hesitancy”.
Addressing vaccine hesitancy
In 2017, the European Centre for Disease Prevention and Control (ECDPC) published its “Catalogue of interventions addressing vaccine hesitancy”, in which it acknowledged that “the history of public concerns about and questioning of vaccines is as old as vaccines themselves” and recognised that “[M]odern day communication capacities have provided many new platforms for speeding up the spread of these anxieties.”
The catalogue is intended as a “practical tool for public health organisations […] to address the challenging problem of vaccine hesitancy” and offers “a collection of interventions […] to measure and address vaccine hesitancy”.
One of the most interesting interventions involved educational programmes with religious leaders, which might be applicable to the current governmental need to increase uptake within varied UK communities. Although not directly comparable, the intervention, with local Sheikhs, the most influential social and spiritual leaders within their communities, were involved in discussions to help their loyal followers understand the benefits of immunisation programmes. The dialogue-based intervention showed a decrease in dropout rates and used a programme of health talks, posters and a film.
The catalogue also details an intervention performed in 2012 in Nigeria, where the aforementioned difficulties with Polio occurred. This intervention managed an absolute increase in vaccination of 73% (96% coverage). It was however a very intensive, targeted approach, involving presentations, long films, a dramatic play and emotive movies containing interviews with Polio sufferers and their families.
The power of social media
Unfortunately, the UK seems to have a problem with the power of social media to influence and spread disinformation. Last year SSZeeMedia looked into virus myths and found that they were widespread. Conspiracy theories are rife and the anti-vaccination crowd within the UK are quite vocal. The ECDPC have a best practice guide for that too, however and advise on how to respond to vocal vaccine deniers in public. There doesn’t seem to be enough in the UK media decrying this behaviour and so far social media publishers have done very little to tackle the issue responsibly.
The catalogue defines vocal vaccine deniers (VVDs) as those who “do not accept recommended vaccines, are not open to a change of mind no matter what the scientific evidence says”. They suggest that these people are perhaps a lost cause and that the main aim of any tackling of these people is to bear in mind their audience: the target audience of any intervention is the general public and vaccine hesitant, rather than vocal vaccine deniers themselves. Thy suggest the following three steps for dealing with VVDs:
- “Disentangle core points and address each separately;
- “identify the technique the denier is using to misinform the public”;
- “respond with key messages”
Something the government have so far failed in doing is directly addressing vaccine fears and perhaps even only exacerbated them, by changing public messaging about the gap between doses with – what the public see as – very little evidence. Given that Pfizer themselves distanced themselves from the extended gap between doses, it’s little wonder that faith in the notion was shaken.
Recent reports indicate that communication apps like WhatsApp are another source of misinformation. Indeed, a close contact of my own recently forwarded me a message that had been circulating amongst her friends and family. She is muslim and the message contained 9 worrying half-truths and facts about the vaccination. The source is not clear, but included warnings that no tests had been performed to determine long-term side effects. She told me the message had been forwarded from a family friend but the original source was not clear.
Christina Marriott, the Chief Executive of the Royal Society for Public Health noted in December 2020 that “anti-vaccination messages have been specifically targeted” at certain ethnic and religious communities. Vaccines deployment minister Nadhim Zahawi encouraged people to check information from “official sources” and said the vaccine was an “incredibly well developed scientific endeavour”.
NHS Race and Health Observatory
In May 2020, the NHS Race and Health Observatory was created, according to the BMJ, to “investigate the impact of race and ethnicity on people’s health and to identify and tackle the specific health challenge facing people of black and ethnic minority origin”.
When the Observatory was announced, Sir Simon Stevens, the CEO of NHS England said
“Ethnicity and race have been shown systematically to influence our health, independent of factors such as age, sex, and socio-economic status. The coronavirus pandemic has injected stark urgency into the need for more action to both understand and tackle deep-seated and longstanding health inequalities facing people from black, Asian and ethnic minority backgrounds.”
He vowed that the Observatory would “bring together expertise to offer practical, useful suggestions for change”.
The NHS Race and Health Observatory’s Director, Dr Habib Naqvi MBE, announced the full board of non-executive directors in mid-January. Its members include the Chair of the Council of the British Medical Association, Dr Chaand Nagpaul and Professor Sir Michael Marmot, of the UCL Institute of Health Equity.
Dr Nagpaul, on his appointment, said “The creation of the Race and Health Observatory is a pivotal moment in the efforts to overcome longstanding race inequalities in health”.
“Through utilising data, evidence and expert analysis, the Observatory will have a key role in recommending action to address inequalities facing BME communities and NHS staff, and vitally, to improve outcomes.”
However, as the vaccine rollout gathers pace and the Clinically Extremely Vulnerable and over 70s start to be offered their jabs, one has to wonder just how many vaccinations have been turned down by older members of Black, Asian and minority ethnic groups. Especially in those old enough to be first generation immigrants who still hold a distrust in authority, living memory of abuse as well as painful lived experience of chronic systematic and endemic racism.
It’s clear that vaccine hesitancy threatens the health of our nation as well as the health of our minorities, something that can only widen the gap in health equality in the UK.
The NHS Race and Health Observatory needs to act quickly to tackle misinformation. Encouragingly, the data from the survey that identified the concerns in the UK Black, Asian and minority ethnic communities willingness to be vaccinated did identify that these respondents were “especially receptive to offers of further health information”.
The RSPH said “these polling results reinforce the need for dedicated efforts to support vaccine uptake among BAME communities, who have already suffered far higher COVID death rates throughout the pandemic”
As vaccinations of health staff continue apace, many from varied backgrounds are doing their best to encourage others to proffer their arm for the needle. Zimbabwean Clinical Service Lead Fungai in Barnet, Enfield and Haringey NHS Trust, known online as @ThatZimNurseFue, is a “BAME C-19 Vaccinator”. She shared her own experience on Twitter, with a poster showing her in a brightly coloured headdress, proudly showing her vaccination card.
Kamlesh Khunti, a GP and Professor of Primary Care Diabetes & Vascular Medicine tweeted on January 28th that he was wholly unsurprised by the BBC headline that that Black over-80s are ‘half as likely’ to have been vaccinated, as this is also seen in flu vaccination programmes. He also pointed that it was predicted in the SAGE report and that we need to implement the recommendations.
Many conversations are ongoing and more and more efforts are being put into working on this difficult issue
Indeed, as Khunti noted, a document named “Factors influencing Covid-19 vaccine uptake among minority ethnic groups” did foresee exactly this scenario and it suggested “[b]arriers to uptake must be understood and addressed within the Covid-19 vaccination programme.
In agreement with the ECDC, then, the SAGE publication suggests:
“To overcome these barriers, multilingual, non-stigmatising communications should be produced and shared, including vaccine offers and endorsements from trusted sources to increase awareness and understanding and to address different religious and cultural concerns (such as whether the vaccine is compliant with the dietary practices of major faiths, or with their ethical positions around medical interventions).”
“Community engagement is essential as health messages and vaccine distribution strategies must be sensitive to local communities. Community forums should include engagement with trusted sources such as healthcare workers, in particular GPs, and scientists from within the target community to respond to concerns about vaccine safety and efficacy”
“ Trust is also undermined by structural and institutional racism and discrimination. Minority ethnic groups have historically been a under-represented within health research, including vaccines trials, which can influence trust in a particular vaccine being perceived as appropriate and safe.”
Adil Ray OBE, the British actor, comedian and creator of popular show, Citizen Kahn, was amongst other British actors and other celebrities of varied heritage who recently came together for a video imploring others to take up the vaccine. The video includes the information that some of the scientists who were involved in developing the vaccine are in fact Muslim themselves, hopefully inspiring pride in those who have viewed it. At last count, 454,000 people had viewed the video on Adil Ray’s Twitter account, but the video is hosted in varied places so it’s impossible to know the true impact or reach. Replies to Ray’s tweet are varied, but some include the misinformation that vitamins and a healthy lifestyle are enough to combat the disease should it be contracted.
The video, also featuring Rageh Omar, Sadiq Khan, Meeral Syal, Konnie Huq, Romesh Ranganathan and Sanjeev Bhaskar calls out common concerns, including the anxiety at the speed at which the vaccine has been developed.
Dr Ranj was recently featured on an ITV advert and also appears in tweets from the Department of Health and Social Care in his capacity as an intensive care doctor
What more can be done?
Whilst celebrities appear to have answered the clarion call for working on the anxieties of their communities, what more could be done? Professor of Diabetes at University Hospital Birmingham, Dr Wasim Hanif suggests that most of the people being targeted on Twitter won’t be found there. He suggests that “The right mediums to promote vaccine uptake in ethnic minorities are Asian TV channels, Radio and WhatsApp”.
Bell Ribeiro-Addy, the Labour MP for Streatham, wrote an impassioned plea for the UK government to put “BAME communities at the heart of the Covid vaccination drive” and pointed at the Prime Minister’s denial of the reality when her colleague Apsana Begum MP “pressed [Boris Johnson] on prioritising BAME communities for vaccination and asked if he acknowledged that structural racism had led to these health disparities”.
She suggests a three step approach, arguing alongside the Royal College of GPs to raise BAME communities in vaccination priority lists and run “targeted public health campaigns”. Finally, she suggests that culturally competent guidance is required, alongside a focus on recording ethnicity data to monitor uptake and enable proactive adjustment of targeting and messaging.
Whatever the government does, we must all work together towards encouraging everyone who is eligible to take the vaccine. We’ll never get through this without a real community effort.