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Exploring Inequalities and Community Experiences of the COVID-19 Vaccination Programme in Greater Manchester

Added Value Case 2021/22

The COVID-19 vaccine programme was rolled out rapidly for public health reasons with little known about whether the barriers to uptake would be similar to those seen with other vaccines such as influenza.

Understanding potential barriers to uptake is an important step in implementation of vaccine strategies that reduce inequalities.  

We  investigated the equity in COVID-19 vaccination coverage in Greater Manchester (GM),  comparing and contrasting data with influenza vaccination coverage using available data from the Greater Manchester Care Record (GMCR).

A detailed in the published paper in PLOS Medicine, we found that ethnic inequalities in COVID-19 vaccine uptake are wider than those seen previously for influenza vaccine and exist even among those recently vaccinated against influenza.

Most worryingly these inequalities were highest amongst people at the highest risk of severe COVID-19, namely older and more clinically vulnerable people, and those living in the most income-deprived areas. The findings overturn the prevailing view that COVID-19 vaccine uptake would simply follow previous trends in people’s willingness to take up vaccinations.

We worked with local communities to explore the experience of the roll out of the COVID-19 vaccination programme, identifying themes which could explain these inequalities.  Existing mistrust stemming from racism, experiences of culturally insensitive healthcare, and awareness of previous unethical healthcare research were all themes raised. Concerns about potential unknown side-effects of COVID-19 vaccines compared with existing vaccines may have been heightened among people from minority ethnic groups due to their underrepresentation in COVID- 19 vaccine trials.  The full summary report is available here.

This work has received numerours awards for it's approach to public engagement; the 2021/22 NIHR Greater Manchester Clinical Research Network's 'Recognising Outstanding Engagement' award; along with two commendations at the 2021/222  University of Manchester ‘Making a Difference’ Social Responsibility Awards  under the categories of  “Outstanding benefit to society through research” and “Outstanding public engagement initiative”.

It also informed a programme of work funded by NHS England's NHS Insights Prioritisation Programme (NIPP), on 'Optimising vaccination in Greater Manchester' in which we are working with the local health and care system and Health Innovation Manchester to gain further insights into promising approaches to targeted vaccination and exploring opportunities for local implementation. 

What has changed as a result of our research?

Our data analysis identified inequalities in vaccine uptake within Greater Manchester (GM), with results from focus groups and interviews providing key insights into the drivers behind these inequalities and informed evidence-led approaches to support vaccine uptake.

The insights from this research have been fed back to senior NHS and Local Authority staff, the GM Vaccination Lead and locality Vaccination Leads, with a positive reception to date. It is anticipated that insights will shape the local response to the Autumn 2022 vaccination programme and further scope for impact is being discussed. 

We have held regular meetings with Manchester City Council Public Health team and vaccination leads to discuss  findings and presented our results at the ARC-GM Stakeholder Workshop (March 2022) and received positive feedback from people working within the GM health and care system.

Our report on uptake amongst young adults has been circulated to GM Vaccination leads, NHS/Greater Manchester Health and Social Care Partnership colleagues, local council public health teams (Rochdale, Oldham, Manchester), the Cabinet Office.

Our insights, propose the wider use of evidence-informed approaches, some of which have been used successfully during the pandemic in areas of GM. 

In particular, the use of text message and/or reminder telephone calls for vaccination appointments; use of home visits to advocate vaccination by culturally skilled volunteers and vaccination during home visits (by health care professional or community health workers).  

Where possible we suggest disinvestment in approaches used locally that contravene these insights, such as the use of market research staff to undertake door-to-door vaccination awareness raising in specific communities. 

Local staff also recognise that, to maximise success, targeted vaccination activities should be guided by relevant local community members. For example, successful women-only clinics and clinics delivered in faith-based settings were developed locally in response to community feedback. More widely, pop-up or mobile vaccination options were deemed most effective in reaching target communities when they were supported by local engagement activities.

We have made national connections, with preliminary discussion held with HM Cabinet Office inter-agency vaccines team  to share research agendas and details of our vaccine related workstreams, along with follow-up meetings with Cabinet Office Research and Insights team.

We have held regular meetings  with Manchester City Council Public Health team and vaccination leads to discuss emerging findings. We have shared the draft manuscript with the team. We also presented results at the ARC-GM Stakeholder Workshop (March 2022) and received positive feedback from people working within the GM health and care system.

We have undertaken further analyses of local area vaccination coverage, again using the Greater Manchester Care Record. We extended our previous analyses to identify areas with lower than predicted vaccination coverage (based on available demographic data).

These additional data-driven insights, alongside stakeholder engagement will help to identify areas and communities for further implementation, with evaluation of these ongoing efforts to improve local confidence and convenience for vaccination. 


Next steps

Greater Manchester has seen high rates of COVID-19 and disproportionally high virus-related morbidity and mortality. Whilst vaccination has been hugely important in preventing COVID-related hospitalisation and mortality, varying rates of vaccine uptake mean some local communities remain more at risk. Identifying inequalities is a vital first step in addressing them.

In addition, our work has generated insights into the drivers of inequalities in vaccine uptake, suggesting what could be done to increase equity in vaccination rates. This research is aimed at reducing inequalities in vaccination and increasing overall rates and will provide a legacy of best practice for vaccination delivery of all types in GM.

Our research  has wider implications beyond vaccination delivery, in which learning can be applied to wider public health interventions in terms of public and community support for local public health measures, especially for future public health crises.  As part of NHS England's NHS Insights Prioritisation Programme (NIPP), funded 'Optimising vaccination in Greater Manchester' research, we are working with local health and care system colleagues to look at future strategies.

We are also expanding this work from a focus on Greater Manchester, to look at data from the whole of England, relying on data from the British Heart Foundation's Data Science Centre.

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