The vaccination rollout in the UK has accelerated in light of the Delta variant and 50% of adults have now had their second covid-19 vaccination. Parth Patel and Thomas Byrne consider how to increase vaccination rates in hard to reach populations

With cases of the Delta (B.1.617.2) coronavirus variant on the way up, our collective anxiety is increasing with it. One way this is manifesting is in renewed fears of vaccine hesitancy, which has fought its way back to the front pages. Matt Hancock, the Secretary of State of Health and Social Care stoked this when he suggested that vaccine hesitancy is behind the surge of the latest variant of concern (it is not).

Concern about vaccine hesitancy is understandable. Vaccines are our way out the pandemic. But whether you want a vaccine is not the only factor that determines whether you get a vaccine. This is a statement of the obvious, but one that is often forgotten in the conversations around ethnic disparities in vaccination rates. It is commonplace to use vaccine hesitancy and vaccination rates interchangeably. 

Perhaps this is because early evidence of higher levels of vaccine hesitancy in some minority ethnic communities mapped well onto ethnic disparities in vaccination rates. But in epidemiology Ockham’s razor is rarely right. Although vaccine hesitancy has been falling dramatically across ethnic groups, according to data from UCL Virus Watch study, Ipsos Mori and the Office for National Statistics, vaccination rates between ethnic groups remains highly unequal. Data up to 12 April shows 93.7% of White British adults over the age of 50 have had at least one vaccine dose compared to 66.8% of Black Caribbean adults and 71.2% of Black African adults over 50. Is it possible that something other than vaccine hesitancy is contributing to these disparities? 

A recent analysis of survey data from 1.4 million adults aged over 55 found people from most ethnic minority backgrounds were more likely to report difficulty walking compared to White British people. The Department for Transport’s national statistics show 39 per cent of Black adults live in households without a car, compared to 17 per cent of White adults. Analysis of Understanding Society data found Black adults and Asian adults over the age of 65 are both around twice as likely to report having no friends who live locally, despite stereotyped assumptions of ethnic minority social networks. It stands to reason these factors might make it more difficult to travel to a vaccination centre. Instead of pointing to the irony of people from ethnic minority backgrounds rejecting a vaccine (given their greater risk of harm from covid-19), the structural racism that shapes covid-19 mortality patterns may also be shaping covid-19 vaccination rates.

This is not to say that vaccine hesitancy is not a problem. To be clear: it is, and although diminishing in scale, will continue to be. But the hyperactivity around hesitancy has led to an attention deficit to structural barriers to vaccine access. 

The result is most policy efforts to narrow vaccination disparities have focussed on information provision. That includes translating public health messages and communicating through trusted voices, such as community leaders and celebrities. These are important, but unlikely to be sufficient alone. That is because such efforts converge on the same thing: giving individuals more information so they can act responsibly. It ignores that information is of little value if you are constrained in your ability to act on it.

Instead of merely asking people from ethnic minority backgrounds to “take control of their own health”, as the government-backed Sewell commission did recently, inequalities would be better addressed if policy targeted structural factors as well as individual agency. For the covid-19 vaccination programme, that might mean taking vaccines to people, instead of asking people to travel to receive their vaccines. Indeed, we may find that door-to-door vaccines, now being piloted in some parts of the UK, are effective at reducing ethnic disparities in vaccination rates. 

Getting vaccinated is a choice, and most people are considering the vaccine carefully and saying yes when it is their turn. But not everyone has an equal chance to enact that choice. To achieve high and equitable vaccination coverage, policy should focus not just on vaccine attitudes, but vaccine access. 

Parth Patel is a clinical research fellow at the UCL Institute of Health Informatics 

Thomas Byrne is a research associate at the UCL Institute of Health Informatics 

Competing interests: none declared.