Getting Under the Skin: Addressing Vaccine Hesitancy in Different Ethnic Communities
Edna Boampong
NHS Shropshire
Telford and Wrekin Integrated Care Board

accine hesitancy among ethnic minority communities has been a challenge to the COVID-19 vaccine program in the UK. This case study explores how the Cheshire and Merseyside Health and Care Partnership addressed this challenge, resulting in significant improvement in vaccine uptake in a short period of time. Among the issues explored in this “deep dive” are reasons for vaccine hesitancy, addressing communication challenges, managing the nuances of different ethnic minority communities, and seeing how aspects of this regional action have been transposed to a national platform.

A few months into the COVID-19 pandemic when I worked in the Cheshire and Merseyside health and care system, I secured funding to commission a program to gather insight into the impact COVID-19 was having on ethnic minority communities. The goal was to find out more about how different ethnic groups were perceiving the vaccine that was about to be rolled out.

As the first and only system in the UK undertaking this effort, the work provided us with an incredible amount of insight ahead of the vaccine rollout and enabled us to massively increase vaccine uptake within ethnic minority groups in Cheshire and Merseyside. It put us ahead of the curve and won three prestigious national awards in 2021: two NHS Communicate Awards (“Best Behaviour Change or Public Health Campaign” and “Use of Insight and Data for Innovation in Communications”) as well as the Health Service Journal (HSJ) Award (“NHS Communications Initiative of the Year”). The work now informs not just the Cheshire and Merseyside’s communication and engagement approaches, but also their commissioning decisions.

What We Faced

Daily reporting in the press and social media of the significantly high and disproportionate number of deaths of ethnic minority NHS staff and other key workers was extremely worrying. Ethnic minority groups were also experiencing disproportionate deaths in their own communities and felt isolated and ignored. There was increased distrust among different ethnic minority groups towards the UK government’s messaging relating to COVID-19.

In December 2020, COVID-19 vaccination uptake data across Cheshire and Merseyside showed that there was a lot of vaccine hesitancy in the area, especially among ethnic minority groups.

The genuine concerns at the root of the vaccine hesitancy were underpinned by uncertainty and ambivalence. Some of these stemmed from individual and group experiences of healthcare, and others related to feeling disenfranchised and lacking access to credible information. A “one-size-fits-all” approach simply wouldn’t work.

What We Did

In this situation, quick and responsive public health thinking was essential. We needed to gain a better understanding of the cultural, behavioral, and religious aspects that influence health and care within these communities, and what might influence their decision to take the COVID-19 vaccine.

This program of work started before the vaccine rollout and led to a significant increase in vaccine uptake in just four months.

A consortium of partners including NHS England (NHSE), Public Health England (PHE), and Cheshire and Merseyside’s directors of public health provided the funding for the research. The steering group included representatives from local authorities, the NHS, PHE, and the voluntary and community sector.

A unique interactive tool was developed during Stage 1 of the campaign which used school census data, indices of multiple deprivation (IMD), and other data sources to refresh the outdated census and give a current understanding of each postcode’s ethnic communities. This enabled us to see exactly where people of different ethnicities lived and segment each group into higher and lower deprivation clusters.

In Stage 2 of the program, we engaged with over 600 residents across all 16 ethnic groups in a detailed quantitative research study.

GPs from the different communities were closely involved in the research, and this contributed to uncovering a myriad of reasons for vaccine hesitancy. These included:

  • concerns over leaving the house
  • travel and access could lead to catching the virus
  • the relative speed at which the vaccine had been produced
  • the vaccine’s efficacy and side effects.

Research showed that the Romani, Irish, Bangladeshi, and some black or mixed groups were the strongest rejecters of the vaccine (over a fifth of residents).

In Stage 3, we wanted to explore the views and themes which had emerged from Stage 2 in greater detail. In early October 2020, we commissioned a research agency that could speak in the languages of some of the key communities to undertake a number of focus groups and in-depth interviews. This meant that the program could engage with “seldom heard” groups, particularly those whose first language was not English.

We then used the insight from the three-stage research program to deliver a behavior change campaign to address the vaccine hesitancy within ethnic minority communities. The campaign also included clear recommendations on how the National Health Service (NHS) needed to work in conjunction with GPs, local community organizations, and faith groups on a program of engagement to build trust.

Partnerships were crucial in ensuring that the right messages reached the right people. Directors of public health were instrumental in connecting teams to those who could cascade the information out. Although health teams were closely involved in delivering the vaccine itself, volunteers also played a key role in reaching out to lots of community groups; mosques, mental health teams, and other services were all involved, and each group was given the tools and materials to deliver their own tailored communications.

Key Outcomes and Benefits

The campaign successfully influenced a long-standing cultural shift in NHS communication and engagement with ethnic minority groups.

  • Increased vaccination uptake in ethnic minority communities from 0.7% in February 2021 to 38.4% in May 2021.
  • Valuable insights gained into how COVID-19-related messages are perceived and acted on by different communities, which were shared nationally.
  • Working closely with different partners helped to quickly build trust.

Outcomes and Benefits

The program used multiple recruitment methods to reach out and engage with communities and enable everyone to provide their views to help us shape our communications approach, including:

  • an online panel
  • social media
  • public relations
  • community outreach
  • local businesses engagement

This helped capture valuable insight into what the program could be doing to improve NHS communication and interventions with these communities. This was a significant challenge given that English was not the first language for 35% of respondents.

We also teamed up with local ethnic minority representatives; this enabled us to directly address the main barriers identified.

The campaign resulted in an impressive uptake in vaccination rates. In February 2021, only 0.7% of minority ethnic individuals who were eligible came forward for vaccination, but this increased incrementally to 13.1% in March, to 30.6% in April, and to 38.4% in May.

The outputs and results from the research program and campaign have been shared nationally. The campaign insights were widely viewed as a trailblazer for significantly contributing to a long-standing cultural shift in NHS communication and engagement with ethnic minority groups.

On Reflection: “Nuances Matter”

I am reflecting on our efforts in this article because the issue was and still is incredibly important to me personally and why I fought hard for this project to get the financial support it needed.

Broad assumed hesitancy was a barrier, so we needed to get quick and essential understanding of the nuances within every different community, as well as the cultural, behavioral, and religious aspects that influence health and care.

For example, vaccine hesitancy campaigns across the Northwest of England initially targeted predominantly the Asian community, but within the Cheshire and Merseyside area there was hesitancy within all ethnic communities and for different reasons.

The research showed there was less vaccine hesitancy in the Indian community than in the Pakistani community and more hesitancy in African groups than in the Afro Caribbean communities. A recognition of these nuances was essential. This meant developing effective strategies and messages for all the different groups within different ethnicities and in turn recognizing their differing concerns and issues.

It’s important that we start building more trust within ethnic minority communities. A significant challenge that surfaced repeatedly during my insight research was the issue of trust. People from ethnic minorities often don’t trust the establishment; they don’t really believe public sector organizations care about them or value them, and people from ethnic minority communities often feel disenfranchised. We, in the public sector, need to demonstrate that we truly believe in equality, diversity, and inclusion and it isn’t just a box-ticking exercise.

The fresh insights uncovered in this case study will leave a lasting legacy and create a cultural shift for not only Cheshire and Merseyside, but for organizations across the country to learn more effective ways to engage with ethnic communities and adapt services and interventions accordingly.

Contact Details

Edna Boampong, Project Director
Director of Communications and Engagement, NHS Shropshire, Telford and Wrekin Integrated Care Board