Earlier this month, when I was shown figures from the UK Health Security Agency about take-up of the flu vaccine in London towards the end of last year, a memory bell rang.
The striking thing about the stats was the low percentage of Londoners in certain vulnerable groups who had received the free jab to which they were entitled. For example, as of the end of November, only 57.4 per cent of London’s over-65s had been vaccinated against flu compared with 71.4 in the same age group across England. It was much the same with pregnant women and very young children.
During the pandemic, London had stood out as place where rates of failure to receive an injection against Covid-19 were higher than elsewhere, with much attention being paid to the “hesitancy” of some ethnic groups.
Different population categories, different disease, different vaccine, different times. But did the low flu jab figures tell a similar story to their Covid-period counterparts? If so, what did they tell us about continuing barriers to Londoners receiving vaccines and any progress made with breaking them down?
Last week, I spoke about these things to Professor Kevin Fenton, who became a familiar figure to many Londoners during the pandemic, initially as the public face of Public Health England in the capital.
In October 2021 he became, and remains, London’s regional director in the Office for Health Improvement and Disparities, which inherited Public Health England’s health improvement functions as part of a reorganisation. One of his other roles is being Sir Sadiq Khan’s statutory public health adviser.
“London, in general, tends to have lower vaccination uptake rates than the rest of the country,” Fenton said. “This pre-dates the pandemic and there are many reasons for it”. Similar patterns are seen in other global cities, such as New York, Paris and Berlin. It’s a big city thing. But London is, of course, distinctive in a wealth of ways.
Having stressed that “vaccinations are critically important” amid the so-called “quad-dremic” of flu, Covid, norovirus and respiratory syncytial virus (RSV), Fenton breaks down the different factors that form London’s low level embrace of them.
Rates vary across the city’s population mosaic and so do the reasons for that. It isn’t all about hesitancy. While there is reluctance rooted in mistrust of health and care services and in some medication itself, separate and sometimes overlapping socio-economic factors are part of the picture too.
“More economically disadvantaged parts of the city tend to have lower vaccine rates than more affluent parts,” Fenton says. “If you are affluent, often you are more engaged with your health. You are probably more able to make better decisions about prioritising your health interventions. You know how to navigate the system.”
By contrast: “If you are struggling with putting food on the table or dealing with heating in your homes. If you don’t trust your health care services, you are less likely to be engaged and to take the steps you need to take the vaccines, even though it’s free.”
The pandemic threw into relief a lack of confidence in health services among some minority groups. As Fenton puts it, it “magnified” differences between different groups that had already existed: “For some, there is a mistrust of the health and care system. With Covid, lots of communities were concerned about the safety and effectiveness of the vaccine, and how quickly it was developed.”
He goes on to emphasise the diversity of reasons for not getting the vaccine within London’s famously diverse population. The problem in some cases was past “bad experiences with the health care system, and so they don’t want to have to go in and have to navigate with the receptionist or talk to a doctor who is not listening to their health needs”.
Reasons vary from ethnic group to ethnic group, but also according how Londoners make a living and other features of their lives.
“It really varies, from Orthodox Jewish communities to black African communities, to Caribbean or Polish communities,” Fenton says. A particularly interesting strand of Covid outreach work was with London’s Romanians, many of whom were receiving information about the pandemic from their country of birth and replicating the high hesitancy level there. And there were others.
“Even in our Chinese communities at the beginning of the availability of the vaccines we saw low uptake rates. I remember in the very early days we did lots of work with Chinese community leaders, having vaccination sites in Chinatown and other areas where we have high Chinese populations,” Fenton says.
“People will understand and relate to the health care system in different ways. But we also know that the practical aspects of getting a vaccine matter. If you have to hold down two jobs to survive, going to your GP practice to arrange to get the vaccine is much harder.” The same may apply if a parent needs to arrange childcare in order to go out to get the jab.
“These low levels of take-up that you’re seeing cannot be explained by the black and minority ethnic population only,” Fenton stresses, with reference to the recent flu figures and others. He points to “generally low uptake rates in our black Caribbean and black African communities, Bangladeshi and Pakistani communities compared to others” but also “high uptakes among British Indians”.
Among white Londoners, a category very much not confined to white British, “we see a lot of variation,” Fenton says. “This is a problem affecting a range of Londoners of all backgrounds. When you have a 32 per cent vaccine uptake, that is not a black issue or a minority issue. That is a Londoner and Londoners issue.”
Looking back to Covid, Fenton recalls the work that was done “to reassure people on the safety and effectiveness of the vaccines”. Additional funding provided as the coronavirus took hold meant it was possible, informed by high-quality data, to focus tailored programmes on groups and communities that were coming forward in smaller numbers, involving “community champions” doing outreach work and vaccination centres being set up in mosques, churches and public buildings to build confidence and maximise convenience.
For Fenton and like-minded colleagues, the additional money enabled “lots of fabulous lessons” to be learned, leading to the conclusion that “delivering a universal service alone and expecting everybody to access it would not work for London”. Ways to provide more equitable and effective services and better public health across the city were identified and enacted. But are they still being put into effect?
“The short answer is we have implemented a number of those lessons from the pandemic, and that has helped us to shape the programmes we have today,” Fenton says. However, delivering what he calls “an enhanced programme” as distinct from simply a universal one, often needs more resources. Post-pandemic, those extra resources have become more difficult to secure, with many competing demands for them. However, Fenton picks out examples of pandemic innovations that have endured.
One is a very local project in the inner east of the city, “the first-community-developed campaign on vaccination in London”. This has entailed “deep engagement” with the Bangladeshi community there. Good, bespoke communications methods are a part of that, addressing a need Fenton regards as a “core lesson” derived from the pandemic.
Another is the huge value of sophisticated data: “I have the privilege of chairing the London immunisation board. We now understand where across the city communities with low vaccination rates are and have the ability to do deep work with the NHS and local government in a new way.”
Spots of low take-up within boroughs and even within wards can now be detected, enabling more effective action to be taken. “None of the patterns that we see are permanent or immutable,” Fenton insists. “What we have learned is that when you are able to target, build trust, engage and use that process to really focus on communities, you can turn things around. This works for vaccinations, and we know it works for screening and for the health check programme too.” His conclusion? “This is what public health is about.”
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As a white British person my lack of uptake for any flu or COVID jabs is based on experience. I had severe blood clots after my second COVID jab and a couple of years ago when I was persuaded to have a flu jab I became seriously ill with the flu. Also my sister’s skin was like a prune after her COVID jab and it was hard to move her arms and one of my friends is still battling with paralysis of the arm where she had the injection. I will not be having another vaccination for either conditions. I have had COVID, it was like flu and lasted 2 weeks. I don’t know if the jab helped me get over this quickly or my immune system is good. I am not complaining, only offering some information as to why there is such a low uptake. I wonder if the blood type of each person is taken into consideration…I think this would help.