Which groups are at risk of under-vaccination? – Expert Reaction

Expert Reactions  |  Published:

While 80 percent of New Zealand’s eligible population is either vaccinated or booked in to get a Covid jab, challenges remain in reaching people on the rollout’s final frontier.

The SMC asked experts to comment on:

Dr Janine Paynter, Senior Research Fellow, Faculty of Medical and Health Sciences, University of Auckland, comments:

“If we look at childhood immunisations we find that remote and rural areas are slower in getting their vaccines. For example, the 6-month vaccination coverage tends to be lower in areas that have comparatively lower access to basic services such as the West Coast. However, the interplay between access to services and deprivation is important because other rural areas such as Southland, which has lower deprivation, has good vaccination rates. Moderately-deprived West Coast vaccination rates catch up with the national average by two years. Northland, suffering both in terms of access to services and having higher deprivation, has consistently low vaccination rates for both childhood immunisation, even by 2 years of age, and is lagging with Covid vaccinations.

“Distinguishing where lower coverage is caused by strong anti-vaccine sentiment from access, unpleasant past experiences with health providers, poverty and transience, and other issues, is quite difficult. For example, looking at declined vaccinations recorded by the Ministry of Health it’s only 5.4% for the 5-year age group. However, the immunisation coverage is about 87% so there is at least 7% of the population for whom there may be a range of barriers to vaccination.

“It’s important to remain optimistic and open to people changing their minds about the vaccine. Health providers and community leaders who have good relationships with their community have an important role in addressing safety concerns, and promoting the benefits of vaccines with respect and patience.

“The Horizons survey on vaccine uptake, while important and useful, is a relatively small non-random sample of New Zealanders. Depending on how participation in this particular survey was promoted or advertised, and then how much discretion is given to skip questions, there may be a bias towards participants who sit at the passionate ends of the spectrum with respect to vaccines, and therefore the results will over-estimate strong anti-vaccine sentiment in New Zealand.”

Conflict of interest statement: “Some of my work on vaccines and infectious disease is funded by GlaxoSmithKline (GSK) a company that manufactures and sells pharmaceuticals including vaccines.”

Dr Jesse Whitehead, Research Fellow, Te Rūnanga Tātari Tatauranga – National Institute of Demographic and Economic Analysis, University of Waikato, comments:

“Although 80% of the total eligible population has either been vaccinated or is booked in, it is essential that we do everything to ensure that 100% of the eligible population has the opportunity to become vaccinated. In particular, we need to prioritise coverage for populations at greatest risk of severe outcomes from Covid-19 infection – Māori, Pacific, disabled people, older people, and people living with socioeconomic constraint.

“Research shows that health services in general are often inaccessible for these priority populations. This can be due to an undersupply of services in areas of high need, a lack of after-hours services, poor physical access for disabled people, and systems that don’t work for people with complex lives and complex needs.

“These issues within the health system have translated into an inequitable vaccination rollout. The distribution of Covid-19 vaccination services has favoured wealthy, white, and urban populations. This has resulted in inequities in vaccination coverage, particularly for Māori. In regions where access to vaccination services is worse, the relative rate of vaccination coverage for Māori is also worse. Although we are yet to see an urban-rural or socioeconomic breakdown of vaccination coverage, I would expect that there are also significant ethnic, socioeconomic, and rural-urban inequities in vaccination coverage within DHB regions.

“In some places Māori and Pacific providers, iwi, and DHBs have mobilised to take the vaccine to people. These efforts need to be better resourced and scaled up to ensure that nobody is left behind – giving all communities protection against Covid-19.”

No conflict of interest.

Livvy Mitchell, Research Analyst, Motu Economic and Public Policy Research, comments:

“Discrimination exists in the access to primary health care in Aotearoa. Our report, evaluating the right to health care and protection in Aotearoa, shows that Māori, Pacific Peoples, disabled people, and people living in lower socioeconomic areas are consistently missing out on doctors and dentist appointments more than others. Some progress has been made for improving the ethnic gap in children’s access to primary health care, but Māori and Pacific children are still clearly disadvantaged.

“The New Zealand Health Survey shows adults’ and children’s unmet needs for health care exists because either the appointments are too expensive, there is no transport available to get to the appointments, or because there are simply not enough appointments available. In the case of children’s unmet need, this also includes the lack of childcare for other children. When we see the same groups of people consistently have a higher unmet need for primary health care compared to others, this suggest there is ongoing structural and direct or indirect discrimination in the access to health care in Aotearoa – a failure by the New Zealand Government to ensure the right to health care and protection is enjoyed by all our people.

“Given these inequalities in primary health care access have existed for a long time, it is reasonable to expect that these populations are also at risk of having unequal access to COVID-19 vaccinations, resulting in under-vaccination. While appointments to get vaccinated are free in Aotearoa, accessing such appointments may still be more difficult for these people if transport, childcare arrangements, and other accessibility factors are not considered in the vaccination roll-out. The New Zealand Government’s recent initiative of offering free taxi rides to people in Tāmaki Makaurau to get to vaccination centres for their first dose is one step in the right direction toward addressing unequal access to COVID-19 vaccinations.”

Conflict of interest statement: Motu is an independent, charitable trust. The findings, conclusions, recommendations, and opinions expressed in our report remain our own and do not necessarily reflect the views of our funders or contributors.

Associate Professor Malcolm Campbell and Dr Matthew Hobbs, GeoHealth Laboratory, University of Canterbury:

“Accessibility to healthcare, and how easy it is to get to and from a place, has many components and is one of several wider systematic barriers that is currently preventing the New Zealand population from achieving optimum vaccination rates.

“Accessibility to healthcare services in Aotearoa New Zealand (NZ) has historically been inequitable. This means that some people can get to healthcare services easier than others. This is important as inequitable service distributions often means that people with poor access to health services are less likely, or less able, to use those services. This includes the inequitable geographical distribution of health services such as hospitals and now COVID-19 vaccination or testing centres. Recent evidence in New Zealand has suggested that spatial accessibility is not shared equally across the vaccine-eligible population. Our studies have shown that priority populations which include Māori, older people, and residents of areas with socioeconomic constraint have, on average, lower spatial access to vaccination services. This was also true for people living in rural areas.

“Ministry of Health guidance has suggested factors which include pre-existing long-term health conditions, areas of high deprivation and a high proportion of Māori/Pacific populations may be at greater risk of contracting COVID-19 and related adverse complications. It is worrying that hurdles to accessing the vaccine disproportionately impact on those who are at the most risk of Covid-19 in terms of transmission and adverse complications. The GeoHealth Laboratory has previously mapped out which areas of New Zealand have a high proportion of older adults alongside high numbers of long-term health conditions, Māori/Pacific populations and areas of high socioeconomic deprivation which importantly includes measures of overcrowded housing. This also points to our housing crisis becoming an important issue in the COVID-19 pandemic. Combined together with evidence which predicts Delta’s spread we know who and we know where we need to prioritise for vaccination.”

No conflict of interest declared.

Dr Rhys Jones, Public Health Physician and Senior Lecturer in Māori Health, University of Auckland, comments:

“Māori are at serious risk of under-vaccination due to systemic failures in the Covid vaccine programme. There are significant inequities in vaccine coverage which, if not urgently addressed, will leave Māori communities with dangerously low levels of coverage. This is extremely concerning as Māori and Pacific communities are at much higher risk of serious outcomes from Covid-19 than other ethnic groups.

“There are many complex factors behind the failure of the programme to achieve equitable coverage. However this outcome was predictable given the Ministry of Health’s approach to the vaccine rollout. It followed a typical ‘mainstream’ health system recipe, with a few specific measures for Māori and Pacific populations. Given the stark social and economic inequities that exist in Aotearoa, and the historical and contemporary impacts of colonisation that result in marginalisation and disenfranchisement of Māori communities, this approach was always going to fail to achieve anything close to equitable coverage.

“We could be in a very different place now if the vaccine programme had been led by Māori from the outset. During the planning phase, a coalition of Māori health providers and community organisations approached the Ministry of Health and offered to provide this leadership. However this offer was not taken up, and we now see massive inequities that need remedial action to fix. Despite this, there is much that can be done immediately to improve Māori vaccine coverage. This will require different leadership, substantial investment, and a shift to prioritise vaccination for Māori. Not only can this be done, it must be done in order to prevent large scale infection and deaths among Māori communities.

“The coverage achieved among border workers (98% of whom have received at least one dose) shows that there is not widespread vaccine resistance in the community. This is likely to be true for Māori – if we get the right leadership, the right relationships, the right incentives and the right workforce, there is no reason why similarly high levels of coverage could not be achieved. If the programme fails to achieve this for Māori it will not be because of vaccine hesitancy – it will be because they have ignored calls from Māori to do what is necessary to achieve equity.”

No conflict of interest declared.

Dr Fran Priddy, Executive Director Vaccine Alliance Aotearoa New Zealand – Ohu Kaupare Huaketo, comments:

“Groups that have lower vaccination rates are sometimes called ‘hard to reach’, but that’s a label put on them because they might not engage with health care/vaccination in the ways we demand. If you turn that perception upside down, it’s not the populations but the program that is not fit for them.

“Looking at other countries and also past experiences with public health outreach locally, there are a number of ways to engage diverse groups. Usually it involves getting down to an almost individual level of communication or influence. Some of these are already being pursued in NZ, but others may not yet be.

  1. Ask people in those groups directly what might work for them, through focus groups or by meeting with key influencers in those groups, and try to deliver on it. If at all possible, put it in the hands of that community to deliver.
  2. Find key influencers in those groups who are willing to spread the word, often by identifying their own network of key influencers who can reach many more people.
  3. Offer individual incentives to get vaccinated, eg cash, lottery ticket, donations, a free meal, a fun event.
  4. Make being unvaccinated an obstacle to enjoyable activities – like attending sports matches, large events, restaurants and shows.
  5. Bring extended families in through their children – school-based vaccination could be considered during the final term of 2021.

“Do all of these things together, not one at a time. These are all easier said than done, and some will raise challenging issues about autonomy and privacy.”

Conflict of interest statement: Dr Priddy is Executive Director of the Government-funded Vaccine Alliance Aotearoa New Zealand – Ohu Kaupare Huaketo, a partnership between the Malaghan Institute, the University of Otago and Victoria University of Wellington. She is Clinical Evaluation Director at Malaghan Institute.

Dr Dianne Sika-Paotonu, Immunologist, Associate Dean (Pacific), Head of University of Otago Wellington Pacific Office, and Senior Lecturer, Pathology & Molecular Medicine, University of Otago Wellington, comments:

“Results from an online survey recently undertaken by Horizon Research indicated that Pacific peoples who had not yet been vaccinated, were no longer the least likely to get a COVID-19 vaccine – these findings were in contrast with previous survey results.

“This Horizon Research work was undertaken in association with the University of Auckland School of Population Health, and showed specifically that Pacific respondents who had not yet been vaccinated, were much more likely to get a COVID-19 vaccine in August (72%), compared with July (62%).

“This result combined with the increasing vaccination rate for Pacific peoples (46% in August, from 26% in July) had lifted the Total Potential vaccination uptake to 85% (July 72%).

“It should be noted these survey results were obtained from 2,334 respondents aged 16 years of age or over in Aotearoa New Zealand, and was carried out between 24 – 29 August, 2021 – prior to the more recent vaccination drives to support Pacific and Māori communities.

“Since this survey, an acceleration in vaccination efforts across the country has resulted in numerous Pacific and Māori-targeted and tailored vaccination events and activities that have been Pacific and Māori-led and community driven, together with Pacific and Māori health providers, which have helped improve vaccine accessibility, and vaccination rates.

“It is hoped more of these highly successful events will be supported to continue as they have an equity focus and utilise approaches that work with people in a way that builds trust, reduces barriers, and is proving successful in reaching Pacific and Māori communities.

“An equity approach means focusing on doing what’s needed to get people the health care and services that they need. Equity-based approaches work because they reduce barriers for people needing to get vaccinated, and in the COVID-19 context, this also involves the Pacific and Māori health workforce leading and delivering vaccination and other services for their communities.

“The COVID-19 pandemic has highlighted inequities in health for Māori and Pacific peoples that were pre-existing, and persistent over time – for decades and generations, and it was known from the outset of the COVID-19 pandemic that Pacific peoples and Māori communities were particularly vulnerable to being disproportionately affected by COVID-19 and would require prioritisation, especially for the vaccination roll-out.

“The implications for the COVID-19 situation moving forward must include having a continued equity focus for vaccination, testing and prevention efforts – this will help reduce barriers, improve access and build trust with communities to ensure people get the help they need, when they need it, whether it be the vaccine or a test or other health and support services.

“We’re continuing to make progress in Aotearoa New Zealand, but vaccination levels will need to continue increasing to help keep everybody safe from COVID-19.”

No conflict of interest declared.

Dr Nadia Charania, Senior Lecturer, Migrant and Refugee Health Research Centre & Faculty of Health and Environmental Sciences, Auckland University of Technology, comments:

“To protect New Zealand society, it is vital that everyone in the country has access to COVID-19 vaccination and that we achieve high coverage rates across the population and geographical areas. National coverage rates can overlook immunisation inequities amongst specific subgroups of the population.

“One subgroup that is at risk of being under-immunised are migrant and refugee background communities. They tend to face substantial barriers to accessing routine vaccinations and therefore are at risk of under-immunisation. The health care system can do more to reduce access barriers related to socio-economic status, language, and culture, to name a few. The COVID-19 pandemic has compounded these existing challenges for those with migrant and refugee backgrounds.

“As we aim for an equitable distribution of COVID-19 vaccines, we must ensure that the specific needs and concerns of migrant and refugee background communities are included in national vaccination plans. A key driver to receive vaccination among migrant and refugee background communities is protection; they are keen to protect themselves, their families, and others.

“It is important that timely and credible vaccine information is translated into migrants’ preferred language and shared widely within communities using various formats and forums. Having cultural mediators and skilled interpreters available would be very beneficial, in addition to offering vaccines at convenient community locations. Importantly – since there is much variation amongst migrant and refugee communities in terms of language, culture, and beliefs – engaging community leaders and organisations to guide tailored information and strategies to improve access to COVID-19 vaccines would be invaluable.”

No conflict of interest. 

Kate Waterworth, Lecturer in Critical Disability Studies, AUT University, comments:

“The Ministry of Health (MOH) does not appear to have collected clear data to inform us of the proportion of disabled New Zealanders (over twelve years old) who are fully or partially vaccinated. This is concerning given we know disabled New Zealanders are more likely to experience poor health outcomes and have issues accessing appropriate healthcare compared with other New Zealanders.

“Earlier in 2021, the MOH categorised New Zealanders into priority groups for vaccination invitations. Group 3 was estimated to have 1.7 million people of higher risk if they catch Covid-19. Many members of this group will identify as disabled (or as having a complex health condition and/or as being older than 65 years).

The Ministry of Health does not have good information as to which individual New Zealanders comprise group 3. MOH data does indicate that at this point 38% or 646,113 people of group 3 are fully vaccinated, with a further 7% of group 3 having had one dose. From this data it appears that there is low rate of vaccination for group 3.

Disabled people may however have been categorised into group 1, (for example being a family member of a border worker), group 2 (for example as a DHB employee) or have been categorised as group 4 (in the general rollout). Therefore at this point the data is unavailable to ascertain whether disabled people have high rates of vaccination or are ‘under vaccinated’.

“If we had useful data available, I imagine we might see stark differences in vaccination rates across the disabled community. For example, a disabled person living in a residential facility may have had access to the vaccination early in the year in that setting, alongside information in an accessible format and clear opportunities for supported decision making. Disabled people living in the community may have experienced barriers in terms of communication and decision making, physical access, and sensory input in the vaccination centre. We can see that efforts have been made to meet these needs in some situations, for example some vaccination sites have ‘low sensory’ sessions and people can discuss access needs with the COVID Vaccination Healthline to determine which site may be most suitable.

“Some disabled people in the community will have close relationships with a team of support workers and the vaccination rates of this group is also relevant to consider. In addition, many families of disabled children or with complex health conditions will be concerned about population rates of vaccination as they will be relying on these (and other public health measures) to keep their babies and children safe. Intersections with rates of vaccination in terms of ethnicity (and the way these can link with restricted income) are also important. This can remind us of the importance of culturally-responsive healthcare for members of the disability community.

“Some disabled people may be wary of the mystery cases currently circulating, and feel it is a health risk to gather with a number of people in a vaccination centre. Some may have had issues with their mask exemption being challenged, or wearing a mask that impairs their communication.

“Disabled people have the right to effective healthcare. Their access needs and their perspectives must be built into the system from the start so they have opportunities to be vaccinated and keep safe from the virus. A number of accommodations are possible, and these should be explored comprehensively by the Ministry of Health.

“Other relevant information is available: People First have prepared a useful toolkit for disabled people, and the Disabled Peoples Assembly has information here. This HealthCare NZ resource is directed at support workers but has useful information to work into service provision. Finally, this Ombudsman report gives some useful background information.”

No conflict of interest declared.

Professor Michael Plank, Te Pūnaha Matatini and University of Canterbury, comments:

“The modelling work we’ve done essentially assumes that vaccine coverage is evenly distributed across the population and in different groups. We know this isn’t true and we also know that any under-vaccinated groups will be at high risk of (a) experiencing a fast-growing outbreak and (b) suffering from higher rates of severe illness, hospitalisation and death. Delta is really good at fining unvaccinated people and groups. This is why it’s essential to look not just at national vaccination rates but also at specific subgroups, and to put additional resources into increasing uptake in under-vaccinated parts of the population.”

Conflict of interest statement: I am partly funded by MBIE for research on mathematical modelling of COVID-19.