Better Health For All

“Vaccination is a topic that provokes strong views, and it can be difficult to engage productively with people who don’t take the same view we do. Understanding how to reach people, not just telling them what they “should” think is essential. That means listening to people’s concerns and responding to them in a meaningful way.” – Claire Cooper, Public Contributor, London

Age, ethnicity, household income and other factors influence people’s willingness to get vaccinated. A one-size-fits-all approach to increasing vaccine uptake doesn’t cut it these days. We need to use different tactics for different groups to address people’s specific concerns. Luckily, research has provided us with a strong evidence base to do this effectively.

At the National Institute for Health and Care Research (NIHR) we have brought together examples of NIHR research on encouraging vaccination across communities and reducing health inequalities. It explores how to engage and communicate effectively with different communities. Our report highlights lots of different ways to increase uptake, but below, I’ve included some of our key findings.

How to engage communities

To build trust and overcome barriers to vaccination we need to understand and respond to the specific needs of different communities. For example, community advocates could increase vaccine uptake among migrants (a group where vaccination rates are low). Services could work with respected members of their community because they understand people’s needs and concerns and are well-placed to deliver trustworthy messages.

But addressing vaccine concerns is not the only thing you need to do; you also have to make it as easy as possible for people to get vaccinated. For example, researchers consulting with Gypsy, Traveller and Roma people found that they would appreciate having a dedicated support officer in GP practices. The community valued health visitors because they provided a bridge to mainstream health services that was accessible to their community.

It’s not enough to wait for people to come forward for vaccination, you have to bring it to them. For instance, a study involving more than 250 pregnant women in the UK and 4 EU countries found that many women were unaware of the need for vaccination during pregnancy. Researchers suggested that clinicians could use pregnancy check-ups to ask about women’s vaccination status and offer to book them an appointment.

Finally, the setting in which vaccines are delivered also matters. Some pharmacies that provide opioid substitution therapies now promote flu vaccination alongside medication pick-up. Sheffield City Council Drug and Alcohol Action team has led a campaign that gradually increased vaccination among people dependent on opioids.

How to communicate effectively

To make sure people understand when, where, how and why to get vaccinated, public health campaigns need to deliver the right message to the right group, via the right channel.

Communication strategies should be agile and targeted. Identifying groups with low vaccine uptake allows services to engage with them about the reasons why they are hesitant. For example, a study investigating pertussis and flu vaccine uptake among pregnant women in England found that younger women, women from ethnic minority groups, women living in areas of greater deprivation, London, and the North East were all less likely to be vaccinated. Tailoring public health messaging to resonate with these groups, through channels they are likely to use, could increase vaccine uptake.

However, some tactics are effective across several communities. Stressing the personal benefits of the COVID-19 vaccine (rather than the benefits to the community) was found to encourage people who were unsure about having the vaccine. 

We will all be aware of the wave of misinformation about vaccines during the pandemic that was linked with lower vaccination rates. Effective strategies to counter this misinformation are crucial. Researchers  found that promoting the scientific consensus that vaccines are safe was one effective strategy. Using humour to dispel vaccine myths also worked. But scare tactics, and failing to acknowledge uncertainty, could be unhelpful.

Last but not least, technology is one of the most powerful tools at our disposal. One of the most effective methods of increasing uptake is simple: phone call reminders can increase attendance at vaccination appointments by 18%. NICE recommends inviting both older and younger people for vaccines using whatever communication they prefer: letter, phone, text, or email.

To sum up

Research shows that listening to and understanding people’s concerns is at the heart of any effective strategy. Services need to make accessing vaccination as easy as possible and public health messages about vaccines need to be adapted and refined for specific audiences. We hope the strategies outlined in our Collection will help those that design and deliver vaccination services. You can read the full Collection here.

Brendan Deeney – Science Writer at NIHR Evidence

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Dental public health operates with a population and systems perspective across the three pillars of public health (healthcare public health, health protection, health improvement), seeking to improve health and prevent disease. Examples of dental public health activities undertaken in Scotland are outlined below:

Healthcare public health

Access to NHS primary dental care in Scotland dramatically reduced due to COVID-19 public health measures. A recent study found that inequality was exacerbated during the pandemic, as it has existed before COVID-19, with a higher proportion of adults and children from the less deprived areas having more contact with a dentist than those in the most deprived.

In April 2023, the Scottish Parliament’s COVID-19 Recovery Committee launched an inquiry into the recovery of NHS dental services. This inquiry will scrutinise what action the Scottish Government is taking to return the provision of NHS dental services to pre-pandemic levels of activity, as set out in the NHS Recovery Plan 2021-2026.

In a recent blog, the Scottish Parliament Information Centre has provided an overview of dentistry in Scotland and also highlighted some of the long-standing challenges for NHS dentistry.

NHS dentistry in Scotland is at a pivotal moment as the British Dental Association enters a process of formal engagement with the Scottish Government, covering fee allocation for the revised Determination I of the Statement of Dental Remuneration. In an answer to a parliamentary question, the Scottish Government has said that payment reform will be implemented by 1 November 2023. To help collecting baseline data before Determination I comes into play on 1 November 2023, a dashboard for indicators of dental access across territorial Boards in Scotland is currently under development.

Health protection

On 23 September 2021, the UK Chief Medical Officers published a joint statement in support of water fluoridation as an effective public health intervention in reducing tooth decay and reducing oral health inequalities. The Consultants in Dental Public Health group and the Directors of Dentistry in Scotland welcome this significant development in their joint statement in November 2021.

Water fluoridation is a devolved issue in the UK. Primary legislation remains in place through the Water (Fluoridation) Act 1985, for Health Boards with the support of local communities to ask Scottish Water to introduce water fluoridation. Policy responsibility for this legislation rests with the Health Protection team in the Scottish Government.

A recent random on-street representative survey in Scotland showed that majority of people were in favour of adding fluoride to water to reduce tooth decay. The two largest NHS Health Boards in Scotland, NHS Greater Glasgow and Clyde and NHS Lothian, have also included additional questions on water fluoridation in their recent public health surveys. The question on water fluoridation can be found on page 27 of the Lothian Public Health Survey 2023. The findings of these surveys will soon be available.

Health improvement

Childsmile is NHS Scotland’s national oral health improvement programme for children. NHS Scotland’s Climate Emergency and Sustainability Strategy 2022-2026 identifies climate change as a looming public health emergency. As an NHS service, Childsmile is supporting NHS Scotland to deliver against its strategic climate emergency and sustainability aims.

NHS National Services Scotland (NSS) and Childsmile have joined forces to launch Recycle and Smile. This new initiative is simple and easy for everyone involved. Childsmile professionals will take the programme’s used toothpaste tubes and toothbrushes to the local Public Dental Service collection site.

NSS recycling partner will collect the used items, break the plastic down into small chips and sterilise it. Once processed, it is ready to be recycled into useful items such as vehicle parts, garden planters and playground equipment.

Recycling all this plastic will contribute to a cleaner, greener and more sustainable Scotland – and that’s certainly something to smile about!

Albert Yeung

Immediate Past President

British Association for the Study of Community Dentistry

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With poverty rising and no end in sight to the financial crisis, it is incumbent on all of us to take collective and meaningful action

For the second time in three years, the UK is facing a public health emergency in which the most vulnerable in our society are bearing the brunt. Like the Covid-19 pandemic that came before it, the cost of living crisis, left unchecked, will widen health inequalities and leave a generation with poorer mental and physical health than their predecessors.

Poverty is a long-standing and deeply entrenched problem in the UK. As income stagnates and inflation grows, increasing numbers of people, who at one time would have been able to weather the storm, are finding themselves unable to afford the basics. Almost 4 million children are now living in poverty, 75% of whom live in a household where at least one person is working. The situation is now worsening further with forecasts suggesting the number of people in absolute poverty will rise from 11 million to 14 million by the end of 2023/24.

The impact this will have on health outcomes is stark. There is a 27-year life-expectancy divide in men and a 21-year difference for women between the least and most deprived areas of the country – a gap that was already widening before the pandemic. Rates of obesity, cardiovascular disease and diabetes are increasing and survey after survey shows physical and mental health is being damaged by the financial crisis.

It is clear that the economic and social circumstances we all live in have a greater influence on our health than any other factor. Yet the inextricable link between economic prosperity and health is often not well understood. Rising poverty levels and widening health inequalities have severe consequences for the individual, for the NHS and social services, and for the economy as a whole.

We cannot simply restate the problem and wring our hands. We need targeted, evidence-based, long-term intervention to tackle this public health crisis at a local, regional and national level.

In May, the Faculty of Public Health, the Royal Society for Public Health, the Royal Society of Medicine, and the Association of Directors of Public Health came together at a special conference to identify meaningful solutions that can be implemented in key areas including child poverty, housing and fuel. Those working in public health are doing the best they can with ever-dwindling budgets but cannot solve this alone. Collective action is needed from national governments, alongside businesses and local councils.

It is important we identify where to direct our energies to have greatest impact. We need clear data and evidence on how poverty and the cost of living crisis is affecting different populations including ethnic minorities, those with young children, the elderly and those with disabilities, and to identify the barriers that individuals face in accessing services and help.

We need a national, wide-ranging strategy to tackle poverty and improve health that includes bold policies on energy prices, income, housing reform, food security, and a living wage. Strategies such as a minimum income guarantee, universal basic income and universal basic services must be seriously considered to ensure economic success and better health for everyone.

We need urgent reform to Universal Credit to ensure households can afford the basics. This also means removing the benefits cap and scrapping the two child limit. Figures show 90% of low income households receiving Universal Credit are going without at least one essential like food, a warm home or toiletries. For people who have lost their job, who are caring for sick relatives, or who have no safety net when life circumstances change, it is unconscionable that they are struggling to feed their families, to heat their homes and keep the lights on.

We need a national housing strategy to deliver more affordable and quality, secure social and rental housing. An estimated 8 million people in England are living in overcrowded, unaffordable or unsuitable homes. Those living in poverty are particularly vulnerable to poor conditions and temporary housing. The tragic death of two-year-old Awaab Ishak from a respiratory illness caused by exposure to mould should be a wake up call to all of us.

Child food poverty is one of the greatest and escalating challenges we have as a nation, but is also one where we have the ability to make real change by widening access to free school meals.

Local authorities are already using data and intelligence to design interventions that meet the needs of their populations. Local public health teams are collaborating with social care, housing, education and the voluntary sector to provide household support grants and emergency food vouchers, wellness checks, and hubs offering access to food banks, clothes and toiletries as well as advice on health and wellbeing and warm spaces in the community. Yet this emergency response is being done against the backdrop of repeated real term cuts in public health funding. We need to move beyond fire-fighting and towards a more sustainable approach to public health.

We have people who are suffering, children who are starving and individuals dying early. No organisation can deal with this alone. Tackling the impact of the cost of living crisis will require prioritisation and collaboration to ensure health, justice and prosperity for everyone.

Professor Kevin Fenton
FPH President

Professor Paul Roderick
Chair, FPH Poverty Special Interest Group

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