Lorna Renwick¹, Andrew Pulford¹, Deborah Watson¹, Nuala Healy¹, Elizabeth Oldcorn¹, Caroline Costongs², Gabriella Sutton²

¹Public Health Scotland (PHS)

²EuroHealthNet

 It is widely acknowledged that the effects of the pandemic have not been experienced equally. As such, this health crisis has exposed and exacerbated pre-existing health inequalities in society. These health inequalities stem from conditions that make people ill (Marmot, 2005),  and pertain to systematic inequalities in employment, education and other sectors.

 COVID-19 is not only a pandemic, but also a syndemic, in view of its propensity to interact with and exacerbate health inequalities (Centre for Global Health Inequalities Research, 2020). Overcoming such vulnerabilities goes beyond strictly bio-medical health measures and should pave the way to an all-encompassing psychosocial approach to health (EuroHealthNet, 2021). In this regard, public health agencies have an important role to play in ensuring that health equity is advocated and should consider health equity impacts when putting measures into place.

 Against this background, the aim of this article is to highlight the importance of recognizing health equity as a building block of public health. This will be exemplified through Public Health Scotland’s efforts in integrating health equity into public health practice throughout the COVID-19 pandemic, and its role as a public health agency in the field of health inequalities.  

 Public Health Scotland: a case study for integrating health equity into public health practices

 As many other public health agencies across the globe,  Public Health Scotland (PHS) worked closely with their government policy leads to deliver a comprehensive public health response from the early days of the COVID-19 pandemic. This included the development and coordination of contact tracing, epidemiological research, expansion of virology services, the development of guidance to support the response, research with academic partners and the provision of daily data dashboards, to support decision-making and the public, with real time data. 

 PHS was launched in April 2020 in the midst of the pandemic. However, there was already a good understanding in Scotland of the wider determinants of health and the impact of inequalities on health outcomes within the legacy organisations from which PHS was formed. As a result, PHS considered the impact of COVID-19 and its associated restrictions on health inequalities, and embedded this approach into its ongoing response, and looking forward into remobilisation and recovery. 

 The examples provided below show how PHS used data and evidence to assess the impact of COVID-19, developed guidance and recommendations to inform policy and the COVID-19 response, and how it is building on this learning to address equity in both policy and practice for the next stages of the COVID-19 response.

A. Data and evidence to assess and understand the impact of COVID on equity

Example 1: The impact on mortality of COVID-19 and non-COVID-19 causes

 An expected rise in deaths was observed in Scotland from the beginning of the COVID-19 pandemic. PHS undertook an analysis to measure inequalities in all-cause, COVID-19 and non-COVID-19 mortality to compare the inequality gaps for all-cause and non-COVID-19 deaths to the equivalent weekly average for the previous five years (2015-19). This analysis showed the impact of inequalities on outcomes for COVID-19, with the relative gap between the least and most deprived areas greater for COVID-19 deaths (Public Health Scotland, 2020a).

 Another paper looking at excess deaths and their underlying cause and area deprivation showed that deaths with an underlying cause of COVID-19 contributed most (82%) to the 32% excess in mortality rates in 2020. However, other underlying causes contributing to the excess were dementia and Alzheimer’s disease (8%), external and ill-defined causes (8%), circulatory causes (3%), other causes (3%), cancer (2%) and diabetes (2%). Deaths from respiratory causes were lower than the average for the time of year (-7% contribution). This is possibly due to COVID-19 being the underlying cause of death for some people who may otherwise have died from respiratory conditions.

 Notably, inequalities in external and ill-defined causes widened the most. Pre-existing inequalities in mortality from dementia and Alzheimer’s disease, external and ill-defined causes, and circulatory causes widened further during the COVID-19 period (Public Health Scotland, 2020b).

 Example 2: The health impacts of social distancing

 PHS contributed to a health impact assessment, predicting that health inequalities would likely widen without action to support those most vulnerable to the economic and other effects of social distancing measures. The paper considered the impact of COVID-19, home isolation, restrictions on non-essential sectors, transport, and the closure of educational establishments. A key message from this assessment is that people on low incomes are most vulnerable to the adverse effects of the infection itself, as well as the measures put in place to mitigate the spread of infections (Douglas, M. et al., 2020).

 Example 3: The impact on ethnicity

 As the disproportionate rates of hospital admissions and mortality from COVID-19 among people from ethnic minority backgrounds became apparent across the United Kingdom, the Scottish Government established the Expert Reference Group on COVID-19 and Ethnicity of which PHS was a key partner.  Recommendations for actions focused on two main areas:

• To improve the completeness and quality of health data relating to ethnicity
• To address systemic issues leading to racialised inequalities in health. 

  More specifically, PHS is leading work to improve the collection of ethnicity data in primary care, as well as work on collating ethnicity data from a wide range of health and care administrative datasets for analytical purposes and to produce comparative statistics.
  

   PHS has published a series of reports on COVID-19 outcomes by ethnic group, showing a changing pattern of risks and outcomes, hospitalisations and deaths, and, more recently, vaccine uptake. PHS has also initiated an audit to assess current levels of completeness and availability of ethnicity data across a wide range of secondary health care datasets (Scottish Government, 2020). 

   

B. Research to inform policy, guidance, and recommendations for Scotland’s COVID-19 response

Example 1: Research on early years

 When Scotland first went into lockdown there was a feeling that the group least affected would probably be young children. They often spent large amounts of time at home and access to education was not seen as essential, unlike older children where maintaining access to education was seen as a priority. However, in PHS there were concerns that this age group was being overlooked. Children develop rapidly when they are young and if critical milestones are missed it can be hard to make up for them later. To address this gap, PHS ran a survey called the ‘COVID-19 Early Years Resilience and Impact Survey (CEYRIS)’. Due to restrictions, this had to be an online survey and was for parents and carers of children aged two to seven years. The survey ran in July 2020 with subsequent rounds undertaken in November 2020 and September 2021.

The survey asked questions about how young children were coping during the pandemic, but also included questions on income, the conditions families were living in, parental wellbeing and job loss during the pandemic. There were over 11,000 completed responses in the first round of the survey, and results showed that, while young children suffer less from the direct health risks associated with contracting COVID-19, they have been more adversely affected by the wider impacts of the pandemic than originally anticipated. Using validated tools, the survey showed that young children’s emotional and social development was being affected. In addition, parents’ mental wellbeing was suffering, and this was associated with increased mental wellbeing concerns for their young children. The children and parents who were most affected were those from poorer families, larger families, families where someone had a long-term health condition, and families who had little or no outside space or who were more isolated, such as lone parents. 

The results showed that the experience of lockdown and the pandemic were worse for children living in low-income households in almost all thematic areas covered by the survey. Inequality was therefore a major factor in how well families coped during lockdown and throughout the pandemic (Public Health Scotland, 2020).

The survey results were used in a variety of forums to underpin and inform action. Policies which encouraged local authorities to open up playgrounds, which allowed young children to freely mix outside and which did not place a limit on the numbers of children mixing were all underpinned by the evidence from this survey. The rapid return of children to nurseries and primary school classes 1-3 in Scotland in February 2021 was based on CEYRIS data, as was the development of a summer programme for children which was based on encouraging social interaction and the promotion of outdoor activities targeted at children from the more deprived areas. The CEYRIS data showed that children from more deprived areas were less likely to be able to play outside or to have access to green space. It was therefore deemed more important to get children mixing and being outside than trying to run a more formal educational ‘catch up’ programme given the impact on mental health and wellbeing.

In this regard, the key outcomes of the survey are as follows:

• As well as informing policy, the data are being used to inform courses and other forms of skills development for workers with young children. For instance, CEYRIS found that more than one in five children had suffered bereavement during the course of the pandemic. Staff therefore needed to be equipped to help these children process their loss.
• CEYRIS also found that poorer families in particular found it hard to access the relevant services (such as health visitors or general practitioners, GPs) for their children during lockdown. The National Children and Families Leadership Group, chaired by Government and Local Authorities, therefore worked with services to try and establish clearer communication and encourage the return of face-to-face interaction when safe.
• The data have also been used by parenting groups to inform their actions, either through lobbying for mitigating action from the Government or directly in, for example, encouraging the re-establishment of parent and toddler groups.

  Example 2: Vaccination - PHS Health Inequalities Impact Assessment Engagement and Consultation Report

  The purpose of this report was to help local Health Boards develop their own Equality Impact Assessments for inclusive and equitable delivery of the Flu and COVID-19 vaccination programmes. PHS led a national Health Inequalities Impact Assessment (HIIA) engagement process, gathering views from the Third Sector, such as Scottish Care, Scottish Refugee Council, disability organisations, Local Authority and National Health Service (NHS) Boards. 

  As part of the engagement, PHS considered mitigating actions to reduce the risk of lower uptake and a lack of confidence in the COVID-19 vaccines and made some broad recommendations. The report has been used by local NHS Boards to influence their local Equality Impact Assessments and is being used by the Scottish Government and National Services Scotland to inform planning of the national vaccination infrastructure; for example, the Digital and Data Workstream has utilised the HIIA Report to inform national digital solutions for vaccine access and information.

  PHS (and NHS Health Scotland before that) have tracked vaccine hesitancy for many years. There were existing pockets of vaccine hesitancy, underpinned by inequalities, but the impact of COVID-19 and the vaccination programme brought this issue into sharp focus. Many of those who were most vulnerable were also those most likely to be vaccine-hesitant. The vaccination programme was an opportunity for PHS to respond rapidly and fairly to what some of most vulnerable groups were telling them.

  As PHS was likely to focus on care homes in the first phase, they worked closely with the care sector to develop a vaccination toolkit to ensure informed consent mechanisms were in place for residents and staff. PHS supported a new national vaccine scheduling tool but ensured the model was built on digital choice, with assertive outreach models for those less likely to respond to written letters or online booking. PHS also ran webinars with BIMA (the Muslim health organisation) to build confidence among the Muslim community and co-produced information for different faiths that spoke to their specific concerns about the vaccines. In response to the report, the Scottish Ambulance Service provided a fleet of mobile vaccination units and buses to target areas of high deprivation (Public Health Scotland, 2021).

  In this regard, the key outcomes of these initiatives are as follows:

• As a national agency, PHS has a clear role in working with those experiencing inequalities to develop resources to inform and expand knowledge of how to tackle health inequalities. 
• When encouraging vaccine uptake in these vulnerable groups, it is important to meet people where they are available and to enable flexibility in appointments. This was very relevant for refugees, homeless groups, and the travelling community.
• Thousands of vaccinators attended the PHS COVID-19 vaccine webinars. PHS used that opportunity to embed inequalities issues and ensure staff were on message, providing a legacy of an understanding of inequalities amongst the workforce for the routine Scottish Immunisation Programme.
• Alternative language formats were developed from the start of the vaccination programme. 
• Building inequalities monitoring into vaccine uptake enabled local partners to understand where coverage was lower, subsequently informing local action plans.

C. Building on learnings to address equity in policy and practice for COVID-19 response and recovery

 Example 1: Understanding the lived experience of COVID-19

The Inclusion Health Group was established to identify, support, and facilitate how public services will mitigate the non-viral, non-health care related, population health consequences of the COVID-19 pandemic, for those who are marginalised and excluded. Key objectives were to:

• Articulate the impact of the national response to COVID-19 on the right to health for marginalised communities;
• Demonstrate how their experience may worsen health inequalities overall in Scotland; and
• Influence decision-makers, by demonstrating how an inclusive and rights-based approach to policy and practice could mitigate the negative impacts of the response to COVID-19 for marginalised communities, including those with experience of exclusion, trauma and/or violence.

 This research project deepened PHS’s understanding of the lived experience and cross-cutting issues experienced by different marginalised communities. Phase one took a peer research approach and the second phase, to be carried out in early 2022, will seek to engage with a wider reach of participants to test and strengthen the findings from phase one.

 Example 2: Building in human rights

 Early in the COVID-19 pandemic, PHS published an Inclusion Health Principles and Practice report, which outlined how a human rights-based approach will support recovery from the COVID-19 pandemic and the associated control measures (Public Health Scotland, 2020c).

Example 3: Targeting employment and financial security to prevent poverty

In the United Kingdom, a range of employment and income measures were put in place to support the workforce while it stayed at home during the initial phase of the pandemic. These included a job retention scheme and specific assistance for the self-employed. A total of £20 was also added to universal credit (a payment made to people who are unemployed or have a low income for living costs). Working tax credits saw an increase as well, which gave a financial boost to low-income households.

As health protection measures were set to be relaxed, PHS called for continued employment and income support for those who needed it, to help minimise impacts on mental and physical health and avoid a further widening in health inequalities. PHS provided evidence and recommendations for policy responses, investments, and interventions focusing on financial security and quality employment. Implementation of these recommendations could prevent people from entering or remaining in poverty, address labour market issues, and help create an inclusive economy (Public Health Scotland, n.d.).  These recommendations targeted measures for those most at risk and with least resources, including:

• Low-income families with children
• Primary care givers (often women and lone parents)
• Young people without prospects for quality and secure jobs
• Disabled and long-term sick people.

The way forward for health equity in public health

As a new organisation, PHS drew on its expertise from the legacy organisations from which it was formed to respond to the pandemic. Part of this was a long-standing and well-evidenced understanding of inequalities in health, their determinants and the economic, societal, and service interventions that prevent and mitigate these inequalities. 

PHS used data and evidence to assess and understand the direct and indirect impacts of COVID-19 on equity; used research to inform policy and develop guidance and recommendations for the Scottish Government’s COVID-19 response; and built on this learning to address equity and embed a human rights approach to the remobilisation of services and the economy as we move forward to recovery. 

This article has described the work that has yet to be done to improve PHS’s collation of routine data on ethnicity and to better understand health outcomes by ethnic group, in order to show a changing pattern of risks, hospitalisations and deaths, and, more recently, vaccine uptake.  Establishing trusted and ongoing relationships between services and vulnerable communities is key in addressing vaccine hesitancy. The value of including those most vulnerable and at-risk in service design has been tested in the COVID-19 response with valuable learning, and ongoing work to embed this approach for the future. 

Learning throughout this process has shown that COVID-19 has exposed and exacerbated inequalities, and to this end, PHS’s response included mitigation for these through some of the measures described above.  As of 21 November 2021, there were a total of 12,028 deaths registered in Scotland where the novel coronavirus (COVID-19) was mentioned on the death certificate. The indirect impact of COVID-19 on Scotland’s health, economy and society will affect many thousands more. 

Preparation for future pandemics needs to account for the inequalities exposed, and address the inequity that persists across our health, social and economic systems. Mitigation measures provide short-term support, but addressing and preventing disparity in the direct and indirect impact of future epidemics requires long-term action against inequalities that are unjust and not inevitable. 

PHS’s mission is to lay a solid foundation that supports long-lasting good health and wellbeing for all communities – especially the most disadvantaged. Community health and wellbeing is complex, but its foundations include an inclusive economy with good work, quality housing and education, accessible and effective health and social care services, clean open spaces, water and sanitation (Public Health Scotland, 2020d). 

Addressing inequalities across the scope of community health and wellbeing is the action that will prevent the previously exposed and exacerbated inequalities caused by COVID-19, and provide a more equal base for future epidemic responses.

References

Centre for Global Health Inequalities Research. (2020). The COVID-19 pandemic and health inequalities: we are not all in it together. https://eurohealthnet.eu/sites/eurohealthnet.eu/files/CHAIN_infographic%20_covid19_and_inequalities_final.pdf

Douglas, M. et al. (2020). Mitigating the wider health effects of covid-19 pandemic response. BMJ, 369:m1557. https://doi.org/10.1136/bmj.m1557

EuroHealthNet. (2021). Health Equity as a Compass for Long-Term Recovery from the Pandemic. https://eurohealthnet.eu/publication/health-equity-compass-long-term-recovery-pandemic

Marmot, M. (2005). Social determinants of health inequalities. Lancet, 365(9464), 1099-1104. http://doi.org/10.1016/S0140-6736(05)71146-6

Public Health Scotland. (2020). COVID-19 Early years resilience and impact survey (CEYRIS). https://www.publichealthscotland.scot/repository/covid-19-early-years-resilience-and-impact-survey-ceyris/

Public Health Scotland. (2020a). COVID-19 weekly excess deaths - Health Inequalities Briefing.   https://publichealthscotland.scot/publications/covid-19-weekly-excess-deaths/covid-19-weekly-excess-deaths-health-inequalities-briefing/

Public Health Scotland. (2020b). Non-COVID-19 excess deaths by cause - Excess deaths by underlying cause and area deprivation 26 August 2020. https://publichealthscotland.scot/publications/non-covid-19-excess-deaths-by-cause/non-covid-19-excess-deaths-by-cause-excess-deaths-by-underlying-cause-and-area-deprivation-26-august-2020/

Public Health Scotland. (2020c). Inclusion health principles and practice: mitigating the impact of COVID-19. https://publichealthscotland.scot/publications/inclusion-health-principles-and-practice-mitigating-the-impact-of-covid-19/

Public Health Scotland. (2020d). A Scotland where everybody thrives: Public Health Scotland’s Strategic Plan 2020 to 2023. https://publichealthscotland.scot/publications/public-health-scotland-strategic-plan-2020-23/

Public Health Scotland. (2021). Support for specific groups and communities. https://publichealthscotland.scot/our-areas-of-work/covid-19/covid-19-vaccinations/covid-19-vaccine-information-and-resources/support-for-specific-groups-and-communities/

Public Health Scotland. (n.d.). Protecting the health of the working age population and their families as lockdown reduces. https://publichealthscotland.scot/media/2686/protecting-future-working-populations-phs-social-mitigation.pdf

Scottish Government. (2020). Expert Reference Group on COVID-19 and Ethnicity: recommendations to Scottish Government. https://www.gov.scot/publications/expert-reference-group-on-covid-19-and-ethnicity-recommendations-to-scottish-government/