A Rapid Systematic Review of Factors Influencing COVID-19 Vaccination Uptake in Minority Ethnic Groups in the UK

COVID-19 has disproportionately affected minority ethnic groups in the United Kingdom. To maximise the effectiveness of the vaccination programme, it is important to understand and address disparities in vaccine uptake. The aim of this review was to identify factors influencing COVID-19 vaccination uptake between minority ethnic groups in the UK. A search was undertaken in peer-reviewed databases, polling websites and grey literature from January 2020–May 2021. Studies were included if they reported data on vaccine uptake or the reasons for or against accepting the COVID-19 vaccination for minority ethnic groups in the UK. Twenty-one papers met the inclusion criteria, all of which were rated as either good or moderate quality. Ethnic minority status was associated with higher vaccine hesitancy and lower vaccine uptake compared with White British groups. Barriers included pre-existing mistrust of formal services, lack of information about the vaccine’s safety, misinformation, inaccessible communications, and logistical issues. Facilitators included inclusive communications which address vaccine concerns via trusted communicators and increased visibility of minority ethnic groups in the media. Community engagement to address the concerns and informational needs of minority ethnic groups using trusted and collaborative community and healthcare networks is likely to increase vaccine equity and uptake.


Introduction
COVID-19 has disproportionately affected minority ethnic groups in the United Kingdom (UK) [1,2]. Ethnicity is a risk factor for adverse outcomes along with other factors such as age, deprivation and comorbidities [1]. However, there is evidence to indicate that some minority ethnic groups have lower intentions to receive COVID-19 vaccinations [3]. This is of concern due to the higher COVID-19 incidence, morbidity and mortality in these groups, and the importance of the vaccination programme as part of a package of measures to manage the pandemic.
Vaccine hesitancy is defined as a delay in acceptance or refusal of vaccination when vaccination services are available [4]. It is characterised by uncertainty and ambivalence and is a legitimate response to fears of safety, concerns about the efficacy of the vaccine, and issues of mistrust towards formal services [5].
In England and Wales, people from Asian ethnic groups make up the second largest percentage of the population (7.5%), followed by Black ethnic groups (3.3%), Mixed/Multiple ethnic groups (2.2%) and Other ethnic groups (1.0%) [6]. The UK's vaccination programme has the potential to exacerbate pre-existing inequalities that the pandemic has exposed and amplified if it does not take into consideration the unequal impact of the pandemic on minority ethnic groups and the factors that enable or hinder vaccination uptake in these groups [7]. To maximise the effectiveness and impact of the vaccination programme, it is important to understand reasons for disparities in uptake which can inform the provision of support for diverse communities, including implications for developing effective public health messaging strategies [5,8].
There is a plethora of vaccination-related evidence across a number of health conditions that predate the COVID-19 pandemic. This evidence has informed early insights such as the likelihood of lower COVID-19 vaccination uptake in minority ethnic healthcare workers based on previous vaccination programmes [5]. Empirical data on COVID-19 vaccination hesitancy and uptake is increasing, with early studies indicating lower vaccine uptake in minority ethnic groups [3]. A synthesis of these studies may offer important insights for each phase of the vaccination programme.

Review Aims
Primary aim: to identify differences in COVID-19 vaccination intention and uptake between minority ethnic groups in the UK.
Secondary aim: to identify barriers and facilitators of COVID-19 vaccination intention and uptake in minority ethnic groups in the UK.

1.
What are the differences between minority ethnic groups' intentions and uptake of COVID-19 vaccination in the UK? 2.
What are the barriers to COVID-19 vaccination acceptance in minority ethnic groups in the UK? 3.
What are the facilitators to COVID-19 vaccination acceptance in minority ethnic groups in the UK? 4.
Are there any differences in barriers and facilitators to COVID-19 vaccination acceptance between minority ethnic groups in the UK?

Method
A rapid review of the literature was undertaken in accordance with PRISMA criteria for systematic reviews [9]. The protocol for this rapid review was registered on PROSPERO (CRD42021253728) [10].

Search Strategy
The search strategy was applied to Web of Science, Ovid, Scopus and APA Psych-INFO for peer reviewed literature, websites of the public polling companies YouGov and Ipsos MORI, and websites detailing public, private, academic and third-sector projects. Grey literature was searched using Google Advanced, and the Public Health England Behavioural Science Research Cell. References and forward citations of relevant articles were also searched. Databases were searched from January 2020 to May 2021.
The following search terms were used: ((vaccin* OR inocul* OR immunis*) AND (COVID-19* OR SARS-CoV-2) AND (uptake OR accept* OR hesitan* OR refus* OR confiden* OR decision* OR concern) AND (ethnic minorit* OR ethnic* OR minorit* OR rac* OR Black* OR African* OR Asian* OR Caribbean OR BME OR BAME OR Roma* OR Eastern European OR migrant OR refugee)).

Inclusion and Exclusion Criteria
Inclusion criteria were: Population: studies and reports that included people from racial and ethnic minority groups in the UK. Studies and reports that did not include racial and ethnic minority group data from the UK were excluded.
Predictors/Exposures: studies that present data on vaccine uptake, the association between psychological predictors and COVID-19 vaccination, or data on reasons for/against accepting COVID-19 vaccination.
Types of studies: original research, quantitative research, qualitative research. Papers were excluded if there was no empirical data, if they reported conference proceedings and/or were not in English.

Data Extraction
For each study or report, details concerning country and region, data collection period, study aims, design, outcome of interest, sampling and recruitment, data collection methods, population characteristics, results, barriers and facilitators of vaccination uptake, and recommendations, were extracted.

Risk of Bias
Risk of bias was assessed using the Mixed Methods Appraisal Tool (MMAT) [11] which evaluates studies on five dimensions based on the study methods. Scoring was adapted in line with a review by Smith, Hodson and Rubin [12] to provide a measure of risk of bias from 1-10. Studies that scored five or under were rated as poor quality, six or seven were moderate quality, and a score of eight or over was rated as good quality. The MMAT was selected as it is a critical appraisal tool designed for systematic reviews that include qualitative, quantitative and mixed-methods studies. While other risk of bias tools are available, the MMAT was selected as it has been validated in several studies and updated in 2018 based on the findings from a literature review of critical appraisal tools, empirical research, and an e-Delphi study with international experts [11].

Procedure
A.K. and J.P. developed the literature search. Screening of titles, abstracts and fulltexts, data extraction and risk of bias assessment were carried out by A.H. and A.K. independently screened a sample of titles, abstracts and full-texts, checked a sample of data extracted for accuracy and completeness, and conducted a risk of bias assessment for a sample of studies. Any discrepancies were discussed and resolved through discussion. A.K. conducted the narrative synthesis.

Search Results
The searches identified 2662 records which were screened, and 29 full-text articles were assessed for eligibility. Of these, 21 were judged to meet the eligibility criteria (see Figure 1).
Seventeen of the 21 studies used quantitative methods, two studies used qualitative methods and two studies used mixed methods. Of the quantitative studies, the majority were cross-sectional surveys (n = 11), and the remaining were cohort studies (n = 6).
Studies were conducted in all countries within the United Kingdom: England (n=3), Northern Ireland (n = 1), Scotland (n = 2), and Wales (n = 1). Within England, two studies were conducted in London (n = 2), and one study was conducted in Bradford and North East, North West, Yorkshire and the Humber, East Midlands, West Midlands, South East and South West (see Table 1 for further details).  * Demographic weights were calculated post-collection on the basis of education and geographical region and of gender interlocked with age, NRS social grade and working status. The sample was designed and weighted for demographic representativeness and is treated as equivalent to a random sample. ** Age data missing for two participants.

Risk of Bias Analysis
Using the MMAT, the mean average risk of bias score was eight from a maximum of ten (where a higher score means lower risk of bias). Based on the available information, 14 of the studies were rated as good quality, seven as moderate quality, and no studies were rated as poor quality (see Table 1).

Narrative Synthesis
A narrative analysis of the results of vaccination intention and uptake between minority ethnic groups in the UK was conducted. Due to heterogeneity of data, it was not possible to conduct a meta-analysis.
Differences between minority ethnic groups were evident with twelve out of 21 studies reporting higher hesitancy and lower uptake in Black groups in comparison with other minority ethnic groups [3,16,[19][20][21][22][23][25][26][27][28][29]. Of these twelve studies, six reported the results for subgroups. In three studies, Black African groups had the highest hesitancy and lowest uptake [26,28,29] and three studies reported Black Caribbean groups were most hesitant followed by other Black groups [16,20,27]. Differences between South Asian groups also exist with Pakistani groups reporting the highest hesitancy, followed by Bangladeshi and Indian groups. Higher uptake and lower hesitancy were reported in Indian [16,19,20,[25][26][27], Bangladeshi [19,20,27] and Chinese [16,19,25] groups compared with other ethnic minority groups. While hesitancy was lower and uptake was higher for Indian, Bangladeshi and Chinese groups compared with other minority groups, the uptake figure was still lower than in White British groups (see Table 2).

Barriers to COVID-19 Vaccination Acceptance in Minority Ethnic Groups
Barriers to COVID-19 vaccination acceptance were reported across the following domains: psychosocial factors, communications, and practical challenges (see Figure 2).

Psychosocial Factors: Trust, Concerns and Beliefs
Heightened vaccine hesitancy was attributed to mistrust including pre-existing lower scientific or medical trust, conspiracy suspicions and attitudes [13,20,21,23,25,30]. Mistrust that results in hesitancy to take the vaccine was reportedly the consequence of negative past experiences that individuals, their family and friends have experienced with formal services [31]. Concerns also included the potential lack of equity for those who choose not to have the vaccine, and that mandating vaccination could create ethnic and racial divides between communities and increase stigma and discrimination [20].
The speed with which vaccines were approved has raised suspicions over whether regulatory standards, meant to protect vulnerable populations, were relaxed for expediency [21]. Under-representation of individuals from ethnic minority backgrounds in vaccine trials also reportedly contributes to hesitancy, along with lack of inclusion of marginalised communities throughout the pandemic [20]. Concerns about the vaccine included how quickly it was produced, that side effects are not known by individuals or those that are producing them, the vaccine has not had time to be fully tested, the vaccine is unsafe, and lack of knowledge about the vaccine [21,24,25,29,32]. As a result, some people wanted to wait three to six months once this information was known, before accepting a vaccine [32].

Communications: Source, Content and Access
Misinformation, complex information, conflicting and changing guidance, overwhelming amounts of material, and contradiction of information between different information sources contributed to a lack of trust, confusion, and ultimately vaccine hesitancy [20,[30][31][32]. Positively framed vaccine information accessed via mainstream media, Government or National Health Service (NHS) sources fuelled suspicions and contributed to mistrust due to concerns of lack of transparency of risks [20].
Negative vaccine attitudes resulted from various information sources that are alternatives to mainstream media, such as social media [14,31], family which plays a big part in the decision to have a vaccine for some minority ethnic groups [16,20,23], and obtaining information from country of origin [30].
People from minority ethnic backgrounds were more likely than White British groups to have received misinformation encouraging them not to have the vaccine [16,[30][31][32]. Some studies cited anecdotes that increased vaccine hesitancy [25], including rumours that ethnic groups are being targeted to test the vaccine or used to harm them [30,32], and concerns about very negative side effects. This was exacerbated by engagement with social media stories which resulted in confusion about whether or not to have the vaccine [32]. Migrants reported specific views ranging from acceptance to misinformation, often originating from social media or word of mouth [30].
Lack of access to information also resulted in communication barriers largely due to low health literacy, poor other language provision, and increased digitalisation of communications. This was particularly an issue for migrant groups due to lack of access to, or knowledge of, technology [20,30].

Practical Issues: Logistics
Barriers to vaccination go beyond psychosocial factors and communication. Logistical and practical barriers, such as the location of vaccine centres and having to use public transport, were also reported as barriers to vaccine uptake [18].

Facilitators to COVID-19 Vaccination Acceptance in Minority Ethnic Groups
Facilitators to COVID-19 vaccination acceptance were reported in relation to trust in communication and vaccine outcomes (see Figure 3). More information about the vaccine, including information about the effectiveness, side effects and ingredients, was identified as a facilitator to reduce hesitancy and increase acceptance [19,23]. Respondents from minority ethnic groups said they would trust the view of someone on social media more than they would trust politicians delivering information about the COVID-19 vaccine's safety and effectiveness [23]. Trusted sources varied and were more likely to be individuals that respondents identified with, such as family, friends, community members and religious leaders [16,20,23,31]. Proactive engagement of healthcare workers from diverse ethnic backgrounds, and increased visibility of less well-represented groups in the media, were also identified as facilitators of vaccine acceptance [20,23,31].

Risk Perception: Confidence in Risk Reduction Outcome of Vaccine
Factors influencing risk perception were varied. Personal experience increased perceived risk based on direct experiences (own or others) [18,20]. Specifically, previous infection, knowing people who had been unwell or died from COVID-19, and concerns about infection of their families and loved ones, increased perceived risk [20]. Hearing positive things about the vaccine and addressing concerns of vaccine safety, such as evidence that the vaccine is safe, lowers risk of catching COVID-19 or reduces the risk of being seriously ill, increased confidence in the risk reduction outcome of the vaccine and, consequently, increased vaccination intention [18,22,25,32].

Differences in Barriers and Facilitators between Minority Ethnic Groups
Differences in barriers and facilitators between minority ethnic groups were infrequently reported and pose difficulties in exploring variations beyond broad categories of 'Black, Asian, White, Other, etc.'. Stated reasons for vaccine hesitancy were often similar across ethnic groups. However, one study noted that, when compared to the White British or Irish group, Black or Black British participants were more likely to state they 'Don't trust vaccines' and the Pakistani or Bangladeshi group cited worries about side-effects [22]. Another study found that the opinion(s) of family and friends were widely trusted and equal with that of a GP in Asian respondents [23].

Discussion
The results of the review indicate increased hesitancy and lower intention to accept the COVID-19 vaccine in UK based minority ethnic groups compared with the White British population. This is similar to other vaccination programmes and suggests a consistency of concerns beyond COVID-19, for people from minority ethnic groups, such as negative experiences and mistrust towards formal services. This review highlights a multitude of factors influencing vaccine hesitancy and uptake both across and within minority ethnic groups. Barriers such as pre-existing mistrust of formal services, lack of knowledge and information about the vaccine's safety, misinformation, complex and changing guidance, inaccessible communications, conflicting information from different information sources, and practical barriers such as the location of vaccine centres, contribute to hesitancy. The results of the narrative synthesis show that Black groups are more likely to cite mistrust of vaccines; this is possibly linked to historical issues of medical malpractice towards Black communities, such as the Tuskegee Syphilis study [5]. Pakistani or Bangladeshi groups have concerns about possible side effects that could be explained by inaccessible communications for some of these groups [8]. Accordingly, facilitators include addressing vaccine concerns via trusted communicators and increased visibility of minority ethnic groups in the media and could be broadened further by delivery of healthcare messages in a range of languages [33].
Since the start of the vaccination programme, work is underway with communities to address increased vaccine hesitancy and lower vaccine uptake in minority ethnic communities. Strategies include a nationally funded Community Champions programme [34,35] which supports local public health teams to work with communities to address local barriers and facilitators, tailored communications and local monitoring and insights [36].Vaccine uptake has increased across all minority ethnic groups since the start of the vaccination programme. In the 50+ age group, vaccine uptake has increased from 73.1% to 81.7% for Pakistani groups, from 83.1% up to 89.5% for Bangladeshi groups, from 61.6% to 67% for Black Caribbean groups, and from 64.9% to 73.5% for Black African groups [37]. A similar pattern is evident in younger age groups [37]. The gap in vaccine intention and uptake between White British and minority ethnic groups has closed but minority ethnic groups still have a lower proportion of vaccine acceptance and uptake [37], which indicates ongoing work with communities is required at each stage of the vaccination programme. A lower proportion of minority ethnic groups receiving a COVID-19 vaccine may not be an issue that is unique to the UK, as Black and Hispanic groups in the United States of America also have lower vaccine uptake. This has been attributed to similar reasons relating to mistrust, practical barriers and systemic challenges [38]. Data on ethnicity is not routinely collected or reported in some countries, which limits further cross-national comparisons.
Underpinning the issues identified in this review is the notion that minority ethnic groups should not be treated as one homogenous group and the need to adopt a personcentred approach to support specific communities by addressing their unique needs and concerns about the COVID-19 vaccine [5,16].

Recommendations
The following recommendations are based on the studies included in this review:

Community Engagement
Vaccine hesitancy is driven, in part, by anxiety fuelled by misinformation or lack of information. There is a need for clear, honest and responsive information that is sensitively framed and nonjudgemental to overcome this [17]. Many respondents from minority ethnic groups that do not want the vaccine would reconsider their decision if they had more information [19]. It is therefore essential to engage with minority ethnic communities to understand what information is required, when, where, and in what format; to coproduce vaccine communication campaigns in a range of media and languages and establish a two-way dialogue directly with people to respond to questions or concerns, and to tackle misinformation [17,19,20,22,30].
It is important to harness connections that exist within communities to counter misinformation. Promoting vaccination via trusted networks such as religious leaders, and people within community support roles such as teachers, nursery workers and advice workers, can ensure the spread of correct information [8,17,32]. In addition to commu-nity engagement, proactive engagement with healthcare workers, particularly those from diverse backgrounds, can increase visibility of less well represented groups and build trust [20,31].
Engagement opportunities for those that are undecided about the vaccine is essential, and collaborative working between community led-events and medical professionals can provide access to educational resources such as information about the UK's health and social care system, clinical trials and the regulation process. This is particularly important in addressing the legacy of historic unethical research and issues faced by Black people in clinical trials [31].

Inclusive Communications
Public health messages should highlight the prosocial benefits of a vaccine and draw on collective identities that are sensitively attuned to different communities [17], but should avoid negative assumptions and stereotyping associated with ethnicity as this may marginalise and stigmatise communities [17,39]. Inclusion of people from different racial and ethnic minority backgrounds in posters, videos and communications will increase opportunities for minority ethnic groups to identity with health messages in a more relatable way; this includes distributing information that has been translated [17,20,30,31].

Practical Application and Service Delivery
The views of minority ethnic communities, once obtained via community engagement efforts, should be integrated into NHS and Public Health England (PHE) teams [19]. Practical barriers, such as location or cost implications, should be addressed to ensure equity in accessibility and opportunity to have the vaccine [20]. Innovations in service delivery, such as translated health advice using online platforms that translate resources and provide language specific advice, and use of multiple communication channels such as text, email, letter and posters in local community hubs, may reduce accessibility issues [30].
Local targeted responses to misinformation can be achieved quickly if processes are in place for systematic monitoring of the circulation of misinformation on social media [17].

Resources
Innovations in service delivery, and utilising the expertise of local community groups to codesign delivery approaches and communications, requires time, planning and financial support. Resourcing support is required for the availability of interpreters and culturally appropriate translations of vaccine advice, alongside community ambassadors, peer support, Community Champions in vaccine centres, and development and implementation of local communication campaigns and events [30,36]. Healthcare professionals should also be provided with resources and time to address the concerns of individual patients about the Covid-19 vaccine [23].

Further Research
Ongoing engagement with minority ethnic groups, including subgroups such as young people, is required to understand and address the barriers to vaccine uptake. Further insight into the barriers and facilitators experienced by different groups will support localised, targeted responses to vaccine concerns. Initiatives to improve uptake in Black ethnic groups within the UK should be an urgent priority, including qualitative explorations of the reasons for vaccine hesitancy and the approaches to overcoming them [22].

Strengths and Limitations of the Review
This review included 21 studies reporting data on UK minority ethnic groups' COVID-19 vaccine intention and uptake. The review includes data that reflects the earlier stages of the vaccination programme, during which older adults and frontline workers were prioritised. It was not possible to synthesise findings based on age, as several papers included in the review did not report such data. In papers where age was reported, this often ranged from 18 to 99 years with a mean age of approximately 46 years. It is important for future research to stratify results based on age, as younger groups may have different reasons for hesitancy in comparison to older groups, which was not possible to establish in this review. As the vaccination programme has progressed, it is likely that some of the respondents who were initially hesitant due to concerns about side effects may hold more positive attitudes and may now believe that the vaccine is safe. For example, recent data shows higher vaccine uptake compared with lower intentions reported in 2020 before the vaccination programme was available [37,40]. However, the implications for policy and practice remain unchanged and can support minority ethnic groups at each stage of the vaccination programme, including offering booster jabs and supporting younger populations.
Lower COVID-19 vaccine intentions and uptake was defined based on the proportion of responses in comparison to White British groups. This is a limitation of the review as the gap between vaccine intention and uptake varied across studies and was not weighted or standardized. As a result, one study may have reported a higher proportion of hesitancy compared with another study, but both were considered equally in terms of vaccine hesitancy.
It was not possible to identify regional differences due to small sample sizes; only two included studies reported regional data in England for some regions [7,9]. Small numbers of respondents in minority ethnic groups did not allow for detailed analysis in some of the studies, which means broad categories of 'BAME' were used [22,23]. In addition to this, the categories for ethnicity self-identification differed across studies and posed difficulties in integrating and synthesising the study findings at a more detailed level. For example, data for some groups was reported as the broad category 'BAME', other studies reported findings for Black or South Asian groups with no distinction between within-group differences such as Black Caribbean or Black African or Pakistani or Indian, whereas other studies did make the distinction between these groups. Standardisation of specific ethnic group categories may provide more detailed insights and facilitate group comparisons in a more meaningful way that can support the design and delivery of vaccination programmes.

Conclusions
It is important to build on the initial success of the UK vaccination programme to achieve sufficient protection at a population level. Although the majority of the eligible UK population has received a COVID-19 vaccine since the vaccine programme was launched in December 2020, including 89.1% of the population who have received a first dose and 81% who have received both doses, [41] vaccination rates remain lower in minority ethnic groups, including younger age groups. It is essential that the views of minority ethnic communities are understood by the NHS and local and central government partners, and are implemented in vaccine service design and delivery. If the concerns of communities are not considered and addressed, there is a risk that the vaccination rollout could exacerbate inequalities by providing inaccessible or inappropriate support. This review identified vaccine hesitancy as multifaceted, but support embedded into specific communities can address the concerns and informational needs of minority ethnicity groups. Using trusted and collaborative healthcare and community networks is likely to increase both vaccine equity and accessibility to vaccinations.
Author Contributions: A.K. and J.M.P. conceptualised the review and developed the systematic review protocol and searches. A.H. conducted the searches, completed the data extraction and risk of bias assessment, which was verified by A.K. and A.K. conducted the narrative synthesis and drafted the initial paper that all authors contributed to. All authors have read and agreed to the published version of the manuscript.