Equity and diversity challenges with COVID-19 and children

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated social inequities along ethnic, racial and socio-economic lines, with significant harmful consequences for children. Building on the lessons learned from community-based initiatives, this commentary proposes a reflection around equity, diversity, and inclusion challenges embedded in child vaccination campaigns during an emergency context. We argue that building equitable and inclusive practices around marginalized communities’ child vaccination is a multifaceted challenge. Beyond good intentions—wanting to protect children—the risks and benefits associated with highlighting diversity in each intervention need to be carefully considered, especially when it comes to a contested/polarizing procedure such as vaccination with a novel type of vaccine. Often, a one-size-fits-all approach negates and perpetuates structural inequities. In other cases, highlighting diversity and inequities may inadvertently increase stigma and discrimination, and further harm or infantilize targeted communities. By providing multiple perspectives, a transdisciplinary approach can support decision-making in a crisis context.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated social inequities along ethnic, racial and socio-economic lines, with significant harmful consequences for children. In marginalized neighbourhoods, these structural and social inequities converge^{Footnote 1}. Families’ and children’s environments have been shattered, while the priority was put on limiting viral transmission through vaccination and non-pharmacological interventions such as physical distancing and lockdown^{Footnote 2 Footnote 3 Footnote 4 Footnote 5 Footnote 6}. In Montréal, Canada, children in lower-income households, racialized groups and in families born outside Canada were less likely to accept COVID-19 vaccination, and adolescents in the most deprived neighbourhoods were half as likely to get vaccinated for COVID-19 compared to their peers in the least deprived neighbourhoods^{Footnote 7}.

In Montréal, a transdisciplinary program to mitigate pandemic-related inequities and associated social tensions, Programme CoVivre - Institut universitaire SHERPA^{Footnote 8 Footnote 9 Footnote 10}, developed three initiatives to address challenges related to the mass vaccination campaign that started in December 2020: 1) the production of a guide to address ethno-racial differences in vaccine hesitancy; 2) the development of tools to decrease social tensions and bullying associated with the vaccination campaign for 12–17 years-old teenagers in schools and in multi-ethnic socio-economically deprived neighbourhoods; and 3) the development of tools to address parents’ vaccine hesitancy regarding their 5–11-year-old’s immunization. These initiatives aimed to transfer information and to buffer conflicts fuelled by the symbolic meaning associated with child vaccination in different faith and ethno-racial communities, but also in the majority in which diverse groups were opposed to vaccination.

All these interventions wove together different disciplinary expertise (paediatric, child mental health, anthropological and historical), to support the rapid production of tools in a crisis context. Building on the lessons learned from these initiatives, this paper aims to launch a reflection around equity, diversity, and inclusion challenges in a public health emergency context, to preserve, as much as possible, children’s wellbeing. More specifically, we raise the following questions: To which extent should vaccination-related programs directly address diversity? What are the possible benefits versus risks of stigmatization when highlighting minority communities’ vulnerabilities to the pandemic direct and indirect impacts? Exposing the rationale underlying the chosen paths of action for these three initiatives, we argue that a transdisciplinary approach can play a key role to inform action when complex decisions are to be taken rapidly.

Addressing the cultural, social and historical dimensions of vaccine hesitancy

The development of a guide to address ethno-racial differences in vaccine hesitancy stemmed from the need to consider context and culture in improving confidence toward the vaccine^{Footnote 11 Footnote 12}. The objective was to raise practitioners’ awareness about the impact of historical (e.g. abuse and medical experimentation on African American and Indigenous communities) and current collective experiences of oppression on the perception of institutional action, to improve cultural safety and establish a respectful dialogue about vaccination with communities.

This well-intentioned process rapidly uncovered problems associated with the oversimplification of very heterogeneous communities (such as Asian, Afro-Caribbean, Faith and First Nations communities), and the associated risks of stereotyping and stigmatizing them. The historical and social sciences perspectives in the team helped us to contextualize a large range of discourses and attitudes. In partnership with community stakeholders, these different perspectives informed our choices about the ways to represent diversity, while cautioning against a standardized use of the tools. The importance of gathering local data with which to develop tailored intervention was also highlighted.

Schools at the heart of the storm: Youth vaccination campaigns

In June 2021, at the launch of the 12–17 year-olds vaccination, the public divide between pro and anti-vaccines in Québec became heated, with threats, protests and aggression towards vaccination teams within schools. Schools’ staff and parents were divided and bullying about vaccination decisions among peers became a worrisome issue. This fuelled fear in multi-ethnic neighbourhoods, jeopardizing the protective character of the schools as safe spaces of learning and inclusion, with youth refusing to attend schools while others would take a more provocative stance in response to the division of the adult community. To mitigate the impact of these tensions and re-establish a sense of community, the Programme CoVivre team began to develop tools for the school staff and for parents.

Although Montréal had an over-representation of minority and socio-economically deprived children among the non-vaccinated, we decided to develop tools which did not emphasize diversity, to rally the majority around the preservation of a protective school climate without stigmatizing the minorities. This decision was based on an appraisal of the social dynamics and included the input of a paediatric infectious disease specialist, to give more credibility to the proposed tools. In this case, the team felt that, given the adversarial tone of the public debate, emphasizing the vulnerability of migrants and ethno-racial communities in terms of vaccine hesitancy, could have increased their designation as scapegoats, because hesitant individuals were depicted as selfish or even criminal in the majority discourse. The tools were very well received and disseminated throughout the education and healthcare systems.

Supporting parental decision-making process about their children’s vaccination

Building on the experience gained with the adolescent vaccination campaign, the team developed additional tools providing medical information, legitimizing vaccine hesitancy as a healthy process and supporting parental decision about the vaccination of their younger children (5–11 years old).

Given the paucity of data available at the time^{Footnote 13}, the team relied on its medical experts to include up to date and nuanced information to support parents’ informed consent. Rapidly, questions around the level of literacy and translations of the produced tools arose. An important dilemma was identified. On the one hand, the transmission of relatively complex information was seen as an exclusion process for parents with lower literacy level, even with a proper translation: on the other hand, oversimplifying the information, necessarily biased by our positive view of vaccination, could be paternalistic, depriving parents of a more comprehensive perspective. Unable to resolve this issue, we favoured a two-step process in which the full information pamphlets were translated and distributed, followed by a second version to be modified with community stakeholders and parents of different literacy levels, to allow communities and parents to determine what they considered essential information. The choice of the best channels to disseminate the information while maximizing trust and outreach was also discussed. Again, the team was conscious that with less time constraints, communities would have adapted the tools to their needs and concerns^{Footnote 14}. Despite the urgency, the team’s diversity enabled a reflection around the need to consider diversity and equity at each step of the process.

Conclusion

Building equitable and inclusive practices around marginalized communities’ child vaccination is a multifaceted challenge^{Footnote 15}. Beyond good intentions—everyone wants to protect children—there is a need to carefully consider the risks and benefits associated with highlighting diversity in each intervention, especially when it comes to a contested/polarizing procedure such as vaccination and novel vaccine. In some cases, as it has been strongly demonstrated during the current pandemic, a one-size-fits-all approach negates and perpetuates structural inequities. In other cases, highlighting diversity and inequities (even when real) may inadvertently increase stigma and discrimination, and further harm or infantilize targeted communities.

Our experience suggests that in this process, a transdisciplinary perspective may inform decision-making, during a pandemic and beyond. By providing different, sometimes opposing or complementary perspectives, this approach informs rapid action without replacing community consultation. It also supports the capacity to collectively endorse difficult choices in a context in which we always need to remember that our actions have multifaceted (and perhaps harmful) consequences.

Authors' statement

CR — Conceptualized, drafted the initial article, reviewed–revised the article

CQ — Completed, reviewed–revised the article, provided insights on specific discipline

ED — Completed, reviewed–revised the article, provided insights on specific discipline

LM — Completed, reviewed–revised the article, provided insights on specific discipline

AV-C — Coordinator of the community interventions, reviewed the article, field insights

TS — Coordinator of the community interventions, reviewed the article, field insights

All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

The content and view expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

Competing interest

None.

Acknowledgements

The Fondation Trottier provided the funding for the CoVivre Project.