For far too long the physical health inequities experienced by people with mental health and addiction issues (tāngata whai ora katoa) have been invisible. Forms of structural discrimination, particularly vaccination policies and eligibility criteria, exacerbate these inequities by excluding or delaying access to life saving vaccinations against infectious diseases. The COVID-19 pandemic has brought these issues to a head. Now is the time for urgent, concerted efforts to bring change at policy and practice levels, to achieve equitable access to vaccination for tāngata whai ora, particularly tāngata whai ora Māori.

The evidence is clear. Tāngata whai ora katoa are at significant risk of poorer health outcomes from COVID-19.[[1]] People with severe mental illnesses (defined as meeting diagnostic criteria for schizophrenia, depression and bipolar disorder) are twice as likely to require hospitalisation if infected with COVID-19, and are almost three-times as likely to die as a result of COVID-19 infection, compared to those with other underlying health conditions.[[2]] There is also a significantly elevated risk for people with problematic substance disorders. Furthermore, the wellbeing of New Zealanders with mental health and addiction issues has been disproportionately affected by stay-at-home orders, with this group being significantly more at risk of lockdown-related psychological distress, anxiety and suicidal ideation.[[3]]

This evidence was recognised in the Ministry of Health’s vaccination roll-out plan when, on 28 May 2021, people with a diagnosis of severe mental illness, or those in contact with specialist mental health and addiction services, were included in Priority Group 3 for earlier vaccination.[[4]]

However, it has recently been suggested that New Zealanders with experience of mental health and addiction issues and health providers may not have realised that they were a priority group for vaccination.[[5]] Furthermore, structural discrimination embedded within the health system makes accessing physical healthcare, including vaccinations, more challenging.[[4]] A large UK cohort study with 58 million participants found that people with a diagnosis of severe mental illness were much less likely to present for COVID-19 vaccination than others.[[6]] Access to other preventative vaccination programmes, like the influenza vaccine, has historically been comparatively low among people with serious mental illness, despite the underlying health risks in this group.[[7]]

In January 2021, the mental health and addiction COVID-19 vaccine expert advisory group recommended, in order to support implementation and vaccination uptake, that the Ministry of Health design and develop a specific information and communication programme for tāngata whai ora katoa alongside people with lived experience and cultural leaders.[[8]] Targeted support and information for tāngata whai ora kotoa only became available towards the end of 2021.

Given experiences in other countries and a lack of any specific communication programme, we suspected that the uptake of vaccinations amongst tāngata whai ora katoa in Aotearoa New Zealand may have been lagging.

This was confirmed by a review of vaccination rate data (as of 29 September 2021) obtained from the Ministry of Health. The COVID-19 two-dose (ie, full) vaccination rate across all people accessing district health board (DHB) specialist mental health and addiction (ie, substance use disorder) services was approximately 30% compared to 48% of the eligible population of Aotearoa (Table 1). As a more telling comparison, the fully vaccinated rates of the over 65 population, also Priority Group 3, on the same date was 85%.[[9]]

Table 1: Vaccination rates of tāngata whai ora katoa (all people in contact with secondary mental health and addiction services) compared to the total eligible population in Aotearoa New Zealand. 29 September 2021.

There is considerable variation between DHBs in vaccination coverage for those using mental health and addiction services, from 37% to 73% on 29 September 2021 (Table 2), despite the Group 3 rollout commencing in June and July. Although the vaccination rates for tāngata whai ora katoa are somewhat higher in those over the age of 65 years (ranging from 33% to 100% depending on DHB), these figures are concerning considering the compounding risk factors of age and health conditions.

There is also considerable variation within tāngata whai ora in contact with mental health and addiction services across Aotearoa, as outlined in Table 1, with coverage being lower among those accessing addiction services. As of 29 September 2021, 30% of mental health and 23% of addiction service tāngata whai ora were fully vaccinated, and 61% of mental health and 50% of addiction service tāngata whai ora had received one dose.

For tāngata whai ora Māori, the data on vaccinations are even more concerning, with only 47% having received first doses (compared with 79% of the general population), and even fewer (38%) Māori in contact with addiction services. This brings into stark relief the deeply entrenched health inequities in Aotearoa New Zealand. Māori have higher rates of chronic health conditions and socioeconomic disadvantage. These risks then overlap with the additional health burden borne by those with mental health and addiction issues, resulting in a double jeopardy situation termed “intersectionality.”[[10]]

Table 2: First dose vaccination rates of tāngata whai ora katoa (all people in contact with secondary mental health and addiction services) by DHB region. 29 September 2021. View Table 2.

The vaccination figures for tāngata whai ora katoa are worryingly low, especially as they are one of the populations most at risk of premature mortality.[[11]] At the time of writing, the delta variant had already infected people with mental health and addiction issues in transitional housing in South Auckland. The risks from infection in unvaccinated people are high, and vulnerable groups will continue to be disproportionately affected. This cannot be allowed to happen. It is imperative that all health and community services become proactively engaged in improving vaccination coverage for this group.

Mental health and addiction services and health practitioners have an important role in being part of the solution to improve vaccination coverage.[[1]] Taking time for a discussion about tangata whai ora thoughts and feelings about vaccination and the reasons for vaccination is likely more effective than a simple offer of a vaccine,[[12]] and helping to remove some of the barriers to vaccination, particularly around transport and costs, are also important. Vaccination training and support is also available for mental health and addiction services staff to carry out vaccinations.

Primary care practices and pharmacists need to proactively contact patients who experience mental health and addiction issues about vaccines, and again offer conversations, listen to and acknowledge any concerns and provide information and practical support to access vaccination clinics. All practitioners need to reach across the divide between mental and physical healthcare. Joining up the silos of mental health, addiction and physical healthcare is overdue.

Working with whole whānau / family / aiga and population groups (eg, people who inject drugs) to support vaccination, rather than focusing on individuals, may likewise be a more effective and welcomed approach. Transportation to vaccination centres, going to centres at quieter times and innovative and proactive solutions, like the well-publicised Shot Bro vaccination buses, are also needed. Outreach is a familiar practice in health services and has an important role in supporting vaccination in a public health crisis.

Some DHBs are already offering at-home or low-sensory vaccination solutions for people with physical and mental health conditions, but this is inconsistent across the country.[[13]] Anecdotal evidence suggests tāngata whai ora intentions to be vaccinated are the same as the general population. The onus is on health services and practitioners to be proactive and ensure tāngata whai ora katoa have all the information they require to have their questions answered and to provide accessible services actively.[[14]]

The Equally Well collaborative, an evidence-informed and action-focused network of champions across the country, are collecting and sharing examples of good practice. It is this collaborative approach that is crucial at times like this, as it takes multiple people across the health and health-related system to address health inequities.

For far too long the physical health inequities experienced by tāngata whai ora katoa have been invisible. It is crucial that all health practitioners, particularly mental health and addiction practitioners, primary care teams and pharmacists, adopt new approaches to engaging and supporting people with mental health and addiction issues around vaccination. Now is certainly the most important time to act to be equally well.

About Equally Well

To find out more or to get involved in the Aotearoa Equally Well collaborative, visit https://www.tepou.co.nz/initiatives/equally-well-physical-health.

To join the discussion, share information and good practice on vaccination and supporting people with mental health and addiction issues, join Whāriki: https://www.tepou.co.nz/initiatives/te-wh%C4%81riki-o-te-ara-oranga.

To access the latest data on tāngata whai ora katoa vaccination rates, visit https://www.tutohi.nz.

Addendum: data on vaccination rates, 14 February 2022

Since this article was first submitted in September 2021, updated data on the vaccination rates of tāngata whai ora have been made available through the data platform, Tūtohi, developed by Wild Bamboo using data provided by the Ministry of Health.

Vaccination rates in this group continue to lag well behind the general population. At 14 February 2022, first and second does rates were as follows: