Disproportionate infection, hospitalisation and death from COVID-19 in ethnic minority groups and Indigenous Peoples: an application of the Priority Public Health Conditions analytical framework.

The COVID-19 pandemic has resulted in disproportionate consequences for ethnic minority groups and Indigenous Peoples. We present an application of the Priority Public Health Conditions (PPHC) framework from the World Health Organisation (WHO), to explicitly address COVID-19 and other respiratory viruses of pandemic potential. This application is supported by evidence that ethnic minority groups were more likely to be infected, implying differential exposure (PPHC level two), be more vulnerable to severe disease once infected (PPHC level three) and have poorer health outcomes following infection (PPHC level four). These inequities are driven by various interconnected dimensions of racism, that compounds with socioeconomic context and position (PPHC level one). We show that, for respiratory viruses, it is important to stratify levels of the PPHC framework by infection status and by societal, community, and individual factors to develop optimal interventions to reduce inequity from COVID-19 and future infectious diseases outbreaks.

Quality of ethnicity data within Scottish health records and implications of misclassification for ethnic inequalities in severe COVID-19: a national linked data study.

BACKGROUND: We compared the quality of ethnicity coding within the Public Health Scotland Ethnicity Look-up (PHS-EL) dataset, and other National Health Service datasets, with the 2011 Scottish Census. METHODS: Measures of quality included the level of missingness and misclassification. We examined the impact of misclassification using Cox proportional hazards to compare the risk of severe coronavirus disease (COVID-19) (hospitalization & death) by ethnic group. RESULTS: Misclassification within PHS-EL was higher for all minority ethnic groups [12.5 to 69.1%] compared with the White Scottish majority [5.1%] and highest in the White Gypsy/Traveller group [69.1%]. Missingness in PHS-EL was highest among the White Other British group [39%] and lowest among the Pakistani group [17%]. PHS-EL data often underestimated severe COVID-19 risk compared with Census data. e.g. in the White Gypsy/Traveller group the Hazard Ratio (HR) was 1.68 [95% Confidence Intervals (CI): 1.03, 2.74] compared with the White Scottish majority using Census ethnicity data and 0.73 [95% CI: 0.10, 5.15] using PHS-EL data; and HR was 2.03 [95% CI: 1.20, 3.44] in the Census for the Bangladeshi group versus 1.45 [95% CI: 0.75, 2.78] in PHS-EL. CONCLUSIONS: Poor quality ethnicity coding in health records can bias estimates, thereby threatening monitoring and understanding ethnic inequalities in health.

Investigating the impact of financial concerns on symptoms of depression in UK healthcare workers: data from the UK-REACH nationwide cohort study.

BACKGROUND: Exploration of the association between financial concerns and depression in UK healthcare workers (HCWs) is paramount given the current 'cost of living crisis', ongoing strike action and recruitment/retention problems in the National Health Service. AIMS: To assess the impact of financial concerns on the risk of depression in HCWs, how these concerns have changed over time and what factors might predict financial concerns. METHOD: We used longitudinal survey data from a UK-wide cohort of HCWs to determine whether financial concerns at baseline (December 2020 to March 2021) were associated with depression (measured with the Public Health Questionnaire-2) at follow-up (June to October 2022). We used logistic regression to examine the association between financial concerns and depression, and ordinal logistic regression to establish predictors of developing financial concerns. RESULTS: A total of 3521 HCWs were included. Those concerned about their financial situation at baseline had higher odds of developing depressive symptoms at follow-up. Financial concerns increased in 43.8% of HCWs and decreased in 9%. Those in nursing, midwifery and other nursing roles had over twice the odds of developing financial concerns compared with those in medical roles. CONCLUSIONS: Financial concerns are increasing in prevalence and predict the later development of depressive symptoms in UK HCWs. Those in nursing, midwifery and other allied nursing roles may have been disproportionately affected. Our results are concerning given the potential effects on sickness absence and staff retention. Policy makers should act to alleviate financial concerns to reduce the impact this may have on a discontent workforce plagued by understaffing.

Ethnic inequalities in positive SARS-CoV-2 tests, infection prognosis, COVID-19 hospitalisations and deaths: analysis of 2 years of a record linked national cohort study in Scotland.

BACKGROUND: This study aims to estimate ethnic inequalities in risk for positive SARS-CoV-2 tests, COVID-19 hospitalisations and deaths over time in Scotland. METHODS: We conducted a population-based cohort study where the 2011 Scottish Census was linked to health records. We included all individuals ≥ 16 years living in Scotland on 1 March 2020. The study period was from 1 March 2020 to 17 April 2022. Self-reported ethnic group was taken from the census and Cox proportional hazard models estimated HRs for positive SARS-CoV-2 tests, hospitalisations and deaths, adjusted for age, sex and health board. We also conducted separate analyses for each of the four waves of COVID-19 to assess changes in risk over time. FINDINGS: Of the 4 358 339 individuals analysed, 1 093 234 positive SARS-CoV-2 tests, 37 437 hospitalisations and 14 158 deaths occurred. The risk of COVID-19 hospitalisation or death among ethnic minority groups was often higher for White Gypsy/Traveller (HR 2.21, 95% CI (1.61 to 3.06)) and Pakistani 2.09 (1.90 to 2.29) groups compared with the white Scottish group. The risk of COVID-19 hospitalisation or death following confirmed positive SARS-CoV-2 test was particularly higher for White Gypsy/Traveller 2.55 (1.81-3.58), Pakistani 1.75 (1.59-1.73) and African 1.61 (1.28-2.03) individuals relative to white Scottish individuals. However, the risk of COVID-19-related death following hospitalisation did not differ. The risk of COVID-19 outcomes for ethnic minority groups was higher in the first three waves compared with the fourth wave. INTERPRETATION: Most ethnic minority groups were at increased risk of adverse COVID-19 outcomes in Scotland, especially White Gypsy/Traveller and Pakistani groups. Ethnic inequalities persisted following community infection but not following hospitalisation, suggesting differences in hospital treatment did not substantially contribute to ethnic inequalities.

Pathways to ethnic inequalities in COVID-19 health outcomes in the United Kingdom: A systematic map.

BACKGROUND: Marked ethnic inequalities in COVID-19 infection and its consequences have been documented. The aim of this paper is to identify the range and nature of evidence on potential pathways which lead to ethnic inequalities in COVID-19 related health outcomes in the United Kingdom (UK). METHODS: We searched six bibliographic and five grey literature databases from 1st December 2019 to 23rd February 2022 for research on pathways to ethnic inequalities in COVID-19 health outcomes in the UK. Meta-data were extracted and coded, using a framework informed by a logic model. Open Science Framework Registration: DOI 10.17605/OSF.IO/HZRB7. RESULTS: The search returned 10,728 records after excluding duplicates, with 123 included (83% peer-reviewed). Mortality was the most common outcome investigated (N = 79), followed by infection (N = 52). The majority of studies were quantitative (N = 93, 75%), with four qualitative studies (3%), seven academic narrative reviews (6%), nine third sector reports (7%) and five government reports (4%), and four systematic reviews or meta-analyses (3%). There were 78 studies which examined comorbidities as a pathway to mortality, infection, and severe disease. Socioeconomic inequalities (N = 67) were also commonly investigated, with considerable research into neighbourhood infrastructure (N = 38) and occupational risk (N = 28). Few studies examined barriers to healthcare (N = 6) and consequences of infection control measures (N = 10). Only 11% of eligible studies theorised racism to be a driver of inequalities and 10% (typically government/third sector reports and qualitative studies) explored this as a pathway. CONCLUSION: This systematic map identified knowledge clusters that may be amenable to subsequent systematic reviews, and critical gaps in the evidence-base requiring additional primary research. Most studies do not incorporate or conceptualise racism as the fundamental cause of ethnic inequalities and therefore the contribution to literature and policy is limited.

Ethnic inequalities in COVID-19 infection, hospitalisation, intensive care admission, and death: a global systematic review and meta-analysis of over 200 million study participants.

Background: COVID-19 has exacerbated existing ethnic inequalities in health. Little is known about whether inequalities in severe disease and deaths, observed globally among minoritised ethnic groups, relates to greater infection risk, poorer prognosis, or both. We analysed global data on COVID-19 clinical outcomes examining inequalities between people from minoritised ethnic groups compared to the ethnic majority group. Methods: Databases (MEDLINE, EMBASE, EMCARE, CINAHL, Cochrane Library) were searched from 1st December 2019 to 3rd October 2022, for studies reporting original clinical data for COVID-19 outcomes disaggregated by ethnicity: infection, hospitalisation, intensive care unit (ICU) admission, and mortality. We assessed inequalities in incidence and prognosis using random-effects meta-analyses, with Grading of Recommendations Assessment, Development, and Evaluation (GRADE) use to assess certainty of findings. Meta-regressions explored the impact of region and time-frame (vaccine roll-out) on heterogeneity. PROSPERO: CRD42021284981. Findings: 77 studies comprising over 200,000,000 participants were included. Compared with White majority populations, we observed an increased risk of testing positive for infection for people from Black (adjusted Risk Ratio [aRR]:1.78, 95% CI:1.59-1.99, I2 = 99.1), South Asian (aRR:3.00, 95% CI:1.59-5.66, I2 = 99.1), Mixed (aRR:1.64, 95% CI:1.02-1.67, I2 = 93.2) and Other ethnic groups (aRR:1.36, 95% CI:1.01-1.82, I2 = 85.6). Black, Hispanic, and South Asian people were more likely to be seropositive. Among population-based studies, Black and Hispanic ethnic groups and Indigenous peoples had an increased risk of hospitalisation; Black, Hispanic, South Asian, East Asian and Mixed ethnic groups and Indigenous peoples had an increased risk of ICU admission. Mortality risk was increased for Hispanic, Mixed, and Indigenous groups. Smaller differences were seen for prognosis following infection. Following hospitalisation, South Asian, East Asian, Black and Mixed ethnic groups had an increased risk of ICU admission, and mortality risk was greater in Mixed ethnic groups. Certainty of evidence ranged from very low to moderate. Interpretation: Our study suggests that systematic ethnic inequalities in COVID-19 health outcomes exist, with large differences in exposure risk and some differences in prognosis following hospitalisation. Response and recovery interventions must focus on tackling drivers of ethnic inequalities which increase exposure risk and vulnerabilities to severe disease, including structural racism and racial discrimination. Funding: ESRC:ES/W000849/1.

Racism as the fundamental cause of ethnic inequities in COVID-19 vaccine hesitancy: A theoretical framework and empirical exploration using the UK Household Longitudinal Study.

Ethnic inequities in COVID-19 vaccine hesitancy have been reported in the United Kingdom (UK), and elsewhere. Explanations have mainly focused on differences in the level of concern about side effects, and in lack of trust in the development and efficacy of vaccines. Here we propose that racism is the fundamental cause of ethnic inequities in vaccine hesitancy. We introduce a theoretical framework detailing the mechanisms by which racism at the structural, institutional, and interpersonal level leads to higher vaccine hesitancy among minoritised ethnic groups. We then use data from Wave 6 of the UK Household Longitudinal Study COVID-19 Survey (November to December 2020) to empirically examine these pathways, operationalised into institutional, community, and individual-level factors. We use the Karlson-Holm-Breen method to formally compare the relationship between ethnicity and vaccine hesitancy once age and gender, sociodemographic variables, and institutional, community, and individual-level factors are accounted for. Based on the Average Partial Effects we calculate the percentage of ethnic inequities explained by each set of factors. Findings show that institutional-level factors (socioeconomic position, area-level deprivation, overcrowding) explained the largest part (42%) of the inequity in vaccine hesistancy for Pakistani or Bangladeshi people, and community-level factors (ethnic density, community cohesion, political efficacy, racism in the area) were the most important factors for Indian and Black groups, explaining 35% and 15% of the inequity, respectively. Our findings suggest that if policy intervened on institutional and community-level factors - shaped by structural and institutional racism - considerable success in reducing ethnic inequities might be achieved.