Discrimination, disadvantage and disempowerment during COVID-19: a qualitative intrasectional analysis of the lived experiences of an ethnically diverse healthcare workforce in the United Kingdom.

BACKGROUND: Healthcare workers (HCWs) in the United Kingdom (UK) have faced many challenges during the COVID-19 pandemic, some of these arising out of their social positions. Existing literature explicating these challenges (e.g., lack of appropriate PPE, redeployment, understaffing) have highlighted inequities in how these have been experienced by HCWs based on ethnicity, gender or, job role. In this paper, we move a step ahead and examine how the intersection of these social positions have impacted HCWs' experiences of challenges during the pandemic. METHODS: We collected qualitative data, using interviews and focus groups, from 164 HCWs from different ethnicities, gender, job roles, migration statuses, and regions in the United Kingdom (UK) between December 2020 and July 2021. Interviews and focus groups were conducted online or by telephone, and recorded with participants' permission. Recordings were transcribed and a hybrid thematic analytical approach integrating inductive data-driven codes with deductive ones informed by an intersectional framework was adopted to analyse the transcripts. RESULTS: Thematic analysis of transcripts identified disempowerment, disadvantage and, discrimination as the three main themes around which HCWs' experiences of challenges were centred, based on their intersecting identities (e.g., ethnicity gender, and/or migration status). Our analysis also acknowledges that disadvantages faced by HCWs were linked to systemic and structural factors at the micro, meso and macro ecosystemic levels. This merging of analysis which is grounded in intersectionality and considers the ecosystemic levels has been termed as 'intrasectionalism'. DISCUSSION: Our research demonstrates how an intrasectional lens can help better understand how different forms of mutually reinforcing inequities exist at all levels within the healthcare workforce and how these impact HCWs from certain backgrounds who face greater disadvantage, discrimination and disempowerment, particularly during times of crisis like the COVID-19 pandemic.

A qualitative study exploring healthcare workers' lived experiences of the impacts of COVID-19 policies and guidelines on maternal and reproductive healthcare services in the United Kingdom.

INTRODUCTION: During the COVID-19 pandemic, pregnant women were regarded as vulnerable to poor health outcomes if infected with the SARS-CoV-2 (COVID-19) virus. To protect the United Kingdom's (UK) National Health Service (NHS) and pregnant patients, strict infection control policies and regulations were implemented. This study aimed to understand the impact of the COVID-19 policies and guidelines on maternal and reproductive health services during the pandemic from the experiences of healthcare workers (HCWs) caring for these patients. METHODS: This qualitative study involved HCWs from the United Kingdom Research study into Ethnicity and COVID-19 outcomes in Healthcare workers (UK-REACH) project. Semi-structured interviews and focus groups were conducted online or by telephone with 44 diverse HCWs. Transcripts were thematically analyzed following Braun and Clarke's principles of qualitative analysis. RESULTS: Three key themes were identified during analysis. First, infection control policies impacted appointment availability, resulting in many cancellations and delays to treatment. Telemedicine was also used extensively to reduce risks from face-to-face consultations, disadvantaging patients from minoritized ethnicities. Secondly, staff shortages and redeployments reduced availability of consultations, appointments, and sonography scans. Finally, staff and patients reported challenges accessing timely, reliable and accurate information and guidance. CONCLUSIONS: COVID-19 demonstrated how a global health crisis can impact maternal and reproductive health services, leading to reduced service quality and surgical delays due to staff redeployment policies. Our findings underscore the implications of policy and future health crises preparedness. This includes tailored infection control policies, addressing elective surgery backlogs early and improved dissemination of relevant vaccine information.

Coverage, completion and outcomes of COVID-19 risk assessments in a multi-ethnic nationwide cohort of UK healthcare workers: a cross-sectional analysis from the UK-REACH Study.

INTRODUCTION: There are limited data on the outcomes of COVID-19 risk assessment in healthcare workers (HCWs) or the association of ethnicity, other sociodemographic and occupational factors with risk assessment outcomes. METHODS: We used questionnaire data from UK-REACH (UK Research study into Ethnicity And COVID-19 outcomes in Healthcare workers), an ethnically diverse, nationwide cohort of UK HCWs. We derived four binary outcomes: (1) offered a risk assessment; (2) completed a risk assessment; (3) working practices changed as a result of the risk assessment; (4) wanted changes to working practices after risk assessment but working practices did not change.We examined the association of ethnicity, other sociodemographic/occupational factors and actual/perceived COVID-19 risk variables on our outcomes using multivariable logistic regression. RESULTS: 8649 HCWs were included in total. HCWs from ethnic minority groups were more likely to report being offered a risk assessment than white HCWs, and those from Asian and black ethnic groups were more likely to report having completed an assessment if offered. Ethnic minority HCWs had lower odds of reporting having their work change as a result of risk assessment. Those from Asian and black ethnic groups were more likely to report no changes to their working practices despite wanting them.Previous SARS-CoV-2 infection was associated with lower odds of being offered a risk assessment and having adjustments made to working practices. DISCUSSION: We found differences in risk assessment outcomes by ethnicity, other sociodemographic/occupational factors and actual/perceived COVID-19 risk factors. These findings are concerning and warrant further research using actual (rather than reported) risk assessment outcomes in an unselected cohort.

One virus, many lives: a qualitative study of lived experiences and quality of life of adults from diverse backgrounds living in the UK during the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-2019) pandemic has had far-reaching consequences for people's lives. In the UK, more than 23 million have been infected and nearly 185 000 have lost their lives. Previous research has looked at differential outcomes of COVID-19, based on socio-demographic factors such as age, sex, ethnicity and deprivation. We conducted a qualitative study with a diverse sample of adults living in the UK, to understand their lived experiences and quality of life (QoL) during the pandemic. METHODS: Participants were recruited with the help of civil society partners and community organisations. Semi-structured interviews were conducted between May and July 2021. Interviews were recorded with permission and transcribed. Transcripts were analysed following an inductive analytical approach as outlined in the Framework Method. RESULTS: 18 participants (≥16 years) representing different ethnicities, sexes, migration and employment statuses and educational qualifications took part. Five key themes and 14 subthemes were identified and presented using the QoL framework. The five key themes describe how COVID-19 affected the following aspects of QoL: (1) financial and economic, (2) physical health, (3) social, (4) mental health and (5) personal fulfilment and affective well-being. The narratives illustrated inequities in the impact of COVID-19 for individuals with intersecting social, economic, and health disparities. CONCLUSION: Our findings demonstrate the multidimensional and differential impact of the pandemic on different population groups, with most of the negative economic impacts being borne by people in low-paid and insecure jobs. Similarly, adverse social, physical and mental health impacts particularly affected people already experiencing displacement, violence, physical and mental illnesses or even those living alone. These findings indicate that COVID-19 impacts have been influenced by intersecting health and socioeconomic inequalities, which pre-existed. These inequities should be taken into consideration while designing pandemic recovery and rebuilding packages.

Caring for Those Who Take Care of Others: Developing Systemic and Sustainable Mental Health Support for the Diverse Healthcare Workforce in the United Kingdom.

Pressures such as high workload, stretched resources, and financial stress are resulting in healthcare workers experiencing high rates of mental health conditions, high suicide rates, high rates of staff absences from work, and high vacancy rates for certain healthcare professions. All of these factors point to the fact that a systematic and sustainable approach to mental health support at different levels and in different ways is more important than ever. In response, we present a holistic analysis of the mental health and wellbeing needs of healthcare workers across the United Kingdom healthcare ecosystem. We recommend that healthcare organisations should consider the specific circumstances of these staff and develop strategies to counter the negative impact of these factors and help safeguard the mental health of their staff.

"The vaccination is positive; I don't think it's the panacea": A qualitative study on COVID-19 vaccine attitudes among ethnically diverse healthcare workers in the United Kingdom.

BACKGROUND: Globally, healthcare workers (HCWs) were prioritised for receiving vaccinations against the coronavirus disease-2019 (COVID-19). Previous research has shown disparities in COVID-19 vaccination uptake among HCWs based on ethnicity, job role, sex, age, and deprivation. However, vaccine attitudes underpinning these variations and factors influencing these attitudes are yet to be fully explored. METHODS: We conducted a qualitative study with 164 HCWs from different ethnicities, sexes, job roles, migration statuses, and regions in the United Kingdom (UK). Interviews and focus groups were conducted online or telephonically, and recorded with participants' permission. Recordings were transcribed and a two-pronged analytical approach was adopted: content analysis for categorising vaccine attitudes and thematic analysis for identifying factors influencing vaccine attitudes. FINDINGS: We identified four different COVID-19 vaccine attitudes among HCWs: Active Acceptance, Passive Acceptance, Passive Decline, and Active Decline. Content analysis of the transcripts showed that HCWs from ethnic minority communities and female HCWs were more likely to either decline (actively/passively) or passively accept vaccination-reflecting hesitancy. Factors influencing these attitudes included: trust; risk perception; social influences; access and equity; considerations about the future. INTERPRETATION: Our data show that attitudes towards COVID-19 vaccine are diverse, and elements of hesitancy may persist even after uptake. This has implications for the sustainability of the COVID-19 vaccine programme, particularly as new components (for example boosters) are being offered. We also found that vaccine attitudes differed by ethnicity, sex and job role, which calls for an intersectional and dynamic approach for improving vaccine uptake among HCWs. Trust, risk perception, social influences, access and equity and future considerations all influence vaccine attitudes and have a bearing on HCWs' decision about accepting or declining the COVID-19 vaccine. Based on our findings, we recommend building trust, addressing structural inequities and, designing inclusive and accessible information to address hesitancy.

Factors influencing the mental health of an ethnically diverse healthcare workforce during COVID-19: a qualitative study in the United Kingdom.

Background: Healthcare workers (HCWs) have been reported to be experiencing a deterioration in their mental health due to COVID-19. In addition, ethnic minority populations in the United Kingdom are disproportionately affected by COVID-19. It is imperative that HCWs are appropriately supported and protected from mental harm during the pandemic. Our research aims to add to the evidence base by providing greater insight into the lived experience of HCWs from diverse ethnic backgrounds during the pandemic that had an impact on their mental health. Methods: We undertook a qualitative work package as part of the United Kingdom Research study into Ethnicity And COVID-19 outcomes among Healthcare workers (UK-REACH). As part of the qualitative research, we carried out 16 focus groups with a total of 61 HCWs between December 2020 and July 2021. The aim of the study was to explore topics such as their experiences, fears and concerns, while working during the pandemic. The purposive sample included ancillary healthcare workers, doctors, nurses, midwives and allied health professionals from diverse ethnic backgrounds to ensure inclusion of underrepresented and disproportionately impacted individuals. We conducted discussions using Microsoft Teams. Recordings were transcribed and thematically analysed. Results: Several factors were identified which impacted on the mental health of HCWs during this period including anxiety (due to inconsistent protocols and policy); fear (of infection); trauma (due to increased exposure to severe illness and death); guilt (of potentially infecting loved ones); and stress (due to longer working hours and increased workload). Conclusion: COVID-19 has affected the mental health of HCWs. We identified a number of factors which may be contributing to a deterioration in mental health for participants from diverse ethnic backgrounds. Healthcare organisations should consider developing strategies to counter the negative impact of these factors, including recommendations made by HCWs themselves.

Antecedentes: Se ha informado que los trabajadores de la salud (HCW, por sus siglas en inglés) están experimentando un deterioro en su salud mental debido al COVID-19. Además, las poblaciones de minorías étnicas en el Reino Unido se ven afectadas de manera desproporcionada por el COVID-19. Es imperativo que los trabajadores de la salud reciban el apoyo adecuado y estén protegidos de afecciones mentales durante la pandemia. Nuestra investigación tiene como objetivo aumentar la base de evidencia al proporcionar una mayor comprensión de la experiencia vivida por los trabajadores de la salud de diversos orígenes étnicos durante la pandemia que tuvieron un impacto en su salud mental.Metodología: Llevamos a cabo un paquete de trabajo cualitativo como parte del estudio de investigación del Reino Unido sobre los resultados de la etnicidad y el COVID-19 entre los trabajadores de la salud (UK-REACH). Como parte de la investigación cualitativa, llevamos a cabo 16 grupos focales con un total de 61 Trabajadores de la Salud entre diciembre de 2020 y julio de 2021. El objetivo del estudio fue explorar temas como sus experiencias, miedos y preocupaciones, mientras trabajaban durante la pandemia. La muestra intencional incluyó trabajadores auxiliares de la salud, médicos, enfermeras, matronas y profesionales de la salud asociados de diversos orígenes étnicos para garantizar la inclusión de personas subrepresentadas y desproporcionadamente afectadas. Llevamos a cabo debates utilizando Microsoft Teams. Las grabaciones fueron transcritas y analizadas temáticamente.Resultados: Se identificaron varios factores que afectaron la salud mental de los trabajadores de la salud durante este período, incluida la ansiedad (debido a protocolos y políticas inconsistentes); miedo (de infección); trauma (debido a una mayor exposición a enfermedades graves y muerte); culpa (de infectar potencialmente a los seres queridos); y estrés (debido a jornadas laborales más largas y mayor carga de trabajo).Conclusión: COVID-19 ha afectado la salud mental de los trabajadores de la salud. Identificamos una serie de factores que pueden estar contribuyendo al deterioro de la salud mental de los participantes de diversos orígenes étnicos. Las organizaciones de atención médica deben considerar el desarrollo de estrategias para contrarrestar el impacto negativo de estos factores, incluidas las recomendaciones hechas por los propios trabajadores de la salud.

Healthcare Workers From Diverse Ethnicities and Their Perceptions of Risk and Experiences of Risk Management During the COVID-19 Pandemic: Qualitative Insights From the United Kingdom-REACH Study.

Introduction: Healthcare workers (HCWs) are at higher risk of being infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Previous studies have examined factors relating to infection amongst HCWs, including those from ethnic minority groups, but there is limited data regarding the lived experiences of HCWs in relation to self-protection and how they deal with SARS-CoV-2 infection prevention. In this study, we presented data from an ethnically diverse sample of HCWs in the United Kingdom (UK) to understand their perceptions of risks and experiences with risk management whilst working throughout the COVID-19 pandemic. Methods: We undertook a qualitative study as part of the United Kingdom Research study into Ethnicity and COVID-19 outcomes among Healthcare workers (United Kingdom-REACH) conducting semi-structured interviews and focus groups which were recorded with participants' permission. Recordings were transcribed and thematically analyzed. Findings: A total of 84 participants were included in the analysis. Five broad themes emerged. First, ethnic minority HCWs spoke about specific risks and vulnerabilities they faced in relation to their ethnicity. Second, participants' experience of risk assessments at work varied; some expressed satisfaction while many critiqued it as a "tick-box" exercise. Third, most participants shared about risks related to shortages, ambiguity in guidance, and inequitable distribution of Personal Protective Equipment (PPE), particularly during the start of the pandemic. Fourth, participants reported risks resulting from understaffing and inappropriate redeployment. Finally, HCWs shared the risk mitigation strategies which they had personally employed to protect themselves, their families, and the public. Conclusion: Healthcare workers identified several areas where they felt at risk and/or had negative experiences of risk management during the pandemic. Our findings indicate that organizational shortcomings may have exposed some HCWs to greater risks of infection compared with others, thereby increasing their emotional and mental burden. Ethnic minority HCWs in particular experienced risks stemming from what they perceived to be institutional and structural racism, thus leading to a loss of trust in employers. These findings have significance in understanding staff safety, wellbeing, and workforce retention in multiethnic staff groups and also highlight the need for more robust, inclusive, and equitable approaches to protect HCWs going forward.

Ethnicity and COVID-19 outcomes among healthcare workers in the UK: UK-REACH ethico-legal research, qualitative research on healthcare workers' experiences and stakeholder engagement protocol.

INTRODUCTION: As the world continues to grapple with the COVID-19 pandemic, emerging evidence suggests that individuals from ethnic minority backgrounds may be disproportionately affected. The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers (UK-REACH) project has been initiated to generate rapid evidence on whether and why ethnicity affects COVID-19 diagnosis and clinical outcomes in healthcare workers (HCWs) in the UK, through five interlinked work packages/work streams, three of which form the basis of this protocol. The ethico-legal work (Work Package 3) aims to understand and address legal, ethical and acceptability issues around big data research; the HCWs' experiences study (Work Package 4) explores their work and personal experiences, perceptions of risk, support and coping mechanisms; the stakeholder engagement work (Work Package 5) aims to provide feedback and support with the formulation and dissemination of the project recommendations. METHODS AND ANALYSIS: Work Package 3 has two different research strands: (A) desk-based doctrinal research; and (B) empirical qualitative research with key opinion leaders. For the empirical research, in-depth interviews will be conducted digitally and recorded with participants' permission. Recordings will be transcribed, coded and analysed using thematic analysis. In Work Package 4, online in-depth interviews and focus groups will be conducted with approximately 150 HCWs, from across the UK, and these will be recorded with participants' consent. The recordings will be transcribed and coded and data will be analysed using thematic analysis. Work Package 5 will achieve its objectives through regular group meetings and in-group discussions. ETHICS AND DISSEMINATION: Ethical approval has been received from the London-Brighton & Sussex Research Ethics Committee of the Health Research Authority (Ref No 20/HRA/4718). Results of the study will be published in open-access journals, and disseminated through conference presentations, project website, stakeholder organisations, media and scientific advisory groups. TRIAL REGISTRATION NUMBER: ISRCTN11811602.

Ethnic differences in SARS-CoV-2 vaccine hesitancy in United Kingdom healthcare workers: Results from the UK-REACH prospective nationwide cohort study.

BACKGROUND: In most countries, healthcare workers (HCWs) represent a priority group for vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) due to their elevated risk of COVID-19 and potential contribution to nosocomial SARS-CoV-2 transmission. Concerns have been raised that HCWs from ethnic minority groups are more likely to be vaccine hesitant (defined by the World Health Organisation as refusing or delaying a vaccination) than those of White ethnicity, but there are limited data on SARS-CoV-2 vaccine hesitancy and its predictors in UK HCWs. METHODS: Nationwide prospective cohort study and qualitative study in a multi-ethnic cohort of clinical and non-clinical UK HCWs. We analysed ethnic differences in SARS-CoV-2 vaccine hesitancy adjusting for demographics, vaccine trust, and perceived risk of COVID-19. We explored reasons for hesitancy in qualitative data using a framework analysis. FINDINGS: 11,584 HCWs were included in the cohort analysis. 23% (2704) reported vaccine hesitancy. Compared to White British HCWs (21.3% hesitant), HCWs from Black Caribbean (54.2%), Mixed White and Black Caribbean (38.1%), Black African (34.4%), Chinese (33.1%), Pakistani (30.4%), and White Other (28.7%) ethnic groups were significantly more likely to be hesitant. In adjusted analysis, Black Caribbean (aOR 3.37, 95% CI 2.11 - 5.37), Black African (aOR 2.05, 95% CI 1.49 - 2.82), White Other ethnic groups (aOR 1.48, 95% CI 1.19 - 1.84) were significantly more likely to be hesitant. Other independent predictors of hesitancy were younger age, female sex, higher score on a COVID-19 conspiracy beliefs scale, lower trust in employer, lack of influenza vaccine uptake in the previous season, previous COVID-19, and pregnancy. Qualitative data from 99 participants identified the following contributors to hesitancy: lack of trust in government and employers, safety concerns due to the speed of vaccine development, lack of ethnic diversity in vaccine studies, and confusing and conflicting information. Participants felt uptake in ethnic minority communities might be improved through inclusive communication, involving HCWs in the vaccine rollout, and promoting vaccination through trusted networks. INTERPRETATION: Despite increased risk of COVID-19, HCWs from some ethnic minority groups are more likely to be vaccine hesitant than their White British colleagues. Strategies to build trust and dispel myths surrounding the COVID-19 vaccine in these communities are urgently required. Emphasis should be placed on the safety and benefit of SARS-CoV-2 vaccination in pregnancy and in those with previous COVID-19. Public health communications should be inclusive, non-stigmatising and utilise trusted networks. FUNDING: UKRI-MRC and NIHR.

Integrated screening of migrants for multiple infectious diseases: Qualitative study of a city-wide programme.

BACKGROUND: Migrants from certain regions are at increased risk of key infectious diseases (including HIV, tuberculosis (TB), hepatitis B and hepatitis C). Although guidelines increasingly recommend integrated screening for multiple infections to reduce morbidity little is known about what migrants and healthcare professionals think about this approach. METHODS: Prospective qualitative study in Leicester, United Kingdom within a novel city-wide integrated screening programme in three iterative phases to understand views about infections and integrated screening. Phase 1 focus groups (nine) with migrants from diverse communities (n = 74); phase 2 semi-structured interviews with healthcare professionals involved in the screening pathway (n = 32); phase 3 semi-structured interviews (n = 23) with individuals having tested positive for one/more infections through the programme. Analysis was informed by the constant comparative process and iterative across phases 1-3. FINDINGS: Migrants' awareness of TB, HIV and hepatitis B/C varied, with greater awareness of TB and HIV than hepatitis B/C; perceived susceptibility to the infections was low. The integrated screening programme was well-received by migrants and professionals; concerns were limited to data-sharing. As anticipated, given the target group, language was cited as a challenge but mitigated by various interpretation strategies. INTERPRETATION: This large qualitative analysis is the first to confirm that integrated screening for key infectious diseases is feasible, positively viewed by, and acceptable to, migrants and healthcare professionals. These findings support recent guideline recommendations and therefore have important implications for policy-makers and clinicians as programmes of this type are more widely implemented in diverse settings. FUNDING: National Institute for Health Research.

Community-based testing of migrants for infectious diseases (COMBAT-ID): impact, acceptability and cost-effectiveness of identifying infectious diseases among migrants in primary care: protocol for an interrupted time-series, qualitative and health economic analysis.

BACKGROUND: Migration is a major global driver of population change. Certain migrants may be at increased risk of infectious diseases, including tuberculosis (TB), HIV, hepatitis B and hepatitis C, and have poorer outcomes. Early diagnosis and management of these infections can reduce morbidity, mortality and onward transmission and is supported by national guidelines. To date, screening initiatives have been sporadic and focused on individual diseases; systematic routine testing of migrant groups for multiple infections is rarely undertaken and its impact is unknown. We describe the protocol for the evaluation of acceptability, effectiveness and cost-effectiveness of an integrated approach to screening migrants for a range of infectious diseases in primary care. METHODS AND ANALYSIS: We will conduct a mixed-methods study which includes an observational cohort with interrupted time-series analysis before and after the introduction of routine screening of migrants for infectious diseases (latent TB, HIV, hepatitis B and hepatitis C) when first registering with primary care within Leicester, UK. We will assess trends in the monthly number and rate of testing and diagnosis for latent TB, HIV, hepatitis B and hepatitis C to determine the effect of the policy change using segmented regression analyses at monthly time-points. Concurrently, we will undertake an integrated qualitative sub-study to understand the views of migrants and healthcare professionals to the new testing policy in primary care. Finally, we will evaluate the cost-effectiveness of combined infection testing for migrants in primary care. ETHICS AND DISSEMINATION: The study has received HRA and NHS approvals for both the interrupted time-series analysis (16/SC/0127) and the qualitative sub-study (16/EM/0159). For the interrupted time-series analysis we will only use fully anonymised data. For the qualitative sub-study, we will gain written, informed, consent. Dissemination of the results will be through local and national meetings/conferences as well as publications in peer-reviewed journals.