Mitigating ethnic disparities in covid-19 and beyond

Edmonton's Race-based Data Table: A municipal approach to addressing systemic racism through the collection and use of disaggregated, race-based data

Recent events, such as the COVID-19 pandemic, have drawn nationwide attention to systemic racism as a serious threat to public health in Canada. One promising approach to address such racism is through developing and implementing standardized procedures for collecting and using disaggregated, race-based data. In this commentary, we summarize why this approach is necessary to address systemic racism in Canada, and highlight municipal actions being taken in Edmonton, Alberta, to move this approach forward. In 2021, a Race-based Data Table, comprising 24 institutions and organizations affiliated with health, education, and policing systems, was formed in Edmonton. It aimed to engage practitioners, systems representatives, academics, and community members in collective advocacy around accessing race-based data to better understand and address disparate health outcomes associated with COVID-19 for racialized communities. Further, the Table intends to co-create a charter and toolkit outlining best practices for ethical, race-based data collection and use with local stakeholders and knowledge users. In documenting the beginning stages of the Table, and in evaluating its ongoing progress, we contribute to national conversations regarding the need for government institutions and other organizations to consistently collect and use race-based data as a means of increasing transparency and accountability in their actions.

Application of information from external data to correct for collider bias in a Covid-19 hospitalised cohort

BACKGROUND

Throughout the Covid-19 pandemic, researchers have made use of electronic health records to research this disease in a rapidly evolving environment of questions and discoveries. These studies are prone to collider bias as they restrict the population of Covid-19 patients to only those with severe disease. Inverse probability weighting is typically used to correct for this bias but requires information from the unrestricted population. Using electronic health records from a South London NHS trust, this work demonstrates a method to correct for collider bias using externally sourced data while examining the relationship between minority ethnicities and poor Covid-19 outcomes.

METHODS

The probability of inclusion within the observed hospitalised cohort was modelled based on estimates from published national data. The model described the relationship between patient ethnicity, hospitalisation, and death due to Covid-19 - a relationship suggested to be susceptible to collider bias. The obtained probabilities (as applied to the observed patient cohort) were used as inverse probability weights in survival analysis examining ethnicity (and covariates) as a risk factor for death due to Covid-19.

RESULTS

Within the observed cohort, unweighted analysis of survival suggested a reduced risk of death in those of Black ethnicity - differing from the published literature. Applying inverse probability weights to this analysis amended this aberrant result to one more compatible with the literature. This effect was consistent when the analysis was applied to patients within only the first wave of Covid-19 and across two waves of Covid-19 and was robust against adjustments to the modelled relationship between hospitalisation, patient ethnicity, and death due to Covid-19 made as part of a sensitivity analysis.

CONCLUSIONS

In conclusion, this analysis demonstrates the feasibility of using external publications to correct for collider bias (or other forms of selection bias) induced by the restriction of a population to a hospitalised cohort using an example from the recent Covid-19 pandemic.

Ethico-racial positioning in campaigns for COVID-19 research and vaccination featuring public figures

This article analyses a set of videos which featured public figures encouraging racially minoritised people in the UK to take the COVID-19 vaccine or get involved in related research. As racially targeted health communication has both potentially beneficial and problematic consequences, it is important to examine this uniquely high-profile case. Using a purposive sample of 10 videos, our thematic content analysis aimed to reveal how racially minoritised people were represented and the types of concerns about the vaccine that were expressed. We found representations of racialised difference that centred on 'community' and invoked shared social experiences. The expressed concerns centred on whether ethnic difference was accounted for in the vaccine's design and development, plus the overarching issue of trust. Our analysis adopts and develops the concept of 'racialisation'; we explore how 'mutuality' underpinned normative calls to action ('ethico-racial imperatives') and how the videos 'responsibilised' racially minoritised people. We discuss two points of tension in this case: the limitations for addressing the causes of mistrust and the risks of reductivism that accompanied the ambiguous notion of community. Our analysis develops scholarship on racialisation in health contexts and provides public health practitioners with insights into the socio-political considerations of racially targeted communications.

COVID-19 vaccine acceptance in the general population and under-resourced communities from high-income countries: realist review

OBJECTIVE

To compare vaccination willingness before rollout and 1 year post-rollout uptake among the general population and under-resourced communities in high-income countries.

DESIGN

A realist review.

DATA SOURCES

Embase, PubMed, Dimensions ai and Google Scholar.

SETTING

High-income countries.

DEFINITIONS

We defined vaccination willingness as the proportion of participants willing or intending to receive vaccines prior to availability. We defined vaccine uptake as the real proportion of the population with complete vaccination as reported by each country until November 2021.

RESULTS

We included data from 62 studies and 18 high-income countries. For studies conducted among general populations, the proportion of vaccination willingness was 67% (95% CI 62% to 72%). In real-world settings, the overall proportion of vaccine uptake among those countries was 73% (95% CI 69% to 76%). 17 studies reported pre-rollout willingness for under-resourced communities. The summary proportion of vaccination willingness from studies reporting results among people from under-resourced communities was 52% (95% CI 0.46% to 0.57%). Real-world evidence about vaccine uptake after rollout among under-resourced communities was limited.

CONCLUSION

Our review emphasises the importance of realist reviews for assessing vaccine acceptance. Limited real-world evidence about vaccine uptake among under-resourced communities in high-income countries is a call to context-specific actions and reporting.

A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates

BACKGROUND

Ethnic inequalities in maternal and neonatal health in the UK are well documented. Concerns exist regarding the use of skin colour in neonatal assessments. Healthcare professionals should be trained to recognise symptoms of diverse skin tones, and comprehensive, and inclusive guidance is necessary for the safe assessment of all infants. Disparities in healthcare provision have been emphasised during the COVID-19 pandemic, and additional research is needed to determine whether such policies adequately address ethnic minority neonates.

METHODS

A desktop search included searches of guidance produced for the United Kingdom (UK). Further searches of the Cochrane and World Health Organization (WHO) were used to identify any international guidance applicable in the UK context.

RESULTS

Several policies and one training resource used descriptors 'pink,' 'pale,' 'pallor,' and 'blue' about neonatal skin and mucous membrane colour. No policies provided specific guidance on how these colour descriptors may appear in neonates with different skin pigmentation. Only the NICE guidance and HEE e-learning resource acknowledged the challenges of assessing jaundice in infants with diverse skin tones, while another guideline noted differences in the accuracy of bilirubin measurements for the assessment of jaundice. Three policies and one training resource advised against relying on visual observation of skin colour when diagnosing neonatal conditions. The training resource included images of ethnic minority neonates, although most images included white infants.

CONCLUSIONS

Inadequate consideration of ethnicity in UK policy and training perpetuates disparities, leading to inaccurate assessments. A review is needed for inclusivity in neonatal care, regardless of skin pigmentation.

Health and social care experience and research perception of different ethnic minority populations in the East Midlands, United Kingdom (REPRESENT study)

INTRODUCTION

Ethnic minority populations experience significant health and social care disparities; despite experiencing a greater burden of diseases, these groups are underrepresented in health and social care research. Consequently, related research can be less applicable to these population groups. The REPRESENT study aims to explore the health and social care experiences of ethnic minorities and other minoritised populations, their research interests and appropriate research practices.

METHODS

Focus groups and semistructured interviews were conducted between May and September 2022 with members of a number of ethnic minority communities in England. Data were audio recorded, transcribed and thematically coded using NVivo 12. Rigour was determined through extensive sampling, iterative data collection and analysis.

FINDINGS

Fifty-two ethnic minority members were engaged in group interviews and one-to-one interviews. Participants included representatives of the following groups: African Caribbean, Eastern European, Gypsy Travellers, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual+, Refugee/Asylum Seekers, Somali and South Asian communities. Interviews were also conducted with ethnic minority healthcare providers and researchers. Three overarching categories were identified: health information, medical service experiences, health and social care concerns and health research. Health and social care services challenges were mostly attributed to discrimination, delayed services, poor cultural relevance and language and cultural barriers. The most influential information sources were local community organisations and word-of-mouth. The main health and social care concerns were chronic long-term health conditions, mental health, maternal health and child development. Recommendations for research involved understanding the motivations for participation, improving communication and empowering communities. Top research priorities were long-term health conditions, health promotion and education, early care interventions and understanding community needs.

INTERPRETATION

Discrimination and bias in health and social care provision have severe implications for worsening ethnic health inequalities. Healthcare commissioning authorities and policymakers can leverage the preference of ethnic minority groups for pharmacy services and community organisations to improve access to care. Improving research interest and engagement requires understanding individual community needs, community sensitivity, research relevance and cultural appropriateness.

PATIENT OR PUBLIC CONTRIBUTION

Members of ethnic minority Patient and Public Involvement and Engagement group and Community Advisory Board supported the REPRESENT study design, conceptualisation and report development.

'C'mon, let's talk: a pilot study of mental health literacy program for Filipino migrant domestic workers in the United Kingdom

PURPOSE

This pilot study of a culturally adapted online mental health literacy (MHL) program called 'Tara, Usap Tayo!' (C'mon, Let's Talk) aims to assess the acceptability, appropriateness, feasibility, and potential effectiveness in improving the help-seeking behavior of Filipino migrant domestic workers in the United Kingdom (UK).

METHODS

Using mixed methods, we conducted a non-randomized single-group study of the online MHL program with 21 participants. The development of this intervention was guided by the Medical Research Council Framework for developing complex interventions and utilized Heim & Kohrt's (2019) framework for cultural adaptation. Content materials from the WHO Mental Health Gap Action Program (mhGAP), WHO Problem Management Plus (PM +) and Adult Improving Access to Psychological Therapies (IAPT) were modified and translated into the Filipino language. The MHL program was delivered online in three sessions for two hours each session. Data were collected at three time points: (T1) pretest; (T2) posttest; and (3) follow-up test. Quantitative data on participants' attitudes towards help-seeking and level of mental health literacy as outcome measures of potential intervention effectiveness were collected at T1, T2 and T3, while focus group discussions (FGDs) to assess participants' feedback on the acceptability, feasibility, and appropriateness of the online MHL program were conducted immediately at T2. Data analysis was done using a thematic approach for qualitative data from the FGDs and descriptive statistics and repeated-measures ANOVA were used to assess the difference in the T1, T2, and T3 tests. Both quantitative and qualitative results were then integrated and triangulated to answer the research questions.

RESULTS

The online MHL program is generally acceptable, appropriate, and feasible for use among Filipino migrant domestic workers. Preliminary findings lend support for its possible effectiveness in improving mental health literacy and help-seeking propensity. The cultural adaptation made in the content, form, and delivery methods of the intervention was acceptable and feasible for this target subcultural group.

CONCLUSION

By improving their mental health literacy and help-seeking propensity, this online MHL program has the potential to provide support to the mental health and well-being of Filipino migrant domestic workers in the UK. Further feasibility study or large-scale randomized controlled trial is needed to confirm the preliminary findings of this study.

Call to action on diabetes care: reaching communities facing health inequalities, health inequities and deprivation

This article presents evidence and policy on the importance of reaching out into local communities with inclusive approaches to try to reduce and prevent inequities and inequalities in diabetes care. The global emergency diabetes is causing and the risks and disproportionately high ethnic disparities are investigated. The article includes some suggestions on changing approaches to reduce health inequalities to enable diabetes care to become more accessible for those who need it the most.

Artificial intelligence for diagnostic and prognostic neuroimaging in dementia: A systematic review

INTRODUCTION

Artificial intelligence (AI) and neuroimaging offer new opportunities for diagnosis and prognosis of dementia.

METHODS

We systematically reviewed studies reporting AI for neuroimaging in diagnosis and/or prognosis of cognitive neurodegenerative diseases.

RESULTS

A total of 255 studies were identified. Most studies relied on the Alzheimer's Disease Neuroimaging Initiative dataset. Algorithmic classifiers were the most commonly used AI method (48%) and discriminative models performed best for differentiating Alzheimer's disease from controls. The accuracy of algorithms varied with the patient cohort, imaging modalities, and stratifiers used. Few studies performed validation in an independent cohort.

DISCUSSION

The literature has several methodological limitations including lack of sufficient algorithm development descriptions and standard definitions. We make recommendations to improve model validation including addressing key clinical questions, providing sufficient description of AI methods and validating findings in independent datasets. Collaborative approaches between experts in AI and medicine will help achieve the promising potential of AI tools in practice.

HIGHLIGHTS

There has been a rapid expansion in the use of machine learning for diagnosis and prognosis in neurodegenerative disease Most studies (71%) relied on the Alzheimer's Disease Neuroimaging Initiative (ADNI) dataset with no other individual dataset used more than five times There has been a recent rise in the use of more complex discriminative models (e.g., neural networks) that performed better than other classifiers for classification of AD vs healthy controls We make recommendations to address methodological considerations, addressing key clinical questions, and validation We also make recommendations for the field more broadly to standardize outcome measures, address gaps in the literature, and monitor sources of bias.

Losing a Loved One During the Covid-19 Pandemic: An On-Line Survey Looking at the Effects on Traumatic Stress, Coping and Post-Traumatic Growth

The Covid-19 pandemic has had a devastating effect across the world. In the UK alone, the death toll is 132,742, with 207 people dying the previous day and a total of 6,825,074 cases of Covid-19 thus far (September 1st, 2021). The aim of this study was to look at post-traumatic stress, coping skills and post-traumatic growth in relatives, who lost a loved one during the pandemic. Some 185 individuals took part in a Qualtrics survey. Participants completed a demographic questionnaire, the Impact of Event Scale-Revised, the Coping Assessment for Bereavement and Loss (CABLE) and the Post-Traumatic Growth Questionnaire. There were two major findings. First, there were very high levels of post-traumatic stress, with 94.6% of the sample scoring above the threshold of 33 for a diagnosis of post-traumatic stress disorder (PTSD). Second, levels of post-traumatic growth were very low. Losing a relative during the Covid-19 pandemic may lead to more PTSD. The circumstances surrounding many Covid deaths, may have long term negative consequences for the bereaved relatives.

'Unable to have a proper conversation over the phone about my concerns': a multimethods evaluation of the impact of COVID-19 on routine childhood vaccination services in London, UK

OBJECTIVES

Investigating the completion rate of 12-month vaccinations and parental perspectives on vaccine services during COVID-19.

STUDY-DESIGN

Service evaluation including parental questionnaire.

METHODS

Uptake of 12-month vaccinations in three London general practices during three periods: pre-COVID (1/3/2018-28/2/2019, n = 826), during COVID (1/3/2019-28/2/2020, n = 775) and post-COVID first wave (1/8/2020-31/1/2021, n = 419). Questionnaire of parents whose children were registered at the practices (1/4/2019-1/22/2021, n = 1350).

RESULTS

Comparing pre-COVID and both COVID cohorts, the completion rates of 12-month vaccines were lower. Haemophilus influenzae type B/meningococcal group C (Hib/MenC) vaccination uptake was 5.6% lower (89.0% vs 83.4%, P=<0.001), meningococcal group B (MenB) booster uptake was 4.4% lower (87.3% vs 82.9%, P = 0.006), pneumococcal conjugate vaccine (PCV) booster uptake was 6% lower (88.0% vs 82.0%, P < 0.001) and measles, mumps and rubella (MMR) vaccine uptake was 5.2% lower (89.1% vs 83.9%, P = 0.003). Black/Black-British ethnicity children had increased odds of missing their 12-month vaccinations compared to White ethnicity children (adjusted odds ratio 0.43 [95% confidence interval 0.24-0.79, P = 0.005; 0.36 [0.20-0.65], P < 0.001; 0.48 [0.27-0.87], P = 0.01; 0.40 [0.22-0.73], P = 0.002; for Hib/MenC, MenB booster, PCV booster and MMR. Comparing pre-COVID and COVID periods, vaccinations coded as not booked increased for MMR (10%), MenB (7%) and PCV booster (8%). Parents reported changes to vaccination services during COVID-19, including difficulties booking and attending appointments and lack of vaccination reminders.

CONCLUSION

A sustained decrease in 12-month childhood vaccination uptake disproportionally affected Black/Black British ethnicity infants during the first wave of the pandemic. Vaccination reminders and availability of healthcare professionals to discuss parental vaccine queries are vital to maintaining uptake.

Insights into parents' perceived worry before and during the COVID-19 pandemic in Australia: inequality and heterogeneity of influences

BACKGROUND

Excessive worry is an invisible disruptive force that has adverse health outcomes and may advance to other forms of disorder, such as anxiety or depression. Addressing worry and its influences is challenging yet crucial for informing public health policy.

METHODS

We examined parents' worries, influences, and variability before and during COVID-19 pandemic and across geography. Parents (n = 340) and their primary school-aged children from five Australian states completed an anonymous online survey in mid-2020. After literature review, we conceptualised the influences and performed a series of regression analyses.

RESULTS

Worry levels and the variables contributing to parents' worry varied before to during the pandemic. The proportion of parents who were "very worried all the time" increased by 14.6% in the early days of the pandemic. During the pandemic, ethnic background modified parents' worry and parents' history of daily distress symptoms was a significant contributor (p < 0.05). Excessive exposure to news remained significant both before and during the pandemic. The primary predictor of parents' worry before COVID-19 was perceived neighbourhood safety, while the main predictor during COVID-19 was financial risk due to income change. Some variable such as neighbourhood safety and financial risk varied in their contribution to worry across geographical regions. The proportion of worried children was higher among distraught parents.

CONCLUSION

Parents' worry during the health pandemic was not triggered by the health risks factors but by the financial risk due to income change. The study depicts inequality in the impact of COVID-19 by ethnic background. Different policies and reported virus case numbers across states may have modified the behaviour of variables contributing to the geography of parents' worry. Exposure to stressors before the COVID-19 pandemic may have helped parents develop coping strategies during stressful events. Parents are encouraged to limit their exposure to stressful news. We advocate for parents-specific tailored policies and emphasise the need for access to appropriate mental health resources for those in need. Advancing research in geographical modelling for mental health may aid in devising much-needed location-targeted interventions and prioritising resources in future events.

Racial and ethnic disparities in COVID-19 diagnosis and adherence to mitigation behaviours in a national United States older adult sample

Older adults and people of colour are vulnerable to the COVID-19 pandemic, and mitigation behaviours reduce COVID-19 infection. We examined racial and ethnic differences in COVID-19 diagnosis and adherence to COVID-19 mitigation behaviours among U.S. older adults. Data were retrieved from the National Health and Aging Trends Study, a nationally representative prospective cohort with 3257 U.S. Medicare beneficiaries aged 65+. COVID-19 variables were collected in 2020; all other data in 2019. Odds of COVID-19 diagnosis and adherence to mitigation behaviours (handwashing, masking, social distancing) were analysed using logistic regression. Compared to White older adults, only Hispanic respondents had 2.7 times significantly higher odds of COVID-19 after adjusting for sociodemographics, health, and mitigation behaviours (aOR = 2.71, 95% CI = 1.20-6.12). Black older adults had 7.9 times significantly higher odds of masking (aOR = 7.94, 95% CI = 2.33-27.04) and 2.3 times higher odds of social distancing (aOR = 2.33, 95% CI = 1.28-4.24), after adjusting for sociodemographics and health. Among all racial and ethnic groups, only Hispanic older adults had a significantly elevated COVID-19 diagnosis. Despite higher adherence to COVID-19 mitigation behaviours among racial and ethnic minorities, especially Black older adults, odds of COVID-19 remained elevated. Research is needed to explore potential mechanisms for higher odds of COVID-19 among minority older adults.

Differences in Health Professionals' Engagement With Electronic Health Records Based on Inpatient Race and Ethnicity

Importance

US health professionals devote a large amount of effort to engaging with patients' electronic health records (EHRs) to deliver care. It is unknown whether patients with different racial and ethnic backgrounds receive equal EHR engagement.

Objective

To investigate whether there are differences in the level of health professionals' EHR engagement for hospitalized patients according to race or ethnicity during inpatient care.

Design, Setting, and Participants

This cross-sectional study analyzed EHR access log data from 2 major medical institutions, Vanderbilt University Medical Center (VUMC) and Northwestern Medicine (NW Medicine), over a 3-year period from January 1, 2018, to December 31, 2020. The study included all adult patients (aged ≥18 years) who were discharged alive after hospitalization for at least 24 hours. The data were analyzed between August 15, 2022, and March 15, 2023.

Exposures

The actions of health professionals in each patient's EHR were based on EHR access log data. Covariates included patients' demographic information, socioeconomic characteristics, and comorbidities.

Main Outcomes and Measures

The primary outcome was the quantity of EHR engagement, as defined by the average number of EHR actions performed by health professionals within a patient's EHR per hour during the patient's hospital stay. Proportional odds logistic regression was applied based on outcome quartiles.

Results

A total of 243 416 adult patients were included from VUMC (mean [SD] age, 51.7 [19.2] years; 54.9% female and 45.1% male; 14.8% Black, 4.9% Hispanic, 77.7% White, and 2.6% other races and ethnicities) and NW Medicine (mean [SD] age, 52.8 [20.6] years; 65.2% female and 34.8% male; 11.7% Black, 12.1% Hispanic, 69.2% White, and 7.0% other races and ethnicities). When combining Black, Hispanic, or other race and ethnicity patients into 1 group, these patients were significantly less likely to receive a higher amount of EHR engagement compared with White patients (adjusted odds ratios, 0.86 [95% CI, 0.83-0.88; P < .001] for VUMC and 0.90 [95% CI, 0.88-0.92; P < .001] for NW Medicine). However, a reduction in this difference was observed from 2018 to 2020.

Conclusions and Relevance

In this cross-sectional study of inpatient EHR engagement, the findings highlight differences in how health professionals distribute their efforts to patients' EHRs, as well as a method to measure these differences. Further investigations are needed to determine whether and how EHR engagement differences are correlated with health care outcomes.

Association between ethnic background and COVID-19 morbidity, mortality and vaccination in England: a multistate cohort analysis using the UK Biobank

OBJECTIVES

Despite growing evidence suggesting increased COVID-19 mortality among people from ethnic minorities, little is known about milder forms of SARS-CoV-2 infection. We sought to explore the association between ethnic background and the probability of testing, testing positive, hospitalisation, COVID-19 mortality and vaccination uptake.

DESIGN

A multistate cohort analysis. Participants were followed between 8 April 2020 and 30 September 2021.

SETTING

The UK Biobank, which stores medical data on around half a million people who were recruited between 2006 and 2010.

PARTICIPANTS

405 541 subjects were eligible for analysis, limited to UK Biobank participants living in England. 23 891 (6%) of participants were non-white.

PRIMARY AND SECONDARY OUTCOME MEASURES

The associations between ethnic background and testing, testing positive, hospitalisation and COVID-19 mortality were studied using multistate survival analyses. The association with single and double-dose vaccination was also modelled. Multistate models adjusted for age, sex and socioeconomic deprivation were fitted to estimate adjusted HRs (aHR) for each of the multistate transitions.

RESULTS

18 172 (4.5%) individuals tested positive, 3285 (0.8%) tested negative and then positive, 1490 (6.9% of those tested positive) were hospitalised, and 129 (0.6%) tested positive at the moment of hospital admission (ie, direct hospitalisation). Finally, 662 (17.4%) died after admission. Compared with white participants, Asian participants had an increased risk of negative to positive transition (aHR 1.24 (95% CI 1.02 to 1.52)), testing positive (95% CI 1.44 (1.33 to 1.55)) and direct hospitalisation (1.61 (95% CI 1.28 to 2.03)). Black participants had an increased risk of hospitalisation following a positive test (1.71 (95% CI 1.29 to 2.27)) and direct hospitalisation (1.90 (95% CI 1.51 to 2.39)). Although not the case for Asians (aHR 1.00 (95% CI 0.98 to 1.02)), black participants had a reduced vaccination probability (0.63 (95% CI 0.62 to 0.65)). In contrast, Chinese participants had a reduced risk of testing negative (aHR 0.64 (95% CI 0.57 to 0.73)), of testing positive (0.40 (95% CI 0.28 to 0.57)) and of vaccination (0.78 (95% CI 0.74 to 0.83)).

CONCLUSIONS

We identified inequities in testing, vaccination and COVID-19 outcomes according to ethnicity in England. Compared with whites, Asian participants had increased risks of infection and admission, and black participants had almost double hospitalisation risk, and a 40% lower vaccine uptake.

Neonatal outcomes of maternal SARS-CoV-2 infection in the UK: a prospective cohort study using active surveillance

BACKGROUND

Newborns may be affected by maternal SARS-CoV-2 infection during pregnancy. We aimed to describe the epidemiology, clinical course and short-term outcomes of babies admitted to a neonatal unit (NNU) following birth to a mother with confirmed SARS-CoV-2 infection within 7 days of birth.

METHODS

This is a UK prospective cohort study; all NHS NNUs, 1 March 2020 to 31 August 2020. Cases were identified via British Paediatric Surveillance Unit with linkage to national obstetric surveillance data. Reporting clinicians completed data forms. Population data were extracted from the National Neonatal Research Database.

RESULTS

A total of 111 NNU admissions (1.98 per 1000 of all NNU admissions) involved 2456 days of neonatal care (median 13 [IQR 5, 34] care days per admission). A total of 74 (67%) babies were preterm. In all, 76 (68%) received respiratory support; 30 were mechanically ventilated. Four term babies received therapeutic hypothermia for hypoxic ischaemic encephalopathy. Twenty-eight mothers received intensive care, with four dying of COVID-19. Eleven (10%) babies were SARS-CoV-2 positive. A total of 105 (95%) babies were discharged home; none of the three deaths before discharge was attributed to SARS-CoV-2.

CONCLUSION

Babies born to mothers with SARS-CoV-2 infection around the time of birth accounted for a low proportion of total NNU admissions over the first 6 months of the UK pandemic. Neonatal SARS-CoV-2 was uncommon.

STUDY REGISTRATION

ISRCTN60033461; protocol available at http://www.npeu.ox.ac.uk/pru-mnhc/research-themes/theme-4/covid-19 .

IMPACT

Neonatal unit admissions of babies born to mothers with SARS-CoV-2 infection comprised only a small proportion of total neonatal admissions in the first 6 months of the pandemic. A high proportion of babies requiring neonatal admission who were born to mothers with confirmed SARS-CoV-2 infection were preterm and had neonatal SARS-CoV-2 infection and/or other conditions associated with long-term sequelae. Adverse neonatal conditions were more common in babies whose SARS-CoV-2-positive mothers required intensive care compared to those whose SARS-CoV-2-positive mothers who did not.

Factors that impact on recruitment to vaccine trials in the context of a pandemic or epidemic: a qualitative evidence synthesis

BACKGROUND

The World Health Organization declared the COVID-19 pandemic on 11 March 2020. Vaccine development and deployment were swiftly prioritised as a method to manage and control disease spread. The development of an effective vaccine relies on people's participation in randomised trials. Recruitment to vaccine trials is particularly challenging as it involves healthy volunteers who may have concerns around the potential risks and benefits associated with rapidly developed vaccines.

OBJECTIVES

To explore the factors that influence a person's decision to participate in a vaccine trial in the context of a pandemic or epidemic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was June 2021.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored the perspectives of adults aged 18 years or older who were invited to take part in vaccine trials in the context of a pandemic or epidemic.

DATA COLLECTION AND ANALYSIS

We assessed the title, abstracts and full texts identified by the search. We used a sampling frame to identify data-rich studies that represented a range of diseases and geographical spread. We used QSR NVivo to manage extracted data. We assessed methodological limitations using an adapted version of the Critical Skills Appraisal Programme (CASP) tool for qualitative studies. We used the 'best-fit framework approach' to analyse and synthesise the evidence from our included studies. We then used the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessment to assess our confidence in each finding and develop implications for practice.

MAIN RESULTS

We included 34 studies in our review. Most studies related to HIV vaccine trials. The other studies related to Ebola virus, tuberculosis, Zika virus and COVID-19. We developed 20 key findings, under three broad themes (with seven subthemes), that described the factors that people consider when deciding whether to take part in a vaccine trial for a pandemic or epidemic disease. Our GRADE-CERQual confidence was high in nine of the key findings, moderate in 10 key findings and low in one key finding. The main reason for downgrading review findings were concerns regarding the relevance and adequacy of the underlying data. As a result of the over-representation of HIV studies, our GRADE-CERQual assessment of some findings was downgraded in terms of relevance because the views described may not reflect those of people regarding vaccine trials for other pandemic or epidemic diseases. Adequacy relates to the degree of richness and quantity of data supporting a review finding. Moderate concerns about adequacy resulted in a downgrading of some review findings. Some factors were considered to be under the control of the trial team. These included how trial information was communicated and the inclusion of people in the community to help with trial information dissemination. Aspects of trial design were also considered under control of the trial team and included convenience of participation, provision of financial incentives and access to additional support services for those taking part in the trial. Other factors influencing people's decision to take part could be personal, from family, friends or wider society. From a personal perceptive, people had concerns about vaccine side effects, vaccine efficacy and possible impact on their daily lives (carer responsibilities, work, etc.). People were also influenced by their families, and the impact participation may have on relationships. The fear of stigma from society influenced the decision to take part. Also, from a societal perspective, the level of trust in governments' involvement in research and trial may influence a person's decision. Finally, the perceived rewards, both personal and societal, were influencing factors on the decision to participate. Personal rewards included access to a vaccine, improved health and improved disease knowledge, and a return to normality in the context of a pandemic or epidemic. Potential societal rewards included helping the community and contributing to science, often motivated by the memories of family and friends who had died from the disease.

AUTHORS' CONCLUSIONS

This review identifies many of the factors that influence a person's decision to take part in a vaccine trial, and these reflect findings from reviews that examine trials more broadly. However, we also recognise some factors that become more important in connection with a vaccine trial in the context of a pandemic or epidemic. These factors include the potential stigma of taking part, the possible adverse effects of a vaccine, the added motivation for helping society, the role of community leaders in trial dissemination, and the level of trust placed in governments and companies developing vaccines. These specific influences need to be considered by trial teams when designing, and communicating about, vaccine trials in the context of a pandemic or epidemic.

Fear, loss and disconnection: the emotional impact of the Covid-19 pandemic upon staff working in mental health services and how the organization can help - a psychoanalytic perspective

This paper describes the work of a psychoanalyst working within NHS mental health services in the UK . The central contribution of a psychoanalytic approach within psychiatric care in offering a committed attempt towards understanding the patients' presentation, rather than treatment primarily aimed at symptom control, is described. Beyond this, the specific contribution of psychoanalytic ideas in establishing a containing framework for staff, and how this strengthens the capacity of the organisation as a whole to contain anxiety and to metabolize complex projective processes is outlined. Examples are given with clinical illustrations of activities which enhance this capacity in ordinary times.The author then turns to the impact of the covid-19 pandemic upon staff and patients, describing how fear, threat and experiences of multiple losses have permeated all areas of our lives and activated primitive defences. The pandemic starkly revealed profoundly disturbing questions about our assumptions and habits, adding to the intensity and multi-layered quality of the anxieties evoked . Urgent attention has been drawn to our deeply problematic relationship with the natural world, our own habitat, and indefensible social inequities have been crudely exposed. Staff have been caught between their own fear, the need to contain increased disturbance in their patients, already struggling with fragmented and disordered states of mind, and pressures from an organisation under intense strain. The capacity of mental health staff to act as containers for their patient's distress has been profoundly challenged and compromised.This paper outlines how the pandemic has highlighted the crucial role of the organisation as a container for anxiety and in supporting staff to do their work in mental health care. In order to strengthen this capacity during the crisis, the author describes how ideas derived from psychoanalytic principles were developed into guidance for NHS Mental Health Trusts during the early days of the pandemic . This guidance was adopted nationally by the Royal College of Psychiatrists and is summarised in this paper.

The impact of engaging with community groups: asset-based approaches and the lived experience of socially vulnerable populations in the UK

Introduction

Asset-based approaches to improve citizen wellbeing and address inequalities are now being adopted by public health practitioners. There is some evidence that participatory approaches and the promotion of community assets have the capacity to mitigate against the social determinants that generate health disparities. However, questions remain about how they work in practice. This paper reports on research carried out to provide insight into how a diverse range of community assets support (or not) the wellbeing of vulnerable citizens and to provide an improved understanding of people's lived experiences including the challenges of citizens who belong to community assets face. Two subsequent studies were undertaken in a region of England comprising of two neighboring municipalities where health inequalities are stark. Both municipalities contain within them areas of social deprivation. The initial study was completed in March 2020, 1 week before England's first COVID-19 lockdown restrictions were introduced and the subsequent study was conducted to explore the impact of social restrictions on the community assets forum members.

Methods

A combined phenomenological and ethnographic methodological approach was adopted for both studies. For the initial study ethnographic methods were used including 42 qualitative face-to-face interviews focusing on the lived experience of participants. Observations, informal conversations, photographs, and field notes were also carried out to allow researchers to become familiar with the setting, to build rapport and trust provide a contextual understanding of the relationship between the activity or place and participants' experiences of wellbeing. For the subsequent study thirty-six interviews (including interviews with community assets leaders) were conducted online or by phone due to COVID-19 social restrictions.

Results and discussion

The studies' findings support the supposition that these groups are community assets which help ameliorate against the social detriments of health and wellbeing that have led to widening health inequalities in the region. The findings from both studies clearly illustrate the importance of sociality for wellbeing, and that participation in these groups are an important determinant of wellbeing. The data demonstrates how social capital is generated within a range of community groups and spaces. It also conveys the needs and deficits existing within groups highlighting the need to provide more assistance to vulnerable citizens. While most themes were common to all community forums, there were some noticeable place-based differences.

Relative contributions of pre-pandemic factors and intra-pandemic activities to differential COVID-19 risk among migrant and non-migrant populations in the Netherlands: lessons for future pandemic preparedness

BACKGROUND

Although risk factors for differences in SARS-CoV-2 infections between migrant and non-migrant populations in high income countries have been identified, their relative contributions to these SARS-CoV-2 infections, which could aid in the preparation for future viral pandemics, remain unknown. We investigated the relative contributions of pre-pandemic factors and intra-pandemic activities to differential SARS-CoV-2 infections in the Netherlands by migration background (Dutch, African Surinamese, South-Asian Surinamese, Ghanaians, Turkish, and Moroccan origin).

METHODS

We utilized pre-pandemic (2011-2015) and intra-pandemic (2020-2021) data from the HELIUS cohort, linked to SARS-CoV-2 PCR test results from Public Health Service of Amsterdam (GGD Amsterdam). Pre-pandemic factors included socio-demographic, medical, and lifestyle factors. Intra-pandemic activities included COVID-19 risk aggravating and mitigating activities such as physical distancing, use of face masks, and other similar activities. We calculated prevalence ratios (PRs) in the HELIUS population that was merged with GGD Amsterdam PCR test data using robust Poisson regression (SARS-CoV-2 PCR test result as outcome, migration background as predictor). We then obtained the distribution of migrant and non-migrant populations in Amsterdam as of January 2021 from Statistics Netherlands. The migrant populations included people who have migrated themselves as well as their offspring. We used PRs and the population distributions to calculate population attributable fractions (PAFs) using the standard formula. We used age and sex adjusted models to introduce pre-pandemic factors and intra-pandemic activities, noting the relative changes in PAFs.

RESULTS

From 20,359 eligible HELIUS participants, 8,595 were linked to GGD Amsterdam PCR test data and included in the study. Pre-pandemic socio-demographic factors (especially education, occupation, and household size) resulted in the largest changes in PAFs when introduced in age and sex adjusted models (up to 45%), followed by pre-pandemic lifestyle factors (up to 23%, especially alcohol consumption). Intra-pandemic activities resulted in the least changes in PAFs when introduced in age and sex adjusted models (up to 16%).

CONCLUSION

Interventions that target pre-pandemic socio-economic status and other drivers of health inequalities between migrant and non-migrant populations are urgently needed at present to better prevent infection disparities in future viral pandemics.

Associations between polygenic risk score and covid-19 susceptibility and severity across ethnic groups: UK Biobank analysis

BACKGROUND

COVID-19 manifests with huge heterogeneity in susceptibility and severity outcomes. UK Black Asian and Minority Ethnic (BAME) groups have demonstrated disproportionate burdens. Some variability remains unexplained, suggesting potential genetic contribution. Polygenic Risk Scores (PRS) can determine genetic predisposition to disease based on Single Nucleotide Polymorphisms (SNPs) within the genome. COVID-19 PRS analyses within non-European samples are extremely limited. We applied a multi-ethnic PRS to a UK-based cohort to understand genetic contribution to COVID-19 variability.

METHODS

We constructed two PRS for susceptibility and severity outcomes based on leading risk-variants from the COVID-19 Host Genetics Initiative. Scores were applied to 447,382 participants from the UK-Biobank. Associations with COVID-19 outcomes were assessed using binary logistic regression and discriminative power was validated using incremental area under receiver operating curve (ΔAUC). Variance explained was compared between ethnic groups via incremental pseudo-R2 (ΔR2).

RESULTS

Compared to those at low genetic risk, those at high risk had a significantly greater risk of severe COVID-19 for White (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.42-1.74), Asian (OR 2.88, 95% CI 1.63-5.09) and Black (OR 1.98, 95% CI 1.11-3.53) ethnic groups. Severity PRS performed best within Asian (ΔAUC 0.9%, ΔR2 0.98%) and Black (ΔAUC 0.6%, ΔR2 0.61%) cohorts. For susceptibility, higher genetic risk was significantly associated with COVID-19 infection risk for the White cohort (OR 1.31, 95% CI 1.26-1.36), but not for Black or Asian groups.

CONCLUSIONS

Significant associations between PRS and COVID-19 outcomes were elicited, establishing a genetic basis for variability in COVID-19. PRS showed utility in identifying high-risk individuals. The multi-ethnic approach allowed applicability of PRS to diverse populations, with the severity model performing well within Black and Asian cohorts. Further studies with larger sample sizes of non-White samples are required to increase statistical power and better assess impacts within BAME populations.

Impact of the government's restrictions and guidance in relation to "social distancing" on the lives of ethnic minority populations: A mixed methods study

Background and Aims

The impacts of the COVID-19 pandemic have not been equal, with a disproportionate impact among ethnic minority communities. Structural inequalities in social determinants of health such as housing and employment have contributed to COVID-19's impact on deprived communities, including many ethnic minority communities. To compare (1) how the UK government's "social distancing" restrictions and guidance were perceived and implemented by ethnic minority populations compared to white populations, (2) the impact of restrictions and guidance upon these groups.

Methods

An explanatory sequential mixed methods study incorporated a quantitative survey and qualitative semi-structured interviews to explore individual perceptions and experiences of COVID-19 and the national restrictions. Survey participants (n = 1587) were recruited from North West England; 60 (4%) participants were from ethnic minority communities. Forty-nine interviews were conducted; 19 (39%) participants were from ethnic minority communities. Interviews were transcribed verbatim and analysed using a thematic approach. Data collection was between April and August 2020.

Results

Significant differences in demographics and household overcrowding were observed between white vs ethnic minority survey respondents, who were also significantly less confident in their knowledge of COVID-19, less likely to be high-risk drinkers, and marginally more likely to have experienced job loss and/or reduced household income. There were no group differences in wellbeing, perceptions, or nonfinancial impacts. Two inter-related themes included: (1) government guidance, incorporating people's knowledge and understanding of the guidance and their confusion/frustration over messaging; (2) the impacts of restrictions on keyworkers, home-schooling, working from home and changes in lifestyle/wellbeing.

Conclusions

Further research is needed on the long-term impacts of COVID-19 on ethnic minority communities. If policy responses to COVID-19 are to benefit ethnic minority communities, there is a need for future studies to consider fundamental societal issues, such as the role of housing and economic disadvantage.

Locked down by inequality: Older people and the COVID-19 pandemic

This paper develops the argument that post-COVID-19 recovery strategies need to focus on building back fairer cities and communities, and that this requires a strong embedding of 'age-friendly' principles to support marginalised groups of older people, especially those living in deprived urban neighbourhoods, trapped in poor quality housing. It shows that older people living in such areas are likely to experience a 'double lockdown' as a result of restrictions imposed by social distancing combined with the intensification of social and spatial inequalities. This argument is presented as follows: first, the paper examines the disproportionate impact of COVID-19 on older people, highlighting how the pandemic is both creating new and reinforcing existing inequalities in ageing along the lines of gender, class, ethnicity, race, ability and sexuality. Second, the paper explores the role of spatial inequalities in the context of COVID-19, highlighting how the pandemic is having a disproportionate impact on deprived urban areas already affected by cuts to public services, the loss of social infrastructure and pressures on the voluntary sector. Finally, the paper examines how interrelated social inequalities at both the individual and spatial level are affecting the lives of older people living in deprived urban neighbourhoods during the pandemic. The paper concludes by developing six principles for 'age-friendly' community recovery planning aimed at maintaining and improving the quality of life and wellbeing of older residents in the post-pandemic city.

The economic impact of the COVID-19 pandemic on ethnic minorities in Manchester: lessons from the early stage of the pandemic

This review summarizes the economic impacts of the pandemic on ethnic minorities, focusing on the city of Manchester. It utilizes multiple reporting sources to explore various dimensions of the economic shock in the UK, linking this to studies of pre-COVID-19 economic and ethnic composition in Manchester and in the combined authority area of Greater Manchester. We then make inferences about the pandemic's short-term impact specific to the city region. Greater Manchester has seen some of the highest rates of COVID-19 and as a result faced particularly stringent "lockdown" regulations. Manchester is the sixth most deprived Local Authority in England, according to 2019 English Indices of Multiple Deprivation. As a consequence, many neighborhoods in the city were always going to be less resilient to the economic shock caused by the pandemic compared with other, less-deprived, areas. Particular challenges for Manchester include the high rates of poor health, low-paid work, low qualifications, poor housing conditions and overcrowding. Ethnic minority groups also faced disparities long before the onset of the pandemic. Within the UK, ethnic minorities were found to be most disadvantaged in terms of employment and housing-particularly in large urban areas containing traditional settlement areas for ethnic minorities. Further, all Black, Asian, and Minority ethnic (BAME) groups in Greater Manchester were less likely to be employed pre-pandemic compared with White people. For example, people of Pakistani and Bangladeshi ethnic backgrounds, especially women, have the lowest levels of employment in Greater Manchester. Finally, unprecedented cuts to public spending as a result of austerity have also disproportionately affected women of an ethnic minority background alongside disabled people, the young and those with no or low-level qualifications. This environment has created and sustained a multiplicative disadvantage for Manchester's ethnic minority residents through the course of the COVID-19 pandemic.

Novel intervention to promote COVID-19 protective behaviours among Black and South Asian communities in the UK: protocol for a mixed-methods pilot evaluation

INTRODUCTION

Culturally appropriate interventions to promote COVID-19 health protective measures among Black and South Asian communities in the UK are needed. We aim to carry out a preliminary evaluation of an intervention to reduce risk of COVID-19 comprising a short film and electronic leaflet.

METHODS AND ANALYSIS

This mixed methods study comprises (1) a focus group to understand how people from the relevant communities interpret and understand the intervention's messages, (2) a before-and-after questionnaire study examining the extent to which the intervention changes intentions and confidence to carry out COVID-19 protective behaviours and (3) a further qualitative study exploring the views of Black and South Asian people of the intervention and the experiences of health professionals offering the intervention. Participants will be recruited through general practices. Data collection will be carried out in the community.

ETHICS AND DISSEMINATION

The study received Health Research Authority approval in June 2021 (Research Ethics Committee Reference 21/LO/0452). All participants provided informed consent. As well as publishing the findings in peer-reviewed journals, we will disseminate the findings through the UK Health Security Agency, NHS England and the Office for Health Improvement and Disparities and ensure culturally appropriate messaging for participants and other members of the target groups.

Translating Cultural Safety to the UK

Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The 'Black Lives Matter' movement has exposed structural racism's contribution to these health inequities. 'Cultural Safety', an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be 'culturally safe'. The ways in which New Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the 'nuts and bolts' of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation.

Ethnic minority representation in UK COVID-19 trials: systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has highlighted health disparities affecting ethnic minority communities. There is growing concern about the lack of diversity in clinical trials. This study aimed to assess the representation of ethnic groups in UK-based COVID-19 randomised controlled trials (RCTs).

METHODS

A systematic review and meta-analysis were undertaken. A search strategy was developed for MEDLINE (Ovid) and Google Scholar (1st January 2020-4th May 2022). Prospective COVID-19 RCTs for vaccines or therapeutics that reported UK data separately with a minimum of 50 participants were eligible. Search results were independently screened, and data extracted into proforma. Percentage of ethnic groups at all trial stages was mapped against Office of National Statistics (ONS) statistics. Post hoc DerSimonian-Laird random-effects meta-analysis of percentages and a meta-regression assessing recruitment over time were conducted. Due to the nature of the review question, risk of bias was not assessed. Data analysis was conducted in Stata v17.0. A protocol was registered (PROSPERO CRD42021244185).

RESULTS

In total, 5319 articles were identified; 30 studies were included, with 118,912 participants. Enrolment to trials was the only stage consistently reported (17 trials). Meta-analysis showed significant heterogeneity across studies, in relation to census-expected proportions at study enrolment. All ethnic groups, apart from Other (1.7% [95% CI 1.1-2.8%] vs ONS 1%) were represented to a lesser extent than ONS statistics, most marked in Black (1% [0.6-1.5%] vs 3.3%) and Asian (5.8% [4.4-7.6%] vs 7.5%) groups, but also apparent in White (84.8% [81.6-87.5%] vs 86%) and Mixed 1.6% [1.2-2.1%] vs 2.2%) groups. Meta-regression showed recruitment of Black participants increased over time (p = 0.009).

CONCLUSIONS

Asian, Black and Mixed ethnic groups are under-represented or incorrectly classified in UK COVID-19 RCTs. Reporting by ethnicity lacks consistency and transparency. Under-representation in clinical trials occurs at multiple levels and requires complex solutions, which should be considered throughout trial conduct. These findings may not apply outside of the UK setting.

Evaluating the impact of COVID-19 pandemic on the physicians' psychological health: A systematic scoping review

Background

COVID-19 has endangered healthcare systems at multiple levels worldwide. Published data suggests that moral dilemmas faced during these unprecedented times have placed physicians at the intersections of ethical and unethical considerations. This phenomenon has questioned the physicians' morality and how that has affected their conduct. The purpose of our review is to tap into the spectrum of the transforming optics of patient care during the pandemic and its impact on psychological wellbeing of physicians.

Methods

We adopted the Arksey and O'Malley's framework, defining research questions, identifying relevant studies, selecting the studies using agreed inclusion and exclusion criteria, charting the data, and summarizing and reporting results. Databases of PubMed/Medline, Web of Science, Scopus, Science Direct, CINAHL, and PsycInfo were searched using a predefined search string. The retrieved titles and abstracts were reviewed. Later, a detailed full-text analysis of the studies which matched our inclusion criteria was performed.

Results

Our first search identified 875 titles and abstracts. After excluding duplicates, irrelevant, and incomplete titles, we selected 28 studies for further analysis. The sample size in 28 studies was 15,509 with an average size of 637 per study. Both quantitative and qualitative approaches were used, with cross-sectional surveys being utilized in all 16 quantitative studies. Using the data from semi-structured interviews, several discrete codes were generated, which led to the identification of five main themes; mental health, individual challenges, decision-making, change in patient care, and support services.

Conclusion

This scoping review reports an alarming rise in psychological distress, moral injury, cynicism, uncertainty, burnout, and grief among physicians during the pandemic. Decision-making and patient care were mostly regulated by rationing, triaging, age, gender, and life expectancy. Poor professional controls and institutional services potentially led to physicians' crumbling wellbeing. This research calls for the remediation of the deteriorating mental health and a restoration of medical profession's advocacy and equity.

Ethnic disparities in COVID-19 outcomes: a multinational cohort study of 20 million individuals from England and Canada

BACKGROUND

Heterogeneous studies have demonstrated ethnic inequalities in the risk of SARS-CoV-2 infection and adverse COVID-19 outcomes. This study evaluates the association between ethnicity and COVID-19 outcomes in two large population-based cohorts from England and Canada and investigates potential explanatory factors for ethnic patterning of severe outcomes.

METHODS

We identified adults aged 18 to 99 years in the QResearch primary care (England) and Ontario (Canada) healthcare administrative population-based datasets (start of follow-up: 24th and 25th Jan 2020 in England and Canada, respectively; end of follow-up: 31st Oct and 30th Sept 2020, respectively). We harmonised the definitions and the design of two cohorts to investigate associations between ethnicity and COVID-19-related death, hospitalisation, and intensive care (ICU) admission, adjusted for confounders, and combined the estimates obtained from survival analyses. We calculated the 'percentage of excess risk mediated' by these risk factors in the QResearch cohort.

RESULTS

There were 9.83 million adults in the QResearch cohort (11,597 deaths; 21,917 hospitalisations; 2932 ICU admissions) and 10.27 million adults in the Ontario cohort (951 deaths; 5132 hospitalisations; 1191 ICU admissions). Compared to the general population, pooled random-effects estimates showed that South Asian ethnicity was associated with an increased risk of COVID-19 death (hazard ratio: 1.63, 95% CI: 1.09-2.44), hospitalisation (1.53; 1.32-1.76), and ICU admission (1.67; 1.23-2.28). Associations with ethnic groups were consistent across levels of deprivation. In QResearch, sociodemographic, lifestyle, and clinical factors accounted for 42.9% (South Asian) and 39.4% (Black) of the excess risk of COVID-19 death.

CONCLUSION

International population-level analyses demonstrate clear ethnic inequalities in COVID-19 risks. Policymakers should be cognisant of the increased risks in some ethnic populations and design equitable health policy as the pandemic continues.

Attitudes toward COVID-19 Vaccine Uptake: A Qualitative Study of Mostly Immigrant Racial/Ethnic Minority Older Adults

(1) Background: Few qualitative studies address diverse older adults' perceptions of COVID-19 vaccination in the United States, including non-English speakers and immigrant populations. This study aims to understand the attitudes of diverse, primarily immigrant older adults in the U.S. toward the COVID-19 vaccine and its influences on their vaccination decision-making. (2) Methods: The research team conducted semi-structured interviews (N = 100) in 2021 focused on understanding ethnically/racially diverse older adults' perceptions of the COVID-19 vaccine. Interviews were recorded, coded, and analyzed using a thematic analysis approach. (3) Results: Thematic analyses identified three themes. (1) Older adults showed mixed attitudes toward the COVID-19 vaccine associated with information consumed and trust in healthcare systems; (2) health concerns and underlying medical conditions were the most influential factors of vaccine uptake; and (3) systemic barriers and trusted figures impacted vaccination decision-making of older adults. (4) Conclusions: Accessible information in diverse languages tailored to the community's fears is needed to combat vaccine mistrust. Vaccine rollout programs need to tackle the fear of vaccine side effects. Attitudes of religious leaders, family members, and physicians considerably influenced vaccine uptake, suggesting their role as trusted members for vaccine messaging for older, primarily immigrant adults. Systemic barriers, namely lack of transportation and inaccessible vaccination sites, contributed to vaccine deterrence.

The Past Is so Present: Understanding COVID-19 Vaccine Hesitancy Among African American Adults Using Qualitative Data

BACKGROUND

African Americans (AAs) are disproportionately affected by structural and social determinants of health, resulting in greater risks of exposure to and deaths from COVID-19. Structural and social determinants of health feed vaccine hesitancy and worsen health disparities.

OBJECTIVE

The present study aims to explore vaccine attitudes and intentions among program participants, understand the role of an African American faith-based wellness program in COVID-19 awareness and vaccine uptake, and solicit potential solutions for this deep-rooted public health problem.

METHODS

Data were collected through 21 in-depth interviews among individuals involved within a community-based wellness program. Sixteen phone and five in-person interviews were conducted with church leaders, lifestyle coaches, and program participants. All interviews were audio-recorded, transcribed verbatim, and inductively and thematically analyzed by three researchers.

FINDINGS

Live Well by Faith (LWBF) acted as a trusted information source for COVID-19 resources for the AA community. Services provided by Live Well by Faith included enrolling community members for vaccines, negotiating vaccine provision to and facilitating the establishment of vaccine clinics at AA churches, and connecting community members to healthcare providers. Despite the role Live Well by Faith played, VH was a significant concern due, in part, to historical mistrust of government and pharmaceutical companies conducting unethical healthcare research among Black populations. Other factors included uncertainty about vaccination (vaccines' safety, efficacy, and necessity), social media misinformation, and political affiliation. Participants expressed the need for government to commit resources towards addressing historical factors and building trust with minority populations.

CONCLUSION

Resource targeting programs such as Live Well by Faith that engage faith and community leaders in co-designed shared and culturally grounded interventions can help restore and strengthen trust in vaccines and governments and reduce vaccine hesitancy.

Community Health Workers as Puentes/Bridges to Increase COVID-19 Health Equity in Latinx Communities of the Southwest U.S

This study documents the pivotal role that Community Health Workers (CHW) played while supporting underserved Latinx communities affected by COVID-19-related health inequities. With the support of CHWs' agencies historically serving three Latinx-dense counties in Arizona, we recruited CHWs who participated in a state-wide COVID-19 testing project. Using phenomenology and narrative qualitative research methods, five focus groups were facilitated in Spanish between August and November 2021. Bilingual research team members conducted the analysis of the Spanish verbatim transcripts and CHWs reviewed the results for validity. Three interconnected themes reflected the CHWs experiences: (1) CHWs as puentes/bridges with deep community embeddedness through shared experiences and social/cultural context, (2) CHWs as communication brokers and transformational agents, playing a pivotal role in responding to the health and socioeconomic challenges posed by the COVID-19 pandemic, (3) CHWs satisfaction and frustration due to their dual role as committed community members but unrecognized and undervalued frontline public health workers. These findings emphasize the CHWs' commitment towards supporting their communities, even amidst the stressors of the pandemic. It is important to continue to integrate the role of CHWs into the larger healthcare system as opposed to relegating them to short term engagements as was the case during the COVID-19 pandemic. This article provides a set of practice, policy, and future research recommendations, emphasizing the need to allocate greater budgetary and training resources in support of CHWs.

Who Presents Where? A Population-Based Analysis of Socio-Demographic Inequalities in Head and Neck Cancer Patients' Referral Routes

Head and neck cancers (HNC) are often late stage at diagnosis; stage is a major determinant of prognosis. The urgent cancer referral pathway (two week wait; 2WW) within England's National Health Service aims to reduce time to diagnosis. We investigated factors associated with HNC route to diagnosis. Data were obtained from the English population-based cancer registry on 66,411 primary invasive HNCs (ICD C01-14 and C31-32) diagnosed 2006-2014. Multivariable logistic regression determined the likelihood of different diagnosis routes by patients' demographic and clinical characteristics. Significant socio-demographic inequalities were observed. Emergency presentations declined over time and 2WW increased. Significant socio-demographic inequalities were observed. Non-white patients, aged over 65, residing in urban areas with advanced disease, were more likely to have emergency presentations. White males aged 55 and older with an oropharynx cancer were more likely to be diagnosed via 2WW. Higher levels of deprivation were associated with both emergency and 2WW routes. Dental referral was more likely in women, with oral cancers and lower stage disease. Despite the decline over time in emergency presentation and the increased use of 2WW, socio-demographic variation is evident in routes to diagnosis. Further work exploring the reasons for these inequalities, and the consequences for patients' care and outcomes, is urgently required.

Association between household composition and severe COVID-19 outcomes in older people by ethnicity: an observational cohort study using the OpenSAFELY platform

BACKGROUND

Ethnic differences in the risk of severe COVID-19 may be linked to household composition. We quantified the association between household composition and risk of severe COVID-19 by ethnicity for older individuals.

METHODS

With the approval of NHS England, we analysed ethnic differences in the association between household composition and severe COVID-19 in people aged 67 or over in England. We defined households by number of age-based generations living together, and used multivariable Cox regression stratified by location and wave of the pandemic and accounted for age, sex, comorbidities, smoking, obesity, housing density and deprivation. We included 2 692 223 people over 67 years in Wave 1 (1 February 2020-31 August 2020) and 2 731 427 in Wave 2 (1 September 2020-31 January 2021).

RESULTS

Multigenerational living was associated with increased risk of severe COVID-19 for White and South Asian older people in both waves [e.g. Wave 2, 67+ living with three other generations vs 67+-year-olds only: White hazard ratio (HR) 1.61 95% CI 1.38-1.87, South Asian HR 1.76 95% CI 1.48-2.10], with a trend for increased risks of severe COVID-19 with increasing generations in Wave 2. There was also an increased risk of severe COVID-19 in Wave 1 associated with living alone for White (HR 1.35 95% CI 1.30-1.41), South Asian (HR 1.47 95% CI 1.18-1.84) and Other (HR 1.72 95% CI 0.99-2.97) ethnicities, an effect that persisted for White older people in Wave 2.

CONCLUSIONS

Both multigenerational living and living alone were associated with severe COVID-19 in older adults. Older South Asian people are over-represented within multigenerational households in England, especially in the most deprived settings, whereas a substantial proportion of White older people live alone. The number of generations in a household, number of occupants, ethnicity and deprivation status are important considerations in the continued roll-out of COVID-19 vaccination and targeting of interventions for future pandemics.

Implicit and explicit ethnic biases in multicultural primary care: the case of trainee general practitioners

Background

General Practitioners (GPs) are the first point of contact for people from ethnic and migrant groups who have health problems. Discrimination can occur in this health care sector. Few studies, however, have investigated implicit and explicit biases in general practice against ethnic and migrant groups. This study, therefore, investigated the extent of implicit ethnic biases and willingness to adapt care to migrant patients among trainee GPs, and the factors involved therein, in order to measure explicit bias and explore a dimension of cultural competence.

Methods

In 2021, data were collected from 207 trainee GPs in the French-speaking part of Belgium. The respondents passed an Implicit Association Test (IAT), a validated tool used to measure implicit biases against ethnic groups. An explicit attitude of willingness to adapt care to diversity, one of the dimensions of cultural competence, was measured using the Hudelson scale.

Results

The overwhelming majority of trainee GPs (82.6%, 95% CI: 0.77 – 0.88) had implicit preferences for their ingroup to the detriment of ethnic and migrant groups. Overall, the majority of respondents considered it the responsibility of GPs to adapt their attitudes and practices to migrants’ needs. More than 50% of trainee GPs, however, considered it the responsibility of migrant patients to adapt to the values and habits of the host country.

Conclusions

This study found that the trainee GPs had high to very high levels of implicit ethnic bias and that they were not always willing to adapt care to the values of migrants. We therefore recommend that they are made aware of this bias and we recommend using the IAT and Hudelson scales as educational tools to address ethnic biases in primary care.

Geographic Heterogeneity in Behavioral and Social Drivers of COVID-19 Vaccination

INTRODUCTION

Little is known about how the drivers of COVID-19 vaccination vary across the U.S. To inform vaccination outreach efforts, this study explores geographic variation in correlates of COVID-19 nonvaccination among adults.

METHODS

Participants were a nationally representative sample of U.S. adults identified through random-digit dialing for the National Immunization Survey-Adult COVID Module. Analyses examined the geographic and temporal landscape of constructs in the Behavioral and Social Drivers of Vaccination Framework among unvaccinated respondents from May 2021 to December 2021 (n=531,798) and sociodemographic and geographic disparities and Behavioral and Social Drivers of Vaccination predictors of COVID-19 nonvaccination from October 2021 to December 2021 (n=187,756).

RESULTS

National coverage with at least 1 dose of COVID-19 vaccine was 79.3% by December 2021, with substantial geographic heterogeneity. Regions with the largest proportion of unvaccinated persons who would probably get a COVID-19 vaccine or were unsure resided in the Southeast and Midwest (Health and Human Services Regions 4 and 5). Both regions had similar temporal trends regarding concerns about COVID-19 and confidence in vaccine importance, although the Southeast had especially low confidence in vaccine safety in December 2021, lowest in Florida (5.5%) and highest in North Carolina (18.0%). The strongest Behavioral and Social Drivers of Vaccination correlate of not receiving a COVID-19 vaccination was lower confidence in COVID-19 vaccine importance (adjusted prevalence ratio=5.19, 95% CI=4.93, 5.47; strongest in the Northeast, Southwest, and Mountain West and weakest in the Southeast and Midwest). Other Behavioral and Social Drivers of Vaccination correlates also varied by region.

CONCLUSIONS

Contributors to nonvaccination showed substantial geographic heterogeneity. Strategies to improve COVID-19 vaccination uptake may need to be tailored regionally.

The role of trust in COVID-19 vaccine hesitancy and acceptance among Black and White Americans

Mass vaccination has been identified as the easiest way to combat the deadly spread of the coronavirus (COVID-19) disease, yet many Americans are still hesitant to be vaccinated. To understand motivations behind why someone is vaccine hesitant, we conceptualized a theoretical model in which demographic variables are positively associated with four types of trust (i.e., trust in institutions, physicians, non-discrimination, and social media). These trust variables, in turn, are positively associated with the outcome variable of vaccine acceptance. A multi-group structural equation modeling analysis of survey data from 1008 U.S. adults suggested that trust in institutions and physicians were important for both White and Black Americans in whether they were vaccine accepting or hesitant, while trust in non-discrimination was important for Black Americans and trust in social media was important for White Americans. Implications of the findings and how they can inform future vaccine campaigns are discussed.

Racial discrimination, low trust in the health system and COVID-19 vaccine uptake: a longitudinal observational study of 633 UK adults from ethnic minority groups

OBJECTIVES

To examine whether racial/ethnic discrimination predicts future COVID-19 vaccine refusal, and whether this association is explained by trust in government and the health system.

DESIGN

Longitudinal observational study of racial/ethnic discrimination occurring since the start of the first lockdown (measured in July 2020) and later COVID-19 vaccine status.

SETTING

UK (England, Scotland, Wales and Northern Ireland).

PARTICIPANTS

A total of 633 adults belonging to ethnic minority groups who took part in the UCL COVID-19 Social Study.

MAIN OUTCOME MEASURES

COVID-19 vaccine refusal (vs. accepted/waiting/had at least one dose) between 23 December 2020 and 14 June 2021.

RESULTS

Nearly 1 in 10 (6.69%) who had refused a COVID-19 vaccine had experienced racial/ethnic discrimination in a medical setting since the start of the pandemic and had experienced twice as many incidents of racial/ethnic discrimination than those who had accepted the vaccine. Structural equation modelling results indicated a nearly four fold (odds ratio = 3.91, 95% confidence interval = 1.40 to 10.92) total effect of racial/ethnic discrimination on refusing the vaccine which was mediated by low trust in the health system to handle the pandemic (odds ratio = 2.49, 95% confidence interval = 1.12 to 5.39). Analyses adjusted for a range of demographic and COVID-19 related factors.

CONCLUSIONS

Findings underscore the importance of addressing racial/ethnic discrimination and the role the National Health Service in regaining trust from ethnic minority groups to increase COVID-19 vaccine uptake among ethnic minority adults.

Same storm, different boats: the impact of COVID-19 on Black students and academic staff in UK and US higher education

The permanence of systemic racism in the UK and USA means that Black people are disadvantaged in myriad ways, including within the Academy. While the disproportionate impact of COVID-19, alongside the Black Lives Matter movement, has increased awareness of the challenges faced by Black communities, these issues remain, both in and beyond higher education. Furthermore, there is still a paucity of research individualising the experiences of Black people, who are often homogenised with other ethnic minority groups. This paper explores the impact of COVID-19 on UK and US Black students and academic staff, utilising a critical race theory (CRT) framework. Analysis revealed that Black students and staff experienced COVID-19 against the backdrop of racism as a "pandemic within a pandemic" (Laurencin and Walker, Cell Systems 11:9-10, 2020), including racial (re)traumatisation, loneliness and isolation. Other themes included precarious employment and exploitation. Recommendations are offered for penetrative interventions that can support Black students and staff in the wake of strained race relations neglecting their adverse experiences and a global pandemic.

The 3%: Positive action for positive change

In 2019 The King’s Fund Library Service in the UK created a positive action graduate traineeship aimed at correcting the lack of ethnic diversity within the library and information profession in the United Kingdom. This commentary, anchored in the critical race theory tenet of counter-narrative, examines the establishment of this post through the lens of critical race theory, providing insight into how white supremacy presents itself in the implementation of anti-racist recruitment practices.

Bio-Politics and Calculative Technologies in COVID-19 Governance: Reflections From England

BACKGROUND

Through the extensive use of public media, the government of England was heavily involved in encouraging and instructing people on how to manage their life during coronavirus disease 2019 (COVID-19). This model of health emergency governance replicates the practice of 'calculative technologies' and 'bio-politics' embedded in population management. Previous research on COVID-19 governance both in the United Kingdom and beyond provides varied revelations on broader 'technologies of government' and bio-politics by numerous governments. However, rarely have any studies explicitly and distinctively highlighted the unique 'calculative technologies' mobilised by governments within their bio-politically designed "technologies of government" to compel the populations to manage their lives under their COVID-19 guidance. The paper therefor examines how the UK government deployed "calculative technologies," as part of its strategies of health governance and governmentality during the first wave of COVID-19 in England.

METHODS

This study uses document analysis as its data collection method. Its review includes documents, press releases, social media disclosures and health guidance issued by the UK government from March to December, 2020. The data are analysed employing the Foucault's governmentality and bio-political scholarship.

RESULTS

The paper's findings reveal the UK government's use of integrated calculative technologies of self-governance in the form of risk calculations and metrices/statistics (eg, death tolls, infection rates), performance management (eg, two metre social distancing, and hand washing for twenty seconds) and discipline and control (eg, fourteen days self-isolation), in addition to a more conventional top-down, managerial decision-making process adopted in the past. By these newly initiated "calculative technologies," the government has "bio-politically" governed the behaviours and lifestyles of vulnerable community members, health workers and general public at a distance, inculcating self-management and individualisation of responsibility.

CONCLUSION

The newly adopted calculative technologies used by the UK government created a multi-faceted discourse of obligations, entitlements and scale of engagement, and facilitated directions about what people should do to protect themselves and others from the spread of the virus. Overall, the overtly and idiosyncratically used calculative technologies resemble a unique 'art of government' and produce a set of 'bio-political' interventions enforcing the populations to manage their own wellbeing and governing them at a distance during COVID-19.

A qualitative study of factors influencing COVID-19 vaccine hesitancy among South Asians in London

Objectives

This qualitative study sought to elicit the views and experiences of patients and health-care professionals to identify the factors associated with COVID-19 vaccine hesitancy among South Asians in London.

Design

In-depth semi-structured telephone and virtual interviews.

Setting

UK.

Participants

Convenience and purposive sample of 12 individuals including patients, clinicians, and a medical receptionist.

Main Outcome Measures

Our dataset identifies and explains the reasons for distinguishing between those individuals who are COVID-19 vaccine-hesitant, and those who are COVID-19 vaccine-anxious.

Results

COVID-19 vaccine hesitancy and the decision on whether to - or not to - vaccinate against COVID-19 involves ongoing and unresolved inner conflict about COVID-19 vaccines. Our findings therefore suggest that some individuals may be existing in a state of inbetweeness; where they are neither pro nor anti vaccination, while simultaneously questioning the many 'truths' surrounding COVID-19 and not just one truth such as the safety of COVID-19 vaccines. We argue that this in-between state is intensified by technology and social media; culminating in the Rashomon Effect, whereby a combination of truths, fractured truths, subjective realities, and unreliable or contradictory sources impact on our perceptions of COVID-19.

Conclusions

Given the complexities arising from the multiple factors influencing vaccine hesitancy and scepticism, 'quick fixes' and 'one size fits all' solutions to address COVID-19 vaccine hesitancy will be ineffective. Therefore, promoting trust and prioritising good after-care as well as on-going care as a response to the effects of the pandemic is vital.

Vaccine Hesitancy: Contemporary Issues and Historical Background

Vaccination, despite being recognized as one of the most effective primary public health measures, is viewed as unsafe and unnecessary by an increasing number of individuals. Anxiety about vaccines and vaccination programs leading to vaccine hesitancy results from a complex mix of social and political influences, cultural and religious beliefs, the availability of and ability to interpret health and scientific information, and personal and population experiences of health systems and government policies. Vaccine hesitancy is becoming a serious threat to vaccination programs, and was identified as one of the World Health Organization’s top ten global health threats in 2019. The negative impact of anti-vaccination movements is frequently cited as one of the major reasons for rising vaccine hesitancy amongst the general public world-wide. This review discusses the various issues surrounding vaccine hesitancy and the anti-vaccine movement, starting with the definitions of vaccine hesitancy and the anti-vaccine movement in their early history and in the modern era, before discussing the key drivers of vaccine hesitancy, particularly across different regions of the world, with a focus on various countries with low-, middle-, or high-income economies with different socio-economic populations. The review concludes with the impact of vaccine hesitancy on herd immunity and social, psychological, and public health measures to counter vaccine hesitancy.

Tracking the incidence and risk factors for SARS-CoV-2 infection using historical maternal booking serum samples

The early transmission dynamics of SARS-CoV-2 in the UK are unknown but their investigation is critical to aid future pandemic planning. We tested over 11,000 anonymised, stored historic antenatal serum samples, given at two north-west London NHS trusts in 2019 and 2020, for total antibody to SARS-CoV-2 receptor binding domain (anti-RBD). Estimated prevalence of seroreactivity increased from 1% prior to mid-February 2020 to 17% in September 2020. Our results show higher prevalence of seroreactivity to SARS-CoV-2 in younger, non-white ethnicity, and more deprived groups. We found no significant interaction between the effects of ethnicity and deprivation. Derived from prevalence, the estimated incidence of seroreactivity reflects the trends observed in daily hospitalisations and deaths in London that followed 10 and 13 days later, respectively. We quantified community transmission of SARS-CoV-2 in London, which peaked in late March / early April 2020 with no evidence of community transmission until after January 2020. Our study was not able to determine the date of introduction of the SARS-CoV-2 virus but demonstrates the value of stored antenatal serum samples as a resource for serosurveillance during future outbreaks.

Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study

AIMS

Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe.

METHODS AND RESULTS

We identified 280 588 admissions with NSTEMI in the UK Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White patients (n = 258 364) and Black, Asian, and Minority Ethnic (BAME) patients (n = 22 194). BAME patients were younger (66 years vs. 73 years, P < 0.001) and more frequently had hypertension (66% vs. 54%, P < 0.001), hypercholesterolaemia (49% vs. 34%, P < 0.001), and diabetes (48% vs. 24%, P < 0.001). BAME patients more frequently received invasive coronary angiography (80% vs. 68%, P < 0.001), percutaneous coronary intervention (PCI) (52% vs. 43%, P < 0.001), and coronary artery bypass graft surgery (9% vs. 7%, P < 0.001). Following propensity score matching, BAME compared with White patients had similar in-hospital all-cause mortality [odds ratio (OR) 0.91, confidence interval (CI) 0.76-1.06; P = 0.23], major bleeding (OR 0.99, CI 0.75-1.25; P = 0.95), re-infarction (OR 1.15, CI 0.84-1.46; P = 0.34), and major adverse cardiovascular events (MACE) (OR 0.94, CI 0.80-1.07; P = 0.35).

CONCLUSION

BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI.

Exploring COVID-19 Vaccine Confidence with People from Black and Asian Backgrounds in England

Aims

Little research has examined factors underlying COVID-19 vaccine hesitancy or refusal in Black and Asian individuals in England, among whom hesitancy tends to be higher than in the general population. This qualitative study aimed to gain an understanding of factors affecting hesitancy in Black and Asian individuals in England, to help address concerns about having the vaccine.

Method

Ninety-five participants (51 women, 42 men, 2 other; 58% were aged between 30 and 49) recruited via a market recruitment agency, local Healthwatch networks, and using a snowballing method, participated in four activities on an online engagement platform, sharing their attitudes towards the COVID-19 vaccine roll-out, and factors shaping their beliefs and concerns, over 5 weeks from April to March 2021.

Results

Inductive thematic analysis revealed five themes: (1) a variety of views on the COVID-19 vaccine, (2) targeted messaging for Black and Asian people as counterproductive, (3) confusion over the purpose of the vaccine roll-out, (4) hesitancy to take the vaccine, and (5) local networks as a trusted source of information.

Conclusions

Our findings suggest that respecting individuals’ agency, transparency of information provided, and the independence of the bodies providing this information are important. Instead of targeted messaging, local networks should be used in campaigns to increase COVID-19 vaccine uptake among Black and Asian individuals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-022-01372-w.