COVID-19 pandemic experiences of students from BAME and White ethnic groups pursuing higher education in the UK: A qualitative comparative exploration.

Background: The new severe acute respiratory syndrome coronavirus 2, SARS-Cov2, more commonly known as COVID-19 continues to be an ongoing cause of one of the most disruptive pandemics worldwide. UK universities comprise students who come from different backgrounds and cultures and the majority returned home or lived alone during the lockdown. This qualitative study aimed to compare the experiences of students from Black, Asian, and Minority Ethnic (BAME) backgrounds and White British students. Materials and methods: An in-depth interview was conducted with each of 35 students-18 from BAME and 17 from White backgrounds-in their homes on Zoom or Microsoft between November 2020 and May 2021. Interview transcripts were checked for accuracy and were analysed using N-Vivo coding software for themes. The pre-pandemic and pandemic experiences of students were collected in the form of a data, including perceptions of the COVID-19 virus, the physical environment in which students lived, and the effect on their general wellbeing, social interactions, online learning, teaching, and assessment. Results: Mental health issues were more prevalent among female students compared to males and this was more evident amongst BAME females who had returned to living at home, possibly due to lack of personal space. There was a reduction in personal hygiene in White females. There was an increase in the use of social media, particularly by BAME females. Students mostly disliked online learning and exams. Concerns were also raised about how universities communicated important information to the students. Conclusion: Based on the recommendations of the WHO in relation to COVID-19, universities need to effectively manage the information they provide to students and build trust through risk communication and community engagement. One important area in this regard is addressing access to mental health services. The reasons why BAME females experience more mental health issues should be explored further.

To What Extent do Social Determinants of Health Modulate Presentation, ITU Admission and Outcomes among Patients with SARS-COV-2 Infection? An Exploration of Household Overcrowding, Air Pollution, Housing Quality, Ethnicity, Comorbidities and Frailty.

Background: Internationally, researchers have called for evidence to support tackling health inequalities during the severe acute respiratory syndrome coronavirus 2 (COVID19) pandemic. Despite the 2020 Marmot review highlighting growing health gaps between wealthy and deprived areas, studies have not explored social determinants of health (ethnicity, frailty, comorbidities, household overcrowding, housing quality, air pollution) as modulators of presentation, intensive care unit (ITU) admissions and outcomes among COVID19 patients. There is an urgent need for studies examining social determinants of health including socioenvironmental risk factors in urban areas to inform the national and international landscape. Methods: An in-depth retrospective cohort study of 408 hospitalized COVID19 patients admitted to the Queen Elizabeth Hospital, Birmingham was conducted. Quantitative data analyses including a two-step cluster analysis were applied to explore the role of social determinants of health as modulators of presentation, ITU admission and outcomes. Results: Patients admitted from highest Living Environment deprivation indices were at increased risk of presenting with multi-lobar pneumonia and, in turn, ITU admission whilst patients admitted from highest Barriers to Housing and Services (BHS) deprivation Indies were at increased risk of ITU admission. Black, Asian and Minority Ethnic (BAME) patients were more likely, than Caucasians, to be admitted from regions of highest Living Environment and BHS deprivation, present with multi-lobar pneumonia and require ITU admission. Conclusion: Household overcrowding deprivation and presentation with multi-lobar pneumonia are potential modulators of ITU admission. Air pollution and housing quality deprivation are potential modulators of presentation with multi-lobar pneumonia. BAME patients are demographically at increased risk of exposure to household overcrowding, air pollution and housing quality deprivation, are more likely to present with multi-lobar pneumonia and require ITU admission. Irrespective of deprivation, consideration of the Charlson Comorbidity Score and the Clinical Frailty Score supports clinicians in stratifying high risk patients.

COVID-19 and BAME Group in the United Kingdom

COVID-19 is known to disproportionately affect ethnic minorities in number of settings. This phenomenon has also been reported in the UK where the black, Asian and minority ethnic (BAME) group has adverse health outcomes in terms of number of both cases and mortality rates when compared to the white local population. This trend is also observed among the BAME staff working in the National Health Service. Number of plausible explanations and the importance of various approaches including social-determinants approach is pointed out. This pandemic has re-ignited the debate on social inequalities, issues around social deprivation and health inequalities within the UK. This article concludes with some policy recommendations.

Religious Influences on the Experience of Family Carers of People with Dementia in a British Pakistani Muslim Community.

This paper reports on a study that begins to address the paucity of research around the religious motivations of Muslim carers of family members with dementia. Seven carers were recruited for interviews from the British Pakistani Muslim community concentrated in the Midlands and North of England. Interview transcripts were analysed thematically using an iterative collaborative methodology. The findings suggested that the Muslim faith plays a pivotal role as a support mechanism for individual carers and their families, but the wider faith community and its leaders did not typically offer support and could impede access to external care. This was a result of cultural pressure and lack of awareness both among religious leaders and the community as a whole. The study concluded that the inequality in access to dementia services may be constructively addressed if service providers engage with these faith concerns in the community and religious leaders to meet the needs of Muslims of British Pakistani origin.

Ticking the right boxes: A critical examination of the perceptions and attitudes towards the black, Asian and minority ethnic (BAME) acronym in the UK

The Black Lives Matter movement and coronavirus pandemic have raised awareness of society's categorisation of non-white people and institutional language used. We add to contemporary debate on the BAME acronym (Black, Asian and minority ethnic) by providing a critical examination of the perceptions and attitudes towards it in the UK. Drawing on in-depth interviews with women from these communities who were working in the hyper-masculinised and white-dominated sporting industry, we privilege the voices of those who traditionally have been omitted. Adopting a Critical Race Theory approach and an intersectional lens three overarching themes were identified: rejection and indifference towards the BAME acronym;filling in the form – inadequacies of the system;and, making up the quota – perpetuating (work-related) insecurity(ies). The findings provide analytical insight into institutional language and highlight the potential for the BAME acronym to cause distress and alienation while preserving the concept of Whiteness. [ FROM AUTHOR]

The mental health experiences of ethnic minorities in the UK during the Coronavirus pandemic: A qualitative exploration.

Background: Worldwide, the Coronavirus pandemic has had a major impact on people's health, lives, and livelihoods. However, this impact has not been felt equally across various population groups. People from ethnic minority backgrounds in the UK have been more adversely affected by the pandemic, especially in terms of their physical health. Their mental health, on the other hand, has received less attention. This study aimed to explore the mental health experiences of UK adults from ethnic minorities during the Coronavirus pandemic. This work forms part of our wider long-term UK population study "Mental Health in the Pandemic." Methods: We conducted an exploratory qualitative study with people from ethnic minority communities across the UK. A series of in-depth interviews were conducted with 15 women, 14 men and 1 non-binary person from ethnic minority backgrounds, aged between 18 and 65 years old (mean age = 40). We utilized purposefully selected maximum variation sampling in order to capture as wide a variety of views, perceptions and experiences as possible. Inclusion criteria: adults (18+) from ethnic minorities across the UK; able to provide full consent to participate; able to participate in a video- or phone-call interview. All interviews took place via MS Teams or Zoom. The gathered data were transcribed verbatim and underwent thematic analysis following Braun and Clarke carried out using NVivo 12 software. Results: The qualitative data analysis yielded seven overarching themes: (1) pandemic-specific mental health and wellbeing experiences; (2) issues relating to the media; (3) coping mechanisms; (4) worries around and attitudes toward vaccination; (5) suggestions for support in moving forward; (6) best and worst experiences during pandemic and lockdowns; (7) biggest areas of change in personal life. Generally, participants' mental health experiences varied with some not being affected by the pandemic in a way related to their ethnicity, some sharing positive experiences and coping strategies (exercising more, spending more time with family, community cohesion), and some expressing negative experiences (eating or drinking more, feeling more isolated, or even racism and abuse, especially toward Asian communities). Concerns were raised around trust issues in relation to the media, the inadequate representation of ethnic minorities, and the spread of fake news especially on social media. Attitudes toward vaccinations varied too, with some people more willing to have the vaccine than others. Conclusion: This study's findings highlight the diversity in the pandemic mental health experiences of ethnic minorities in the UK and has implications for policy, practice and further research. To enable moving forward beyond the pandemic, our study surfaced the need for culturally appropriate mental health support, financial support (as a key mental health determinant), accurate media representation, and clear communication messaging from the Governments of the UK.

Prognosticating COVID Therapeutic Responses: Ambiguous Loss and Disenfranchised Grief.

Conventionally, therapeutic assessments, interventions, and treatments have focussed on death-related "losses and grief" responses. It is purported that the COVID-19 aftermath has resulted in losses that cannot always be encapsulated using this method. In search of reasoning, models and theories that explain the sweeping mass destruction that COVID-19 has caused, key concepts arise in terms of how we should deal with losses and in turn support patients in the health and social care sector, (notwithstanding formal therapeutic services). There is a crucial need to embrace ambiguous loss and disenfranchised grief into everyday terminology and be acquainted with these issues, thereby adapting how services/clinicians now embrace loss and grief work. Integral to this process is to recognize that there has been a disproportionate impact on Black and minority ethnic communities, and we now need to ensure services are "seriously culturally competent." Primary Care services/IAPT/health and social care/voluntary sector are all likely to be at the forefront of delivering these interventions and are already established gatekeepers. So, this article discusses the prognostic therapeutic response to non-death related losses and grief, not restricted to the formal echelons of therapeutic provision.

The reorganisation of emergency general surgery services during the COVID-19 pandemic in the UK: outcomes of delayed presentation, socio-economic deprivation and Black, Asian and Minority Ethnic patients.

INTRODUCTION: The COVID-19 pandemic is a global public health emergency. Lockdown restrictions and the reconfiguration of healthcare systems to accommodate an increase in critical care capacity have had an impact on 'non-COVID' specialties. This study characterises the utilisation of emergency general surgery (EGS) services during the UK lockdown period at a university teaching hospital with a catchment population that represents one of the most deprived and ethnically diverse areas in the UK. METHODS: EGS admissions during the UK lockdown period (March to May 2020) were compared with the same period in 2019. Patient demographics were recorded together with clinical presentation, hospital stay and treatment outcomes, and readmission data. RESULTS: The study included 645 patients, comprising 223 in the COVID-19 period and 422 in the non-COVID-19 period. There was no difference in age, sex, comorbidity or socio-economic status. A lower proportion of patients of Black, Asian and Minority Ethnicity (BAME) were admitted during the pandemic (20.6% vs 35.4%, p < 0.05). The duration of symptoms prior to presentation was longer, and admission clinical parameters and serum inflammatory markers. More patients presented with an acute kidney injury (9.9% vs 4.7%, p = 0.012). There was no difference in perioperative outcomes or 30-day mortality, but more patients were readmitted following conservative management (10.6% vs 4.7%, p = 0.023). CONCLUSIONS: The reorganisation of EGS to a senior-led model has been successful in terms of outcomes and access to treatment despite a more unwell population. There was a significantly lower proportion of BAME admissions suggesting additional barriers to healthcare access under pandemic lockdown conditions.

A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: Perspectives of healthcare professionals.

INTRODUCTION: Healthcare inequalities and ethnicity are closely related. Evidence has demonstrated that patients from ethnic minority groups are more likely to report a long-term illness than their white counterparts; yet, in some cases, minority groups have reported poorer adherence to prescribed medicines and may be less likely to access medicine services. Knowledge of the barriers and facilitators that impact ethnic minority access to medicine services is required to ensure that services are fit for purpose to meet and support the needs of all. METHODS: Semistructured interviews with healthcare professionals were conducted between October and December 2020, using telephone and video call-based software. Perspectives on barriers and facilitators were discussed. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee. RESULTS: Eighteen healthcare professionals were interviewed across primary, secondary and tertiary care settings; their roles spanned medicine, pharmacy and dentistry. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medicine services for ethnic minority patients. These centred around patient expectations of health services; appreciating cultural stigma and acceptance of certain health conditions; and individually addressing communication and language needs. CONCLUSION: This study provides much-needed evidence relating to the barriers and facilitators impacting minority ethnic communities when seeking medicine support. The results of this study have important implications for the delivery of person-centred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services. PATIENT OR PUBLIC CONTRIBUTION: The Patient and Public Involvement and Engagement (PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.

Coronavirus (COVID-19) Pandemic and Health Workers of an Ethnic Group-A Slant on a Shocking Report.

The coronavirus (COVID-19) pandemic is an unprecedented challenge to all health care professionals. I present a brief report on a shocking report, released recently in the UK on this matter.

Exploring intersectionality: an international yet individual issue.

This article explores both reported and personal experiences of intersectionality within the healthcare system, which is often due to systemic inequalities as well as deep ingrained perceptions and opinions. With my perspective as both a medical student and rare disease patient battling generalised Myasthenia Gravis, I uncover and expose the aspects of intersectionality which are often brushed under the carpet. Moreover, I identify potential routes which we may collectively, as both clinicians and patients, embark upon to navigate our way out of this systemic snare. For those reading and engaging with this article, I endeavour to humanise the publicised figures surrounding rare disease and emphasise that within each figure there are patients, just like myself, who too may be experiencing the multifactorial issues arising from intersectionality. Furthermore, the coronavirus pandemic has highlighted and emphasised the pre-existing divide in the treatment of societal groups, for those both receiving and delivering care. We have long attempted to plaster over this chronic wound however the distressing outcomes of this pandemic have forced us to address this shameful truth from its core. Intersectionality is a disease which is destroying our healthcare system from within. However, unlike many rare diseases, intersectionality can be abolished.

Necroeconomics: How necro legacies help us understand the value of death and the protection of life during the covid-19 pandemic

»Nekroökonomie: Wie Nekro-Vermächtnisse uns helfen, den Wert des Todes und den Schutz des Lebens während der COVID-19-Pandemie zu verstehen«. The paper offers an analysis of how three historical legacies shaped the context for responses to the COVID-19 pandemic in England. They are firstly, necrospeculation, the ability to turn destructiveness into profit and produce new capitalist value. The second is the legacy of thanatocracy, the enactment of mass and organised killing as an official policy of the state. The third necro legacy, social reproduction, is not just about violent death and accumulation, but also the state’s divestment of responsibility to women for the protection of life itself. What these violent legacies have in common as they entwine throughout history is the continuing relationship between property, accumulation, and disposable peoples, showing how economic and moral value is both captured and erased through classifications of class, race, and gender. Bringing these legacies on a journey, we will see how they are modified and repeated in the present. Death during COVID-19 was used as an opportunity for speculation, consolidation of political power, and manipulation of the economy in the interests of the super-rich, government ministers, their friends, and the virus. True to neo-liberal philosophy, they “never let a serious crisis go to waste.” Their predatory practices led to many people being callously disregarded, neglected, and unprotected, exposing those considered to be surplus to state and capital requirements. The pandemic revealed that the social contract was broken as the matter of state responsibility for protection of the people was transferred by the government to individuals. The paper will also show how some groups attempted to protect others and save lives. © 2021, GESIS - Leibniz Institute for the Social Sciences. All rights reserved.

Equality and diversity in health governance systems: are we getting it right and are there lessons from COVID-19?

The COVID-19 pandemic highlighted major challenges in governance and inequalities particularly among those from Black, Asian and minority ethnic (BAME) groups. This paper focuses on the BAME community and explores this through a governance lens, with particular reference to the representation and functioning of boards involved in healthcare and building a transparent culture. To illustrate this, the paper utilises a series of structured reflective questions with model answers termed Right Question, Right Answer and links to the Centre for Quality in Governance (CQG) Maturity Matrix. This article highlights the need to improve diversity and accountability of health and care organisations to their staff and local population. For governance to be effective, it must be aligned and comply with healthcare system regulations to ensure improvement of legislative acts and standards. The paper aims to inform government policy by moving from rhetoric, or merely describing challenges, to action and change by increasing accountability.

Understanding the perceptions of UK COVID-19 contact tracing app in the BAME community in Leicester

PurposeDigital contact tracing technologies are critical to the fight against COVID-19 in many countries including the UK. However, a number of ethical, legal and socio-economic concerns that can affect uptake of the app have been raised. The purpose of this research is to explore the perceptions of the UK digital contact tracing app in the Black, Asian and Minority Ethnic (BAME) community in Leicester and how this can affect its deployment and implementation.Design/methodology/approachData was collected through virtual focus groups in Leicester, UK. A total of 28 participants were recruited for the study. All participants are members of the BAME community, and data was thematically analysed with NVivo 11.FindingsA majority of the participants were unwilling to download and use the app owing to legal and ethical concerns. A minority were willing to use the app based on the need to protect public health. There was a general understanding that lack of uptake will negatively affect the fight against COVID-19 in BAME communities and an acknowledgement of the need for the government to rebuild trust through transparency and development of regulatory safeguards to enhance privacy and prevent misuse.Originality/valueTo the best of the authors’ knowledge, the research makes original contributions being the first robust study conducted to explore perceptions of marginalised communities, particularly BAME which may be adversely impacted by the deployment of the app. By exploring community-based perceptions, this study further contributes to the emerging citizens’ perceptions on digital contact tracing which is crucial to the effectiveness and the development of an efficient, community-specific response to public attitudes towards the app. The findings can also help the development of responsible innovation approaches that balances the competing interests of digital health interventions with the needs and expectations of the BAME community in the UK.

Measuring the exposure of Black, Asian and other ethnic groups to COVID-infected neighbourhoods in English towns and cities.

Drawing on the work of The Doreen Lawrence Review-a report on the disproportionate impact of COVID-19 on Black, Asian and minority ethnic communities in the UK-this paper develops an index of exposure, measuring which ethnic groups have been most exposed to COVID-19 infected residential neighbourhoods during the first and second waves of the pandemic in England. The index is based on a Bayesian Poisson model with a random intercept in the linear predictor, allowing for extra-Poisson variation at neighbourhood and town/city scales. This permits within-city differences to be decoupled from broader regional trends in the disease. The research finds that members of ethnic minority groups can be living in areas with higher infection rates but also that the risk of exposure is distributed unevenly across these groups. Initially, in the first wave, the disease disproportionately affected Black residents but, as the pandemic has progressed, especially the Pakistani but also the Bangladeshi and Indian groups have had the highest exposure. This higher exposure of the Pakistani group is not straightforwardly a function of neighbourhood deprivation because it is present across a range of average house prices. We find evidence to support the view, expressed in The Doreen Lawrence Review, that it is linked to occupational and environmental exposure, particularly residential density but, having allowed for these factors, differences between the towns and cities remain.

Fit-testing of respiratory protective equipment in the UK during the initial response to the COVID-19 pandemic.

BACKGROUND: Public Health England guidance stipulates the use of filtering facepiece (FFP3) masks for healthcare workers engaged in aerosol-generating procedures. Mask fit-testing of respiratory protective equipment is essential to protect healthcare workers from aerosolized particles. AIM: To analyse the outcome of mask fit-testing across National Health Service (NHS) hospitals in the UK during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Using the Freedom of Information Act, 137 NHS hospitals were approached on May 26th, 2020 by an independent researcher to provide data on the outcome of fit-testing at each site. FINDINGS: Ninety-six hospitals responded to the request between May 26th, 2020 to October 29th, 2020. There was a total of 86 mask types used across 56 hospitals, 13 of which were used in at least 10% of these hospitals; the most frequently used was the FFP3M1863, used by 92.86% of hospitals. Overall fit-testing pass rates were provided by 32 hospitals with mean pass rate of 80.74%. The most successful masks, in terms of fit-test failure rates, were the Alpha Solway 3030V and the Alpha Solway S-3V (both reporting mean fit-test failures of 2%). Male- and female-specific pass and failure rates were provided by seven hospitals. Across the seven hospitals, 20.1% of men tested failed the fit-test for all masks used, whereas 19.9% of women tested failed the fit-test for all masks used. Failure rates were significantly higher in staff from Black, Asian, and Minority Ethnic (BAME) backgrounds 644/2507 (25.69%) across four hospitals. CONCLUSION: Twenty percent of healthcare workers tested during the first response to the pandemic failed fit-testing for masks. A small sample revealed that this was most prominent in staff from BAME backgrounds.

'Black African' identification and the COVID-19 pandemic in Britain: A site for sociological, ethical and policy debate.

This paper is a narrative review of the use of collective terminology in relation to race and health in Britain, with particular reference to the 'Black African' community. 'Black Africans' have been categorised in the 1991-2011 censuses with added free-text in 2021 in response to user demand. However, the UK government is increasingly reporting data for the 'Black' pan-ethnicity, especially in the even more generalised 'BAME' ('Black, Asian and Minority Ethnic') acronym in COVID-19 pandemic reports. The consequences of this practice are addressed. Firstly, with respect to ethical challenges, Black Africans find their conscription by government into the term BAME offensive and do not accept it as a self-descriptor. This labelling, which subsumes Black Africans' self-assigned ethnicity in the census, and consequent misrecognition may be interpreted as a micro-aggression (a term coined in the 1970s but used here to denote microinvalidation), as suggested in the current black activism of the 'Black Lives Matter movement'. Secondly, ONS has warned that concealed heterogeneity renders the pan-ethnicities unreliably crude, making them scientifically inaccurate. Analysts are recommended to present ethnic group data for the full census classification where possible for reasons of validity and respect for the patient as arbiter of their ethnic group.

Differential perceptions regarding personal protective equipment use during the COVID-19 pandemic by NHS healthcare professionals based on ethnicity, sex and professional experience.

OBJECTIVES: To capture perceptions regarding personal protective equipment (PPE) among healthcare professionals during the COVID-19 pandemic, including staff subgroups at high risk for severe COVID-19, such as black and minority ethnic (BAME) groups. DESIGN: Electronically distributed survey with semi-quantitative analysis. Survey distributed at a major academic NHS tertiary referral centre in the West Midlands with a diverse medical workforce to medically qualified staff who completed COVID-19 redeployment training. (N=121; 47% female; 49% of BAME background; 26% international medical graduates). RESULTS: All demographic groups reported overall good awareness of when and how to use PPE during COVID-19 pandemic. Statistically significant differences in the perceptions regarding PPE use during COVID-19 were noted between BAME vs non-BAME staff, international vs UK medical graduates, and male vs female participants, as well as between professionals at different stages of their career. The differences related to perceptions around availability, degree of protection provided, perceived inconvenience, ability to raise concerns about availability, confidence in sharing underlying health conditions with managers and the impact of full PPE in emergency situations causing delay patient care. CONCLUSIONS: Amongst medically qualified staff, significant differences exist in the perceptions relating to the, availability and effectiveness of PPE during the COVID-19 pandemic depending on country of training, ethnic background and sex. GAFREC STUDY APPROVAL: Study ID GF0392.

The UPTAKE study: implications for the future of COVID-19 vaccination trial recruitment in UK and beyond.

BACKGROUND: Developing a safe and effective vaccine will be the principal way of controlling the COVID-19 pandemic. However, current COVID-19 vaccination trials are not adequately representing a diverse participant population in terms of age, ethnicity and comorbidities. Achieving the representative recruitment targets that are adequately powered to the study remains one of the greatest challenges in clinical trial management. To ensure accuracy and generalisability of the safety and efficacy conclusions generated by clinical trials, it is crucial to recruit patient cohorts as representative as possible of the future target population. Missing these targets can lead to reduced validity of the study results and can often slow down drug development leading to costly delays. OBJECTIVE: This study explores the key factors related to perceptions and participation in vaccination trials. METHODS: This study involved an anonymous cross-sectional online survey circulated across the UK. Statistical analysis was done in six phases. Multi-nominal logistic models examined demographic and geographic factors that may impact vaccine uptake. RESULTS: The survey had 4884 participants of which 9.44% were Black Asian Minority Ethnic (BAME). Overall, 2020 (41.4%) respondents were interested in participating in vaccine trials; 27.6% of the respondents were not interested and 31.1% were unsure. The most interested groups were male (OR = 1.29), graduates (OR = 1.28), the 40-49 and 50-59 age groups (OR = 1.88 and OR = 1.46 respectively) and those with no health issues (OR = 1.06). The least interested groups were BAME (OR = 0.43), those from villages and small towns (OR = 0.66 and 0.54 respectively) and those aged 70 and above (OR = 1.11). CONCLUSIONS: In order to have a vaccination that is generalisable to the entire population, greater work needs to be done in engaging a diverse cohort of participants. Public health campaigns need to be targeted in improving trial recruitment rates for the elderly, BAME community and the less educated rural population.