Mental health in a diverse sample of healthcare workers during the COVID-19 pandemic: cross-sectional analysis of the UK-REACH study

ObjectivesTo investigate how ethnicity and other sociodemographic, work, and physical health factors are related to mental health in UK healthcare and ancillary workers (HCWs), and how structural inequities in these factors may contribute to differences in mental health by ethnicity. DesignCross-sectional analysis of baseline data from the UK-REACH national cohort study SettingHCWs across UK healthcare settings. Participants11,695 HCWs working between December 2020-March 2021. Main outcome measuresAnxiety or depression symptoms (4-item Patient Health Questionnaire, cut-off >3), and Post-Traumatic Stress Disorder (PTSD) symptoms (3-item civilian PTSD Checklist, cut-off >5). ResultsAsian, Black, Mixed/multiple and Other ethnic groups had greater odds of PTSD than the White ethnic group. Differences in anxiety/depression were less pronounced. Younger, female HCWs, and those who were not doctors had increased odds of symptoms of both PTSD and anxiety/depression. Ethnic minority HCWs were more likely to experience the following work factors that were also associated with mental ill-health: workplace discrimination, feeling insecure in raising workplace concerns, seeing more patients with COVID-19, reporting lack of access to personal protective equipment (PPE), and working longer hours and night shifts. Ethnic minority HCWs were also more likely to live in a deprived area and have experienced bereavement due to COVID-19. After adjusting for sociodemographic and work factors, ethnic differences in PTSD were less pronounced and ethnic minority HCWs had lower odds of anxiety/depression compared to White HCWs. ConclusionsEthnic minority HCWs were more likely to experience PTSD and disproportionately experienced work and sociodemographic factors associated with PTSD, anxiety and depression. These findings could help inform future work to develop workplace strategies to safeguard HCWs mental health. This will only be possible with adequate investment in staff recruitment and retention, alongside concerted efforts to address inequities due to structural discrimination. Summary boxO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIThe pandemic is placing healthcare workers under immense pressure, and there is currently a mental health crisis amongst NHS staff C_LIO_LIEthnic inequities in health outcomes are driven by structural discrimination, which occurs inside and outside the workplace C_LIO_LIInvestigating ethnic inequities in the mental health of healthcare workers requires large diverse studies, of which few exist C_LI What this study addsO_LIIn UK-REACH (N=11,695), ethnic minority staff had higher odds of Post-Traumatic Stress Disorder symptoms; we report many other factors associated with mental-ill health, including those experienced disproportionately by ethnic minority staff, such as workplace discrimination, contact with more patients with COVID-19, and bereavement due to COVID-19 C_LIO_LIThese findings underline the moral and practical need to care for staff mental health and wellbeing, which includes tackling structural inequities in the workplace; improving staff mental health may also reduce workforce understaffing due to absence and attrition C_LI

Mental Health During COVID-19: A Qualitative Study with Ethnically Diverse Healthcare Workers in the United Kingdom

IntroductionHealthcare workers are experiencing deterioration in their mental health due to COVID-19. Ethnic minority populations in the United Kingdom are disproportionately affected by COVID-19, with a higher death rate and poorer physical and mental health outcomes. It is important that healthcare organisations consider the specific context and mental, as well as physical, health needs of an ethnically diverse healthcare workforce in order to better support them during, and after, the COVID-19 pandemic. MethodsWe undertook a qualitative work package as part of the United Kingdom Research study into Ethnicity and COVID-19 outcomes among healthcare workers (UK-REACH). As part of the qualitative research, we conducted focus group discussions with healthcare workers between December 2020 and July 2021, and covered topics such as their experiences, fears and concerns, and perceptions about safety and protection, while working during the pandemic. The purposive sample included ancillary health workers, doctors, nurses, midwives and allied health professionals from diverse ethnic backgrounds. We conducted discussions using Microsoft Teams. Recordings were transcribed and thematically analysed. FindingsWe carried out 16 focus groups with a total of 61 participants. Several factors were identified which contributed to, and potentially exacerbated, the poor mental health of ethnic minority healthcare workers during this period including anxiety (due to inconsistent protocols and policy); fear (of infection); trauma (due to increased exposure to severe illness and death); guilt (of potentially infecting loved ones); and stress (due to longer working hours and increased workload). ConclusionCOVID-19 has affected the mental health of healthcare workers. We identified a number of factors which may be contributing to a deterioration in mental health across diverse ethnic groups. Healthcare organisations should consider developing strategies to counter the negative impact of these factors. This paper will help employers of healthcare workers and other relevant policy makers better understand the wider implications and potential risks of COVID-19 and assist in developing strategies to safeguard the mental health of these healthcare workers going forward, and reduce ethnic disparities. Key messagesO_ST_ABSWhat is already known about this subjectC_ST_ABSO_LIHealthcare Workers (HCWs) are experiencing deterioration of their mental health due to COVID-19 C_LIO_LIEthnic minority populations and HCWs are disproportionately affected by COVID-19 C_LIO_LIMore research is needed on the specific factors influencing the mental health of ethnically diverse healthcare workforces C_LI What are the new findingsProminent factors influencing the mental health and emotional wellbeing of this population include: O_LIanxiety (due to inconsistent protocols and policy) C_LIO_LIfear (of infection) C_LIO_LItrauma (due to increased exposure to severe illness and death) C_LIO_LIguilt (of potentially infecting loved ones) C_LIO_LIstress (due to longer working hours and increased workload) C_LI How might this impact on policy or clinical practice in the foreseeable futureO_LIHealthcare organisations should consider the specific circumstances of these staff and develop strategies to counter the negative impact of these factors and help safeguard the mental health of their staff C_LI

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

BackgroundGlobally, healthcare workers (HCWs) are prioritised for receiving vaccinations against the coronavirus disease-2019 (COVID-19). Previous research has shown disparities in COVID-19 vaccination uptake among HCWs based on ethnicity, job role, sex, age, and deprivation. However, vaccine attitudes underpinning these variations are yet to be fully explored. MethodsWe conducted a qualitative study with 164 HCWs from different ethnicities, sexes, job roles, migration statuses, and regions in the United Kingdom (UK). Interviews and focus groups were conducted using Microsoft Teams or telephone, and recorded with participants permission. Recordings were transcribed and thematically analysed following an inductive approach. FindingsWe conducted an in-depth analysis of 53 randomly selected transcripts (involving 82 participants) to generate rapid evidence. Four different vaccine attitudes were identified: Active Acceptance, Passive Acceptance, Passive Decline, and Active Decline. Factors influencing vaccine acceptance include: knowledge of vaccine; risk perception; positive attitude towards other vaccines; social influences; and considerations about the future. Correspondingly, barriers to vaccine acceptance were identified as, low trust in the vaccine and historical (mis)trust, inadequate communication, and inequities in delivery and access. Opinion on mandatory vaccination was divided. InterpretationOur data show that vaccine attitudes are diverse and elements of hesitancy may remain even after vaccine acceptance. This has implications for the sustainability of the vaccine programme, particularly as new components (e.g. boosters) are being added. Based on our findings we recommend trust-building, designing inclusive and accessible information, and addressing structural inequities for improving vaccine uptake among HCWs. FundingUKRI-MRC and NIHR.

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

BackgroundIn most countries, healthcare workers (HCWs) represent a priority group for vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) due to their elevated risk of COVID-19 and potential contribution to nosocomial SARS-CoV-2 transmission. Concerns have been raised that HCWs from ethnic minority groups are more likely to be vaccine hesitant (defined by the World Health Organisation as refusing or delaying a vaccination) than those of White ethnicity, but there are limited data on SARS-CoV-2 vaccine hesitancy and its predictors in UK HCWs. MethodsNationwide prospective cohort study and qualitative study in a multi-ethnic cohort of clinical and non-clinical UK HCWs. We analysed ethnic differences in SARS-CoV-2 vaccine hesitancy adjusting for demographics, vaccine trust, and perceived risk of COVID-19. We explored reasons for hesitancy in qualitative data using a framework analysis. Findings11,584 HCWs were included in the cohort analysis. 23% (2704) reported vaccine hesitancy. Compared to White British HCWs (21.3% hesitant), HCWs from Black Caribbean (54.2%), Mixed White and Black Caribbean (38.1%), Black African (34.4%), Chinese (33.1%), Pakistani (30.4%), and White Other (28.7%) ethnic groups were significantly more likely to be hesitant. In adjusted analysis, Black Caribbean (aOR 3.37, 95% CI 2.11 - 5.37), Black African (aOR 2.05, 95% CI 1.49 - 2.82), White Other ethnic groups (aOR 1.48, 95% CI 1.19 - 1.84) were significantly more likely to be hesitant. Other independent predictors of hesitancy were younger age, female sex, higher score on a COVID-19 conspiracy beliefs scale, lower trust in employer, lack of influenza vaccine uptake in the previous season, previous COVID-19, and pregnancy. Qualitative data from 99 participants identified the following contributors to hesitancy: lack of trust in government and employers, safety concerns due to the speed of vaccine development, lack of ethnic diversity in vaccine studies, and confusing and conflicting information. Participants felt uptake in ethnic minority communities might be improved through inclusive communication, involving HCWs in the vaccine rollout, and promoting vaccination through trusted networks. InterpretationDespite increased risk of COVID-19, HCWs from some ethnic minority groups are more likely to be vaccine hesitant than their White British colleagues. Strategies to build trust and dispel myths surrounding the COVID-19 vaccine in these communities are urgently required. Public health communications should be inclusive, non-stigmatising and utilise trusted networks. FundingMRC-UK Research and Innovation (MR/V027549/1), the Department of Health and Social Care through the National Institute for Health Research (NIHR), and NIHR Biomedical Research Centres and NIHR Applied Research Collaboration East Midlands. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched Pubmed using the following search terms ((COVID-19).ti,ab OR (SARS-CoV-2).ti,ab) AND ((vaccine).ti,ab OR (vaccination).ti,ab OR (immunisation).ti,ab)) AND ((healthcare worker).ti,ab OR (health worker).ti,ab OR (doctor).ti,ab OR (nurse).ti,ab OR (healthcare professional).ti,ab)) AND ((hesitancy).ti,ab OR (refusal).ti,ab OR (uptake).ti,ab)). The search returned 60 results, of which 38 were excluded after title and abstract screening, 11 studies were not conducted in a population of healthcare workers, 20 did not present data on vaccine intention or uptake, 5 were related to vaccines other than the SARS-CoV-2 vaccine, 1 was unrelated to vaccination and 1 had been withdrawn. The 22 remaining articles were survey studies focussed on SARS-CoV-2 vaccine intention in healthcare workers. Estimates of SARS-CoV-2 vaccine acceptance varied widely from 27{middle dot}7% - 94{middle dot}5% depending on the country in which the study was performed, and the occupational group studied. Only 2 studies (both conducted in the USA) had a sample size greater than 10,000. Most studies found females, non-medical healthcare staff and those refusing influenza vaccine to be more likely to be hesitant. There was conflicting evidence about the effects of age and previous COVID-19 on hesitancy. Only 3 studies (all from the USA), presented data disaggregated by ethnicity, all finding Black ethnic HCWs were most likely to be hesitant. Common themes amongst studies that investigated reasons for vaccine hesitancy were concerns about safety of vaccines, fear of side effects and short development timeframes. We did not find any studies on SARS-CoV-2 vaccine hesitancy in UK healthcare workers in the published literature. Added value of this studyThis study is amongst the largest SARS-CoV-2 vaccine hesitancy studies in the literature. It is the largest study outside the USA and is the only study in UK HCWs. Our work focusses on the association of ethnicity with vaccine hesitancy, and we are the first study outside the USA to present results by ethnic group. The large number of ethnic minority HCWs in our study allows for examination of the outcome by more granular ethnicity categories than have previously been studied, allowing us to detect important differences in vaccine hesitancy levels within the broad White and Asian ethnic groupings. Our large sample size and the richness of our cohort study dataset allows us to control for many potential confounders in our multivariable analysis, and provide novel data on important potential drivers of hesitancy including discrimination, COVID-19 conspiracy beliefs, religion/religiosity and personality traits. Additionally, we combine quantitative with qualitative data providing a deeper understanding of the drivers of hesitancy and potential strategies to improve vaccine uptake in HCWs from ethnic minority communities. Implications of all the available evidenceAround a quarter of UK healthcare workers reported SARS-CoV-2 vaccine hesitancy. In accordance with previous studies in other countries, we determined that female sex and lack of influenza vaccine in the previous season were important predictors of SARS-CoV-2 vaccine hesitancy in UK HCWs, although in contrast to most studies in the published literature, after adjustment we do not demonstrate differences in hesitancy levels by occupational role. Importantly, previous literature provides conflicting evidence of the effects of age and previous SARS-CoV-2 infection on vaccine hesitancy. In our study, younger HCWs and those with evidence of previous COVID-19 were more likely to be hesitant. This study provides novel data on increased hesitancy levels within Black Caribbean, Mixed White and Black Caribbean, Black African, Chinese, Pakistani and White Other ethnic groups. Mistrust (of vaccines in general, in SARS-CoV-2 vaccines specifically, in healthcare systems and research) and misinformation appear to be important drivers of hesitancy within HCWS in the UK. Our data indicate that despite facing an increased risk of COVID-19 compared to their White colleagues, UK HCWs from some ethnic minority groups continue to exhibit greater levels of SARS-CoV-2 vaccine hesitancy. This study provides policy makers with evidence to inform strategies to improve uptake.

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

IntroductionAs the world continues to grapple with the COVID-19 pandemic, emerging evidence suggests that individuals from ethnic minority backgrounds may be disproportionately affected. The UK-REACH project has been initiated to understand ethnic differentials in COVID-19 outcomes among healthcare workers (HCWs) in the United Kingdom (UK) through five inter-linked work packages. The ethico-legal work package (Work Package 3) aims to understand and address legal, ethical and acceptability issues around big data research; the healthcare workers experiences work package (Work Package 4) is a qualitative study exploring healthcare workers experiences during COVID-19 and; the stakeholder engagement work package (Work Package 5) aims to provide feedback and support with the formulation and dissemination of the project recommendations. Methods and AnalysisWork Package 3 has two different research strands: (a) desk-based doctrinal research; and (b) empirical qualitative research with key opinion leaders. For the empirical research, in-depth interviews will be conducted digitally and recorded with participants permission. Recordings will be transcribed, coded and analysed using thematic analysis. In Work Package 4, online in-depth interviews and focus groups will be conducted with approximately 150 HCWs, from across the UK, and these will be recorded with participants consent. The recordings will be transcribed, coded and data will be analysed using thematic analysis. Work Package 5 will achieve its objectives through regular group meetings and in-group discussions. Ethics and DisseminationEthical approval has been received from the London - Brighton & Sussex Research Ethics Committee of the Health Research Authority (Ref No. 20/HRA/4718). Results of the study will be published in open access journals, and disseminated through conference presentations, project website, stakeholder organisations, media and scientific advisory groups. Registration DetailsRegistered with the International Standard Randomised Controlled Trial Number registry (ISRCTN11811602). STRENGTHS AND LIMITATIONS OF THIS STUDYO_LIThe dual approach of doctrinal and empirical research (Work Package 3) on the use of personal data by UK-REACH will give a comprehensive understanding of the ethical and legal implications of the study, and perceptions about its use of data. C_LIO_LIQualitative research with healthcare workers in the UK on their experiences during the COVID-19 pandemic (Work Package 4) will provide insight into personal behaviour, perceptions of risk and coping mechanisms adopted both inside and outside of the work environment. C_LIO_LIStakeholder engagement (Work Package 5) from professional regulatory bodies and staff groups is embedded within the UK-REACH study to provide feedback on project activities and support with project recommendations. C_LIO_LIThe target participants (key opinion leaders) for Work Package 3 empirical study will likely come from predominantly White backgrounds which may limit the breadth of views obtained in interviews. This limitation will be mitigated by active recruitment of opinion leaders from a wide variety of ethnic backgrounds and active interaction with Work Package 5. C_LIO_LIDue to the pandemic restrictions, interviews and focus group discussions will be conducted via online methods as a substitute for face-to-face meetings, posing practical and technological challenges for dynamic interaction with participants. C_LI