Ethnic minority staff working in an acute NHS Trust and their experiences and perceptions of COVID-19 vaccination

Introduction

Background

On 30^th January 2020, the Director General of the World Health Organization (WHO) declared the novel corona virus [coronavirus disease 2019 (COVID-19)] outbreak a public health emergency of international concern that required the maximum level of alarm (1).

As the pandemic spread, statisticians around the world began to report an increased risk of COVID-19 mortality among the Black, Asian and Minority Ethnic (BAME) population (2-4). According to global and UK contact tracing demographic data, healthcare workers showed higher risk of contracting COVID-19 (5,6). In the United Kingdom, 13.8% of the population is from a minority ethnic background; however, 19% of COVID-19 related hospital deaths and 35% of patients admitted in critical care units in England were people from BAME groups (7). The difference in COVID-19 mortality rates between ethnic groups has been attributed to socio-economic, demographic, and geographical factors, which may have increased COVID-19 transmission rates (2,3,7,8).

In January 2021, it was reported that there was substantially lower COVID-19 vaccine uptake among members of BAME staff in several NHS Trusts across the United Kingdom (9). UK data evaluating the intention of vaccination revealed around 82% stating they were likely to take up COVID-19 vaccine, and 18% unlikely. However, vaccine hesitancy was highest in Black or Black British ethnic groups with 72% stating they were unlikely to be vaccinated followed by 42% of Pakistani/Bangladeshi ethnicity (10). Concerns were raised that healthcare workers’ vaccine hesitancy might spread to other members of society, outside the healthcare profession.

Rationale and knowledge gap

A review of literature found inequalities between BAME groups affected by COVID-19 infection compared to the white population. The review also highlighted the social and structural determinants of health that may contribute to the disparities in COVID-19 incidence, treatment, morbidity and mortality in BAME groups. There is some evidence which supports the hypothesis that BAME groups are more likely to test positive for COVID-19 than those identifying as white British (2) but there is insufficient evidence to draw conclusions. Hence, this study was conducted to explore and illuminate better understanding of the experiences and perceptions of around 3,000 ethnic minority staff working in a large NHS Trust with more than 12,000 employees.

Objectives

The objectives of this study were:

• To conduct an online survey and audio-recorded semi-structured interviews among ethnic minority staff about their experiences and perceptions of COVID-19 vaccination;
• To explore and understand ethnic minority staff rationale for taking or not taking COVID-19 vaccine;
• To produce research-informed recommendations to better protect and support ethnic minority staff from highly communicable infections.

Methods

Convergent mixed methods design was used where quantitative and qualitative components were conducted simultaneously (11) among the accessible population of around 3,000 ethnic minority. A cross-sectional online survey [Supplementary file (Appendix 1)] was used to collect quantitative data and semi-structured audio-recorded interviews [Supplementary file (Appendix 2)] were conducted to collect qualitative data. An online survey was appropriate for this study because it is standardised, reliable and valid as well as being quick, flexible, accessible and cost effective for participants (12). Semi-structured interviews were also used in this study because they allow researchers to have a prepared interview schedule as a guide, but they also accommodate some degree of freedom to follow-up and clarify obscure points that might occur during the interview (13).

The target participants for the online survey were set to 100 with 10 being set for the semi-structured interviews taken from the subset of the online survey participants. Below are the inclusion and exclusion criteria.

Inclusion criteria:

• Ethnic minority staff working in the study site Trust;
• Able to give consent;
• Able to speak and read English without the help of an interpreter;
• Aged 18 to 75 years.

Exclusion criteria:

• White British staff;
• Unable to consent;
• Unable to speak or read English without an interpreter;
• Lack of mental capacity;
• Below 18 and above 75 years old.

Online survey

The online survey was created using Microsoft Forms and was tested for readability, access and ease of completion with three ethnic minority staff from other Trusts who were not included in the actual study. Their feedback indicated that the survey questionnaire was easy to understand, and the instructions were easy to follow. The software was user-friendly and required participants to put their initial in the consent box to complete the survey which took less than 10 minutes. Survey data was automatically stored as Microsoft Forms responses and was downloaded into a password protected excel spreadsheet with no issues.

The online survey was sent to all staff through the Trust Media and Communications department and BAME staff network. Social media adverts were posted online and printed posters with a QR code were posted in public places across the Trust to increase participation. No official list of BAME staff was available, so the Participation Information Sheet (PIS) was sent globally to all staff in the Trust. Participation in this study was entirely voluntary, free from coercion and participants could withdraw without giving any reason at any time prior to the submission of responses. Once data had been submitted and been anonymised, it was no longer possible to identify, and the data would be included in the study. No request for withdrawal was received.

The target participants for the online survey were 100. However, after 5 weeks, there were only 54 responses, so data collection was extended for another 7 weeks. At the end of 12 weeks, 73 had completed the survey, 69 were ethnic minority staff and 4 were white British. Only 60 read the PIS and 1 did not speak and understand English without an interpreter. Following the approved research protocol for this study, 59 respondents were included in the data analysis. Descriptive statistics (mean, median and mode) including standard deviation, skewness and kurtosis were calculated using excel formula (Table 1).

At the end of the online survey, participants were given the option to provide their contact details if they were willing to take part in the semi-structured audio-recorded interview to understand in more depth, their experiences and perceptions of COVID-19 vaccination.

Semi-structured interviews

The convenient sampling technique was used to recruit ten participants on a first come, first served basis when they provided their contact details. Participants contact details were removed immediately from the survey data after it has been stored. Each participant was allocated a study identification number which was used throughout the interview to conceal their identity. All participants preferred a virtual interview though all were offered face to face. This turned out beneficial both for the researcher and participants in terms of flexibility, accessibility, cost and control as to whether they have their camera on or off during interview. All participants kept their camera off throughout the interview. All interviews were conducted on Microsoft Teams with the auto-transcription feature making the production of accurate transcriptions less time consuming. The researcher read the consent form at the beginning of the interview and asked the participant to verbally consent by saying ‘I am happy to participate in this interview’ which was recorded and saved separately from the actual interview. Interviews were conducted once informed consent had been secured. Each interview lasted almost an hour. Transcription was done immediately after each interview before the next was conducted. By doing so, participant responses were still fresh in the mind of the researcher making it easier to correlate with the auto-transcription.

It was reiterated at the start of the interview that participants could withdraw at any point without giving any explanation. They just needed to inform the researcher, and the interview would be terminated. None of the participants withdrew from the interview. After 9 participants were interviewed, it was believed that data saturation had been reached as there were no new insights emerging from the transcripts, so data collection was closed. Qualitative data analysis was done using the constant comparison thematic technique (14). At the end of the interview, participant’s contact details were deleted from the file making the data completely anonymous.

Data integration

The integration of quantitative and qualitative data is a unique core feature of a mixed methods study (15,16). Effective integration of data can produce more comprehensive and in-depth insights than otherwise might be possible, as well as enriching findings generated from different components of the study (17).

The two components of this research study were the online survey which generated quantitative data and the semi-structured interviews which generated qualitative data. Deliberate and systematic integration of both quantitative and qualitative data ensures that ‘the whole is greater than the sum of the parts’ (18). Their combination leads to a better understanding of the topic being explored (19). Fundamentally, quantitative and qualitative components of the study are ‘mutually illuminating’ (20).

Clearly, these advantages can only occur if the data are integrated effectively. Failure to integrate effectively can produce essentially two independent studies, rather than a single, unified mixed-methods study (12,16,19,20). Different approaches to data integration include merging, embedding, and connecting the data sets (12). Merging was used (Figure 1) and is appropriate for this study design.

Figure 1 Integration in data collection and analysis through merging. Adapted from Curry and Nunes-Smith [2015].

Quantitative and qualitative data collection were done simultaneously but analysed independently then merged using the Pillar Integration Process (PIP) (Figure 2). Findings were compared and interpreted to identify complementarity, concordance, and divergence among data sets.

Figure 2 Diagrammatic representation of the PIP process. COVID-19, coronavirus disease 2019; PIP, Pillar Integration Process.

The four stages of PIP were completed sequentially after completing the initial quantitative and qualitative data analysis. The arrows demonstrate how the joint display was completed from the outside column first, then working towards the central column where data integration was completed. Integrated findings that have been developed and refined from the listing, matching, and checking stages were compared and analysed. Four PILLAR Themes were built: (I) anxiety and fear; (II) feeling isolated and lack of support; (III) impact of faith and religious belief and (IV) opposition to mandatory COVID-19 vaccination for healthcare workers.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Science Interdivisional Research Ethics Committee of the University of Oxford with reference R80686/RE001. Final approval to conduct this study was granted by the National Health Service (NHS) Health Research Authority (HRA) with reference 22/PRO0348. Data collection took place from May 2022 to September 2022 and informed consent was obtained from all individual participants.

Results

A total of 73 surveys were returned, which included 4 surveys invalid because they were not ethnic minority staff. Nine did not read the PIS and 1 did not speak and understand English without an interpreter. As per study protocol, 59 respondents were included in the data analysis. Figure 3 presents participants’ gender and age while Figure 4 presents their housing situation and household size.

Figure 3 Survey participants demographics—gender and age.

Figure 4 Housing situation and Household size.

The majority of the participants (71%) were female. In terms of age, a plurality (42%) were between 26 and 35 years old. In terms of ethnicity, Filipinos, 27% (n=16) and Indians 25% (n=15) were the top 2 highest respondents.

The majority (59%) of participants were living with 3–5 people in the house which increased the risk of spreading COVID-19. However, it was not specified whether they are family members or individual tenants living in the same house.

A 5-point Likert scale {very satisfied [5], satisfied [4], neither satisfied nor dissatisfied [3], dissatisfied [2], very dissatisfied [1]} was used to determine the level of satisfaction of participants on the information they received about COVID-19. Three questions (1 point each) were asked to test participants’ knowledge on COVID-19 transmission.

Both mean scores (satisfaction =4.06, knowledge =2.72) showed that participants had a high level of satisfaction on the information they received about COVID-19, and they have a high level of knowledge about its transmission.

The standard deviation of both satisfaction and knowledge were close to zero (normal value is less than 1) and the skewness were within normal values (between −0.05 and 0.5). These indicate that the data were symmetrical and well represented.

The integrated results from online survey and semi-structured interviews initially revealed 8 themes. Through further familiarisation with the data, review of initial codes and analysis, 4 major pillar themes were built. These were anxiety and fear; feeling isolated and lack of support; impact of faith and religious beliefs and opposition to mandatory COVID-19 vaccination for healthcare workers.

Anxiety and fear

All participants were anxious about becoming infected, as well as being worried about passing on the virus to family members, friends, and colleagues. They feared both the long-term complications of COVID-19 and the side effects of the vaccines. They were worried about the short and long-term impact of COVID-19 on the education of their children.

Feeling isolated and lack of support

Participants experienced loneliness and isolation. They felt forgotten and neglected, especially those who were single and living alone. They did not receive clear and sufficient guidance and support, especially from their management team.

Impact of faith and religious beliefs

Many participants had strong faith and religious beliefs. They highlighted the importance of their religion and the role of their religious leaders, especially in relation to their well-being. They were supported by their churches, visited by their faith leaders. They believed and followed the advice of their religious leaders.

Opposition to mandatory COVID-19 vaccination

The majority (89%) of the participants were strongly against mandatory COVID-19 vaccination. They believed it infringed human rights, democracy, and personal choice. According to the participants, forcing people to receive COVID-19 vaccine is a form of injustice and is not the right way to go.

Discussion

Key findings

One interesting finding from this study was the impact and influence of faith and religion on ethnic minority staff in the fight against COVID-19, particularly regarding their mental health and well-being. Often the focus is on physical and psychological aspects of life. The spiritual is often missed. There are four facets of a person (21), these are biological (physical health or illness and body experiences), psychological (emotions, feelings, thoughts, behaviours and memories), social (relationships, socio-economic and social identity) and spiritual (beliefs, rituals, and relation to transcendent). Respondents from this study highlighted the support they received from their religious leaders, and their trust in them.

Another significant finding of this study is the very low participation rate (2.3%) of BAME staff (69 out of 3,000). Filipinos (27%) and Indians (25%) were the highest responding ethnic groups. One possible reason might be due to the high numbers of these ethnicities in the Trust, but it is difficult to ascertain as data about the total staff by ethnicity was not available. This needs further exploration.

Despite good knowledge (mean =2.73 out of 3.0) amongst respondents about the transmission of COVID-19, 76% (n=45) of them became infected with the virus. It was not possible to establish whether the infection was acquired at work or outside work. What was apparent, however, was the feeling of lack of support and guidance from managers as well as the lack of follow-up from them. Participants felt isolated, very worried, and often did not know what to do and when to go back to work.

Strengths and limitations

The strengths of this study are the participants themselves who are from ethnic minorities and often did not have the opportunity to voice their opinion. Another strength is the use of mixed methods. Qualitative and quantitative findings were compared and interpreted and have identified complementarity, concordance, and divergence among data sets. Their combination leads to a better understanding of the experiences and perceptions of the minority ethnic staff regarding COVID-19 vaccination.

On the other hand, the limitations of this study include the small sample size and being conducted in only one NHS Trust. All participants were permanent employees, and no agency worker participated. Staff who needed an interpreter were excluded due to lack of financial resources. A convenience sampling method was used which means the ability to generalise is minimal. Respondent validation was not undertaken due to time and resource constraints.

Comparison with similar research

The findings of this study support previous studies (2,4,9) regarding low participation rate among ethnic minority staff in research studies. However, the study contradicts the report of low uptake of COVID-19 vaccination among ethnic minority staff in the NHS (2).

Explanation of findings

One potential explanation for the low participation rate in this study is the absence of a record of ethnic minority staff working in the Trust. Also, a lack of time due to workload may be another reason for not participating in this study.

The role of the Trust multi-faith chaplaincy service might also have contributed to access to diverse faith services of ethnic staff to their religious leaders during COVID-19 pandemic.

Implications and actions needed

Results of this study strongly recommend the following actions:

• To improve records and statistics as part of equality, diversity, and inclusion agenda, employers should gather data on staff ethnicity.
• To improve representation and engagement from different ethnic groups to help participation in research and other quality improvement projects, employers should identify appropriate representatives and allies.
• Employers should evaluate the effectiveness of their existing support to ethnic minorities who are under-represented in their organization, including regular agency workers.
• Employers should consider how to address the feeling of isolation and lack of support among their ethnic minority staff.
• Employers should engage with local religious leaders, including hospital Chaplains and local churches. Religious leaders and houses of worship are effective means of disseminating information to staff. Currently, they are under-utilized, if utilised at all. Employers should work with them, encouraging religious events and festivals to enhance the spiritual life and well-being of staff.
• Ethnic minority staff should work with their employers in meeting their biological, psychological, social, and spiritual needs.
• Employers should encourage and enable ethnic minority staff to participate in research to help improve understanding of their needs and challenges.

Conclusions

This study provided a better understanding of the experiences and perceptions of ethnic minority staff regarding COVID-19 vaccination in a NHS Trust. Almost all participants were vaccinated and had good knowledge about COVID-19. Reasons for taking COVID-19 vaccine include protecting self, families, work colleagues and communities as well as resuming social activities.

This study re-iterated a lack of engagement with research among ethnic minority staff themselves and especially agency workers.

A new understanding of the importance of the role of religious leaders and places of worship has been also highlighted by the study. Many ethnic minority staff have religious affiliations and look to the advice of their religious leaders.

Further research is needed to understand the lack of engagement and research participation among ethnic minority staff.

Acknowledgments

The authors would like to acknowledge the following for their advice and support: Jenny Turner, Research Support Specialist, R&D OUH Joint Research Office; Stephanie Gilham, Research Support Specialist, R&D OUH Joint Research Office; Professor Helen Walthall, PhD, Director of Nursing and Midwifery Research and Innovation, OUH; Carol Forde-Johnston, Recruitment and Retention Lead, NOTSSCaN, OUH; Florian Stoermer, Divisional Director of Nursing, NOTSSCaN, OUH; Dr. Louise Stayt, Divisional Research Lead, NOTSSCaN, OUH. The authors also would like to acknowledge the sponsorship of Oxford University Hospitals NHS Foundation Trust and the OUH BAME Staff Network for sharing the online survey questionnaire.

Footnote

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-82/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-82/prf

Funding: This work was supported by the National Institute for Health Research (NIHR), Oxford Biomedical Research Centre (OBRC) and Oxford University Hospitals (OUH) NHS Foundation Trust Joint Research Office (NIHR RCF 20/060).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-82/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all the work in ensuring that questions related to the accuracy or integrity of any part of aspects of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Medical Sciences Interdivisional Research Ethics Committee of the University of Oxford with reference R80686/RE001. Final approval to conduct this study was granted by the National Health Service (NHS) Health Research Authority (HRA) with reference 22/PRO0348. Data collection took place from May 2022 to September 2022, and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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