Atiya Kamal

Background: Black communities in England experience health inequalities rooted in structural racism, socioeconomic deprivation, and systemic exclusion from health systems that fail to address their specific needs. Digital health technologies offer potential for reducing these disparities, yet the existing evidence reveals an absence of culturally appropriate digital interventions designed with and for Black communities in England. Objective: To synthesise evidence on the structural and cultural determinants of health inequality affecting Black people in England and examine the potential of health apps for delivering culturally appropriate health promotion. Methods: This is a purposive, critical narrative literature review, not a systematic review; it does not aim for exhaustive or fully reproducible search coverage but for a structured, purposive synthesis of the evidence base relevant to four thematic domains. Purposive sampling was used to identify literature across the PubMed/MEDLINE, PsycINFO, Google Scholar, and policy databases. Findings were thematically synthesised around four domains: structural determinants of health inequality; cultural diversity and representation within Black communities; digital inclusion and health app access; and theoretical frameworks for culturally appropriate intervention design. Findings: Three intertwined problems underpin the absence of culturally appropriate digital health tools for Black communities: structural exclusion from health systems; methodological shortcomings of aggregating heterogeneous populations under broad ethnic labels such as BAME; and the systematic exclusion of Black people from digital health design processes. We propose a multi-layered theoretical framework combining the Health Belief Model, Beattie’s community development paradigm, and McCurdie’s user-centred design principles to guide the co-design of a culturally appropriate health promotion app. Conclusions: A culturally appropriate health promotion app for Black communities in England appears to be a promising and potentially feasible direction, provided it is developed through authentic community partnership and grounded in theories that account for structural determinants of health; this conclusion is conceptual, and no user research, prototype testing, or feasibility study has yet been undertaken to confirm it. These are identified as necessary next steps rather than results already achieved.

Background/Objectives: Healthcare workers (HCWs) have a crucial role in addressing vaccine hesitancy in ethnic minority populations as they are a trusted source of information. The aim of this systematic review is to synthesise and evaluate behaviour change techniques (BCTs) and strategies in interventions aimed at HCWs to promote vaccine uptake among ethnic minority populations. Methods: The literature was systematically searched in peer-reviewed databases and the grey literature. Studies were included if they reported interventions for respiratory and routinely recommended vaccine-preventable diseases which were delivered by HCWs to increase vaccine uptake in ethnic minority groups. Interventions were coded using the Behaviour Change Wheel (BCW) and BCT Taxonomy. Results: From 7250 records identified, 14 studies were included in the review. Vaccines targeted by interventions included influenza, pneumococcal disease, pertussis, tetanus, diphtheria, meningitis and hepatitis B. Seven BCW intervention types, six policy options and 22 BCTs were identified. Main intervention types used were persuasion, enablement and education. Effective interventions had multi-components and were tailored to specific populations. Staff training to improve vaccine recommendation and dialogue with patients, and prompts/cues were associated with positive effects, but there was no strong evidence to recommend one specific intervention strategy over another as effectiveness was linked to a multitude of BCTs and intervention types. Conclusions: Several strategies aimed at HCWs can be used and tailored to increase vaccine uptake among ethnic minority communities; however, this does not address all issues related to low vaccine uptake. While HCWs are necessary, without system-level enablement, they cannot fully address barriers to vaccine uptake.

People from Black and Asian backgrounds are more likely to die from COVID-19 but less likely to be vaccinated, threatening to exacerbate health inequalities already experienced by ethnic minority groups. The literature suggests that mistrust rooted in structural inequality (including socioeconomic position and experience of racism) may be a key barrier to COVID-19 vaccine uptake. Understanding and addressing structural inequality is likely to lead to longer-term impacts than information alone. The aim of this study is to draw on health and sociological theories of structure and agency to inform our understanding of how structural factors influence vaccine confidence. We conducted qualitative interviews and focus groups with 22 people from London and the surrounding areas from December 2021 to March 2022. Fourteen participants were members of the public from ethnic minority backgrounds, and seven were professionals working with the public to address concerns and encourage vaccine uptake. Our findings suggest that people from ethnic minority backgrounds make decisions regarding COVID-19 vaccination based on a combination of how they experience external social structures (including lack of credibility and clarity from political authority, neglect by health services, and structural racism) and internal processes (weighing up COVID-19 vaccine harms and benefits and concerns about vaccine development and deployment). We may be able to support knowledge accumulation through the provision of reliable and accessible information, particularly through primary and community care, but we recommend a number of changes to research, policy and practice that address structural inequalities. These include working with communities to improve ethnicity data collection, increasing funding allocation to health conditions where ethnic minority communities experience poorer outcomes, greater transparency and public engagement in the vaccine development process, and culturally adapted research recruitment processes.

Emotion regulation and/or obesity have been linked to compassion, self-criticism and ‘dark’ personality traits but the relationship between these factors is unclear as most research has focused on the big five personality traits. Here, we investigated the influence of dark personality traits on emotional dysregulation, compassion and BMI. 300 participants completed measures of emotion dysregulation, compassion, self-criticism and dark tetrad personality traits; also providing their BMI. MLR revealed psychopathy, high self-criticism and low compassion ‘for self’ predicted poor emotion regulation; accounting for > 50% of the variance. Whilst their effects on BMI were also significant, no factors singularly predicted BMI. Our research offers important insights into the complexity of factors that may contribute to poor emotion regulation. Of novel value, we found a link between self-compassion, self-criticism and emotion regulation; with self-criticism emerging as the biggest predictor of emotion dysregulation of all explored variables. Although implications for obesity are limited, it is notable that our population demonstrated less obesity than the general public. This is important, as it ascertains that emotion dysregulation, self-criticism, low self-compassion and dark personality traits are not associated with BMI in those of healthy weight.

COVID-19 caused significant morbidity and mortality amongst ethnic minority groups, but vaccine uptake remained lower than non-minoritised groups. Interventions to increase vaccine uptake among ethnic minority communities are crucial. This systematic review synthesises and evaluates behaviour change techniques (BCTs) in interventions to increase vaccination uptake in ethnic minority populations. We searched five databases and grey literature sources. From 7637 records identified, 23 studies were included in the review. Interventions were categorised using the Behaviour Change Wheel (BCW) and Behaviour Change Taxonomy v1. Vaccines included influenza, pertussis, tetanus, diphtheria, meningitis and hepatitis. Interventions were primarily delivered in health centres/clinics and community settings. Six BCW intervention functions and policy categories and 26 BCTs were identified. The main intervention functions used were education, persuasion and enablement. Overall, effective interventions had multi-components and were tailored to specific populations. No strong evidence was observed to recommend specific interventions, but raising awareness and involvement of community organisations was associated with positive effects. Several strategies are used to increase vaccine uptake among ethnic minority communities; however, these do not address all issues related to low vaccine acceptance. There is a strong need for an increased understanding of addressing vaccine hesitancy among ethnic minority groups.

Aims: To explore nurses' experiences of providing support to South Asian (SA) people with dementia and their family carers and to identify barriers and enablers of good transcultural care.Design: A qualitative, phenomenological design was used.Methods: Fifteen registered community and in-patient nurses were recruited via one NHS Mental Health Foundation Trust. Nurses were from diverse backgrounds (Black, Ghanaian, Irish, Mauritian and White), 13 females and 2 males, and had been qualified from between 2 and 49 years. One-to-one semi-structured interviews were conducted between July and October 2019.Results: A thematic analysis identified three themes. 'Communication challenges' highlighted the impact of language barriers and the consequences of misunderstandings due to a dissonance in cultural values between nurses and interpreters. 'The bi-directional impact of culture' identified the two-way dynamics of transcultural work, the process of countering mutual stigma, and revealed an original perspective on how 'cultural desire' grows through practice experiences rather than being a prior motivation for learning. 'Learning experiences' showed that most learning was informal, experiential and prolonged, with nurses feeling they had unmet learning needs.Conclusion: Nurses have minimal training opportunities and are under-supported in their transcultural work, potentially perpetuating the disadvantages that SA people with dementia and their families face in relation to healthcare. Enhanced cultural understanding of self and others and application of specific communication strategies could support nurses, together with interpreters, to build rapport and effective working relationships with each other and service users.Impact: Transcultural nursing is a key competency, but nurses experience difficulties with providing care which is recognized as effective by SA family carers. The development of more acceptable and effective services requires improved mutual cultural understanding between nurses, interpreters and families, underpinned by joint brief training interventions, leading to more effective professional communication, better care outcomes and improved satisfaction with services.

People from Black and Asian backgrounds are more likely to die from Covid-19 but less likely to be vaccinated, threatening to exacerbate health inequalities already experienced by ethnic minority groups. Literature suggests that mistrust rooted in structural inequality may be a key barrier to Covid-19 vaccine uptake. We need to better understand how structural inequalities influence vaccine confidence. Understanding and addressing these processes is likely to lead to longer-term impacts than information alone. We draw on health and sociological theories of structure and agency to inform our understanding of structural factors. We conducted qualitative interviews and focus groups with 22 people from London and surrounding areas in December 2021 to March 2022. Fifteen participants were members of the public from ethnic minority backgrounds and 7 were professionals working with the public to address concerns and encourage vaccine uptake. Our findings suggest that people from ethnic minority backgrounds make decisions regarding Covid-19 vaccination based on a combination of how they experience external social structures (including political authority, social positioning and racial inequality) and internal processes (what they believe and understand about Covid-19 vaccines). We may be able to support knowledge accumulation through the provision of reliable and accessible information, particularly through primary and community care. But we recommend a number of changes to research, policy and practice which address structural inequalities. These include working with communities to improve ethnicity data collection, increasing funding allocation to health conditions where ethnic minority communities experience poorer outcomes, greater transparency and public engagement in the vaccine development process, and culturally adapted research recruitment processes.

A lesson identified from the COVID-19 pandemic is that we need to extend existing best practice for intervention development by establishing better methods of rapidly coproducing public health interventions and messaging to support all population groups to protect themselves and their communities, together with better methods of rapidly evaluating interventions to determine which are acceptable and effective. This paper describes the Agile Co-production and Evaluation (ACE) framework, which is intended to provide a focus for investigating new ways of rapidly developing effective interventions and messaging by combining co-production methods with large-scale testing and/or real-world evaluation. We briefly review some of the participatory, qualitative and quantitative methods that could potentially be combined and propose a research agenda to further develop, refine and validate packages of methods in a variety of public health contexts to determine which combinations are feasible, cost-effective and achieve the goal of improving health and reducing health inequalities.

Objectives: To explore attitudes and intentions towards COVID-19 vaccination, and influences and sources of information about COVID-19 across diverse ethnic groups (EGs) in the UK. Design: Remote qualitative interviews and focus groups (FGs) conducted June-October 2020 before UK COVID-19 vaccine approval. Data were transcribed and analysed through inductive thematic analysis. Setting: General public in the community across England and Wales. Participants: 100 participants from 19 self-identified EGs with spoken English or Punjabi. Results: Mistrust and doubt were common themes across all EGs including white British and minority EGs, but more pronounced amongst Bangladeshi, Pakistani, Black ethnicities and Travellers. Many participants shared concerns about perceived lack of information about COVID-19 vaccine safety, efficacy and potential unknown adverse effects. Across EGs participants stated occupations with public contact, older adults and vulnerable groups should be prioritised for vaccination. Perceived risk, social influences, occupation, age, co-morbidities and engagement with healthcare influenced participants’ intentions to accept vaccination once available; all Jewish FG participants intended to accept, while all Traveller FG participants indicated they probably would not. Facilitators to COVID-19 vaccine uptake across all EGs included: desire to return to normality and protect health and wellbeing; perceived higher risk of infection; evidence of vaccine safety and efficacy; vaccine availability and accessibility. COVID-19 information sources were influenced by social factors, culture and religion and included: friends, family; media and news outlets; and research literature. Participants across most different EGs were concerned about misinformation or had negative attitudes towards the media. Conclusions: During vaccination programme roll-out, including boosters, commissioners and vaccine providers should provide accurate information, authentic community outreach, and use appropriate channels to disseminate information and counter misinformation. Adopting a context-specific approach to vaccine resources, interventions and policies and empowering communities has potential to increase trust in the programme. Article summary: strengths and limitations: This is amongst the largest qualitative studies on attitudes to the COVID-19 pandemic in the UK general public across ethnic groups (EGs), ages and religions, adding insights from a broader range of participants. Qualitative methodology enabled discussion of participants’ responses around COVID-19 vaccination, probing to collect rich data to inform recommendations across EGs. Most data collection was undertaken in English, possibly excluding sectors of the population who may access COVID-19 information through different sources due to language. Data collection was June-October 2020 before COVID-19 vaccines were licensed. Attitudes are highly responsive to current information around a COVID-19 vaccine, as well as the state of the pandemic and perceived risk. Data were collected prior to much of the intervention work, putting the attitudes and intentions expressed in this study in a context of minimal community engagement and support. This provides a baseline snapshot of attitudes, providing the option to explore and assess the impact of such interventions. Socioeconomic data and index of multiple deprivation were not collected, limiting the ability to determine a possible accumulative effect of factors such as socioeconomic status, ethnicity and age.