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Background: Healthcare workers (HCWs) in the United Kingdom (UK) have faced many challenges during the COVID-19 pandemic, some of these arising out of their social positions. Existing literature explicating these challenges (e.g., lack of appropriate PPE, redeployment, understaffing) have highlighted inequities in how these have been experienced by HCWs based on ethnicity, gender or, job role. In this paper, we move a step ahead and examine how the intersection of these social positions have impacted HCWs' experiences of challenges during the pandemic. Methods: We collected qualitative data, using interviews and focus groups, from 164 HCWs from different ethnicities, gender, job roles, migration statuses, and regions in the United Kingdom (UK) between December 2020 and July 2021. Interviews and focus groups were conducted online or by telephone, and recorded with participants' permission. Recordings were transcribed and a hybrid thematic analytical approach integrating inductive data-driven codes with deductive ones informed by an intersectional framework was adopted to analyse the transcripts. Results: Thematic analysis of transcripts identified disempowerment, disadvantage and, discrimination as the three main themes around which HCWs' experiences of challenges were centred, based on their intersecting identities (e.g., ethnicity gender, and/or migration status). Our analysis also acknowledges that disadvantages faced by HCWs were linked to systemic and structural factors at the micro, meso and macro ecosystemic levels. This merging of analysis which is grounded in intersectionality and considers the ecosystemic levels has been termed as 'intrasectionalism'. Discussion: Our research demonstrates how an intrasectional lens can help better understand how different forms of mutually reinforcing inequities exist at all levels within the healthcare workforce and how these impact HCWs from certain backgrounds who face greater disadvantage, discrimination and disempowerment, particularly during times of crisis like the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background Healthcare workers (HCWs), particularly those from ethnic minority groups, have been shown to be at disproportionately higher risk of infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) compared to the general population. However, there is insufficient evidence on how demographic and occupational factors influence infection risk among ethnic minority HCWs. Methods and findings We conducted a cross-sectional analysis using data from the baseline questionnaire of the United Kingdom Research study into Ethnicity and Coronavirus Disease 2019 (COVID-19) Outcomes in Healthcare workers (UK-REACH) cohort study, administered between December 2020 and March 2021. We used logistic regression to examine associations of demographic, household, and occupational risk factors with SARS-CoV-2 infection (defined by polymerase chain reaction (PCR), serology, or suspected COVID-19) in a diverse group of HCWs. The primary exposure of interest was self-reported ethnicity. Among 10,772 HCWs who worked during the first UK national lockdown in March 2020, the median age was 45 (interquartile range [IQR] 35 to 54), 75.1% were female and 29.6% were from ethnic minority groups. A total of 2,496 (23.2%) reported previous SARS-CoV-2 infection. The fully adjusted model contained the following dependent variables: demographic factors (age, sex, ethnicity, migration status, deprivation, religiosity), household factors (living with key workers, shared spaces in accommodation, number of people in household), health factors (presence/absence of diabetes or immunosuppression, smoking history, shielding status, SARS-CoV-2 vaccination status), the extent of social mixing outside of the household, and occupational factors (job role, the area in which a participant worked, use of public transport to work, exposure to confirmed suspected COVID-19 patients, personal protective equipment [PPE] access, aerosol generating procedure exposure, night shift pattern, and the UK region of workplace). After adjustment, demographic and household factors associated with increased odds of infection included younger age, living with other key workers, and higher religiosity. Important occupational risk factors associated with increased odds of infection included attending to a higher number of COVID-19 positive patients (aOR 2.59, 95% CI 2.11 to 3.18 for [greater than or equal to]21 patients per week versus none), working in a nursing or midwifery role (1.30, 1.11 to 1.53, compared to doctors), reporting a lack of access to PPE (1.29, 1.17 to 1.43), and working in an ambulance (2.00, 1.56 to 2.58) or hospital inpatient setting (1.55, 1.38 to 1.75). Those who worked in intensive care units were less likely to have been infected (0.76, 0.64 to 0.92) than those who did not. Black HCWs were more likely to have been infected than their White colleagues, an effect which attenuated after adjustment for other known risk factors. This study is limited by self-selection bias and the cross sectional nature of the study means we cannot infer the direction of causality. Conclusions We identified key sociodemographic and occupational risk factors associated with SARS-CoV-2 infection among UK HCWs, and have determined factors that might contribute to a disproportionate odds of infection in HCWs from Black ethnic groups. These findings demonstrate the importance of social and occupational factors in driving ethnic disparities in COVID-19 outcomes, and should inform policies, including targeted vaccination strategies and risk assessments aimed at protecting HCWs in future waves of the COVID-19 pandemic. Trial registration The study was prospectively registered at ISRCTN (reference number: ISRCTN11811602)., Author(s): Christopher A. Martin 1,2, Daniel Pan 1,2, Carl Melbourne 3, Lucy Teece 4, Avinash Aujayeb 5, Rebecca F. Baggaley 1, Luke Bryant 1, Sue Carr 6,7, Bindu Gregary 8, [...]

Evidence shows that medical students from Minority Ethnic (ME) backgrounds and male medical students underperform in undergraduate examinations. Our study confirmed these findings in first year clinical (year 3) medical students, and further explored this disparity in performance. We conducted a series of meta-analyses to measure the effects of sex and ethnic group on the written examination and Objective Structured Clinical Examination (OSCE) scores of three groups of year 3 medical students at two London UK medical schools (n = 1,051; 46.0% male; 48.7% White). Male and ME students scored lower on written and OSCE assessments. Both assessments were statistically significantly correlated (mean r = 0.45) and therefore the effects of sex and ethnic group were measured on each exam after being adjusted for the effect of the other. Although sex and ethnic differences remained on the OSCE when adjusted for written performance, these differences disappeared on the written when it was adjusted for OSCE performance. These findings may reflect a relative deficit in practical clinical knowledge in male and ME year 3 students. Results were unlikely to be due to examiner bias, as the machine-marked unadjusted written exam results showed significant sex and ethnic differences.

Key Features The UK-REACH cohort was established to understand why ethnic minority healthcare workers (HCWs) are at risk of poorer outcomes from COVID-19 when compared with their White ethnic counterparts in the UK. The UK-REACH study is a UK-wide study, capturing information from the wide range of roles that form healthcare services in the UK, including ancillary workers who are often not included in such studies. One was via an invitation from the various healthcare regulators and membership bodies within the UK, whereas the other was through a selection of National Health Service (NHS) trusts and health boards throughout the UK. UK-REACH is a UK-wide prospective cohort established in November 2020 in response to the COVID-19 pandemic.[1] COVID-19 has spread rapidly across the world, causing significant levels of morbidity and mortality, and devastating health economies in many countries. [Extracted from the article]

The aim of UK-REACH ("The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers") is to understand if, how, and why healthcare workers (HCWs) in the United Kingdom (UK) from ethnic minority groups are at increased risk of poor outcomes from COVID-19. In this article, we present findings from the ethical and legal stream of the study, which undertook qualitative research seeking to understand and address legal, ethical, and social acceptability issues around data protection, privacy, and information governance associated with the linkage of HCWs' registration data and healthcare data. We interviewed 22 key opinion leaders in healthcare and health research from across the UK in two-to-one semi-structured interviews. Transcripts were coded using qualitative thematic analysis. Participants told us that a significant aspect of Big Data research in public health is varying drivers of mistrust—of the research itself, research staff and funders, and broader concerns of mistrust within participant communities, particularly in the context of COVID-19 and those situated in more marginalised community settings. However, despite the challenges, participants also identified ways in which legally compliant and ethically informed approaches to research can be crafted to mitigate or overcome mistrust and establish greater confidence in Big Data public health research. Overall, our research indicates that a "Big Data Ethics by Design" approach to research in this area can help assure (1) that meaningful community and participant engagement is taking place and that extant challenges are addressed, and (2) that any new challenges or hitherto unknown unknowns can be rapidly and properly considered to ensure potential (but material) harms are identified and minimised where necessary. Our findings indicate such an approach, in turn, will help drive better scientific breakthroughs that translate into medical innovations and effective public health interventions, which benefit the publics studied, including those who are often marginalised in research. [ABSTRACT FROM AUTHOR]

Students from lower socio-economic backgrounds who were educated in state funded schools are underrepresented in medicine in the UK. Widening access to medical students from these backgrounds has become a key political and research priority. It is known that medical schools vary in the number of applicants attracted and accepted from non-traditional backgrounds but the reasons for this are poorly understood. This study aims to explore what applicants value when choosing medical schools to apply to and how this relates to their socioeconomic background. We conducted a multicentre qualitative interview study, purposively sampling applicants and recent entrants based on socioeconomic background, stage of application and medical school of application. We recruited participants from eight UK medical schools. Participants attended semi-structured interviews. We performed a framework analysis, identifying codes inductively from the data. Sixty-six individuals participated: 35 applicants and 31 first year medical students. Seven main themes were identified; course style, proximity to home, prestige, medical school culture, geographical area, university resources, and fitting in. These were prioritised differently depending on participants' background. Participants from lower socioeconomic backgrounds described proximity to home as a higher priority. This was typically as they intended to be living at home for at least part of the course. Those from higher socioeconomic backgrounds were more concerned with the perceived prestige of medical schools. Since medicine is a highly selective course, only offered at a minority of UK higher education institutions, these differences in priorities may help explain observed differential patterns of medical school applications and success rates by applicant social background. [ABSTRACT FROM AUTHOR]

University students are a critical group for vaccination programmes against COVID-19, meningococcal disease (MenACWY) and measles, mumps and rubella (MMR). We aimed to evaluate risk factors for vaccine hesitancy and views about on-campus vaccine delivery among university students. Data were obtained through a cross-sectional anonymous online questionnaire study of undergraduate students in June 2021 and analysed by univariate and multivariate tests to detect associations. Complete data were obtained from 827 participants (7.6% response-rate). Self-reporting of COVID-19 vaccine status indicated uptake by two-thirds (64%; 527/827), willing for 23% (194/827), refusal by 5% (40/827) and uncertain results for 8% (66/827). Hesitancy for COVID-19 vaccines was 5% (40/761). COVID-19 vaccine hesitancy was associated with Black ethnicity (aOR, 7.01, 95% CI, 1.8–27.3) and concerns about vaccine side-effects (aOR, 1.72; 95% CI, 1.23–2.39). Uncertainty about vaccine status was frequently observed for MMR (11%) and MenACWY (26%) vaccines. Campus-associated COVID-19 vaccine campaigns were favoured by UK-based students (definitely, 45%; somewhat, 16%) and UK-based international students (definitely, 62%; somewhat, 12%). Limitations of this study were use of use of a cross-sectional approach, self-selection of the response cohort, slight biases in the demographics and a strict definition of vaccine hesitancy. Vaccine hesitancy and uncertainty about vaccine status are concerns for effective vaccine programmes. Extending capabilities of digital platforms for accessing vaccine information and sector-wide implementation of on-campus vaccine delivery are strategies for improving vaccine uptake among students. Future studies of vaccine hesitancy among students should aim to extend our observations to student populations in a wider range of university settings and with broader definitions of vaccine hesitancy. [ABSTRACT FROM AUTHOR]

Abstract Background Ethnic minority (EM) medical students and doctors underperform academically, but little evidence exists on how to ameliorate the problem. Psychologists Cohen et al. recently demonstrated that a written self-affirmation intervention substantially improved EM adolescents' school grades several months later. Cohen et al.'s methods were replicated in the different setting of UK undergraduate medical education. Methods All 348 Year 3 white (W) and EM students at one UK medical school were randomly allocated to an intervention condition (writing about one's own values) or a control condition (writing about another's values), via their tutor group. Students and assessors were blind to the existence of the study. Group comparisons on post-intervention written and OSCE (clinical) assessment scores adjusted for baseline written assessment scores were made using two-way analysis of covariance. All assessment scores were transformed to z-scores (mean = 0 standard deviation = 1) for ease of comparison. Comparisons between types of words used in essays were calculated using t-tests. The study was covered by University Ethics Committee guidelines. Results Groups were statistically identical at baseline on demographic and psychological factors, and analysis was by intention to treat [intervention group EM n = 95, W n = 79; control group EM n = 77; W n = 84]. As predicted, there was a significant ethnicity by intervention interaction [F(4,334) = 5.74; p = 0.017] on the written assessment. Unexpectedly, this was due to decreased scores in the W intervention group [mean difference = 0.283; (95% CI = 0.093 to 0.474] not improved EM intervention group scores [mean difference = -0.060 (95% CI = -0.268 to 0.148)]. On the OSCE, both W and EM intervention groups outperformed controls [mean difference = 0.261; (95%CI = -0.047 to -0.476; p = 0.013)]. The intervention group used more optimistic words (p < 0.001) and more "I" and "self" pronouns in their essays (p < 0.001), whereas the control group used more "other" pronouns (p < 0.001) and more negations (p < 0.001). Discussion Cohen et al.'s finding that a brief self-affirmation task narrowed the ethnic academic achievement gap was replicated on the written assessment but against expectations, this was due to reduced performance in the W group. On the OSCE, the intervention improved performance in both W and EM groups. In the intervention condition, participants tended to write about themselves and used more optimistic words than in the control group, indicating the task was completed as requested. The study shows that minimal interventions can have substantial educational outcomes several months later, which has implications for the multitude of seemingly trivial changes in teaching that are made on an everyday basis, whose consequences are never formally assessed.

Abstract Background UK medical students and doctors from ethnic minorities underperform in undergraduate and postgraduate examinations. Although it is assumed that white (W) and non-white (NW) students enter medical school with similar qualifications, neither the qualifications of NW students, nor their educational background have been looked at in detail. This study uses two large-scale databases to examine the educational attainment of W and NW students. Methods Attainment at GCSE and A level, and selection for medical school in relation to ethnicity, were analysed in two separate databases. The 10th cohort of the Youth Cohort Study provided data on 13,698 students taking GCSEs in 1999 in England and Wales, and their subsequent progression to A level. UCAS provided data for 1,484,650 applicants applying for admission to UK universities and colleges in 2003, 2004 and 2005, of whom 52,557 applied to medical school, and 23,443 were accepted. Results NW students achieve lower grades at GCSE overall, although achievement at the highest grades was similar to that of W students. NW students have higher educational aspirations, being more likely to go on to take A levels, especially in science and particularly chemistry, despite relatively lower achievement at GCSE. As a result, NW students perform less well at A level than W students, and hence NW students applying to university also have lower A-level grades than W students, both generally, and for medical school applicants. NW medical school entrants have lower A level grades than W entrants, with an effect size of about -0.10. Conclusion The effect size for the difference between white and non-white medical school entrants is about B0.10, which would mean that for a typical medical school examination there might be about 5 NW failures for each 4 W failures. However, this effect can only explain a portion of the overall effect size found in undergraduate and postgraduate examinations of about -0.32.

Abstract Background More and more medical school applicants in England and Wales are gaining the maximum grade at A level of AAA, and the UK Government has now agreed to pilot the introduction of a new A* grade. This study assessed the likely utility of additional grades of A* or of A**. Methods Statistical analysis of university selection data collected by the Universities and Colleges Admissions Service (UCAS), consisting of data from 1,484,650 applicants to UCAS for the years 2003, 2004 and 2005, of whom 23,628 were medical school applicants, and of these 14,510 were medical school entrants from the UK, aged under 21, and with three or four A level results. The main outcome measure was the number of points scored by applicants in their best three A level subjects. Results Censored normal distributions showed a good fit to the data using maximum likelihood modelling. If it were the case that A* grades had already been introduced, then at present about 11% of medical school applicants and 18% of entrants would achieve the maximum score of 3 A*s. Projections for the years 2010, 2015 and 2020 suggest that about 26%, 35% and 46% of medical school entrants would have 3 A* grades. Conclusion Although A* grades at A level will help in medical student selection, within a decade, a third of medical students will gain maximum grades. While revising the A level system there is a strong argument, as proposed in the Tomlinson Report, for introducing an A** grade.

Abstract Background Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients. Methods Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour. Results 85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning. Conclusion The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.

The Annual Review of Competence Progression is used to determine whether trainee doctors in the United Kingdom are safe and competent to progress to the next training stage. In this article we provide evidence to inform recommendations to enhance the validity of the summative and formative elements of the Annual Review of Competency Progression. The work was commissioned as part of a Health Education England review. We systematic searched the peer reviewed and grey literature, synthesising findings with information from national, local and specialty-specific Annual Review of Competence Progression guidance, critically evaluating the findings in the context of literature on assessing competence in medical education. National guidance lacked detail resulting in variability across locations and specialties, threatening validity and reliability. Trainees and trainers were concerned that the Annual Review of Competence Progression only reliably identifies the most poorly performing trainees. Feedback is not routinely provided, which can leave those with performance difficulties unsupported and high performers demotivated. Variability in the provision and quality of feedback can negatively affect learning. The Annual Review of Competence Progression functions as a high-stakes assessment, likely to have a significant impact on patient care. It should be subject to the same rigorous evaluation as other high-stakes assessments; there should be consistency in procedures across locations, specialties and grades; and all trainees should receive high-quality feedback. [ABSTRACT FROM AUTHOR]

Background: Tests of competence are written and clinical assessments taken by doctors under investigation by the General Medical Council (GMC) who have significant performance concerns. Male doctors on average perform more poorly in clinical assessments than female doctors, and are more likely to be sanctioned. It is unclear why.Aim: To examine sex differences in the tests of competence assessment scores of GPs under investigation by the GMC, compared with GPs not under investigation, and whether scores mediate any relationship between sex and sanction likelihood.Design and Setting: Retrospective cohort study of GPs' administrative tests of competence data.Method: Analysis of variance was undertaken to compare written and clinical tests of competence performance by sex and GP group (under investigation versus volunteers). Path analysis was conducted to explore the relationship between sex, written and clinical tests of competence performance, and investigation outcome.Results: On the written test, female GPs under investigation outperformed male GPs under investigation (Cohen's d = 0.28, P = 0.01); there was no sex difference in the volunteer group (Cohen's d = 0.02, P = 0.93). On the clinical assessment, female GPs outperformed male GPs in both groups (Cohen's d = 0.61, P<0.0001). A higher clinical score predicted remaining on the UK medical register without a warning or sanction, with no independent effect of sex controlling for assessment performance.Conclusion: Female GPs outperform male GPs on clinical assessments, even among GPs with generally very poor performance. Male GPs under investigation may have particularly poor knowledge. Further research is required to understand potential sex differences in doctors who take tests of competence and how these impact on sex differences in investigation outcomes. [ABSTRACT FROM AUTHOR]

The authors use the example of 'contextual admissions' in the UK to demonstrate the importance of clarity, transparency and evidence for overcoming myths that surround fair and equitable selection. [ABSTRACT FROM AUTHOR]

Objectives To explore how representatives from organisations with responsibility for doctors in training perceive risks to the educational progression of UK medical graduates from black and minority ethnic groups (BME UKGs), and graduates of non-UK medical schools (international medical graduates (IMGs)). To identify the barriers to and facilitators of change. Design Qualitative semistructured individual and group interview study. Setting Postgraduate medical education in the UK. Participants Individuals with roles in examinations and/or curriculum design from UK medical Royal Colleges. Employees of NHS Employers. Results Representatives from 11 medical Royal Colleges (n=29) and NHS Employers (n=2) took part (55% medically qualified, 61% male, 71% white British/Irish, 23% Asian/Asian British, 6% missing ethnicity). Risks were perceived as significant, although more so for IMGs than for BME UKGs. Participants based significance ratings on evidence obtained largely through personal experience. A lack of evidence led to downgrading of significance. Participants were pessimistic about effecting change, two main barriers being sensitivities around race and the isolation of interventions. Participants felt that organisations should acknowledge problems, but felt concerned about being transparent without a solution; and talking about race with trainees was felt to be difficult. Participants mentioned 63 schemes aiming to address differential attainment, but these were typically local or specialty-specific, were not aimed at BME UKGs and were largely unevaluated. Participants felt that national change was needed, but only felt empowered to effect change locally or within their specialty. Conclusions Representatives from organisations responsible for training doctors perceived the risks faced by BME UKGs and IMGs as significant but difficult to change. Strategies to help organisations address these risks include: increased openness to discussing race (including ethnic differences in attainment among UKGs); better sharing of information and resources nationally to empower organisations to effect change locally and within specialties; and evaluation of evidence-based interventions. [ABSTRACT FROM AUTHOR]

Background: Asian medical students and doctors receive lower scores on average than their white counterparts in examinations in the UK and internationally (a phenomenon known as "differential attainment"). This could be due to examiner bias or to social, psychological or cultural influences on learning or performance. We investigated whether students' scores or feedback show influence of ethnicity-related bias; whether examiners unconsciously bring to mind (activate) stereotypes when judging Asian students' performance; whether activation depends on the stereotypicality of students' performances; and whether stereotypes influence examiner memories of performances.Methods: This is a randomised, double-blinded, controlled, Internet-based trial. We created near-identical videos of medical student performances on a simulated Objective Structured Clinical Exam using British Asian and white British actors. Examiners were randomly assigned to watch performances from white and Asian students that were either consistent or inconsistent with a previously described stereotype of Asian students' performance. We compared the two examiner groups in terms of the following: the scores and feedback they gave white and Asian students; how much the Asian stereotype was activated in their minds (response times to Asian-stereotypical vs neutral words in a lexical decision task); and whether the stereotype influenced memories of student performances (recognition rates for real vs invented stereotype-consistent vs stereotype-inconsistent phrases from one of the videos).Results: Examiners responded to Asian-stereotypical words (716 ms, 95% confidence interval (CI) 702-731 ms) faster than neutral words (769 ms, 95% CI 753-786 ms, p < 0.001), suggesting Asian stereotypes were activated (or at least active) in examiners' minds. This occurred regardless of whether examiners observed stereotype-consistent or stereotype-inconsistent performances. Despite this stereotype activation, student ethnicity had no influence on examiners' scores; on the feedback examiners gave; or on examiners' memories for one performance.Conclusions: Examiner bias does not appear to explain the differential attainment of Asian students in UK medical schools. Efforts to ensure equality should focus on social, psychological and cultural factors that may disadvantage learning or performance in Asian and other minority ethnic students. [ABSTRACT FROM AUTHOR]

Physician dissatisfaction in the workplace has consequences for patient safety. Currently in the UK, 1 in 5 doctors who enter specialist training in obstetrics and gynaecology leave the programme before completion. Trainee attrition has implications for workforce planning, organization of healthcare services and patient care. The authors conducted a survey of current trainees' and former trainees' views concerning attrition and 'peri-attrition' -- a term coined to describe the trainee who has seriously considered leaving the specialty. The authors identified six key themes which describe trainees' feelings about attrition in obstetrics and gynaecology: morale and undermining; training processes and paperwork; support and supervision; work--life balance and realities of life; NHS environment; and job satisfaction. This article discusses themes of an under-resourced health service, bullying, lack of work--life balance and poor personal support. [ABSTRACT FROM AUTHOR]