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Abstract
Objectives To explore the perspectives of ethnic minority community leaders in relation to: the impact of the COVID-19 pandemic on their communities; and their community’s perception, understanding and adherence to government guidelines on COVID-19 public health measures.
Design A phenomenological approach was adopted using qualitative semistructured interviews.
Settings Community organisations and places of worships in the West Midlands, England.
Participants Community leaders recruited through organisations representing ethnic minority communities and religious places of worship.
Results A total of 19 participants took part. Participants alluded to historical and structural differences for the observed disparities in COVID-19 morbidity and mortality. Many struggled with lockdown measures which impeded cultural and religious gatherings that were deemed to be integral to the community. Cultural and social practices led to many suffering on their own as discussion of mental health was still deemed a taboo within many communities. Many expressed their community’s reluctance to report symptoms for the fear of financial and physical health implications. They reported increase in hate crime which was deemed to be exacerbated due to perceived insensitive messaging from authority officials and historical racism in the society. Access and adherence to government guidelines was an issue for many due to language and digital barriers. Reinforcement from trusted community and religious leaders encouraged adherence. Points of support such as food banks were vital in ensuring essential supplies during the pandemic. Many could not afford or have access to masks and sanitisers.
Conclusion The study highlights the perceived impact of the COVID-19 pandemic on ethnic minority communities. Government agencies and public health agencies need to integrate with the community, and community leaders can enable dissemination of key messages to deliver targeted yet sensitive public health advice which incorporates cultural and religious practices. Addressing the root causes of disparities is imperative to mitigate current and future pandemics.
- COVID-19
- public health
- qualitative research
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
To our knowledge, this is the first study in England to investigate the understanding of risk and impact of COVID-19 using the perspectives of ethnic minority community leaders.
Participants represented diverse ethnic minority community organisations and places of worship.
Participant recruitment was limited to one of the seven regions within England with the highest proportion of ethnic minority populations.
Results may not be transferable to any ethnic minority communities not represented in the data.
Introduction
COVID-19 was declared a global pandemic in March 2020, with over 120 000 deaths from the virus in the UK as of February 2021.1 There was early recognition that ethnic minority groups in the UK were disproportionately affected,2 3 which came to public attention when the first 10 doctors who had died from COVID-19 were of ethnic minority origin.4 During the first wave in April 2020, approximately 35% of almost 2000 intensive care patients for COVID-19 in England, Wales and Northern Ireland were non-White.5 However, ethnic minority groups only constitute 13% of the UK’s population.6 Recent estimates suggest that Chinese, Indian, Pakistani, other Asian, Black Caribbean and other Black ethnicity had between 10% and 50% higher mortality risk compared with the White British population.7
Historically, health inequalities have been a concern for ethnic minority groups; for example, disparity has been observed through higher prevalence of type 2 diabetes and cardiovascular disease in South Asian communities.8 The concept is defined as ‘avoidable and unfair differences’ shaped by their surrounding circumstances.9 Factors such as socioeconomic status and environmental conditions—which are largely influenced by structural biases based on ethnicity—collectively drive inequalities that are perpetuated by institutional racism. This culminates in ethnic minority groups suffering worse health outcomes owing to unfair access of resources that could otherwise ameliorate their wider determinants of health.10 11 While literature reinforces the understanding that ethnic minority groups are disproportionately affected by COVID-19, there is a lack of research that aims to understand the disparity from the perspectives of ethnic minority communities.
Urgency of further study into the association between ethnicity and COVID-19 was highlighted in research and policy domains in early 2020. Data from the Office for National Statistics (ONS) proposed that existing comorbidities in ethnic minority patients with COVID-19 could have contributed towards the disparity.12 However, the debate later incorporated wider social and structural disparities. Factors such as deprivation, living conditions and nature of employment were linked to higher morbidity and mortality in ethnic minority populations.13
In addition to the disparities in morbidity and mortality directly as a result of COVID-19, anecdotal reports have stated that ethnic minority communities have been underprotected and stigmatised during this pandemic.14 Currently, however, there is a sparse literature exploring the understanding of ethnic minority groups on how they, themselves, perceive their disparity in COVID-19.
To mitigate the pandemic and its impact, diverse information was disseminated through social and broadcast media by the UK government and public health organisations. Slogans such as ‘Stay Home, Protect the NHS (National Health Service), Save Lives’ endeavoured to support the first national lockdown in the UK. During this period, non-essential businesses, community organisations and places of worship, which are integral to many ethnic minority communities, were inaccessible.15 Downloadable translations of key documents, including posters for COVID-19 symptoms, were made available through Public Health England in 11 different languages.16 However, ethnic minority communities’ understanding of pandemic-related communication from the government and public health organisations has not yet been investigated.
The aim of this study was to explore the perspectives of ethnic minority community leaders in relation to: the impact of the COVID-19 pandemic on their communities; and their community’s perception, understanding and adherence to government guidelines on COVID-19 public health measures.
Methods
Design
A phenomenological approach using qualitative study design was adopted.17
Study population, sampling strategy and recruitment
For the purpose of this study, community leaders were defined as any personnel who were in a position to speak on behalf of their community in their community role, including: community activists, religious leaders, primary school officials and local business owners. Such representatives of the organisations, businesses and places of worship serving a predominantly ethnic minority community in the West Midlands region of England (a region that suffered most ethnic minority-related hospital admissions and mortality) were searched online, then invited via email or telephone. Organisations were identified through internet, social media searches and acquaintances of the research team (all representing ethnic minority communities). Those expressing interest were emailed a participant information sheet and consent form. Additional recruitment was made through snowball sampling. The ethnic groups of interest (online supplemental material 1) were of those recommended by the UK government.18
Supplemental material
Data collection material and methods
An interview topic guide (online supplemental material 2) was developed with 19 open-ended questions on three key areas regarding ethnic minority communities': (1) understanding of acquiring COVID-19 risk and disparity in health outcomes; (2) beliefs and perspectives relating to COVID-19; and (3) understanding and adherence to government-issued guidance and public health measures on COVID-19. Probes elicited a comprehensive insight from participants. To test face and content validity, the research team developed questions based on existing literature and a pilot interview was conducted with an ethnic minority community member which ensured clarity of the questions. No changes had to be made to the topic guide.
Participants were recruited and interviewed between October and November 2020 for approximately 45 minutes over Zoom or telephone by research student FM. The researcher received training for qualitative data generation and analysis and conducted interviews for training purposes. Relevant demographic information was collected prior to the interview. The researcher also developed rapport with the participants at this stage. Interviews were audio recorded using the recording function on Zoom or a digital voice recorder, respectively.
Data processing and analysis
Recordings were transcribed verbatim into Microsoft Word. Data were anonymised to remove any identifiable information. Transcripts were exported onto Microsoft Excel and then thematically analysed by two researchers (FM and VP) using the framework technique.19–21 The initial coding was reviewed between the research team through analysis of the first two transcripts before an agreed version was produced that could be applied to the rest of the transcripts. New themes were added as they emerged during the subsequent analysis of other transcripts.
Reporting was conducted to comply with the Consolidated Criteria for Reporting Qualitative Research guideline22 and checklist (online supplemental material 3).
Supplemental material
Patient and public involvement
Apart from members of public’s participation in the research as study subjects, no other patient and public involvement activities were conducted for this research due to time and resource constraints.
Results
A total of 19 participants from various community leadership roles and ethnic minority representations took part (table 1). Four overarching themes and 11 subthemes were identified (tables 2–5). Themes related to: (a) perceived impact of COVID-19 and lockdown on well-being; (b) understanding of risk and disparity in health outcomes for COVID-19; (c) perception, understanding and adherence to government guidance in relation to COVID-19; and (d) accessibility and use of community services, and other points of support, during the pandemic. Narrative summaries of each theme are presented below and illustrative quotes are presented in tables 2–5 dedicated to each theme.
Demographics of recruited study participants
Perceived impact of COVID-19 and lockdown on well-being
Understanding of risk and disparity in health outcomes for COVID-19
Perception, understanding and adherence to government guidance in relation to COVID-19
Accessibility and use of community services, and other points of support, during the pandemic
Perceived impact of COVID-19 and lockdown on well-being
Mental health impact and psychological well-being
This was widely expressed by all participants, with feelings of anxiety being exacerbated by social isolation appearing to culminate in emotional fatigue, owing to the longevity of the pandemic. Participants alluded to the close-knit nature of ethnic minority communities, and the pandemic and lockdown had an immense impact on their social well-being. Some also reported that women within families may have suffered a notable impact due to additional strain from domestic responsibilities during lockdown (table 2).
While participants differed in their perspectives on whether adequate mental health support was available during and after the first national lockdown, all recognised that further education within their respective communities was required to break the taboo that presented a barrier to expressing emotion, and encourage those who require support to actively seek it. Participants of Asian and Black African communities described that mental health was still deemed a taboo within their communities and many had to suffer in isolation (table 2).
Financial impact
The subsequent financial impact from the national lockdown was an over-riding concern for ethnic minority communities, particularly for those on lower incomes and in self-employment. Financial insecurity as a result of the pandemic was especially difficult for families, as several participants mentioned that many in their communities were reliant on government welfare (table 2).
Physical health impact
Current and future physical health was a concern expressed by many participants (table 2). They recognised that their communities are often predisposed to certain chronic conditions which may result in worse outcomes, due to the current treatment prioritisation of COVID-19. Examples stipulated by participants related to the impact on the ongoing treatment of patients with sickle cell anaemia, thalassaemia and prostate cancer that were deemed to be highly prevalent among Black African communities. Therefore, those with underlying conditions were taking extra precautions to maintain optimum health, should they be affected by COVID-19.
Leaders mentioned their community’s fear of being admitted to hospital due to the worry of potentially dying away from loved ones. Mistrust in the health services appeared to be propagated by social media and prior negative experiences in healthcare; this stopped many from self-reporting if they had symptoms (table 2).
Social impact
Some participants reported an increase in targeted online hate crime, perhaps due to media representation of their community during this pandemic (table 2). The high prevalence of COVID-19 in ethnic minority communities and the media representations have resurfaced historic structural racism against their community, with some commenting strongly on the perceived discrimination. Similarly, leaders noted the perceived lack of support for their respective ethnic minority groups regarding COVID-19 and its effects.
Participants also described how the taboo within their own communities meant that many were suffering in isolation. Many would also be unwilling to report symptoms if it meant that they would have to self-isolate, due to consequent financial loss and, sometimes, stigmatisation from fellow community members (table 2).
Leaders expressed their communities’ struggles with restrictions on social distancing and lockdown measures that had greatly impacted on what would otherwise be high-volume cultural and religious gatherings, from festivities to funerals (table 2).
Understanding of risk and disparity in health outcomes for COVID-19
Acceptance, scepticism and ignorance
Participants spoke of varying degrees of acceptance, with most describing their communities accepting their increased risk of transmission, infection and worse health outcomes compared with the White British population. However, scepticism of the virus’s impact was expressed by some participants, particularly due to the disproportionate death toll in the UK compared with their native country (table 3). This outlook extended to scepticism that vaccines were being administered initially to ethnic minority communities as an experimentation. This was especially reported by Black community leaders who voiced the concerns of younger demographics, relating it to involvement in social movements and antiestablishment rhetoric. All mentioned that the greatest health impact was on those who were elderly and vulnerable within their community, including those with underlying health conditions and disabilities (table 3).
Perceptions around ethnic, cultural, societal and environmental contexts as risk factors
Neighbourhood deprivation was commonly described, with many commenting on poor lifestyles and socioeconomic status fuelling the disparity (table 3). This was linked to education level and employment nature, especially for those in the service sector with high public exposure. Participants discussed multigenerational living contributing towards the high prevalence. For younger generations who were conscious of the risk, it was reported that some may have struggled to communicate this to elders within their family and wider community due to cultural hierarchies (table 3).
Perception, understanding and adherence to government guidance in relation to COVID-19
Understanding and clarity
Almost all participants stated that government guidance was inconsistent and lacked clarity. The subsequent effect was worsened for community members who were not fluent in English, with translated guidance lacking in forms that could be accessed and understood by all. This, combined with the community’s close-knit nature, was reported to have perhaps influenced their misinterpretation of social distancing guidelines between households (table 4).
Poor outreach
Digital exclusivity exacerbated weak understanding, with leaders mentioning that the pandemic revealed the lack of digital access for their most deprived (table 4). Participants described how they themselves took on the role of disseminating government guidance; a common sentiment was that of wonder to how else their community would have received such information without their input. Some mentioned that media representation and comments by government officials made their community feel marginalised, as it sometimes appeared to be targeted directly towards particular ethnic groups (table 4).
Adherence to or lack of government guidance
Participants deemed that communities in more deprived areas appeared to have weaker uptake of guidelines.
Facilitators affecting adherence included personal value, such as being able to resume congregational worship. Reinforcement from local authority and trusted community and religious leaders encouraged adherence. Other risk avoidance behaviours included the use of home remedies, which were perceived to have great benefit and were linked to cultural and religious practices (table 4). In contrast, the simplicity of some guidelines (wearing face masks and avoiding non-essential travel) appeared to make some question the necessity of abiding by them, especially when government officials were also seen to publicly break the rules without consequence (table 4).
Accessibility and use of community services, and other points of support, during the pandemic
Accessibility and lack of resources
Some mentioned their community had restricted or no access to culturally appropriate service providers and places of worship that they would normally frequent. Many commented on inadequate access to general practitioners, a healthcare professional their community holds in high regard and would usually turn to (table 5).
Points of support
All commented on their community’s feeling of servitude towards each other during the pandemic (table 5). Family and friends were reported to be the immediate support network. As lockdown restrictions eased, community centres and places of worship were stated to have responded to their local’s needs by launching services, such as food banks and befriending projects, which were not previously required (table 5).
Discussion
The aim of this study was to investigate the impact of the COVID-19 pandemic on ethnic minority communities. The findings reveal the inequalities as experienced by leaders of diverse ethnic minorities. Participants alluded to the disparities in infection rates and outcomes to historical and structural discrimination. Many community members experienced racism and stigmatisation during the pandemic, mirroring patterns of historical bias in the wider determinants of health against minority ethnic groups. This exacerbated mistrust in the healthcare system and government officials, with many believing that COVID-19 was another example of health disparity arising from marginalised ethnic groups suffering systemic discrimination.
Our findings also demonstrated some hesitancy on vaccine uptake within minority ethnic groups, especially noted by Black communities. Thus, clear and targeted public health information directed at minority ethnic groups is required to establish and strengthen trust in the vaccine, promoting uptake. However, the UK’s ‘colour-blind vaccination model’ is believed to further amplify the ethnic disparity of COVID-19, as it does not prioritise nor account for the clear health inequality in minority ethnic groups, arguably exacerbating structural discrimination.23
Participants in this study identified that community members faced barriers in adherence to government guidelines; lack of English proficiency particularly contributed to this. Despite translated documents, there was often an issue of illiteracy in the native language for some community members, with a number of participants mentioning the need for interpreters to verbally deliver guidance. It is known that deliverance of government guidelines was markedly affected by digital exclusion. In 2019, only 10.6% of White ethnic groups in the West Midlands were found to be ‘internet non-users’, while the collective percentage for all other ethnic groups (as included in our study) was reported at 39.9%.24 It is, however, likely that barriers in understanding government guidance could also be relevant to other communities in the general population, including those who identify themselves as ‘White British’, and in particular among those with lower levels of literacy. In addition, some participants in this study described that lack of access to sanitisers and masks during the early phase of the pandemic led to further difficulties in adherence for the most disadvantaged in their community.
Cultural and social practices within the communities led to many suffering on their own as discussion of mental health was still deemed a taboo for many ethnic minorities. Stigmatisation of mental health has frequently been documented within ethnic minority communities; this perceived barrier to seeking support from peers or professionals was described by our study participants. Our findings also revealed a mental health impact from the lockdown particularly on women with familial responsibilities in ethnic minority communities. This also extended to the lack of adequate bereavement support. Many communities could not grieve as usual due to lockdown restrictions. For instance, the Muslim community initially could not perform burial rites within 24 hours, an otherwise expected practice. This was quickly ameliorated by emergency government legislation which respected the community’s wishes.25 Such practice from authority level should be implemented for other minority ethnic groups regarding the particular challenges their communities face during this pandemic.
Participants described overcrowding due to multigenerational living as a risk factor for the observed disparities and contributor to weak adherence of social distancing guidelines. Many alluded to poor housing conditions. The ONS has reported that only 2% of White British households are overcrowded, compared with 10% for other ethnic groups.26 Participants also commented on the typical nature of employment of their community members, including low-paid key worker roles during the pandemic (such as transport operatives and hospital porters) which overexposed them to the virus. High prevalence of such employment among ethnic minority communities has been linked to poorer education levels associated with historic structural biases and systemic inequality.27 This is reiterated by research stating that such factors interplay with ethnicity, resulting in poor health for minority ethnic groups.28
Strength and limitations
To our knowledge, this was the first study to investigate the understanding of risk and impact of COVID-19 using the perspectives of ethnic minority community leaders in England. An extensive variety of community leaders were recruited through an intensive search of ethnic minority community organisations, businesses and places of worship. Thus, key informants could share the experiences of the COVID-19 pandemic on their ethnic minority community through the study’s qualitative design. The interviewing researcher’s own ethnic minority origin may have also allowed participants to openly discuss sensitive issues, thus eliciting detailed perspectives. Leaders not of ethnic minority origin themselves but who could speak on behalf of ethnic minority communities (such as councillors of White ethnicity representing a West Midlands constituency with a high ethnic demographic) were approached, but we did not receive response from anyone available to participate.
Duplicate analysis of interviews provided rigour, and data saturation was assumed after 19 participants since no new themes had emerged. However, these findings are not representative of all ethnic minority groups. For example, we could not recruit anyone from East Asian communities. Moreover, our methodology’s use of government-standardised ethnic grouping was very broad, but our results indicated that the experiences of this pandemic varied hugely across different ethnicities that would otherwise be classed together under one collective BAME (Black, Asian and minority ethnic) term. For instance, the Somali diaspora in inner-city Birmingham had very different understanding and experiences of COVID-19 compared with the Caribbean community in outskirt boroughs. To investigate this further, research is imperative to examine the effects of the pandemic on specific ethnic minority groups. While our findings have given an insight into this, caution is advised when considering recommendations as we did not achieve data saturation for each individual subgroup. For example, there may well be differences between British Indians who are Sikh or Hindu, but would otherwise be classified together under one ethnicity. Similarly, we may not have captured the specific concerns and experiences of a particular ethnic minority from participants who represented various ethnic groups, such as the religious leaders. Therefore, it is essential that any proposed recommendation is tailored specifically to the needs of each ethnic minority group and not restricted by a singular umbrella term such as BAME, which otherwise wrongly implies homogeneity between such distinct communities. Another limitation to our study is the lack of a comparator group that would allow for investigation of any differences in the perspectives and experiences between minority ethnic groups and White British during the pandemic.
Although not an aim of this study, there is weakness in its lack of generalisability as it was limited to a geographical region within England. Similarly, given the qualitative nature of this study, the sample size was limited to 19 participants. However, the recruited region represents the second highest proportion of ethnic minority populations within England.29
Implications for practice and research
Further work needs to be urgently undertaken during this ongoing pandemic to improve adherence to the government guidelines within ethnic minority communities and mitigate the disproportionate impact of COVID-19. This includes increasing outreach and providing logistical and financial support at a grass-roots level to the most vulnerable in already marginalised communities. Public health guidance must be produced in different languages and dialects through accessible media, on how to stay safe from COVID-19 and to challenge myths propagated by social media. Public health campaigns should incorporate nuances that ethnic minority communities can resonate with, such as the perceived benefit of home remedies, to deliver targeted but culturally sensitive interventions. All aforementioned recommendations should be implemented with cooperation between health services and trusted community networks, religious leaders and local stakeholders. This approach would be beneficial in other global or national public health interventions and any future pandemics, should they occur.
Future research could investigate which intrademographic characteristics within a certain ethnic minority community affect their perceptions and impact of COVID-19, and to what extent. This includes factors identified by this study, such as cultural hierarchies. Further studies could also explore specific ethnicity-related barriers in adherence to COVID-19 government guidance. The collective addressing of all non-White demographics into one overarching ‘BAME’ category should also be questioned and adapted, as this study has demonstrated that one solution will not encompass the needs of all ethnic minority communities. Perspectives of other population groups who are likely to face multiple social disadvantages during the time of pandemic, such as the homeless populations,30–32 refugees33 and single people living,34 need to be researched.
Conclusion
Ethnic minority community leader participants of this study alluded to historical and structural discrimination for the observed disparities in COVID-19 morbidity and mortality. In addition, cultural and social practices within the communities led to many suffering on their own as discussion of mental health was still deemed a taboo within many communities. Racial discriminations added to their worries during the pandemic. Reinforcement from trusted community and religious leaders encouraged adherence to government guidelines. Points of support such as food banks were vital in ensuring essential supplies during the pandemic. Government agencies and public health bodies must integrate with the community, and community leaders must disseminate the key messages to deliver targeted yet sensitive public health advice which incorporates cultural and religious practices. Addressing the root cause of disparities is imperative to mitigate current and future pandemics. These must be tackled by using appropriate and targeted public health interventions. Since the distinct ethnic minorities may face unique challenges due to cultural, economic and geographical variances, future research is needed to capture the specific barriers faced by each community. Such interventions should be initiated by the governmental sphere foremost, then perpetuated by local authority in collaboration with community leaders. Ultimately, all strategies must be guided by ethnic minority communities themselves in order to successfully meet their needs.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval was obtained from the University of Birmingham School of Pharmacy Ethics Committee (reference number: UoB/SoP/2020-64). Informed consent was received from all participants.
Acknowledgments
We are grateful to every participant for their time and support in this study, without whom this research could not have been conducted, with particular thanks to the West Bromwich African Caribbean Resource Centre.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors FM, VP and DA codesigned the study. FM conducted all interviews and transcribed the data. FM and VP conducted the analysis in duplicate to which DA and KK added their input through expert comments. FM led the write-up of the manuscript to which all authors contributed through editing and expert comments. All authors agree to the final version of the manuscript. Vibhu Paudyal is responsible for the overall content as the guarantor of this publication.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.