Negotiating the racial and ethnic boundaries of citizenship: white South African migrants in the UK and their sense of belonging

This PhD thesis is based on a qualitative interview study of white South Africans who have migrated to the UK in the post-apartheid era, focusing on their sense of belonging and ‘racial’/ethnic boundary-processes in society. With the increasing South African emigration in the post-apartheid era, the UK has been South Africans’ primary destination. Nevertheless, this migrant group has received relatively little scholarly attention. It could seem as though South Africans have been considered less interesting for research purposes, as their typical status as white and relatively privileged migrants appears to have made them better perceived by the British state apparatus and public than many ‘non-white’ and other disadvantaged migrants (Crawford 2011). By investigating migrants’ sense of belonging, this thesis complements the traditional preoccupations with the formal rights and duties of citizenship (e.g. Marshall 1998 [1963]). Moreover, the analytical insights of ‘intersectionality’ can rectify the one-dimensional conceptualisations (e.g. Kymlicka 1995) which run the risk of labelling all members of an ethnic minority or migrant group as equally disadvantaged without considering how social categories like gender and class might position them differently in particular ‘social hierarchies’. ‘Intersectionality’ – as typically applied to reveal intersecting categorisations/oppressions affecting multiply disadvantaged groups such as black women – can therefore be employed also when demonstrating how members of relatively privileged groups may be situated differently according to ethnicity, class, gender, and so on. Noticeably, varying forms of inclusion and exclusion can be negotiated simultaneously depending on the social categories being underscored (Yuval-Davis 2011a). The psychosocial concerns affecting even relatively privileged migrant groups – as migrants in a new context – are evidenced by the ways in which white South Africans negotiate away boundaries of exclusion by drawing on the more privileged aspects of their group status in order to distinguish themselves from disadvantaged groups in British and South African society

Negotiating the racial and ethnic boundaries of citizenship: white South African migrants in the UK and their sense of belonging

This PhD thesis is based on a qualitative interview study of white South Africans who have migrated to the UK in the post-apartheid era, focusing on their sense of belonging and ‘racial’/ethnic boundary-processes in society. With the increasing South African emigration in the post-apartheid era, the UK has been South Africans’ primary destination. Nevertheless, this migrant group has received relatively little scholarly attention. It could seem as though South Africans have been considered less interesting for research purposes, as their typical status as white and relatively privileged migrants appears to have made them better perceived by the British state apparatus and public than many ‘non-white’ and other disadvantaged migrants (Crawford 2011). By investigating migrants’ sense of belonging, this thesis complements the traditional preoccupations with the formal rights and duties of citizenship (e.g. Marshall 1998 [1963]). Moreover, the analytical insights of ‘intersectionality’ can rectify the one-dimensional conceptualisations (e.g. Kymlicka 1995) which run the risk of labelling all members of an ethnic minority or migrant group as equally disadvantaged without considering how social categories like gender and class might position them differently in particular ‘social hierarchies’. ‘Intersectionality’ – as typically applied to reveal intersecting categorisations/oppressions affecting multiply disadvantaged groups such as black women – can therefore be employed also when demonstrating how members of relatively privileged groups may be situated differently according to ethnicity, class, gender, and so on. Noticeably, varying forms of inclusion and exclusion can be negotiated simultaneously depending on the social categories being underscored (Yuval-Davis 2011a). The psychosocial concerns affecting even relatively privileged migrant groups – as migrants in a new context – are evidenced by the ways in which white South Africans negotiate away boundaries of exclusion by drawing on the more privileged aspects of their group status in order to distinguish themselves from disadvantaged groups in British and South African society

Experience-based investigation and codesign of approaches to prevent and reduce Mental Health Act use (CO-PACT): a protocol

INTRODUCTION: The Independent Review of the Mental Health Act (MHA) in England and Wales confirmed increasing levels of compulsory detentions, especially for racialised communities. This research aims to: (a) understand the causes of and propose preventive opportunities to reduce the disproportionate use of the MHA, (b) use an adapted form of experience-based codesign (EBCD) to facilitate system-wide changes and (c) foreground the voices of service users at risk of detention to radically reform policy and implement new legislation to ensure the principles of equity are retained. METHODS AND ANALYSIS: This is a qualitative study, using a comparative case study design. This study is composed of five work packages; photovoice workshops will be conducted in eight local systems with service users and healthcare professionals separately (WP1); a series of three EBCD workshops in each local system to develop approaches that reduce detentions and improve the experience of people from racialised communities. This will inform a comparative analysis and national knowledge exchange workshop (WP2); an evaluation led by the patient and public involvement group to better understand what it is like for people to participate in photovoice, codesign and participatory research (WP3); an economic evaluation (WP4) and dissemination strategy (WP5). The impact of the involvement of patients and public will be independently evaluated. ETHICS AND DISSEMINATION: This study is sponsored by the University of Oxford and granted ethical approval from the NHS Research Ethics Committee and Health Research Authority (21/SC/0204). The outputs from this study will be shared through several local and national channels

Tackling barriers to COVID-19 vaccine uptake in London: a mixed-methods evaluation

BACKGROUND: In response to the COVID-19 pandemic, the first vaccine was administered in December 2020 in England. However, vaccination uptake has historically been lower in London than in other English regions. METHODS: Mixed-methods: This comprised an analysis of cumulative percentage uptake across London between 8 December 2020 and 6 June 2021 by vaccine priority cohorts and ethnicity. We also undertook thematic analyses of uptake barriers, interventions to tackle these and key learning from a qualitative survey of 27 London local authority representatives, vaccine plans from London's five Integrated Care Systems and interviews with 38 London system representatives. RESULTS: Vaccine uptake was lower in Black ethnic (57-65% uptake) compared with the White British group (90% uptake). Trust was a critical issue, including mistrust in the vaccine itself and in authorities administering or promoting it. The balance between putative costs and benefits of vaccination created uptake barriers for zero-hour and shift workers. Intensive, targeted and 'hyper-local' initiatives, which sustained community relationships and were not constrained by administrative boundaries, helped tackle these barriers. CONCLUSIONS: The success of the national vaccination programme depended on conceding local autonomy, investing in responsive and long-term partnerships to engender trust through in-depth understanding of communities' beliefs

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Background Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal. Objectives The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views. Design A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres. Setting The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals. Participants A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents. Interventions The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback. Main outcome measures The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds. Data sources National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used. Review methods Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26). Limitations Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services. Conclusions Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment. Future work Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications. Trial registration This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

© The Author(s). 2018Background: As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales. Methods: Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses. Results: Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes. Conclusions: Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform. Trial registration: CRD42017071663Peer reviewedFinal Published versio

Tackling barriers to COVID-19 vaccine uptake in London: a mixed-methods evaluation.

BACKGROUND: In response to the COVID-19 pandemic, the first vaccine was administered in December 2020 in England. However, vaccination uptake has historically been lower in London than in other English regions. METHODS: Mixed-methods: This comprised an analysis of cumulative percentage uptake across London between 8 December 2020 and 6 June 2021 by vaccine priority cohorts and ethnicity. We also undertook thematic analyses of uptake barriers, interventions to tackle these and key learning from a qualitative survey of 27 London local authority representatives, vaccine plans from London's five Integrated Care Systems and interviews with 38 London system representatives. RESULTS: Vaccine uptake was lower in Black ethnic (57-65% uptake) compared with the White British group (90% uptake). Trust was a critical issue, including mistrust in the vaccine itself and in authorities administering or promoting it. The balance between putative costs and benefits of vaccination created uptake barriers for zero-hour and shift workers. Intensive, targeted and 'hyper-local' initiatives, which sustained community relationships and were not constrained by administrative boundaries, helped tackle these barriers. CONCLUSIONS: The success of the national vaccination programme depended on conceding local autonomy, investing in responsive and long-term partnerships to engender trust through in-depth understanding of communities' beliefs

A Delphi study and ranking exercise to support commissioning services:Future delivery of Thrombectomy services in England

Background: Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed to using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke. Methods: A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR). Results: Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n=43) and BSNR members (86%, n=21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography. Conclusions: The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is conveying suspected stroke patients for CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience centre

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses.

This is a post-peer-review, pre-copyedit version of an article published in Social Psychiatry and Psychiatric Epidemiology. The final authenticated version is available online at: https://doi.org/10.1007/s00127-019-01758-yPURPOSE: Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England. METHODS: Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously. RESULTS: We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4). CONCLUSIONS: The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.Lankelly Chase Foundatio

Identifying evidence of effectiveness in the co-creation of research: a systematic review and meta-analysis of the international healthcare literature.

This is a pre-copyedited, author-produced version of an article accepted for publication in Journal of Public Health, following peer review. The version of record: Kristoffer Halvorsrud, Justyna Kucharska, Katherine Adlington, Katja Rüdell, Eva Brown Hajdukova, James Nazroo, Maria Haarmans, James Rhodes, Kamaldeep Bhui, Identifying evidence of effectiveness in the co-creation of research: a systematic review and meta-analysis of the international healthcare literature, Journal of Public Health, fdz126, https://doi.org/10.1093/pubmed/fdz126 is available online at: https://doi.org/10.1093/pubmed/fdz126.BACKGROUND: To investigate and address the evidence gap on the effectiveness of co-creation/production in international health research. METHODS: An initial systematic search of previous reviews published by 22 July 2017 in Medline, Embase, PsycINFO, Scopus and Web of Science. We extracted reported aims, elements and outcomes of co-creation/production from 50 reviews; however, reviews rarely tested effectiveness against intended outcomes. We therefore checked the reference lists in 13 included systematic reviews that cited quantitative studies involving the public/patients in the design and/or implementation of research projects to conduct meta-analyses on their effectiveness using standardized mean difference (SMD). RESULTS: Twenty-six primary studies were included, showing moderate positive effects for community functions (SMD = 0.56, 95%CI = 0.29-0.84, n = 11) and small positive effects for physical health (SMD = 0.25, 95%CI = 0.07-0.42, n = 9), health-promoting behaviour (SMD = 0.14, 95%CI = 0.03-0.26, n = 11), self-efficacy (SMD = 0.34, 95%CI = 0.01-0.67, n = 3) and health service access/receipt (SMD = 0.36, 95%CI = 0.21-0.52, n = 12). Non-academic stakeholders that co-created more than one research stage showed significantly favourable mental health outcomes. However, co-creation was rarely extended to later stages (evaluation/dissemination), with few studies specifically with ethnic minority groups. CONCLUSIONS: The co-creation of research may improve several health-related outcomes and public health more broadly, but research is lacking on its longer term effects