Golubic, Rajna

Osuafor, Christopher N

Ray, Sumantra

English

Apollo (Cambridge)

EClinicalMedicine 31 (2021) 100672Contents lists available at ScienceDirectEClinicalMedicinejournal homepage: https://www.journals.elsevier.com/eclinicalmedicineCommentaryEthnic inclusivity and preventative health research in addressing healthinequalities and developing evidence base.Christopher N. Osuafora,b,*, Rajna Golubicc,d, Sumantra Rayd,e,faDepartment of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdomb Department of Medicine for the Elderly, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United KingdomcWellcome Trust, MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, United Kingdomd NNEdPro Global Centre for Nutrition and Health, St John’s Innovation Centre, Cambridge, United Kingdome School of Biomedical Sciences, Ulster University, Coleraine, Northern Irelandf School of Humanities and Social Sciences, University of Cambridge, Cambridge, United KingdomA R T I C L E I N F OArticle history:Received 23 September 2020Accepted 18 November 2020Available online 5 December 2020* Corresponding author.E-mail address: co400@cam.ac.uk (C.N. Osuafor).https://doi.org/10.1016/j.eclinm.2020.1006722589-5370/© 2020 The Author(s). Published by ElsevierKeywords:EthnicityHealth researchHealth inequalitiesLtd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)Covid-19 has exposed the existing deep-rooted health and widerinequalities that persist in our society, especially amongst those liv-ing in the most deprived neighbourhoods and people from Black andMinority Ethnic communities [12]. We now have an unprecedentedopportunity to foster a research culture which will proactivelyengage participation from those at greatest risk of adverse healthoutcomes, yielding much needed data and evidence to articulateunmet needs. This can potentially mitigate under-representation inpopulation-level risk assessments as well as the planning, deliveryand utilisation of health interventions and healthcare services sensi-tive to the needs of such minority groups.Ethnicity is a complex construct which acts as a proxy for chronicdisease phenotypes and therapeutic response, reflecting the differen-ces in disease pathophysiology and drug metabolism [3]. Some of thewell-studied examples include type 2 diabetes and hypertension.Meta-analyses of published randomised controlled trials concludedthat Sodium-glucose co-transporter-2 (SGLT2) inhibitors and Dipep-tidyl-peptidase-4 (DPP4) inhibitors are more effective in loweringHbA1c amongst Asians than amongst White individuals [4]. Recently,it has been highlighted that Black and Minority Ethnic populationsare at a greater risk of various micronutrient deficiencies, which mayunderpin the mechanisms contributing to a higher risk of adverseoutcomes associated with COVID-19 [5].Under-representation of ethnic minority groups in clinicalresearch has been widely reported [6]. The reasons for under-repre-sentation of these groups in research are complex and could beattributable to hesitancy on the part of participants, lack of inclusionby healthcare staff or researchers, often on the pretext of linguisticbarriers, and other socioeconomic factors as well as entrenchedstructural inequalities [7]. Navigating these complexities requiresconsiderable planning. In the planning process, we should considerthat in the UK, 20.7% of the healthcare workforce comprises of non-White ethnicities [8]. In the US, 34.8% of the health workforce ismade up of Hispanics, Blacks or African Americans, Asians and indi-viduals reporting Multiple and Other races [9]. This diversity in thehealthcare workforce needs to be better reflected in the leadershiproles, especially in research.Inclusive and diverse healthcare research, therefore, can bestrengthened by exploring five domains. Drawing from thesedomains, we hereby propose a Health Research Inclusivity Model(Fig. 1) which is centred around increasing Research Participationand developed through Research Leadership, Research Policy,Research Funding and Research Reporting.Addressing ethnic complexities in research should start withimproving Research Participation by involving under-representedgroups in all primary research, which will inadvertently lead todeveloping evidence for clinical practice. Improvements like targetedoutreach programs are required to increase participation of all groupswithin the population in research. These improvements will help cre-ate an inclusive health service agenda and treatment guidelinesFig. 1. Health Research Inclusivity Model.2 C.N. Osuafor et al. / EClinicalMedicine 31 (2021) 100672which would consider ethnicity-specific risk of health outcomes andprovide the best possible support for all service users.In relation to Research Leadership, there should be promotion ofpractices that ensure regional Research Ethics Committees’ staffingreflects the diversity of the community. Those in senior managementroles and leadership in these committees should take into considerationthe lived experiences of the ethnic minorities in this section of theworkforce. This leadership should also lay emphasis on preventativehealth research that will target behaviour, social and physical factorsand health-related policies that negatively affect these communities.We call for research institutions to have a Research Policy whereresearchers are mandated to aim for the participants in their researchto match, at least in percentage terms, the overall ethnic compositionof its local community. This should be backed up by training sessionson how to reach out to minority ethnic communities and those frommost deprived neighbourhoods to invite them to participate inresearch. To ensure its implementation, independent Research EthicsCommittees should provide oversight, ensuring that these under-rep-resented groups are considered at planning and recruitment stages ofresearch development. To ensure that there is no discrimination basedon language, standard regulatory approval should explore actionsresearchers and research organisations take to include non-Englishspeakers who would otherwise meet their proposed inclusion criteria.Funding agencies also have a role to play in addressing healthinequalities through Research Funding. The Centre for Black andMinority Ethnic Health supported by the National Institute of HealthResearch, which aims to address inequalities in health care accessand health outcomes of ethnic and migrant communities, is wellwithin this remit [10]. Research themes focussed specifically onexploring the complex reasons for under-representation of ethnicminority groups in research and providing solution to the barriers toparticipation in research should be priority. Consideration should begiven to explore patient, physician or healthcare delivery factors thataddress any potential delay in diagnosis, delay in treatment initiationor treatment discontinuation amongst ethnic minorities from child-birth to palliative care.Finally, standard methods of Research Reporting for all researchstudies, should mandatorily include data on ethnicity in the table con-taining socio-demographic characteristics, not just age and sex. Also,reporting by Research Ethics Committees should include data on Blacks,Asians, Hispanics,Multiple andOther races involvement as a percentageof all research approved over a time-period (annually or bi-annually).In conclusion, encouraging ethnic and socio-cultural inclusivity inthe core activities of researchers, research agencies and healthcareorganisations is fundamental in addressing health inequalities andimproving our evidence base. The Health Research Inclusivity Modeldescribed presents recommendations which will help navigate thischallenge.FundingChristopher N. Osuafor was supported by the Cambridge BHF Centreof Research Excellence (CRE, Centre Code: RE/18/1/34,212). Rajna Golu-bic was supported by a National Institute of Health Research (NIHR)Academic Clinical Fellowship. Sumantra Ray was supported by NNEd-Pro core funding held with the British Dietetic Association (BDA).DisclaimerThe content of this commentary is solely the responsibility of theauthors and does not necessarily represent the official views of theCambridge BHF CRE, NIHR, NNEdPro or BDA.Declaration of Competing InterestSumantra Ray is the Founding Chair and Executive Director of theNNEdPro Global Centre for Nutrition and Health. The other authorshave nothing to disclose.C.N. Osuafor et al. / EClinicalMedicine 31 (2021) 100672 3AcknowledgementWe would like to acknowledge Dr Anu Obaro for providing adviceon the design of the Health Research Inclusivity Model.References[1] Pareek M, Bangash MN, Pareek N, Pan D, Sze S, Minhas JS, et al. Ethnicity andCOVID-19: an urgent public health research priority. Lancet 2020;395(May 2(10234)):1421–2.[2] Pan D, Sze S, Minhas JS, Bangash MN, Pareek N, Divall P, et al. The impact of eth-nicity on clinical outcomes in COVID-19: a systematic review. EClinicalMedicine2020;23:100404.[3] Chaturvedi N, Eastwood S. Prescribing by ethnicity: (im)precision medicine? Dia-betes Care 2020;43(8):1687–9.[4] Ramamoorthy A, Pacanowski MA, Bull J, Zhang L. Racial/ethnic differences in drugdisposition and response: review of recently approved drugs. Clin Pharm Ther2015;97(3):263–73.[5] McAuliffe S, Ray S, Fallon E, Bradfield J, Eden T, Kohlmeier M. Dietary micronutrientsin the wake of COVID-19: an appraisal of evidence with a focus on high-risk groupsand preventative healthcare. BMJ Nutrition, Prevent Health 2020;3(1):93–9.[6] Smart A, Harrison E. The under-representation of minority ethnic groups in UKmedical research. Ethn Health 2016;22(1):65–82.[7] Treweek S, Forouhi NG, Narayan KMV, Khunti K. COVID-19 and ethnicity: whowill research results apply to? Lancet 2020;395(10242):1955–7.[8] Gov.uk. Ethnicity facts and figures. NHS workforce: https://www.ethnicity-facts-figures.service.gov.uk/workforce-and-business/workforce-diversity/nhs-work-force/latest (accessed August 22, 2020).[9] Bhw.hrsa.gov. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/diversityush-ealthoccupations.pdf (accessed August 24, 2020).[10] Centre for BME Health  Home  The Centre for Black and Minority Ethnic (BME).Centreforbmehealth.org.uk. https://centreforbmehealth.org.uk/ (accessed August10, 2020).

Ethnic inclusivity and preventative health research in addressing health inequalities and developing evidence base.

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Ethnic inclusivity and preventative health research in addressing health inequalities and developing evidence base.

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