The Incidence of Stomach Bugs Across Differing Minorities

Abstract

The exposure patterns across ethnic groups are unclear for gastrointestinal infections that cause self-limiting symptoms, significantly burdening UK healthcare services and the economy. This study seeks to fill this gap by exploring how inequalities arise in managing gastrointestinal infections in UK ethnic groups. A qualitative study using semi-structured interviews was undertaken. Recruitment was conducted through community gatekeepers using flyers. Participants were interviewed in person or virtually and gave written informed consent. Interviews were audio-recorded using a password-protected digital recorder, transcribed verbatim and analysed using reflexive thematic analysis. 38 interviews were conducted with 12 women of Pakistani (n = 7), Bangladeshi (n = 2), Indian (n = 2) and Arab ethnicity (n = 1) and 26 men of Black (n= 23), Pakistani (n = 2) and Indian (n = 1) ethnicity. This enabled exploring within-ethnic group experiences of participants who self-defined their ethnicity. Themes such as managing food preparation (n = 18), travel abroad (n = 17) and personal cleanliness (n = 3) were consistently reported across transcripts. The evidence infers the need to adapt control measures to these specific risks in ethnic minority communities and understand the mechanisms that predispose them more to risk.

Introduction

Being socially engaged with race requires critically reflecting on the practices, beliefs and experiences that construct human behaviours, shape interactions and impact society. This article on positionality and reflexivity commences with an introduction to the research undertaken by me, the researcher, my worldview of reality (ontology), theory of knowledge (epistemology) and methodology, before delving into the recruitment, interview conduct and implications of these findings. The reflections are derived from a qualitative, semi-structured interview study to explore the experiences, practices and everyday beliefs relating to gastrointestinal infections across 38 ethnic minorities in a UK context. In this article, I scrutinise the key reflections in my research study and situate this within the theoretical framework of intersectionality to understand how shared characteristics like age, gender and class compound existing inequalities. I ask the readers to dwell upon their notions of stomach bugs and concepts of 'reflexivity', 'ethnicity' and 'positionality'; research on these topics has increased in contemporary academic discourse, and they should invoke a thorough understanding of what they stand for instead of being used as mere buzzwords.

Study Rationale

Gastrointestinal infections usually cause self-limiting symptoms such as diarrhoea, vomiting and abdominal pain (Tam et al., 2012). However, these symptoms can cause people to take time off work and school, thus significantly burdening UK healthcare services and the economy (Tam et al., 2011). Additionally, there is evidence that more disadvantaged groups are both more at risk of exposure to gastrointestinal infections and experience more severe consequences (Adams et al., 2017; Rotherham et al., 2019). In-depth studies are required to highlight vulnerable subgroups and susceptibility factors influencing the onset of gastrointestinal infections, including elderly and child populations, alongside ethnic groups (Tam et al., 2012). There is some evidence that people of South Asian ethnicity are more likely to have enteric fever (Braddick et al., 1993; Ispahani and Slack, 2000), helicobacter pylori (Stone et al., 2008), enterobacteria (Rao et al., 2015) and infectious gastroenteritis (de Lusignan et al., 2020). Some studies indicate high risk, particularly in the UK South Asian community (Charlett et al., 2003; Gillespie et al., 2008; Morris-Cunnington et al., 2004; Rose et al., 2020). While evidence suggests an association between ethnicity and gastrointestinal infections, we still need to fully understand the potential pathways generating these inequalities. Diderichsen et al. (2001) created a model to highlight that these inequalities could develop across multiple levels. Ethnic minority groups may be more exposed to gastrointestinal infections; they may be more susceptible or vulnerable, for example, due to pre-existing conditions. Equally, they may experience more severe consequences due to discrimination in access to health services or the labour market (Katikreddi et al., 2021). There is evidence for a few of these pathways.

For example, overcrowded housing remains higher in ethnic minority groups, notably Pakistani, Bangladeshi and Black African people (Olowokure et al., 1999; Sethi et al., 2001; Brown, 2020; Iacobucci, 2021). In addition to this, people from ethnic minority groups are more likely to live in multigenerational households than white British individuals. Living in accommodation with fewer rooms, rented or social housing, and overcrowding are significant risk factors for gastrointestinal infections (Majeed et al., 1992; Nazroo and Becares, 2020; Razai et al., 2021). Indeed, living in multigenerational households has been associated with helicobacter pylori (Brown, 2000). Potential intersections exist between these ethnic inequalities in gastrointestinal infections and gender, socioeconomic status and geography. For example, ethnic minorities are concentrated in urban areas and are significantly associated with a higher risk of illness due to differences in housing and intergenerational living.

Methods

Qualitative semi-structured interviews were utilised to forefront the lived experiences of UK ethnic minorities. Semi-structured interviews are navigated by a list of questions or topics deemed pertinent to collect information from participants with perceptions, personal beliefs, experiences, attitudes and notions related to the phenomenon under study (DeJonckheere and Vaughn, 2019). The research added to the existing qualitative evidence on gastrointestinal infections by understanding the multiple causative pathways leading to increased susceptibility in ethnic minorities, thus supplying insights into the adopted responses and behaviours (Adams et al., 2019). This was achieved by considering the broader social context of gastrointestinal infections between UK ethnic groups. Study objectives included to:

• Explore whether experiences of gastrointestinal infections differ between class, gender and age and how these potentially interact to influence the experience of gastrointestinal infections in ethnic minorities. 

• Draw out the policy implications of these findings for measures that aim to reduce the risk of gastrointestinal infections in ethnic minorities. 

Ethical approval was given by the University of Liverpool, and I collected primary data over 11 months. Snowball sampling helped access and approach participants through recommendations from other participants with relevant knowledge and characteristics (Ngozwana, 2018). However, this could have excluded those with more severe symptoms or who needed more information on the study, overrepresenting first-engaged interviewees (Kirchherr and Charles, 2018; Badu, O’Brien and Mitchell, 2019). Similarly, purposive sampling is cost and time-effective, and its rationale lies in selecting information-rich 'cases' to generate insights into the phenomenon under scrutiny. However, both strategies are prone to selection bias due to the limited probability of obtaining a generalisable sample.

Participants were given the choice to be interviewed via Zoom or WhatsApp audio. It was also duly acknowledged that face-to-face interviews could not be feasible for all interested participants being conducted at one specific community centre, whilst digital inequalities could persist when accessing participants digitally, which could impede the effectiveness of semi-structured interviews. For example, individuals with poorer literacy skills could struggle to use telephones. Initially, 3 interviews took place in 1 Blackburn community centre with participants of South Asian ethnicity (1 British Pakistani male and 2 females of British Pakistani and Bangladeshi ethnicities respectively). However, as recruitment lasted over 6 months (August 2022 to May 2023), the ethnic composition of participants expanded from South Asian to include participants of Arab, Black British, Black African, Black Caribbean and Black Mixed ethnicity, spanning multiple UK cities, age groups and occupations. Thus, a general UK population sample (excluding healthcare professionals), who were adults, partners and parents with gastrointestinal infections over the past ten months, were represented in this study.

To facilitate the interviews, a topic guide was used to navigate through participant responses regarding exposure(s) to gastrointestinal infections, which was iteratively refined and consulted on by a public advisor. This topic guide's questions were like those developed by a colleague conducting narrative interviews to explore socioeconomic inequalities in gastrointestinal infections (Rotherham et al., 2019). Cue cards were also created, with key topics of interest that were relevant to the research. An Amazon/Love to Shop voucher incentive was imbursed to participants for their time. The participant information sheet needed to be written in a simple language to be accessible to all, and some sheets were translated into Urdu, physically handed out to women’s group leaders and pinned onto a notice board at 1 community centre. Consent was mandated through a signed, written consent form circulated to all participants before the interviews, with verbal consent acknowledged before the interviews commenced. The researcher debriefed participants before and after the interviews, with a list of services to signpost them to, had they become distressed. Recruitment continued until data saturation was reached and when no new data was elicited in the interviews.

Analysis

All interviews were recorded using a password-protected audio-recording device and transcribed verbatim from Urdu language (n= 5) and English (n= 33); 30 of these English interviews were transcribed by a professional transcriber. Interview data was iteratively coded and analysed using reflexive thematic analysis (Castleberry and Nolen, 2018; Braun and Clarke, 2019; White et al., 2020). This included data familiarisation through repeated readings and initial coding developed and refined throughout the analysis (Byrne, 2021). An inductive, latent approach to thematic analysis was selected so that themes existed in a pre-existing coding frame instead of emerging from my analytic preconceptions. This extended beyond the expressed meanings of participants to unravel the underlying patterns emerging in the data, reflecting on the researcher's own theoretical and interpretive frameworks instead of a deductive, semantic approach concerned with surface-level, descriptive meanings. To mitigate researcher bias, I double-coded themes to ensure themes emerged organically from the data, enforcing data validity. A public advisor and two supervisors verified the codes from 6 transcripts to increase the probability of developing credible findings. All transcripts were transferred into NVivo to organise the codes and develop larger themes. 

The Novice Qualitative Researcher: All Praise Thee, PhD Student!

Having an interdisciplinary academic background in sociology and global health, the research I am most interested in cuts across the overarching theme of tackling health and social inequalities and the social determinants of health entrenched across all domains of society, requiring an intersectoral and interdisciplinary approach to mitigate, as well as considering the sociology of health and illness. While qualitative research had been at the crux of my research training, I had yet to gain prior experience conducting interviews. This meant I had to articulate to participants that I was a PhD researcher. A PhD researcher is technically classed as a 'student' without a Dr title, unlike postdocs or professors who possess a larger resume filled with glittering publications, awarded grants and teaching responsibilities. As a PhD researcher, it can be difficult to detail your expertise, especially when you don't have any in the first place! The myth that I was an experienced researcher therefore had to be dispelled.

I also had to communicate the benefits of engaging with this study, why it was important and the potential implications of these findings for the participants. One male British Indian participant interviewed face-to-face commented on my attitude, that my body language was positive and that I seemed polite and genuinely interested in the research. Sometimes, a little politeness goes a long way, and you don't need to be an authoritative, stern 'I know it all' PhD student with a vision to change the world with your research. I kept reiterating that I was a new interviewer and had never done this before. When visiting charities and community organisations, I was informed of past experiences the community gatekeepers encountered with researchers. They were reported as being intimidating with their body language (sitting with their legs crossed), secretively making notes and carrying clipboards with a checklist, assuming they had the authority to “control” participants and their worldviews condescendingly.

The construction of meaning through the layperson's perspective can illustrate how they perceive illness causation and treatment, most notably how illness processes link with laypeople's broader structural and social contexts, clinicians and communities (Le et al., 2017; Zaharias, 2018). However, lay knowledge and individual experiences are often negated and thrown out the window. The ‘professional’ mindset can be 'we are the ones who know what we're doing'. Such a mindset prompts a socially desirable response which does not align with the subjective experiences of managing the symptoms of gastrointestinal infections in ethnic minority groups. The relationship between participants and researcher must consist of mutual respect and consideration, allowing flexibility, whereas a significant power imbalance hinders openness. Ensuring that my observations, about the participants and their gastrointestinal infection experiences, authentically represented their social worlds was crucial. Debriefing and reiterating the whole point of conducting the interviews in the first place was integral. Not all participants frankly cared about the importance of signing the consent form and how data is stored, destroyed or used. The use of pseudo names was warmly received – one participant even jokingly referred to me as Aisha instead of Iram. So, the participant's attempt to understand and reciprocate my research problem of conducting a reasonable number of interviews was greatly appreciated.

The Repercussions of Recruitment

Recruitment was conducted through community gatekeepers using flyers. I dropped leaflets at clothing shops and eateries, spoke to local charity founders and emailed public health consultants and charity leaders in Blackburn. I was also invited twice to speak about my study at the Pendle Community Radio Station, which helped facilitate recruitment. As I am a British-born female Pakistani, I anticipated a larger turnout of Pakistani male and female respondents. However, most of the females I had engaged with initially at one of the community centres were Gujarati Indian Africans, who were born in the Indian state of Gujarat and had migrated to Uganda, then were forced into exile during a military coup in the 1970s, eventually settling in Blackburn and other UK towns. This anecdote enabled me to consider the following:

• Dispelling the notion that I would recruit more female than male participants as previously expected.

• Acquiring nuance by refining the topic guide to get participants to talk in-depth.

• Increasing the interview duration and not ending topics abruptly.

• The recruitment criteria had to be broadened from Pakistani to include all South Asians and, ultimately, all ethnic minority groups.

• The research setting needed to change from one specific Northwest town to the whole UK, with more community organisations and gatekeepers engaged.

My co-researchers agreed that the inclusion criteria had to be diversified since the original sample was too limiting, resulting in a narrowed focus and targeting a specific sub-ethnic group. This implied that I would need to target a range of South Asians as their ‘exposures’ were likely to be somewhat homogeneous to the original research participants, i.e. similar languages are spoken, cultural references (food), Indian subcontinent travel, shared cultural heritage, allowing an exploration of comparable themes or ‘narratives’ emerging through transcripts.

Positionality and Reflexivity

A post-positivist ontology, constructivist epistemology and qualitative methodology underpinned the research. A post-positivist paradigm (worldview) rejects the notion that human behaviour can be probed through methods of scientific inquiry. Thus, while an independent reality is to be examined, the truth can only be approximated and never objectively understood. On the other hand, the paradigm is derived from a positivist standpoint where no objective truth is acknowledged, while the reality is presumed to be independent of the researcher (Aliyu et al., 2015). This approach was selected because it assumes a stable existence through empirical methods. It complements qualitative research to unravel how specific themes and frames emerge in the data analysed by grouping and coding meanings against the broader contexts of participants. This also aligns with the constructivist epistemology. Constructivist epistemology is concerned with understanding the social, historical and cultural contexts. These contexts produce meaning and how participants construct aspects of their social reality.

For example, the constructs could include participants' exposures to gastrointestinal infections, their social and physical environments and how they perceive their exposure to infection as a salient construct of their social reality. At the same time, a qualitative approach will allow the researcher to delve deeply into the phenomenon under study and deconstruct it extensively. While a phenomenological approach could be used, the present approach seeks to understand the lived experience of participants and map the essence of these experiences in specific spatiotemporal contexts. This means the emphasis is not on how participants construct social realities or meanings, but on exploring and understanding the meanings people form of the (social) worlds in which they live. A constructivist approach, thus, aims to perceive social phenomena through the lens of the participants. That is, the perspective of those who perceived the social world (Neubauer et al., 2019). Finally, the constructivist epistemology supports the notion that participants reconstruct truth and reality through regular discourse, daily practices and contexts. This involves meanings relying upon participants' context and social milieu (Ward et al., 2015).

Reflexivity denotes a process of the researcher being vigilant about the implications of their methods because their actions determine how research shapes up, since the researcher is the primary instrument of data analysis and requires detaching some of their perceptions from the data collection. Thus, researchers as facilitators or 'initiators' can exert their epistemological and ontological perceptions, overlooking bias (Vogl et al., 2019). Ethical conduct in qualitative research warrants a reflexive response to participant circumstances. The researcher consciously creates knowledge in partnership with the respondent; the latter answers questions requiring them explicitly to consider issues in depth that they have not previously engaged in (Husband, 2020).

A key challenge in data analysis that the researcher envisions is impinging their understanding on the participants; therefore, the researcher must acknowledge their own epistemology and assumptions made. This is because I am of Pakistani origin and possesses insights into the languages, cultures, behaviours and practices adopted by most British Pakistanis. Having said this, I circumvented bias by engaging in bracketing, which is when the researcher intends to remain detached throughout the research process from the participants to increase the scientific rigour of the study. Thus, for example, I consciously avoided incorporating my personal experiences of the phenomenon under study.

The tenets of bracketing entail mental preparation in which the researcher identifies and redefines their methodological standpoint. Furthermore, I initially grasped the scope of the literature and engaged with this less critically, helping to contextualise the findings in the broader research domain (Ataro, 2020). Finally, I was acutely aware of the importance of ethics and undertook training in qualitative methods. These supplemented understandings of reflexivity, positionality and conducting qualitative research with public members. For instance, it is imperative to avoid homogenising the Pakistani ethnic group as a single category. This would prevent participants' experiences from being generalisable to the Pakistani community. Instead, it is helpful to consider multiple, unevenly stable Pakistani ethnic groupings where people's experiences and perspectives are shaped by their gender, class, sexuality, linguistic backgrounds, geographical location, family and migration histories.

I started with a post-positivist standpoint – the truth can only be approximated and never truly gauged. Research, however, can never be value-free; the values of both the researcher and participants and these values stem from socio-cultural worlds, beliefs and behaviours. I utilised this approach in previous research projects, and it did not require additional thought. However, there is no one-size-fits-all approach, and the epistemology had to be rooted in the research question and aligned with the methodology. I have also used a socio-constructivist approach (Kuhn, 1962; Berger and Luckman, 1966) in previous research projects. These approaches reflect my worldview and align with my educational background, and I can thus justify why these have been chosen. Correspondingly, it was imperative to maintain openness for understanding during the interview so that the interviewer does not seek to conform to existing beliefs and avoids a priori assumptions of the participants and their experiences. As a novice qualitative researcher, I therefore undertook qualitative research training and developed critical thinking skills to understand how people view reality (ontology), create knowledge (epistemology) and how we can acquire these insights (methodology).

 ‘Us vs. Them’: The Duality of the Insider/Outsider

As an ‘outsider’, I was a PhD student informed by the aetiological causes of gastrointestinal infections and illnesses and aware of the epidemiology, abreast of the literature on the socioeconomic consequences of these infections in the UK. Many of the participants were also not aware of the actual gastrointestinal pathogen they were affected by. This meant there was a sense of unravelling the ‘patterns of illness’ different ethnic groups exhibit, i.e. some may seek healthcare later than others or have distinct exposures (like travel abroad or food eating habits). Consequently, whilst the research was seeking objectivity; the idea that a truth exists “out there” independently which is value-free, it led towards assuming a post-positivist epistemology that the truth can only partially be approximated and never fully acquired.

Simultaneously, I was an ‘insider’ who is British Pakistani, but fully educated in the UK, whose first language is Urdu; this also meant I was oblivious to the experiences of migrants, refugees and sexual minorities who were participants I happened to recruit. I could borrow insights from the literature and ensure my sample fully represented my socio-cultural background. However, this would not be a true approximation of the truth I set out to discover initially. That gastrointestinal infections occur across social and ethnic groups was a truth. Still, most of my knowledge and experiences were grounded in theory, having no working experience of learning ‘on the go’ but rather absorbing ‘textbook theoretical knowledge’ transmitted in educational settings.

 I struggled to detach my understanding of participants given I was an insider and their experiences felt relatable to me. For example, my mother forcibly feeding me Calpol as a child when I was ill. Such insights help me identify the participants' raw human emotions, particularly the mothers. The experience of managing a stomach bug (the topic itself) is ubiquitous; everyone will have experienced this directly or indirectly. Hence, my positionality evolved from my experiences (how I ‘position’ knowledge first-hand and my research objectives) to how my participants perceived me as an insider-outsider.

Research ostensibly privileges researchers over participants (Ronzi et al., 2023). I have lived experiences of discrimination related to racism, misogyny, low income and living in a deprived area and fell within some participants’ age range. Yet, the duality of insider/outsider was diluted since I  was actively conscious of and held both positions simultaneously, and navigating this was not straightforward. As an apparent ‘insider’, I do position myself as someone who is acquainted with cultures and beliefs many ethnic minorities may possess, but I’m not someone entirely representative of them. I’m a female, born, raised and educated in England. I am Pakistani by ethnicity and raised by women with no paternal influences. This helps explain why the women were easier to engage with for me, whether Indian or Bangladeshi or even of my ethnicity – Pakistani. They were approachable, and I referred to them as Aunty throughout, even during recruitment and in the interview (across transcripts). This indicated the relationship's familiarity and openness, placing both interviewee and interviewer at ease. On the other hand, the anxiousness was palpable with male participants as I spoke to the opposite gender. The cultural respect and familiarity were nowhere near sight because I wanted to get over the interviews ASAP. Therefore, the conversations did not seem as engaging as I could not elicit that familiarity and establish openness in the first place. There was less humour, which indicates engagement and leads to more talk.

These understandings resonated with the white female transcriber who transcribed interviews verbatim in English language and noted that the men mumbled their way through the interviews, not because they were African or Asian who did not wish to delve into detail and were largely impatient. Instead, she suggested, they may have conversed more openly if I had interviewed them face-to-face, that they may have been multitasking while being interviewed, as the constant background chatter and occasional prompting from others inferred. So, while virtual interviews increased convenience and access, reducing research costs, they could have impeded a naturally occurring conversation with a specific goal (to discuss exposure to gastrointestinal infections) and impacted building trust (Winsper et al., 2023).

Another contrasting, gendered dynamic was that the men found the monetary aspect lucrative and perhaps rightly so as an incentive for their time – they constantly asked me about when the voucher would reach them via email and, ironically, there ended up being more email exchange about the voucher than interview exchange. Conversely, the women did not care to be reimbursed for their time – it was simply a goodwill gesture from their end as they witnessed me frantically trying to recruit as many women who did not seem to be particularly interested since I am still an outsider at the end of the day, irrespective of my positionality as someone from an ethnic minority background and therefore, in some respects, ‘one of them’.

It also seemed to me that this was a logical response from these women – we don’t bug someone randomly on the train; if we do, they move away, ignore us or worse; give us an evil bombastic side-eye. It’s the same with positionality influencing recruitment and data generation where there must be a degree of familiarity to allow openness and engender meaningful data relevant to the research question, avoiding cold feet and putting aside personal preferences to treat the interviewee solely as a co-creator of knowledge. They are an objective source of knowledge, irrespective of their gender, age and cultural background. I failed to overcome this (viewing the male participants as sole participants and not random men) due to my own positionality and preferences. For instance, I’d rather speak to a female nurse than have a male doctor inspect me. Participants are ultimately strangers at the end of the day, bearing no uncanny resemblance to the researcher, even if they’re of the same gender and ethnicity. Perhaps the participants of this study may have opened up more to a researcher who was White British and male and who could have probed the participants further to speak in detail about specific incidents relevant to the research question and foster more meaningful data. So, it is not just important who is doing the research, but how the researcher conducts their research.

An Original Contribution to Knowledge

Ethnic inequalities in health are a salient public health issue exacerbated by the COVID-19 pandemic (Nazroo et al., 2020). These inequalities have reinforced an increased risk of infection, poor health outcomes and severe disease for ethnic minority groups and have exposed limitations in previous efforts to collect ethnicity data systematically. For example, name-recognition software can predict the ethnicity of certain ethnic groups and has been used for the same. However, neither name recognition to assign individuals to ethnicity, nor the ethnic distribution of residence areas effectively determines ethnicities for all ethnic groups (Iqbal et al., 2012).

Ethnic differences in the incidence or prevalence of gastrointestinal infections have been less emphasised when compared to literature detailing socioeconomic status effects on gastrointestinal infections. Studies on inequalities in gastrointestinal infections by socioeconomic status have investigated disease burden in different socioeconomic groups, despite the limited evidence on the relationship between socioeconomic status and gastrointestinal infections (Adams et al., 2017). Studies on gastrointestinal infections and ethnicity have used mainly two ethnic categorisations – white and non-white – that fail to capture differences within and across different ethnic groups and risk bias (Bhopal, 2004). These categories promote obsolete majority/minority discourse when using specific binary frameworks like white and non-white.[1]

So, efforts to establish the actual burden of ethnic inequalities in health are obscured by a lack of government efforts, incomplete data on ethnicity and confounding factors. Moreover, the challenges of investigating such factors are challenged by the differences in presenting cases, their reporting, identification, diagnosis and investigation, so the actual differences in risk require consideration in addition to the artefactual discrepancies (Bessell et al., 2010). Even where the non-white category is fragmented, broad terms can still be used that do not capture significant differences in culture and heritage. An example would be that using 'Asian' as a stand-alone grouping does not account for differences within different sub-categories, circumventing the representativeness of all ethnic minority groups equally and failing to reflect heterogeneity within and across ethnic groups.

My significant original contribution to knowledge has explored gastrointestinal infections through the lens of ethnicity, which has yet to be explored in this group of infections in the UK. The preliminary findings from this study corroborate existing literature that there are more similarities than divergences in participant experiences of gastrointestinal infections across ethnic groups, such as the burden of care disproportionately affecting women (McGaroll et al., 2020). Nevertheless, we do not know if the impact of these experiences within and across ethnic groups is entirely representative of the broader ethnic categories that they belong to – such as Asian vs Indian, Pakistani and Bangladeshi – or if there are inequalities in their impact on ethnic minorities living in different circumstances – such as UK national vs migrant vs refugee.

Likewise, the sample may not wholly represent UK ethnic minorities' experiences of gastrointestinal infections as this sample comprised a small sample of certain ethnic groups, elucidating that the differences explored cannot be inferred across all ethnic categories. An ethnography may have been better utilised than interviews since interviews were predominantly conducted online and negated non-verbal communication, which could have captured insights into what participants feel and do. The interviews were also difficult to transcribe due to multiple accents being heard from across the UK. Ethnography could be explored with this topic in future by ‘observing’ how effective the separation of meat and vegetables is, the preparation of a specific meal, or how much time participants spend washing their hands before eating.  Conversely, it is conducive for researchers to plan the times, resources and funding required to engage in inclusive and diverse recruitment. This could save time in hindsight and expedite engagement with more ethnic minority groups (Morris et al., 2022).

Footnotes

[1] The national Sure Start evaluation used a three-way split which was similarly unhelpful in distinguishing between differing minorities: Black, White and Asian.

References

Adams N.L., Byrne L., Rose T.C., Adak G.K., Jenkins C., Charlett A. et al. (2019) ‘Influence of socio-economic status on Shiga toxin-producing Escherichia coli (STEC) infection incidence, risk factors and clinical features.’, Epidemiol Infect. : 147.

Adams, N.L., Rose, T.C., Barr, B. et al. (2017). ‘Socioeconomic status is associated with symptom severity and sickness absence in people with infectious intestinal disease in the UK.’  Journal of Infection. Vol 17 (1): 1-9.

Aliyu A.A., Singhry I.M., Adamu H., Abubakar M.M. (2015)  ‘Ontology, Epistemology and Axiology in Quantitative and Qualitative Research: Elucidation of the Research Philosophical Misconception’. Proc Acad Conf Mediterr Publ Res Int New Dir Uncommon [Internet]. Vol. 2 No 1: 1–26. Available from: https://www.researchgate.net/publication/318721927

Ataro G. (2020) ‘Methods, methodological challenges and lesson learned from phenomenological study about OSCE experience: Overview of paradigm-driven qualitative approach in medical education’, Ann Med Surg [Internet]. 49(August 2019):19–23. Available from: https://doi.org/10.1016/j.amsu.2019.11.013

Badu E., O'Brien A.P. and Mitchell R. (2019) ‘An integrative review on methodological considerations in mental health research - Design, sampling, data collection procedure and quality assurance.’, Arch Public Heal. 77(1):1–15.

Berger, P. L., Luckmann, T., & Luckmann, T. (1966). The social construction of reality: a treatise in the sociology of knowledge. [1st ed.] Harmondsworth: Penguin.

Bessell P.R., Matthews L., Smith-Palmer A., Rotariu O., Strachan N.J.C., Forbes K.J., et al. (2010) ‘Geographic determinants of reported human Campylobacter infections in Scotland.’ BMC Public Health: 10.

Bhopal, R. (2004) ‘Glossary of terms relating to ethnicity and race: for reflection and debate.’, J Epidemiol Community Health, 58(6):441–5.

Braddick M.R. and Sharp J.C.M. (1993) ‘Enteric fever in Scotland 1975-1990’. Public Health. 107(3):193–8.

Braun V., and Clarke V. (2019) ‘Reflecting on reflexive thematic analysis. Qualitative Research in Sport’, Exercise and Health. 

Brown L.M. (2020) Helicobacter pylori: Epidemiology and routes of transmission. Epidemiol Rev. 22(2):283–97. 

Byrne D. (2021) ‘A worked example of Braun and Clarke's approach to reflexive thematic analysis.’ Qual Quant. 120. 

Castleberry A. and Nolen A. (2018) ‘Thematic analysis of qualitative research data: Is it as easy as it sounds?’ Currents in Pharmacy Teaching and Learning. 

Charlett A., Cowden J.M., Frost J.A., Gillespie I.A., Millward J.., Neal R. et al. (2003) ‘Ethnicity and Campylobacter infection: A population-based questionnaire survey.’ J Infect. 47(3):210–6.

De Lusignan S., Sherlock J., Ferreira F., O'Brien S. and Joy M. (2020) ‘Household presentation of acute gastroenteritis in a primary care sentinel network’, Retrospective database studies’, BMC Public Health, 20(1):1–12.

DeJonckheere M., Vaughn L.M.(2019) ‘Semistructured interviewing in primary care research: A balance of relationship and rigour.’, Fam Med Community Heal. 7(2):1–8.

Diderichsen, F., Evans, T. and Whitehead M. (2001) ‘The Social Basis of Disparities in Health.’ In: Evans, T., Whitehead, M., Diderichsen, F., Bhuiya, A. and Wirth, M. (eds). Challenging Inequities in Health: From Ethics to Action. [Online] Available at: https://oxford.universitypressscholarship.com/view/10.1093/acprof:oso/9780195137408.001.0001/acprof-9780195137408-chapter-2 [Accessed 17 January 2022]

Gillespie I.A., O'Brien S.J., Penman C., Tompkins D., Cowden J., and Humphrey T.J. (2008) ‘Demographic determinants for Campylobacter infecti.on in England and Wales: Implications for future epidemiological studies.’ Epidemiol Infect. 136(12):1717–25. http://www.hprugi.nihr.ac.uk/about-us/

Husband, G. (2020) ‘Ethical data collection and recognising the impact of semi-structured interviews on research respondents.’ Educ Sci. 10(8):1–12.

Iacobucci G. (2021) ‘Covid-19: New UK variant may be linked to increased death rate, early data indicate.’, BMJ. 372:1–2.

Iqbal G., Johnson M.R.D., Szczepura A., Wilson S., Gumber A. and Dunn J.A. (2012) ‘UK ethnicity data collection for healthcare statistics: The South Asian perspective.’ BMC Public Health [Internet]. 12(1):243. Available from: http://www.biomedcentral.com/1471-2458/12/243

Ispahani P., and Slack R.C.B..(2000) ‘Enteric fever and other extraintestinal salmonellosis in University Hospital, Nottingham, UK, between 1980 and 1997’, Eur J Clin Microbiol Infect Dis. 9(9):679–87.

Katikireddi S.V., Lal S., Carrol E.D. et al. (2021). ‘Unequal impact of the COVID-19 crisis on minority ethnic groups: A framework for understanding and addressing inequalities’, J Epidemiol Community Health. 1–5.

Kirchherr J. and Charles K. (2018) ‘Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia.’, PLoS One. 13(8):1–17. 

Kuhn, T. S. (1962) The structure of scientific revolutions. Chicago: University of Chicago Press.

Le A., Miller K. and McMullin J. (2017) ‘From particularities to context: Refining our thinking on illness narratives.’, AMA Journal of Ethics.

Majeed F.A., Stuart J.M., Cartwright K.A.V. et al.  (1992). ‘An outbreak of hepatitis A in Gloucester, UK.’ Epidemiol Infect. 109(1):167–73.

McGarrol S., Kaley A., Eastham R., Whitehead M. and Limmer M. (2021) ‘Disgusting disruptions: Capturing the everyday experience and burden of managing gastrointestinal infections in the home.’, Health Soc Care Community. Jan;29(1): 284-293. doi: 10.1111/hsc.13091. Epub 2020 Jul 13. PMID: 32656872.

Morris, L., Dumville, J., Treweek, S. et al. (2022). ‘Evaluating a tool to improve engagement and recruitment of under-served groups in trials.’ Trials 23, 867. https://doi.org/10.1186/s13063-022-06747-2

Morris-Cunnington M.C., Edmunds W.J., Miller E. and Brown D.W.G. (2004) ‘A population-based seroprevalence study of hepatitis A virus using oral fluid in England and Wales.’, Am J Epidemiol. 159(8):786–94.

Nazroo J. and Becares L. (2020) ‘Evidence for ethnic inequalities in mortality related to COVID-19 infections: Findings from an ecological analysis of England.’, BMJ Open. 10(12).

Neubauer B.E., Witkop C.T. and Varpio L. (2019) ‘How phenomenology can help us learn from the experiences of others.’, Perspect Med Educ.

Ngozwana N. (2018) ‘Ethical Dilemmas in Qualitative Research Methodology: Researcher's Reflections.’, Int J Educ Methodol. 4(1):19–28.’

Olowokure B., Hawker J., Weinberg J. et al. (1999). ‘Deprivation and hospital admission for infectious intestinal diseases.’, Lancet.

Rao G.G., Batura D., Batura N. and Nielsen P.B. (2015) Key demographic characteristics of patients with bacteriuria due to extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in a multiethnic community, in North West London.’, Infect Dis (Auckl). 47(10):719–24.

Razai M.S., Kankam H.K.N., Majeed A. et al. (2021). ‘Mitigating ethnic disparities in covid-19 and beyond.’, BMJ, 372:1–5.

Rose T.C., Adams N.L., Whitehead M., et al. (2020). ‘Neighbourhood unemployment and other socio-demographic predictors of emergency hospitalisation for infectious intestinal disease in England: A longitudinal ecological study: Predictors of infectious intestinal disease hospitalisation.’, J Infect. 81(5):736–42. 

Rotherham, S. (2019) Inequalities in gastrointestinal infections in families with young children: an ethnographic approach. 2019. [Thesis]

Ronzi,S., Gravenhorst, K., Rinaldi, C., Villarroel-Williams,N. Ejegi-Memeh, S. et al. (2023) ‘Intersectionality and public understandings of health inequity in England: learning from the views and experiences of young adults.’, Elsevier Public Health. https://doi.org/10.1016/j.puhe.2023.07.002

Sethi D., Cumberland P., Hudson M.J. et al. (2001).’ A study of infectious intestinal disease in England: Risk factors associated with group A rotavirus in children.’, Epidemiol Infect. 126(1):63–70. 

Stone A.M., Patel H., Panja K.K., et al. (1998). ‘Results of Helicobacter pylori screening and eradication in a multi-ethnic community in central England.’ Eur J Gastroenterol Hepatol. 10(11): 957–6.

Tam C.C. and O’Brien S.J. (2016) ‘Economic cost of campylobacter, norovirus and rotavirus disease in the United Kingdom.’ PLoS One. 11(2):1–12. 

Tam C.C., Rodrigues L.C., Viviani L. et al. (2012). ‘Longitudinal study of infectious intestinal disease in the UK (IID2 study): Incidence in the community and presenting to general practice.’ Gut 61(1):69–77. 

Vogl S., Schmidt E.M. and  Zartler U. (2019) ‘Triangulating perspectives: ontology and epistemology in the analysis of qualitative multiple perspective interviews.’, Int J Soc Res Methodol [Internet]. 22(6):611–24. Available from: https://doi.org/10.1080/13645579.2019.1630901

Ward K., Hoare K.J. and Gott M. (2015) ‘Evolving from a positivist to constructionist epistemology while using grounded theory: Reflections of a novice researcher.’ J Res Nurs. 20(6):449–62.

White A.M., Castle I.J.P., Hingson R.W. and Powell P.A.. (2020) ‘Using Death Certificates to Explore Changes in Alcohol-Related Mortality in the United States, 1999 to 2017.’, Alcohol Clin Exp Res. 44(1):178–87.

Winsper, C., Bhattacharya, R., Bhuli, K. et al. (2023). ‘Improving mental healthcare access and experience for people from minority ethnic groups: an England-wide multisite experience-based codesign (EBCD) study.’, BMJ Mental Health, 26. e300709. ISSN 2755-9734

Zaharias G. (2018) ‘What is narrative-based medicine?: Narrative-Based medicine 1.’, Canadian Family Physician.

Author Biography

Iram Zahair is a third year PhD Researcher at the Health Protection Research Unit in Gastrointestinal Infections (HPRUGI) at the University of Liverpool. Iram’s research background is situated in sociology and public health studies, and her PhD project explores UK ethnic inequalities in gastrointestinal infections using mixed methods.

Ethics and Funding Statement

Ethical approval for this research was given by the University of Liverpool. This study was funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Gastrointestinal Infections, a partnership between Public Health England, the Universities of Liverpool and Warwick. The views expressed are those of the author(s) and not necessarily of the NIHR.

How to cite this paper: Zahair, I. (2024). The Incidence of Stomach Bugs Across Differing Minorities. ‘Race’ and Socially Engaged Research Working Paper 2023: Contributions from inaugural conference held in York. Volume 1, pp. 48-65, https://sites.google.com/view/raceandsociallyengagedresearch/publications/working-paper/2024-volume-1