The coronavirus disease (COVID-19) pandemic has demanded a lot from public health authorities in terms of pharmaceutical and non-pharmaceutical interventions to prevent severe disease, hospitalization, and death. While these interventions have proven immensely useful in keeping the general public aware of the consequences and adverse effects of not adhering to existing protocols, the immigrant communities in different countries have not benefited significantly.

Study: Uptake of Covid-19 preventive measures among 10 immigrant ethnic groups in Norway. Image Credit: Maridav/Shutterstock

Research conducted across Scandinavian countries has shown stark differences due to pre-existing social and health disparities among immigrants and non-immigrants who have been diagnosed, hospitalized, and died from COVID-19. The available data point towards the deleterious effects of pervasive social determinants like inadequate living and working conditions, cultural and linguistic barriers, poor knowledge, and limited social networks limiting migrants' adequate health literacy and awareness. The evidence thus far highlights addressing underlying conditions of vulnerability linked with migrants' socio-economic situation as an effective measure to curb COVID-19 related adversities among migrants.

A Norwegian study found a notification and hospitalization rate of 251 and 21 per 100,000, respectively, for non-immigrants, compared to 567 and 61 per 100,000, for immigrants. This implies an increased risk of hospitalization among immigrants. The notification rate was highest among immigrants from Somalia (2057), Pakistan (1868), Iraq (1616), and Afghanistan (1391). However, there has not been any clear-cut qualitative reference on the impact of socio-economic and socio-cultural factors on immigrants' uptake on preventive measures of COVID-19 in Norway.

Norwegian public health researchers published a study in the preprint server medRxiv* addressing this gap and attempting to understand the exact factors that make immigrants more vulnerable to COVID-19 related fatalities.

About the study

Researchers from the Norwegian Institute of Public Health (NIPH) and the research consultancy firm Opinion recruited the participants using purposive and snowballing methods. A highly diverse group of immigrant individuals were selected to ensure an unbiased study. The participants were selected based on occupation, education, age, and length of residency in Norway. A total of 88 participants from 10 different ethnic groups from Somalia, Iraq, Pakistan, Afghanistan, Poland, Sri Lanka, Turkey, Bosnia/Serbia, Eritrea, and Syria were selected for this study.

Of the 88 participants, 49 were females, and 39 were males, with their ages varying from 19 to 78 years old. Although most participants lived in Norway for 15 years, some had immigrated recently, while others were born in Norway. Of those who reported their education level, 30 had a university education, whereas others had a secondary school or lower. 

Participants were asked questions about the overrepresentation of immigrants in people infected by the coronavirus and those hospitalized due to COVID-19. All participants were consistent in highlighting one crucial point to the researchers: overcrowded households, front-line jobs, lack of proper education, differences in language, religious barriers, and economic burdens were the major contributors to higher infection rates among their communities.

Most immigrant families lived in borderline or extreme poverty, forcing them to live in smaller, constricted spaces making them more vulnerable to infection due to lack of social distancing. Quarantining and caring simultaneously for infected family members was also difficult, given that this scenario might have contributed to increased hospitalization and death rates. Frequently visiting relatives and family friends only added to the disease burden.

Front-line workers who formed a majority of the immigrant communities were exposed to cases first-hand that predisposed them to infection and hospitalization. Lower incomes further constrained their means to get proper treatment for the disease. Poor health literacy, lack of education, and inadequate knowledge among peers were major contributors to increased disease burdens. While some thought the virus was not contagious, others believed that the virus only affected people from a specific religion or faith – all stemming from inadequate knowledge and education.

Religious fatalism ideology, implying the belief that disease prevention is beyond human control, was also reported by some participants to play a critical role in the spread of the infection. Cultural boundaries that forced people to shake hands, hug or greet each other with some form of physical contact were stated by others.

Inadequate risk perception, lack of authoritarian rule, fear of stigma, and societal pressures were other factors reported by migrants. However, despite all these factors, it was evident that immigrant communities had become aware of their own lack of adherence that could have had even worse outcomes with time.

Implications

This study showed that despite the improved understanding of patients on the risks and health outcomes due to lack of adherence to COVID-19 protocols, there were two main determinants to higher infection rates among immigrants – socio-economic and socio-cultural.

The stark difference in numbers for COVID-19 related fatalities among immigrants only highlights the ever-existing gap that divides healthcare access for immigrants based on discrimination and stigma. Regardless of the ongoing pandemic, studies like these should be used as stepping stones to consider tailored policies and interventions that help equalize the social determinants of health among migrants and natives alike.

*Important notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.