COVID-19, vaccines and immigrants

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    We need more knowledge about migrant health as well as a high level of professional reflection to prevent the stigmatisation of particularly vulnerable groups.

    Those of us who work with migrant health often say that migrant background is an independent health determinant (1). The association between migrant background and health differs in the various migrant groups. Consequently, the effects of specific measures to improve health services for these groups must be evaluated before implementation. For several years, researchers have been calling for systematic data on migrant background to be accessible in health registers. The Norwegian authorities have been opposed to this because of legal objections based on the fear of misuse of such data and the stigmatisation of certain groups.

    During the coronavirus pandemic, it was journalists who first warned of an over-representation of immigrants, particularly from Somalia, among those testing positive for COVID-19 (2). Thereafter, the health authorities also acknowledged the need for official, reliable data. In due course, the Norwegian Institute of Public Health published regular coronavirus statistics on immigrants in Norway (3). Thanks to this information, the authorities decided to ally themselves with immigrant groups and initiate targeted measures to solve some of the specific challenges facing these groups. Official data on health among immigrants was helpful during the coronavirus crisis.

    It is not because being born in a particular country or having specific genes means that you do not want to get vaccinated

    Now that data are finally accessible, researchers are quickly beginning to use it in their research, and the results must be interpreted. Although this is always important, in this case it is crucial for preventing misuse of the results to support a political stance or as a consequence of other interests that may harm immigrants themselves. The association between the coronavirus pandemic and the health of the individual immigrant is not easy to understand or explain.

    The significance of socioeconomic factors such as family and housing situation, education and income, differs according to the degree of integration, language skills, digital expertise, trust in the system or the degree of contact with people from other countries (4).

    However, it not just individual factors that explain the association. Healthcare services in Norway are not always distributed equitably, and this may have changed for the worse during the pandemic. The use of interpreters, for example, was already low and seems to have declined considerably during the pandemic (5). Researchers are attempting, therefore, to use register data to understand the degree to which different variables explain immigrant outcomes. We have now learned, for example, that socioeconomic factors explain around half of the variation in the number of deaths among immigrants (6). This is something we can and should do something about!

    The study by Kraft et al. on vaccine coverage in relation to immigrant background and variation according to socioeconomic and demographic characteristics now published in the Journal of the Norwegian Medical Association is a good example of such use of register data (7). The study shows that immigrants have lower vaccine coverage and that there are wide variations among immigrants according to their country of origin. It also shows the importance of socioeconomic factors in explaining some of the differences.

    In their conclusion, Kraft et al. state that there is an association between COVID-19 infection or vaccination coverage and having an immigrant background. What does this mean? Unfortunately, we have seen in previous studies that the association is perfunctorily explained as 'culture' – with no elaboration of what is meant. Meanwhile, the concept of 'cultural stance' is often presented in a static manner, which fails to reflect current knowledge and does not allow for potential improvement.

    Many studies show how immigrants' experiences in their new country can impact on their health. Contact with Norwegian society over time, not least in times of crises such as the coronavirus pandemic, can alter their stance and their view of vaccines as well as their trust in the (health) authorities (8). Therefore we should reflect on the meaning of the variable, 'country background'; a variable we will be seeing frequently in research articles. It is not because being born in a particular country or having specific genes means that you do not want to get vaccinated. On the contrary, it is because of what you experienced in your country of origin and the culture in which you grew up. After a few years in Norway, however, you can potentially change and at the same time influence the majority culture – what we refer to as being integrated into society.

    In other words, immigrant background is a dynamic proxy for something more complex that we do not yet know enough about. More knowledge and reflection are now vital. The goal is better health for everyone, including immigrant groups.

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