Engaging the vulnerable: A rapid review of public health communication aimed at migrants during the COVID-19 pandemic in Europe

Addressing COVID-19 Vaccine Hesitancy and Uptake Among African Immigrants: Lessons from a Community-Based Outreach Program

In 2021, the African Cultural Alliance of North America (ACANA) implemented a community-based vaccine education and outreach program to decrease hesitancy and increase COVID-19 vaccine uptake among African immigrants in Philadelphia. The program had three components: (1) tailored messaging on the benefits of vaccines by trusted community health navigators in familiar languages/dialects, (2) use of educational/tabling events, and (3) establishment of a vaccine clinic in community settings. Using secondary data analysis, in-depth interviews, focus group discussions and a self-administered survey, we explored (i) the impact and effectiveness of the outreach program and extent of vaccine uptake, (ii) African immigrants' beliefs about the COVID-19 pandemic and the vaccine, and (iii) barriers and facilitators of vaccine knowledge, uptake, and hesitancy. Our analysis showed that ACANA's outreach program was effective in addressing several cultural, logistic, and systematic barriers to vaccine uptake. The program distributed 2000 educational/informational flyers, reached 3000 community members via social media campaigns, and an additional 2320 through other person-to-person outreach events. The program was effective and resulted in the vaccination of 1265 community members over the course of the outreach. The impact of this outreach underscores the critical role of community-based organizations in addressing COVID-19 vaccine hesitancy and increasing vaccine uptake in underserved and minority communities. The paper concludes with suggestions and recommendations for using community-based outreach programs to increase COVID-19 vaccine uptake and decrease hesitancy.

"It's no use saying it in English": A qualitative study exploring community leaders' perceptions of the challenges and opportunities with translating and interpreting COVID-19 related public health messaging to reach ethnic minorities in Australia

BACKGROUND

The Australian Government implemented a range of public health response strategies and communication approaches to reduce the spread of COVID-19; however, concerns have been raised around a failure to sufficiently consider culturally and linguistically diverse (CaLD) communities in these processes. This research aimed to understand the factors that have impacted COVID-19 communication and engagement efforts during the pandemic from the perspective of key CaLD community and faith-based leaders. A further aim was to understand the processes that could be adopted to support future communication strategies, including promoting pandemic-related vaccines.

APPROACH

This study included 29 key informant interviews with community and faith-based leaders in New South Wales, Australia.

RESULTS

The overwhelming message from community leaders was a sense of shared responsibility between their organisations and governments in communicating pertinent and accurate COVID-19 related information to CaLD communities. They expressed a sense of duty to keep their community members safe. However, community leaders and others shouldered significant costs related to resources and time that need to be acknowledged by governments in preparing for future disease outbreaks. They felt that governments should consider: 1) improving communication between governments and CaLD organisations; 2) responding to the specific CaLD needs with greater agility; 3) foregrounding social media in their communication strategy; 4) reinvesting in local public health units to know their population; 5) developing a health ambassadors model program; 6) preparing a hybrid model of translators/interpreters to fill the gap; and, 7) reimagining vaccine information campaigns to target CaLD communities better.

CONCLUSION

Given the technical details about the COVID-19 virus conveyed in government information campaigns and the media, ensuring the most vulnerable populations, including people from CaLD backgrounds, access clear, concise and timely public health messaging from governments and community organisations requires further attention.

The incidence of COVID-19-related hospitalisation in migrants in the UK: Findings from the Virus Watch prospective community cohort study

Background

Migrants in the United Kingdom (UK) may be at higher risk of SARS-CoV-2 exposure; however, little is known about their risk of COVID-19-related hospitalisation during waves 1-3 of the pandemic.

Methods

We analysed secondary care data linked to Virus Watch study data for adults and estimated COVID-19-related hospitalisation incidence rates by migration status. To estimate the total effect of migration status on COVID-19 hospitalisation rates, we ran mixed-effect Poisson regression for wave 1 (01/03/2020-31/08/2020; wildtype), and mixed-effect negative binomial regressions for waves 2 (01/09/2020-31/05/2021; Alpha) and 3 (01/06/2020-31/11/2021; Delta). Results of all models were then meta-analysed.

Results

Of 30,276 adults in the analyses, 26,492 (87.5 %) were UK-born and 3,784 (12.5 %) were migrants. COVID-19-related hospitalisation incidence rates for UK-born and migrant individuals across waves 1-3 were 2.7 [95 % CI 2.2-3.2], and 4.6 [3.1-6.7] per 1,000 person-years, respectively. Pooled incidence rate ratios across waves suggested increased rate of COVID-19-related hospitalisation in migrants compared to UK-born individuals in unadjusted 1.68 [1.08-2.60] and adjusted analyses 1.35 [0.71-2.60].

Conclusion

Our findings suggest migration populations in the UK have excess risk of COVID-19-related hospitalisations and underscore the need for more equitable interventions particularly aimed at COVID-19 vaccination uptake among migrants.

COVID-19 related morbidity and mortality in people experiencing homelessness in the Netherlands

INTRODUCTION

People who are homeless might be more at risk for getting infected by the SARS-COV-2 virus or for experiencing severe course of the infection due to their often more fragile health, unmet health needs, and poorer living conditions. This study aims to gain insight into the morbidity and mortality of the SARS-COV-2 virus among the homeless population in the Netherlands.

METHODS

In this observational retrospective study, anonymized data about patients experiencing homelessness who contacted a street doctor were gathered in nine cities in the Netherlands from March 2020 until March 2021. Data included patient characteristics, COVID-19 -related symptoms, diagnosis, and disease course of a SARS-COV-2 infection.

RESULTS

Of the total 1419 patients in whom 1544 COVID-19 related consults were registered, 16% tested positive for a SARS-COV-2 infection, and an additional 12% were clinically suspected of having a SARS-COV-2 infection but were seen before there were any COVID-19 tests available in General Practice or for some other reason not tested. Significantly more (p = <0.001) patients born outside the European Union tested positive for a SARS-COV-2 infection (36%) compared to the remainder of the population (20%). The most discerning symptom for being tested positive was loss of taste and smell (29% vs 6% in the negative tested group and 2% in the suspected group), fever (24% vs 13% in the negative tested group but 18% in the suspected group), and headache (26% vs 17% resp 14%), and fatigue (29% vs 20 resp 17%). Cough, dyspnea and common cold were more often seen in the clinically suspected but not tested group). Of the group that tested positive for a SARS-COV-2 infection, 10% were hospitalized. Two patients were admitted to intensive care and one patient died. Of patients who were clinically suspected of a SARS-COV-2 infection, 5% were hospitalized.

CONCLUSION

COVID-19 was not widespread among people experiencing homelessness in the Netherlands, but the number of hospitalizations in this study was relatively high. Monitoring this population during a pandemic is necessary to take prompt action when needed.

COVID-19 vaccination coverage for half a million non-EU migrants and refugees in England

Despite evidence suggesting that some migrants are at risk of under-immunization and have experienced severe health inequities during the pandemic, data are limited on migrants' COVID-19 vaccine coverage globally. Here we linked data from non-European Union migrants and resettled refugees to the national COVID-19 vaccination dataset in England. We estimated patterns in second and third dose delays and overdue doses between 12 December 2020 and 20 April 2022 by age, visa type and ethnicity. Of the 465,470 linked records, 91.8% (427,073/465,470) of migrants received a second dose and 51.3% (238,721/465,470) received a third. Refugees had the highest risk of delayed second (adjusted odds ratio 1.66; 95% confidence interval 1.55-1.79) and third dose (1.55; 1.43-1.69). Black migrants were twice as likely to have a second dose delayed (2.37; 2.23-2.54) than white migrants, but this trend reversed for the third dose. Older migrants (>65 years) were four times less likely to have received their second or third dose compared with the general population in England aged >65 or older. Policymakers, researchers and practitioners should work to understand and address personal and structural barriers to vaccination for diverse migrant populations.

Rapidly developing communications materials during public health emergencies: the Âu Cơ campaign in the USA

During public health emergencies, health communication materials to contain the outbreak are needed promptly, which prevents the use of standard approaches for getting feedback from the intended audience. We propose a strategy for rapidly obtaining community feedback on new health communication materials during the public health emergencies. We illustrate this with COVID-19 testing campaign in a Vietnamese-American enclave in the USA. The project included community-based COVID-19 testing and communication activities to increase the awareness of the testing centers and encourage frequent testing. Our strategy involves two main components: (i) use of a research team with an existing trust relationship with the community and that includes researchers from that community and (ii) co-design of communication materials using community-based gatekeepers and a cultural broker. We developed brochures and posters to increase the awareness of the COVID-19 testing services. The cultural broker and community-based partners identified salient message concepts and worked with the researchers to define the objectives and content of the materials, which were then reviewed by the entire team. In lieu of standard pretesting, we relied on feedback on mockups of the materials and subsequent revisions from the community-based gatekeepers and cultural broker. Our strategy strikes a balance between the need to urgently disseminate new materials and the need for community input. One key takeaway is that effective planning for public health emergencies must start long before the crisis occurs.

Measuring media-related health and mental health information acquisition among Latino adults in the United States

OBJECTIVES

We developed and evaluated new media-related health information acquisition measures for U.S.-based Latino populations.

METHODS

In 2021, a sample of U.S.-based Latino adults (N = 1574) self-completed a 20-min survey of health information acquisition measures across three language/cultural dimensions: Spanish media, Latino-tailored media in English, and general media in English. Socio-demographics were also ascertained. Means and standard deviations for the health acquisition measures were adjusted for age and sex and reported across nativity status.

RESULTS

The sample was diverse across age, gender, race, ethnicity, socioeconomic status, migration, and language competency. Internal consistency reliability of developed scales was excellent overall and within age, gender, race, ethnicity, and socioeconomic subgroups (Cronbach's alphas = 0.86-0.94). English media scales had higher means overall indicating higher prolonged quantity (i.e., dosage) than Spanish media scales. In contrast, standard deviations for Spanish media scales were higher overall indicating broader reach at lower doses than English media scales.

CONCLUSIONS

Findings suggest English-language media is popular among Latino populations overall. However, Spanish-language media retains broad reach through both passive and active exposure. Our findings demonstrate the value of including more nuanced measurement of health information acquisition such as the scales developed in this study to improve health promotion among Latino populations.

Co-designing a theory-informed, multicomponent intervention to increase vaccine uptake with Congolese migrants: A qualitative, community-based participatory research study (LISOLO MALAMU)

INTRODUCTION

Disparities in the uptake of routine and COVID-19 vaccinations have been observed in migrant populations, and attributed to issues of mistrust, access and low vaccine confidence. Participatory research approaches and behaviour change theory hold the potential for developing tailored vaccination interventions that address these complex barriers in partnership with communities and should be explored further.

METHODS

This study used a theory-informed, community-based participatory research approach to co-design a culturally tailored behaviour change intervention aimed at increasing COVID-19 vaccine uptake among Congolese migrants in London, United Kingdom (2021-2022). It was designed and led by a community-academic partnership in response to unmet needs in the Congolese community as the COVID-19 pandemic started. Barriers and facilitators to COVID-19 vaccination, information and communication preferences, and intervention suggestions were explored through qualitative in-depth interviews with Congolese migrants, thematically analysed, and mapped to the theoretical domains framework (TDF) and the capability, opportunity, motivation, behaviour model to identify target behaviours and strategies to include in interventions. Interventions were co-designed and tailored in workshops involving Congolese migrants.

RESULTS

Thirty-two Congolese adult migrants (24 (75%) women, mean 14.3 (SD: 7.5) years in the United Kingdom, mean age 52.6 (SD: 11.0) years) took part in in-depth interviews and 16 (same sample) took part in co-design workshops. Fourteen barriers and 10 facilitators to COVID-19 vaccination were identified; most barrier data related to four TDF domains (beliefs about consequences; emotion; social influences and environmental context and resources), and the behavioural diagnosis concluded interventions should target improving psychological capability, reflective and automatic motivations and social opportunities. Strategies included culturally tailored behaviour change techniques based on education, persuasion, modelling, enablement and environmental restructuring, which resulted in a co-designed intervention comprising community-led workshops, plays and posters. Findings and interventions were disseminated through a community celebration event.

CONCLUSIONS

Our study demonstrates how behavioural theory can be applied to co-designing tailored interventions with underserved migrant communities through a participatory research paradigm to address a range of health issues and inequalities. Future research should build on this empowering approach, with the goal of developing more sensitive vaccination services and interventions which respond to migrant communities' unique cultural needs and realities.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement (PPI) were embedded in the participatory study design and approach, with community members co-producing all stages of the study and co-authoring this paper. An independent PPI board (St George's Migrant Health Research Group Patient and Public Involvement Advisory Board) comprising five adult migrants with lived experience of accessing healthcare in the United Kingdom were also consulted at significant points over the course of the study.

Communication to promote and support physical distancing for COVID-19 prevention and control

BACKGROUND

This review is an update of a rapid review undertaken in 2020 to identify relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control. The rapid review was published when little was known about transmission, treatment or future vaccination, and when physical distancing measures (isolation, quarantine, contact tracing, crowd avoidance, work and school measures) were the cornerstone of public health responses globally. This updated review includes more recent evidence to extend what we know about effective pandemic public health communication. This includes considerations of changes needed over time to maintain responsiveness to pandemic transmission waves, the (in)equities and variable needs of groups within communities due to the pandemic, and highlights again the critical role of effective communication as integral to the public health response.

OBJECTIVES

To update the evidence on the question 'What are relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control?', our primary focus was communication approaches to promote and support acceptance, uptake and adherence to physical distancing.

SECONDARY OBJECTIVE

to explore and identify key elements of effective communication for physical distancing measures for different (diverse) populations and groups.

SEARCH METHODS

We searched MEDLINE, Embase and Cochrane Library databases from inception, with searches for this update including the period 1 January 2020 to 18 August 2021. Systematic review and study repositories and grey literature sources were searched in August 2021 and guidelines identified for the eCOVID19 Recommendations Map were screened (November 2021).

SELECTION CRITERIA

Guidelines or reviews focusing on communication (information, education, reminders, facilitating decision-making, skills acquisition, supporting behaviour change, support, involvement in decision-making) related to physical distancing measures for prevention and/or control of COVID-19 or selected other diseases (sudden acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza, Ebola virus disease (EVD) or tuberculosis (TB)) were included. New evidence was added to guidelines, reviews and primary studies included in the 2020 review.

DATA COLLECTION AND ANALYSIS

Methods were based on the original rapid review, using methods developed by McMaster University and informed by Cochrane rapid review guidance. Screening, data extraction, quality assessment and synthesis were conducted by one author and checked by a second author. Synthesis of results was conducted using modified framework analysis, with themes from the original review used as an initial framework.

MAIN RESULTS

This review update includes 68 studies, with 17 guidelines and 20 reviews added to the original 31 studies. Synthesis identified six major themes, which can be used to inform policy and decision-making related to planning and implementing communication about a public health emergency and measures to protect the community. Theme 1: Strengthening public trust and countering misinformation: essential foundations for effective public health communication Recognising the key role of public trust is essential. Working to build and maintain trust over time underpins the success of public health communications and, therefore, the effectiveness of public health prevention measures. Theme 2: Two-way communication: involving communities to improve the dissemination, accessibility and acceptability of information Two-way communication (engagement) with the public is needed over the course of a public health emergency: at first, recognition of a health threat (despite uncertainties), and regularly as public health measures are introduced or adjusted. Engagement needs to be embedded at all stages of the response and inform tailoring of communications and implementation of public health measures over time. Theme 3: Development of and preparation for public communication: target audience, equity and tailoring Communication and information must be tailored to reach all groups within populations, and explicitly consider existing inequities and the needs of disadvantaged groups, including those who are underserved, vulnerable, from diverse cultural or language groups, or who have lower educational attainment. Awareness that implementing public health measures may magnify existing or emerging inequities is also needed in response planning, enactment and adjustment over time. Theme 4: Public communication features: content, timing and duration, delivery Public communication needs to be based on clear, consistent, actionable and timely (up-to-date) information about preventive measures, including the benefits (whether for individual, social groupings or wider society), harms (likewise) and rationale for use, and include information about supports available to help follow recommended measures. Communication needs to occur through multiple channels and/or formats to build public trust and reach more of the community. Theme 5: Supporting behaviour change at individual and population levels Supporting implementation of public health measures with practical supports and services (e.g. essential supplies, financial support) is critical. Information about available supports must be widely disseminated and well understood. Supports and communication related to them require flexibility and tailoring to explicitly consider community needs, including those of vulnerable groups. Proactively monitoring and countering stigma related to preventive measures (e.g. quarantine) is also necessary to support adherence. Theme 6: Fostering and sustaining receptiveness and responsiveness to public health communication Efforts to foster and sustain public receptiveness and responsiveness to public health communication are needed throughout a public health emergency. Trust, acceptance and behaviours change over time, and communication needs to be adaptive and responsive to these changing needs. Ongoing community engagement efforts should inform communication and public health response measures.

AUTHORS' CONCLUSIONS

Implications for practice Evidence highlights the critical role of communication throughout a public health emergency. Like any intervention, communication can be done well or poorly, but the consequences of poor communication during a pandemic may mean the difference between life and death. The approaches to effective communication identified in this review can be used by policymakers and decision-makers, working closely with communication teams, to plan, implement and adjust public communications over the course of a public health emergency like the COVID-19 pandemic. Implications for research Despite massive growth in research during the COVID-19 period, gaps in the evidence persist and require high-quality, meaningful research. This includes investigating the experiences of people at heightened COVID-19 risk, and identifying barriers to implementing public communication and protective health measures particular to lower- and middle-income countries, and how to overcome these.

Social media users' perceptions about health mis- and disinformation on social media

This study used recently released nationally representative data with new measures on health information seeking to estimate the prevalence and predictors of adult social media users' perceptions of health mis- and disinformation on social media. Most adults who use social media perceive some (46%) or a lot (36%) of false or misleading health information on social media, but nearly one-fifth reported either none or a little (18%). More than two-thirds of participants reported that they were unable to assess social media information as true or false (67%). Our study identified certain population groups that might be a focus of future intervention work, such as participants who use social media to make decisions. The perception by social media users that false and misleading health information on social media is highly prevalent may lend greater urgency to mitigate the spread of false or misleading health information that harms public health.

Resources used and trusted regarding child health information by culturally and linguistically diverse communities in Australia: An online cross-sectional survey

BACKGROUND

Parents' play a proactive role in seeking health information to ensure optimal growth and development for their children. To date, very little is known about the differences between information seeking behaviour for child health and engagement with resources between culturally and linguistically diverse (CALD) and non-CALD parents.

OBJECTIVE

To investigate the differences in resources used and trusted for information related to child health behaviours and engagement with online features among CALD and non-CALD respondents in Australia.

METHODS

An analysis of a theory informed online cross-sectional survey was conducted using data from 122 CALD and 399 non-CALD parents who had a child younger than 24 months or were currently pregnant in Australia. Descriptive statistics and chi-squared were used to compare the differences, and logistic regression models were used to identify factors associated with using health resources.

RESULTS

The most trusted sources for information reported by respondents were health professionals (76.2 %), websites run by health professionals (59.5 %), and government websites (53.2 %). Social media was significantly more trusted as a source of information for child health behaviours among CALD respondents than non-CALD respondents (odds ratio (OR) 1.92, P = 0.01). In contrast, booklets/ pamphlets and friends were significantly more trusted by non-CALD parents than for CALD parents (OR 0.54, P = 0.02). General search engines were used very frequently among CALD respondents for child health information (39.3 % vs 24.1 %, p = 0.013). Overall, the most common features respondents enjoyed on websites were images (81 %), videos (40.1 %), and discussion forums (39.9 %). CALD respondents significantly favoured videos (p = 0.003) while non-CALD respondents preferred obtaining information through attachments (p < 0.001).

CONCLUSIONS

Despite parents' reporting health professionals, websites run by health professionals, and government websites as trustworthy, general search engines and social media were still the most frequently used information source for parents with young children. Credible resources parents deem as trustworthy should take into account effective and engaging means of disseminating information that are accessible to both CALD and non-CALD communities.

Risk communication and community engagement with vulnerable groups: Perceptions of social-services CSOs during Covid-19

Risk communication enables people to be prepared, respond and recover from public health risks which can only be realized with a considerable amount of community engagement. Enabling community involvement is necessary in order to reach and protect vulnerable people during epidemics. In situations of acute emergency, it is difficult to reach everyone, which makes it necessary to work with intermediaries such as social and care facilities and civil society organizations (CSOs) who work to support the most vulnerable in our societies. This paper analyses the perceptions of experts working in social facilities or CSOs of Covid-19 RCCE efforts in Austria. It starts from a broad understanding of vulnerability which combines medical, social and economic determinants. We conducted 21 semi-structured interviews with CSO and social facility managers. The UNICEF core community engagement standards (2020) were used as a framework for qualitative content analysis. The results show that CSO's and social facilities were essential for allowing community involvement of vulnerable people in Austria during the pandemic. For the CSO's and social facilities participation of their vulnerable clients was a real challenge especially because direct contact was difficult and public services were switched to digital only. Nonetheless, they all put a lot of effort into adapting and discussing Covid-19 regulations and measures with their clients and employees which in many cases led to acceptance of public health measures. The study gives recommendations on how community engagement could be enhanced especially from government actors and how CSO's could be addressed more as essential partners.

Association of sociodemographic characteristics with self-perceived access to COVID-19 information and adherence to preventive measures among migrant origin and general populations in Finland: a cross-sectional study

OBJECTIVES

This study examines how access to COVID-19 information and adherence to preventive measures varies by sociodemographic characteristics, and whether the associations differ among the migrant origin and the general Finnish population. Additionally, the association of perceived access to information with adherence to preventive measures is examined.

DESIGN

Cross-sectional, population-based random sample.

BACKGROUND

Equity in access to information is crucial for securing individual well-being and successful management of a crisis at population level.

SETTING

Persons who have a residence permit in Finland.

PARTICIPANTS

Migrant origin population constituted of persons aged 21-66 years born abroad, who took part in the Impact of the Coronavirus on the Wellbeing of the Foreign Born Population (MigCOVID) Survey conducted from October 2020 to February 2021 (n=3611). Participants in the FinHealth 2017 Follow-up Survey conducted within the same time frame, representing the general Finnish population, constituted the reference group (n=3490).

OUTCOME MEASURES

Self-perceived access to COVID-19 information, adherence to preventive measures.

RESULTS

Self-perceived access to information and adherence to preventive measures was overall high both among the migrant origin and the general population. Perceived adequate access to information was associated with living in Finland for 12 years or longer (OR 1.94, 95% CI 1.05-3.57) and excellent Finnish/Swedish language skills (OR 2.71, 95% CI 1.62-4.53) among the migrant origin population and with higher education (OR 3.56, 95% CI 1.49-8.55 for tertiary and OR 2.87, 95% CI 1.25-6.59 for secondary) among the general population. The association between examined sociodemographic characteristics with adherence to preventive measures varied by study group.

CONCLUSIONS

Findings on the association of perceived access to information with language proficiency in official languages highlight the need for rapid multilingual and simple language crisis communications. Findings also suggest that crisis communications and measures designed to influence health behaviours at population level may not be directly transferable if the aim is to influence health behaviours also among ethnically and culturally diverse populations.

Codesigning an intervention to strengthen COVID-19 vaccine uptake in Congolese migrants in the UK (LISOLO MALAMU): a participatory qualitative study protocol

INTRODUCTION

Migrants positively contribute to host societies yet experience barriers to health and vaccination services and systems and are considered to be an underimmunised group in many European countries. The COVID-19 pandemic has highlighted stark inequities in vaccine uptake, with migrants facing access and informational barriers and lower vaccine confidence. A key challenge, therefore, is developing tailored vaccination interventions, services and systems which account for and respond to the unique drivers of vaccine uptake in different migrant populations. Participatory research approaches, which meaningfully involve communities in co-constructing knowledge and solutions, have generated considerable interest in recent years for those tasked with designing and delivering public health interventions. How such approaches can be used to strengthen initiatives for COVID-19 and routine vaccination merits greater consideration.

METHODS AND ANALYSIS

LISOLO MALAMU ('Good Talk') is a community-based participatory research study which uses qualitative and coproduction methodologies to involve adult Congolese migrants in developing a tailored intervention to increase COVID-19 vaccine uptake. Led by a community-academic coalition, the study will involve (1) semistructured in-depth interviews with adult Congolese migrants (born in Democratic Republic of Congo, >18 years), (2) interviews with professional stakeholders and (3) codesign workshops with adult Congolese migrants. Qualitative data will be analysed collaboratively using reflexive thematic analysis, and behaviour change theory will be used in parallel to support the coproduction of interventions and make recommendations across socioecological levels. The study will run from approximately November 2021 to November 2022.

ETHICS AND DISSEMINATION

Ethics approval was granted by the St George's University Research Ethics Committee (REC reference: 2021.0128). Study findings will be disseminated to a range of local, national and international audiences, and a community celebration event will be held to show impact and recognise contributions. Recommendations for implementation and evaluation of prototyped interventions will be made.

Impact of COVID-19 on the Belgian HIV epidemic: slowdown of HIV transmission and testing and adaptation of care

BACKGROUND

To gain insight into the impact of the COVID-19 pandemic and containment measures on the HIV epidemic and services, this study aims to describe HIV trends in 2020 and compare them with previous years.

METHODS

Belgian national HIV surveillance data 2017-2020 were analysed for trends in HIV testing, HIV diagnoses, VL measurements, ART uptake and PrEP purchase. Descriptive statistics from 2020 are compared to annual averages from 2017 to 2019 (proportional difference, %).

RESULTS

In 2020, 725 HIV infections were diagnosed in Belgium (- 21.5% compared to 2019). The decline was most pronounced during the first lockdown in April-May but also present in July-December. The number of HIV tests performed decreased by 17.6% in 2020, particularly in March-May and October-December (- 57.5% in April and -25.4% in November 2020 compared to monthly 2017-19 numbers). Diagnosis of acute HIV infections decreased by 47.1% in 2020 (n = 27) compared to 2019 (n = 51). Late HIV diagnoses decreased by 24.7% (95% CI [- 40.7%; -9.7%]) in 2020 compared to 2019. Of patients in care in 2019, 11.8% interrupted HIV care in 2020 compared to 9.1% yearly in the 3 previous years. The number of HIV patients with VL monitoring per month dropped in March-May 2020, whilst proportions of VL suppression and ART coverage remained above 86% and 98.5% respectively in 2020. PrEP purchases, number of purchasers and starters dropped during April-May 2020 (respectively - 45.7%, - 47.4%, - 77.9% in April compared to February 2020).

CONCLUSIONS

The significant decrease in HIV diagnoses in Belgium in 2020 coincided with the COVID-19 pandemic and following containment measures, particularly in April-May during the first lockdown. A slowdown of HIV transmission due to reduced HIV risk exposure is suggested by the halving in diagnosis of acute HIV infections in March-December 2020 compared to the previous year, and the adaptive decrease in PrEP use and PrEP initiation from April onwards. Despite a slight increase in HIV care interruptions, the indicators of quality of HIV care remained stable. Access to prevention, testing and care for all people living with HIV and at risk of acquiring HIV is a priority during and after times of pandemic.

COVID-19 Information in Sweden: Opinions of Immigrants with Limited Proficiency in Swedish

COVID-19 has highlighted the importance of health information for prevention of communicable disease. Knowledge about groups that have high risk is important to prevent disease transmission. In Sweden, immigrants have been identified as one such group. Yet, little is known about where they have sourced information about COVID-19 and their opinions toward it. The aim of this study was to describe the COVID-19 information sources used by immigrants with limited proficiency in Swedish as well as their opinions on how comprehensive the information has been, the importance of the recommendations and their possibility to follow them. A cross-sectional survey was conducted via introductory Swedish language classes in Region Uppsala (n = 855). The results showed the immigrants were using different information sources, with the majority using school, media and social media. The immigrants' opinions about COVID-19 information differed. Most reported they knew where to find information; however, over two-fifths reported the recommendations from the authorities should be more extensive. The majority reported it is important to follow the recommendations, whereas the possibility to follow the recommendations was more mixed. Age differences in opinions toward COVID-19 information were detected. Although the results were largely positive, there still appears to be a need for improvement in how immigrant groups with limited ability in the host country´s language are reached. Effective health communication that engages the whole nation is an important factor authorities should commit to as we face the current pandemic. This research suggests that an approach tailored by age could be helpful.

Loneliness and quality of life: Perceived online and offline social support among Sub-Saharan African students in China during the COVID-19 lockdowns

<b>Objective/background: </b>The COVID-19 pandemic disrupted education globally, triggering fear and uncertainties for students. However, there is currently no research evidence to document the loneliness experience of Sub-Saharan African (SSA) students in China and how social support influenced their quality of life (QoL). This study explored the effect of COVID-19-induced loneliness and social support on the QoL of SSA students in China.<br /> <b>Method:</b> The study adopted an institutional-based cross-sectional survey through an online questionnaire on social media platforms to investigate the QoL of SSA students in Chinese universities. Pearson correlation matrix and regression analysis were conducted to validate the association of loneliness, social support (online and offline), and socio-demographic attributes on the student’s QoL.<br /> <b>Result: </b>In the population of 358 SSA students appraised in the study, loneliness experience was negatively associated with QoL. Online social support and offline social support were positively associated with QoL. The linear regression shows that loneliness, social support, and socio-demographic attributes explain 25.7% (psychological health), 26.6% (physical health), 24.9% (environmental health), and 30.3% (social relation) of the variance in the QoL domains. By evaluating the EUROHIS subjective QoL, loneliness independently accounts for 24.5% of the variance in the subjective QoL of the SSA students examined in the study (model 1). In comparison, the added effects of social supports and socio-demographic attributes on model 3 explained 32% of the subjective QoL.<br /> <b>Conclusion: </b>It is strongly recommended that loneliness eradication programs be implemented in these universities among SSA students who experience loneliness that negates their QoL. Interventions should focus on how these students can integrate and build social networks (online and offline) to improve social interaction and support for better QoL.

Risk Communication Distributed among Migrant Workers during the COVID-19 Crisis in Thailand: Analysis on Structural and Networking Gaps

Language and cultural barriers among migrant workers hamper access to health risk information. This study aims to explore health risk communication structure and processes and identify the communication network of migrant workers during the COVID-19 pandemic in Thailand. This study used a parallel mixed-methods design combined with in-depth interviews and questionnaires for social network analysis from November 2020 to June 2021 in the headquarter district of Samut Sakhon, Ranong, and Phuket provinces. We conducted purposive sampling of representatives from public and non-public organisations and local communities. Thirty-six key informants participated in in-depth interviews, and fifty-six respondents completed the questionnaire for social network analysis. Although health risk communication included various activities, there was no formal governing body responsible for health risk communication among migrants, and monitoring and evaluation of communication process were not well-implemented. The health risk communication network was centralised, especially in the rural area; however, migrant health volunteers (MHVs) and local media were key sources of information for most migrants in communities. Overall, a governing body led by the government with intersectional collaboration and a health risk communication process should be promoted while considering migrants’ characteristics and concerns. The health risk communication network should identify key communicators such as MHVs and local media. This can be an effective strategy to fill the gap of information dependency.

Access to Health-Related Information, Health Services, and Welfare Services among South and Southeast Asian Immigrants in Japan: A Qualitative Study

Migrants face several challenges in their daily lives in the host country due to limited knowledge about the language, culture, and social system of the host country. Their vulnerability increases in a time of crisis. During the COVID-19 pandemic, migrant communities were severely affected. Evidence on migrants' access to COVID-19-related information and services is limited. We conducted a qualitative, descriptive study among migrants from Vietnam, Myanmar, and Nepal living in Japan to explore the barriers and promoting factors for their access to health-related information, health services, and welfare services during the first wave of COVID-19. We used a thematic analysis to identify key themes according to the study's objectives. Further, these themes were assessed using an adapted version of the ecological model. The migrants mainly relied on the information available on social networking sites and were not aware of formal sources of information. Language was a major barrier, followed by cognitive bottlenecks and time constraints for migrants accessing health-related information and services. Social media, short-form information provided using their native language or plain Japanese and illustrations, and supportive people around could help them to access health-related information and services. The findings from this study demonstrate how migrants can represent a vulnerable group in a host country, even more so in a time of crisis.

Working With Refugees' Health During COVID-19—The Experience of Health- and Social Care Workers in Sweden

Introduction

In Sweden, often seen as one of the most egalitarian countries, the COVID-19 pandemic exposed high levels of health inequality, especially harming people with a refugee background. This is also despite Sweden's image as a refugee-friendly country. In this context, the aim of this paper is to better understand how Swedish health- and social workers have reacted to the health- and social needs of refugees during the pandemic. The Swedish case is particularly interesting because, as seen in the paper, health- and social workers had the task of communicating health guidance to refugees who were sometimes more reliant on information from abroad where the consensus on COVID-19 restrictions ran contrary to the approach recommended by the Swedish public health authority.

Method

The study utilizes a qualitative content analysis of 13 in-depth interviews with health- and social workers in Sweden, active in the care of refugees within different kinds of health- and social care settings.

Results

The analysis showed that healthcare services have remained open during the pandemic but with new precautions at reception areas impacting how refugees access healthcare. As discussed in the article, the shift to digital tools has particularly impacted refugees, worsening already existing barriers to healthcare services faced by those with refugee status. Public health recommendations were poorly designed to the needs of refugees whose living conditions often prevented them from self-isolation and social distancing. Furthermore, Sweden's initially non-restrictive approach to the pandemic instructed health- and social-workers to encourage refugees to take far fewer precautions (e.g., self-isolation, home-schooling, pregnant women to avoid virus hotspots) compared both with European neighbors and the international media typically used by refugees. When Sweden shifted toward a more restrictive approach, health- and social-workers had to revise their guidance in relation to the new recommendations around precautions.

Conclusion

Refugees have faced increased barriers to maintaining their health and wellbeing during the pandemic that exceed those experienced by the rest of the Swedish population. Refugees have, in general, taken precautions in regard to social distancing and followed recommendations but faced challenges with social distancing due to isolation and crowded living. Public health authorities have often failed to acknowledge that individuals use increasingly diverse sources of knowledge when trying to protect their health, and that not everyone has access to the knowledge needed to access healthcare and social systems. At the same time, there is a need to acknowledge that refugees are sometimes a source of expertise that was ignored by the Swedish health and social system during the pandemic. There is a need for urgent efforts to halt the worsening health conditions for this specific group, but also to counter knock-on societal effects and rising health inequity.

Readability, understandability and language accessibility of Swedish websites about the coronavirus disease 2019: a cross-sectional study

BACKGROUND

The COVID-19 pandemic has caused significant morbidity and mortality. To mitigate its spread, members in the general population were prompted to apply significant behavioral changes. This required an effective dissemination of understandable information accessible for people with a wide range of literacy backgrounds. The aim of this study was to investigate the readability, understandability and language accessibility of Swedish consumer-oriented websites containing information about COVID-19.

METHODS

Websites were identified through systematic searches in Google.se (n = 76), and were collected in May 2020 when the pandemic spread started in Sweden. Readability and understandability were assessed with the Readability Index, the Ensuring Quality Information for Patients (EQIP) tool, and the Patient Education Materials Assessment Tool Understandability subscale (PEMAT-PU).

RESULTS

The median total sample score for Readability Index was 42.0, with the majority of scores being classified as moderate (n = 30, 39%) or difficult (n = 43, 57%). Median total sample scores were for EQIP 54.0% (IQR = 17.0, Range = 8-75) and for PEMAT-PU 60.0% (IQR = 14.75, Range = 12-87). The majority of the websites did not have any texts or links containing information in an alternative language (n = 58, 76%).

CONCLUSIONS

Swedish websites contained information of difficult readability and understandability at the beginning of the coronavirus disease 2019 pandemic, with few providing information available in alternative languages. It is possible that these deficits contributed to the spread and impact of the virus. There is a need for studies investigating methods aiming to enhance the readability, understandability and language accessibility of web-based information at the beginning of an epidemic or pandemic.

How Does Migration Background Affect COVID-19 Vaccination Intentions? A Complex Relationship Between General Attitudes, Religiosity, Acculturation and Fears of Infection

Objectives

The aim of the study is to investigate the relationship between migration background and COVID-19 vaccine intentions, exploring multiple mediation paths. We argue that the migrational and sociocultural background influences general attitudes toward health and political/public institutions. The effects of these general attitudes on vaccination intentions are mediated by fears of infection. Additionally, we analyze a migrant-only model including acculturation variables (years since migration, foreign and host country media consumption) and region of origin (European vs. Non-European). Design: The data (n = 1027) stem from an online access panel collected between March 15 and March 25, 2021. Quotas for gender and age were set according the online population of Germany. The use of an oversampling framework for first generation migrants resulted in a sample with 50% first generation migrants and 50% native Germans without migration background. Models were calculated using a Structural Equation Modeling approach.

Results

Migration background both increases and decreases antecedents of vaccination intentions. Being a migrant increases positive antecedents like religiosity, which in turn positively influence general attitudes and thus fears of infection and vaccination intentions. But being a migrant has also a significant direct negative association with vaccination intentions, implying missing mediators. Increasing years since migration increase host country (German) media consumption and decrease consumption of media from the country of origin. Both media variables are positively associated with political trust and health consciousness. Additionally, European compared to Non-European migrants have less political trust, fear of personal infection and lower vaccination intentions on the whole.

Conclusions

The study found that vaccination intentions can be understood by applying the proposed hypothetical structure. We found complex associations of the migration and sociocultural background and COVID-19 vaccination intentions, where antecedents of vaccination intentions are both increased and decreased by migration background and migration specific factors.

Considering social inequalities in health in large-scale testing for COVID-19 in Montréal: a qualitative case study

BACKGROUND

Evidence continues to demonstrate that certain marginalised populations are disproportionately affected by COVID-19. While many studies document the impacts of COVID-19 on social inequalities in health, none has examined how public health responses to the pandemic have unfolded to address these inequities in Canada. The purpose of our study was to assess how social inequalities in health were considered in the design and planning of large-scale COVID-19 testing programs in Montréal (Québec, Canada).

METHODS

Part of the multicountry study HoSPiCOVID, this article reports on a qualitative case study of large-scale testing for COVID-19 in Montréal. We conducted semi-structured interviews with 19 stakeholders involved in planning large-scale testing or working with vulnerable populations during the pandemic. We developed interview guides and a codebook using existing literature on policy design and planning, and analysed data deductively and inductively using thematic analysis in NVivo.

RESULTS

Our findings suggest that large-scale COVID-19 testing in Montréal did not initially consider social inequalities in health in its design and planning phases. Considering the sense of urgency brought by the pandemic, participants noted the challenges linked to the uptake of an intersectoral approach and of a unified vision of social inequalities in health. However, adaptations were gradually made to large-scale testing to improve its accessibility, acceptability, and availability. Actors from the community sector, among others, played an important role in supporting the health sector to address the needs of specific subgroups of the population.

CONCLUSIONS

These findings contribute to the reflections on the lessons learned from COVID-19, highlighting that public health programs must tackle structural barriers to accessing healthcare services during health crises. This will be necessary to ensure that pandemic preparedness and response, including large-scale testing, do not further increase social inequalities in health.

Impacto de la Covid-19 sobre la población migrante residente en Argentina a la luz de las dificultades que obstaculizan su acceso a la salud

Resumen Este artículo persigue un doble propósito. En primer lugar, presentar los resultados de un trabajo exploratorio que indaga si las personas migrantes se vieron más afectadas que las nacionales por la Covid-19 en Argentina. Para ello, se evalúa el comportamiento de indicadores como el nivel de testeos, contagios y decesos por Covid-19 entre la población nativa y migrante, con base en datos inéditos solicitados a la Dirección Nacional de Epidemiología e Información Estratégica del Ministerio de Salud de la Nación, para el período de enero de 2020 y mayo de 2021. En segundo lugar, este artículo busca aproximar un análisis interpretativo de las posibles causas que pueden haber influido en la afectación diferencial encontrada sobre la población migrante. Con este fin, y bajo el supuesto de que la población migrante se encuentra en una situación de desventaja estructural, se trabaja con procesamientos propios de la Encuesta Nacional Migrante de Argentina 2020, así como con un vasto conjunto de estudios académicos complementarios, presentando de manera integral las dificultades directas e indirectas que enfrenta la población migrante para acceder al sistema de salud, un derecho reconocido en la norma incondicionalmente.

Healthcare and social needs of international migrants during the COVID-19 pandemic in Latin America: analysis of the Chilean case

International migrants are a particularly vulnerable group in the context of the coronavirus disease 2019 (COVID-19) pandemic. Immigrants in Chile tend to experience multidimensional poverty and layers of social vulnerability. Our analysis aims to describe the perceived social and health-related needs of international migrants during the COVID-19 pandemic in Chile in terms of migration as a social determinant of health and layered social vulnerability. We carried out a qualitative analysis of responses to an open-ended question focused on the social and health-related needs linked to the pandemic included in an online questionnaire disseminated during April 2020 aimed at international migrants residing in Chile. The information gathered was thematically analysed. We included 1690 participants. They expressed needs related to health and others linked to the overall socio-economic and political response, employment, material conditions and psychosocial aspects. They also reported needs related to ‘being a migrant’. Additionally, some participants described situations of vulnerability. We analysed their needs and situations of vulnerability identified around the following emerging frames: (a) work and living conditions, (b) regularisation traps and perceived lack of support and (c) and physical and mental health needs. International migrants in Chile report experiencing interrelated layers of social vulnerability during the COVID-19 pandemic, where ‘being a migrant’ exacerbates physical and mental health risks. The issues revealed are immediate and direct public health challenges, as well as different aspects of social vulnerability linked to migratory status, employment and barriers to accessing healthcare that should be addressed through comprehensive policies and measures.

A Case Study of Community-based, Cross-sectoral Crisis Response to the COVID-19 Pandemic: Serving Racialized Immigrant Communities

Crises-such as the COVID-19 pandemic-bring about myriad problems in magnitude (severity), dynamism (quality), and urgency (timing). Collaborative models that bring together actors from both the public and private sector have thus emerged for institutionalized and community-based crisis response. Such models aim particularly to reach vulnerable, hard-to-reach communities, such as racialized immigrant communities that are among those disproportionately impacted at times of crisis. This paper presents a case study of a community-based, cross-sectoral collaborative formed to respond to the COVID-19 pandemic and specifically targeting immigrant communities. Findings inform a conceptual framework that illustrates the integration of two spheres of service: crisis supports, characterized by a short-term approach, broad-based reach and general objectives; and settlement supports, characterized by their long-term approach, trust relations and targeted objectives, such as language supports and culturally appropriate outreach.

Three myths of disseminating COVID-19 information to vulnerable migrants in Japan: lessons learned during the pandemic

This paper discusses the challenges of disseminating COVID-19 information to migrant populations by sharing our trial-and-error approach. In 2018, the Migrants’ Neighbor Network & Action (MINNA), a consortium of individuals and organizations that addressed the issues of accessing relevant information and services for migrants in Japan, was launched. Amidst the COVID-19 pandemic, the MINNA attempted to investigate and improve access to health information among Vietnamese, Nepali, and Burmese migrants in Japan. We had three assumptions in distribution of information to reach a large audience, such as building a multilingual website, requesting stakeholders to disseminate information, or posting on Facebook. None of our assumptions were sufficient to reach the target audience in the context of COVID-19, as total number of views that accessed our materials were less than 300 at most. We viewed these myths as the result of overlooking critical elements of effective communication strategies. Eventually, MINNA managed to establish communication with the manager of a Facebook page with the largest number of followers from the Vietnamese community in Japan. Compared with our previous attempts, the messages were delivered to a large audience on the Facebook page, such as the article on COVID-19 vaccines that was viewed more than 300,000 times. In public health emergencies, interactive process of information dissemination is necessary. It is a key component for risk communication and should be prioritized. Breakthroughs in communicating with a larger audience could be possible through partnerships with online communities.

Developing Machine Learning and Statistical Tools to Evaluate the Accessibility of Public Health Advice on Infectious Diseases among Vulnerable People

Background

From Ebola, Zika, to the latest COVID-19 pandemic, outbreaks of highly infectious diseases continue to reveal severe consequences of social and health inequalities. People from low socioeconomic and educational backgrounds as well as low health literacy tend to be affected by the uncertainty, complexity, volatility, and progressiveness of public health crises and emergencies. A key lesson that governments have taken from the ongoing coronavirus pandemic is the importance of developing and disseminating highly accessible, actionable, inclusive, coherent public health advice, which represent a critical tool to help people with diverse cultural, educational backgrounds and varying abilities to effectively implement health policies at the grassroots level.

Objective

We aimed to translate the best practices of accessible, inclusive public health advice (purposefully designed for people with low socioeconomic and educational background, health literacy levels, limited English proficiency, and cognitive/functional impairments) on COVID-19 from health authorities in English-speaking multicultural countries (USA, Australia, and UK) to adaptive tools for the evaluation of the accessibility of public health advice in other languages.

Methods

We developed an optimised Bayesian classifier to produce probabilistic prediction of the accessibility of official health advice among vulnerable people including migrants and foreigners living in China. We developed an adaptive statistical formula for the rapid evaluation of the accessibility of health advice among vulnerable people in China.

Results

Our study provides needed research tools to fill in a persistent gap in Chinese public health research on accessible, inclusive communication of infectious diseases' prevention and management. For the probabilistic prediction, using the optimised Bayesian machine learning classifier (GNB), the largest positive likelihood ratio (LR+) 16.685 (95% confidence interval: 4.35, 64.04) was identified when the probability threshold was set at 0.2 (sensitivity: 0.98; specificity: 0.94).

Conclusion

Effective communication of health risks through accessible, inclusive, actionable public advice represents a powerful tool to reduce health inequalities amidst health crises and emergencies. Our study translated the best-practice public health advice developed during the pandemic into intuitive machine learning classifiers for health authorities to develop evidence-based guidelines of accessible health advice. In addition, we developed adaptive statistical tools for frontline health professionals to assess accessibility of public health advice for people from non-English speaking backgrounds.

Reducing the impact of the coronavirus on disadvantaged migrants and ethnic minorities

Studies from several countries have shown that the COVID-19 pandemic has disproportionally affected migrants. Many have numerous risk factors making them vulnerable to infection and poor clinical outcome. Policies to mitigate this effect need to take into account public health principles of inclusion, universal health coverage and the right to health. In addition, the migrant health agenda has been compromised by the suspension of asylum processes and resettlement, border closures, increased deportations and lockdown of camps and excessively restrictive public health measures. International organizations including the World Health Organization and the World Bank have recommended measures to actively counter racism, xenophobia and discrimination by systemically including migrants in the COVID-19 pandemic response. Such recommendations include issuing additional support, targeted communication and reducing barriers to accessing health services and information. Some countries have had specific policies and outreach to migrant groups, including facilitating vaccination. Measures and policies targeting migrants should be evaluated, and good models disseminated widely.

Strategies of communicating health-related risks to vulnerable groups of immigrants during a pandemic: a scoping review of qualitative and quantitative evidence

Purpose

The purpose of this rapid scoping review was to map existing literature on risk communication strategies implemented by authorities and aimed at vulnerable immigrants in the context of pandemics.

Design/methodology/approach

Existing literature on the topic was charted in terms of its nature and volume by summarizing evidence regarding the communication strategies. Literature searches were conducted in Academic Search Premier and CINAHL, databases were searched from 2011 to present on March 31, 2021.

Findings

Five articles met the criteria and were included in this review, pointing at limited research in this area. The findings indicated that a close interaction between communication authorities and immigrants is important. Community education, building trust in communication sources, clear risk communication and inclusive decision-making among all were found to be important when communicating health risks to immigrants.

Research limitations/implications

The primary limitation of this rapid scoping review is that the literature searches were conducted in only two databases, namely, Academic Search Premier and CINAHL. A wider search across several other databases could have given more profound results. Furthermore, some studies where immigrants were conceptualized as, for instance, “disadvantaged groups” might be overseen due to a choice of the search strategy used in this study. There are also certain limitations related to the studies included in this review.

Practical implications

Identifying efficient ways of conveying recommendations may further assist authorities and scientists in developing more effective health-related risk communication.

Originality/value

This study covered health-related risk communication in the context of pandemics, addressing the need to investigate different groups of immigrants and the challenges related to communicating risks to these groups.

Regional Characteristics of the Second Wave of SARS-CoV-2 Infections and COVID-19 Deaths in Germany

(1) Background: In the absence of individual level information, the aim of this study was to identify the regional key features explaining SARS-CoV-2 infections and COVID-19 deaths during the upswing of the second wave in Germany. (2) Methods: We used COVID-19 diagnoses and deaths from 1 October to 15 December 2020, on the county-level, differentiating five two-week time periods. For each period, we calculated the age-standardized COVID-19 incidence and death rates on the county level. We trained gradient boosting models to predict the incidence and death rates by 155 indicators and identified the top 20 associations using Shap values. (3) Results: Counties with low socioeconomic status (SES) had higher infection and death rates, as had those with high international migration, a high proportion of foreigners, and a large nursing home population. The importance of these characteristics changed over time. During the period of intense exponential increase in infections, the proportion of the population that voted for the Alternative for Germany (AfD) party in the last federal election was among the top characteristics correlated with high incidence and death rates. (4) Machine learning approaches can reveal regional characteristics that are associated with high rates of infection and mortality.

"I Just Want Some Clear Answers": Challenges and Tactics Adopted by Migrants in Denmark When Accessing Health Risk Information about COVID-19

Health risk communication plays a crucial role in preventing the spread of infectious disease outbreaks such as the current coronavirus (SARS-CoV-2). Yet, migrants are far too often forgotten in health risk communication responses. We investigate the challenges and efforts made by migrants in Denmark—in the initial months of the pandemic—to access information about COVID-19. We draw on 18 semi-structured interviews conducted in May and June 2020. All interviews are thematically coded and analyzed. Our analysis reveals that many of the migrants faced several challenges, including accessing information in a language understandable to them and navigating constant streams of official news flows issuing instructions about which actions to take. However, we also note that the participating migrants found numerous creative ways to address some of these challenges, often aided by digital tools, helping them access crucial health and risk information. This paper highlights that migrants constitute an underserved group in times of crises. They are vulnerable to getting left behind in pandemic communication responses. However, we also identify key protective factors, social resources, and agentic capabilities, which help them cope with health and risk information deficits. National governments need to take heed of these findings to inform future pandemic responses.

The impact of the COVID-19 pandemic on refugees and asylum seekers in Greece: A retrospective analysis of national surveillance data from 2020

BACKGROUND

Migrants globally, including refugees and asylum seekers, have experienced adverse clinical and socioeconomic impacts of the COVID-19 pandemic. For approximately 56,000 refugees and asylum seekers in Reception and Identification Centers (RICs) and Reception Sites (RS) in Greece, living in severely substandard living conditions, prevention measures have been impossible with limited provision in terms of routine testing, surveillance, and access to healthcare. These migrant populations have experienced prolonged lockdowns and restricted movement since the pandemic began. We aimed to assess the impact of COVID-19 on refugees and asylum seekers in reception facilities in Greece and explore implications for policy and practice.

METHODS

A retrospective analysis of policy documents and national surveillance data was conducted to identify COVID-19 outbreaks and estimate incidence among asylum seekers and refugees residing in these camps during the first 9 months of the epidemic in Greece (26th February - 15th November 2020). Incidence proportion (IP) of COVID-19 confirmed cases was calculated for three population groups (refugees and asylum seekers in RICs, refugees and asylum seekers in RSs, and the general population in Greece) during three time periods (first wave, second wave, and overall across the 9-month period).

FINDINGS

Twenty-five COVID-19 outbreaks were identified in refugee and asylum seeker reception facilities, with 6 (85.7%) of 7 RICs and 18 (56.3%) of 32 RSs reporting at least one outbreak during the study period. The overall 9-month COVID-19 IP among refugee and asylum seeker populations residing in RSs on the Greek mainland was 1758 cases per 100,000 population; in RICs the incidence was 2052 cases per 100,000 population. Compared to the general population the risk of COVID-19 infection among refugees and asylum seekers in reception facilities was 2.5 to 3 times higher (p-value<0.001). The risk of acquiring COVID-19 infection was higher among refugee and asylum seeker populations in RSs on the Greek mainland (IP ratio: 2.45; 95% CI: 2.25-2.68) but higher still among refugee and asylum seeker populations in RICs in the Greek islands and the land border with Turkey (IP ratio: 2.86; 95% CI: 2.64-3.10), where living conditions are particularly poor.

INTERPRETATION

We identified high levels of COVID-19 transmission among refugees and asylum seekers in reception facilities in Greece. The risk of COVID-19 infection among these enclosed population groups has been significantly higher than the general population of Greece, and risk increases as living conditions deteriorate. These data have immediate implications for policy and practice. Strategies are now needed to ensure refugee and asylum seeker populations are included in national response plans to reduce transmission in at-risk groups for COVID-19, alongside inclusion in plans for COVID-19 vaccine roll out.

Health equity during COVID-19: A qualitative study on the consequences of the syndemic on refugees' and asylum seekers' health in reception centres in Bologna (Italy)

Background

As coronavirus infection spread across the world, the dramatic consequences of Sars-CoV-2 and confinement measures highlighted the disparities within our society, impacting more severely on the wellbeing of the most disadvantaged groups of people, such as migrants. The structural characteristics of reception centres create many challenges in the implementation of measures to contrast the diffusion of the virus, putting refugees and asylum seekers (RAS) even more at risk. For these reasons, we carried out a qualitative study to analyze the impact of the syndemic on the health of RAS who reside in reception facilities in Bologna (one of the cities with the highest number of migrants in Italy) and the measures that were introduced to contrast the diffusion of Sars-CoV-2.

Methods

Between April and September 2020, we interviewed 25 professionals and volunteers who were critical in the management of the COVID-19 epidemic in reception centres. Key-informants were selected through a snowball sampling process and covered various professions (i.e. doctors, nurses, social workers, psychologists, cultural mediators, anthropologists, lawyers). The semi-structured interviews explored the consequences of COVID-19 on the health of RAS living in reception centres, the measures implemented to contrast the diffusion of the epidemic and the challenges that interviewees had in handling the emergency. After transcription, the interviews were analyzed using deductive and inductive approaches.

Results

All key-informants agreed to participate in the study. Even though various measures were implemented in reception centres (i.e. mass quarantine, supply of personal protective equipment, risk communication campaigns and specific governance tools) they often had a discriminatory approach towards migrants and only considered the biomedical aspects of COVID-19, excluding its social roots and repercussions. This factor, together with the lack of an effective governance system at both the local and the national level, was the most relevant issue associated with the management of the syndemic in reception facilities and affected all the social determinants that shape the health profile of RAS.

Conclusions

The study revealed the importance of social factors in the management of the syndemic in reception centres. It also highlighted how the underlying causes of the impact of COVID-19 are tightly correlated to the political and social approaches of local and national institutions to migration. In order to guarantee the well-being of society as a whole and successfully control the epidemic, it is necessary to consider migration as a human reality rather than an emergency, and demolish all the policies and bureaucratic systems that act as structural violence on RAS. This process brings into play different levels of responsibility and many action plans. We need to develop intersectoral collaborations for more holistic and interconnected practices, while investing the resources to build a worthy reception system and effective social protection programs. This way it will be possible to develop more inclusive approaches to public health and guarantee the conditions for RAS' empowerment.

What must be done to tackle vaccine hesitancy and barriers to COVID-19 vaccination in migrants?

Migrants have been disproportionately impacted by COVID-19 and emerging evidence suggests they may face barriers to COVID-19 vaccination. Participatory approaches and engagement strategies are urgently needed to strengthen uptake, alongside innovative delivery mechanisms and sharing of best practice, to ensure migrants are better consider within countries’ existing vaccine priority structures.

The Mental Health Impact of 2019-nCOVID on Healthcare Workers From North-Eastern Piedmont, Italy. Focus on Burnout

The 2019-nCOVID pandemic as a public health emergency has faced healthcare systems with unprecedented challenges. Our study aimed to focus on the mental health impact of the 2019-nCOVID pandemic on healthcare workers (HCWs) from North-Eastern Piedmont, Italy. For this purpose, we performed an online survey which was e-mailed to HCWs at the end of the first peak of the pandemic. We involved both frontline and not-frontline HCWs, employed in the hospital or in healthcare services outside the hospital. The primary outcome of our research was the assessment of burnout, while secondary outcomes included the investigation of anxiety, depression, and post-traumatic stress symptoms. We observed higher levels of burnout (especially in the Depersonalization and Personal Accomplishment dimensions), in females, in HCWs aged <30 years, in those exposed to changes in their daily and family habits, in those who had to change their duties at work and in residents in training. In our HCWs sample we found lower levels of anxiety and depression than those reported in the literature. The problematic levels of burnout and adverse psychological outcomes observed during the pandemic cannot be underestimated. Given the recurrence in autumn 2020 of a new pandemic peak, which has once again put a strain on the health system and HCWs, it is supported the importance of a careful assessment of HCWs' mental health, and of the possible risk and protective factors both in the work environment and in the extra-work one.

Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: A systematic review

BACKGROUND

Migrants in high-income countries may be at increased risk of COVID-19 due to their health and social circumstances, yet the extent to which they are affected and their predisposing risk factors are not clearly understood. We did a systematic review to assess clinical outcomes of COVID-19 in migrant populations, indirect health and social impacts, and to determine key risk factors.

METHODS

We did a systematic review following PRISMA guidelines (PROSPERO CRD42020222135). We searched multiple databases to 18/11/2020 for peer-reviewed and grey literature on migrants (foreign-born) and COVID-19 in 82 high-income countries. We used our international networks to source national datasets and grey literature. Data were extracted on primary outcomes (cases, hospitalisations, deaths) and we evaluated secondary outcomes on indirect health and social impacts and risk factors using narrative synthesis.

RESULTS

3016 data sources were screened with 158 from 15 countries included in the analysis (35 data sources for primary outcomes: cases [21], hospitalisations [4]; deaths [15]; 123 for secondary outcomes). We found that migrants are at increased risk of infection and are disproportionately represented among COVID-19 cases. Available datasets suggest a similarly disproportionate representation of migrants in reported COVID-19 deaths, as well as increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps have been especially affected. Migrants experience risk factors including high-risk occupations, overcrowded accommodation, and barriers to healthcare including inadequate information, language barriers, and reduced entitlement.

CONCLUSIONS

Migrants in high-income countries are at high risk of exposure to, and infection with, COVID-19. These data are of immediate relevance to national public health and policy responses to the pandemic. Robust data on testing uptake and clinical outcomes in migrants, and barriers and facilitators to COVID-19 vaccination, are urgently needed, alongside strengthening engagement with diverse migrant groups.