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Gozzi P, Persson M, Nielsen A, Kilander H, Kågesten AE, Iwarsson KE, Ljungcrantz D, Bredell M, Larsson EC. Contraceptive access and use among women with migratory experience living in high-income countries: a scoping review. BMC Public Health 2024; 24:2569. [PMID: 39304878 DOI: 10.1186/s12889-024-19778-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 08/13/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Women who have migrated often encounter difficulties in accessing healthcare and experience inequitable sexual and reproductive health outcomes in destination countries. These health inequities include contraceptive access and use. To better understand what influences contraceptive access and use, this scoping review set out to synthesize the evidence on contraceptive access and use and on associated interventions among women with migratory experience in high-income countries (HICs) in Europe, North America and Australasia. METHODS The scientific databases PubMed, Web of Science and CINAHL were searched for peer-reviewed quantitative, qualitative and mixed method articles published between January 2000 and June 2023. Articles were included if they reported on studies exploring contraceptive use to prevent pregnancies among women of reproductive age with migratory experience living in HICs. Two researchers independently screened and extracted data from the articles. Findings were categorized by patient and health system level factors according to Levesque et al.'s framework of access to health care. RESULTS A total of 68 articles were included, about half (n = 32) from North America. The articles focused on the individual level rather than the health system level, including aspects such as women's contraceptive knowledge, the influence of culture and religion on accessing and using contraception, partner involvement, and differing health insurance coverage. On the health system level, the articles highlighted lack of information on contraceptive services, cultural (in)adequacy of services and communication aspects, contraceptives' side effects, as well as geographic availability and cost of services. The review further identified three articles reporting on interventions related to contraceptive counselling. CONCLUSIONS There is a lack of knowledge regarding how health systems impose obstacles to contraceptive services for women with migratory experience on an organizational level, as research has focused heavily on the individual level. This review's findings may serve as a foundation for further research and advances in policy and practice, specifically recommending early provision of health system related information and contraceptive education, engagement of male partners in contraceptive discourses, cultural competency training for healthcare professionals, and strengthening of interpretation services for contraceptive counselling.
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Affiliation(s)
- P Gozzi
- Department of Global Public Health, Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden.
| | - M Persson
- Department of Global Public Health, Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - A Nielsen
- Department of Global Public Health, Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden
- Center for Epidemiology and Community Medicine, Region Stockholm, Sweden
| | - H Kilander
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - A E Kågesten
- Department of Global Public Health, Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden
| | - K Emtell Iwarsson
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
| | - D Ljungcrantz
- The Public Health Agency of Sweden (Folkhälsomyndigheten), Stockholm, Sweden
| | - M Bredell
- The Public Health Agency of Sweden (Folkhälsomyndigheten), Stockholm, Sweden
| | - E C Larsson
- Department of Global Public Health, Global and Sexual Health, Karolinska Institutet, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Wiedmeyer ML, Machado S, Tayyar E, Sierra-Heredia C, Bozorgi Y, Hagos S, Goldenberg S, Lavergne R. How immigration shapes health disadvantages and what healthcare organizations can do to deliver more equitable care. Healthc Manage Forum 2024:8404704241265675. [PMID: 39045719 DOI: 10.1177/08404704241265675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
That immigration is a determinant of health and that immigration systems themselves contribute to structural disadvantage remains under-addressed within healthcare in Canada. This article offers context for how immigration shapes health, and recommendations for how health systems can be better prepared to respond to the diverse needs of immigrants and migrants (together referred to as im/migrants), based on a community-based research project in British Columbia. Findings call attention to the varied and intersecting ways in which immigration status, access to health insurance, language, experiences of trauma and discrimination, lack of support for health system limits access to healthcare, and the roles community-based organizations play in supporting access. Recommendations are intended to help make sure that all health services are accessible to everyone, and move beyond a homogenizing category of "newcomers" into practical, meaningful strategies that attend to diverse and intersecting community needs.
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Affiliation(s)
| | - Stefanie Machado
- Centre for Gender and Sexual Health Equity, Vancouver, BC, Canada
| | - Elmira Tayyar
- Centre for Gender and Sexual Health Equity, Vancouver, BC, Canada
| | | | - Yasmin Bozorgi
- Centre for Gender and Sexual Health Equity, Vancouver, BC, Canada
| | - Selamawit Hagos
- Centre for Gender and Sexual Health Equity, Vancouver, BC, Canada
| | - Shira Goldenberg
- San Diego State, San Diego, California, Unites States of America
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He JW, Terry AL, Lizotte D, Bauer G, Ryan BL. Understanding intersectional inequality in access to primary care providers using multilevel analysis of individual heterogeneity and discriminatory accuracy. PLoS One 2024; 19:e0296657. [PMID: 38241267 PMCID: PMC10798491 DOI: 10.1371/journal.pone.0296657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 12/15/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection. METHODS AND FINDINGS Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income. CONCLUSIONS Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.
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Affiliation(s)
- Jennifer W. He
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Amanda L. Terry
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Family Medicine, Western University, London, Ontario, Canada
| | - Dan Lizotte
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Computer Science, Western University, London, Ontario, Canada
| | - Greta Bauer
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Institute for Sexual and Gender Health, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Bridget L. Ryan
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Family Medicine, Western University, London, Ontario, Canada
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Machado S, Karsiem S, Lavergne MR, Goldenberg S, Wiedmeyer ML. Respectful community engagement in health research with diverse im/migrant communities. BMJ Open 2023; 13:e077391. [PMID: 38097234 PMCID: PMC10729093 DOI: 10.1136/bmjopen-2023-077391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Global migration and immigration are increasing, and migrants and immigrants (im/migrants) have specific health needs and healthcare experiences. Yet, im/migrant involvement in immigration and health research in Canada is inconsistent. Heretofore, involvement has primarily been in research planning, data collection and analysis, with little community involvement during knowledge exchange or through training and colearning opportunities. Community engagement has been especially uncommon in mixed-method and quantitative research in Canada. OBJECTIVE This article describes lessons learnt from the Evaluating Inequities in Refugee & Immigrants' Health Access (IRIS) project from 2018 to 2023, an ongoing mixed-method, community-based research project in British Columbia, Canada. Specifically, we share our core community engagement project structures, Commitments to Community and our Community Engagement Backbone, both collaboratively developed with im/migrant community memebers. PARTICIPANTS People with varied experiences of im/migration and connections to multiple, specific im/migrant communities participate in the project as participants, community researchers, community advisory board members, faculty members and students. Core research activities are supported in English, Farsi, Spanish and Tigrinya. We engage community members throughout the research process, from identifying research topics to knowledge exchange. CONCLUSION We found that these structures offer an accessible visual representation of the project's commitments to community engagement, and the ways these commitments are demonstrated through values and action. Our training opportunities, colearning activities and knowledge exchange efforts also confirmed the accuracy of interpretation, prompted additional analysis to clarify or add depth to findings, and helped us identify additional research topics. We hope these learnings can be used to expand engagement with diverse im/migrant communities in health and immigration research.
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Affiliation(s)
- Stefanie Machado
- Centre for Gender & Sexual Health Equity, Vancouver, British Columbia, Canada
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samira Karsiem
- Centre for Gender & Sexual Health Equity, Vancouver, British Columbia, Canada
| | - M Ruth Lavergne
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Shira Goldenberg
- Centre for Gender & Sexual Health Equity, Vancouver, British Columbia, Canada
- San Diego State University, San Diego, California, USA
| | - Mei-Ling Wiedmeyer
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Department of Family Practice, UBC, Vancouver, British Columbia, Canada
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Garasia S, Bishop V, Clayton S, Pinnington G, Arinze C, Jalil E. Health outcomes, health services utilization, and costs consequences of medicare uninsurance among migrants in Canada: a systematic review. BMC Health Serv Res 2023; 23:427. [PMID: 37138351 PMCID: PMC10154752 DOI: 10.1186/s12913-023-09417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/18/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This systematic review sought to assess quantitative evidence on health outcomes, health services use, and health care costs among uninsured migrant populations in Canada. METHODS OVID MEDLINE, Embase, Global Health, EconLit, and grey literature were searched to identify relevant literature published up until March 2021. The Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool was used to assess the quality of studies. RESULTS Ten studies were included. Data showed that there are differences among insured and uninsured groups in reported health outcomes and health services use. No quantitative studies on economic costs were captured. CONCLUSIONS Our findings indicate a need to review policies regarding accessible and affordable health care for migrants. Increasing funding to community health centers may improve service utilization and health outcomes among this population.
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Affiliation(s)
- Sophiya Garasia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.
| | - Valerie Bishop
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Stephanie Clayton
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Genevieve Pinnington
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Chika Arinze
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Ezza Jalil
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
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Wang P, Li S, Wang Z, Jiao M, Zhang Y, Huang W, Ning N, Gao L, Shan L, Li Y, Wu Q. Perceptions of the benefits of the basic medical insurance system among the insured: a mixed methods research of a northern city in China. Front Public Health 2023; 11:1043153. [PMID: 37139382 PMCID: PMC10149763 DOI: 10.3389/fpubh.2023.1043153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
Background The perceptions of the benefits of the basic medical insurance system among the insured not only reflect the system's performance but also the public's basic medical insurance policy literacy, valuable information for countries that have entered the stage of deepening reform. This study aims to examine the factors that affect the perceptions of the benefits of the basic medical insurance system in China, diagnose the key problems, and propose corresponding measures for improvement. Methods A mixed method design was used. Data for the quantitative study were obtained from a cross-sectional questionnaire survey (n = 1,045) of residents of Harbin who had enrolled for basic medical insurance system. A quota sampling method was further adopted. A multivariate logistic regression model was then employed to identify the factors influencing the perceptions of the benefits of the basic medical insurance system, followed by semi-structured interviews with 30 conveniently selected key informants. Interpretative phenomenological analysis was used to analyze the interview data. Results Approximately 44% of insured persons reported low perceptions of benefits. The logistic regression model showed that low perceptions of the benefits of the basic medical insurance system was positively correlated with the experience of daily drug purchases (OR = 1.967), perceptions of recognition with basic medical insurance system (OR = 1.948), perceptions of the financial burden of participation costs (OR = 1.887), perceptions of the convenience of using basic medical insurance for medical treatment (OR = 1.770), perceptions of the financial burden of daily drug purchases costs (OR = 1.721), perceptions of the financial burden of hospitalization costs (OR = 1.570), and type of basic medical insurance system (OR = 1.456). The results of the qualitative analysis showed that the key problem areas of perceptions of the benefits of the basic medical insurance system were: (I) system design of basic medical insurance; (II) intuitive cognition of the insured; (III) rational cognition of the insured; and (IV) the system environment. Conclusions Improving the perceptions of the benefits of the basic medical insurance system of the insured requires joint efforts in improving system design and implementation, exploring effective publicity methods of basic medical insurance system information, supporting public policy literacy, and promoting the health system environment.
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Affiliation(s)
- Peng Wang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Shuyi Li
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Zhizhen Wang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Mingli Jiao
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- Research Center of Health Policy and Management, School of Health Management, Harbin Medical University, Harbin, China
| | - Yuchao Zhang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Weiqi Huang
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ning Ning
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Lijun Gao
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Linghan Shan
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ye Li
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- Research Center of Health Policy and Management, School of Health Management, Harbin Medical University, Harbin, China
| | - Qunhong Wu
- Department of Social Medicine, School of Health Management, Harbin Medical University, Harbin, China
- School of Public Health, Harbin Medical University, Harbin, China
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Goldenberg SM, Schafers S, Grassby MHS, Machado S, Lavergne R, Wiedmeyer ML. 'We don't have the right to get sick': A qualitative study of gaps in public health insurance among Im/migrant women in British Columbia, Canada. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001131. [PMID: 36962991 PMCID: PMC10022316 DOI: 10.1371/journal.pgph.0001131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023]
Abstract
Globally, the exclusion of im/migrants from public health care systems remains a significant health and human rights issue, calling into question claims of 'universality' of public health systems where eligibility for coverage is determined by immigration status. We aimed to describe lived experiences of health insurance coverage and the health and social impacts of gaps in health insurance amongst im/migrant women in British Columbia (BC), Canada. This analysis draws on qualitative in-depth interviews (n = 78) with im/migrant women and im/migrant-focused service providers (n = 10) conducted between July 2018-March 2021 in Metro Vancouver, BC, as part of a larger community-based, mixed-methods study of im/migrants' health access (IRIS). In contrast to common perceptions of Canada's health system as 'universal', participants faced multifaceted barriers to health insurance and necessary healthcare for themselves and their families following arrival in BC. Narratives highlighted the ways in which ineligibility for public health insurance coverage resulted in unmet needs for essential sexual and reproductive health and preventive care among im/migrant women, children, and families. Participants also described ineligibility for public health insurance as resulting in a high economic burden, and that exclusion from public health insurance perpetuated experiences of discrimination, invisibility, and exclusion from systems of care amongst im/migrant participants. Despite these structural challenges, participant narratives highlighted the crucial role of community-based supports for minimizing harm and navigating oppressive immigration and health systems. Changes to immigration and health policies are required to remove barriers to public health care for im/migrant women and ensure that Canada's health system is accessible to all. Expanding health insurance options to cover all residents and decoupling health insurance eligibility from immigration status are recommended, alongside implementation of 'Sanctuary' policies at the local level.
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Affiliation(s)
- Shira M Goldenberg
- Division of Epidemiology and Biostatistics, San Diego State University, San Diego, CA, United States of America
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada
| | - Shaina Schafers
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Maggie Hamel-Smith Grassby
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Stefanie Machado
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Ruth Lavergne
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Mei-Ling Wiedmeyer
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, University Boulevard, Vancouver, BC, Canada
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Lin S. COVID-19 Pandemic and Im/migrants' Elevated Health Concerns in Canada: Vaccine Hesitancy, Anticipated Stigma, and Risk Perception of Accessing Care. J Immigr Minor Health 2022; 24:896-908. [PMID: 35212825 PMCID: PMC8874751 DOI: 10.1007/s10903-022-01337-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 01/10/2023]
Abstract
Vaccine hesitancy has taken a toll on COVID-19 immunization globally. This study aims to characterize three COVID-19-related health concerns (i.e., vaccine hesitancy, anticipated stigma, and risk perception) in Canada and how they differ based on im/migration status and other social determinants. Data were obtained from a nationwide probability sample of the Canadian Perspective Survey Series 3 (June 15 to 21, 2020). Multivariable binary logistic regression analysis was performed to investigate the association between each COVID-19 concern and nativity status, while controlling for socio-demographics. Of 3522 participants aged ≥ 25 years, the estimated overall prevalence of vaccine hesitancy was 16.9%, with im/migrants being greater than non-immigrants (21.5% vs. 15.5%, p < 0.001). After controlling for all covariates, im/migrants had around two-fold greater odds of all three health concerns, including risk perception of accessing care (aOR 2.44, 95% CI 1.89-3.15), anticipated stigma of being targeted (aOR 2.24, 95% CI 1.81, 2.78) and COVID-19 vaccine hesitancy (aOR 1.99, 95% CI 1.57-2.52), compared to their Canadian-born peers. Among vaccine-hesitant individuals (n = 596), im/migrants reported higher concerns, than non-immigrants, on vaccine safety (71.3% vs. 49.5%), side effects (66.4% vs 47.3%) and mistrust in vaccinations (12.5% vs 6.6%) as possible reasons of vaccine refusal. For migrant justice, health authorities should ensure equitable access to COVID-19 vaccines and other health-enhancing resources for im/migrants to mitigate their heightened fear, stigma, and mistrust of new vaccines amidst turbulent times.
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Affiliation(s)
- Shen Lin
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Toronto, ON, M5S 1V4, Canada.
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