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Department of Public Health and Caring Science
Migrants’ opinions about COVID-19 information in Region Uppsala
- A quantitative study
Author Supervisors Sagal Roble Georgina Warner Josefin Wångdahl
Master thesis in Public Health 30 credits 2021 Examinator Karin Nordin
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SAMMANFATTNING
Bakgrund: Migration är en del av hälsansbestämningsfaktorer, att vara migrant kan leda till att individen är mer utsatt för negativa hälsoeffekter. Såsom i andra kriser är migranter även utsatta för både direkta och indirekta effekter av COVID-19.
Syfte: Att undersöka migranter i Region Uppsala uppfattningar kring COVID-19 information med hänsyn till omfattning, viktighet och möjlighet att följa.
Metod: En kvantitativ studie baserad på en sekundär data från Region Uppsala. Urvalet bestod av n=855 deltagare mellan åldrarna 15 och 70 år. Data samlades in mellan september och oktober 2020. Deskriptivanalys genomfördes för att analysera migranters uppfattningar och icke parametriska analyser användes för att undersöka samband mellan ålder och migranters uppfattningar gällande COVID-19 information.
Resultat: Migranterna i studien använde olika källor för att få information om COVID-19. Majoriteten av migranterna rapporterade skola, TV och sociala medier som källor. Migranters uppfattningar kring COVID-19 med hänsyn till omfattning, viktighet och möjlighet att följa, skilde sig åt. De flesta av migranterna hade kännedom för var de kunde hitta information om COVID-19, däremot rapporterade nästan hälften av migranterna att rekommendationerna från myndigheter bör vara mer omfattande. Det förekom skillnader mellan åldersgrupperna gällande att COVID-19 information skulle vara mindre omfattande samt om de har nödvändig information om myndigheternas arbete hittills och läget i världen. Det förekommer skillnader mellan åldersgrupperna gällande vikten av att följa COVID-19 rekommendationer, där yngre gruppen indikerade lägre nivå av viktighet. Det förekom även skillnader mellan åldersgrupperna när det gällde möjligheten till att följa rekommendationen stanna hemma vid symtom och hålla avstånd, där den yngre åldersgruppen indikerade lägre möjlighet att följa rekommendationerna.
Slutsats: Migranters uppfattningar kring COVID-19 information i Region Uppsala skilde sig åt. Resultatet visar att interventioner kan vara till fördel för att förbättra migranternas inhämtande av hälsoinformation och literacy, samtidigt finns det behov av en ålder anpassat intervention. Page 3 of 57
ABSTRACT
Background: Migration adds particular dimensions to social determinants of health, as being a migrant can make a person more vulnerable to negative health effects. Like in other crises, migrants are vulnerable to both direct and indirect impacts of COVID-19.
Aim: To examine migrants’ opinions about COVID-19 information in Region Uppsala, with regard to comprehensiveness, importance and possibility to follow.
Method: A descriptive cross-sectional study was conducted based on secondary data obtained from Uppsala County Council. The sample consisted of n=855 participants aged between 15 and 70 years. Data were retrieved between September and October 2020. Descriptive analysis was used to explore migrants’ opinions, and non-parametric analysis was used to investigate the association between age and migrants’ opinions about COVID-19 information.
Results: Migrants were using different sources for COVID-19 information, with the majority seeking information via school, TV and social media. The migrants’ opinions about the COVID-19 information with regard to comprehensiveness, importance and possibility to follow differed. Most of the migrants knew where to find information regarding COVID-19; however, nearly half of the migrants reported that the recommendations from the authorities should be more extensive. Age differences were detected when it came to wanting the information to be less extensive, and having the necessary information about the authorities work so far and the situation globally. Differences were found between the age groups when it came to the importance of the COVID-19 recommendations, with the younger group indicating a lower level of importance. There were also age differences when it came to the possibility of following the recommendations of staying at home if you are sick and keeping distance, with the younger group indicating a lower possibility to follow the recommendations.
Conclusions: Migrants’ opinions about COVID-19 information in Region Uppsala differed. The results indicate that interventions can be of use, in order to improve migrants’ health information seeking and literacy and an approach tailored by age could be helpful. Page 4 of 57
Acknowledgements
First and foremost, all praise is due to Allah (God).
I would like to express my gratitude to my supervisors Georgina Warner and Josefin Wångdahl, for their guidance and inspiring discussions.
I would like to thank the Region Uppsala for providing me with data. Special thanks to all the administrators and lecturers of the Uppsala University for giving me the opportunity to be part of this master’s program and also gain more comprehensive knowledge of public health sciences.
I would like to thank my loved ones, who have supported me throughout the entire process, especially my mother and my father; despite being the Prime Minister of Somalia. They always made sure to support me, will be grateful forever for your love.
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TABLE OF CONTENTS
1. BACKGROUND...... 7 1.1 Migration and migrants ...... 7 1.1.1 Migrants’ health ...... 7 1.2 Health information and health communication ...... 8 1.2.1 Health and health promotion ...... 8 1.2.2 Health information ...... 9 1.2.3 Health communication ...... 9 1.3 COVID-19...... 11 1.3.1 Health communication and COVID-19 ...... 12 1.3.2 COVID-19 and vulnerable groups ...... 13 1.4 Problem explanation...... 14 1.5 Aim ...... 15 2. METHOD ...... 16 2.1 Design ...... 16 2.1.1 Selection of participants ...... 16 2.1.1.1 Inclusion criteria ...... 16 2.1.1.2 Exclusion criteria ...... 17 2.2 Data collection ...... 17 2.3 Ethical considerations ...... 17 2.4 Procedure ...... 18 2.4.1 Questionnaire ...... 18 2.4.2 Independent variables ...... 19 2.4.3 Dependent variables ...... 19 2.5 Data analysis ...... 20 3. RESULTS ...... 22 3.1 Descriptive statistics ...... 22 3.1.1 Sample characteristics ...... 22 3.1.2 Information sources about COVID-19 ...... 24 3.2 Migrants’ opinions towards COVID-19information ...... 25 3.2.1 Comprehensiveness of information ...... 25 3.2.2 Importance of recommendations ...... 26 3.2.3 Possibility to follow recommendations ...... 27 3.3 Association between age and migrants’ opinions about information regarding COVID-19 ...... 28 Page 6 of 57
3.3.1 Comprehensiveness of information ...... 28 3.3.2 Importance of recommendations ...... 30 3.3.3 Possibility to follow recommendations ...... 31 4. DISCUSSION ...... 32 4.1 Result discussion ...... 32 4.2 Method discussion...... 35 5. CONCLUSIONS...... 38 6. REFERENCES ...... 39 7. APPENDIX ...... 48
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1. BACKGROUND
1.1 Migration and migrants
The population of Sweden have increased by the beginning of the 2000s by 1.4 million due to higher immigration than emigration (SCB, 2020). In the end of 2019, the Sweden’s population was 10 million. Immigration has been going on from 1930s until the middle of 1970s due to labour immigration in Sweden. After the labour immigrations, in the late 1980s Sweden received a vast number of migrants due to war and terror. Sweden was furthermore the third largest recipient country of individual asylum applications in the year 2015. In 2017 one fifth of the Swedish population were born abroad (Helgesson et al., 2019). This can have a complex impact on the country’s health care systems as they face new pressures of responding fast to the new health care needs. Migrants are not a homogenous group, which can implicates determining their health status of these population is difficult task (Hunter, 2016). A migrant can be defined as “any person who is moving or has moved across an international border or within a State away from his or her habitual place of residence, regardless of the persons legal status, whether the movement is voluntary or involuntary, what the causes for the movement are, or what the length of the stay is” (IOM, 2018). This study focuses on newly arrived migrants i.e., people that have received an asylum and are at the same time covered by the law on the establishment of new arrivals (Region Uppsala, 2020).
Adult migrants in Sweden can participate in a state-subsidized language training, which is taught through the language program Swedish for immigrants (SFI). Swedish for immigrants is an educational setting and it targets students from around the world with different cultural, language and educational background. The purpose of SFI is to provide migrants with sufficient language skills and competence to have the ability to integrate in the Swedish society. The goal is also to strengthen their position in their working and social life (Ahlgren & Rydell, 2002).
1.1.1 Migrants’ health
Migrants’ health is affected throughout the entire migrations process, starting from arrival to post migration and settling down in the new country (Hynie, 2018). Even though research shows that migrants often have relatively good health when they arrive in the destination country, studies also Page 8 of 57 show that non-western migrants had an increased level of disease several years after arrival. Migration includes risks and opportunities in both social and economic conditions. Studies show that migrants tend to be vulnerable to poor mental health and infection diseases (Hynie, 2018). Migration itself adds a particular dimension to social determinants of health, as being a migrant can make a person more vulnerable to negative effects of health (International Organization for Migrants, 2006). Poor socio-economic environments and living conditions, limited access to educational opportunities and psychological stresses could be leading to health inequalities, which are common when being a migrant. Studies also show that migrants have an increased risk of inequality es in the social determinants of health, such as lower income, bad conditions of employment, lower quality of housing, lacking skills in the host language, last but not least risk of discrimination. The previously mentioned factors can affect migrants’ social position and can increase the risk of illness and mental illness (Hynie, 2018). These factors can impact migrant’s health due to language barriers, racial discrimination or limited knowledge about the health system (Baumeister, 2019). Aside from the structural determinants of migrants’ health, research shows they also have an increased risk of behaviours that affect their health negatively, such as smoking and physical inactivity compared to the population born in the country (Public Health Agency of Sweden, 2019). At the same time studies show that non-western immigrants underutilize the health care system compared to other groups, the reasoning of this could be due previous healthcare experiences, language barriers, knowledge and cultural background (Diaz et al., 2015). It is already well known that individuals with foreign background does not utilize the health care in an optimal way. This kind of ill health leads to difficulty for migrants to establish in a new society, to participate in the labour market and at the same time to be involved in the Swedish society (Wångdahl, 2017).
1.2 Health information and health communication
1.2.1 Health and health promotion
There are several definitions of health. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not only the absence of disease or infirmity” (WHO, 1986). Health is considered a fundamental human right and it involves individuals physical, social, and mental well-being. Health could also be seen beneficial recourse, which enables individuals to live a productive life. Health promotion is a big aspect in the public health sector, Page 9 of 57 which indicates the process of enabling people to increase control over, and to improve their health (WHO, 1986).
1.2.2 Health information
In today’s society health information is received from various sources such as media, social media, internet sources and advertisement, the educational system and health care system (UNHCR, 2017). The health information sources vary, and this cause that individuals may have difficulty to know which source to rely on. Individuals also have limited language skills which could lead to poor translation and may affect the ability to understand information (Mårtensson, Westerling & Wångdahl, 2020).). Seeking health information has a positive influence on individuals health knowledge, health behaviours, prevention activities, healthcare service usage and the relationship with healthcare professionals (Patel, Barker & Siminerio, 2014). Individuals who obtain and utilize health information tend to have healthier life; this makes health information seeking an indicator for health equity (Ahn & Chae, 2019). Migrants are known for having lower accessibility to health information, due to language and cultural differences, their socioeconomic position and unfamiliar to the healthcare systems. Most of them also have low linguistic ability which is associated with significantly low online accessibility and utilization of information technology regarding health information (Ahn & Chae, 2019).
1.2.3 Health communication
Health communication is the communication between health intuitions, health professionals and the wider general public (Behrouz et al., 2020). According to The European Centre Disease Prevention there is six components of health communication: risk communication, crisis communication, outbreak communication, health literacy, health education and health advocacy (Tang et al., 2020). Health communication has a positive impact on health-related behaviours, attitudes and beliefs. In order for health communication to be successful of for example an outbreak, the population in the countries must be able to access, understand and use the information being communicated (Behrouz et al., 2020). Health communication has been a successful tool across countries to control the spread of COVID-19 (Lee et al., 2020). A well developed and accurate health communication can facilitate how the population handle uncertainty and fear and also accomplish adherence to needed behaviour change and also meet the individuals fear and raise hope in the face of a crisis (Finset et al., 2020). Page 10 of 57
1.2.4 Health Literacy
Health Literacy was introduced in the 1970s. It is an important part of public health work and healthcare and there are many definitions of health literacy (Sorensen et al., 2012). Health literacy means placing a person’s own health, and that of one’s family and community into context and also understanding which factors that can influence it and at the same knowing how to address it. Individuals with good level of health literacy has the ability to take responsibility for their own health as well as family and community health (Sorensens et al., 2012). According to Nutbeam (2000) health literacy consist of three dimensions. Functional health literacy, which implies the basic writing and reading skills that makes it possible to function in everyday life. Communicative or interactive health literacy which is slightly more advanced cognitive abilities together with social abilities makes it possible for individuals to able to create a meaningful everyday life to a greater extent communication and to add new information to changing conditions. The last level indicates with decisive health literacy that involves even more advanced cognitive and social abilities that can be applied to critically analyse information and utilize it to achieve greater control over situations that arise in individual’s life (Nutbeam, 2000). Health literacy is not static and can be influenced by various factors, such as education, environment, culture and life situation. Factors that also are linked to people’s ability to acquire, use and understand health information (Nutbeam, 2006).
Health literacy is important and includes having the ability to impart knowledge and information and also make decision for themselves in matters concerning their health (Ringsberg Olander & Tillgren, 2014). Health literacy can facilitate difficulty between reliable information on COVID-19 information and misinformation on the topic and it also helps navigating sources of health information. Health literacy empowers people to make informed health decisions and to practice both healthy and preventive behaviours in the time of the pandemic (Okan et al., 2020). Individuals’ development of health literacy can be prevented if lack in literacy occurs, this leads to limited personal and social development (Nutbeam, 2006). Studies show indicates that individuals with low literacy do not utilize the health care as much and they also lack the knowledge to be able to contribute and influence their own health, e.g., such as improving their lifestyle (Eichler et al., 2009). The COVID-19 pandemic has highlighted that poor health literacy among individuals is an underestimated public health problem (Paakkari & Okan, 2020).
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Studies highlight that marginalized groups such as migrants has low health literacy levels (Sorensens et al., 2015). Besides having increased vulnerability to low health literacy, migrants are at the same risk of serious health inequities and worse health outcomes (Wångdahl et al., 2018). Studies show that there are factors that have an impact on the level of health literacy among migrants, these are for example language proficiency, education level, gender, age and income. This may also be due to confusion or misunderstand regarding available health care system or health information (Wångdahl et al., 2018; Ward et al., 2019). When it comes to COVID-19 it is essential that there is an effective health communication with the whole population, this also means that health communication is adapted to meet the needs of marginalized groups, for example migrants (Behrouz et al., 2020).
1.3 COVID-19
In January 2020, the Public Health Agency of Sweden writes that a new coronavirus has been discovered in Wuhan, a city in China (Folkhälsomyndigheten, 2020a). The virus has been named COVID-19 and is thought to come from exotic animals sold locally fish market in Wuhan. This new corona virus belongs to the same virus family as SARS (Severe acute respiratory disease) and the disease can spread by respiratory droplets among people who are in close contact with each other. This can spread by when an infected person sneezes, coughs or talks with a person and small drops around then. These droplets can cause infection by inhalation or direct with nose or mouth (WHO, 2021). COVID-19 has reached a global spread and the pandemic has influenced the lives of million people around the world. COVID-19 has forced public health authorities to divert their attention towards the disease and simultaneously find a way to prevent the spread of the disease.
Focus and restriction in Sweden has been different compared to other countries (Baral et al., 2021). In Sweden, we have received various recommendation in an attempt to prevent the spread of COVID-19. There are both local and general restrictions, which are: • Stay home if you’re sick • Keep distance • Avoid larger social gathering • Wash your hands often • Cough and sneeze into the armpit Page 12 of 57
• Avoid touching eyes, nose and mouth • Work from home (Folkhälsomyndigheten, 2020b).
During the first month of COVID-19 pandemic, elders was advised to limit their social contacts as much as possible. Secondary schools and universities were conducted to distance education to prevent gathering in classrooms (Public Health Agency of Sweden, 2021). Public gatherings such as events, concerts, sports events have been prohibited. Unlike other countries around the world, Sweden decided that neither towns nor cities are going to be put into a lockdown. There are recommended hygiene practices that should be followed in order to minimize the risk of spreading the virus to others. Other recommendations include safety behaviors such as maintaining physical distance, refraining from unnecessary traveling, carefully washing your hands and avoid touching your face.
1.3.1 Health communication and COVID-19
Majority of the people in the world are getting COVID-19 information across various sources such as television, health care providers and health officials and internet news portal (Shafiq et al., 2021; Mohamad et al., 2020). In a study conducted in Malaysia, females were more likely to obtain information from traditional media and family members and older people were less likely to obtain from internet and work (Mohamad et al., 2020). In a study exploring migrants’ knowledge and attitude showed that only half of the sample had good knowledge about COVID-19. Shafiq et al. (2021) study shows that participants older than 55 years old and higher educational background had higher average COVID-19 knowledge. Females and people with higher education demonstrated higher level of COVID-19 knowledge and had positive attitudes towards it (Wang et al., 2020). Vulnerable groups such as black and African American and Native Americans had lower average knowledge about COVID-19 than for example whites. Those with good knowledge had a positive attitude towards COVID-19 information and positive attitude was also associated with level of trust to the country’s institutions (Wang et al., 2020; Shafiq et al., 2021).
For this reason, it is important to establish a good COVID-19 communication that is both culturally and community based. Government authorities have to deliver clear information to the population Page 13 of 57 in order to work preventive. Customized public health work is needed to ensure that migrants have suitable knowledge to protect their health during pandemics (Wang et al., 2020).
1.3.2 COVID-19 and vulnerable groups
The COVID-19 pandemic has hit the Swedish society hard, for the most part the health care system has faced several challenges (Region Stockholm, 2020). Reports also show that some groups have been more vulnerable than others, in terms of mortality and in intensive care (Public Health Agency of Sweden, 2020). Socio-economic factors are an important aspect that can explain the COVID-19 mortality. Household size, overcrowding and income are major factors (Region Stockholm, 2020). Migrants are a vulnerable group in the society and millions of migrants live in housing conditions where social distancing is difficult to perform, especially during a pandemic, where the housing could be the intention for the spread of the infection among this population (Koh, 2020). Because of overcrowded housing conditions, as well as higher incidence of poverty and having occupations where for example physical distancing is impossible, migrants are at much higher risk of contracting COVID-19 (OECD, 2020).
During the first outbreak of COVID-19 in Sweden, there were significant differences in the COVID- 19 burden between the geographical areas (Public Health Agency of Sweden, 2021). Data shows that immigrants from low- and middle-income countries are at a higher risk of COVID-19 infection than, for example, non-immigrants. COVID-19 has affected socio-demographic groups unequally, statistics show that elderly people, men, individuals with socioeconomic disadvantage and individuals born in certain countries and some areas have also been hit harder than other (Region Stockholm, 2020). In Sweden, immigrant groups from Syria, Somalia and Iraq had higher rates of COVID-19 and as well as greater risk of mortality (Drefahl et al., 2020). Studies also show similar outcomes, where ethnic minorities tend to have higher incidence of COVID-19 and also the hospitalization compared to Whites (Niedwiedz, 2020). Immigrants in Norway had higher rates of COVID-19 than Norwegian born, the differences also increased when considering for age especially for mortality rates (Indseth et al., 2021). The risk of COVID-19 could once more be explained by socioeconomic factors, ethnicity and socioeconomic position can strongly influence health outcomes for diseases. Ethnic minorities and socioeconomically disadvantages populations have before been impacted by previous pandemics (Williamson, Walker & Bashkaran, 2020). Knowledge Page 14 of 57 about groups that have high risk is important to prevent disease transmission and there is a need of action, like community engagement and health communication strategies to improve their health. The COVID-19 highlights the importance of health literacy in order for prevention of communicable disease.
1.4 Problem explanation
The world has since the beginning of 2020 been witnessing one of the biggest health crises, COVID- 19 (WHO, 2021). According to WHO (2021) there are more than 103 million confirmed cases and more than 2 million deaths. Like in other crisis, migrants are vulnerable to both direct and indirect impacts of the coronavirus. The ability to avoid COVID-19, such as keeping social distance, receiving adequate health care and simultaneously coping with the social, economic and psychological effects of the pandemic can be influenced by different factors (Cramarenco, 2020). These factors include living and working conditions, the authorities not considering cultural and linguistic diversity, xenophobia, the lack of limited local knowledge and networks (Liem at al., 2020). Research highlights migrants have limited health literacy (Wångdahl et al., 2018). Little is known about what information sources migrants use to find information about COVID-19 and their opinions towards information with regard to comprehensiveness, importance and difficulty to follow. A good health communication can be a successful tool if the population in the countries are able to access, understand and use the information that’s being communicated (Behrouz et al., 2020). COVID-19 highlights the importance of health literacy in order for prevention of communicable disease. It is also important that there is an effective health communication with the whole population. This means that health communication is adapted to meet the needs or vulnerable groups, such as migrants (Behrouz et al., 2020). This study can give more knowledge that can be used to support of the public health work to be focused on the needs of health promotion efforts among migrants and having more knowledge among this demographic group.
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1.5 Aim
The aim of the study was to examine migrants’ opinions about COVID-19 information in Region Uppsala, with regard to comprehensiveness, importance and possibility to follow.
1.5.1 Research questions
1. What information sources are migrants using to find information about COVID-19? 2. What are migrants’ opinions about COVID-19 information, with regard to comprehensiveness, importance and possibility to follow? 3. Is age associated with migrants’ opinions about COVID-19 information?
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2. METHOD
In this chapter, the choice of method for the study follows. A description of the design, participant selection, data collection method, approach, ethical considerations and analysis method are stated.
2.1 Design
Quantitative design was used, which is used to study different phenomenon and to examine prevalence, correlation and differences (Bowling, 2014). The design of this study is a descriptive cross-sectional study based on secondary data which have been obtained from Uppsala County Council. Cross-sectional studies are performed to understand public health problems and are usually conducted at a single time. This method design is carried out during a short period of time without a follow up period, it is suitable for the purpose of examining associations (Merrill, 2013).
2.1.1 Selection of participants
In this study, survey data from newly arrived migrants residing in Region Uppsala which consists of 8 municipalities, was analysed. The population in Region Uppsala is 383 713, of which 71 555 are born abroad (SCB, 2021). Seven out of eight municipalities in Region Uppsala participated in the survey. One of the municipalities was excluded due to participating in another survey conducted by the Public Health Agency of Sweden earlier in the year.
SFI is a national free Swedish course offered to immigrants. It is a state-funded program, and it is municipalities’ responsibility to provide SFI. The program ensures adult Swedish immigrants have the right to free basic language tuition. The main goal of the SFI program is that they follow the Swedish national integration policy (2009/10:60) and the aim of is “active participation in society”. Furthermore, the goal is also to provide students with linguistic tools for communication and active participation in the new society and their working lives (Sandwall, 2010).
2.1.1.1 Inclusion criteria
• Newly arrived migrants • Aged between 15 and 70 years old Page 17 of 57
• Participating in SFI programs or secondary school introduction program • Living in Uppsala, Enköping, Håbo, Knivsta, Tierp, Heby and Östhammar municipalities.
2.1.1.2 Exclusion criteria
• Secondary school aged children in Heby municipality were excluded due to an absence of the introduction program in this area • Älvkarleby municipality was excluded due to participating in the Public Health Agency of Sweden’s survey in April 2020.
2.2 Data collection
The data were collected by Invandrarindex who cooperated with Uppsala County Council on this project in September 2020. Invandrarindex is an organization that promotes newly arrived migrants’ ideas, opinions and experiences. Their goal is to create a mutual understanding along with improve the integration system through by increased knowledge (Invandrarindex, 2021). The data were collected through an electronical questionnaire accommodated for self-reporting (see Appendix A). All of the students in the SFI program and introduction program received an information letter and introduction on how to answer the questionnaire electronically by the responsible teacher. The respondents answered the questionnaire during SFI lessons and lessons in Gymnasiet introduction during a teacher’s presence. Data were collected between 28 September and 16 October 2020.
2.3 Ethical considerations
In scientific research, there is potential to study new and old phenomena which can improve the health of people and their living conditions. However, researchers need to consider ethical principles since it can determine the importance of the research and, at the same time, protect the participants of the study. In the field of humanities and social science in Sweden, there are ethical principles that need to be followed. These are the: information requirement, confidentiality requirement, consent requirement and utilization requirement (Vetenskapsrådet, 2002).
The collection of data was conducted by Invandrarindex, as mentioned. The information requirement means the study’s aim and purpose have been presented clearly, it also means to clarify Page 18 of 57 what rights the participants have (Vetenskapsrådet, 2002). According to Region Uppsala the participants were informed about the purpose of the survey. The consent requirement was also informed to the participants; that it was voluntary to participate. The confidentiality requirement implicates securing information regarding participants, this also implicates that the result of the study should be presented in a way so that participants’ personal information will not be revealed. In this case, Region Uppsala did not request identifiable information (e.g., name, personal number etc.) from the participants. The dataset has only been shared with those working directly on the project and will only be reviewed at certain times during the data collection and analysis process. The utilization requirement means that the information regarding participants will only be used for the purposes of this study. To secure this, a data sharing agreement letter, that mediates data will be used in order to investigate the aim of the study has been signed, between the author, supervisor and Region Uppsala.
2.4 Procedure
2.4.1 Questionnaire
The questionnaire consisted of 22 questions and was made available in six different languages, which were: Arabic, English, Farsi, Somali, Swedish and Tigrinya (see Appendix A for Swedish version). Invandrarindex used the Public Health Agency of Sweden’s COVID-19 survey to the general public (Appendix A) and adjusted the questionnaires for the target group. The survey adjustments consisted of adding questions about SFI level and year of arrival to Sweden. The questionnaire has not been used before, since COVID-19 is a new widely spread disease, and so the reliability and validity of the items have not been assessed.
To examine and answer the research questions in this study, a selection of the questions on the survey were analysed. The main variables that were used in this study were: information sources; opinions towards COVID-19 information with regard to comprehensiveness, importance and possibility to follow; age.
To address the first research question regarding information sources, survey question 12 “During the last seven days, how did you get information about the corona virus?” was used. This question gave the respondents several types of answers (see Appendix A). Page 19 of 57
In order to answer the second research question, migrants’ opinion towards COVID-19 information with regard to comprehensiveness, survey question 9 “What do you think about the authority’s information to individuals with regards to the new corona virus?” and survey question 11 “Do you think you have the information you need about the new corona virus?” were used. For importance, survey question 8 “How important do you think it is to follow the authority’s information regarding the new corona virus?” was used. Possibility to follow was assessed by using survey question 7 “How do you feel about following the authority’s information in response to the new corona virus?”.
Survey question 15 “How old are you?” was used to see if age is associated with migrants’ opinion about COVID-19 information.
2.4.2 Independent variables
In this present study age and language proficiency were the independent variables. In the questionnaire, the age question had seven options (Appendix A). These are 15-20, 21-30, 31-40, 41- 50, 51-60, 61-70 and 71 years or older. Due to a small number of responses in some of the age ranges used in the survey, the age ranges were collapsed into 3 categories: 15-30 years, 31-50 years, and 51-70 years.
2.4.3 Dependent variables
In this study, the dependent variable was their opinion about information regarding COVID-19. Survey questions 7,8, 9 and 11 will be used and adjusted. The survey questions 7 and 8 were questions presented on a scale level and had seven option responses, including “do not know” and “won’t answer”. The latter options were treated as missing data and only definitive response options (1-5 on the scale) were included in the analysis (see Table 1).
For survey question 9, which has five response options, only the first three options which are: it should be less extensive, it is moderate extensive & it should be more extensive were included in the analysis. The options “do not know” and “won’t answer” were excluded. Concerning survey question 11, the yes and no response options were analysed and “do not want to answer” and “do not know” were excluded (see Table 1). Page 20 of 57
Table 1. Survey questions, response options and coding Variables Survey question Response options (SPSS code) Information regarding COVID-19
Comprehensive 9. What do you think about the authority’s It should be more extensive (1) information regarding the new coronavirus? It is extensive enough (2) It should be less extensive (3)
11. Do you think you have the information YES (1) you need about corona virus regarding: NO (2) The authorities work so far? Where you can find new information? Where you can turn for questions? What you can do yourself? Who are the risk groups? The situation in Sweden? The situation globally?
Importance 8. How important do you think it is to follow Unimportant (1) the authority’s recommendations regarding Quite unimportant (2) the corona virus? Neither important nor unimportant (3) Staying at home if you have symptoms Quite important (4) Not visiting the elderly Important (5) Keeping distance
Possibility to follow 7. How do you feel about following the Very difficult (1) authority’s recommendations regarding the Quite difficult (2) corona virus? Neither difficult nor difficult (3) Staying at home if you have symptoms Quite easy (4) Not visiting the elderly Very easy (5) Keeping distance
Age 15. How old are you? 15-30 years (1) 31-50 years (2) 51-70 years (3)
2.5 Data analysis
The IBM SPSS Statistics program was used when analysing the data statistically for this study. In the analysis process, a descriptive analysis of the study population was conducted. Demographic data were presented, including percentages and frequencies of study participants’ age, which municipalities they were resident in, their SFI level, when they came to Sweden and if they were born outside the EU or not. Page 21 of 57
Descriptive analysis was used in order to study the demographic data, first and second research questions regarding information sources and opinion towards COVID-19 information. This type of descriptive statistics summarizes data and simultaneously provides information about the sample (Creswell & Creswell, 2018). The results were presented in frequencies, percentages, means and standard deviations.
In order to answer the third research questions, if age was associated with their opinions about COVID-19 information, chi-square and Kruskal-Wallis tests were conducted to determine the relation between the variables (Jamieson, 2004). Chi-square test is an analysis method that is used when both the outcome variable and the exposure variable are categorical (Ejlertsson, 2012). The Kruskal-Wallis test is often used to study whether there are differences between two or more groups. It is a non-parametric test, which has been selected because the response categories in Likert scales have a rank order, but the intervals between values cannot be presumed equal (Jamieson, 2004).
Due to using more than two variables in the analysis, post-hoc pairwise tests were used when a significant association was found. When chi-square tests were used, pairwise z-tests were conducted (Sharpe, 2015). After using Kruskal-Wallis for the analysis, Dunn’s test was used when a significant association was found (Dinno, 2015). In order to avoid type 1 errors in the analysis (i.e. false positives) by repeated significance testing, the Bonferroni correction was applied (Nahler, 2009).
Survey questions 7, 8, 9 and 11 were recoded into new different variables to adjust the answer options. For the present study, chi-square tests will be used to analyse survey questions 9 and 11. Definitive response options (Yes/No) concerning survey question 9 will be included in the analysis. Concerning survey question 11, only the first three response options were analysed.
In the present study, Kruskal-Wallis tests were used to analyse survey questions 7 and 8. Definitive response options (1-5) were included in the analysis. Due to a small number of responses in some of the age ranges used in the survey, the age ranges were collapsed into 3 categories: 15–30 years, 31–50 years, and 51–70 years.
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3. RESULTS
3.1 Descriptive statistics
3.1.1 Sample characteristics
The majority of the migrants were between 15 and 30 years old (53.4%), followed by 31 to 50 years old (37.9 %), and a small amount between 51 to 70 years old (8.7%). A decent amount of the students were female (49.4%) and males (46.1%). The majority of the migrants were residents in Uppsala municipality (64.8%). Of those that indicated their year of arrival, most arrived since 2015. In terms of native country, most of the migrants in this sample were born outside the EU (79.3%). Of those who indicated their SFI level, 28.4% was at level 1 (lowest), 38.5% was at level 2 (middle) and 33.2% was at level 3 (highest). Table 2 presents the descriptive statistics for the survey respondents (n=855).
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Table 1. Descriptive statistics of the sample
Variables n % Age 15-30 years 363 53% 31-50 years 258 38% 51-70 years 59 9% Missing 175
Municipality Enköping 96 11% Heby 48 6% Håbo 28 3% Knivsta 28 3% Tierps 54 6% Uppsala 543 65% Östhammar 21 3% Missing 20
SFI level 1 (lowest ability) 129 28% 2 (middle) 175 39% 3 (highest ability) 151 33% Missing 400
Arrival to Sweden 2011 or earlier 24 3% 2012 10 1% 2013 17 2% 2014 38 5% 2015 153 22% 2016 51 7% 2017 108 15% 2018 129 18% 2019 94 13% 2020 53 8% Missing 158
EU born Born within EU 60 9% Born outside EU 532 79% Missing 184
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3.1.2 Information sources about COVID-19
The informants in the sample used different tools to get information regarding COVID-19. Most of the migrants were getting their information from the school, like SFI and the secondary school (53%) and the media, such as TV, radio or newspapers (51%). Another common source was social media was also used as a tool, where 46% answered they get information from Facebook and other social media pages. The Swedish news in another language, for example Al Kompis, Aktarr etc. was also a way for the migrants to get information regarding COVID-19. Thereafter the most common sources were friends and acquaintances (30%).
Figure 1. Migrants’ information sources regarding COVID-19 in percentage (n=688)
Other ways 15 Swedish news in another language 33 Foreign Media 15 Public Health Agency website 18 Internet searching (Google etc) 28 Social Media (Facebook etc) 46 Media (TV, radio, newspaper) 51 The Healthcare 14
1177 Vårguiden 27 Information Sources Information Work 10 School (SFI etc) 53 Friends or acquaintances 30 Have not recieved any information 12
% 0 10 20 30 40 50 60 70 80 90 100
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3.2 Migrants’ opinions towards COVID-19information
3.2.1 Comprehensiveness of information
The vast majority of the migrants knew where to find information regarding COVID-19. Yet, 19% of the migrants did not know where to turn with questions. A predominant amount of the migrants implicated they had information on what they can do themselves (91%) and how the situation in Sweden looked like (89%) (Table 2). The majority of the migrants in the sample (86%) reported that they knew where to find new information regarding COVID-19; yet, 44% of migrants reported that the recommendations from the authorities should be more extensive.
Table 2. Descriptive analysis of whether or not the respondents felt they had the information they needed about COVID-19 n % The authorities’ work so far Yes 434 82% No 93 18%
Where you can find new information Yes 388 86% No 61 14%
Where you can turn with questions Yes 348 81% No 82 19%
What you can do yourself Yes 431 91% No 43 9%
Who are the risk group Yes 384 87% No 56 13%
The situation in Sweden Yes 408 89% No 52 11%
The situation globally Yes 64 86% No 392 14% Page 26 of 57
3.2.2 Importance of recommendations
Most of the migrants reported that it is important to follow the COVID-19 recommendations. They reported that it was ‘important’ or ‘quite important’ to follow (61-70%). The other respondents were spread across the response options; the average scores were around 4 out of 5 whereby a higher score indicated a greater level of importance (see Table 3).
Table 3. Importance to follow COVID-19 recommendations Importance n % M SD Stay home if you have symptoms 4.2 1.46 (1) Unimportant 29 4% (2) Quite unimportant 27 4% (3) Neither important nor unimportant 30 4% (4) Quite important 87 12% (5) Important 502 70%
Do not visit the elderly 3.9 1.65 (1) Unimportant 29 4% (2) Quite unimportant 24 4% (3) Neither important nor unimportant 38 6% (4) Quite important 98 15% (5) Important 397 61%
Keep distance 4.2 1.47 (1) Unimportant 37 5% (2) Quite unimportant 17 2% (3) Neither important nor unimportant 28 4% (4) Quite important 95 14% (5) Important 466 68%
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3.2.3 Possibility to follow recommendations
The opinions about the possibility to follow the recommendations were quite mixed. Whilst around a third of the respondents indicated that it was ‘very easy’ to follow them, the other respondents were spread across the response options and the average scores were all around 3 out of 5, whereby a higher score indicated a higher level of ease to follow. A larger proportion indicated they found them ‘very easy’ or ‘quite easy’ to follow than ‘very hard’ or ‘quite hard’ across all of the recommendations (see Table 4).
Table 4. Possibility to follow COVID-19 recommendations Possibility to follow n % M SD Stay home if you have symptoms 3,2 1,6 (1) Very hard 100 14% (2) Quite hard 80 11% (3) Neither easy nor hard 132 18% (4) Quite easy 124 17% (5) Very easy 224 31%
Do not visit the elderly 3,2 1,8 (1) Very hard 70 10% (2) Quite hard 63 9% (3) Neither easy nor hard 86 13% (4) Quite easy 98 15% (5) Very easy 248 38%
Keep distance 3,4 1,6 (1) Very hard 99 15% (2) Quite hard 79 12% (3) Neither easy nor hard 84 12% (4) Quite easy 124 18% (5) Very easy 256 38%
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3.3 Association between age and migrants’ opinions about information regarding COVID-19
3.3.1 Comprehensiveness of information
The respondents’ opinions on the comprehensiveness of the authority’s information regarding
COVID-19, in terms of whether it should be more or less extensive, differed by age group, (χ2 = 11.445, df= 4, p=0,022). Pairwise Z tests were carried out for the three pairs of age groups (15-30 years/31-50 years; 15-30 years/51-70 years; 31-50 years/51-70 years). There was evidence (p < 0,05) of a difference between the youngest age group (15-30 years) and the middle age group (31- 50 years) on the information being less extensive. This held true after applying the Bonferroni correction for multiple comparisons. The distribution of responses by age group is presented in Table 5.
Table 5. Distribution of responses regarding the comprehensiveness of the authority’s COVID-19 information, by age group. It should be It is extensive It should be n less extensive enough more extensive 15 – 30 years 37 (15%)a 103 (41%) 109 (44%) 249 31 – 50 years 13 (6%)a 93 (46%) 96 (48%) 202 51 – 70 years 6 (12%) 28 (56%) 16 (32%) 50 a significant at the 0,05 level based on z-test
The proportions of respondents indicating ‘yes’ or ‘no’ on the survey question regarding whether or not they had the information they needed about COVID-19 are presented by age group in Table 6. A series of chi-square tests indicated that the respondents’ opinions on having the information they needed differed by age group for: the authorities’ work so far (χ2 = 7.557, df= 2, p=0,023); what you can do yourself (χ2 = 7.253, df= 2, p=0,027); and the situation globally (χ2 = 6.298, df= 2, p=0,043). Pairwise Z tests were carried out for the three pairs of age groups. There was evidence (p < 0,05) of a difference between the oldest age group (51-70 years) and the middle age group (31-50 years) for the authorities’ work so far and the situation globally. This held true after applying the Bonferroni correction for multiple comparisons. It was not possible to perform Z tests for what you Page 29 of 57 can do yourself because the proportion of respondents in the oldest age category (51-70 years) that responded “no” to the question was equal to zero, which violates the assumptions for the test.
Table 6. Distribution of responses regarding having the necessary information, by age group Do you think you have the Chi- information you need about 15-30 years 31-50 years 51-70 years n square P corona virus regarding: value The authorities’ work so far? Yes 214 (83%) 157 (79%)a 47 (96%)a 418 0,023* No 45 (17%) 41 (21%)b 2 (4%)b Where you can find new information? 197 (87%) 145 (86%) 34 (90%) 376 0,814 Yes 29 (13%) 24 (14%) 4 (11%) No Where you can turn for questions? Yes 171 (83%) 133 (80%) 35 (83%) 339 0,747 No 35 (17%) 33 (20%) 7 (17%) What you can do yourself? Yes 210 (92%) 160 (88%) 47 (100%) 395 0,027* No 18 (8%) 22 (12%) 0 (0%) Who are the risk groups? Yes 187 (87%) 137 (86%) 48 (98%) 372 0,067 No 29 (13%) 22 (14%) 1 (2%) The situation in Sweden? Yes 200 (87%) 147 (88%) 49 (98%) 386 0,089 No 29 (13%) 20 (12%) 1 (2%) The situation globally? Yes 196 (86%) 137 (84%)c 47 (98%)c 380 0,043* No 33 (14%) 26 (16%)d 1 (2%)d *significant at the 0,05 level based on chi-square test a, b, c, d significant at the 0,05 level based on z-test
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3.3.2 Importance of recommendations
When asked to rate the importance of following the authorities’ COVID-19 recommendations, from 1 (unimportant) to 5 (important), the responses differed by age group for all of the recommendations: staying at home if you have symptoms (H(2) = 8,795, p = 0,012); not visiting the elderly (H(2) = 15,839, p = 0,000; and keeping distance (H(2) = 19,255, p = 0,000). Dunn’s pairwise tests were carried out for the three pairs of age groups. There was evidence (p < 0,05) of a difference between the youngest age group (15-30 years) and the other age groups on all recommendations, with the younger group generally reporting lower scores indicating a lower level of importance. This held true after applying the Bonferroni correction for multiple comparisons. The distribution of responses by age group is presented in Table 7.
Table 7. Distribution of responses regarding the importance of following the authority’s COVID-19 recommendations, by age group Neither Quite Quite Important Unimportant important nor n unimportant important (5) (1) unimportant (2) (4) (3) Staying at home if you have symptoms 15-30 yearsa 16 (5%) 15 (5%) 19 (6%) 46 (14%) 226 (70%) 322 31-50 years 8 (3%) 10 (4%) 10 (4%) 25 (10%) 191 (78%) 244 51-70 yearsa 0 (0%) 0 (0%) 1 (2%) 8 (14%) 48 (84%) 57 Not visiting the elderly 15-30 yearsb 15 (4%) 16 (6%) 20 (8%) 54 (20%) 160 (60%) 265 31-50 years 8 (4%) 3 (1%) 16 (7%) 33 (15%) 163 (73%) 223 51-70 yearsb 1 (2%) 0 (0%) 1 (2%) 7 (14%) 42 (82%) 51 Keeping distance 15-30 yearsc 20 (7%) 14 (5%) 17 (6%) 54 (17%) 205 (66%) 310 31-50 years 9 (4%) 2 (1%) 9 (4%) 28 (12%) 182 (79%) 299 51-70 yearsc 1 (2%) 0 (0%) 0 (0%) 5 (10%) 46 (89%) 52 a, b, c significant at the 0,05 level based on Dunn’s test
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3.3.3 Possibility to follow recommendations
When asked to rate the possibility to follow the authority’s COVID-19 recommendations, from 1 (very difficult) to 5 (easy), the responses differed by age group for two of the three recommendations: staying at home if you have symptoms (H(2) = 18,636, p = 0,000); and keeping distance (H(2) = 19,316, p = 0,000). Dunn’s pairwise tests were carried out for the three pairs of age groups. For staying at home if you have symptoms there was evidence (p < 0,05) of a difference between the oldest age group (51-70 years) and the other age groups, with the older group generally reporting higher scores indicating a higher level of possibility (i.e. they found it easier to follow the recommendation). For keeping distance, there was evidence (p < 0,05) of a difference between the youngest age group (15-30 years) and the other age groups, with the younger group generally reporting lower scores indicating a lower level of possibility (i.e. they found it more difficult to follow the recommendation). This held true after applying the Bonferroni correction for multiple comparisons. The distribution of responses by age group is presented in Table 8.
Table 8. Distribution of responses regarding the possibility to follow the authority’s COVID-19 recommendations, by age group Very Quite Neither difficult Quite Easy difficult difficult nor easy easy (5) n (1) (2) (3) (4) Staying at home if you have symptoms 15-30 yearsa 60 (19%) 39 (12%) 63 (20%) 56 (18%) 99 (31%) 317 31-50 yearsb 31 (13%) 30 (13%) 51 (22%) 47 (20%) 76 (32%) 235 51-70 yearsa,b 2 (4%) 2 (4%) 7 (13%) 16 (29%) 29 (52%) 56 Not visiting the elderly 15-30 years 31 (12%) 30 (12%) 37 (15%) 46 (18%) 112 (44%) 256 31-50 years 27 (13%) 25 (12%) 37 (17%) 30 (14%) 95 (44%) 214 51-70 years 5 (10%) 1 (2%) 6 (12%) 15 (29%) 25 (48%) 52 Keeping distance 15-30 yearsc,d 59 (19%) 51 (17%) 37 (12%) 59 (19%) 103 (33%) 309 31-50 yearsc 25 (11%) 21 (9%) 36 (16%) 47 (20%) 101 (44%) 230 51-70 yearsd 4 (8%) 2 (4%) 5 (10%) 13 (26%) 27 (53%) 51 a, b, c, d significant at the 0,05-level based on Dunn’s test Page 32 of 57
4. DISCUSSION
The present study examined how migrants in Region Uppsala have searched for and their opinions about COVID-19 information. How respondent age interacted with their opinions towards COVID- 19 information was explored.
The results showed that migrants were using different sources regarding COVID-19 information, with the majority using school, TV and social media as a tool. Migrants’ opinions about the COVID- 19 information with regard to comprehensiveness, importance and possibility to follow differed. Most of the migrants knew where to find information regarding COVID-19; however, nearly half of the migrants reported that the recommendations from the authorities should be more extensive. The majority of the migrants reported that it is important to follow the recommendations. A larger proportion indicated they found them ‘very easy’ or ‘quite easy’ to follow than ‘very hard’ or ‘quite hard’ across all of the recommendations. Age differences were detected when it came to wanting the information to be less extensive, and having the necessary information about the authorities work so far and the situation globally. Differences were found between the age groups when it came to the importance of the COVID-19 recommendations, with the younger group indicating a lower level of importance. There were also age group differences when it came to the possibility of following the recommendations of staying at home if you are sick and keeping distance, with the younger group indicating a lower possibility to follow the recommendations
4.1 Result discussion
In this study, the majority of the migrants were getting information regarding COVID-19 from different kinds of tools such as school, like SFI and secondary school, and media, such as TV and newspapers. These could be seen as good sources of COVID-19 information since the school, national TV and newspaper tend to use reliable sources. This is in line with similar studies that show people get COVID-19 information from different sources such as TV and internet news portals (Shafiq et al., 2021; Mohamed et al., 2020).
Many of the migrants (46%) also got information from social media, such as Facebook and other pages. Even though social media can be used to improve knowledge regarding health information it Page 33 of 57 can also create potential risks for individuals. A distribution of low-quality information can cause harm for the population even though engagement in social media can be seen as a factor influencing in improving individual’s health. When using social media as a source of information there is a high risk of people encountering misleading information (Sumayyia et al., 2019). Health institutions and policymakers can help reduce the potential harm of misleading or incorrect information being transmitted through social media by promoting reliable information. Using social media could also lead to migrants having misleading information regarding COVID-19 from friends and family countries around the world. The misleading information could include COVID-19 information from other countries, such as their policies and recommendations, which might not align with those in Sweden. Furthermore, this misleading information can create different opinions about the COVID- 19 recommendations the Swedish Public Health Agency communicates out to the nation, such as regarding some of the recommendations as less important.
The result in this study showed that the migrants generally knew where to find information regarding COVID-19; yet, did not know where they could turn with questions and how the authorities are working regarding the prevention of COVID-19. Even though the majority knew where to find information, 44% of the migrants reported that the COVID-19 information should be more extensive. In addition, this can be understood by the help of the health literacy model, according to Nutbeam (2006) it implies the ability to absorb knowledge about health information and make their own decisions regarding health issues. In this case, there could be a lack ability to obtain and understand knowledge and information regarding COVID-19 information among migrants in the sample. This is considered as a weakness since low health literacy can lead to affecting individual’s health and also limit personal and social development (Nutbeam, 2006).
The reports from migrants in this sample that the recommendations should be more extensive could also be associated with how the information the authorities were sending out the information. It could be that it was not suitable for them. In a paper assessing Public Health Agencies’ online communications about COVID-19, Tagliacozzo et al (2021) stated that when spreading tailored information, all social groups were not considered equally. Groups like immigrants hardly received tailored information towards them in Sweden (Tagliacozzo et al., 2021). There is a need for well- developed health information and health communication so that authorities can facilitate how the population can handle misinformation and fear (Finset et al., 2020). Page 34 of 57
Since the participants of this study are at different levels in their Swedish language ability, the absence of reliable information in their language could cause harm and social media can also easily spread inaccurate information which can lead to panics and frustration (Park & Lee, 2016). Since migrants are seen as a ‘hard to reach’ group according to Behrouz et al. (2020) when it comes to public health communication if they are not targeted appropriately. There is a need for public health authorities to address language barriers adequately (Behrouz et al., 2020). It is essential that migrants have access and the possibility to follow the COVID-19 advice and recommendation to help stop the spread of it (Kluge et al., 2020). Most of all a creation of national migrant targeted risk communication is also recommended by the WHO (2020).
The study result shows the majority of migrants in the sample reported that it is important to follow the recommendations of staying home if you are sick, not visiting the elderly and keeping distance. More reported that it was ‘very easy’ or ‘quite easy’ than ‘very hard’ or ‘quite hard’. Even though the migrants reported that it was important to follow the COVID-19 recommendations, the opinions towards the possibility to follow the recommendations differed. Around a third of the respondents reported that it was ‘very easy’ to follow them, the others were spread across the response options. Around 14% indicated that it was ‘very hard’ to follow the recommendation keep distance and stay home if you are sick and 10% reported it was hard to not visit the elderly. Previous studies show that immigrant groups have higher rates of COVID-19 and hospitalization due to the disease (Drefahl et al., 2020). A possible explanation of this could be socio-economic factors, household and income, as it plays a big role when it comes to COVID-19 (Bertelink et al., 2020; Region Stockholm, 2020).
As mentioned, migrants are a vulnerable group in society and many of them live in housing conditions where keeping distance is difficult which then leads to migrants being at much higher risk of contracting the infection (Koh, 2020; OECD 2020). Income is an important factor and being socioeconomically vulnerable might make it more difficult to follow the recommendation to stay at home if you have symptoms when you need to go to work to achieve a stable income to survive (Koh, 2020). According to Calderon-Larranaga et al. (2020), reduced income may lead to home overcrowding, reduced educational level and lower health literacy, which may impact access to and understanding of the public health advice. Page 35 of 57
With regard to the age differences detected in this study, previous research shows there is stronger misinformation belief among younger adults and, among older adults there is possible ‘backfire effect’ of good information (Santosh et al., 2021). Studies also show that older adults are able to deploy their more extensive general knowledge to critically evaluate new health information (Santosh et al., 2021).
4.2 Method discussion
A quantitative methodological has been used for this study. This design made it possible to numerically summarise migrants’ opinions towards COVID-19 information as well as consider associations with their age. As the subgroup analysis to explore associations with age involved more than two variables, post-hoc pairwise tests were used. When running so many analyses there is a risk of ‘type 1 errors’, which means detecting false positives. To account for this, the Bonferonni correction was applied (Nahler, 2009).
By using a quantitative survey method, personal bias is reduced because the researcher and the participants are not in direct contact. Yet, this can also limit the research. Participants do not have the opportunity to ask for clarification or elaborate upon their answers, especially when using closed questions. This means the data might not be robust enough to explain complex phenomenon. There is a further limitation of using cross-sectional survey, as this design does not clarify a causal direction of association (Bruce et al., 2018).
The study used secondary data from Region Uppsala. Secondary data is defined as further analysis of a dataset already existing to address different research purposes. It has both benefits and limitation. The benefits can be seen as it saves time since data is already available, and mostly has a larger number of participants and data is mostly verified. Secondary data can also be seen helpful in providing new insights and direction for another research. Even though it has benefits, there is also limitation such as the data not suiting the research question of your study, and there could have been bias since the researcher did not obtain the data which can affect the study (Windle, 2010).
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The study population was newly arrived migrants living in Region Uppsala. A good number of respondents was achieved, with a total of 855 participants; although the number of migrants targeted, and thus the response rate, is not known. Given the regional restriction of the survey dissemination, the study does not represent the whole population of newly arrived migrants in Sweden. If possible, the author would aim for a broader population such as a nationally representative sample. The respondents in the group were also very mixed when it came to age and Swedish language proficiency. This could be seen as a strength.However, not all subgroups were well represented; for example, there were not as many participants in the category ‘51-70 years’. The author could not impact the selections of the participants, since it was secondary data that was used. Only those attending SFI classes participated and no other migrants, therefore it is hard to say this sample represents all migrants in Region Uppsala, let alone Sweden. The external validity, which means the possibility to generalise the results, is somewhat limited in this study (Creswell & Creswell, 2018).
The data were collected by Region Uppsala through Invandrarindex by online questionnaire (Appendix A). Since data were only collected through SFI classes on online survey there might be individuals who maybe missed the lesson and did not get chance to answer the survey and they could give important data. Since a teacher was available during the answering of the questionnaire it may have had an impact on the response they were answering. The positive side of this is that the respondents could have gotten the support from them, but this could have causes bias if their teacher could see what they responded and they might have answered in a way they thought the teacher would expect or find favorable.
Since the questionnaire was available in six different languages, it was considered accessible for the target group. However, translating languages can affect the face validity of the questions since words in one language can be described differently in another language. This could complicate for the respondents and confuse them to not know what to answer, but also cause inconsistencies among the responses being analysed. As previously mentioned, the questions used for the survey has not been validated and this indicates the questions have not been reviewed and accepted which is a weakness regarding the validity of the survey. As far as the author knows, the reliability of the survey was not tested either so it is unclear whether the questions would be stable over time.
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Even though the survey had a lot of respondents, many of the questions had missing data. Missing data presents various problems, such as reducing statistical power and the loss of data can also cause bias in the estimation parameters. Missing data can also reduce the representativeness of the samples and complicate the analysis of the data (Kang, 2013). In total, 855 participants responded at least partially to the survey, yet some of the survey questions had only around 400 respondents. There was a relatively low number of participants after missing data. This was an issue for the subgroup analysis as the number of participants in the ‘51-70 years’ age group was particularly low. This affected the analysis; for example, pairwise tests could not be performed for one variable.
For the analysis of the survey data ‘don’t know’ responses were considered to be non-substantive responses and a form of item non-response and therefore treated as missing data. However, this could have somehow affected the results and introduced bias. There are a number of reasons why a respondent might select ‘don’t know’. It could be that they did not understand the question, or the information was too sensitive.
The ethical principles of information requirement, consent requirement, confidentiality requirement, and utilization requirement were followed and considered throughout the study. Research topics that are sensitive can differ throughout time and among societies (Vetenskapsrådet, 2002) and consequently this may be an ethical aspect to consider. In addition, no questions were mandatory to fill in, which was chosen for the purpose of not forcing any answers. Therefore, each participant could decide on which questions they were willing to answer. However, a result of not conducting the survey directly is that the author has little knowledge about the information participants were provided about the survey or the consent procedure.
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6. CONCLUSIONS
Results from this study show that migrants’ opinion about COVID-19 information in Region Uppsala differed. Most of the migrants knew where to find information regarding COVID-19 information; however, nearly half of the migrants reported that the recommendations from the authorities should be more extensive. Age differences in the opinions towards COVID-19 information were detected. The results indicate that interventions can be of use in order to improve migrants’ health information seeking. Public health science is scientific field that focuses on improving quality of life by either preventing ill-health or promoting health. In this context that means enabling authorities to improve their health information to the population so that it is suitable for every group in the society. A public health strategy that can be beneficial for the migrants is needed. There is a need of improvement in how migrants’ groups are reached, effective health communication that engages the whole nation is an important factor to authorities should commit as we face the current pandemic. This research suggests that an approach tailored by age could be helpful. Further research concerning migrants’ opinions about COVID-19 information is encouraged.
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10. APPENDIX
Klicka i rutan uppe till höger för att välja språk
Den här undersökningen syftar till att ge Region Uppsala en bild av hur du upplever Corona-pandemin just nu och ditt behov av information. Kunskapen som vi får av svaren kommer vi använda till att göra vår information bättre. Det är frivilligt att svara och du kan sluta när du vill.
Stort tack för att du är med!
1. Vilken kommun bor du i?
Enköping
Heby
Håbo
Knivsta
Tierps
Uppsala
Östhammar
Vet inte
Jag vill inte svara
2. Känner du idag oro för din egen hälsa på grund av det nya coronaviruset?
Ja
Nej
Jag vet inte
Jag vill inte svara
3. Känner du idag oro för din familjs hälsa på grund av det nya coronaviruset?
Ja
Nej
Jag vet inte
Jag vill inte svara
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