COVID-19 mortality and use of intensive care among ethnic minorities – a Danish register study

Background

Migrants and ethnic minorities are disproportionately affected by the Coronavirus Disease 2019 (COVID-19) pandemic compared to the majority population. Therefore, we studied mortality and use of mechanical ventilation (MV) by country of birth and migrant status in a nationwide cohort in Denmark.

Methods

Nationwide register data on all cases hospitalized for > 24-hours with COVID-19 between February 2020 and March 2021. Main outcome measures were mortality and MV within 30 days of hospitalization for COVID-19. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by region of origin and migrant status using logistic regression analyses, adjusting for age, sex, comorbidity and sociodemographic factors.

Results

Of 6,406 patients, 977 (15%) died and 342 (5%) were treated with mechanical ventilation. Immigrants (OR:0.55;95%CI: 0.44-0.70) and individuals of non-Western origin had a lower odds (OR: 0.49; 95% CI: 0.37-0.65) of death upon admission with COVID-19 compared to Danish born individuals. Immigrants and descendants (OR: 1.62; 95% CI: 1.22-2.15) as well as individuals of non-Western origin (OR: 1.83; 95% CI: 1.35-2.47) had a significantly higher odds of MV compared to Danish born individuals. Outcomes of individuals with Western origin did not differ.

Conclusions

Immigrants and individuals of non-Western origin had a significantly lower COVID-19 associated mortality compared to individuals of Danish origin after adjustment for sociodemographic factors and comorbidity. In contrast, the odds of MV was higher for immigrants and individuals of non-Western origin compared to individuals of Danish origin.

Key messages

• Immigrants and individuals of non-Western origin had a significantly lower COVID-19 associated mortality compared to individuals of Danish origin.

• Risk of technical ventilation was higher for immigrants and individuals of non-Western origin compared to individuals of Danish origin.

Universal screening for postpartum depression? Inequalities and barriers among immigrant mothers

Background

Postpartum depression (PPD) is a serious public health concern affecting 12% of women globally. Early detection is necessary to provide timely support. In Scandinavian countries, universal screening is recommended. However, migrant women, who are at increased risk of PPD, seem to be screened less often. Still, there is limited knowledge about 1) how acculturation relates to screening, and 2) how healthcare providers navigate PDD screening with migrant women.

Aims and methods

We used a mixed-methods approach to explore whether and why inequalities in PPD screening using the Edinburgh postpartum depression scale (EPDS) may exist in the context of universal PPD screening within the free home-visiting program in Denmark. Data from 77,694 infants and their mothers participating in the Danish home-visiting program (2015-2018) was used to examine the prevalence of participation in PPD screening and its association with migrant status and acculturation factors. We interviewed 16 health visitors to examine qualitatively challenges and strategies used when assessing PPD among immigrant mothers.

Results

Immigrant women were 80% more likely to lack screening (adj. RR 1.81-1.90). All factors indicating lower acculturation, such as shorter length of residence, older age at migration, and having studied abroad were independently associated with increased risk of lack of screening. Thematic analysis of qualitative data showed how cultural and linguistic differences and organizational constraints limit health visitors’ ability to assess immigrant women's mental health needs. Although health visitors often used EPDS as an opener to talk about mental health, they did not use it as an ‘assessment’.

Conclusions

This study shows inequalities in PPD screening than may result in reduced use of mental health services among immigrant women. The experiences of health visitors shed light on how to improve the identification of PPD among immigrant mothers.

Key messages

• Migrant women in Denmark, even those who have migrated as children, are at risk of being left out of PPD screening programs.

• Limited organizational support and cultural competences makes PPD screening among immigrant women not feasible for maternal health visitors.

Implementing a diversity sensitive curriculum in medical education – challenges and potentials

Background

Migrant and ethnic minority populations in Europe are growing, consequently increasing the need for the health systems and health educations to adapt to an increasingly diverse population with diverse needs. Improving health professionals' diversity competences has been proposed as one of the solutions to tackle inequalities in health between different ethnic groups and ensure that all patients receive the care that they need. The objective of this study was therefore to investigate potentials and challenges for implementing diversity competences in medical teaching programmes.

Methods

Four focus groups interviews and one individual interview was conducted with three groups of stakeholders: medical students, course leaders and newly graduated medical physicians. The focus group and individual interviews were conducted physically and digital and one focus group used both. The interviews had a duration between 30-90 minutes and informed consent was obtained from all participants. The data was transcribed and were coded using content analysis.

Results

6 main themes and 14 sub-themes were identified in the analyses. One theme indicated that there was a general wish for more focus on diversity competences in the curriculum. Other themes pointed to challenges regarding competing priorities in the context of medical education, a condescending discourse about social and humanistic medicine and lack of support to medical students regarding challenges in relation to migrant and ethnic minority patients in the clinical settings. Another major theme focused on medical teachers' challenges when teaching a diverse classroom.

Conclusions

Our results showed that action in this area is needed. The themes indicated that many opportunities to implement diversity competence in curriculum exist, but also illuminated the challenges. The results suggested a need for focusing on individual competences for medical teachers and students, but also for organisational change.

Key messages

A widespread interest for implementing diversity competence in curriculum, but competence development for teachers is also needed. Important to focus on individual competences, but also on organisational change.

How to promote maternal mental well-being in refugee mothers through home visiting: the Danish experience

Refugee women are at increased risk to develop perinatal mental health problems, including postpartum depression. The fact that refugee and immigrant women suffering PPD are more likely to be exposed to poverty, lack of social support, or restricted working opportunities suggest that a comprehensive approach that addresses the broader social determinants of health is suited to effectively support their perinatal mental health needs. However, public health programs with such a comprehensive approach are scarce in most European countries. We will present qualitative findings from ‘Health nurses strengthen integration', a universal home visiting program aimed to strengthen the integration of refugee families in Denmark. The program includes a minimum of five 2-h meetings including a mind-mapping of families' psychosocial needs, a focus on parenting in a new culture, and support to connect with social and health services. Nurses are trained in cultural competencies and are provided with interpreters. We conducted 3 focus groups (n = 11) and 2 interviews with health visitors (HV) and 9 interviews with refugee mothers to identify what aspects of a comprehensive approach that foster families' integration can support the mental well-being of refugee mothers after birth. Using thematic network analysis we found how the structure, extra time, and training in cultural competence facilitated HV to use critical self-reflection and cultural sensitivity, use respectful curiosity, create a safe space for sharing, and ‘hand-hold' families in interactions with other services. These practices permitted HV understand the complex needs of families, build trust, and facilitate interactions with others services. Interviews with families illustrated how 1) feeling that someone cared ‘like family', 2) and build-bridging with services (doctor, school, job center) reduced families daily stress. Using the family stress and adaptation theory we will discuss program and policy implications.

“No papers. No doctor”: undocumented immigrant women’s access to maternity care services in Denmark

Background

In Denmark, undocumented immigrants have restricted access to health care including maternity care. Nordic studies describe that undocumented immigrant women face many barriers to access maternity care during pregnancy however, literature in a Danish setting is lacking. This study aims at exploring undocumented immigrant women's experience of and their access to maternity care services in Denmark.

Methods

The study setting was a non-governmental Health Clinic in Denmark, that provides primary health care, including maternity care, to undocumented immigrants. We recruited 21 undocumented immigrant women, conducted semi-structured interviews from 01.2018 to 01.2019. The data was analyzed through systematic text condensation.

Results

Undocumented immigrant women experience several barriers to access maternity care services in Denmark. We identified four themes with subthemes. i) Access to public maternity care services; the experiences with public maternity care providers, fear of deportation and concerns about having to pay for care. ii) Use of private and non-governmental maternity care services; the feeling of being safe at the Health Clinic, reaching care is challenged by logistics and choosing to pay for private health care services. iii) Perception of entitlements to care; wishing for a fair treatment, and uncertainty of what to expect when reaching a public health care facility. iv) Being dependent; dependency on the Health Clinic, social support from network and seeking information from other sources.

Conclusions

Our findings contribute with insights to understand the health behavior of undocumented immigrant women. Accessing public maternity care services is, apart from legal restrictions, dominated by fear of being reported to the immigration authorities, concerns about payment, and the management of rules from the health provider's perspective. Many of them depend on the Health Clinic as well as their personal networks for care and protection.

Key messages

Undocumented immigrant women face many barriers to access maternity care services. Inclusive policies for access to maternity care are needed to safeguard the health of the women and children.

Health assessment of newly arrived refugees to the Municipality of Copenhagen, Denmark

Background

Research data on the health status of newly arrived refugees is sparse. Newly arrived refugees and family reunified in The Municipality of Copenhagen has since 2016 been offered a general health assessment. These assessments are conducted by clinicians with expertise in refugee and migrant health from the Section of Immigrant Health. This study describes the sociodemographic characteristics and the burden of disease in this population.

Methods

In this cross-sectional study the population consists of adult patients examined January 2017 to February 2019. Clinicians performed the health assessment including a questionnaire regarding sociodemographics, medical history, symptoms, traumatic events during/before migration, a clinical examination and blood samples.

Results

The population had an equal presentation of males (N = 81) and females (N = 79) primarily from Syria (33%) and Iran (29%). The median age was 31,5 years (SD = 10,9). 67% had ≥8 years of schooling, while 11% had a maximum of 2 years. More than half had experienced war and 50% persecution. 76% suffered from Vitamin D deficiency, 31% of B12 deficiency and 12% of anemia. Few suffered from infectious and somatic diseases, yet many experiences symptoms such as pain (53%) and headaches (54%). 33% presented with symptoms of PTSD.

Conclusions

A high frequency of micronutrition deficiency was prevalent in the refugee group. Furthermore, many suffered from physical symptoms while very few had serious somatic issues. Numerous traumatic experiences were reported and 33% presented with symptoms of PTSD. The data is presumably a reflection of the healthy migrant bias.

Key messages

Despite refugees presumably being tested pre-entry and at holding level, they still suffer several health issues when granted asylum. Many newly arrived refugees suffer from micronutrition deficiency. These conditions are easily treated and could enhance the overall health of the individual.

[Access to Danish health care by immigrant women. Access to hospital care among immigrant women with breast cancer compared with Danish women]

The study aim is to measure possible differences in access to health care among immigrant women with breast cancer compared with Danish women. We used tumour size at diagnosis as a proxy measure of access. The Danish Central Personal Register provided information from 1977-1996 on women between 20-75 years born in countries in which Islam is the dominating faith. These data were linked to the Danish Breast Cancer Cooperative Group, which registers data concerning tumour size. Sixty-five immigrant women with breast cancer were identified and matched with a control population of Danish women. The study showed larger tumours at diagnosis among women from ethnic minority groups compared to Danes. However, this tendency was not significant. Furthermore, mammographic screening had a significant effect on the tumour sizes of Danish women, but not on those of immigrants. The study indicates ethnic inequalities related to access to health services as measured by tumour size.