Migration, refugees, and health literacy

According to the United Nations Refugee Agency (UNHCR), at least 82.4 million people worldwide had been forced to flee their homes by the end of 2020 due to persecution, conflict, violence, human rights violations, or events that seriously disrupted public order. Nearly 26.4 million of them are refugees (UNHCR, 2021). 

The demographic changes in the world have also had an impact on the demographic changes in the Nordic countries, which have experienced an increase in the number of refugees.  

As already mentioned, migrants and refugees are at risk of limited health literacy. It is therefore important to focus on and understand their health literacy level in order to help them and their families to better health.

In 1990–2019, the population of the Nordic region increased by 17.7 percent. Around two-thirds of the total population increase is due to net migration: emigrants are outnumbered by immigrants. In 2019 the total population of the Nordic region was around 27.3 million.

The population increase in 1990–2019 is uneven across the Nordic region. The population increase was 20 percent or higher in Sweden, Åland Islands, Norway, and Iceland; 13 percent in Denmark; and 11 percent in Finland. In the Faroe Islands the increase was around 7.5 percent, while Greenland only had a 0.8 percent increase. In Sweden, Norway, Denmark, and Åland Islands, immigration was the main reason for population growth. In Finland, natural increase and net migration were almost at equivalent levels, whereas natural increase in Iceland, Faroe Islands, and Greenland was the main reason for population growth. While there are between-country differences, immigration has overall played the key role in population change in the Nordic region, with Sweden having an absolute net migration of more than 1.2 million people during 1990–2019 (Grunfelder et al., 2020).

The migrant composition has also changed significantly in 1990–2019, shifting from primarily exchange of people between the Nordic countries in the 1990s to inflows from an increasingly diverse range of countries from 2000s and up until today. During the decade of 2010–2019, the focus was on refugees, and during the 2015 refugee crisis the Nordic countries received a large number of asylum seekers in comparison with many other European countries. Sweden stands out as the Nordic country with by far the largest refugee in-flow. The majority of refugees seeking asylum in Sweden, Norway, Denmark, and Finland during 2014–2017 came from Syria, Somalia, Iraq, Eritrea, and Afghanistan (Karlsdóttir et al., 2018).

Migrants is an umbrella term for people who move away from their place of usual residence. The reason for migrating can be either out of choice (for example, due to a job or education), or out of necessity (for example, due to war, torture, persecution, or poverty). Refugees are migrants who have migrated out of necessity (United Nations, n.d.; WHO Europe, 2018). 

Refugees are people who are unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion. Refugees are people who have fled war, violence, conflict, or persecution and have crossed an international border to find safety in another country (UNHCR, n.d.).

As the number of refugees in the Nordic countries has increased significantly since 2010, they are an important group to focus on in terms of health, too.

Refugees are a heterogeneous group with individuals from different countries with various backgrounds and previous experiences, but there are some health problems – such as psychological ill-health and low perceived self-rated health – that are often seen among refugees. Such lifestyle factors as stress, smoking, and physical inactivity are also common among refugees as are different lifestyle-related diseases such as type 2 diabetes. Other health problems such as sexual and reproductive health, perinatal and maternal mortality, and violence in close relationships leading to death are also prevalent in some refugee groups. At the same time, many refugees refrain from seeking healthcare even when they need it, and their participation in health promotion and disease prevention such as screening and vaccination programmes is less common than among the majority population (Wångdahl & Sørensen, 2020; Wångdahl et al., 2018).

The refugees’ health problems are often related to the social determinants of health, including age, gender, literacy, level of education, and socioeconomic factors. Exposure to health risks in the country of origin and during the flight such as violence, oppression, sanitary nuisances, lack of food and clean water, and healthcare can also be contributing factors. Factors related to resettlement in the new country include the risk of poverty, unemployment, social isolation, discrimination, and limited access to health information and healthcare due to language barriers (Wångdahl, 2017; Hempler et al., 2020). Migration is also seen as an independent social determinant for health (Thomas, 2016).

There are thus barriers that limit migrants’ and refugees’ access to healthcare and also limit their participation in health-promoting and disease-preventing activities. This is often due to the challenge of finding and understanding information about health and healthcare, not trusting the healthcare system, and not knowing how to get in contact with it. Communication problems related to both language and cultural issues between refugees and healthcare professionals are also common and can relate to limited health literacy on both an individual and organisational level (Wångdahl & Sørensen, 2020; Wångdahl, 2017).

Among some groups of refugees, it may be relevant to focus on the cultural differences in family structure and gender roles, as these may also have an impact on family health.

Some refugees come from countries where gender inequality is high, where the family structure is often patriarchal, and where women’s educational attainment and employment tends to be low. The women’s fertility rate tends to remain high in the host country, too, which is a key challenge for women’s integration in the new country both in terms of the labour market and health, and not only in relation to their own health but also the health of their family (Liebig & Tronstad, 2018).

A study from Norway on Somali refugee women shows that Somali women’s limited health literacy can have a significant impact on health information exchange and help-seeking for immigrant families. This is because women often play a central caring role in their families and the immediate community. Health planners should therefore pay particular attention to the limited health literacy of refugee women, as this can have significant implications for the health outcomes of migrant families (Gele et al., 2016). 

Also, the new host countries’ welfare institutions are designed to serve citizens with a relatively homogeneous cultural background and with a life course normally taking place in the host country. With increasing immigration, this is no longer a sustainable assumption. Immigrants arrive with different linguistic, cultural, and social experiences, norms and knowledge, and welfare institutions must adapt to this new reality if they are to serve their purpose of treating everyone equally (Hempler et al., 2020).

Two studies on participation in cervical cancer screening from Finland (Idehen et al., 2020) and Denmark (Hertzum-Larsen et al., 2019) both indicate that the lowest participation rate is among Somali women compared to other groups of immigrant women and native-born women. Neither of the two studies directly measures health literacy, but they do point out some barriers that might be a contributing factor to why the participation rate is so low among some immigrant women. These barriers relate to health literacy on both an individual and an organisational level. Some individual barriers pertain to low socioeconomic status, unemployment, illiteracy, poor language proficiency, lower awareness of the objective of screening, lower perceived cancer risk, mistrust in healthcare authorities, and cultural/religious beliefs. It may also be that information about the screening is given in the national language only, the invitation comes in a letter, there are no female screeners, the women have limited access to healthcare, and interpretation services are inadequate (Hertzum-Larsen et al., 2019; Idehen et al., 2020) – all of which constitute institutional barriers.

"It is therefore important that the host country focuses on the people who have a disease, not on the disease itself."

It is therefore important that the host country focuses on the people who have a disease, not on the disease itself, and on the possibility of early integration of migrants into a tailored health system. This may also help to determine the long-term health status of the migrant population (Gele et al., 2016; Sodemann, 2020).