To the best of our knowledge, our study is the first to show that migrants report a significantly lower probability, by approximately a third, of being offered the vaccine than non-migrants. The main factors taken into account by Norway when initially offering the vaccine were age, having comorbidities, working in a health care, and, later, living in an area with high rates of infection. While there were substantially fewer migrants in the oldest age category, there was an approximately even share of migrants and non-migrants among those reporting underlying health conditions in our study population. Further, a larger proportion of migrants than non-migrants worked in healthcare jobs with patient contact. All the parishes in our survey were among the prioritised areas for vaccination and had a high percentage of migrants, which allowed us to recruit many migrants. Nonetheless, even after controlling for the prioritization variables, which should theoretically have been the only contributors to observed disparities, significant differences between migrants and non-migrants were still observed.
However, differences in receiving an offer cannot fully explain the disparities in vaccination uptake. Unadjusted survey results show lower vaccination rates for migrants as compared to non-migrants among those offered a vaccine (79.9% vs. 91.1%), which is consistent with register data from Norway [9] and research in other countries regarding low vaccination uptake among migrants and ethnic minorities [21]. Nonetheless, our results suggest that issues associated with the necessary precondition of being offered a vaccine also play a role in observed vaccination differences. However, we cannot take for granted that being offered a vaccine is the same as reporting the offer, as the offer must be recognized and understood as such by the recipient to be reported. In-depth exploration of this process would require a qualitative approach, but our data can give some light to the mechanisms underlying the process.
Analyses of demographic and socioeconomic factors indicate higher level of completed education and female sex as, respectively, negatively and positively associated with reporting an offer of the vaccine. Females more often use health services and are therefore to a higher degree registered with the GP with several health conditions. Higher educated people tend to be healthier and use the GP to a lesser degree. Correlations with other variables that we have not measured, could also partially explain why people with higher levels of completed education reported having been offered a vaccine to a lesser degree. Further study, including interactions with income and other related variables, is necessary, as these results might reflect an underlying mechanism increasing health inequalities, especially since low income has previously been correlated with both notified cases of COVID-19 and hospitalizations in Norway [22].
To better understand the underlying mechanisms in the differences in access specific to migrants, we considered two variables related to the migrant background of the participants: language spoken at home and length of stay in the country. Language has previously been understood as the main key to vaccine uptake among migrants, and translating information has been the main strategy in the Nordic countries to target this group [23]. However, in our analyses, language spoken at home was not significantly related to reporting a vaccine offer among migrants. Similarly, there is growing evidence from Norway and Sweden showing higher rates of disease and death among non-migrants married to migrants compared to non-migrant only couples, supporting the suggestion that language alone is insufficient for explaining higher hospitalization and COVID-19 death rates among migrants [24, 25]. However, our question did not directly assess Norwegian proficiency for the individual participant, which might have diluted any association if some of the participants who spoke both or only other languages at home were proficient in Norwegian. Supporting this is the fact that we could find some association between vaccine offer acknowledgment and those who only spoke a foreign language at home in the analyses by country of origin. Also, a strongly contributing reason for our results might be the self-selection of participants in this survey, as more than 90% of respondents completed the survey in Norwegian despite having the option to complete the survey in different languages.
The duration of residence in Norway emerged as a key and consistent explanatory variable for vaccine offer, in accordance with a recent Norwegian report of actual vaccination rates among migrants [9]. The length of time a migrant has lived in a country is a complex variable related to several possible bottlenecks in the offer of the vaccination as shown in Fig. 1, such as inclusion in the municipal population register where the individuals have registered their age and address; access to and use of health care services, including GPs who were key in providing information on comorbidities [15]; and the degree of health literacy and digital literacy related to receiving the message and understanding it in Norwegian, which has recently been shown to be lower among migrants [26, 27]. Thus, all these factors should be specifically addressed in the future by policymakers and health services organizers when trying to reach the whole population with vaccination programs or other health programs.
We detected very few significant differences in being offered the vaccine based on birth country when we compared countries to each other. For comparisons of the top five represented countries, Sweden was selected as the reference for logistic regression because of its proximity and linguistic and cultural similarities to Norway. However, due to these factors and possible family and work connections leading to frequent mobility between the two at least when travel/borders were relatively open, many Swedish-born migrants may be registered in Sweden and have been offered the vaccine through the Swedish system. If so, their experiences may not fully reflect those of either the Norwegian-born group or people born in other countries, leading to confounding of results for these comparisons. The number of individuals in the other national groups were probably too low to be able to find statistically significant results at the 0.05 level. However, in addition to significantly lower ORs for migrants from Poland, interesting trends in these analyses are the tendencies of lower ORs for reporting being offered a vaccine for migrants from Pakistan and Somalia and the high OR for those from the Philippines, which mirror the vaccination rates of these groups in the national statistics [9]. This happened even though in Oslo municipality, where this study was conducted, Polish and Somali speaking personal were at times available and responsible for making invitations by phone to those with names that indicated origin from those areas.
Our sampling method targeted the six eastern parishes in Oslo where the largest shares of migrants live in Norway. Migrants are generally younger than non-migrants, more often have health care related jobs and have been more often infected by COVID-19 [9]. In these ways, the differences among migrants and non-migrants in our population are as expected. Although we cannot explain the reasons for a higher representation of men in the migrant population, our results are adjusted for sex. Even though one of the strengths of this study is the high percentage of migrants in our survey, including nearly a fourth of the net sample, they are still underrepresented relative to the areas we chose and, as stated above, the numbers might have been too small to detect significant differences for some analyses. Furthermore, the composition of countries and the long mean length of stay reveals that migrants in our survey were not representative of the migrant population in Norway [28]. Thus, even though we adjusted for several socioeconomic, epidemiological, and other factors, these analyses must be cautiously interpreted. Additional weaknesses with our survey are the generally low response rate which is otherwise typical for this type of survey, and that the population reached was composed of persons that are registered in the municipality. Thus, people who could not be reached to get an offer of the vaccine because of lack of registration, were not included in our population either. Probably, the share of migrants reporting having received an invitation to be vaccinated had been even lower if we had reached those with shorter lengths of stay in Norway and those with lower Norwegian proficiency levels.
Finally, it could be argued that our results do not reflect the actual offer of a vaccination but rather the report of a perceived offer by the population. It is possible that respondents did not recognize an offer or do not recall receiving it. It is known, for example, that migrants who do not speak Norwegian do not answer the telephone when the caller is not known. However, as shown in Fig. 1 and stated in the framework by Levesque et al., the perception of an offer is necessary to be able to seek, reach, and engage in healthcare. From that point of view, equity in health care services is not determined by the sender of a health care message, but by the receiver.