As the global death toll of COVID-19 continues to rise, so grows the importance of mitigating its collateral effects on health equity. Of concern are refugee and non-refugee immigrant communities already facing myriad social, economic and health disparities. However, devising and implementing COVID-19 public health messaging, education, and disease surveillance strategies for multicultural and multilingual communities with varied backgrounds is complex. To develop sustainable and contextually-relevant solutions, close engagement with and empowerment of the local community is essential.
Resettlement agencies employing socially, linguistically, and culturally congruent health navigators joined forces with local university health providers to form a community-clinical partnership. This enabled 195 diverse refugee and non-refugee immigrant households to screen for COVID-19 and engage in dialogue that provided insight into community mindset and behaviors in the context of the pandemic. The benefits have been multifold.
Prevalence of COVID-19
This study found a 0.2% test positivity rate amongst local asymptomatic refugees and non-refugee immigrants at a time when the county test positivity rate was 0.8-1.2% . This was an encouraging finding, given higher rates of infection in minority communities cited across the U.S. In July, a similar refugee population was screened in the nearby city of Utica whereby 650 individuals showed an 8% positivity rate in the context of an overall county positivity rate of 1.2% .
A number of factors may have contributed to the relatively low COVID-19 positivity rate observed in this study cohort. When the study began in mid-July of 2020, the local community was seeing a significant decline in COVID-19 cases—schools had not yet re-opened in person learning and social gatherings were limited—and it is possible that our observations are reflective of that. Additionally, the study may have captured a lower risk subpopulation within the target population due to screening of mainly asymptomatic participants, the voluntary nature of participation, and high rate of high-risk employment in the population that may have logistically prohibited participation. The study team attempted to minimize such influences through flexible screening times and targeted recruitment efforts. Notably, low positivity rates might also be attributed, in part, to supportive community leaders and health navigators that have focused on disseminating preventative public health messaging since the pandemic’s start .
Data informed outreach & education
Targeted outreach facilitated efforts to capture a cohort reflective of the greater Syracuse refugee and non-refugee immigrant population. For example, upon initial demographic review (weeks 1-3), subjects originating from Syria, Iran, Iraq, Somalia, and Yemen were notably under-represented when compared to the greater Syracuse population [31,32]. All 5 countries received increased study representation after health navigators began targeted recruitment efforts. Ultimately, the study population comprised individuals of varied age, country of origin, primary spoken language, education, and employment background. Though participation was welcomed to all Syracuse refugee and non-refugee immigrant residents, targeted recruitment helped ensure inclusion of a diversity of ethnicity, background and experience - facilitating cross-culturally-informed education.
Most study participants reported activities and behaviors well-aligned with current public health recommendations during the pandemic, such as mask-wearing outside the home, physical distancing, and hand-washing/sanitizing. However, the prevalence of COVID-19 related myths uncovered by local resettlement agencies, qualitative feedback from health navigators as to why clients have refused study participation, and other survey findings highlight an ongoing need for COVID-19-related support and education.
Surveys offered a window into potentially effective approaches for scaled and targeted health messaging. Respondents most frequently cited media sources as their primary means for receiving COVID-19 related health information. However, they reported healthcare and local community-based resources as their most trusted sources of COVID-19 information. Social media pages with content informed by local clinicians, health professionals, and community leaders could minimize ambiguity of health messaging, facilitate accurate risk appraisal, inform protective behaviors, and allow for more trusted engagement with this population [33–35].
In addition to offering strategies for outreach, survey findings illuminate specific areas for improved education related to supporting appropriate risk appraisal, debunking myths, and enhancing protective behaviors. For example, the vast majority of household representatives did not perceive their households as high risk despite many having large household sizes and members working in high-risk settings. The misinformation and education gaps discovered through surveys must ultimately be considered in the context educational attainment. In this study, 41.2% of adults had either no formal education or completed primary school only. Accordingly, educational interventions can be tailored to meet the needs of individual households through collaboration with health navigators.
Community empowerment and social supports
Widespread loss, grief, and loneliness, layered with challenges to the stability of livelihoods and social networks, are just a few of the insults to mental health and wellbeing that persist amidst the COVID-19 pandemic and its resulting social and economic upheaval [2,8,36–40]. This study found that COVID-19 has impacted multiple psychosocial pathways, including household emotional health, financial security, and children’s education. Over 60% of survey respondents reported increased concern within each of the 6 concern-categories explored. While this may be an appropriate and informed response amongst a pandemic, refugee and non-refugee immigrant individuals experience a disproportionately high prevalence of traumatic events in their lifetimes and the pandemic has the potential to compound psychosocial stress [41–46]. These findings highlight the need to incorporate exploration of the psychosocial impacts of the pandemic in future studies and health-promoting interventions .
Given its positive influence on health and wellbeing, the value of strengthening social supports should not be understated . This public health intervention increased participants’ engagement with respected community resources and local healthcare workers during challenging times. Re-purposing community health navigators to focus on debunking COVID-19 myths, promoting public health education, and offering free household COVID screening opened doors to conversations previously hidden behind stigma, poor understanding, and shame. Connection to community resources also enabled delivery of food boxes, cleaning supplies, face masks and other social supports like employment, health, and school tutoring services, to families isolated by language and technology barriers. The team observed a shift in community confidence over the study period of 3 months, when on multiple occasions families who presented for initial testing with one household member later returned with remaining members and neighbors.
Social support, a known resilience-promoting factor, likely enhances the baseline resilience, resourcefulness, and capacity for adversity-activated growth that is well-documented within the refugee and non-refugee immigrant community – thereby promoting improvements in health and well-being during these unprecedented times [37,38,48–51].
Moving forward, this community-clinical partnership will shift efforts toward community resilience in the face of ongoing pandemic threat. Semi-structured interviews, aimed at understanding the community’s evolving COVID-19-related needs and perceptions, will occur with refugee community members, leaders, health navigators, and other stakeholders. Actionable insight will guide iterative evaluation and adaptation of interventions to address community needs. COVID-19 surveillance and public health education outreach will continue.
It is possible that survey responses, particularly those related to COVID-19 related behavior, activities, and knowledge, were affected by framing and confirmation, attribution, and social desirability biases. Minimization of biases was attempted by administering surveys through trusted and trained community members, asking mostly open-ended questions, and urging interviewers to avoid providing examples for questions. Self-selection bias must also be considered when interpreting both COVID-19 screening results and survey findings. This study offered a free service for a historically disadvantaged and underserved population, hence randomizing and controlling enrollment was not within the study intent. Thus, it is possible those that voluntarily enrolled had a more advanced COVID-19 knowledge base, had increased level of COVID-19 related concern, and practiced more precautionary measures compared to their uninterested counterparts.