Engaging the vulnerable: A rapid review of public health communication aimed at migrants during the COVID-19 pandemic in Europe.

BACKGROUND: The World Health Organization recommends national risk communications tools targeting migrant communities to contain the spread of COVID-19. Within Europe, migrants are often left behind in healthcare due to structural barriers driven by hostile environment measures. This study aimed to assess inclusion of migrants in COVID-19 prevention measures by evaluating if governmental risk communications are available in common migrant languages across Europe.
METHODS: A rapid review was performed in June 2020 to understand the availability of government produced risk communications across Council of Europe member states, namely: COVID-19 health communications, migrant-specific guidelines and COVID-19 helplines.
RESULTS: 96% (45/47) of countries sampled had online government COVID-19 advice. 30% (15/47) issued information in their official language(s), whilst 64% (30/47) of countries delivered information in additional languages. 48% (23/47) translated information into at least one migrant language. However, information on testing or healthcare entitlements in common migrant languages was only found in 6% (3/47). Half (53%; 25/47) of the countries with COVID-19 helpline offered information in at least one alternative language.No government produced risk communications on disease prevention targeting people in refugee camps or informal settlements.
CONCLUSIONS: There are clear gaps in the availability of translated COVID-19 risk communications across Europe, excluding migrants from the COVID-19 response. Governments must reflect on the inclusion of migrants within their COVID-19 response and seek to engage vulnerable communities. Governments should urgently partner with non-governmental organizations who already play a key role in addressing unmet health needs.

Introduction

By declaring COVID-19 a public health emergency of international concern, the World Health Organisation (WHO) called for immediate action from governments to prepare their populations and health systems through a coordinated international response (World Health Organization, 2020). COVID-19 rapidly became a global pandemic requiring universal precautions to curb its spread (Sun et al., 2020). Across the world, public health interventions were implemented and communicated through national risk communication strategies.

COVID-19 can be fatal particularly in those with underlying health conditions (Sun et al., 2020). With no curative treatment or vaccine currently available, the control of COVID-19 relies on public health interventions alone (Adhikari et al., 2020). Therefore, ensuring populations have access to accurate information on the prevention, identification and management of COVID-19 is a critical step for any territory hoping to control an outbreak (Atchison et al., 2020). Health communication is an integral public health measure in infectious disease outbreak response (Laverack, 2017).

Health communication

Health communication is multifaceted, encompassing the communication between health institutions, health professionals and the wider general public. The European Centre Disease Prevention and Control (ECDC) defines six components of health communication (Table 1).

Table 1

Components of health communication, as defined by ECDC (Tang et al., 2020).

Component	Definition
Risk communication	A sustained communication process with a diverse audience about the likely outcomes of health and behavioural attitudes.
Crisis communication	A reactive communication effort in the event of an unforeseen event.
Outbreak communication	Communication that aims to bring an outbreak under control as quickly as possible, with as little social disruption as possible.
Health literacy	The capacity an individual has to access and effectively use health related information, in order to promote and maintain good health.
Health education	Teaching that influences a person's knowledge, attitudes’ and behaviours connected to health in a positive way.
Health advocacy	Raising awareness and promoting health and access to quality healthcare at individual and community levels.

Health communication activities can have a positive impact on health-related attitudes, beliefs and behaviours and have had success across countries that have been able to control the spread of COVID-19 so far (Tang et al., 2020, Lee et al., 2020).

For health communication to be a successful component of an outbreak response, entire populations of affected countries must be able to access, understand and comprehend the information being communicated (Kar and Cochran, 2019). It is essential that in the context of COVID-19 there is effective health communication with the whole population, following a “the health of one is the health of all” mindset. This includes health communication adapted to meet the needs of marginalised populations, such as migrants.

Migrant populations

Since 2015 more than a million people, predominantly asylum seekers, have risked their lives entering Europe (Beirens, 2020, UNHCR, 2020). This has come at a high cost; since 2017 over 2,700 people are believed to have gone missing or died whilst crossing the Mediterranean sea alone (UNHCR, 2020).

Simultaneously, exclusive policy and practice towards migrants has fostered a hostile environment throughout Europe, widening health and social inequalities between migrant communities particularly within the realms of accessibility, acceptability, availability and quality of health services (Shahvisi, 2019, Weller et al., 2019).

COVID-19 is of particular concern in the context of the health of migrants. Migrants show poorer health outcomes due to the impact of social determinants of health (Hargreaves et al., 2020). Almost 1 in 10 people living within the WHO European Region is an international migrant, a population known to be disproportionately affected by both communicable diseases, including vaccine preventable diseases, and non-communicable diseases (World Health Organization, 2019). Migrants and refugees are overrepresented within homeless populations, exposing them to overcrowded conditions without the ability to social distance, quarantine or practice basic hygiene measures vital for the prevention of infectious disease transmission. In addition, they are often seen as a ‘hard to reach’ group when it comes to public health communications and if not targeted appropriately, public health advice may not address linguistic or cultural barriers adequately. Migrant workers, many of Black, African and Minority Ethnic (BAME) background, have been identified to be at a higher risk of mortality from COVID-19 (Public Health England, 2020). An analysis by Public Health England on COVID-19 and its impact on BAME communities highlights the effects of racism and discrimination faced by this community as a root cause affecting health, and exposure risk and disease progression risk (Public Health England, 2020). In addition, this analysis evidences the detrimental effects of a hostile environment against migrants that continue to have adverse health effects (Doctors of the World UK, 2019).

Addressing these inequalities is a key element in pandemic preparedness and response, with efforts aimed at whole populations needed to effectively control an outbreak (Anderson et al., 2020).

Study rationale

In efforts to address various migrant health concerns within Europe, it has been acknowledged that there is a need for clear materials that are translated and culturally adapted (De Vito et al., 2017, Chiu, 2009). The WHO ‘Risk communication and community engagement for COVID-19’ guideline encourages that migrants and refugees are amongst the primary target audience for COVID-19 information messaging (World Health Organization, 2019).

As such, COVID-19 risk communications should be specifically tailored, available and accessible to migrant groups across Europe.

Aim

This study aims to characterise whether or not national governmental public health communications on COVID-19 are publicly available and accessible in the most common native languages of migrant groups across Europe. This work assesses common themes of public health communications, in order to evaluate effective engagement of migrants by governments through public health communications on COVID-19.

Methods

This study was conducted through a quantitative rapid review to synthesise current evidence around COVID-19, migrant groups and public health communication. This review evaluated official government public health communications across all 47 member states of Council of Europe (2019).

UN DESA defines migrant as “any person who changes his or her country of usual residence” (United Nations, 1998). This definition for migrants was used for all data collection. Demographic data (Table 2) was obtained from the World Bank and the United Nation (UN) DESA Population division (United Nations, 2019).

Table 2

Thematic framework.

Themes	Sub-themes
Changing social behaviours	Limitation of movement - lockdownPublic spacesPublic transportInternational travelProtecting employees and customers
Disease education	TestingTransmissionSeeking help – helpline, treatment centresSigns and symptomsTreatmentVaccination
Disease prevention	HandwashingFacemaskRespiratory hygienePhysical distancing
Maternal and child health	PregnancyChildbirthChild health – physical, social and mental wellbeingViolence against women
Mental health and wellbeing	Coping strategiesPsychological support available

47 websites of all Council of Europe government ministries were screened by all authors to determine: whether a COVID-19 helpline was available; what languages that helpline was available in and what COVID-19 public health communications were available online and in which languages. In addition, particular resources that were explicitly aimed at migrant communities were identified from official government websites. Data collection was completed on the 12/06/2020.

A thematic framework was developed and used to code and then collate themes and sub-themes of the available written COVID-19 government resources, in order to analyse the collated data (Table 2).

Results

Country demographics

Across the 47 countries studied there were 42 official languages. The most commonly identified migrant languages across European countries were: Arabic (n=11), German (n=10), Ukrainian (n=10) and Russian (n=10) (United Nations, 1998, United Nations, 2019). Small border countries had the highest proportion of migrant populations – Monaco (68%) and Lichtenstein (67%). However, the highest absolute number of migrants within a population were in Germany (n=13,016,207), followed by Russia (n=11,558,244) and the UK (n= 9,370,908).

Table 3 outlines countries included in the study (n=47).

Table 3

Baseline characteristics (UN DESA population division, The World Bank).

Country	Migrant (%)	Official Language(s)	Most Common Migrant Languages
Albania	1.7	Albanian	Greek, Italian, English
Andorra	58.5	Catalan	Spanish, French, Portuguese
Armenia	6.4	Armenian	Azerbaijani, Georgian, Russian
Austria	19.9	German	German, Serbian, Turkish
Azerbaijan	2.5	Azerbaijani	Armenian, Georgia, Russian
Belgium	17.2	Dutch, French, German	Arabic, French, Dutch
Bosnia and Herzegovina	1.1	Bosnian, Serbian, Croatian	Croatian, Serbian, Montenegrin
Bulgaria	2.4	Bulgarian	Russian, Arabic, Turkish
Croatia	12.5	Croatian	Bosnian, Serbian, German
Cyprus	16	Greek, Turkish	English, Georgian, Greek
Czech Republic	4.8	Czech, Slovak	Ukrainian, Slovak, Vietnamese
Denmark	12.5	Danish	Polish, Arabi, German, Turkish
Estonia	14.4	Estonian	Russian, Ukrainian, Belarussian
Finland	6.9	Finnish, Swedish	Estonian, Swedish, Arabic
France	12.8	French	Arabic, Portuguese, Italian
Georgia	2	Georgian	Russian, Armenian, Ukrainian
Germany	15.7	German	Polish, Turkish, Russian, Arabic
Greece	11.6	Greek	Albanian, German, Georgian
Hungary	5.3	Hungarian	Romanian, Ukrainian, Serbian
Iceland	15.5	Icelandic	Polish, Danish, English
Ireland	17.1	English, Irish	English, Polish, Lithuanian
Italy	10.4	Italian	Romanian, Albanian, Arabic
Latvia	12.4	Latvian	Russian, Ukrainian, Belarusian
Liechtenstein	67	German	German, French, Italian, Turkish
Lithuania	4.2	Lithuanian	Russian, Ukrainian, Belarusian
Luxembourg	47.4	French, German, Luxembourgish	Portuguese, French, German, Italian
Malta	19.3	English, Maltese	English, Italian, Somali
Monaco	68	French	French, Italian
Montenegro	11.3	Montenegrin	Bosnian, Serbian, German
Netherlands	13.4	Dutch	Turkish, Arabic, Dutch, Polish
North Macedonia	6.3	Macedonian, Albanian	Albanian, Turkish, Serbian
Norway	16.1	Norwegian, Sami	Polish, Swedish, Lithuanian, Somali
Poland	1.7	Polish	Ukrainian, Belarusian, German
Portugal	8.7	Portuguese	Portuguese, French
Republic of Moldova	2.6	Romanian	Ukrainian, Russian
Romania	2.4	Romanian	Romanian, Italian, Spanish
Russian Federation	8	Russian	Ukrainian, Kazakh, Uzbek
San Marino	16.3	Italian	Italian
Serbia	9.4	Serbian	Bosnian, Montenegrin, Croatian
Slovak Republic	3.4	Slovak	Czech, Hungarian, Ukrainian
Slovenia	12.2	Slovene	Bosnian, Croatian, Serbian
Spain	13.1	Spanish	Arabic, Romanian, Spanish, English
Sweden	20	Swedish	Arabic, Finish, Polish, Farsi
Switzerland	29.9	French, German, Italian, Romansh	German, Italian, Portuguese, French, Turkish
Turkey	7	Turkish	Arabic, Bulgarian, German
Ukraine	11.3	Ukrainian	Russian
United Kingdom	14.1	English	Hindi, Polish, Urdu

Availability of government COVID-19 phone helpline

Of the 47 European countries studied, we found that the majority (n=43) had a dedicated COVID-19 helpline telephone number. Summary of results is available in Supplementary File 1. Approximately half of these helplines were available exclusively in the official language(s) of the country (n= 20). However, there were examples where the helplines were available in additional alternative languages (n=23), most commonly English. However, only 19% (n=9) countries had the option to access a COVID-19 helpline in at least one of the three commonest migrant languages of that country through the telephone (Table 4).

Table 4

Translation of risk communications tools.

Risk Communication Intervention	% of countries with information available in official language	% of countries with information available in additional alternative language	% of countries with information available in common migrant language
COVID-19 Helpline	91% (43/47)	49% (23/47)	19% (9/47)
Hand washing Poster	36% (17/47)	26% (12/47)	6% (3/47)
Face masks Poster	26% (12/47)	13% (6/47)	9% (4/47)
Respiratory hygiene Poster	34% (16/47)	28% (13/47)	17% (8/47)

Availability of written, on-line governmental COVID-19 materials

It was possible to find written, online governmental COVID-19 material for 96% of countries (n=45). In 11 countries this material was only available in the official language(s). However, in 28 countries there was also material available in alternative languages, and in 23 countries this included at least one of the three most common migrant languages of that country. The most common European languages of the material included English, French and German. Arabic, Turkish and Farsi were the most common non-European languages across all themes.

Themes of written, online government COVID-19 materials

The most common themes of written, online government COVID-19 materials across all countries, irrespective of language, were disease education and information on changing social behaviour to prevent disease spread. Table 2 is a summary of the thematic framework from our results.

Materials aiming to promote COVID-19 prevention measures such as handwashing, use of face masks and respiratory hygiene were common examples of health communications. The breakdown of how these were translated into alternative and common migrant languages of each country are summarised in Table 4.

Information on COVID-19 testing procedure, how to access healthcare during the pandemic or whether entitlements to health services had changed during state of emergency were rarely (n=3) available in common migrant languages through health communication tools. Public Health England, Denmark and the Netherlands did provide migrant-specific guidance in 40 languages on what health entitlements were during the COVID-19 pandemic.

Maternal and child health information during the COVID-19 pandemic was available across only 15% (7/47) of countries. This information was translated into at least one migrant language in all cases found.

Belgium was the only country to provide posters on mental health and wellbeing and COVID-19 with translated versions in Dutch, English, French, German, Albanian, Amharic, Arabic, Armenian, Arabic, Armenian, Berber, Bulgarian, Chinese, Dari Farsi, Hebrew, Italian, Kinyarwanda, Lingala, Pashto, Polish, Portuguese, Russian, Serbian-Croatian, Somali, Spanish, Swahili, Tigrinya, Turkish and Urdu.

Government-provided mental health helplines or specific information regarding mental health in the context of the COVID-19 pandemic targeting migrant groups were not available in any of the countries included.

Specific information for migrant communities in refugee camps or informal settlements

Although guidance on COVID-19 prevention in refugee camps, detention centres or informal settlements is available from WHO (World Health Organization, 2020), no public health communications in the form of posters or infographics on disease prevention targeting specifically migrant groups and their health needs was found across the 47 European countries included in the study.

Discussion

With COVID-19 clusters reported in migrant dominated workplaces across Europe by mainstream media sources (Huggler and Badcock, 2020), it is essential that migrants have access to COVID-19 advice and information to help stop the spread of infection. Migrant communities are often stigmatised and are already inequitably served by many healthcare systems in Europe (Kluge et al., 2020). Living conditions for migrants across Europe are often overcrowded and migrants have been highlighted to be at a higher risk of communicable disease outbreaks than the general population (Greenaway and Castelli, 2019). Barriers to accessing healthcare have also been raised as a concern for migrant health (De Vito et al., 2017). It is therefore imperative that appropriate preventative health messaging which is tailored to these specific migrant needs is clear during COVID-19 if the already existing barriers are to be overcome.

Reports suggest that 15% of the refugee population are children who are likely to suffer from indirect consequences from the COVID-19 pandemic (You et al., 2020), it is concerning that those most vulnerable within European society will suffer most from gaps in the COVID-19 response. This study was conducted as a rapid review during a developing pandemic and due to time constraints posed, focused specifically on the availability of translated online materials from governments and not the quality. There is a gap in the current research body for further research in this area to understand the quality and appropriateness of the translated materials being produced by governments for migrant populations. However, the authors believe that due to the time sensitive nature of information in a pandemic this research will assist in understanding the initial response of governments in the pandemic, with specific regards to public health communications for migrants.

The creation of a national migrant targeted risk communication to slow and contain the spread of COVID-19 is recommended by the WHO (World Health Organization, 2020). However, with a minority of governments in Europe having produced these, or migrant focused health promotion material, many non-government organisations have been fulfilling this recommendation. Doctors of the World UK together with the British Red Cross have produced, and frequently updated, a comprehensive guidance specifically for migrant communities, which was based on government guidance and translated into 61 languages (Doctors of the World UK, 2020).The International Organization for Migration (IOM) have published translated COVID-19 advice to inform Migrant communities (International Organization Migration, 2020). The WHO Regional Office for Europe produced communications relating to the pandemic in 42 languages (World Health Organization. WHO Coronavirus Information). Despite the availability of these publications many European governments have failed to sign-post to these resources on national web pages, in the absence of nationally created communications. This calls into question the commitment of governments to reach its migrant populations in their COVID-19 communication strategies.

There is a human rights obligation for governments to act on the needs of migrants in the pandemic including but not limited to translation of public health communications. A joint statement from UNHCR, IOM, OHCHR and WHO was released stressing the need to protect migrant, refugee and stateless person's during this pandemic (UNHCR, 2020). International aid organisation Médecins Sans Frontiers have made similar calls relating to their concerns over the spread of COVID-19 in refugee camps in Greece (Médecins Sans Frontières MSF International, 2020). Doctors of the World UK has called for the UK government to produce and maintain accessible COVID-19 guidance in languages that reflect the country multilingual communities (Doctors of the World UK. DOTW, 2020). It is clear that civil society organizations support increased government focus on migrant groups during this pandemic and moving forward.

Policy actions for European Union members

The European Union is in a privileged position in regard to co-ordinating a comprehensive response to the COVID-19 pandemic. The European Commission has pushed for a European coordinated response to counter the economic impact of COVID-19 and it should strive to implement a harmonized health communication response through agencies like the European Centre for Disease Prevention and Control (ECDC).

Recommendations

Create national migrant targeted risk communications

Members states must produce health risk communications tools in all migrant languages to ensure health promotion, protection and education messages reach vulnerable groups.

Distribution of standardised health risk communication through the European Centre for Disease Prevention and Control (ECDC).

The ECDC has produced health messages in different European languages (European Centre for Disease Prevention and Control, 2020). However, these messages are not available in common migrant languages. The ECDC is an ideal platform to produce and distribute standardised risk communications tools in migrant languages.

Working with non-governmental organisations (NGOs) and migrant community groups

Countries must engage with NGOs and members of migrant communities to provide appropriate information on COVID-19 and deliver acceptable, appropriate, accessible health services to migrant groups.

Accessible COVID-19 Helplines

Member states must strive to deliver COVID-19 available in different migrant languages. This would be best delivered in partnership with NGOs and community groups.

Engagement of migrants in refugee camps or informal settlements

Specific health communication strategies must be implemented to address the health needs of migrants living in refugee camps or informal settlements.

Optimise social protection to mitigate the impact of COVID-19 on health inequalities and financial security

As countries commence to reopen their economies, migrant communities must be included in the legal and social protection measures regardless of their immigration status.

Limitations of the rapid review

This rapid review serves as comprehensive analysis of how Council of Europe members engaged migrants during the first wave of the COVID-19 pandemic. However, it is only reflective of the work carried out by governments up to June 2020. We recognise that countries have continued to build their health communications tools since then and progress in this field may not have been included. In addition, due to the time constrains of this rapid review, we only focused on national level work. We acknowledge that there will be work done at regional or local level that we have not been able to capture. The broad scope nature of the review means only risk communications tools implemented by national governments have been included and we have not addressed further work done by non-governmental organisations.

Further research

Future work should continue to explore how migrant communities are reached during the COVID-19 response. We suggest further qualitative analysis of the health communications tools used, exploring how health communications are adapted to target specific populations and the effectiveness of these communications. In addition, we encourage further study of the impact of COVID-19 on migrant groups. Our results indicate wide gaps in the information currently available to migrant communities. When designing pandemic response, policy efforts from national governments must include migrant communities themselves as well as non-governmental organizations in order to be truly responsive to migrant communities and beyond.

The use of health communications as a public health response to COVID-19 has been varied across Europe, especially with regards to government engagement with migrant communities. Countries have focused their health communications on hand washing, use of facemask and respiratory hygiene. However, there is a clear gap in the availability of materials on COVID-19 testing and health entitlements in migrant languages or focused towards migrants, despite this being a key step in the WHO National COVID-19 response plan recommendations.

Conclusion

We highlight a great variation in the availability of appropriate health communication in common migrant languages during the first wave of the COVID-19 pandemic across Council of Europe members. There is urgent need for further research into the quality and availability of health promotion materials made available by European governments during the COVID-19 pandemic, as a well as the role of other stakeholders. Migrants without a secure immigration status are already facing structural barriers across the region and will suffer most from the consequences of the COVID-19 outbreak. Effective health communications that engage the whole population following a “health of one is the health of all” mindset is key to pandemic response and a strategy that all governments should commit to as we face further surges in COVID-19 cases.

Declaration of Competing Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.