Adults with an immigrant background – that is, both people born abroad and their Swedish-born children – had a significantly higher incidence of severe COVID-19 compared with Swedish-born individuals with two Swedish-born parents. This is shown by a new study conducted by public health researchers at Stockholm University. According to the research team, addressing social inequalities is a key strategy for improving preparedness for future pandemics.
Although it is well documented that first-generation immigrants were disproportionately affected during the pandemic, there is a lack of knowledge about their children. In particular, there is limited knowledge about people who were born abroad but came to Sweden as children. In Sweden, people with one or two foreign-born parents make up about 13 percent of the population, making this group important for understanding long-term inequalities in public health.
A new study from Stockholm University shows that adults who were born abroad and arrived in Sweden as children, as well as Swedish-born individuals with foreign-born parents, were more severely affected by the COVID-19 pandemic than people born in Sweden to two Swedish-born parents.
The study is one of the first in Europe to examine hospitalization, intensive care treatment, and mortality due to COVID-19 infection among adults with different migration backgrounds during the coronavirus pandemic.
“It is well known that immigrants who came to Sweden as adults were severely affected by the pandemic. But our study shows that those who came to Sweden as children and people born in Sweden with foreign-born parents were affected to a similar extent,” says Agneta Cederström, researcher at the Department of Public Health Sciences, Stockholm University, and first author of the study.
Higher COVID-19 morbidity and mortality among people with a foreign background
The study shows that the risk was particularly high among people with roots in countries in the Global South, such as Africa, Latin America, the Caribbean, and Oceania – regardless of whether they were born abroad or in Sweden.
After adjusting for socioeconomic factors – living conditions and underlying health conditions – the risks in these groups were only partially reduced.
“These are some of the factors we can take into account using register data, but there is other relevant information that could not be examined in the current study. For example, people with insecure employment conditions or jobs that do not allow remote work may find it harder to follow recommendations to reduce the spread of infection,” says Sol P. Juárez, Senior Lecturer at the Department of Public Health Sciences, Stockholm University. She is the project leader of a research project aimed at explaining COVID-19 mortality among immigrants in Sweden.
Implications for future public health planning
Limited language skills or lack of familiarity with the Swedish healthcare system – for example, knowing how to get tested when infection is suspected – are often cited as explanations for why the pandemic hit foreign-born individuals harder. However, these factors apply to a lesser extent to people who came to Sweden as children or who were born and raised in Sweden. Nevertheless, people with a foreign background were affected almost as severely as their foreign-born parents.
“Many of the factors that made foreign-born adults more vulnerable—such as employment in healthcare-related occupations, insecure working conditions, and lower vaccination rates—are also found among Swedish-born individuals with a foreign background. When preparing for future pandemics, it is crucial to design preventive measures that reach groups at higher risk of being more severely affected by infectious diseases,” says Mikael Rostila, Professor at the Department of Public Health Sciences, Stockholm University, and co-author of the study.
Nearly 8 million people included in the study
Using Swedish population registers, the researchers followed nearly 8 million adults from December 2019 to June 2021. Individuals were categorized by immigrant generation:
- First generation: born abroad and came to Sweden as adults
- 1.5 generation: born abroad and came to Sweden as children
- Second generation: born in Sweden with two foreign-born parents
- 2.5 generation: born in Sweden with one foreign-born parent
“It is very important to clarify that the term ‘immigrant generation’ is a technical term often used in research. We use it solely to better understand inequality processes rooted in migration. The term should not be used outside this context, as it may unintentionally divide or stigmatize individuals who have the same rights and should have the same opportunities as everyone else,” says Sol P. Juárez, Senior Lecturer at the Department of Public Health Sciences, Stockholm University.
The research team emphasizes that efforts to reduce social inequalities are a key strategy for improving preparedness for future pandemics.
For more information about the study, contact:
Agneta Cederström, researcher at the Department of Public Health Sciences,
agneta.cederstrom@su.se
Håkan Soold
Facts
The article “COVID-19 outcomes by immigrant generation in Sweden: a national cohort population-based study” was recently published in the scientific journal European Journal of Public Health.
The study is part of the research project Explanations for excess mortality in COVID-19 among immigrants in Sweden, led by Sol P. Juárez, Senior Lecturer at the Department of Public Health Sciences, Stockholm University. The project is funded by Forte – the Swedish Research Council for Health, Working Life and Welfare.
The authors of the study are Agneta Cederström, Mikael Rostila, and Sol P. Juárez, all at the Department of Public Health Sciences, Stockholm University.