COVID-19 Information in Sweden: Opinions of Immigrants with Limited Proficiency in Swedish

ABSTRACT

COVID-19 has highlighted the importance of health information for prevention of communicable disease. Knowledge about groups that have high risk is important to prevent disease transmission. In Sweden, immigrants have been identified as one such group. Yet, little is known about where they have sourced information about COVID-19 and their opinions toward it. The aim of this study was to describe the COVID-19 information sources used by immigrants with limited proficiency in Swedish as well as their opinions on how comprehensive the information has been, the importance of the recommendations and their possibility to follow them. A cross-sectional survey was conducted via introductory Swedish language classes in Region Uppsala (n = 855). The results showed the immigrants were using different information sources, with the majority using school, media and social media. The immigrants’ opinions about COVID-19 information differed. Most reported they knew where to find information; however, over two-fifths reported the recommendations from the authorities should be more extensive. The majority reported it is important to follow the recommendations, whereas the possibility to follow the recommendations was more mixed. Age differences in opinions toward COVID-19 information were detected. Although the results were largely positive, there still appears to be a need for improvement in how immigrant groups with limited ability in the host country´s language are reached. Effective health communication that engages the whole nation is an important factor authorities should commit to as we face the current pandemic. This research suggests that an approach tailored by age could be helpful.

KEYWORDS:

• immigrants
• health information
• COVID-19
• opinions
• Sweden

Introduction

In January 2020, the Public Health Agency of Sweden announced that a new coronavirus had been discovered in Wuhan, China (Public Health Agency of Sweden, 2020). Societal control measures in Sweden have differed from other countries (Baral et al., 2021). Within a month, older people were advised to limit their social contacts as much as possible. Soon after, upper secondary schools and universities were instructed to move to distance education to prevent gathering in classrooms (Public Health Agency of Sweden, 2020). Public gatherings such as concerts and sports events were prohibited. Unlike other countries around the world, Sweden decided not to implement a “lockdown”. Recommended hygiene practices were communicated, in order to minimize the risk of spreading the virus to others. Other recommendations included safety behaviors such as maintaining physical distance, refraining from unnecessary travel, carefully washing hands and avoiding touching the face.

Health communication is the communication between health institutions, health professionals and the wider general public (Maldonado et al., 2020). In order for health communication to be successful, for example during a pandemic, all members of the population must be able to access, understand and use the information being communicated (Maldonado et al., 2020). Well-developed and accurate health communication can facilitate how the population accomplish behavior change, handle uncertainty and raise hope in the face of a crisis (Finset et al., 2020). Generally speaking, seeking health information has a positive influence on individuals’ health knowledge, health behaviors, prevention activities, healthcare service usage and their relationships with healthcare professionals (Patel et al., 2014). Individuals who obtain and utilize health information tend to have a healthier life; this makes health information seeking an indicator for health equity (Ahn & Chae, 2019). COVID-19 has highlighted the importance of health information in order for prevention of communicable disease. Knowledge about groups that have high risk is important to prevent disease transmission. There is a need for action to reach these groups, such as community engagement and targeted health communication strategies.

Immigrants as a risk group

Immigrants are known for having lower accessibility to health information, due to language and cultural differences, their socioeconomic position and unfamiliarity with the healthcare system (Ahn & Chae, 2019). Health literacy, i.e. being able to place a person’s own health, and that of one’s family and community into context, understanding which factors can influence it and at the same time knowing how to address it, has been highlighted as a key factor for this group (Sorensen et al., 2015; Wangdahl et al., 2018). The International Organization for Migration defines an international immigrant as “a non-national person who is moving into a country for the purpose of settlement” (Perruchoud & Redpath-Cross, 2011). This paper focuses on immigrants whom have low ability in the host country language i.e. those attending Swedish language classes. This may affect their ability to understand health information (Martensson et al., 2020) and is associated with significantly low online accessibility and utilization of information technology regarding health information (Ahn & Chae, 2019). From 2015 to 2019, over 650,000 residence permits were granted in Sweden (Swedish Migration Agency, 2021), which means that many people in Sweden have limited ability in the Swedish language. A review of government-produced COVID-19 information sources across Europe highlighted clear gaps in the availability of translated COVID-19 risk communications (Maldonado et al., 2020), indicating an exclusion of this vulnerable population from the COVID-19 response. Yet, little is known about what information sources immigrants with limited proficiency in Swedish have used to find information about COVID-19 and their opinions toward the information. Investigation of COVID-19 information sources among this group is therefore warranted. The aforementioned “gaps” in available information indicate that the comprehensiveness of the information should also be assessed.

The effectiveness of public health information is underpinned by compliance, i.e. the public following the guidance. Compliance is influenced by how important people perceive the guidance to be; yet, another aspect that should be considered is the possibility to follow guidelines (Van Den Broucke, 2020). In Sweden, immigrants whom have been in the country a few years and have limited proficiency in Swedish have been identified as a COVID-19 risk group. Immigrants from Syria, Somalia and Iraq have experienced higher rates of COVID-19, as well as greater risk of mortality (Drefahl et al., 2020). The elevated rates of COVID-19 mortality among immigrants align with previous research that highlights immigrants’ vulnerability to serious health inequities and poorer health outcomes (Wangdahl et al., 2018). Socioeconomic factors are an important aspect that can, in part, explain COVID-19 mortality. Household size, overcrowding and income have all been shown to be influential (Bartelink et al., 2020). Immigrants are a vulnerable group that tend to live in housing conditions where social distancing is difficult to perform (Koh, 2020). Overcrowded housing conditions, as well as higher incidence of poverty and having occupations where physical distancing is challenging, places immigrants at higher risk of contracting COVID-19 (OECD, 2020).

Age differences in health information needs and compliance

There is evidence that health literacy is lower among older age groups (Sorensen et al., 2015). One aspect of this is functional health literacy, i.e. the ability to read and comprehend health-related information, which has been shown to decrease with age (Baker et al., 2000; Gazmararian et al., 1999; Williams et al., 1995). This could be attributed to a general decline in reading ability and effortful processing of information (Baker et al., 2000; Kirsch et al., 1993). Relevant to the immigration context, age has been identified as a potentially important factor in foreign language acquisition. Immigrants arriving at an older age have to invest more effort than young arrivals to reach an equivalent level of host country language proficiency (Isphording, 2014). This age difference is further amplified if the first language is linguistically distant to the destination language (Isphording, 2014). It has also been suggested that adult students lack adaptation skills to current methodologies of foreign language teaching (Bernal Castañeda, 2017).

Age could also affect how immigrants are accessing health information about COVID-19. Research indicates that the use of online resources for obtaining health information is increasing (Fox & Jones, 2011). Since the outbreak of COVID-19, there have been many (formal and informal) posts on websites and social media platforms including Facebook, Instagram, and Twitter about public health guidelines and governmental instructions. Yet, age could play an important role in whether or not people are accessing COVID-19 information in this way. Age differences in Internet use are well established, with older individuals far less likely than younger ones to use the Internet for information (Stronge et al., 2006). Moreover, older people report greater difficulty in locating information on the Internet (Stronge et al., 2006). In terms of seeking health information online, research indicates that there is greater uptake of eHealth initiatives by younger individuals (Kontos et al., 2014; Tennant et al., 2015). Yet, although the Internet can enable relative ease of access to health information, there is also a risk of misinformation. Without the necessary eHealth literacy to effectively search for and appraise online health information, users may uncover poor quality health information. For example, an assessment of COVID-19 information on Twitter reported that around a quarter of tweets included misinformation (Kouzy et al., 2020). COVID-19 misinformation on Swedish websites has also been highlighted as a concern (Stern et al., 2021). Research shows there is stronger COVID-19 misinformation belief among younger adults, and that older adults are able to deploy their more extensive general knowledge to critically evaluate new health information (Santosh et al., 2021).

With regard to compliance with public health measures aimed to control COVID-19, age differences have been identified in serval international studies whereby younger individuals report lower levels of compliance (Barari et al., 2020; Brankston et al., 2021; Lin et al., 2021). One study explored the characteristics of young adults associated with compliance in Switzerland and identified differences according to migrant background, with noncompliance more common among young adults with a non-migrant background (Nivette et al., 2021). Yet, exploration of age differences among immigrants is lacking.

Aim

The aim of this study was to describe the COVID-19 information sources used by immigrants with limited proficiency in Swedish as well as their opinions on how comprehensive the information has been, the importance of the recommendations and their possibility to follow the recommendations. A further aim was to explore how age interacted with their opinions about the COVID-19 information. The research can be used to improve Public Health Agency knowledge of this demographic group and focus health promotion efforts on their needs.

Materials and methods

A cross-sectional survey was conducted via introductory Swedish language classes at upper secondary schools and Swedish for Immigrants (SFI) language classes in Region Uppsala. The population in Region Uppsala is 383 713, of which 71,555 were born abroad (SCB, 2021). Seven out of eight municipalities in Region Uppsala participated in the survey. One of the municipalities was excluded due to participating in another survey conducted by the Public Health Agency of Sweden earlier in the year. In Sweden, one can voluntarily enroll to upper secondary school from 16 to 20 years to receive education free of charge. Many upper secondary schools offer “introduction” classes to immigrant students to teach the Swedish language and culture. SFI is a free national Swedish course offered to adult immigrants. It is a state-funded program that ensures Swedish immigrants have the right to free basic language tuition. SFI forms part of an establishment program that all immigrants who have received a Swedish residential permit due to asylum, or as a relative to somebody who has, take part in to receive an establishment grant of approximately 300 Swedish krona (35 US dollars) per day, as well as other benefits such as housing support. The establishment program runs for around 2 years, and must not exceed 3 years. Due to this, it is likely that few of those in the sample were established in the Swedish society.

The survey was administered electronically. All of the students in introductory Swedish language classes at upper secondary school and the SFI program received an information letter and instructions on how to answer the questionnaire electronically by their responsible teacher. The respondents answered the questionnaire during a language lesson in the presence of their teacher. Data were collected between 28th September and 16 October 2020. The survey consisted of 22 questions and was made available in six different languages, which were: Arabic, English, Farsi, Somali, Swedish and Tigrinya. The languages were selected by Region Uppsala based on the demographics of language class attendees. To examine and answer the research questions in this study, a selection of the questions on the survey were analyzed (Table 1).

Table 1. Variables, survey questions, and response options.

Variables	Survey question	Responce Options
Age	How old are you?	15–20 years
		21-30
		31-40
		41-50
		51-60
		61-70
		71 or older
Gender	Are you … ?	Male
		Female
		I don’t want to answer
		Other
Year of arrival	What year did you come to Sweden?	2020
		2019
		2018
		2017
		2016
		2015
		2014
		2013
		2012
		2011 or earlier
		Do not want to answer
Native country	Were you born in a country inside or outside the EU (European Union)?	Within the EU (European Union)
		Outside the EU (European Union)
		Do not know/do not want to answer
SFI level	Which level of SFI do you read?	1
		2
		3
COVID-19 information source(s)	How have you received information about the corona virus in the last seven days? You can select several responses.	Have not received any information
		Friends or acquaintances
		School (SFI, upper secondary school)
		At work
		1177 care guide (phone or online)
		Healthcare
		Media (radio, newspaper, TV)
		Social media (e.g. Facebook, Twitter, Instagram, blogger, YouTube)
		Internet search via search engine (e.g. Google, Bing, Yahoo)
		Swedish Public Health Agency website
		Foreign media (e.g. Al Jazeera)
		Swedish news in other languages (e.g. Al Kompis, Aktarr)
		Other ways
Comprehensiveness of COVID-19 information	What do you think about the authorities’ information regarding the new coronavirus?	It should be more extensive
		It is extensive enough
		It should be less extensive
	Do you think you have the information you need about corona virus regarding: The authorities’ work so far? Where you can find new information? Where you can turn for questions? What you can do yourself? Who are the risk groups? The situation in Sweden? The situation globally?	Yes No
Importance of recommendations	How important do you think it is to follow the authorities’ recommendations regarding the corona virus? Staying at home if you have symptoms Not visiting the elderly Keeping distance	Unimportant (1) Quite unimportant (2) Neither important nor unimportant (3) Quite important (4) Important (5)
Possibility to follow recommendation	How do you feel about following the authorities’ recommendations regarding the corona virus? Staying at home if you have symptoms Not visiting the elderly Keeping distance	Very difficult (1) Quite difficult (2) Neither difficult nor difficult (3) Quite easy (4) Very easy (5)

The Swedish legislation on ethical review for research involving human subjects (SFS 2003:460) stipulates that it applies to “research involving the processing of: personal data referred to in article 9 in the EU data protection regulation (sensitive personal data); or personal data on offenses involving crime, criminal convictions, coercive measures or administrative detentions”. The survey of this study was anonymous and no personal details about the participants were sought or stored. The brief background questions included in the survey were carefully designed to be broad and not leading to a risk of identifying individual participants. Thus, the survey could be conducted without ethical review but with consideration to ethical principles.

IBM SPSS Statistics version 27 was used to conduct the analysis. Descriptive analysis was used to portray the sample characteristics and explore COVID-19 information sources and opinion toward the information. Due to a small number of responses in some of the age ranges used in the survey, the age ranges were collapsed into 3 categories: 15–30 years, 31–50 years, and 51–70 years. Only definite response options were included in the analysis, i.e. “Don’t know” and “Do not want to respond” responses were excluded. In order to explore whether age was associated with opinions about COVID-19 information, chi-square and Kruskal-Wallis tests were conducted. Post-hoc pairwise tests were used when a significant association was found. When chi-square tests were used, pairwise z-tests were conducted (Sharpe, 2015). After using Kruskal-Wallis for the analysis, Dunn’s test was utilized (Dinno, 2015). In order to avoid type 1 errors in the analysis (i.e. false positives) by repeated significance testing, the Bonferroni correction was applied (Nahler, 2009).

Results

Sample characteristics

In total, 855 immigrants completed at least part of the survey. The majority of respondents were between 15 and 30 years old (53%), followed by 31 to 50 years old (38%), and a small amount between 51 to 70 years old (9%). Around half were female (49%) and half male (46%), with a small proportion not declaring their gender (5%). The majority of the immigrants were residents in Uppsala municipality (65%). Of those that indicated their year of arrival, most arrived since 2015 (83%) i.e. they had been in Sweden for a maximum of 5 years (1 year: 8%; 2 years: 13%; 3 years: 18%; 4 years: 15%; 5 years: 7%; 6 years: 5%; 7 years: 2%; 8 years: 1%; 9 or more years: 3%). In terms of native country, most of the immigrants in this sample were born outside the EU (79%). Of those who indicated their SFI level, 28% was at level 1 (lowest), 39% was at level 2 (middle) and 33% was at level 3 (highest). Half chose to respond to the survey in Swedish (50%). Of the alternative languages, 18% responded in Arabic, 10% in Tigrinya, 9% in English, 6% in Somali and 6% in Farsi.

COVID-19 information sources

The respondents used various tools to get information regarding COVID-19. Most of the immigrants were getting their information from school, like SFI and the upper secondary school (53%) and the media, such as TV, radio or newspapers (51%). Another common source was social media, where 46% answered they get information from sites such as Facebook, Twitter, Instagram, blogger, or YouTube. Swedish news in another language, such as Al Kompis and Aktarr, was also a way for the immigrants to get information about COVID-19 (33%), as was via friends and acquaintances (30%). The Public Health Agency website was not as commonly used (18%).

Immigrants’ opinions about COVID-19 information

Comprehensiveness of information

The vast majority of respondents felt they had the necessary information about the authorities’ work so far (82%), where to find information regarding COVID-19 (86%), what they can do themselves (91%), who are the risk group (87%), and how the situation looked in Sweden (89%) and globally (86%). Yet, when directly asked about the comprehensiveness of the information, the largest proportion of respondents reported the information from the authorities should be more extensive (44%), and nearly a fifth (19%) did not know where to turn with questions.

Importance of following recommendations

When asked to rate the importance of following the authorities’ COVID-19 recommendations, from 1 (unimportant) to 5 (important), most reported that it is “important” to stay home if you have symptoms (70%), not visit the elderly (61%), and to keep distance (68%). The average scores were around 4 out of 5 across all the recommendations (range: 4.3–4.5).

Possibility to follow recommendations

The opinions about the possibility to follow the recommendations were quite mixed. Whilst around a third of the respondents indicated that it was “very easy” to follow them (31–38%), the other responses were mixed. The average scores were all around 3 out of 5, whereby a higher score indicated a higher level of ease to follow (range: 3.2–3.6). A larger proportion indicated they found them ‘very easy’ or ‘quite easy’ to follow than ‘very hard’ or ‘quite hard’ across all of the recommendations (staying at home if you have symptoms; not visiting the elderly; and keeping distance).

Association between age and immigrants’ opinions about COVID-19 information

Comprehensiveness of information

The respondents’ opinions on the comprehensiveness of the authorities’ information regarding COVID-19, in terms of whether it should be more or less extensive, differed by age group, (χ² (4, N = 501) = 11.445, p = .022). Pairwise Z tests were carried out for the three pairs of age groups (15–30 years/31–50 years; 15–30 years/51–70 years; 31–50 years/51–70 years). There was evidence (p < .05) of a difference between the youngest age group (15–30 years) and the middle age group (31–50 years) on the information being less extensive. This held true after applying the Bonferroni correction for multiple comparisons. The distribution of responses by age group is presented in Table 2.

Table 2. Distribution of responses regarding the comprehensiveness of the authorities’ COVID-19 information, by age group.

	It should be less extensive	It is extensive enough	It should be more extensive	n
15–30 years	37 (15%)^a	103 (41%)	109 (44%)	249
31–50 years	13 (6%)^a	93 (46%)	96 (48%)	202
51–70 years	6 (12%)	28 (56%)	16 (32%)	50

asignificant at the .05 level based on z-test.

The proportions of respondents indicating “yes” or ‘no’ on the survey question regarding whether or not they had the information they needed about COVID-19 are presented by age group in Table 3. A series of chi-square tests indicated that the respondents’ opinions on having the information they needed differed by age group for: the authorities’ work so far (χ² (2, N = 418) = 7.557, p = .023); what you can do yourself (χ² (2, N = 395) = 7.253, p = .027); and the situation globally (χ² (2, N = 380) = 6.298, p = .043). Pairwise Z tests were carried out for the three pairs of age groups. There was evidence (p < .05) of a difference between the oldest age group (51–70 years) and the middle age group (31–50 years) for the authorities’ work so far and the situation globally. This held true after applying the Bonferroni correction for multiple comparisons. It was not possible to perform Z tests for what you can do yourself because the proportion of respondents in the oldest age category (51–70 years) that responded “no” to the question was equal to zero, which violates the assumptions for the test.

Table 3. Distribution of responses regarding having the necessary information, by age group.

Do you think you have the information you need about corona virus regarding:	15–30 years	31–50 years	51–70 years	n	Chi-square P value
The authorities’ work so far?
Yes	214 (83%)	157 (79%)^a	47 (96%)^a	418	023*
No	45 (17%)	41 (21%)^b	2 (4%)^b
Where you can find new information?
Yes	197 (87%)	145 (86%)	34 (90%)	376	814
No	29 (13%)	24 (14%)	4 (11%)
Where you can turn for questions?
Yes	171 (83%)	133 (80%)	35 (83%)	339	747
No	35 (17%)	33 (20%)	7 (17%)
What you can do yourself?
Yes	210 (92%)	160 (88%)	47 (100%)	395	027*
No	18 (8%)	22 (12%)	0 (0%)
Who are the risk groups?
Yes	187 (87%)	137 (86%)	48 (98%)	372	067
No	29 (13%)	22 (14%)	1 (2%)
The situation in Sweden?
Yes	200 (87%)	147 (88%)	49 (98%)	386	089
No	29 (13%)	20 (12%)	1 (2%)
The situation globally?
Yes	196 (86%)	137 (84%)^c	47 (98%)^c	380	043*
No	33 (14%)	26 (16%)^d	1 (2%)^d

*significant at the .05 level based on chi-square test.

bsignificant at the .05 level based on z-test.

Importance of following recommendations

When asked to rate the importance of following the authorities’ COVID-19 recommendations, from 1 (unimportant) to 5 (important), the responses differed by age group for all of the recommendations: staying at home if you have symptoms (H(2) = 8.795, p = .012); not visiting the elderly (H(2) = 15.839, p < .001; and keeping distance (H(2) = 19.255, p < .001). Dunn’s pairwise tests were carried out for the three pairs of age groups. There was evidence (p < .05) of a difference between the youngest age group (15–30 years) and the other age groups on all recommendations, with the younger group generally reporting lower scores indicating a lower level of importance. This held true after applying the Bonferroni correction for multiple comparisons. The distribution of responses by age group is presented in Table 4.

Table 4. Distribution of responses regarding the importance of following the authorities’ COVID-19 recommendations, by age group.

	Unimportant	Quite unimportant	Neither important nor unimportant	Quite important	Important	n
	(1)	(2)	(3)	(4)	(5)
Staying at home if you have symptoms
15–30 years^a	16 (5%)	15 (5%)	19 (6%)	46 (14%)	226 (70%)	322
31–50 years	8 (3%)	10 (4%)	10 (4%)	25 (10%)	191 (78%)	244
51–70 years^a	0 (0%)	0 (0%)	1 (2%)	8 (14%)	48 (84%)	57
Not visiting the elderly 15-
30 years^b	15 (4%)	16 (6%)	20 (8%)	54 (20%)	160 (60%)	265
31–50 years	8 (4%)	3 (1%)	16 (7%)	33 (15%)	163 (73%)	223
51–70 years^b	1 (2%)	0 (0%)	1 (2%)	7 (14%)	42 (82%)	51
Keeping distance
15–30 years^c	20 (7%)	14 (5%)	17 (6%)	54 (17%)	205 (66%)	310
31–50 years	9 (4%)	2 (1%)	9 (4%)	28 (12%)	182 (79%)	299
51–70 years^c	1 (2%)	0 (0%)	0 (0%)	5 (10%)	46 (89%)	52

asignificant at the .05 level based on Dunn’s test.

Possibility to follow recommendations

When asked to rate the possibility to follow the authorities’ COVID-19 recommendations, from 1 (very difficult) to 5 (easy), the responses differed by age group for two of the three recommendations: staying at home if you have symptoms (H(2) = 18.636, p < .001); and keeping distance (H(2) = 19.316, p < .001). Dunn’s pairwise tests were carried out for the three pairs of age groups. For staying at home if you have symptoms there was evidence (p < .05) of a difference between the oldest age group (51–70 years) and the other age groups, with the older group generally reporting higher scores indicating a higher level of possibility (i.e. they found it easier to follow the recommendation). For keeping distance, there was evidence (p < .05) of a difference between the youngest age group (15–30 years) and the other age groups, with the younger group generally reporting lower scores indicating a lower level of possibility (i.e. they found it more difficult to follow the recommendation). This held true after applying the Bonferroni correction for multiple comparisons. The distribution of responses by age group is presented in Table 5.

Table 5. Distribution of responses regarding the possibility to follow the authorities’ COVID-19 recommendations, by age group.

	Very difficult	Quite difficult	Neither difficult nor easy	Quite easy	Easy	n
	(1)	(2)	(3)	(4)	(5)
Staying at home if you have symptoms
15–30 years^a	60 (19%)	39 (12%)	63 (20%)	56 (18%)	99 (31%)	317
31–50 years^b	31 (13%)	30 (13%)	51 (22%)	47 (20%)	76 (32%)	235
51–70 years^a,b	2 (4%)	2 (4%)	7 (13%)	16 (29%)	29 (52%)	56
Not visiting the elderly
15–30 years	31 (12%)	30 (12%)	37 (15%)	46 (18%)	112 (44%)	256
31–50 years	27 (13%)	25 (12%)	37 (17%)	30 (14%)	95 (44%)	214
51–70 years	5 (10%)	1 (2%)	6 (12%)	15 (29%)	25 (48%)	52
Keeping distance
15–30 years^c,d	59 (19%)	51 (17%)	37 (12%)	59 (19%)	103 (33%)	309
31–50 years^c	25 (11%)	21 (9%)	36 (16%)	47 (20%)	101 (44%)	230
51–70 years^d	4 (8%)	2 (4%)	5 (10%)	13 (26%)	27 (53%)	51

asignificant at the .05-level based on Dunn’s test.

Discussion

In this study, the majority of immigrants were getting COVID-19 information from school and media, such as radio, TV and newspapers. These could be seen as good sources of COVID-19 information since schools national TV and newspapers tend to use reliable sources. This is in line with similar studies that show people get COVID-19 information from different sources such as TV and Internet news portals (Elhadad et al., 2020; Shafiq et al., 2021). Yet, many of the immigrants (46%) also got information from social media. Even though social media can be used to improve knowledge regarding health information, it can also create potential risks for individuals. A distribution of low-quality information can cause harm for the population even though engagement in social media can be seen as a factor influencing improved individual health. When using social media as a source of information there is a high risk of people encountering misleading information (Sumayyia et al., 2019). Indeed, an analysis of COVID-19 information on Swedish websites concluded there were substantial quality deficits at the beginning of the pandemic, with information counteracting public recommendations for preventive measures (Stern et al., 2021). This highlights a critical need for standardization of how to disseminate high-quality web-based information when new epidemics and pandemics emerge. This issue is especially problematic if individuals have low health literacy, as this can affect their ability to judge whether the health information is reliable. A domino effect could also take place if misunderstood information is transmitted through friends and acquaintances. A number of corrective interventions for misinformation exist. Research indicates that providing factual elaboration or alternative explanations in addition to warning about the presence of misinformation is most effective (Blank & Launay, 2014; Walter & Murphy, 2018). Health institutions and policymakers can help reduce the potential harm of misleading or incorrect information being transmitted through social media by promoting reliable information. Using social media could also lead to immigrants having misleading information regarding COVID-19 from friends and family countries around the world, whom are disseminating international information that contradicts local information.

The reports from immigrants in this sample that the recommendations should be more extensive could also be associated with how the information the authorities were sending out the information. It could be the communication method was not suitable for them. In a paper assessing Public Health Agencies’ online communications about COVID-19, Tagliacozzo et al. (2021) stated that when spreading tailored information, not all social groups were considered equally. Groups like immigrants hardly received tailored information toward them in Sweden (Tagliacozzo et al., 2021). There is a need for well-developed health information and health communication so that authorities can facilitate how the population can handle misinformation and fear (Finset et al., 2020).

Even though the immigrants generally reported it was important to follow the COVID-19 recommendations, opinions toward the possibility to follow the recommendations differed. Previous studies show that immigrant groups have higher rates of COVID-19 and hospitalization due to the disease (Drefahl et al., 2020). A possible explanation of this could be socioeconomic factors, household and income, as it plays a significant role when it comes to COVID-19 (Bartelink et al., 2020). Income is an important factor and being socioeconomically vulnerable might make it more difficult to follow the recommendation to stay at home if you have symptoms when you need to go to work to achieve a stable income to survive (Koh, 2020). According to Calderon-Larranaga et al. (2020), reduced income may also lead to home overcrowding, reduced educational level and lower health literacy, which may impact access to and understanding of the public health advice.

With regard to the age differences detected in this study, international studies have indicated age-related differences in attitudes toward COVID-19. For instance, younger individuals were less likely to engage in preventative behaviors, such as hand washing and keeping social distance in Italy (Barari et al., 2020). In the United States (US), younger individuals have been shown to view COVID-19 as a less serious health risk (Pew Research Center, 2020). In Canada, younger individuals were less likely to consider COVID-19 public health measures to be effective and had less confidence in their ability to comply (Brankston et al., 2021). A large-scale multi-national evaluation of compliance with COVID-19 public health measures also detected age differences, with younger age associated with lower compliance (Lin et al., 2021). These findings align with the present study, in which younger respondents reported lower importance of following COVID-19 recommendations. When considering the dissemination of health information, this means that age-based messaging strategies could be effective – for both immigrants and wider society. Considering the aforementioned need to achieve a stable income, it is also logical that younger age groups are more likely to be of working age and have a greater need to leave home to attend work.

Limitations

Given the regional restriction of the survey dissemination, the study does not represent the whole population of immigrants in Sweden. Only those attending school language classes and SFI classes participated, therefore it is hard to say this sample represents all immigrants in Region Uppsala, let alone Sweden. This means the external validity of the results is somewhat limited. Since the questionnaire was available in six different languages, it was considered accessible for the target group. However, translating languages can affect the face validity of the questions since words in one language can be described differently in another language. This could lead to confusion among the respondents, but also cause inconsistencies among the responses being analyzed. In total, 855 participants responded at least partially to the survey, yet some of the survey questions had under 400 responses. This was an issue, particularly for the subgroup analysis; the number of participants in the “51–70 years” age group was markedly low. ‘Don’t know’ responses were considered to be non-substantive and a form of item non-response and therefore treated as missing data. While including these responses in analysis enhances representativeness, it can also introduce random error. Yet, the exclusion could have somehow affected the results and introduced bias. There are a number of reasons why a respondent might select ‘Don’t know’. It could be that they did not understand the question, or the information was too sensitive. ‘Don’t know’ responses were examined and no demographic pattern was identified, indicating that the non-responses were at random. Further demographic information about the sample could have also benefitted the study; for instance, education level might affect the type of work and income the participants have, which in turn could affect their possibility to follow the COVID-19 recommendations.

Practical implications

This survey reveals several practical implications worthy of future study. Greater emphasis should be given to tailored information for immigrant groups. Mheidly and Fares (2020) recommend direct health communication strategies toward minority populations such as media campaigns designed for role models of different racial and ethnic backgrounds, to improve relevancy and perceived importance of health information. Similarly, Mangrio et al. (2020) recommend using influencers within immigrant communities to disseminate health information, as well as developing linguistically and culturally appropriate information. There are some examples of tailored health information from other regions in Sweden, such as COVID-19 information developed and produced by cultural mediators in Skåne (Partnership Skåne, 2021); yet, a national strategy is required. A further practical implication could be tailored information for different age groups, with a particular focus on conveying the importance of health information to younger groups, among immigrants and perhaps more generally too. An experimental study conducted in the US demonstrated that health messages highlighting COVID-19 risks to younger adults, in addition to risks to older adults, made individuals perceive the disease as a more serious threat, although the effect appeared to be limited to areas where infection rates were high (Utych & Fowler, 2020). A final practical implication is the standardization of how to disseminate high-quality web-based information when new epidemics and pandemics emerge, and how to reduce the potential harm of misleading or incorrect information being transmitted. Mheidly and Fares (2020) propose several strategies to achieve this. They highlight the need to give medical and scientific professionals more exposure, including formal verification of their accounts on popular social media platforms and promotion of their posts. Mheidly and Fares (2020) also make the case for promotion of public health organizations via search engines and general monitoring of social media. With regard to health communication content, they recommend promoting a dialogue with the public to understand concerns, as well as adopting an empathic style of communication. It is important that diverse perspectives and voices are included in such dialogue, to be able to meet the needs and expectations of different immigrant groups, of various ages. This community engagement approach has been shown to improve health behaviors and outcomes among disadvantaged populations (Cyril et al., 2015) and is championed by the European Center for Disease Prevention and Control (ECDC). In the context of promoting COVID-19 vaccination uptake among immigrant groups, the ECDC recommend co-production of health communication strategies to ensure inclusive and acceptable approaches (European Center for Disease Prevention and Control, 2021).

Conclusions

Results from this study show that immigrants with limited proficiency in Swedish had differing opinions about COVID-19 information in a region of Sweden. Most of the immigrants reported that they knew where to find information regarding COVID-19 information; however, over two-fifths of the immigrants reported that the recommendations from the authorities should be more extensive. Age differences in the opinions toward COVID-19 information were detected. Although the results were largely positive, there still appears to be a need for improvement in how immigrant groups with limited ability in the host country´s language are reached. Effective health communication that engages the whole nation is an important factor that authorities should commit to as we face the current pandemic. This research suggests that an approach tailored by age could be helpful. Further research concerning immigrants’ opinions about COVID-19 information is encouraged.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors received no funding for the work reported in this article. The data were collected by Invandrarindex, who cooperated with Uppsala County Council.