Ethnicity, Culture and Language

Risk during pandemic is influenced by ethnicity, culture and language [11, 24, 40, 43, 45-46]. The literature reviewed suggests vaccination rates are lower among ethnic minorities. It also suggests access to appropriate and quality care and health care seeking behaviors are influenced by language, cultural beliefs, attitudes, and socio-economic barriers. In this review, the general findings related to ethnicity, culture and language as risk factors during pandemic include: a) lower vaccination and health care seeking behaviors among ethic groups, particularly immigrants; b) lack of knowledge about risk and mistrust of health care professionals influenced attitudes and beliefs toward vaccination and accessing care; c) higher hospital admission rates among Aboriginal populations; d) language and cultural barriers negatively influence reception and comprehension of health information; and d) discrimination and stigmatization toward Asian populations during outbreaks which originated from Asia.

Enarson & Walsh [24] identified new immigrants and cultural minorities among Canada’s 10 high risk populations during a natural disaster. Recent immigration status has also been identified as a risk factor that could lead to increased rates of influenza among newcomers in Europe [25]. In an examination of 37 pandemic plans, the needs of migrant workers and immigrants were only addressed in two [8]. This is a concern in the U.S. and echoed in Canada given that the number of both documented and non-documented immigrants has been steadily increasing [11, 100].

Immigrants may not have received preventative health measures such as childhood vaccinations for many infectious diseases, and they often lack access to health services in the new country. Socially marginalized groups may also face barriers to accessing health information via the internet or the telephone if these items are not available or present in the home [49]. However, in the aftermath of Hurricane Katrina, emergency planners have begun to realize the importance of including racially and ethnically diverse communities in the planning phases of preparedness plans [104].

Data from the Canadian Community Health Survey shows vaccination rates for H1N1 in 2009 were lower among immigrants in Canada [105]. Rates of vaccination, for seasonal influenza and other infectious diseases, among different ethnic groups have been studied extensively in the United States. The U.S. studies focused mainly on vaccination uptake rates between African- Americans, Whites and Hispanics [66-67, 77, 84-85, 88, 106-109], as well as Vietnamese and other Asian minorities [110], and comparisons between multiple ethnic groups [65]. Lower vaccination rates among African Americans and other ethnic minorities, compared with White ethic groups, is a consistent finding in the literature from the U.S. [77, 88, 95, 107, 111-112].

Attitudes and beliefs toward pandemic, lack of access to care, mistrust of health care professionals and health authorities, and lack of knowledge have all been found to contribute to lower vaccination rates among ethnic minorities [61, 113]. In a study conducted in the U.S. which focused on African Americans, Asians, Native Hawaiians, other Pacific Islander, and Latino populations, Hutchins et al. [92] cite “socioeconomic disadvantages; cultural, educational, and linguistic barriers; and lack of access to and use of health care” (p. 261) as factors that increase vulnerability during a pandemic. In a study examining vaccination rates in older adults, Fiscella et al. [66] found significant racial and ethnic barriers and disparities that contribute to

poor uptake on vaccines and mortality among elderly minority groups. The observation that African Americans chose to get vaccinated less than other ethnic and cultural groups prompted Cameron et al. [89] to conduct focus groups to determine the underlying reasons for discrepancies in vaccination rates. Convenience of vaccination clinics emerged as an important determinant of vaccine uptake for African Americans.

Sengupta et al. [114] conducted a qualitative study to determine which barriers and facilitators influenced African-American older adults to get vaccinated for influenza. Structural factors, such as lack of insurance and limited access to physicians for information were barriers, as well as social influences (eg. being discouraged from getting the vaccine by people in their social networks). They identified several structural and personal factors facilitated vaccine uptake, including reminders from health professionals, insurance coverage, being knowledgeable about influenza, taking into account their own health conditions, their age, and believing the immunization would prevent the community from getting sick. These findings are consistent with Schwartz et al. [106] who found that interventions involving health communication at the time of the doctor’s appointment were effective in increasing vaccine among older adults who are members of ethnic minority groups. Furthermore, Sambamoorthi & Findley [115] reported that health literacy, fear of the healthcare system or the vaccine, and convenience of clinics were all important determinants of whether ethnic populations were vaccinated.

Studies examining infection, mortality rates, vaccinations and hospital admissions among Aboriginal populations, in the context of pandemic, have been conducted in the U.S. [75], Canada [116] and other countries such as New Zealand [117] and Australia [74, 118-121]. The literature consistently shows risk of contracting influenza and hospital admissions are higher for Aboriginal populations, partially due to co-morbidity (eg. diabetes), however social context such as poverty, homelessness, living in remote communities, and delays in accessing or seeking health care also contribute to vulnerability in pandemic for Aboriginal populations [74-75, 120, 122]. McIntyre and Menzies [120] also identified urban dwelling Aboriginal populations as being particularly at risk, because their indigenous status often goes un-recognized, which highlights the importance of targeted vaccination programs for Indigenous groups living in urban centers.

In a Canadian study based in Manitoba, which examined H1N1 hospital admissions, Aboriginal populations were over-represented; a common trend observed in previous outbreaks of influenza [116]. Flint et al. [122] conducted a study examining hospital admissions among Indigenous populations in Australia and also found that despite their relatively small population, they made up 16% percent of all hospital H1N1 admissions during the 2009 outbreak. Similar findings were reported in studies examining American Indian populations in the United States [75, 79, 123].

Language and culture are intricately linked to ethnicity, and influence people’s ability to receive and understand public health information, as well as their access to appropriate and quality health services. In Canada, Aboriginal populations are overrepresented in the homeless population by a factor of 10 [71]. This can have significant implications for this group receiving the necessary treatment if they were ever to develop influenza. There is also substantial differences among Aboriginal groups themselves. In an American study, a panel of experts was consulted and expressed that solutions should be tailored to meet the specific sizes of the Native

American tribes because they may have different needs based on their compositions [124]. This same group of experts also expressed the need for more funding to be directed toward preventative measures, and noted that public health programs were often missing for these populations.

Another factor which contributes to the classification of racial and ethnic minorities as high risk populations is discrimination and stigma. This is evidenced by the experiences of Asian Canadians and immigrants during the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) [125]. The SARS outbreak originated in China and spread globally in a matter of weeks. Discrimination toward Asian, and particularly Chinese, people in Canada was experienced at multiple levels, from direct comments in schools, at workplaces, health care facilities, and public transit, to distasteful cartoons in the newspaper. Businesses in the Chinatown districts of several cities experienced dangerously low patronage, forcing financial hardship on many families.

Some groups isolate themselves from society for cultural and religious reasons (eg. Amish communities). These populations often have lower vaccination rates, which can contribute to vulnerability in pandemic [126]. Religious gatherings can also heighten the risk of disease transmission. Shafi et al. [21] discussed the risk associated with the Hajj pilgrimage to Mecca, which more than 2 million Muslims attend every year. Transmission of influenza during mass gatherings is a particular concern for public health officials.

Belmaker et al. [13] highlighted the pandemic risk associated with semi-nomadic populations, in particular the Bedouin Arabs in Israel, who have similar living / social environments (overcrowded common living spaces, high unemployment, large families) to people in developing countries, but they live in the outskirts of urban areas in a developed society, in this case, Israel. The members of this ethnic community usually don’t have health insurance, but in 1995 Israel instituted universal health coverage which provided all Bedouin Arabs access to primary care. This was deemed to be an important factor in the increase in rates of immunization for communicable diseases such as measles. The concepts from this study could be explored with other semi-nomadic cultural groups, refugees and immigrants.