The health of migrants, refugees and those of migrant origin in Norway
Updated
|Migrants, refugees and those of migrant origin (hereafter called migrants) constitute a significant proportion of Norway’s population. Migrants are a complex group with different backgrounds, reasons for immigration and varying lengths of residence. The effect of these and other factors affects the health and living conditions of migrant groups differently.
Key messages
- There are major differences among people of migrant origin in Norway regarding living conditions, lifestyle, and incidence of disease.
- There is little or no data and research on many migrant groups, and an overview of the health of migrant groups and their use of health services use is lacking.
- In general, migrants are younger and healthier than the general population, with lower mortality and higher life expectancy. However, the longer the length in Norway the closer their health profile resembles that of the general population.
- Certain diseases, conditions, and behaviours are more common among some migrant groups than in the general population. These include being overweight or obese, musculoskeletal disorders, type 2 diabetes, smoking, and vitamin D deficiency.
- Certain diseases, conditions, and lifestyle factors are less prevalent among some migrant groups compared to the general population, such as several forms of cancer and alcohol use.
- The proportion of migrants with a high level of mental health problems is on average greater than the general population. Perceived racism and discrimination can significantly affect mental health.
- Some groups such as refugees and elderly migrants may be particularly vulnerable to poor health.
- Migrants use health services to a lesser extent than the general population, but health service use varies widely with age, length of residence, reason for immigration, and country of origin.
Health of migrants, refugees and those of migrant origin
Immigrants make up a large part of the Norwegian population. Although people with an immigrant background are a complex group, their overall health status needs closer examination. In this chapter, we consider various aspects of immigrant life: living conditions, physical and mental health, and access to and use of health services that may have an impact on the public health of people with an immigrant background. It is important to raise awareness of health and disease among different immigrant groups to target public health measures and reduce health inequalities.
We mainly use the terms “immigrants,” “Norwegian-born with immigrant parents,” and the “general population” in the same way as Statistics Norway (SSB) defines and uses the terms in their official statistics (SSB, 2019). The term “people with an immigrant background” is used as a collective term for immigrants and Norwegian-born individuals with immigrant parents. When referring to specific research articles and reports, other divisions, definitions, and terms will also be referred to.
This chapter provides a quick introduction to what we currently know about health and disease and the important public health challenges among people with an immigrant background in Norway. It does not cover all of the topics and research published in the field of migration and health and therefore must be seen in connection with other chapters in the Public Health Report (NIPH).
This chapter begins with an overview of the existing knowledge base on immigrants and those who are Norwegian-born with immigrant parents in Norway, and the field of migration and health. This is followed by a brief introduction to their living conditions, life expectancy and mortality, and living habits and lifestyle. Non-communicable diseases, mental health, health consequences of racism and discrimination, infectious diseases, sexual and reproductive health, work and health, and accidents among these two immigrant groups is also discussed. The chapter ends with a look at health and disease among some vulnerable immigrant groups and their use of health services.
When reading this chapter, do keep in mind that our knowledge base on this subject is limited. There are many groups of immigrants without data or studies.
What do we know about migration and health: the knowledge base
What we know so far about health and the use of health services among people with an immigrant background is based primarily on results from individual health surveys, qualitative studies, and analyses of national register data (Laue et al., 2021). While research and work in this subject area has increased, there remains, for several reasons, a lacuna of knowledge. National register data must be linked with data on immigration or country background from Statistics Norway or the National Population Register to be able to say something about health and illness among immigrants. This requires permission and funding. Decisions taken by the National Council for Priority Setting In Health Care in 2011 and 2012 should contribute to increasing the availability of data on immigrant health (Directorate of Health, 2019).
Knowledge about health based on register data only includes individuals who are registered in the country at any time, excluding undocumented immigrants and migrant workers who have lived in Norway for less than six months. There is no overview of asylum seekers’ use of health services and medicines since they are difficult to identify in register data.
Questionnaires and health surveys are usually not adapted for immigrants in terms of language, content, or recruitment. Therefore, participation by immigrants is often low. Smaller studies are usually only aimed at a few immigrant groups, and the overall picture of immigrant health is incomplete. Many studies have been carried out on larger immigrant groups, such as Pakistanis and Somalis, with relatively long periods of residence in Norway. On the other hand, we know little about migrant workers, especially those who are in Norway for short periods, and family reunification as a group. Health varies with country of origin, reason for immigration, length of residence, age, gender, and education, but in many studies do not highlight these factors. In addition, we have few analyses that monitor the same group over time, so little is known about how health among immigrants and their use of health services develops. There are few intervention studies and evaluations of public health initiatives for people with an immigrant background. A greater focus is needed on user participation in health and healthcare services and research that investigates self-reported health needs in several immigrant groups (Laue et al, 2021; Jakobsen & Spilker, 2020).
Clearly, knowledge on several immigrant groups is either limited or non-existent. Much of what is presented here is based on data from the 2016 Statistics Norway’s Living Conditions Survey among immigrants from 12 countries (Statistics Norway, 2017). In many areas of health, data are not collected systematically or regularly, so some of the current knowledge is based on older studies.
Immigrants and people born in Norway to immigrant parents
At the start of 2022, immigrants and those born in Norway with immigrant parents accounted for more than 1 million people, i.e. 18.9 percent of the population, of which 15.1 percent are immigrants and 3.8 percent are Norwegian-born with immigrant parents. The number of immigrants in Norway has nearly quadrupled since 2000 (SSB, 2022a, Steinkellner, 2022).
Immigrants and those born in Norway with immigrant parents are heterogeneous groups, with origins from over 200 countries and self-governing regions (SSB, 2018a). About half of immigrants and those born in Norway with immigrant parents come from European countries, while about one third come from Asian countries and 14 percent from African countries. Among people born in Norway with immigrant parents, 43 percent have parents born in Asia, 34 percent have parents born in Europe, and 20 percent have parents born in Africa. The five largest immigrant groups by country of origin are Poland, Lithuania, Sweden, Syria, and Somalia (SSB, 2022a). See Figure 1 for an overview of the 20 largest immigrant groups as of 1 January 2022.
Immigrants as a group are younger than the general population. A higher proportion of immigrants are between the ages of 25 and 44 and a lower proportion constitute the elderly. In the group born in Norway with immigrant parents, over 70 percent are under the age of 18 (SSB, 2022a).
Since 1990, about one third of immigrants arrived in Norway as migrant workers, one third for family reunification, almost 20 percent as refugees, and 10 percent for education. As of 1 January 2022, there were 244,600 people residing in Norway as refugees or family members of refugees (SSB, 2022a).
Some immigrants have a relatively short residency in Norway. One quarter of all immigrants have lived in Norway for less than five years, and every second immigrant has lived here for less than ten years. There is an association between length of stay and several indicators of Social integration (IMDi, 2021a).
Migration and health
The field of migration and health focuses on how migration processes and migrant backgrounds can affect the status of health and incidence of disease, as well as access to and quality of health services among immigrants. Immigrants and those who are Norwegian-born with immigrant parents are a complex group with various reasons for immigration and different risk factors for disease.
Most immigrants are younger and healthier than the general population upon arrival in Norway. Migration is a demanding journey, and often the healthiest and most resourceful undertake it. This phenomenon is often called the healthy migrant effect (Kumar & Diaz, 2019). However, immigrant health profiles conform to the profile of the general population after 5 to 10 years, and immigrants with longer periods of residence often have worse health than the general population. This is explained through the hypothesis of the exhausted migrant, which points to the overall effect of various factors before, during, and after migration on health (see figure 2).
Genetic factors and the situation in their homeland, with or without traumatic events before and during migration, can affect individual health in a new country. Immigrant status can also affect socioeconomic status because of a lack of an integration policy or discrimination in areas such as work or education. Immigrant status can also affect rights and accessibility to healthcare services, which can impact their use and relevance. These factors combined can have a direct effect on health and indirectly negatively affect risk factors for disease (e.g. inadequate diet or physical activity) (Kumar & Diaz, 2019).
Living conditions and health
Immigrants generally have worse living conditions than the general population in terms of finances, employment, working conditions, housing standards, social participation, and health, according to the Living Conditions Survey among people with an immigrant background (SSB, 2017). Finances can affect living standards and social participation. Statistics Norway’s income statistics show that, overall, immigrants in Norway have a lower income level than the general population and are more often defined as having a low income (Wiggen & Vrålstad, 2017). It is more common for immigrants to state that they do not have enough money to cover their essential needs.
Employment statistics from Statistics Norway show that participation in working life is lower among immigrants from some countries than the general population. There is a significantly higher proportion of immigrants registered as unemployed (SSB, 2022b), which can adversely affect household finances and quality of life. Fewer immigrants own their own home than the general population, and a higher proportion find housing costs burdensome. More immigrants also live in cramped conditions compared to the general population (Wiggen & Vrålstad, 2017). The proportion receiving disability benefits is lower among immigrants than the general population, whereas nearly half of people who receive social assistance have an immigrant background (SSB, 2022c).
The proportion of married immigrants is significantly higher than the general population. However, several immigrants report that they lack close friends. Immigrants are more troubled by loneliness compared to the general population (Wiggen & Vrålstad, 2017).
Living conditions vary greatly for immigrants. Immigrants from some countries have similar living conditions to the general population and have a high degree of employment, own housing of a good standard, and are in good health. Immigrants from some other countries are disadvantaged, with low employment, poor housing standards and poorer health. Other migrant groups score well in some areas of living conditions and worse in others. Despite poorer living conditions, immigrants are equally satisfied with life in general, housing, and work compared with the rest of the population. Immigrants report trust in the host country's institutions and a sense of belonging to Norway (Wiggen & Vrålstad, 2017).
Socio-economic status is important for both physical (Kjøllesdal et al., 2019) and mental health among immigrants (Abebe et al., 2014; Levecque & van Rossem, 2015). For example, higher education is related to better self-assessed health and a lower risk of cardiovascular disease and functional impairment among immigrants. However, the association between education and health appears to be weaker among immigrants than in the general population. This may be because education from the homeland does not always correspond to occupation, income, or status in Norway. Other underlying factors may also influence this association.
Employment is linked to several health outcomes among immigrants: good self-assessed health and a lower risk of diabetes, cardiovascular disease, back and neck problems ,and reduced functional capacity. Higher income is also related to better self-assessed health and a lower risk of diabetes, high blood pressure, mental health problems, and sleep problems (Kjøllesdal et al., 2019). Good social support and social integration are associated with good health, both physically and psychologically (Abebe et al., 2014; Levecque & van Rossem, 2015; Noam et al., 2014; Oppedal & Idsoe, 2015; Kjøllesdal et al., 2019).
Life expectancy and mortality
According to several studies, immigrants in Norway generally have a lower mortality rate and a higher life expectancy than the general population (Wallace et al., 2022; Syse et al., 2018). This applies to both men and women in different age groups. Figure 3 shows the development in life expectancy at birth among immigrants and the general population in Norway over time.
In 2019, immigrant women’s life expectancy at birth was almost two years higher than that of Norwegian-born women, while the corresponding figure for men was just over one year. The relative differences also continue when looking at life expectancy at ages 25, 50, and 75 (Wallace et al., 2022). However, there is some uncertainty about the calculation of life expectancy for immigrants. There are currently few older immigrants in Norway, and because the registration of emigration among immigrants may be lacking, life expectancy may be artificially high. Deaths are not registered in Norway among immigrants who have emigrated but are still registered as residents.
Life expectancy among immigrants is also higher in the context of certain social conditions, such as education and family relationships. Among immigrants, and disregarding possible problems with lack of emigration registration, we find that mortality varies according to country of origin, reason for immigration, and length of residence (Syse et al., 2018). While certain groups clearly have lower mortality than the general population (e.g., groups from South-East Asia), mortality among Nordic immigrants is similar to other studies. People who have migrated for work and education have a far lower mortality rate than refugees.
However, in general, mortality increases with length of residence in Norway. The longer immigrants are in Norway, the more similar their health becomes to the general population, including mortality. Over time, we expect to have far more immigrants with long residence, as well as far more elderly immigrants, which may have implications for their care service needs (Syse & Tønnessen, 2022).
Lifestyle
Physical activity
According to the Living Conditions Survey among immigrants in 2016, the proportion of immigrants who train or exercise once a week or more is lower than in the general population (Kjøllesdal et al., 2019). This is confirmed by previous studies (Rabanal et al., 2013). Immigrant women exercise less than immigrant men, while the opposite is the case for the general population (Kjøllesdal et al., 2019). In a pilot study among Italian immigrants, most reported becoming more physically active after moving to Norway (Calogiuri, et al., 2021).
Children with an immigrant background from countries outside the European Union (EU)/European Economic Area (EEA), North America, Australia, and New Zealand are less physically active than other children. This is shown by a survey of physical activity among 6-, 9-, and 15-year-old children and adolescents in 2011 (Directorate of Health, 2012a) and the survey Youth in Oslo 2015 (NOVA, 2015).
Diet
We know little about diet among immigrants in Norway (Directorate of Health, 2012b). A study among immigrants from South Asia showed dietary changes in this group after the move to Norway, and most often in a negative direction, with a higher intake of fat and sugar and a lower intake of fibre (Wandel et al., 2008). In the STORK Groruddalen survey, pregnant immigrant women from countries outside Europe had a higher intake of added sugar and a lower intake of whole grains than pregnant women without an immigrant background (Sommer et al., 2013). A study among Somali immigrants in Oslo found that the salt intake in this group was somewhat higher than recommended by the World Health Organization (WHO), but somewhat lower than in the general population (Chen et al., 2018). They also had a lower intake of iodine than recommended (Madar et al., 2018).
Several studies have shown that vitamin D deficiency is widespread among immigrants from Africa and Asia (Eggemoen et al., 2013; Holvik et al., 2005; Meyer et al., 2004). This particularly applies to immigrants from the Middle East, countries south of the Sahara, and South Asia, where around three out of four have a vitamin D deficiency. Pregnant women and teenage girls are particularly susceptible to vitamin D deficiency (Eggemoen et al., 2013; Eggemoen et al., 2016).
Overweight
Obesity, defined as a body mass index (BMI) over 30, appears to be more widespread in certain immigrant groups than in the general population. This is shown by studies with height and weight measurements and Statistics Norway’s Living Conditions Survey among immigrants in 2016 (Kjøllesdal et al., 2019; Jenum et al., 2012a; Kumar et al., 2006; Iversen et al., 2013; Ahmed et al., 2018).
In the survey, the proportion of overweight or obese women (BMI > 25) was highest among women from Pakistan, Somalia, Turkey, Kosovo, and Iraq (50-59 percent) and low among women from Vietnam. Among men from Poland, Turkey, Bosnia-Herzegovina, Kosovo, and Pakistan, 70 percent or more were overweight or obese (Kjøllesdal et al., 2019). There are large gender differences in some groups, particularly among Somali immigrants, where obesity is much more common among women than men. The proportion who are overweight or obese increased with age and the likelihood of being overweight or obese was greater among married and cohabitating individuals than those who were single. No correlation was found with education or length of residence (Qureshi et al., 2020). These data are based on self-reported height and weight, which typically gives a lower proportion of people who are overweight or obesity than with measured values.
In a study comparing the incidence of obesity between Somalis in Somaliland and Somalis in Norway, a significantly higher incidence was found in Norway, which indicates that negative changes result after migration to Norway (Ahmed et al., 2018). A study from 2013 shows the same, where obesity among Somali immigrant women was found to be associated with length of stay and little physical activity (Gele & Mbalilaki, 2013). Early prevention of obesity is therefore important.
Smoking
The proportion of smokers has fallen sharply over the past 15 years, both among immigrants and in the general population. However, data from the Living Conditions Survey among immigrants show that there is still a significant proportion of immigrant men who smoke - 40 percent - especially among those from Vietnam, Poland, Turkey, and Kosovo.
The proportion of immigrant women who smoke varies by homeland, from almost none or very few women from Afghanistan, Eritrea, Sri Lanka, Somalia, and Pakistan to around 30 percent of women from Turkey, Poland, and Kosovo (Kjøllesdal et al., 2019).
Alcohol
The proportion of immigrants who have consumed alcohol in the past year is lower than in the general population, especially among women (figure 5). Alcohol use varies greatly by homeland, and among the countries included in the Living Conditions Survey among immigrants in 2016; immigrants from Pakistan and Somalia have the lowest proportion who consumed alcohol (Kjøllesdal, et al., 2019).
Non-communicable diseases
The proportion of immigrants with at least one chronic disease (35 percent) is roughly the same as in the general population (34 percent) according to the Living Conditions Survey among immigrants in 2016. The survey showed that variations between the groups are greater than between the general population and immigrants as a whole. As with the general population, the proportion reporting a chronic disease was higher among women compared with men and increased with age (SSB, 2017).
Diabetes
In Europe, studies show that the incidence of and mortality rates from type 2 diabetes are higher among immigrants than in the general population. Immigrants develop the disease at a younger age and have more frequent complications (Stirbu et al., 2006; Addo et al., 2017; Bennet et al., 2014; Jørgensen et al., 2014). Immigrants in Norway with origins from South Asia and some countries in Africa are at higher risk of type 2 diabetes and more often develop type 2 diabetes at a younger age than ethnic Norwegians (Rabanal et al., 2013). The MoRo project investigated the incidence of type 2 diabetes in the districts of Romsås and Furuset in Oslo. Among people from Sri Lanka, India, and Pakistan, 20–24 percent aged 30–59 years had existing or newly diagnosed type 2 diabetes compared to 3–6 percent in the general population (Jenum et al., 2012a; Jenum et al., 2012b). However, there is a lower number of new cases of type 1 diabetes among immigrant children from the Middle East, South-Eastern Europe, and Asia than in the general population (Dzidzonu, et al., 2016).
Cardiovascular diseases
In the available data, there is great variation in the incidence, risk, and development of cardiovascular disease among immigrants. The variation depends on country of origin, how long they have lived in Norway, and changes in habits and lifestyle. Some immigrant groups are at lower risk of cardiovascular disease than the general population, while other immigrant groups are at higher risk (Rabanal et al., 2013; Rabanal et al., 2017). Immigrants from South Asia (India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and Myanmar) have a significantly increased risk of both heart attack and stroke compared to the general population. Immigrants from the former Yugoslavia are at increased risk of heart attacks. Men in this group also are at increased risk of stroke. Immigrants from East Asia are at lower risk of cardiovascular disease than the general population (Rabanal et al., 2013; Rabanal et al., 2015; Rabanal et al., 2017).
Cancer
In general, immigrants are at lower risk of cancer than Norwegian-born people, although some forms of cancer occur more frequently among some immigrant groups (Hjerkind et al., 2017; Kreftregisteret, 2019). For example, men from Europe, especially Eastern Europe, have a higher incidence of lung cancer compared to Norwegian-born men. Liver cancer is another form of cancer with a high incidence among immigrants, particularly among men from the Middle East, Africa, and Asia and among women from Asia. These figures must be interpreted with caution because the number of cancer cases among immigrants is low, and the figures are therefore more prone to random variations.
Immigrants from Eastern Europe are at higher risk of stomach cancer compared to people born in Norway. With regard to colon and rectal cancer, immigrants from low-income countries are at lower risk than immigrants from high-income countries and the general Norwegian population (Cancer Register, 2019). Immigrants from low-income countries in Asia and Africa are at lower risk of breast cancer than the general population and immigrants from high-income countries, although breast cancer diagnosis among immigrants from low-income countries often takes place after the disease has progressed (Thøgersen, 2017; Latif, 2015). This could be because immigrant women have lower attendance at breast cancer screenings (Bhargava, 2017) or because breast cancer among women from low-income countries often appears before they reach the age where screening is offered (Thøgersen, 2017). In the future, the number of cancer patients among immigrants is expected to increase because immigrants are currently relatively young and cancer risk increases with age (Cancer Register, 2020).
Screening to detect early cases of cervical and breast cancer
Immigrant women are less likely to accept the offer of screening for cervical cancer than women born in Norway (Møen et al., 2017). The incidence of cervical cancer in women with an immigrant background is still low compared to the situation in many immigrants’ homelands. A qualitative survey (Gele et al., 2017) shows three types of barriers to screening: lack of knowledge about screening, stigma linked to the disease, and low confidence in the healthcare system. An intervention study among women from Pakistan and Somalia shows that it is possible to overcome these barriers through personal communication, invitations, and reminders about cancer screening (Qureshi et al., 2019). An intervention aimed at GP practices on the importance of immigrant women also being screened for cervical cancer significantly increased their participation (Møen et al., 2020).
Mammography screening does not reach immigrant women to the same extent as women born in Norway. One study showed significantly lower attendance for immigrant women, even when adjusting for sociodemographic factors (Bhargava et al., 2018; Bhargava et al., 2021). The relationship between sociodemographic factors and participation in mammography screening varies between different groups of immigrant women (Le et al., 2019).
Chronic obstructive pulmonary disease (COPD)
There are no figures for the incidence of chronic obstructive pulmonary disease (COPD) among immigrants in Norway. The Living Conditions Survey among immigrants in 2016 reports a somewhat higher proportion of people from Kosovo, Turkey, and Iraq with chronic bronchitis, COPD, or emphysema: 3–4 percent compared to 2 percent in the general population (SSB, 2017). Smoking is significantly more widespread in some groups, and it can be assumed that the incidence of COPD in some immigrant groups will increase with an increasing proportion of older immigrants. Tuberculosis is also a risk factor for COPD (Directorate of Health, 2012c; van Zyl Smit 2010; LHL, 2022). A study from the Netherlands has shown under-diagnosis and under-treatment of COPD among immigrants (Directorate of Health, 2012c).
Musculoskeletal disorders
In the Living Conditions Survey among immigrants (SSB, 2017), 18 percent of respondents reported a back problem and 11 percent a neck problem. Corresponding figures in the general population were 12 percent and 8 percent respectively. Back and neck problems were most common among immigrants from Bosnia and Herzegovina, Kosovo, Turkey, Iraq, and Iran. Osteoarthritis (wear-and-tear arthritis) was more common among immigrants from Turkey, Iraq, and Vietnam (13–16 percent) than in the general population (5 percent). The proportion of musculoskeletal disorders increased with age (Kjøllesdal et al., 2019). The most common occupations among immigrants are in sales and service as well as craft occupations (SSB, 2017; STAMI 2021). Awkward lifting is particularly linked to neck and shoulder pain (STAMI, 2021). A working day where you stand and walk a lot can also involve stress that, over time, causes or exacerbates problems in the legs, knees, hips, and back (STAMI, 2021; Nordic Council of Ministers, 2019).
Dementia
Based on data from HUNT (Health Study in Nord-Trøndelag), figures on dementia incidence in the population have been calculated for the first time (Gjøra et al., 2020). However, there are no figures on the incidence of dementia among immigrants in Norway. Studies in the United States, England, and the Netherlands have found a higher incidence of dementia in some ethnic groups, while registered studies in Norway and other countries have shown that fewer immigrants are diagnosed with dementia. This does not necessarily indicate a lower incidence but may be related to access to and quality of healthcare services (Cappa et.al, 2022; Diaz et al. 2015a; Spilker & Kumar, 2016).
Mental health and well-being
The migration process
The migration process includes relocating to an unfamiliar country and adapting to a new culture, combined with experiences in the homeland prior to departure. For immigrants with a refugee background, this can mean detention or a stay in a refugee camp and a long and dangerous escape route before arrival in a new country with applications for a residence permit or asylum. Each phase of the migration process therefore has conditions and experiences that can impact immigrant health, especially mental health (Giacco, 2020).
Regarding refugees, researchers have studied the significance of torture, violence and other war-related trauma before migration on mental health. With other immigrant groups, the focus has been on how economic, social, and cultural factors in the period after relocation can affect mental health. Living conditions and life situation in the new country can be as significant for refugees’ mental health as previous traumatic experiences (Li et al., 2016).
Many immigrants maintain a connection to their country of origin and to family and friends who still live there. War and conflict in the homeland can also affect mental health long after resettlement (Guribye, 2011).
Quality of life
Immigrants are equally, or almost equally, satisfied with life as the general population (Barstad, 2018). Statistics Norway’s Quality of Life survey from 2020/2021 shows, however, that immigrants from the Middle East and Central and South Asia are, on average, slightly less satisfied with life (Dalen & Larsson, 2022). Among immigrants from EU countries, North America, Oceania, and South and Central America, only 18 percent report low satisfaction compared to around 25 percent among immigrants in total and in the general population. In a study of health and quality of life among Syrian quota refugees in transit and after settlement in Norway, the respondents reported as good a quality of life as the general population one year after arrival in Norway (Haj-Younes et al., 2020). Factors such as low income, poor living conditions, unemployment, and being single are associated with a lower quality of life (Dalen & Larsson, 2022).
Mental health problems and disorders
Findings from the Living Conditions Survey among immigrants show that mental health problems increase with age among immigrants, in contrast with the general population. Mental health problems are more common among women than men, and immigrants with lower education and lower income are more susceptible to mental health problems than those with higher education and income. However, there are major differences between the various country groups included in the Living Conditions Survey among immigrants regarding mental health problems (figure 6) (Kjøllesdal et al., 2019). In addition to lower socioeconomic status, the risk of mental health problems is also linked to language barriers, perceived discrimination due to immigrant background, and other negative life events. Trust in others and belonging to both Norway and the homeland are linked to a lower risk of mental health problems (Abebe et al., 2014; Levecque & Van Rossem, 2015; Straiton et al., 2019a).
Statistics Norway has also conducted a Living Conditions Survey among people 16–39-years-old born in Norway with immigrant parents from Turkey, Pakistan, Vietnam, and Sri Lanka. The proportion with mental health problems was slightly higher in these groups (8 percent) compared to the general population (approximately 6 percent). Among people with parents from Turkey, approximately 11 percent reported mental health problems (SSB, 2018b).
According to some international studies, refugees, both adults and children, often have a high level of mental health problems—higher than migrant workers and the general population (Blackmore et al., 2020; Bronstein & Montgomery, 2011; Lindert et al., 2009). Health register data in Norway show that 16–19 percent of adult refugees consult a doctor for mental health problems (Straiton et al., 2017a). In the general population, the proportion is 10–12 percent (Straiton et al., 2014).
In a survey of around 900 adult Syrian refugees, approximately 36 percent reported symptoms of anxiety and depression and 35 percent reported symptoms of post-traumatic stress. Traumatic events were associated with an increased incidence of these symptoms. Over 40 percent of the sample reported five or more traumatic events, such as having experienced war at close range and terrifying life-threatening situations (Fjeld-Solberg et al., 2020).
In contrast, the incidence of mental health problems was much lower in another study which focused on Syrian quota refugees, where only 11 percent reported symptoms of anxiety and depression one year after arriving in Norway. Furthermore, these quota refugees report better mental health currently than in the transit phase (Strømme et al., 2021a).
Stressful life events before migration, such as separation from and loss of family members, captivity, torture, and other war-related experiences, are particularly associated with an increased risk of depression and post-traumatic stress disorders (PTSD) (Fjeld-Solberg et al., 2020; Priebe et al., 2016). Burdens after migration, such as uncertainty related to the asylum application process, settlement, and adaptation are also important for understanding psychological problems among adults and children with a refugee background and unaccompanied minor refugees (Hajak et al., 2021; Jakobsen et al., 2014 ; Jore et al., 2020; Keles et al., 2016; Teodorescu et al., 2012). Poor living conditions are also associated with poorer mental health (Strømme et al., 2021b).
A study of diagnosed mental disorders in several immigrant groups showed that immigrants from Iran had a higher incidence of several mental health disorders, including depression and substance abuse disorders, compared to the general population (Ekeberg & Abebe, 2021). The other groups that were studied—Polish, Pakistani, and Somali immigrants, as well as descendants of Pakistani immigrants—had a lower incidence of mental health disorders. The exceptions were schizophrenia and PTSD where the incidence was higher than in the general population, with the exception of immigrants from Poland. Alcohol and drug use disorders were also lower among Polish, Somali, and Pakistani immigrants. This study uses the Norwegian Patient Register (NPR), which registers mental health diagnoses in the specialist health service. Immigrants may experience barriers when it comes to the use of health services, particularly for mental health problems. The lower incidence of mental health disorders in this survey may therefore also reflect immigrants seeking help to a lesser extent than the general population (Ekeberg & Abebe, 2021).
We have limited knowledge about the incidence of mental health disorders among immigrants in general. We also lack an overview of mental health among asylum seekers. The studies on mental health among immigrants from EU countries and other migrant workers are limited, and we lack an overview of the mental health of groups who come to Norway to settle down with a spouse without an immigrant background. Little is known about the occurrence of substance use disorders among immigrants (Kour et al., 2020).
There is little research on undocumented migrants, but existing studies indicate that they are a particularly vulnerable group in the context of mental health. Almost 90 per ent report mental health problems (Myhrvold & Småstuen, 2017). Being employed was not positive for this group’s mental health. One explanation could be that many people experience exploitation and poor working conditions. Quality of life is also greatly affected by unsafe living conditions (Myhrvold & Småstuen, 2019).
Suicide
Studies in Norway show a lower risk of suicide among people with an immigrant background compared to the general population, but a higher risk among people born in Norway with a foreign-born parent and particularly high for people born abroad with at least one Norwegian-born parent. The latter category includes those adopted abroad who cannot be distinguished as a separate group in the data material. The rates are not age-adjusted. The difference in risk only applied to men, except for women born abroad with at least one Norwegian parent. Suicide risk was particularly lower for immigrants from Asia and Africa and for people born in Norway with parents from Asia. This did not apply to people born in Norway with one foreign-born parent from Africa or Asia. For this group, the risk of suicide was highest for people with one parent from Latin America. For people born abroad with at least one Norwegian-born parent, the risk of suicide was particularly high for people born in Latin America or Asia (Puzo et al., 2017; 2018a, 2019). The association between socioeconomic factors and suicide risk was largely the same for people with and without an immigrant background, but the strength of the association varied with immigrant background (Puzo et al., 2018b).
Child and adolescent mental health
It is currently unclear if mental health problems are more widespread among children and adolescents with an immigrant background than children and adolescents in the general population. Different studies give slightly different results (Abebe et al., 2014; NOVA, 2015; Bakken & Osnes, 2021; Noam et al., 2014).
Oslo is the municipality with the maximum number of people with an immigrant background. Among those who participated in Young in Oslo 2021 (Bakken & Osnes, 2021), about one in three adolescents has two parents who were both born abroad. In the report, this group is referred to as “adolescents with an immigrant background,” regardless of whether the adolescents themselves were born abroad or have lived in Norway all their lives. The report examines differences and similarities between adolescents with and without an immigrant background.
The study reveals that adolescents with and without an immigrant background in Oslo have approximately the same level of mental health problems. When it comes to quality of life, the survey shows that adolescents, regardless of district or social strata, are largely satisfied with their lives. However, social patterns do exist. Adolescents who grow up in families and in districts with the most resources have a greater chance of being satisfied. Here, there is little difference between adolescents with and without an immigrant background (Bakken & Osnes, 2021).
In the UngKul study, however, it was found that emotional problems, such as anxiety and symptoms of depression, were more widespread among children and adolescents with an immigrant background than among children and adolescents in the general population. Regarding behavioural problems, there were small differences among the boys, while girls with an immigrant background had the lowest incidence (Alves et al., 2014; Noam et al., 2014; Oppedal et al., 2008).
Financial problems in the family, school-related pressures, and perceived discrimination, together with traumatic experiences before migration, increase the risk of mental health problems among children and adolescents with an immigrant background. Good support from parents and a social network, together with belonging to both a Norwegian and an original culture, is health-promoting and important for good mental health (Alves et al., 2014; Noam et al., 2014; Oppedal & Guribye, 2011).
Unaccompanied minor refugees are a particularly vulnerable group. Immediately after arriving in Norway, half of unaccompanied minors display a high level of post-traumatic stress. Symptoms of anxiety and depression are also widespread (Jensen et al., 2015; Vervliet et al., 2014; Jakobsen et al., 2014.)
Single minor asylum seekers also struggle with mental health problems long after they have settled in the municipalities (Andersson et al., 2021; Seglem et al., 2014). According to a study, unaccompanied minor refugees had approximately the same level of anxiety and post-traumatic stress after five years in Norway as upon arrival, while their levels of depression decreased. Approximately four out of ten of these unaccompanied minor refugees experienced such a high level of post-traumatic stress symptoms after five years in Norway that they could have been diagnosed with PTSD (Jensen et al., 2019). Despite this, the proportion who report being satisfied with life is the same in all three groups: unaccompanied minor refugees, children with an immigrant background, and other children (Seglem et al., 2014).
Health consequences of racism and discrimination
The association between discrimination and poor health has been documented in several studies and confirmed in knowledge summaries (Pascoe & Smart Richman, 2009; Rask et al., 2018; Wollscheid et al., 2021). Discrimination can be harmful in several ways, both directly and indirectly. An attack on one’s ethnic identity or experiences of unfair treatment can cause a strong and persistent emotional strain, which over time can impact health. Various forms of exclusion can also lead to poorer access to and lower use of health services, financial problems, or other health-related resource shortages. Discrimination is associated with social isolation, which in turn can increase the risk of an unhealthy lifestyle (Williams et al., 2019). A clear association between discrimination, self-esteem, and depression has been demonstrated. However, several studies show that people who experience discrimination are also at greater risk of somatic illness and functional impairment such as chronic pain conditions, diabetes, and cardiovascular disease (Harris et al., 2006).
Discrimination is challenging to measure and there are relatively few studies on this issue from Norway. The available studies indicate that discrimination is a widespread phenomenon in Norway (Midtbøen & Lidén, 2015). In this study, based on Statistics Norway’s Living Conditions Survey in 2016, more than 25 percent of respondents had experienced discrimination during the previous year because of their immigrant background. The youngest age groups (16–25 years), including those with good Norwegian skills and those with poor finances, experienced the most discrimination (Straiton et al., 2019a).
Data from the Living Conditions Survey among immigrants also shows that among those who experienced discrimination, there were roughly twice as many who reported mental health problems as among those who stated that they had not experienced discrimination during the previous year (Straiton et al., 2019a; Kjøllesdal et al ., 2019).
The extent of perceived discrimination varies based on country of origin and there is great variation in perceived discrimination in different fields, such as in the health service (6.5 percent), educational institutions (14.3 percent), at work (16.4 percent), and when seeking employment (31 percent) (Kjøllesdal et al., 2019). People born in Norway to immigrant parents from Turkey, Pakistan, Sri Lanka, and Vietnam seem to experience discrimination to roughly the same extent as their parents’ generation (SSB, 2018b).
The high incidence of discrimination in working life has also been documented in experimental studies (Midtbøen, 2015; Midtbøen & Quillian, 2021). Based on this literature, it can be concluded that there are no signs of change in the extent of discrimination over time, that discrimination is as great a barrier for descendants of immigrants as for immigrants ,and that the extent of discrimination against job seekers with a background from Africa, Asia, the Middle East, and South America is significantly greater than discrimination against job seekers from Europe.
Many immigrants also experience housing discrimination. A Nordic survey (Skovgaard Nielsen et al., 2015) describes perceived discrimination among Somalis in Oslo both when renting and buying housing.
Foreign adoptees also experience discrimination. A report from the Norwegian Institute for Urban and Regional Research (NIBR) at OsloMet shows that approximately half of adoptees from abroad have experienced racism and discrimination in childhood and adolescence, with people with darker skin experiencing more than those with lighter skin. The nature of the experiences varies from subtle hints to gross verbal and physical attacks. Around 38 percent of respondents said that they had no one to share their experiences of racism and discrimination with while growing up (Leirvik et al., 2021). Foreign adoptees are not included in Statistics Norway’s definition of and data on people with an immigrant background, but they can face many of the same challenges as people with an immigrant background in terms of racism and discrimination.
Despite the connections between racism, discrimination, and health being well-documented in several foreign studies, little attention has been given to the matter in Norway.
Infectious diseases
Immigrants in general have a similar incidence of infections as the general population, but are dispensed antibiotics less frequently than the rest, according to a study using data from the Norwegian Prescription Database (NorPD) (Gimeno Feliu et.al., 2016). However, immigrants from countries in Africa and Asia comprise a large proportion of people in Norway who are diagnosed with chronic infectious diseases like tuberculosis, HIV, and hepatitis B (Arnesen et al., 2022; Caugant et al., 2022; Norwegian Institute of Public Health, 2022a). Those who are diagnosed are often either infected in their homeland, with the disease being discovered upon arrival in Norway, or are infected during a subsequent visit to their homeland.
In 2021, there were 155 reported cases of tuberculosis in Norway. Of these, 83 percent originated outside of Norway (Arnesen et al., 2022). In the five-year period from 2017–2021, 467 (57 percent) of the total 815 reported cases of HIV-infected immigrants were infected before arrival in Norway, with half of them already having known their positive HIV status. In the same period, 1,657 cases of chronic hepatitis B were reported, of which 95 percent were detected among immigrants who were infected before arriving in Norway (Caugant et al., 2022).
When immigrants from Africa and Asia visit their homeland, they are at increased risk of contracting some infectious diseases. In some cases, during the period from 2015–2019, they are significantly overrepresented for some diseases compared to other foreign travellers. Among all registered cases in the Norwegian Surveillance System for Communicable Diseases (MSIS) of paratyphoid and typhoid fever, more than 90 percent were infected abroad and two-thirds were among immigrants visiting their former homeland. Around 40 percent of malaria cases originate before migration to Norway, while around 30 percent of malaria cases are infected during visits to former homelands (Lyngstad et al., 2020). Many immigrants are unaware that after several years of living in Norway they have lost much of their immunity against certain diseases that they had in their homeland. This underlines the importance of advice, vaccination, and prophylaxis.
COVID-19 among people with an immigrant background
In Norway, the COVID-19 pandemic has affected some immigrant groups and Norwegian-born people with immigrant parents more than the general population. Despite people with an immigrant background in Norway being relatively young, certain groups of both immigrants and those born in Norway to immigrant parents have been overrepresented among confirmed cases and COVID-19-associated hospital admissions. There is great variation in COVID-19 infections between different groups (Indseth (ed), 2021).
Immigrant health during and after the pandemic is detailed in a separate chapter in the Public Health Report’s (NIPH)thematic edition 2021: Public health after COVID-19 (Indseth & Labberton, 2021b).
From February 2020 to June 2021, people with an immigrant background, who made up around 18.5 percent of the population (SSB, 2021), represented approximately 43 percent of all confirmed cases of infection and around 44 percent of hospital admissions (Indseth et al., 2021c). Certain immigrant groups have been more affected by COVID-19, particularly immigrants from Pakistan, Somalia, Iraq, Turkey, and Afghanistan. Ventilator use during hospitalisation and the number of deaths related to COVID-19 have been relatively low in Norway. Nevertheless, several studies indicate that people from Africa and Asia are at increased risk of requiring breathing assistance and of dying from COVID-19. This is especially true after age-adjustment, which is the most important risk factor during the course of a severe disease and for death from COVID-19 (Indseth et al., 2021c; 2021e; Telle et al., 2021).
Various hypotheses as to why some immigrant groups have had a higher incidence of infection and severe COVID-19 have been discussed. Studies in Norway over the past two years indicate that the overrepresentation is due to a number of factors which, individually, have only a modest effect, but when combined, result in increased vulnerability and large biases in COVID-19-related infections and hospital admission (Elgersma et al., 2021; Indseth et al., 2021a, 2021d, 2021f; Indseth T. (ed) 2021; Kjøllesdal et al., 2021a; Kjøllesdal & Magnusson, 2021b; Labberton et al., 2022; Methi et al., 2021; Nilsen et al., 2021; Orderud et al., 2021; Rambøll, 2021; Skogheim et al., 2020a, 2020b, 2021).
From these studies, the following factors are important partial explanations:
- Socioeconomic conditions such as occupation, housing, income, and education
- Central vs. non-central residence
- Frequency and pattern of foreign travel
- Delays in TISK work (testing, isolation, contact tracing, and quarantine)
- Family structure
- Social environment and social interactions
It is assumed that language skills, health literacy, digital competence, and differences in media use also explain some of the differences. Differences in medical risk, such as underlying conditions that increase the risk of severe COVID-19 disease, are not important explanations based on the data so far. There are several other possible factors about which there is too little knowledge, such as genetics and different compliance with infection control measures and advice.
Lower vaccination coverage against COVID-19 has been registered in some immigrant groups (Coronavirus Immunisation Programme 2021a, 2021b, 2021c; Kraft et al., 2021; Rolfheim-Bye et al., 2021). As of 27 April 2022, 89 percent of the adult population had been vaccinated with two doses of the COVID-19 vaccine. Among adult immigrants, the corresponding proportion was 71 percent, but there was great variation between different groups, with some immigrant groups having higher vaccination coverage than those who are Norwegian-born (Beredt C19, Norwegian Institute of Public Health, 2022b) (see Figure 7).
There are several reasons for these differences in the national coverage of the COVID-19 vaccine. Both practical and structural barriers—difficulties due to lack of national identification numbers or access to digital solutions, challenges in reaching out to certain groups, or differences in attitudes towards the COVID-19 vaccine, for example—are probably significant. A longer period of residence in Norway may be important for higher vaccination coverage among immigrants (Vinjerui et al., 2022; Diaz et al., 2022). Some immigrants may also have been vaccinated in their homeland without this being registered in Norway, although the proportion is estimated to be so small that it only explains a modest part of the difference in vaccination coverage between immigrants and the general population (Nilsen et al., 2022). We need more information on (a) which groups are more exposed to lower vaccination coverage and (b) what promotes or inhibits vaccination (Coronavirus Immunisation Programme, 2021a, 2021b; Rolfheim-Bye et al., 2021).
Sexual and reproductive health
Fertility
Total fertility rates in Norway have fallen sharply in recent years. In 2018, the total fertility rate for immigrant women was 1.87, while it was 1.5 for women in the general population. Fertility in all groups of immigrant women based on regions was higher than for Norwegian-born women, but with large variations depending on their homeland (Andersen, 2019). For Norwegian-born women with immigrant parents, the fertility rate was 1.48. Traditionally, women from Africa have had the highest fertility, but their fertility has also declined. Currently, women from Syria and Eritrea have the highest fertility (3.51 and 3.27 respectively). Both groups have had a short period of residence in Norway, and immigrant women’s fertility decreases with length of residence. An example is the fertility of Somali women, which in the span of two years, from 2017 to 2019, decreased by 0.41 to 2.42 (Andersen, 2019).
During the COVID-19 pandemic, fertility rates increased again, from 1.48 in 2020 to 1.55 in 2021 (Andersen, 2022). Fertility figures for women with an immigrant background have not yet been issued for this period.
Births
The proportion of women giving birth who migrated to Norway increased from 19.9 percent in 2008 to 30.2 percent in 2019. The proportion of births to foreign-born mothers is greatest in the South-East region at 33.3 percent (Directorate of Health, 2020).
Pregnancy and childbirth complications
A literature review of published research on pregnancy and maternity care among immigrants in Norway shows that immigrant women are at increased risk of adverse pregnancy outcomes (Bains et al., 2021a). Gestational diabetes occurs more frequently among women from Asia and Africa. Studies have shown an increased risk of severe hyperemesis and a higher incidence of severe vitamin D deficiency in women with an immigrant background. The risk of postnatal depression is higher for women from the Middle East and South Asia compared to women from Western Europe. There are large differences in the incidence of pregnancy complications between the various immigrant groups, which change with duration of stay in Norway. However, the risk of preeclampsia and hypertension was lower for immigrant women than for Norwegian women (Bains et al., 2021a). Some of these pregnancy complications lead to an increased risk associated with childbirth and stillbirth (Norwegian Institute of Health, 2022c). Female genital mutilation, especially type 3 as defined by WHO (with re-stitching of the labia and obstruction of the birth canal) is common among women from some countries in the Horn of Africa. This entails a risk of birth complications and stillbirths (WHO, 2022).
Data from the Medical Birth Registry of Norway (MBRN) from 2008 to 2018 show that immigrant women generally had an increased incidence of birth complications. There was a higher incidence of Caesarean section and the use of forceps and vacuum during labour among women born in Latin America, the Caribbean, and sub-Saharan Africa than women born in Norway. Furthermore, women born in sub-Saharan Africa had the highest proportion of induced births, while this proportion was lowest for women born in South-East Asia, East Asia, and Oceania. Immigrant women generally also experienced greater bleeding during labour than Norwegian-born women (Directorate of Health, 2020).
Data from the MBRN also show systematic differences in who received epidural pain relief during childbirth: fewer than average women from sub-Saharan Africa and higher than the average in women from South America and the Caribbean (Waldum et al., 2020).
Newborns
Perinatal mortality from 2008 to 2018 was higher for children born to mothers born in Pakistan (10.3 per 1,000 births), Somalia (9.8 per 1,000 births), Syria (8.1 per 1,000 births), Eritrea (7.6 per 1,000 births), and Iraq (6.5 per 1,000 births) than for women born in Norway (4.6 per 1,000 births). However, there were also groups that had lower perinatal mortality than women born in Norway (Directorate of Health, 2020).
Breastfeeding
Breastfeeding practices among women with an immigrant background are influenced by what is common in their homeland, and also by what they experience in Norway. In many low- and middle-income countries, 80 to 90 percent of children are breastfed until they are at least one-year-old (Neves et al., 2021), while only 48 percent of Norwegian children receive breast milk at one year of age (Paulsen et al., 2020).
A study in Norway among women born in Somalia and Iraq found that the incidence of breastfeeding at 12 months of age was similar to that for mothers born in Norway (Grewal et al., 2016a), but most had stopped fully breastfeeding after just one month (Grewal et al., 2016b). There is a lack of data on the prevalence of breastfeeding in other immigrant groups.
Abortion
International studies show that unwanted pregnancies and abortions occur to a greater extent among women with immigrant and minority backgrounds. Among women who have had an abortion, knowledge and use of contraceptives appear to be lower among immigrant women (Omland et al., 2014). A study based on data on abortions carried out in Oslo during 2000–2003 shows higher abortion rates among immigrant women living in Oslo, both among women categorised as migrant workers and women with a refugee background (Vangen et al., 2008). The Norwegian Register of Pregnancy Termination does not contain information that makes it possible to link data with the women’s homeland. There are, therefore, no regular data on abortion among women with an immigrant background in Norway.
Contraception
A prescription database study with data from 2008 shows that hormonal contraception was prescribed and dispensed significantly less often to immigrant women than the equivalent for women born in Norway (Omland et al., 2014). A recent survey indicates that at least some groups of immigrant women lack knowledge about and have an unmet need for contraception. (Gele et al., 2019).
Female genital mutilation
Norway has had several action plans to prevent female genital mutilation, and to establish nationwide treatment for women who have been exposed to the practice. Approximately 17,000 women and girls living in Norway may have been exposed to ritual circumcision before coming to Norway (Ziyada et al., 2016). In addition, around 15,000 girls may be at potential risk as they come from countries where the practice is widespread. Studies indicate declining support for the practice among people living in Norway who come from countries where circumcision is widespread, but there remains considerable ambivalence about the practice and about seeking treatment (Johansen, 2017, Johansen 2019). The Opening intervention outside childbirth are available at hospitals in all health regions and are described together with an overview of the health problems caused by female genital mutilation (Taraldsen et al., 2021).
Sexual abuse and violence in close relationships
The report Seksuelle krenkelser og hjelpsøking blant utsatte innvandrere - en undersøkelse av erfaringer i hjelpeapparatet og politiet summarises the little research there is on sexual abuse and violence in close relationships among people with an immigrant background (Bjørnholt et al., 2021). The report also presents findings from a qualitative survey among people who work in the health system and the police. While immigrants are overrepresented at shelters, they are underrepresented among the population seeking help from support centres for incest and sexual abuse. Barriers to seeking help or reporting abuse may be the same as in the general population, but there may also be additional barriers such as taboos about sexuality, lack of knowledge, and lack of family support, such that seeking help or reporting abuse can be perceived as risky. There is also a lack of knowledge and professional uncertainty in emergency services and the police, as well as very little use of interpreters. The researchers emphasise that this pilot study is small and qualitative, and that those who have been interviewed have mainly discussed some groups of immigrants who are in the target group for measures and services related to the themes of honour-related violence, forced marriage, and negative social control. We therefore need more information in this area on other immigrant and vulnerable groups such as asylum seekers and undocumented migrants (Bjørnholt et al., 2021).
Work and health
Immigrant attachment to working life is also important from a health perspective. Work does not just provide an income; it also provides freedom and security. For many, work is also a space where information is shared and where you can experience recognition and social support. The proportion of immigrants employed in 2021 was 68.9 percent compared to 79.2 percent of the general population (SSB, 2022b). However, there are major differences between immigrant groups. In general, refugees and family reunified refugees have a lower employment rate than migrant workers (IMDi, 2021b).
There are several reasons why more immigrants than those who are Norwegian-born are unemployed. Many lack an approved education from their homeland, some have language challenges, and many women stay at home caring for children or other family members. Discriminatory attitudes and structures in working life are also a barrier (Midtbøen & Quillian, 2021). Many people experience discrimination during recruitment and in the workplace (Aambø, 2021).
Immigrants are clearly overrepresented in sales and service occupations as craftsmen, machine operators, transport workers, cleaners, and healthcare workers. Gender differences in employment are greater among immigrants than in the general population. Part-time and temporary employment are more common. Many immigrants work in professions without educational requirements. This is related to the level of education of the entire group (Revold, 2017; STAMI, 2021). There are large variations in educational level according to country of origin, and the proportion with only primary school education is higher than in the general population. However, the proportion with four years of education or more from university or college is also higher among immigrants (SSB, 2022d; Revold, 2017). Around 40 percent of immigrants with higher education are overqualified for their job compared to 14 percent of the general population. This gives them a significantly lower salary level than immigrants with higher education who are not overqualified for their job (Edelmann & Villund, 2022).
Employment patterns indicate that the various immigrant groups are exposed to varying degrees of unfavourable working environment factors such as harmful noise, dust and gas, and physically demanding work with heavy lifting, etc. Many employed immigrants are also exposed to psychosocial stressors such as monotonous and repetitive work tasks, working alone, and having little control over their work day (Revold, 2017; Arbeidstilsynet, 2018; STAMI 2021). It is more common among employed immigrants to feel physically and mentally exhausted at the end of a workday. Compared to the general population, almost twice as many migrants have taken at least 14 days leave of absence because of work-related sickness in the past year. Four times as many have been exposed to an accident at work in the previous 12 months (Revold, 2017; Arbeidstilsynet, 2012; Arbeidstilsynet 2018).
According to The Directorate of Integration and Diversity (IMDi), immigrants in the labour market were hit harder by the restrictions during the COVID-19 pandemic than the general population. Immigrants are greatly overrepresented among those employed in the industries that were hardest hit by the pandemic during 2020 (IMDi, 2021b).
Accidents
Overall, a lower incidence of injuries among immigrants than in the general population has also been documented in Norway (Ohm et al., 2020). The difference applies to treatment for accidents in both primary and specialist healthcare, and is greatest for immigrants from Asia, Africa, and European countries outside the EU/EEA. The rates are particularly low for the treatment of fractures and poisoning injuries. However, immigrants are overrepresented in the statistics for violent injuries, traffic accidents, and work accidents (Ohm et al. 2020).
Health of select groups
Life course perspective, health, and illness
Health is affected by our social and physical surroundings and our living habits throughout life, from before birth, through childhood and adulthood, to old age (Kroenke, 2008). For immigrants, experiences and exposures both from the homeland and in Norway can affect health later in life. A significant proportion of children who grow up in Norway with immigrant parents live in families with low socioeconomic status and limited resources, which can affect health both in childhood and adulthood (SSB, 2017). For adult immigrants, low education and income, lack of a social network, poor knowledge of Norwegian, and low health literacy, as well as poor knowledge of the Norwegian health system, can be barriers to good health (Kjøllesdal et al., 2019).
Immigrants in Norway are aging. Among those who came to Norway as adults, many may have poor knowledge of Norwegian and are not well-integrated into Norwegian society. This is a vulnerable group in terms of poor health (Kjøllesdal et al., 2022; Debesay et al., 2018). This can be challenging for families who often live between two cultures, for the elderly themselves, and for the healthcare system. A particular challenge in this context can be dementia (Spilker & Kumar, 2016).
Children and adolescents with an immigrant background
Among children and adolescents under the age of 19, around 7 percent are immigrants and 12 percent were born in Norway to immigrant parents. There is little research on children and adolescents with an immigrant background in Norway, but the findings indicate that these children generally do not have worse health than other children.
Register data from the primary healthcare service has shown that children who come to Norway as immigrants from low- and middle-income countries have less asthma and allergies, but more stomach and intestinal complaints than children who are not immigrants (Fadnes et al., 2016). Among children born in Norway to immigrant parents, a higher proportion compared to children without an immigrant background suffered from upper respiratory tract infections, eczema, stomach and intestinal problems, and problems related to dental health. The same data indicates that age upon arrival in Norway is linked to the use of health services, which were used less among those who came to Norway late in adolescence. Immigrant children also used fewer medications than non-immigrants after adjusting for age and gender (Fadnes & Diaz, 2017). The proportion of Norwegian-born children referred to specialist health services for conditions related to obesity, other nutritional challenges, certain infections, and skin diseases is higher among those who had immigrant parents than among those who did not (Kjøllesdal et al., 2021c).
Among vaccines in the Childhood Immunisation Programme, there is some variation in the degree of coverage among different immigrant groups for various vaccines. With regard to vaccination against measles, for instance, there is somewhat lower coverage in the Somali population than in the general population (Jennes et al., 2021). In addition, coverage figures from SYSVAK show that among 2-year-olds in 2020, children born to parents from Poland, Lithuania, and Romania also had a somewhat lower coverage rate for this vaccine.
Elderly immigrants
Just as the number of elderly people in Norway and Europe is increasing, so are elderly immigrants. Many of the experiences of aging, such as increased risk of disease, functional impairment, and deteriorating health, are common to all people. Older immigrants may experience additional burdens linked to their marginalised position and low socioeconomic status, which can affect their health and present challenges in terms of access to health and care services. Networks, support in the local community, and care from family can reduce the negative aspects of ill health (Spilker & Kumar, 2016; Ssanova, 2020).
Norway currently has few elderly immigrants; as of 1 January 2021, they made up 7 percent of all seniors (age 60 or older) and 11 percent of all immigrants. In comparison, the proportion of elderly people over 60 in the Norwegian population is 24 percent. There are 90,000 immigrants over the age of 60 from 197 countries. The proportion of elderly immigrants who are married is high and many live in multi-family households, but this varies by country group. The group of elderly immigrants will increase considerably in the future. According to population projections, elderly immigrants will make up 24 percent of all older people over 60 in 2060, mostly from countries in Africa and Asia (SSB, 2022e).
The knowledge we have about the health of elderly immigrants is also largely based on Statistics Norway’s Living Conditions Survey from 2016 and the 12 immigrant groups that were studied. There are significantly fewer elderly immigrants (55–74 years old), both women and men, who rate their own health as good or very good, and a larger proportion of immigrant women and immigrant men with chronic diseases, impaired function and who report symptoms of mental health problems than in the general population. There is a large gender difference among immigrants between the ages of 40 and 54 who rate their own health as good. Immigrant women’s self-assessed health deteriorates more gradually, while it falls drastically for immigrant men with increasing age, and there is no difference in the 55–74 age group. The number of elderly respondents in the survey is low. In general, we know little about immigrant health, especially in terms of gender differences that can help explain why immigrant men’s self-assessed health deteriorates to such a large extent and the proportion of older immigrants with reduced functional capacity increases significantly (SSB, 2022e; Hamre, 2017; Debesay et al., 2022). A register analysis of multimorbidity (having two or more diagnoses) among immigrants based on reason for immigration and length of stay in Norway shows that the incidence is highest among refugees. Multimorbidity doubles for all groups of immigrants within five years in Norway and increases rapidly with age for working immigrants, especially women (Diaz et al., 2015b).
People with disabilities
In the Living Conditions Survey among immigrants, the proportion who reported impaired function (the extent to which health problems affected the individual’s daily life, both congenital and acquired illness and injury) was significantly higher compared to a similar survey in the general population. However, there is great variation between the various immigrant groups in the survey (Kjøllesdal et al., 2019). In a qualitative interview survey, it emerged that many families with an immigrant background who have children with disabilities face challenges regarding healthcare services. Lack of familiarity with the system, language challenges, and limited use of interpreters results into a challenging interaction with healthcare services for many (Berg, 2014).
Knowledge and research on impaired functioning among people with an immigrant background is limited. Little is known about who the immigrants with disabilities are and whether there are any disabilities or health conditions that are particularly widespread (Bufdir, 2022).
LGBTQ people with an immigrant background
LGBTQ people with an immigrant background are a complex group representing many individuals with different experiences, but knowledge about this group is limited (Bufdir, 2021). A main finding in the Living Conditions Survey among homosexuals with an immigrant background (Eggebø et al., 2018) is that they are exposed to discrimination and marginalisation in several areas of society. This is mainly because of their immigrant background, race, and ethnicity, and also because they break the norms of gender and sexuality. The respondents report racism and discrimination in homosexual environments, as well as discrimination and marginalisation because of their gender identity and sexual orientation in larger society, especially from people with the same country or regional background.
Experiences of harassment and negative attitudes towards homosexuality in everyday life are burdensome and limit the opportunity to live openly as gay. Homosexual refugees are particularly vulnerable to discrimination and marginalisation. The two foundations of discrimination also work together and impact social status, finances, residence status, and health. Most of the respondents in this survey stated that they were in good health, although a significant proportion reported mental health challenges, suicidal thoughts, and exposure to sexual abuse (Eggebø et al., 2018).
Interpretation
Language barriers between the patient/user and healthcare personnel and failure to use a qualified interpreter can have serious consequences, including serious illness not being detected, incorrect diagnosis and treatment, complications, increased length of stay, and readmission to the hospital. Patients may have a poorer understanding of their own illness and the necessary self-treatment and follow-up. There is an underuse of qualified interpreters in health services and health personnel have insufficient knowledge of and expertise in using interpreters (NOU, 2014; Felberg, 2022; Bakken & Stray-Pedersen 2019; Bains et al., 2021b; Bains et al., 2021c, Czapka et al., 2019; Agenda Kaupang, 2020; Felberg & Sagli, 2019). People with an immigrant background with the weakest Norwegian skills more often have poorer health than those with good Norwegian skills, a challenge resulting from the underuse of interpreters (Kjøllesdal et al., 2022). IMDi is the national professional authority for interpreting in the public sector and provides advice, guidance, and information on the use of interpreters (IMDi, 2022). The Directorate of Health has prepared a guide on communication via interpreters for managers and personnel in health and care services (Directorate of Health, 2011).
Health literacy
Health literacy directly affects an individual’s ability to find, understand, assess, and use health information and health services, which, in turn, affects how they promote their own health, manage illness, and use health services in an efficient way (Ministry of Health and Care, 2019). The degree of health literacy is linked to education, finances, and language skills, and groups of immigrants may be particularly vulnerable (Gele, et al. 2016; Sørensen & Wångdahl, 2019). A survey of health literacy in the entire population in Norway shows that about one third have low health literacy and lack key skills and knowledge (Le et al., 2021a), while a corresponding survey of five immigrant groups shows that this applied to 40 percent of the respondents in two of the groups (Le et al., 2021b). Targeted measures can increase immigrant health literacy, but more knowledge is needed about the type of interventions, and it is important to increase health personnel’s knowledge about health literacy in different groups in the population and how to adapt services and communication to different needs (Le et al., 2021a; 2021b; Sørensen & Wångdahl, 2019; Fernández-Gutiérrez et al., 2018; Fox et al., 2022).
Equitable health services and utilization of health services
Although there are many significant conditions for immigrant health that lie outside the domain of health services, there is much that this sector can do to equalize health differences. By breaking down organisational, financial, linguistic, and cultural barriers, health services can ensure that everyone has equal opportunity to seek, receive, and make good use of the available quality healthcare.
Several Norwegian studies have shown that people with an immigrant background can experience barriers when accessing health services. Information about how health and care services are organised is rarely available in languages other than Norwegian and English. This leads to a lack of knowledge about services and rights, which is an important prerequisite to being able to use existing services (Straiton & Myhre, 2017b). Healthcare personnel may lack knowledge and competence about common health challenges among people with an immigrant background (Diaz & Kumar, 2018). Perceived discrimination and racism from healthcare personnel and the feeling that the symptoms are not taken seriously due to an immigrant background can make the services less attractive (Mbanya et al., 2019; Arora et al., 2019). Language barriers and other communication problems can cause misunderstandings and have serious consequences for diagnosis, treatment, and rehabilitation, despite the right to an interpreter (Czapka et al., 2019; Schein et al., 2019; Tschirhart et al., 2019). In addition, health literacy and different perceptions about health, symptoms of disease and when one should see a doctor can have an impact on diagnosis and treatment (Harris et al., 2020). Stigma linked to mental illness can be a major obstacle to seeking help for mental health problems (Næss, 2019; Straiton et al., 2018). When faced with sickness or disease, some may prefer to look elsewhere, for example, to religious leaders (Markova et al., 2020), health services in their home country (Czapka, 2010), or informal support from friends and family (Straiton, et al., 2017c), especially regarding mental health problems.
To learn more about which barriers contribute to unnecessary health differences, mapping and register studies as well as user surveys and qualitative analyses are necessary. The research that exists nevertheless provides an indication of the degree to which the Norwegian health service appears as an equal service to immigrant patients as well (Kjøllesdal et al., 2020; Lane et al., 2017; Levesque et al., 2013).
Utilization of health services
Overall, immigrants use general practitioners and emergency services to a somewhat lesser extent than the general population (Fadnes & Diaz, 2017; Sandvik et al., 2012; Statistics Norway, 2022e). This trend also applies to immigrant children under the age of 18. There is great variation between different groups.
In 2021, around 65 percent of immigrants (all ages) visited a general practitioner at least once. The corresponding proportion in the general population was around 72 percent (SSB, 2022f). Use of a general practitioner is particularly low among immigrants from EU countries outside of the Nordic countries (see figure 9) (SSB, 2022g).
Register studies show that use of a general practitioner increases with length of residence in Norway (Diaz et al., 2015c). Although the proportion of immigrants who visit their doctor is lower than in the general population, immigrants who use their doctor are more often frequent users, where frequent use is defined as more than seven consultations in a year (Diaz et al., 2014a). Immigrants report lower satisfaction with their family doctor than the general population (Kjøllesdal et al., 2020).
Adult immigrants are also admitted to the hospital somewhat less often than the general population (Elstad, 2016; Finnvold, 2018). Here there are also differences according to country of origin and reason for immigration. Among refugees, the proportion admitted to hospital was higher than in the general population, but lower among migrant workers. The proportions were highest among immigrants from South and West Asia, but lowest among immigrants from the rest of Asia and Europe. The lower admission rate for serious illnesses is partly explained by immigrants being younger than the general population. While the risk of hospital admission in the general population is higher among those with lower education and income than those with higher education and income, there is no such pattern among immigrants (Finnvold, 2018).
Older immigrants use health services to a somewhat lesser extent than people over 60 in the general population. The proportion of immigrants using their family doctor is lower than among other elderly people, but there is greater variation in scope between groups of immigrants and age (SSB, 2022e; Diaz & Kumar, 2014b). Immigrants from countries outside the EEA who are under 75 use their family doctor a lot, while the very oldest in this immigrant group have very little use. The proportion of elderly immigrants who use municipal health and care services is also consistently lower than among other elderly people and the differences increase with age (SSB, 2022e).
Health services for mental health
For mental health, the use of both general practitioner and specialist health services is lower among immigrants than in the general population, but there are large differences according to homeland, length of residence and reason for immigration (Abebe et al., 2017; Straiton et al., 2019b; Straiton et al., 2014). Among immigrants, people from countries in the Middle East often have higher use of health services, while people from countries in South-East Asia and Eastern European EU countries have the lowest use. In general, immigrants with longer periods of residence seek mental health services to a greater extent than immigrants with shorter periods of residence, and refugees use health services to a greater extent than other immigrants for mental health problems. A review of European studies on mental health service use among refugees and asylum seekers shows insufficient use of these services (Satinsky et al., 2019).
Among people who have been in contact with the primary healthcare service for mental health problems, the difference in use of the specialist healthcare service among immigrants and the general population is smaller (Straiton et al., 2022). This may indicate that the biggest challenges in accessing and seeking help lie at the primary healthcare level.
Dental health care
There are few studies on how often immigrants visit the dentist. The Living Conditions Survey among immigrants in 2016 shows that the proportion who visited a dentist within the previous 12 months was lower among immigrants than in the general population, with the exception of immigrants from Poland (SSB, 2017).
Less than half of immigrants from Somalia, Eritrea, Pakistan, and Afghanistan reported visiting a dentist the year before the survey, compared with almost three out of four in the general population. It can be assumed that dental costs are a major barrier for many, particularly among low-income immigrants (Debesay et al., 2019).
Use of medicines
Studies using data from NorPD show that a lower proportion of immigrants collect prescription medicines compared to the general population (Diaz et al., 2015c; Fadnes & Diaz, 2017; Gimeno-Feliu et al., 2016), but there are differences according to homeland. The probability of using medicines is about half as great among immigrant children as among children without an immigrant background (Fadnes & Diaz, 2017). A lower proportion of immigrant women, particularly from Eastern Europe, Asia, and Africa, use hormonal contraception compared to women in the general population (Omland et al., 2014). Adult descendants also have relatively low use of medicines in some groups (Diaz et al., 2019). Among women who have consulted a doctor for mental health problems, there is a lower proportion of immigrant women from Russia, Pakistan, Thailand, and the Philippines who use antidepressants and anxiolytics compared to women in the general population (Straiton et al., 2016).
Research indicates that culture, religion, and language barriers can affect medication use among immigrants. For example, almost half of Pakistani immigrants with lifestyle diseases changed their medication use during the fasting month of Ramadan. This could be because of perceptions about fasting during Ramadan, misunderstandings due to language problems, as well as cultural perceptions about the use of medicine (Håkonsen & Toverud, 2011; 2012).