The Disproportionate Impact of COVID-19 on Immigrants and Refugees with Chronic Illnesses
This community-based research project delved into the compounded effects of the COVID-19 pandemic on immigrants and refugees living with cancer, and mental health and addiction disorders. The study, a collaboration including Access Alliance, sought to understand the challenges faced by individuals at the intersection of social and clinical disadvantage during a public health crisis. The central question guiding the research was: What happens to those who are at the intersection of social and clinical disadvantage during a pandemic?
The project aimed to identify systemic barriers to equitable healthcare access during pandemics, co-develop actionable solutions with stakeholders to address disparities, and inform policy and programming to protect vulnerable populations in future crises. The insights gained from this research offer actionable recommendations to address the unique needs of these populations in future public health crises.
The study provides a roadmap for building crisis-resistant health systems that centre equity, creating lasting protection for Canada’s most vulnerable communities by addressing both clinical needs and social determinants.
Why This Research Matters
The COVID-19 pandemic did not impact all segments of the population equally. Immigrants, despite representing only a quarter of Ontario’s population, accounted for almost half of the province’s COVID-19 cases. This disproportionate impact highlights the structural inequities that immigrants and refugees face, such as unemployment and crowded housing, which heightened their vulnerability to the virus.
Even before the pandemic, immigrants and refugees encountered challenges in accessing primary care, navigating language barriers, and trusting healthcare systems. Systemic issues, including the exclusion of foreign-trained healthcare providers, inadequate mental health resources, and fragmented social services, further exacerbated these difficulties. The pandemic intensified these disparities through service closures, misinformation, and reduced preventive care, such as cancer screenings.
Chronic conditions like cancer, mental health and addiction amplify these vulnerabilities. This project addressed gaps in understanding how COVID-19 exacerbated disparities for clinically and socially marginalized groups, providing evidence to inform equity-centred policies.
The findings revealed alarming disparities: immigrants with cancer were three times more likely to be hospitalized and four times more likely to die from COVID-19 than non-immigrants without cancer. Similarly, immigrants with mental health and addiction disorders faced 52% higher COVID-19 diagnosis rates and 65% higher mortality rates compared to non-immigrants without such conditions. Systemic issues such as language barriers, lack of culturally safe care, and workforce shortages were identified as contributing factors.
Key Research Questions and Methodology
The research was guided by three key questions:
- How did COVID-19 disproportionately affect immigrants and refugees with cancer or mental health and addiction disorders?
- What structural barriers limited access to cancer/mental health and addiction services during the pandemic?
- What community-driven strategies can improve crisis responsiveness?
Researchers conducted a population-based retrospective cohort study using linked Ontario healthcare administrative databases. The study period spanned from March 31, 2020, to December 31, 2021, corresponding to COVID-19 waves 1-4 and the first 16 days of wave 5.
This study was the first in Ontario to analyze COVID-19 outcomes through both clinical and social lenses, combining population-level health data with community wisdom gathered through Think Tanks. It also prioritized solutions co-created by patients, providers, and policymakers through direct community consultations. Visit the project website for more details on the methods and recommendations from Think Tanks, community reports and other publications.
Key Findings
The research underscores how systemic inequities rooted in racism, socioeconomic status, and geography were exacerbated by COVID-19. Racialized groups already faced lower screening rates and higher cancer mortality before the pandemic, and pandemic-related disruptions deepened these gaps.
Lower-income neighborhoods and newer immigrants experienced significantly reduced access to essential services, leading to delayed screenings. Mental health challenges surged, with 67% of patients reporting heightened anxiety and 63% citing increased stress.
Immigrants with cancer faced delays in diagnosis and treatment due to a lack of family doctors and systemic navigation support. Solutions prioritized leveraging foreign-trained providers as “health ambassadors” and connecting newcomers to care upon arrival.
Participant quote: “I had no OHIP, no family doctor, and didn’t know how to access care after my cancer diagnosis”.
The combination of immigration status and pre-existing mental health and addiction issues significantly influenced adverse COVID-19 outcomes. Pandemic isolation worsened mental health, particularly for youth and seniors, while virtual care excluded those with limited tech literacy.
Participant quote: “Lockdowns felt like imprisonment… we had no guidance on managing stress”.
Several system-related findings emerged, including:
- System Fragmentation: Virtual care excluded a significant portion of immigrants with limited digital literacy, and silos between health, housing, and immigration policies left families struggling to meet basic needs.
- Cultural Inequities: Lower vaccination uptake among Black and Latin American immigrants was linked to historical mistrust.
- Social Inequities: A significant proportion of immigrants with cancer resided in ethnically concentrated, high-deprivation areas.
- Clinical Inequities: More immigrants lacked a primary care provider and had higher rates of comorbidities.
Key Recommendations
Stakeholders emphasized the need for urgent policy reforms, such as targeted outreach, programs co-designed with affected communities, and infrastructure investments to ensure equitable care during crises. Recommendations include:
- Improving access to health, social, and economic resources for immigrants and refugees and fostering intersectoral collaboration across services.
- Prioritizing proactive primary care connections for immigrants and refugees and increasing both health and digital literacy.
- Enhancing service access through community engagement, including culturally specific outreach and care.
- Ensuring culturally competent service delivery and tailored programs for local needs, including leveraging internationally educated health professionals as community health ambassadors.
How the Research Can Be Used
Access Alliance can use this research to advocate for OHIP coverage for language interpreter services, champion peer-led navigation programs, and partner with settlement agencies to integrate health promotion and awareness. Policymakers can use the findings to fast-track licensure for internationally educated health professionals and mandate cultural safety training in accreditation standards. Healthcare providers can work with community organizations to implement health connection protocols throughout the immigration and settlement process, while community organizations can train community health workers in trauma-informed health support and establish pop-up vaccination clinics in faith centres.
The study uniquely centres stakeholder engagement through surveys, focus groups, and roundtables with healthcare providers, patients, and policymakers to highlight actionable solutions, connecting fragmented care during the pandemic to broader structural issues.
Knowledge Mobilization Activities
A project website was created that includes more information about research methods and recommendations from Think Tank consultations, community reports and publications.
Upcoming knowledge mobilization activities will include:
- stakeholder and community workshops and webinars to promote understanding and facilitate discussions on the study’s outcomes
- posting to various newsletters and communities of practice to reach Settlement and Health practitioners
- community presentations and validation sessions where study findings are shared directly with local groups, encouraging engagement and feedback with Think Tank participants, partner agencies, Community Reference Groups, and other community gatherings
- cultural adaptation of materials to ensure relevance and accessibility for different cultural groups within affected communities
- training sessions with community leaders to better understand and communicate the findings
- training with health providers such as workshops on cultural safety and trauma-informed care for providers that includes curriculum from our Community Based Research Training for Peer Researchers
- conference and other with community leaders, researchers, and stakeholders to dive deeper into study results and foster a dialogue about their implications where study participants, researchers, and local community members can discuss the findings, challenges, and next steps in a collaborative setting
- other multimedia recordings such as videos and audio/podcasts that capture all of the KM activities above and provide findings, discussions, and actions in additionally accessible ways. This could include the creation or curation/sharing of existing multilingual videos and guides on navigating cancer care and mental health & addictions care, featuring testimonials from patients and service providers
- policy briefs that summarize key findings on screening delays and mental health impacts for government stakeholders
- more as our research, organization, and community partners provide input
Related Articles
Silent Voices of Immigrants and Refugees Battling with Mental Health and Addiction during COVID-19: A Follow- Up Population-Based Cohort Retrospective Study in Ontario, Canada
This article examines the compounded effects of social and clinical disadvantages, specifically focusing on the combined impact of immigration status and pre-existing mental health and addiction, on COVID-19 outcomes (vaccination rates, diagnoses, hospitalizations, ICU admissions, and mortality).
Related Access Alliance Activities
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Client Perspectives on the Impacts of COVID-19
Recognizing the significant changes and challenges facing the centre and our community a year into the COVID-19 pandemic in Toronto, Access Alliance initiated a strategic planning process in the spring of 2021. To fully understand the situation, we needed to engage directly with our service-users. We conducted seven virtual focus groups between April 8 and 21, 2021 (using the Zoom platform). A total of 64 community members took part, including people of various genders, ages, education levels, sexual orientations, and cultural backgrounds.
Vaccine Engagement Impact Report
Taylor Massey-Oakridge-Victoria Village was one of the least vaccinated neighbourhoods during the summer/fall of 2021. With a coordinated effort between the partners, we raised the vaccination rate above the City’s average and significantly reduced the COVID-19 hospitalization rates during the pandemic peak.
Vaccine hesitancy among Syrian refugee parents in Canada: A multifaceted challenge in public health
This multi-country multi-institute study, housed at Access Alliance, investigates vaccine hesitancy among Syrian refugee parents in Canada. Researchers examined the factors that influence their willingness to accept COVID-19 vaccination.