General discussion 9 271 observed these differences to increase between the first and second COVID-19 waves[3]. Moreover, it was demonstrated that persons with a migration background had a higher risk of COVID-19-related death than the population of Dutch origin throughout the prevaccination era[4]. Meanwhile, similar observations were made in other high-income countries (HICs) [5, 6]: initially the United Kingdom[7, 8] and United States of America [9, 10] but later also Sweden, Denmark, Italy and France[11]. 9.1.1 The factors driving inequalities in COVID-19 burden are multi-factorial The disparities in COVID-19 hospitalisation rates were likely driven by a complex interplay of social, cultural, and biological factors that affected both COVID-19 exposure and the risk of developing severe disease. Firstly, individuals with a first- or second-generation migration background in the Netherlands are more likely to be employed in front-line occupations, such as cashiers, cleaners, and hospitality workers[12], associated with frequent daily contacts and thus increased risk of SARS-CoV-2 exposure and infection. Within households, moreover, nonWestern/European migrant communities are more likely to live with a greater number of family members under one roof, thus increasing the risk of transmission in the home environment[13]. Secondly, the increased risk of infection among migrant populations may be further compounded by decreased access to diagnostic testing services, due to language barriers or reduced health literacy, allowing SARS-CoV-2 transmission to continue without appropriate intervention. We additionally found that, independent of migration background, living in a city district with a lower socio-economic status (SES) was associated with a greater COVID-19 burden during the first and second waves. Employment in industries where social distancing measures may be difficult to adhere to (such as hospitality and transport[14]) and where working from home is not feasible, may underlie the increased risk of infection in city districts with lower- compared to higher socio-economic status. The risk of COVID-19 hospitalisation was highest among individuals with migration background who resided in low-SES city districts, compared to ethnic-Dutch individuals living in central Amsterdam (this thesis, Chapter 2 and Chapter 3). This demonstrates the composite effect of these risk factors on driving COVID-19 disparities. Further studies have demonstrated that additional associated factors, such as self-reported disability, area deprivation and religion, may also be associated with increased risk of SARS-CoV-2 infection[15].
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