We recently conducted a major review of literature from 16 countries in Europe, representing 366,529 migrants, to understand why migrants are less likely to be vaccinated and which migrant groups may benefit from specific interventions to increase their vaccination uptake. We found various barriers to participating in vaccination programmes, including language, literacy and communication barriers, practical and legal barriers to accessing and delivering vaccination services, service barriers (such as lack of specific guidelines and knowledge of healthcare professionals), and concerns about safety and side-effects and stigma regarding various vaccines.
We also identified 23 factors that may determine undervaccination among migrant groups (based on statistically significant associations), such as being of African, Asian or eastern European origin, having migrated recently or being refugees or asylum seekers. Although these findings should be interpreted with caution, they likely reflect the interplay of numerous individual and social factors influencing vaccination uptake, including weakened health and vaccination systems, unavailability of certain vaccines in origin and transit countries, language barriers, social exclusion, and relative poverty, precarity and deprivation experienced by these particular groups along the migration trajectory.
According to the report “Reducing COVID 19 transmission and strengthening vaccine uptake among migrant populations in the EU/EEA” produced by the European Center for Disease Prevention and Control (ECDC) and released in June 2021, EU countries have detected some groups of migrants and ethnic minorities who have low vaccination coverage rates and their high exposure to the virus implies the need to implement a targeted vaccination plan, dedicated in particular to the most fragile categories such as migrant farmers, those present in reception and detention centres, homeless shelters or other community facilities. Among the factors that increase these risks are employment conditions, housing conditions characterised by overcrowding and the low level of accessibility to public health and information services.
A1: The Vaccine Confidence Project (VCP) focuses on confidence as a demand-side barrier that is increasingly driving a wedge between populations and immunization. Our Vaccine Confidence Index measures perceptions of vaccines in terms of their importance, safety, effectiveness, and compatibility with personal beliefs. We pair this with socio-demographic indicators to understand confidence within and between populations as well as to track levers and trends in confidence over time.
Confidence is rooted in trust, not just in the vaccine but also in the people and systems that administer them. For people living in poverty or socially excluded groups, many of whom have fallen through the holes in the safety nets meant to support them, that trust may already be broken. Additionally, grievous crimes have been historically committed against people living in poverty and minority groups—including forced sterilization and unethical human experimentation, i.e. the Tuskegee syphilis trial. Trust, historically and presently, when it comes to public health and vaccination is ruptured and needs to be urgently addressed.
While we have socio-economic status included in most of our surveys, there is more we can do to be reaching people living in poverty as well as socially excluded groups. This is a challenge across our sector. Accessibility goes both ways, and often nationally representative surveys miss marginalized groups. Surveys administered online of via phone don’t always reach the people we may need to hear from most. This is a challenge we are looking to address through more of our qualitative research.
Access is definitely a key contributor but we’ve also seen other issues. Among families affected by poverty (income poverty, severe material deprivation or social exclusion) in large European countries data indicates that, it is less likely for them to seek vaccination for their family, because of lower trust in institutions (confidence), limited access to health services and information about vaccination, often due to the digital gap (convenience) and competing priorities (complacency) other than vaccination such as work, house or food insecurity.
I think one important counterpoint is that there is not always a clean/direct correlation between poverty and vaccination rates. Some studies show a mixed effect – for example a study on HPV vaccination in the US showed that while higher poverty levels at the state level was correlated with reduced vaccination, the precise opposite was true at the county level and at the household income level. It is hard to explain this beyond showcasing significant levels heterogeneity in the data, which in turn means we need to be a bit cautious about how we draw up our vaccination policies. Also, there’s actually not a great amount of research on the link between poverty and vaccination; there is a need for more studies here to clarify the relationship and causalities here, especially outside of the US.
At present, there are approximately 800,000 people in a condition of health and social fragility present in Italy (primarily irregular immigrants and homeless) (see: [Fondazione Veronesi: Irregular and homeless: the invisible of the vaccine]): we are talking about about 500/600,000 irregular immigrants, about 45,000 homeless, according to the latest census, and about 200,000 people who have applied for regularisation - and therefore have every right to be registered within the public health system - but they are substantially in a bureaucratic limbo that does not allow them to access the completion of the procedure.
I agree, the digital gap is a significant issue for this populations. Whilst it means they are less likely to be impacted by misinformation, it can also mean that they have limited access to ‘good’ information or understanding entitlements with regard to access to health services.
A1- Social determinants play a key part- education, trust and financial stability. The lack of clear and consistent communication.
False claims by vaccine manufacturers as was the case in Spain with respect to HPV (over marketing- advertisements across Europe on Spanish airlines- making promises and then changing the narrative).
It is also important to remember that in London, poverty disproportionately affects those from ethnic minority backgrounds. In the UK the Joseph Rowntree Foundation estimate that 40% of Black British, Black African and Black Caribbean families live in poverty, versus 21% of White families.
Those from ethnic minority backgrounds, particularly Black and Asian backgrounds, are more likely to be vaccine hesitant than those from White backgrounds, due to a range of factors, including
awareness of historic and ongoing systemic racism in the healthcare system and wider government sector
personal prior experiences with the health system
specific concerns about historic actions of pharmaceutical companies, for example Pfizer’s role in unethical clinical trials in Nigeria in the 1990s
cultural/religious concerns around the implications of vaccination, e.g. with HPV
We see the effect of this in Southwark, where Black communities experience considerable inequalities in COVID-19 and flu vaccination uptake.
Already in February 2021 The Italian Medicines Agency - AIFA had explained that in order to proceed with the immunisation of the most socially fragile individuals it would have been necessary to allow access to the vaccine also to irregular immigrants in possession of the “STP” number (“Straniero Temporaneamente Presente”: a code issued by the Italian Regions which allows foreigners without a residence permit to access essential and emergency health services).
A1: Great question! And also, if you can get time off, is it paid time off such that you aren’t sacrificing vital income to get vaccinated? Extending operating hours at vaccination sites could be a potential solution and also encouraging employers to adapt equitable policies and practices.
Vaccine hesitancy is clearly a significant factor in vaccine uptake, but I’ve also seen mixed data on correlation between vaccine hesitancy and socio-economic status – in some cases there appears to be a link, in others not (for example vaccine acceptance rates have in many cases been much higher in low/middle-income countries than in eg. the US)…so hesitate to draw to many conclusions over this.
A1: Migrant groups are certainly an under-research population, and a growing one at that as we consider climate migrants, migrants due to increased conflicts around the globe, and economic migrants that are helping to address some of the workforce gaps in countries with ageing populations. They are a particularly interesting population when it comes to vaccine confidence as their trusted sources of information may be in either/or, or both their home and host country, as well as during their travel in between. We are undertaking a new study looking at migrant populations in London who are un or under-vaccinated and will partner with non-profits immigrant and refugee groups as well as GPs and healthcare professionals to understand the barriers in confidence and opportunities for programs that could boost vaccine confidence and forge a more symbiotic relationship between migrant populations and health systems.
Yes, and I think there is also a mixed effect observed around vaccine hesitancy and income/education level in low and middle income countries versus high income countries - I’m sure @rachel.eagan from the Vaccine Confidence Project might be better placed to expand on this, though!
very interesting Gus - it does seem that there are multiple studies out there that show the links in specific circumstances/regions but no overarching data collection at an EU level. How could data collection be improved to better track equity and vaccination uptake…
I think a gig challenge is that sadly the social determinants of health are worsening across the EU - and poverty is ‘deepening and widening’. A report in the UK this week cited that 1 in 3 children in the north east of the UK live now in poverty. This is worse than 2001 levels. Life expectancy in this country has also dropped especially for women living in the most deprived 10% of areas.