Disaggregated data is sparse; available data points to significant disparities
• Challenges exist with enumeration and characterization of urban poor.
• Where data is available, clear inequities are seen among the urban poor.
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Ok. Question 2 coming up: What are the main barriers to vaccination for people living in poverty - are there any urban-rural variations to this?
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Yes, in the context of COVID-19, Public Health England, for example, concluded with unusually forthright language that structural racism and discrimination was a key factor increasing the risk of exposure to and death from covid-19 among ethnic minority groups, which in itself was a result of ethnic minorities having poorer access to healthcare and poor experiences of care and treatment related to racial discrimination and marginalisation. And this has its own obvious effects - marginalised ethnic groups have had higher rates and earlier onset of disease, more aggressive progression of disease, and overall poorer survival rates. In polio vaccination, repeated studies – such as this one in Guinea – have shown that socio-economic inequalities was strongly correlated with vaccination uptake, especially in factors like mothers’ education.
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A2. Geographic access may vary, but “social” access issues may the same. Increasingly your legal status may also make you reluctant to come forward and seek care.
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There are so many gaps in data collection and unification of systems across Europe! In the UK routine data on country of birth is not collected making it very difficult to measure immunisation rates among migrant populations, despite migrants making up more than 14% of the population. + lots more gaps/opportunities that would strengthen surveillance and monitoring of health outcomes and inequalities
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We can’t speak to urban-rural variations to this as Southwark is an inner city area.
The main barriers to accessing vaccinations for those living in poverty vary – experiences of poverty are also shaped by other factors such as ethnic background and migration status. Some common barriers include:
Issues with accessing primary care due to language barriers, concern about migration status or poor prior experiences with the NHS
Distrust of vaccination due to systemic racism and/or the spread of misinformation during the COVID-19 pandemic and prior vaccine scares such as the discredited Wakefield studies
Lack of time and other resources, for example money for travel, especially for families, to attend vaccination appointments
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A2: Numerous frameworks exist that can help us look at and understand vaccination behaviour and determinants, for example, the 5As, which organises all non socio-demographic factors into the 5 domains of Access, Acceptance, Awareness, Affordability (financial and non-financial) and Activation (behavioural ‘nudging’ interventions).
In our review, we found that access and acceptance were the most commonly reported barriers to vaccination among migrants in Europe, however migrants can face a multitude of barriers depending on their circumstances.
Our definition of migrants (foreign-born) is broad and therefore encompasses diverse migration experiences and people; a person fleeing war or persecution; a person migrating from a rural area to a city to work; a student temporarily living overseas; a person who has been trafficked across borders for labour exploitation; an executive who has moved between high income countries for work, etc. Their health outcomes will vary greatly depending on their experience of social determinants of health - non-medical factors such as income, working conditions, housing, employment, education, social inclusion, discrimination, and access to health and social care. Health and illness are said to follow a social gradient, therefore, the lower someone’s socioeconomic position, the worse their chances for health.
Not all migrant groups will face health and vaccination inequities, while some migrant groups will also share experiences with other non-migrant, marginalised groups, such as low-income communities. As much as poverty can be a driver of migration (although evidence shows that the poorest of the poor often do not have the resources to migrate), those who migrate can also become at higher risk of poverty and social exclusion in their destination countries. In the UK, asylum seekers are not entitled to work or claim benefits while their asylum claim is being reviewed, and many face delays in receiving support, or find their support stopped or suspended when their claim is refused. New refugees lose all asylum support, including housing, just 28 days after being granted leave to remain in the UK. Many migrants end up living in the most deprived areas of the country and in poor and insecure accommodation.
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People often talk about 3 main barriers to vaccination… I’m interested in whether we think these are the same for those living in poverty or social exclusion?
• Confidence : including whether, the system and people who deliver it are seen as reliable and competent, and policy makers and health institutions are trusted
• Complacency: whether people see no major risk from catching an illness
• Convenience: including whether vaccines are accessible and affordable, whether the purpose of vaccination is clear and whether vaccines are supported by cultural context.
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In Italy, as also Intersos points out - who is very committed to the issue - in the various regional health systems, the obstacles to vaccination for the most marginalised population groups are many and different from each other, especially for people not registered in the public health system or without a valid residence permit. The segments of the population in conditions of social exclusion are often generally defined as “hard to reach”, difficult to reach, although this category is in reality varied and, without recognizing the characteristics and needs of the various populations that compose it, it is not possible to guarantee effective access to vaccination, let alone the effective basic health protection that the law would provide.
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A2: I’ve summarised some of the key barriers to vaccination experienced by migrants below that we identified in our review, beginning with access and affordability, which are the most relevant to today’s discussion. These barriers are not exhaustive. I have also included examples of other barriers (e.g. awareness and acceptance) that some migrant populations face, and which may be indirectly associated with circumstances of poverty and inequality.
Access
- Language, literacy and communication barriers
- Resource and capacity constraints
- Practical barriers
- Legal barriers
- Distrust of health system or authorities; sense of alienation and disempowerment
- Specific provider-level barriers
Lack of access to translated or tailored health information and culturally competent services are a major barrier to vaccination for many migrant populations. Migrants and refugees in particular may experience digital exclusion, language and literacy barriers and lack of interpreting services to facilitate patient-provider interactions. Health/vaccination information is often provided in written formats (leaflets, forms) when in fact many migrant populations prefer to receive and can better engage with oral information.
The availability of vaccines and logistics of bringing them to refugee, migrant and mobile populations can be a major barrier to access in some settings. Migrants also face numerous practical and legal barriers to accessing healthcare and vaccination services, including insecure housing, lack of a fixed address, and uncertainty around legal entitlement to services. Although migrants are entitled to access primary care free of charge in the UK, many are unaware of their entitlement, are wrongly challenged or turned away from care or do not come forward due to fear around legal implications or of being charged. In the UK, harsh immigration policies and the so-called “hostile environment” towards migrants has diminished trust in immunisation/health services, service providers, and government. As a result, even after governments made clear that COVID-19 vaccines would be available regardless of immigration status, many migrant populations were still reluctant to come forward, in the UK and European countries. A Red Cross Red Crescent report emphasised that lack of documentation and fear of arrest, detention or deportation were preventing access to COVID-19 vaccination for migrants globally.
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A1: A great point! Vaccine hesitancy/confidence is very context specific and variable across time, country, and sub-populations. I find confidence measure to be particularly useful in detecting, large, national trends and then drilling down into the socio-demographic indicators afterwards to explore if there are any particular populations driving or contributing to the trend, whether confidence is higher or lower among different income groups or between genders or education levels.
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A2. • Challenges associated with identifying caregivers and unimmunized children in crowded and highly mobile areas; transient groups utilize fewer health services, further complicating identification.
• Many children in LMIC do not encounter the health system before age five.
• Catchment areas are ill defined and accurate denominators can be difficult to measure.
• Higher average rates of immunization in urban settings and quickly changing denominators (which can lead to coverage rates > 100%) reduce political urgency.
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A2:
Affordability
- Direct cost of vaccination
- Indirect costs, e.g. cost of travelling to vaccination appointment
- Competing priorities, e.g. feeding family, childcare
Routine vaccinations are available free of charge in the UK, so direct costs of vaccination do not pose a major barrier here for the individual. However, many migrants living in poverty and deprivation may still be deterred by indirect costs, such as transport fares and working time lost. In one of our recent studies (being prepared for publication), migrants expressed not wanting to risk losing working time due to experiencing COVID-19 vaccine side effects and needing time off work, or to face unexpected medical costs if they needed to seek care. In a recent study led by my colleague Anna Deal, migrants with precarious immigration status said that if they could be confident there would be no associated costs, more of their community would present for COVID-19 vaccination. Migrants may also face competing priorities, such as caring for their children or earning a living wage, which they deem more important. In this case, offering more flexible and walk-in appointments have been shown to improve attendance, although they are still rarely implemented consistently in practice.
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Costs and transportation are clearly major logistical barriers in poverty-stricken areas. Not all vaccinations are publicly funded, and by extension they will very often be out of reach to significant pockets of society due to limited affordability. Transport costs are also not insignificant factors and are often brought up in patient surveys as a barrier to healthcare. This is particularly true in rural areas, where the cost of transport is higher both in terms of distance but also time, both of which have costs attached to them. Another HPV vaccination study, this time in boys, also showed that poverty was not statistically linked to initial vaccination…but interestingly it was linked to completion rates. And there was a clear rural/urban divide here – boys from urban area had higher chance of both initiating and completing vaccination than boys in rural areas.
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A2:
Activation
Lack of interventions that encourage/nudge individuals to vaccinate, including lack of information or practical support from healthcare professionals when desired; blanket approaches that are not tailored to the specific needs of the target population
Sometimes opportunities are missed to encourage vaccine uptake in migrants due to, for example, a lack of tailored information or practical support from healthcare professionals or trusted sources when desired. Many adult migrants are unaware of their need for catch-up vaccinations (vaccinations missed during childhood). Increased education and awareness of health professionals of migrants’ health and vaccination needs, and in delivering culturally-competent and sensitive care, as well as tailored interventions and nudges, may facilitate vaccination opportunities and result in increased uptake.
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A2:
Acceptance
- Worries about vaccine safety and side-effects
- Cultural, religious and social barriers, including stigma around specific vaccines
- Distrust of health system or authorities; suspicion of motives
- Misinformation or lack of information to inform decision-making
- Low perception of risk of disease or importance of vaccination
Several studies have shown that social norms, cultural and religious acceptability, and stigma can create barriers to vaccine uptake. Distrust of vaccination or the wider health system can also influence acceptance of vaccination. This can be exacerbated by social exclusion or precarity in resettlement, both of which are reported to reduce vaccine confidence. For example, a US study showed that Karen refugees’ perceptions of vaccine safety decreased with time spent in the US. The effects of structural racism and contemporary and historical discrimination are extremely significant and have been highlighted during the COVID-19 pandemic. In addition to having worse health outcomes, many migrant and ethnic minority communities expressed concerns that they might be used as “guinea pigs” in the COVID-19 vaccine roll-out, and French doctors explicitly suggested that COVID-19 vaccines should be tested first on African populations.
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A2:
Awareness
- Lack of knowledge about disease or vaccination needs
- Lack of knowledge about entitlement to vaccination (being entitled to access the health system free of charge)
- Misinformation or lack of information
Knowledge barriers about vaccination and low health literacy are evident in migrant populations, however few studies have measured the effect of knowledge on vaccine uptake, and it has been shown that knowledge alone is often not enough to change vaccination behaviour. We have already highlighted above how being unaware of one’s entitlement to receive vaccination or not knowing where to receive vaccination can pose barriers. In the absence of translated, tailored or reliable public health information, migrants are also likely to turn to alternative and unregulated sources of information which may shape their beliefs about vaccination.
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What unites the various “hard to reach” populations is actually a general exclusion from society, as well as a partial recognition of individual rights. In fact, these people enjoy limited, fragmented or sometimes absent access to the regional health system, have a frequently reduced health capital compared to the average population due to social and health marginalisation, which also collides with various linguistic and cultural obstacles—which involve, in general, a reduced knowledge of one’s state of health, and, more specifically, further difficulties in carrying out a precise anamnesis in the pre-vaccination phase. In a period of health emergency such as the one from which we are struggling to emerge from, but also in order to establish a so-called “life-long vaccination culture”, it is essential to provide direct, efficient access to vaccination without prerequisites for all people present in the national territory. For full access to vaccination, and more generally to the health system, it is necessary to remove informational, logistic, linguistic-cultural, administrative obstacles, through binding, centralised and standardised indications for all regions. To this end, a targeted vaccination plan needs to be implemented, dedicated in particular to the most socially fragile groups, such as farm workers, people in reception and repatriation centres, as well as obviously homeless people.
In addition to this, the lower levels of access to scientifically correct information and the presence of linguistic-cultural barriers which can lead to reduced participation rates in the vaccination campaign for some groups of people cannot be underestimated. To counter the hesitations in vaccination, which also involves part of the foreign population present in Italy, it would be necessary to carry out specific information campaigns, enhancing cultural-linguistic mediation where necessary.
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A2. Misinformation and lack of trust spreads locally – and can be studied, and addressed. In the local context. This is an area of “action research” we need to develop, to make sure vaccines become vaccinations.
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A2: Affordability, accessibility, competing priorities, and trust are barriers impacting vaccination rates for people living in poverty. I detailed these in my lengthy response to question one (see A1) so I will try to concentrate on variations between populations here and focus my response on vaccine confidence.
Vaccine confidence is a complex and context specific challenge, varying across time, place, sociodemographic characteristics, and vaccines. People living in poverty and socially excluded groups are a dynamic population and cannot be viewed as homogeneous. Yes, there are urban and rural variations—rural healthcare workers are often in shortage or serve rural communities short-term, which can hinder the trust (i.e., confidence) many patients require from their providers to accept care, while healthcare workers are more prevalent in urban settings—and there are similarities—I mentioned in A1 that accessibility can be a challenge in both rural and urban settings. But there are more nuanced variations still. People living in poverty and socially excluded groups have unique experiences based in gender, age, disability, whether or not that person is also a caregiver to a child or elder, culture, veteran status, religion, race., etc. Therefore, the barriers—not just in vaccine confidence but also in affordability, accessibility, and competing priorities—each individual face are multifaceted and evolving.
Restoring trust, and indeed addressing any of these barriers, requires substantial investments in time and resources—both in providing the short-term solutions to prevent real-time and near future crisis but also in identifying and meaningfully addressing the root cause of barriers that inhibit us from providing long-term solutions, which, often, require policy and systems change. I may even add that addressing barriers requires us—people in business, people in research and academia, heck, all of us—to consider and implement values change.
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