Defining the determinants of under-vaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review

Abstract

Diverse migrant populations in Europe are at risk of under-immunisation and have recently shown lower levels of COVID-19 vaccination intent and uptake. Understanding the determinants of vaccine uptake in migrants is critical to address immediate COVID-19 vaccination inequities, and longer-term will help improve coverage for routine vaccinations, aligning with the goals of the new Immunisation Agenda 2030. We did a systematic review following PRISMA guidelines and using a PICOS framework (PROSPERO CRD42020219214; MEDLINE, CINAHL, PsycINFO databases, 1 January 2000 – 14 September 2021) exploring barriers and facilitators to vaccine uptake and determinants of under-vaccination in migrants in the EU/EEA, UK, and Switzerland. We categorised barriers/facilitators using the ‘5As’ Determinants of Vaccine Uptake Taxonomy. 5259 data sources were screened, with 67 studies included from 16 countries, representing 366,529 migrants. Access barriers were most commonly reported (language, literacy and communication barriers; practical and legal barriers to accessing/delivering vaccination services; service barriers, including lack of specific guidelines and knowledge of healthcare professionals) for key vaccines including MMR, DTP, HPV, influenza, polio, COVID-19 vaccines. Acceptance barriers were mostly reported in Eastern European and Muslim communities for HPV, measles, and influenza vaccines. We identified 23 determinants of under-vaccination in migrants, including geographical origin (where 25/26 (96%) studies showed significance) – particularly African/Eastern European origin; recent migration; being a refugee/asylum seeker; higher income; parental education level; no healthcare contact in the past year; and lower language skills. Facilitators of migrants’ vaccine uptake included tailored vaccination messaging, community outreach and ‘nudging’ interventions. Migrants’ barriers to accessing healthcare are already well documented, and this review confirms their role in limiting vaccine uptake. These data hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19. Our findings suggested that targeted, evidence-informed strategies are needed to address access and acceptance barriers to vaccination in migrants, including the development of migrant-sensitive and adaptable vaccination services and systems, unambiguous public health messaging, and coproduction of tailored interventions.

“We don’t routinely check vaccination background in adults”: A national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care

“…Tackling hesitancy and educating migrant and broader ethnic minority communities about the benefits of vaccination across the life-course will also be a critical component (22,27), with COVID-19 presenting numerous innovations in service delivery in this area that merit further consideration to routine vaccination going forward including outreach, policy shifts to facilitate registration of migrants with primary care providers, and anonymous vaccination in trusted locations (22,28). We found that certain nationality groups (Somali, Eastern-Europeans and Bangladeshi) may be more hesitant to receive vaccines than others, or reluctant to receive certain vaccines, aligning with a recent systematic review that found nationality/country of origin to be a key determinant of vaccine uptake for routine vaccines and COVID-19 vaccines in European datasets (7). In this study, acceptance barriers were mostly reported in Eastern European and Muslim migrants for HPV, measles, and influenza vaccines, with 23 significant determinants of under-vaccination in migrants found (p<0.05), including African origin, recent migration, and being a refugee/asylum seeker (7).…”

“…We found that certain nationality groups (Somali, Eastern-Europeans and Bangladeshi) may be more hesitant to receive vaccines than others, or reluctant to receive certain vaccines, aligning with a recent systematic review that found nationality/country of origin to be a key determinant of vaccine uptake for routine vaccines and COVID-19 vaccines in European datasets (7). In this study, acceptance barriers were mostly reported in Eastern European and Muslim migrants for HPV, measles, and influenza vaccines, with 23 significant determinants of under-vaccination in migrants found (p<0.05), including African origin, recent migration, and being a refugee/asylum seeker (7).…”

“…However, adolescent and adult migrants, beyond school age, are often not routinely incorporated into vaccination programmes on arrival to most European countries, including the UK (6). The COVID-19 pandemic has highlighted shortfalls in engaging older migrants, and other marginalised groups, in vaccination programmes (7), yet it has also presented a range of new opportunities and innovations in vaccine service delivery and policy making to these groups, which merit greater consideration beyond the pandemic.…”

How Does Migration Background Affect COVID-19 Vaccination Intentions? A Complex Relationship Between General Attitudes, Religiosity, Acculturation and Fears of Infection

“…Higher levels of acculturation were actually found to be significant predictors of lower levels of vaccination in HPV ( 52 ) and MMR and Hepatitis B ( 53 ). On the other hand, a systematic literature review revealed that more recent (and therefore less acculturated) migrants tend to be undervaccinated ( 54 ). In the specific case of COVID-19 vaccination intention it was shown that acculturation was not a statistically significant predictor of vaccination intentions ( 55 ).…”

Understanding dynamic complexity in context—Enriching contextual analysis in implementation science from a constructivist perspective

“…During the COVID-19 pandemic, vaccination hesitancy varies considerably among social groups that share common spaces, e.g., younger individuals, low-income communities, rural residents, or migrant populations (70,71). E.g., younger adults' concerns vary from those in other social groups as their doubts about the safety or side/adverse effects of vaccines may focus more on fertility/pregnancy (60).…”