Strategies and action points to ensure equitable uptake of COVID-19 vaccinations: A national qualitative interview study to explore the views of undocumented migrants, asylum seekers, and refugees

Abstract

Introduction

Early evidence confirms lower COVID-19 vaccine uptake in established ethnic minority populations, yet there has been little focus on understanding vaccine hesitancy and barriers to vaccination in migrants. Growing populations of precarious migrants (including undocumented migrants, asylum seekers and refugees) in the UK and Europe are considered to be under-immunised groups and may be excluded from health systems, yet little is known about their views on COVID-19 vaccines specifically, which are essential to identify key solutions and action points to strengthen vaccine roll-out.

Methods

We did an in-depth semi-structured qualitative interview study of recently arrived migrants (foreign-born, >18 years old; <10 years in the UK) to the UK with precarious immigration status between September 2020 and March 2021, seeking their input into strategies to strengthen COVID-19 vaccine delivery and uptake. We used the ‘Three Cs’ model (confidence, complacency and convenience) to explore COVID-19 vaccine hesitancy, barriers and access. Data were analysed using a thematic framework approach. Data collection continued until data saturation was reached, and no novel concepts were arising. The study was approved by the University of London ethics committee (REC 2020.00630).

Results

We approached 20 migrant support groups nationwide, recruiting 32 migrants (mean age 37.1 years; 21 [66%] female; mean time in the UK 5.6 years [SD 3.7 years]), including refugees (n = 3), asylum seekers (n = 19), undocumented migrants (n = 8) and migrants with limited leave to remain (n = 2) from 15 different countries (5 WHO regions). 23 (72%) of 32 migrants reported being hesitant about accepting a COVID-19 vaccine and communicated concerns over vaccine content, side-effects, lack of accessible information in an appropriate language, lack of trust in the health system and low perceived need. Participants reported a range of barriers to accessing the COVID-19 vaccine and expressed concerns that their communities would be excluded from or de-prioritised in the roll-out. Undocumented migrants described fears over being charged and facing immigration checks if they present for a vaccine. All participants (n = 10) interviewed after recent government announcements that COVID-19 vaccines can be accessed without facing immigration checks remained unaware of this. Participants stated that convenience of access would be a key factor in their decision around whether to accept a vaccine and proposed alternative access points to primary care services (for example, walk-in centres in trusted places such as foodbanks, community centres and charities), alongside promoting registration with primary care for all, and working closely with communities to produce accessible information on COVID-19 vaccination.

Conclusions

Precarious migrants may be hesitant about accepting a COVID-19 vaccine and face multiple and unique barriers to access, requiring simple but innovative solutions to ensure equitable access and uptake. Vaccine hesitancy and low awareness around entitlement and relevant access points could be easily addressed with clear, accessible, and tailored information campaigns, co-produced and delivered by trusted sources within marginalised migrant communities. These findings have immediate relevance to the COVID-19 vaccination initiatives in the UK and in other European and high-income countries with diverse migrant populations.

Funding

NIHR

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SciScore for 10.1101/2021.04.12.21255313: (What is this?)

Please note, not all rigor criteria are appropriate for all manuscripts.

Table 1: Rigor

Ethics	Consent: Ethics and informed consent: Ethics was granted by St George’s, University of London Research Ethics Committee (REC 2020.0058 and 2020.00630). IRB: Ethics and informed consent: Ethics was granted by St George’s, University of London Research Ethics Committee (REC 2020.0058 and 2020.00630).
Sex as a biological variable	not detected.
Randomization	not detected.
Blinding	not detected.
Power Analysis	not detected.

Table 2: Resources

No key resources detected.

Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

However, our study has a number of limitations, including a lack of geographical representation from across the UK (most participants were resident in London or the North East). Whilst interpreters were available for participants, only two requested this service, meaning the study may have a bias towards those who have a higher level of English language. However, the interviews were designed to encourage discussion of participant’s wider community, meaning those with less language skills were often indirectly represented by their peers. Additionally, the researchers’ ethnicity and professional training may have influenced responses through perceived power differentials; the anonymous nature of telephone interviews, however, may have encouraged participants to share their views more freely. This study has generated valuable insight into potential solutions and strategies to achieve equitable COVID-19 vaccine uptake among precarious migrants in the UK, with implications for other marginalised groups and with findings salient beyond the pandemic. More research is urgently needed to explore risk factors for low COVID-19 vaccine uptake in migrant and other vulnerable communities, to assess the extent to which barriers to access, vaccine hesitancy and circulating misinformation are playing a role. Research is now needed to ensure monitoring of equitable vaccine uptake in a wide variety of marginalised groups. Going forward, it will be critical that lessons learned during this pande...

Results from TrialIdentifier: No clinical trial numbers were referenced.

Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

Results from JetFighter: We did not find any issues relating to colormaps.

Results from rtransparent:

Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
No protocol registration statement was detected.

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