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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Migrants arriving in Europe may face a range of personal and practical barriers to vaccination. Research found that tailored messages about vaccination, community-based interventions, and convenient local clinics can encourage underserved groups to have vaccinations. Recommendations include improving migrants’ access to primary healthcare and co-designing strategies and services.

Migrants are a diverse group of people, from many different countries. They include refugees, asylum seekers and international workers. Differing healthcare systems around the world, and various barriers to vaccination experienced by mobile groups, mean that some migrants arriving in Europe have not had routine vaccinations. This puts some nationality groups at risk from certain diseases, including COVID-19.

Researchers set out to design strategies to increase vaccination among migrant groups. They reviewed previous studies in which migrants described what had encouraged – or discouraged – them from having a vaccine. They assessed studies that objectively measured the link between different factors (such as how long they had been in the host country, or their migrant status) and being under-vaccinated.

The research identified multiple barriers to key vaccines. Barriers were in communication, were practical and legal, and within services (such as a lack of specific guidelines for healthcare professionals). Some issues were specific to particular groups. For example, eastern European and Muslim migrants were least likely to accept vaccines for human papillomavirus, measles and influenza. Migrants’ country of origin, having migrated recently, or being a refugee or asylum seeker, were associated with being under-vaccinated.

The review concluded that action is needed on multiple levels. Countries need clear vaccination policies that meet migrants’ needs. Healthcare professionals need specific training to help them understand and respond to migrants’ health needs (cultural competence). Service design could better meet the social, cultural and linguistic needs of migrants. Migrant populations need to be actively involved in co-designing interventions. Long-term efforts could address structural barriers, discrimination and racism, alongside building the trust of migrants in health and vaccination services.

More information about vaccination is available on the NHS website.

What’s the issue?

Some migrants may have missed vaccines and doses in their countries of origin and not be aligned with European vaccine schedules when they arrive. For example, during the pandemic, some nationality groups of migrants were less likely to be fully vaccinated against COVID-19 vaccines than the host population.

Previous studies have described barriers to routine vaccinations. However, there is little detailed research on the needs of diverse migrant populations, and what drives vaccine uptake in specific migrant groups.

Finding new ways to overcome these barriers can help countries improve their vaccine programmes. This research supports the World Health Organization’s new Immunisation Agenda 2030. The Agenda aims to increase the uptake of vaccines among people at all stages of life, and to help underserved groups to access vaccines.

What’s new?

Findings were based on data on 366,529 migrants in 67 papers about vaccine uptake. Studies were published in European countries between 2000 and 2021. Most datasets covered vaccines for measles, human papillomavirus, diphtheria, tetanus or whooping cough.

The researchers found that under-vaccination (partial or delayed vaccination) was more common among people from Africa, eastern Europe, the eastern Mediterranean and Asia. Recently-arrived migrants, refugees and asylum seekers were more likely to be under-vaccinated than other migrants. As were those with lower income, lack of citizenship, and lack of contact with healthcare services. Neither gender nor age was strongly linked to vaccination status.

Barriers to migrants seeking vaccination included:

  • language and literacy; people needed interpreting services, translated information, and tailored accessible information (some migrant groups preferred oral to written information, for example)
  • lack of understanding about the need for, or their entitlement to vaccines, concern about side-effects and potential stigma
  • health professionals’ lack of knowledge of vaccination guidelines for migrants, particularly older migrants who missed vaccines or doses in their countries of origin as children; migrants’ distrust of healthcare professionals because of their experience of, or rumours of discrimination
  • practical and legal difficulties; people who moved frequently or had no fixed address could struggle to register for health services, travel to vaccination centres could be costly, some lacked knowledge of their vaccine history, or worried about being questioned on their immigration status.

Vaccine uptake was improved by:

  • tailored communication about vaccinations, including face-to-face conversations, information about the benefits of vaccination, personalised reminders (nudge behaviours); messages aligned to religious teachings on health were helpful
  • clear and sensitive policies, such as screening for vaccination on arrival
  • community-based interventions, in which community members act as vaccine advocates in collaboration with services
  • regular access to healthcare systems, with vaccination offered in convenient and familiar local settings; increasing the number of walk-in clinics, and ensuring access for all groups.

Why is this important?

This study explored the main barriers and facilitators to vaccine uptake in different migrant populations. It looked at the factors associated with being under-vaccinated.

Migrants’ access to vaccination programmes in high-income countries, including for COVID-19, could be improved. Strategies include clear vaccination policies, educating healthcare professionals about the vaccination needs of newly-arrived migrants, and involving migrants in co-designing appropriate and acceptable services and systems.  

Widespread vaccination helps avoid disease outbreaks, and promotes better health and wellbeing in individuals and across populations. This reduces pressure on healthcare services. Action is needed at different levels to develop vaccination services, systems and policies that are acceptable and successful in migrant populations, the study concluded.  

What’s next?

Clear policies and consistent public health messaging on migrant vaccinations are needed. Building trust in healthcare soon after migrants arrive, helps nurture positive attitudes towards healthcare and vaccinations.

Working with migrants to co-produce tailored materials (translated and in appropriate formats, written and verbal as appropriate) could increase their confidence in information. Understanding the cultural issues that matter to specific migrant groups will help frame messages about vaccination.

More flexible appointments and clinics held in local, familiar places, may improve vaccine uptake. These measures could widen access for adults and some children who are excluded from current approaches (at schools, for example).

Further research could explore innovative ways to involve migrant populations in co-designing vaccination systems and services. Better and more consistent recording of migrant immunisations would strengthen future research. It would be useful to understand generational effects, and how migrants’ views and behaviours relating to vaccination change over time in the new host country.

You may be interested to read

This Alert was based on: Crawshaw A, and others. Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review. The Lancet Infectious Diseases 2022;22:E254-266.

Research describing barriers to vaccine uptake: Thomson A, and others. The 5As: A practical taxonomy for the determinants of vaccine uptake. Vaccine 2016;34:1018-1024.

The World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind. January 2021.

The World Health Organization. Ensuring the integration of refugees and migrants in immunization policies, planning and service delivery globally. July 2022.

European Centre for Disease Prevention and Control. Public health guidance on screening and vaccination for infectious diseases in newly arrived migrants within the EU/EEA. December 2018.

A toolkit to help communicate about COVID-19 vaccines and combat misinformation: The COVID-19 Vaccine Communication Handbook.

A toolkit designed by Doctors of the World to boost confidence in vaccines.

A study by some of the members of the current team looking at ways to tackle the barriers migrants face for COVID-19 vaccination. Crawshaw A, and others. What must be done to tackle vaccine hesitancy and barriers to COVID-19 vaccination in migrants? Journal of Travel Medicine 2021;28:taab048.

An NIHR Evidence Alert: Better access to healthcare for Gypsy, Roma and Traveller communities is key to increasing vaccination rates: research makes five recommendations

Funding: NIHR (NIHR300072).

Conflicts of Interest: Full details can be found on the original research.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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