Strategies Needed to Increase Immunization in Migrant Populations

As difficult as it is to attain high levels of vaccination in established communities, the difficulties are compounded for migrant populations, in the view of investigators who call for strategies to improve access to, and acceptance of immunization programs.

In their systematic review of studies on the determinants of vaccine uptake and under-vaccination in migrant populations in The Lancet Infectious Diseases, Alison Crawshaw, MPhil, Migrant Health Research Group, Institute for Infection and Immunity, St George's University of London, and colleagues suggest that high income countries of Europe can improve outreach and public health by offering better tailored and culturally sensitive programs.

"Migrants in Europe are one of several under-immunized groups and might be excluded from initiatives to promote catch-up vaccination for missed vaccines and doses on arrival in some European countries," Crawshaw and colleagues observe. "Our review confirms that migrants' barriers to accessing health care limit vaccine uptake, and shows that a range of access barriers exist for key vaccines, including language, literacy, communication, practical, legal, and service barriers."

Crawshaw and colleagues conducted their review of literature published from 2000 to 2021, focusing on 67 studies from 16 countries that involved 366,529 migrants (defined as foreign-born individuals). To explore barriers and facilitators of routine vaccines such as measles-mumps-rubella as well as influenza and COVID-19, they employed search terms that included the "5As" taxonomy: access, awareness, affordability, acceptance, and activation.

The investigators found that low literacy, language differences and lack of interpreting services were common barriers to vaccine uptake. Health care providers reported that the time allocated for each individual's vaccination was often inadequate given the need to overcome such communication barriers.

Among the logistic and legal circumstances that could be barriers to accessing vaccine programs were temporary housing with no fixed address, programs located in mainstream venues such as schools not in proximity to migrant communities, and the fear of disclosing lack of citizenship,

"Asylum seekers, refugees, and migrants with precarious immigration status in 2 UK studies expressed concern that they would be deprioritized or excluded from the COVID-19 vaccine roll-out because of their status," Crawshaw and colleagues related, "and undocumented migrants remained unaware that they could access COVID-19 vaccination free of charge and without immigration checks after the government widened the process."

The investigators identified 23 specific determinants of under-vaccination. The populations most likely to require catch-up vaccinations from deficits in their origin countries were from Africa, eastern Europe, the eastern Mediterranean, and Asia; and this was particularly common among recently arrived migrants, refugees and asylum seekers.

Crawshaw and colleagues call for reducing legal barriers to, and increasing opportunities to access routine and catch-up vaccination. In the short-term, they see need to strengthen the capacity of host country health systems. Longer-term measures would include improving coordination of policies, guidelines and vaccination delivery.

They found several studies that identified successful methods of facilitating vaccine uptake, including tailoring vaccination messaging based on specific perceptions, beliefs or barriers; personalized "push" reminders; and community outreach.

"COVID-19 has presented new opportunities to engage more effectively with migrants and other marginalized groups around vaccination,and future research must focus on identifying novel and participatory approaches," Crawshaw and colleagues urge.