https://orcid.org/0009-0006-8570-9394
Figures
Abstract
Objective
This study aimed to map the existing literature to identify predictors of COVID-19 vaccine acceptability among refugees, immigrants, and other migrant populations.
Methods
A systematic search of Medline, Embase, Scopus, APA PsycInfo and Cumulative Index of Nursing and Allied Health Literature (CINAHL) was conducted up to 31 January 2023 to identify the relevant English peer-reviewed observational studies. Two independent reviewers screened abstracts, selected studies, and extracted data.
Results
We identified 34 cross-sectional studies, primarily conducted in high income countries (76%). Lower vaccine acceptance was associated with mistrust in the host countries’ government and healthcare system, concerns about the safety and effectiveness of COVID-19 vaccines, limited knowledge of COVID-19 infection and vaccines, lower COVID-19 risk perception, and lower integration level in the host country. Female gender, younger age, lower education level, and being single were associated with lower vaccine acceptance in most studies. Additionally, sources of information about COVID-19 and vaccines and previous history of COVID-19 infection, also influence vaccine acceptance. Vaccine acceptability towards COVID-19 booster doses and various vaccine brands were not adequately studied.
Citation: Yazdani Y, Pai P, Sayfi S, Mohammadi A, Perdes S, Spitzer D, et al. (2024) Predictors of COVID-19 vaccine acceptability among refugees and other migrant populations: A systematic scoping review. PLoS ONE 19(7): e0292143. https://doi.org/10.1371/journal.pone.0292143
Editor: Roberto Scendoni, University of Macerata: Universita degli Studi di Macerata, ITALY
Received: September 12, 2023; Accepted: January 18, 2024; Published: July 5, 2024
Copyright: © 2024 Yazdani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This research was funded by the Canadian Institutes of Health Research (CIHR). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Initial of the authors who received CIHR grant: GF, KP, DS CIHR grant number: 477172 URL CIHR: https://cihr-irsc.gc.ca/e/193.html.
Competing interests: We have no conflicts of interest to disclose.
Introduction
The COVID-19 pandemic poses a significant threat to public health, not only in terms of its impact on mortality and morbidity, but also due to the social and economic disruptions it has caused, as well as the burden of public health restrictions [1]. To combat this, one of the most crucial prevention strategies is widespread vaccination among the population [2].
In addition to barriers to equitable access to COVID-19 vaccines, vaccine hesitancy compounds the challenges faced, increasing the difficulties to achieve widespread vaccination coverage. Vaccine hesitancy is defined as the delay or refusal of vaccination despite its availability by the WHO Strategic Advisory Group of Experts on Immunization (SAGE) working group on vaccine hesitancy [3].
Understanding the factors that contribute to vaccine hesitancy is a complex and context-specific task. For COVID-19 vaccines, skepticism has arisen due to the novelty of the disease and concerns about their safety and efficacy. These concerns have been amplified by the prevalence of false or misleading information, or misinformation, leading to what the WHO has labeled an "infodemic" [4].
Previous research indicates that certain populations, including Refugee, Immigrant, and Migrant (RIM) populations, are at higher risk of vaccine hesitancy [5]. While there is limited research on the determinants of vaccine hesitancy in these groups, studies have shown that lack of accessibility, mistrust stemming from culturally insensitive healthcare practices, and discrimination experienced when seeking care are common reasons [6]. Furthermore, RIM populations face elevated risks of COVID-19 exposure due to their overrepresentation in high-risk occupations, crowded living conditions, social deprivation, and barriers to accessing reliable information on preventive measures [7]. Identifying predictors of COVID-19 vaccine acceptance in RIM populations could inform strategies to overcome potential obstacles and ensure effective vaccination campaigns.
Materials and methods
In this review, we applied the enhanced version of the Joanna Briggs Institute (JBI) scoping review guidance [8].
Ethics statement
This Scoping review is exempt from the research ethics review as it is based on peer reviewed published works.
Population, Concept, and Context
Our population of interest were refugees and other migrant populations. The International Organization for Migration (IOM) defines a migrant as “A person who moves away from his or her place of usual residence” [9]. Our study focused on predictors of COVID-19 vaccine acceptability among international migrants. A list of the relevant terms is available in Table 1.
Inclusion criteria
Observational, peer-reviewed studies published in English up until January 31, 2023, focusing on predictors of COVID-19 vaccine acceptability and similar concepts (vaccine hesitancy and vaccine intention) among RIM populations were eligible. Participants of all age groups were eligible, and studies from any country were included, regardless of their income class. We also included general population studies if more than 50% of their participants were immigrants or refugees, or a separate sub-group analysis of RIM were reported. Reviews were not eligible; however, the references of relevant reviews were screened in order to find any eligible original research articles.
Exclusion criteria
Qualitative studies, editorials, and commentaries were excluded. Additionally, studies focusing solely on vaccine uptake and coverage were excluded unless they also reported information about predictors of vaccine acceptance or intention.
Search methods
Keywords, and index terms suggested by refugee and immigrant health professionals and the Western University research librarian, helped us develop a comprehensive search strategy for the targeted databases. We searched the following databases, without any search restrictions: Medline, Embase, Scopus, APA PsycInfo and Cumulative Index of Nursing and Allied Health Literature (CINAHL). We also searched the World Health Organization (WHO), The United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM) websites for relevant information. Our full Medline search strategy is presented in S1 Table.
Screening and selection
Following the search, all identified publications were collated and uploaded on COVIDENCE (a web-based platform that manages systematic review data) to review and remove duplicates. All the stages of screening were done separately by two reviewers. Any conflicts between primary reviewers were resolved through discussion and getting the opinion of a third senior reviewer.
Data extraction and management
Two reviewers extracted and charted the data, using a data extraction tool based on a previously reported conceptual framework (S2 Table) [10].
Synthesis of the results
Finally, we presented the results according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) S1 Checklist [11] in tabular form, accompanied by a narrative summary. As a scoping review, our study aimed to provide an overview of the existing literature rather than to assess the quality of included studies.
Results
Out of the total 1847 studies screened, 34 studies were found to meet the inclusion criteria. No further relevant studies were found on WHO, IOM or UNHCR websites. Fig 1 displays the study selection process details and provides reasons for excluding articles. Common reasons for excluding articles were their focus on factors related to vaccine coverage/uptake and barriers to vaccine access, a predominant non-migrant population, and inappropriate study design.
Characteristics of included studies
Characteristics of included studies along with the databases these studies are retrieved from are shown in Table 2. We also present a descriptive analysis of the included studies in Table 3. Most studies were conducted nationally (89%), and in high income countries (76%). Forty eight percent of all migrant participants were female and 52% were male. Eight (24%) and two (6%) articles studied refugees and undocumented migrants respectively, while one (3%) focused on international students exclusively.
Ninety percent of studies were conducted after the first WHO recommendation regarding COVID-19 vaccination, released in December 2020. Only two studies (6%) examined migrants’ hesitancy towards getting COVID-19 booster dose and three (9%) evaluated participants’ preferences regarding different vaccine brands offered or their country of origin. No information was provided regarding whether the type of vaccine provided for immigrants and refugees differs from that given to the general population and whether this distinction contributes to hesitancy. In the study by Kitro et al., the majority of respondents expressed a preference for imported vaccines, particularly those from the US [27]. However, in Talafha et al.’s study, most participants indicated that their comfort with vaccines was not contingent on whether they were developed in America/Europe versus other regions [41]. In Ali et al.’s study, some participants mentioned the possibility of accepting a specific vaccine while rejecting another; however, the study did not provide information about their preferred types of vaccines [17].
The variables examined in different studies are reported in S3 Table. However, only some studies investigated the association of these factors with vaccine acceptance/intention/hesitancy (Table 4). According to the literature review and based on the conceptual framework used [10], we categorized predictors of COVID-19 vaccine acceptance into four major groups:
- Sociodemographic factors
- Communication-related factors
- COVID-19 vaccine- related factors
- Covid-19 infection related factors
Sociodemographic factors
Most common sociodemographic factors associated with COVID-19 acceptance were gender, age, level of education, and marital status (Table 4). Female gender [12, 14–17, 21, 24, 25, 33, 35, 45], younger age [16, 17, 19, 24, 26, 27, 29–32, 34], lower level of education [14, 19, 21, 24, 30, 33, 35, 36, 40, 42], and being single [12, 15, 30] were associated with lower vaccine acceptance in most studies. Only a limited number of studies have investigated the acceptance of Covid-19 vaccines during pregnancy, with none specifically addressing breastfeeding. In the study by Akturk et al., pregnancy was categorized as “other reasons” for vaccine hesitancy [14]. Meanwhile, Ali et al. found that a majority of respondents were either uncertain or opposed to the idea of administering the vaccine to pregnant women [17].
Some of the other sociodemographic influencers of COVID-19 vaccine acceptance were sexual orientation [33], income [23, 30], region of origin [12, 24, 45], religion [12, 24], migratory background [13, 35, 36, 44], employment status [15, 30, 35], years living in host countries [19, 28, 31, 42, 44], racialized status [21, 40], working in health care settings [27, 32, 33], language fluency [31, 44], having comorbidities [34], and having insurance [40]. In two studies, refugees living outside the refugee camps were less likely to accept COVID-19 vaccination [36, 37]. Additionally, one study examined the relationship between different personality traits and COVID-19 vaccine hesitancy. In this study higher Conscientiousness, lower Openness and Neuroticism were associated with lower vaccine acceptance [35].
Communication-related factors
Among the studies that examined the association between trust in authorities and COVID-19 vaccine acceptance, five studies (63%) found a positive association between level of trust in government and host country’s health care system and COVID-19 vaccine acceptance [19, 21, 28, 29, 35]. Moreover, participants’ preference to get vaccinated against COVID-19 was significantly associated with their source of COVID-19 information in 55% of studies examining this association (Table 4). Additionally, participants who had more exposure to confidence-inducing news and had no exposure to concerning news regarding COVID-19 vaccines were more likely to get the booster dose [19].
COVID-19 vaccine-related factors
Concerns regarding the safety/side effects of COVID-19 vaccine was a prominent factor associated with lower vaccine acceptability in 10 studies (77%) evaluating this association [15, 19, 22, 25–27, 37, 41, 44, 45]. Perceived vaccine efficacy was also another predictor of vaccine acceptability. Eight articles (89%) reported lower acceptance among participants who had mistrust in COVID-19 vaccines’ effectiveness [15, 19, 22, 26, 37, 41, 43, 45]. Another reason for lower vaccine acceptance was the belief that COVID-19 vaccines were developed too quickly and that the rushed pace of testing them would become problematic in the future. Being concerned about vaccine development was positively associated with vaccine hesitancy in all three studies evaluating this association [15, 21, 41]. Additionally, six studies examined the participants’ knowledge/attitude scores towards COVID-19 vaccines [13, 17, 19, 27, 28, 41]. Two studies showed that people with greater knowledge of COVID-19 vaccines had higher intention to get vaccinated [17, 19]. Non-COVID-19 vaccine refusal and negative attitude towards vaccines in general were associated with lower COVID-19 vaccine acceptance [12, 22, 34]. Also, getting the seasonal flu vaccination [15, 41] were a positive predictor of vaccine acceptance.
COVID-19 infection-related factors
Among studies that examined the association of COVID-19 risk perception and vaccine acceptability, nine (90%) found a positive association [17, 19, 22–25, 29, 44, 45]; whereby, participants who had higher COVID-19 risk perception had higher vaccine acceptability. Only four out of the 11 studies [14, 21, 23, 25, 26, 30, 33, 36, 41, 42, 44] that evaluated the relationship between COVID-19 vaccine acceptance and previous history of exposure/infection with COVID-19 disease reported a significant association [21, 33, 41, 44]. In the study by Frisco et al. previous infection with COVID-19 was associated with higher vaccine acceptance [21], while Ogunbajo et al. suggested that previous positive COVID-19 test was higher among vaccine hesitant participants [33]. Moreover, West et al. found that vaccine acceptance was higher among workers who had more COVID-19 exposure through crowded housing [44]. Talafha et al. reported that previous COVID-19 exposure did not affect the respondents’ willingness to take the vaccine. Some studies examined the association of vaccine acceptability with knowledge and attitude regarding COVID-19 infection. All reported that higher COVID-19 infection knowledge and attitude scores were associated with higher vaccine acceptability [14, 27, 32, 41]. Participants’ health behaviors during COVID-19 pandemic were other factors measured in some studies. They found wearing a face mask and social distancing were associated with higher COVID-19 vaccine acceptance/intention [23, 27, 36].
Other factors associated with COVID-19 vaccine hesitancy
Although concerns regarding vaccine safety and effectiveness and lower COVID-19 risk perceptions were among most common predictors of vaccine hesitancy, fear of needles [22, 45], belief in house remedies [22], religious reasons [22, 23, 26], belief in natural exposure to germs and viruses as the best protection and avoiding any interference with nature [15, 22] were other reasons for not getting the vaccine, reported by vaccine hesitant or anti vaccine individuals.
Shaw et al. reported that individuals with high vaccine acceptability had a lower social vulnerability index [39]. Another study by page et al. showed that higher immigration enforcement exposure, such as experiencing or knowing someone who experienced immigration raids, detention or deportation, was associated with lower odds of COVID-19 vaccine acceptance [34]. In contrast, acculturation and social integration of migrants were associated with higher vaccine acceptance [28, 42], as well as cues to action [17, 43] and social norms [17]. Cues to action, refers to being motivated to get vaccinated by seeing neighbors, community leaders, doctors, or politicians receive the vaccine; whereas vaccination as a social norm refers to the higher likelihood of getting vaccinated when most people an individual knew had received the vaccine.
Discussion
Our findings suggest that predictors of COVID-19 vaccine acceptance among migrant populations can be categorized in four major groups: “sociodemographic factors”, “communication-related factors”, “COVID-19 vaccine-related factors” and “COVID-19 infection- related factors”. Lower vaccine acceptance was associated with mistrust in the host countries’ government and healthcare system, concerns about the safety and effectiveness of COVID-19 vaccines, limited knowledge of COVID-19 infection and vaccines, lower COVID-19 risk perception, and lower integration level in the host country. Also, female gender, younger age, lower education level, and being single were sociodemographic factors associated with lower vaccine acceptance in most studies. Sources of information regarding COVID-19 and vaccines and previous history of COVID-19 infection were other influencers of vaccine acceptance.
A systematic review on qualitative studies on COVID-19 vaccine hesitancy among ethnic minorities similarly identified five major themes for drivers of vaccine hesitancy among these populations: 1) Institutional mistrust, 2) Lack of confidence in vaccine and development process, 3) Lack of reliable information or messengers, 4) Complacency/perceived lack of need and 5) Structural barriers to vaccine [46].
While our findings show that most studies reported lower vaccine acceptance among immigrant women, as the association between sex/gender and COVID-19 vaccine acceptance among RIM was significant in only 44% of studies examining this association, further analytic investigation is needed on this matter. In a meta-analysis conducted by Alimoradi et al. the pooled prevalence of Covid-19 vaccine acceptance did not significantly differ according to gender in migrants and ethnic minorities [47]. Another systematic review on determinants of routine and COVID-19 vaccine uptake among RIM also reported no strong association with gender [48]. Higher skepticism among females might be even more important to achieve higher vaccination coverage, as this can directly affect children COVID-19 vaccination rate, because mothers appear less willing to vaccinate their children against COVID-19 than fathers [49, 50].
Furthermore, there is insufficient research on attitudes toward Covid-19 vaccination during pregnancy and breastfeeding among RIM populations. A systematic review and meta-analysis on the prevalence of COVID-19 vaccine acceptance among pregnant women revealed that only 49% of participants were accepting of the COVID-19 vaccine [51]. Pregnant and breastfeeding immigrant and refugee women encounter unique concerns, particularly when resettled in countries with vaccination guidelines differing from their country of origin [52]. The presence of cultural, linguistic, and informational gaps amplifies hesitancy within these vulnerable subgroups. Given their lived experiences with systemic racism and mistrust in the healthcare system, it becomes essential to tailor public health messaging specifically for them [53].
Understanding the sociodemographic predictors of vaccine acceptability can help to improve community engagement strategies to increase vaccination uptake in populations with lower vaccine acceptance, such as outreach initiatives for under-immunized ethnic groups [54]. One example is a successful program addressed low vaccination rates among women of Rohingya refugees in Cox’s Bazar, Bangladesh. Strategies included educational programs, women-only radio clubs, religious group-study sessions, and employing female vaccinators. These measures improved access to accurate information and created a comfortable environment for refugee women to get vaccinated [55].
Other sociodemographic factors of potentially great importance among migrant populations include migration status, years living in the host country, region of origin, language fluency, religion, and immigration enforcement exposure [12, 13, 18, 24, 31, 42, 45]. Evidence suggests that language barriers and cultural variations are prominent factors that can affect these populations’ intention to be immunized [12].
The term “vaccine hesitancy” might imprecisely blame individuals, while there are several fundamental factors that may lead to making this decision [56]. Our findings corroborate previous research that suggests trust in the host country’s government and public health authorities are key factors that affect migrants’ attitude towards COVID-19 vaccines and vaccination decision making [49, 56, 57]. Lack of trust among migrant communities can stem from previous experience of xenophobia, racial discrimination, and anti-migrant politics [48, 57, 58]. A qualitative systematic review of COVID-19 vaccine hesitancy by Shearn et al. showed that “feeling unheard, ignored or excluded from the healthcare system” caused institutional mistrust resulting in COVID-19 vaccine hesitancy among RIM populations [46]. Moreover, trust also plays a crucial role in acceptance of non-COVID vaccines among RIM population [57].
Previous research also suggests that source of information is an important influencer of vaccination decision making [59]; however, this factor might be more complicated among RIM populations based on different cultural and linguistic backgrounds and adaptation level within host countries. Moreover, the lack of adequate information in migrants’ primary languages often lead to reliance on community networks, traditional and social media, which might lead to confusion and inability to discern factual information from misinformation [29, 34, 38]. Similarly, in non-COVID vaccination context, the overwhelming amount of contradictory information and false claims spread through social media regarding vaccines undermines the efforts to encourage vaccine acceptance among migrants [57].
A systematic review by Romate et al. suggests that the perceived safety and effectiveness of COVID-19 vaccines as well as risk perception of COVID-19 infection is associated with both “knowledge” and “trust” factors [60]. Additionally, our study revealed that increased knowledge level about both COVID-19 infection and vaccines among migrants were associated with higher vaccine acceptability. These findings reinforce previous research that investigated these associations among general populations [61, 62]. Applying various community engagement strategies may help build trust and address knowledge gaps and misinformation among these diverse communities [63]. Previous research suggests “using high touch rather than high-tech approaches”; Involving community health workers can also ensure trustworthy sources of information and tailoring new health recommendations [56].
Our study also suggests that higher levels of migrants’ acculturation and integration in the host country is associated with higher COVID-19 vaccine acceptance [28, 42, 44]. Previous research similarly showed that migrants living in societies with lower integration policies for migrant populations experience poorer health conditions [42, 64, 65]. Strategies that facilitate migrants’ psychological, social, economic, political, navigational, and linguistic integration in a host country can, in turn affect other vaccine hesitancy related factors such as trust in authorities and misinformation [42].
The ethical dimensions surrounding COVID-19 vaccination are multifaceted, with specific considerations for vulnerable groups such as the elderly residing in nursing homes. Obtaining informed consent poses challenges given their advanced age and potential cognitive limitations. Legal frameworks in Western nations emphasize the importance of involving individuals in healthcare decisions, even when faced with psychological weaknesses. These ethical dilemmas underscore the need for systematic approaches to protect the health of individuals within these fragile communities [66].
Another marginalized group that needs more attention are people with disabilities. Research shows some of the individuals with disabilities may exhibit higher levels of vaccine hesitancy, primarily due to heightened concerns about vaccine safety compared to the perceived risks associated with COVID-19 infection [67]. Incorporating universal accessibility into vaccination initiatives, sites, and communication is crucial to address the unique needs of individuals with disabilities [68]. Tailored communication strategies, written in plain language and disseminated in accessible formats, can contribute to reducing hesitancy among individuals with disabilities [67].
Implication for public health policy
Our findings may help inform the programs and community outreach strategies to improve uptake of COVID-19 vaccines in migrant and refugee subgroups with lower vaccine acceptance. Reducing mistrust in authorities and addressing knowledge gaps among migrant populations is crucial for improving COVID-19 vaccine acceptance and similar public health challenges.
Limitations
It is noteworthy that we noticed some limitations in the included studies. Due to the cross-sectional design of included studies, we cannot make causal claims. While these findings can provide valuable insights into factors associated with lower COVID-19 vaccine acceptance among migrant populations, it’s important to note that the majority of studies employed non-random sampling strategies. This implies that participants may not be truly representative of migrant populations; therefore, caution should be exercised when generalizing the study findings. Further, using online platforms to recruit study participants and survey in English or the host country’s language, can skew the data towards more acculturated, connected, and less vulnerable study participants. Moreover, most studies did not consider potential confounding variables such as having comorbidities, health literacy, duration of residence in host country in their analyses. Finally, recall bias, selection bias, and social desirability bias were other issues which might have affected the included studies’ findings.
Conclusion
The acceptability of COVID-19 vaccines among RIM is influenced by various factors, including sociodemographic characteristics, communication-related factors, COVID-19 vaccine-related factors, and COVID-19 infection-related factors. Targeted vaccination plans, community engagement strategies, and efforts to address knowledge gaps and build trust are crucial for promoting vaccine acceptance among RIM populations.
Future studies
Evaluation of migrant population’s attitude towards the COVID-19 booster dose(s) and different types and brands of COVID-19 vaccines would be beneficial. Furthermore, there is a need for more studies on COVID-19 vaccine acceptance among specific subgroups of refugees and migrants, including pregnant and breastfeeding women, children and individual with disabilities. Conducting a systematic review with an equity lens to explore sociodemographic factors associated with vaccine acceptance could enhance our understanding and aid in identifying subpopulations of migrants with lower vaccine acceptance.
Supporting information
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0292143.s001
(DOCX)
S3 Table. Factors examined in included studies.
https://doi.org/10.1371/journal.pone.0292143.s004
(PDF)
Acknowledgments
All authors were actively involved in discussing and refining the research questions. Kevin Pottie contributed to receiving the grant, provided expertise in designing research objectives, defining the inclusion and exclusion criteria and search strategy as well as manuscript revision. Gabriel Fabreau and Denise Spitzer contributed to receiving the grant, formulating the research objectives and editing the manuscript, ensuring its quality and accuracy throughout the process. Yasaman Yazdani and Poojitha Pai contributed to defining the search strategy, conducting the literature search, and screening articles for inclusion, data extraction, synthesizing the findings, and drafting sections of the report. Shahab Sayfi contributed to the screening process and interpretation of the results. Arash Mohammadi and Saber Perdes contributed to manuscript revision. All authors reviewed and approved the final manuscript for publication.
We would like to thank Ms. Roxanne Isard, research and scholarly communication librarian at Western University, for her helpful guidance in developing this study’s search strategy.
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