key: cord-0730505-brbfjjuv authors: Deal, Anna; Hayward, Sally E; Huda, Mashal; Knights, Felicity; Crawshaw, Alison F; Carter, Jessica; Hassan, Osama B; Farah, Yasmin; Ciftci, Yusuf; Rowland-Pomp, May; Rustage, Kieran; Goldsmith, Lucy; Hartmann, Monika; Mounier-Jack, Sandra; Burns, Rachel; Miller, Anna; Wurie, Fatima; Campos-Matos, Ines; Majeed, Azeem; Hargreaves, Sally title: 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 date: 2021-05-27 journal: J Migr Health DOI: 10.1016/j.jmh.2021.100050 sha: 1830580b3def74e50cf89f3f5a6f28c84699200d doc_id: 730505 cord_uid: brbfjjuv 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 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 rollout. We did an in-depth semi-structured qualitative interview study of recently arrived migrants (foreignborn, >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). 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 Introduction Ethnic minority and migrant populations have been disproportionately affected by the COVID-19 pandemic in the UK (1-3), yet early evidence suggests low intent and uptake of the COVID-19 vaccination (4) (5) (6) (7) (8) (9) . Specifically, numerous UK surveys show low vaccine intent in Black, black British and Asian ethnic minorities in the UK. One recent survey showed only 57% people from Black, Asian, and minority ethnic backgrounds would accept a COVID-19 vaccine, compared to 79% of White respondents (10) . Recently published UK vaccine uptake data for the over 70's age-group has shown lower vaccination rates in ethnic minority groups, particularly Black African (58.8%) compared to White British 91.3% (11) . Lack of trust in government or health systems, social exclusion, and long running issues of discrimination have been highlighted as contributors to COVID-19 vaccine hesitancy in minority ethnic groups (4) (5) (6) 9) . None of the currently available datasets, however, give insight specifically into the views of migrants (defined as foreign-born) (12) . In particular, recently arrived migrants with precarious immigration status such as undocumented migrants, asylum seekers and refugees, who are known to face many unique barriers and even exclusion from health systems, have not been well considered in research to date around the COVID-19 vaccine. Many are concerned that vulnerable groups, including precarious migrants, homeless populations, and Roma communities, as well those living in highly deprived areas, may not be reached in the COVID-19 vaccine roll-out without specific interventions to facilitate engagement with these communities in order to strengthen delivery and uptake (13, 14) . In the UK, the COVID-19 vaccination roll-out will be predominantly carried out through existing healthcare services, however, large numbers of migrants are currently excluded from these for a number of reasons. These include perceived or true lack of entitlement to access healthcare, fear around charging or links to immigration services and poor understanding of the system, often compounded by language barriers (15, 16) . These barriers have been exacerbated in many cases by increasing digitalisation of healthcare services during the pandemic (17, 18) . Adult migrants are widely excluded from vaccination services on arrival to the UK and Europe, due to structural and policy shortfalls in engaging them in catch-up vaccination campaigns (19, 20) , even though ensuring high levels of coverage and equitable access are key priorities of the European Vaccine Action Plan and the Sustainable Development Goals (SDGs) (21) . Specifically, undocumented migrants or those with limited leave to remain, asylum seekers and refugees, those residing in temporary asylum accommodation, detention centres, and other high-risk settings, as well as several groups of lowskilled labour migrants, are also often highly marginalised and excluded from health and vaccination systems, yet their views are rarely sought to inform policy and practice. Around 1.2 million undocumented migrants alone may be currently residing in the UK (22) , of whom many may not be registered with primary healthcare services where COVID-19 vaccination is currently being delivered. Policies aiming to restrict access to healthcare for overseas visitors in the UK, as part of the political 'hostile environment' towards undocumented migrants, which has included patient data sharing agreements between the health service and the Home Office for immigration enforcement purposes (23) , have caused a lack of trust and confusion around entitlement to healthcare among both NHS staff and patients (24) (25) (26) . This has resulted in precarious migrants only accessing services when in urgent need and avoiding preventative health services such as vaccination (16) , with calls for immigration data sharing and immigration checks at health services to be suspended during the pandemic. Increased social exclusion during the pandemic may have exacerbated long-running issues of mistrust and mutual lack of understanding between public health services and migrants, impacting on their willingness to present to health services to get vaccinated (18, 27) . Precarious migrants have been reported to be avoiding hospitals for fear of charging if they are negative for COVID-19 (28), despite Public Health England specifically stating that COVID-19 vaccines are free of charge and no immigration checks will be carried out (29). For COVID-19 vaccination strategies to be effective in the UK, the vast majority of the adult population will undoubtedly need to be vaccinated now and in the future (30) , including migrants and other marginalised groups who may have a range of risk factors related to COVID-19. It is essential that we better understand factors affecting vaccine intention and acceptance among precarious migrant groups to better understand their views or concerns and to define strategies to ensure equitable access and delivery. We therefore did an in-depth qualitative interview study of recently arrived (<10 years) precarious migrants to explore views on the COVID-19 vaccine, including barriers to access, seeking their input into defining action points and developing solutions to strengthen delivery and uptake in marginalised migrant communities. We used a qualitative methodology consisting of in-depth semi-structured interviews, to explore the perspectives of recently arrived migrants (residing in the UK <10 years). We specifically aimed to recruit migrants with precarious immigration status, including refugees, asylum seekers and undocumented migrants (including visa overstayers, refused asylum seekers, and others lacking documentation), and individuals with limited leave to remain (migrants on temporary visas, with no recourse to public funds). The research design was ideally suited to the exploratory nature of the Recently arrived migrants were recruited using purposive and snowball sampling, with the aim of recruiting participants from a broad range of nationalities, migrant statuses and age groups. Adverts for the study and participant information sheets were circulated to 20 UK-based migrant support groups and on social media. Those who expressed an interest in taking part were contacted by telephone and the study was explained to them with interpreters available on request. Ethics was granted by St George's, University of London Research Ethics Committee (REC 2020.0058 and 2020.00630). Participant information sheets were circulated, and informed consent was acquired in writing prior to arranging a telephone interview. In-depth semi-structured interviews were conducted by telephone (by AD, SEH) and lasted minutes. Participants were compensated with an online shopping voucher (worth £37), as per INVOLVE NIHR criteria for participant involvement in research studies (31) . Interviews were audiorecorded then transcribed verbatim; transcripts were checked for accuracy and anonymised. Data collection ended when data saturation was reached, and no novel concepts were arising (13) . Data collection and theme development took place concurrently and continued until the team agreed unanimously that saturation, at a thematic level had been reached. Data were then analysed using the thematic framework technique (32) in NVIVO 12. We used the 'Three Cs' model of vaccine hesitancy, which focuses on issues pertaining to confidence in the vaccine, complacency, and convenience which are considered to influence an individuals' views on whether to have a vaccine or not (33, 34) . Finally, we did a sub-analysis exploring views and levels of hesitancy among migrants interviewed before (September and November 2020) and after (between January and March 2021) the beginning of the COVID-19 vaccination roll-out in the UK. We carried out 32 interviews (4 th September 2020 to 8 th March 2021), with 17 interviews done between September and November 2020 and 15 between January and March 2021. Participants reported their migration status as seeking asylum (n = 19), refugees (n = 3), undocumented (n = 8) and limited leave to remain (n = 2). The mean age across the study sample was 37.1 years (SD: 7.6 years); 21 (66%) participants were female. The mean duration of stay in the UK was 5.6 years (SD 3.1 years), with 17 (53%) participants who had resided for five or less years in the UK, and 15 (47%) who had stayed been in the UK 5-10 years. Multiple nationalities were represented among respondents, with participants coming from five WHO regions and 15 different countries. Participant demographics are further described in Table 1 . Asylum seekers Participants raised similar concerns around how they were going to access the COVID-19 vaccine, stemming from concerns around existing access issues to primary care, such as language barriers, trust issues, or perceived lack of entitlement. However, some barriers identified varied by migrant status, with undocumented participants and those with limited leave to remain often reporting different barriers to refugees and asylum seekers. Concerns were raised that some precarious migrants, particularly those who are undocumented, are not registered at a GP practice and will therefore be excluded from the COVID-19 vaccine roll-out. "Some of the asylum-seekers and the refugees, they don't have a GP, so I don't know how the government will help out with that. If the government can speak with the charities, because a lot of these refugees and asylum-seekers, they use different charities" -Asylum seeker 16 Participants stated that they have historically relied on charities and walk-in centres for healthcare and help with GP registration, and that the discontinuation or digitalisation of many of these services during lockdown has heavily affected them, impacting on their ability to register with a GP. Very recently arrived migrants (<2 years in the UK) described difficulties registering with a GP using the digital NHS system in place during the pandemic. Additional barriers to access through primary care are further discussed in the vaccine hesitancy "convenience" section below. Many participants described a lack of trust in both healthcare or wider governance systems, with bad previous experiences and anecdotes from friends or family often a contributing factor. In particular, difficulty understanding the NHS system on arrival and poor treatment by staff during registration processes was reported as a factor affecting trust in healthcare services for asylum seekers and refugees, which may impact on COVID-19 vaccine uptake in these groups. Experiences of being charged for healthcare, particularly maternity services, amongst undocumented migrants has led to a lack of trust in government messaging and perpetuated fear around charging and immigration checks, which they felt could have implications for vaccine roll-out. Participants reported a range of views on the COVID-19 vaccines, ranging from complete acceptance to fear and distrust, which are summarised in Figure 1 . When we explored differences between pre- Confidence was a key factor for the majority of those who stated they were, at the time of interview, hesitant about accepting a vaccine (n = 23). These included worries around potential side-effects and insufficient testing of the vaccine during clinical trials to ensure its safety. Some participants also described fears around theories based on misinformation, often originating from social media or word of mouth, with many describing feeling conflicted about which information sources to trust. Of those who stated they would definitely not accept a vaccine (n = 2), one said this was due to lack of clinical trials data and the other stated religious reasons (considered vaccines anti-Islamic). In general, those who described stronger feelings of social exclusion during the pandemic were more likely to express distrust in a vaccine. Participants stated that convenience would be a key factor in their decision on whether to accept a vaccine or not. The most commonly mentioned concern was ease of access, including having enough understandable information on where and when they would have to present as well as a preference for familiar settings requiring minimal travel. Those who reported having positive past experiences with their GP, particularly refugees and asylum seekers, mostly stated they would feel most comfortable receiving the vaccination in primary care. In contrast, those with undocumented status generally put more importance on being assured anonymity when presenting for the vaccination, and many preferred to access it through walk-in centres or trusted charities. Costs associated with the vaccine, both direct and indirect (e.g. travel), were also a major factor for many participants, with many unsure if the vaccine would be free despite existing government messaging that the vaccines will not be charged for. Participants stated that if they were confident there would be no associated costs, this would enable many more people within their communities to present for a vaccine. Many participants who were currently hesitant about accepting a COVID-19 vaccine stated they would need more information before making their decision, preferably in their own language, on potential side effects of the vaccines, vaccine contents, summaries of clinical trial data, and when and how they would be invited for a vaccine. Several participants stated that they would like circulating misinformation to be directly addressed by official information sources (including the Government and the NHS). Many undocumented participants also described that they would need more information about whether documentation would be asked for at their access points (e.g. walk-in clinics), and felt that they currently lacked information in this area. A wide range of formats were suggested for improving information accessibility and reach, which are further explored in Table 2 , including both traditional methods (leaflets, TV news channels, internet-based sources, posters) and more novel ideas (social media, community champions, existing charity networks). It was felt that a flexible, holistic approach, with information available in as many formats and languages as possible would be the most effective. Participants described a wide range of strategies that they considered would be useful to either encourage them to accept a vaccine for themselves, or to increase the accessibility and reach of the vaccination programme for other precarious migrants in their communities. Participants highlighted strategies to combat the four main issues presented as hindering COVID-19 vaccine access for precarious migrants, namely, trust in the system, lack of defined vaccine access points for those with restricted access to healthcare, low vaccine confidence, and lack of accessible information on COVID-19 vaccines, migrants' entitlement to access a vaccine, and if it would be free. The proposed strategies are described in detail in Table 2 , and include using trusted groups or sources (NGOs, community groups) for communication, and to use these same groups as access points for COVID-19 vaccine delivery (for example, as hosts for walk-in centres). In addition, participants suggested campaigns to increase awareness of entitlement to primary care were also required. Increased funding for, and collaboration with, charities and community groups who act as a major source of healthcare and information to precarious migrants was also highlighted. reported feeling hesitant about accepting a COVID-19 vaccine. Reasons given included concerns over vaccine content, side effects, lack of information or low perceived need, suggesting hesitancy could be easily addressed with clear, accessible and tailored information campaigns. Concerns were expressed that migrants may be excluded from the vaccine roll-out, and that migrants not registered with the health system had no access point for the vaccine. In addition, a wide variety of barriers to the vaccine were highlighted, including lack of registration with primary care services, fears over charging for the vaccine, data sharing between the health service and immigration enforcement, lack of information on alternative access points, and other issues relating to convenience. Our data suggest that the campaign allowing undocumented migrants to get a COVID-19 vaccine without immigration checks and free of charge may need to be more effectively communicated. A range of strategies and solutions were proposed by respondents to increase vaccine uptake, including culturally and linguistically accessible information campaigns in a range of formats and languages, innovative, trusted and well-defined access points, more flexible entry points to primary care, and increased collaboration with charities or groups already working with affected communities. These findings have direct implications for policy and practice during the current roll-out in the UK, but also will be salient for other routine vaccination campaigns, as migrants are known to be an underimmunised group generally (35) . Our findings also highlight the consequences of excluding vulnerable groups from health systems and re-emphasize the importance of universal access to healthcare and effectively engaging with communities when formulating policy responses, which become particularly pertinent in the context of public health emergencies. We found that precarious migrants may face a broad range of barriers to COVID-19 vaccination access, particularly those with undocumented status and others who are not registered with primary healthcare services. Lack of trust in authorities was a key theme, as well as concerns around immigration checks or other unwanted questions from healthcare providers if they present for a COVID-19 vaccine. These concerns were often based on previous experiences of charging by the NHS, poor treatment by NHS staff and the current hostile political environment that has embedded immigration enforcement within public services such as the health system (through mechanisms such as data sharing), which have been previously well-documented as barriers in access to healthcare (16, 24) . The UK government announced in early February that undocumented migrants can register with a GP to get a COVID-19 vaccine without facing immigration checks (36) , however, no statements have been made around whether this may lead to data sharing or immigration enforcement in the future. Furthermore, none of the participants interviewed in this study post- (39), and walk-in centres opening in community centres and places of worship, which could be replicated to engage groups such as undocumented migrants, refugees and asylum centres (40, 41) . It is essential that vulnerable groups are made fully aware of such access points available to them, through collaborations with existing and trusted groups working in relevant communities, alongside scaling-up information campaigns to increase awareness of entitlement to register and use GP services (36) . As well as supporting COVID-19 vaccine uptake, this could leave a lasting, positive impact on access to healthcare and confidence in vaccination going forwards, as marginalised communities are encouraged by the vaccination programme to come forward and register with primary care services. Vaccine hesitancy issues were surprisingly common among participants, and mostly stemmed from a lack of accessible and understandable information, leading to concerns around vaccine contents, potential side effects and increased susceptibility to misinformation. An increased susceptibility to misinformation, often circulating on social media or by word-of-mouth, is known to be linked to an individual's level of confusion, distress or mistrust around their social world (42) . Our results suggest that a lack of accessible official information, social exclusion, and previous negative experiences with authorities (either health or political), may influence on susceptibility to misinformation. We have shown that hesitancy linked to circulating conspiracy theories was higher earlier in the pandemic (September -November 2020), before the start of the vaccination roll-out, suggesting recent messaging may have had some positive effect. These findings reflect similar findings from the Virus Watch study showing that 86% of adults in England and Wales (across all ethnic groups) who were reluctant or intending to refuse a COVID-19 vaccine in December 2020 had changed their mind in February 2021 (43) . Hesitancy due to concerns around side-effects, vaccine contents and feeling clinical trials had been inadequate or too short, were voiced, particularly post-vaccine licensing (January-March 2021), with many expressing that they did not feel they had access to enough information. Another key influencing factor may be due to COVID-19 vaccine hesitancy and lower vaccine uptake in the early stages of the roll-out among healthcare staff from some ethnic minority groups (44, 45) , who are often looked up to and trusted by their communities for health advice. Our results suggest that in precarious migrant groups, vaccine hesitancy issues could be relatively straightforward to address with clear, accessible and tailored information campaigns in a wide range of formats and languages. This should be done through existing schemes such as NHS community champions or Patient and Public Engagement groups (46) or through new collaborations with existing, trusted actors, such as charities, community groups and communities themselves, to ensure equitable uptake (14, 47) . Engaging precarious migrants, particularly undocumented individuals, in research has been rarely done to date, yet is essential to reveal unheard realities that these communities experience. Indeed, this study has shown that these groups may not be as 'hard to reach' as has historically been suggested, if appropriate communications channels are used (for example, through social media or trusted charities/community groups). 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 pandemic around the importance of inclusiveness in health systems and principles of universal health coverage are embedded in the policy response, to improve access to health systems for excluded groups and to improve health outcomes in these growing populations in European and other high-income countries.  Ensure strong and wide-reaching communication around strategies to support migrant populations to access COVID-19 vaccinations and the wider healthcare system -specifically undocumented migrants and those in high-risk settings such as asylum centres/accommodation -to ensure they are aware of options available to them and to allow equitable vaccine uptake in migrants currently outside of health systems.  Implement accessible information campaigns in a wide range of formats and languages on COVID-19 vaccines (including side-effects, vaccine contents, counters to misinformation, entitlement and access points), delivered through trusted community sources (NGOs, community groups, religious groups, homeless centres, food banks). Information campaigns must be sensitive, culturally appropriate and must not risk stigmatising individual communities, which could negatively impact trust and engagement.  Urgently conduct more research to explore risk factors for low COVID-19 vaccine uptake in migrant communities, to assess the extent to which vaccine hesitancy and circulating misinformation is playing a role, to better elucidate both individual and structural barriers to vaccination and strengthen monitoring to ensure equitable vaccine uptake in a wide variety of marginalised groups.  There is a need to strengthen routine data systems in the UK and Europe to increase understanding around levels of access to health care, vaccination uptake, and health outcomes in diverse and growing migrant populations  Ensure lessons learned during this pandemic around the importance of inclusion in health systems, through initiatives such as Universal Health Coverage, are meaningfully embedded in policy responses going forward We declare that we have no conflicts of interest. 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Aljazeera Understanding Covid-19 misinformation and vaccine hesitancy in context: Findings from a qualitative study involving citizens in Bradford patterns and psychological influences on COVID-19 vaccination intention: findings from a large prospective community cohort study in England and Wales (Virus Watch). medRxiv Association of demographic and occupational factors with SARS-CoV-2 vaccine uptake in a multi-ethnic UK healthcare workforce: a rapid real-world analysis Covid:19: Ethnic minority health staff are less likely to take up vaccine, early data show The role of Community Champions networks to increase engagement in the context of COVID-19: Evidence and best practice The COVID-19 vaccines rush: participatory community engagement matters more than ever We are grateful to the study participants who gave their time and shared their experiences and ideas, as well as members of our Project Board of migrant representatives for their valuable input.