key: cord-0971210-bfu4lzk5
authors: Abba-Aji, Mohammed; Stuckler, David; Galea, Sandro; McKee, Martin
title: Ethnic/racial minorities’ and migrants’ access to COVID-19 vaccines: A systematic review of barriers and facilitators.
date: 2022-02-18
journal: J Migr Health
DOI: 10.1016/j.jmh.2022.100086
sha: 890835c50a7e1dd98c0c161cf62c8c4eaff1ed69
doc_id: 971210
cord_uid: bfu4lzk5

BACKGROUND: There are widespread concerns that ethnic minorities and migrants may have inadequate access to COVID-19 vaccines. . Improving vaccine uptake among these vulnerable groups is important towards controlling the spread of COVID-19 and reducing unnecessary mortality. Here we perform a systematic review of ethnic minorities’ and migrants’ access to and acceptance of COVID-19 vaccines. METHODS: We searched PubMed and Web of Science databases for papers published between 1 January 2020 and 7 October 2021. Studies were included if they were peer-reviewed articles; written in English, included data or estimates of ethnic minorities’ or migrants’ access to vaccines; and employed either qualitative or quantitative methods. Of a total of 248 studies screened, 33 met these criteria and included in the final sample. Risk of bias in the included studies was assessed using Newcastle Ottawa Scale and Critical Appraisal Skills Program tools. We conducted a Synthesis Without Meta-analysis for quantitative studies and a Framework synthesis for qualitative studies. RESULTS: 31 of the included studies were conducted in high-income countries, including in the US (n = 17 studies), UK (n = 10), Qatar (n = 2), Israel (n = 1) and France (n = 1). One study was in an upper middle-income country -China (n=1) and another covered multiple countries (n = 1). 26 studies reported outcomes for ethnic minorities while 9 studies reported on migrants. Most of the studies were quantitative -cross sectional studies (n=24) and ecological (n=4). The remaining were qualitative (n=4) and mixed methods (n=1). There was consistent evidence of elevated levels of COVID-19 vaccine hesitancy among Black/Afro-Caribbean groups in the US and UK, while studies of Hispanic/Latino populations in the US and Asian populations in the UK provided mixed pictures, with levels higher, lower, or the same as their White counterparts. Asians in the US had the highest COVID-19 vaccine acceptance compared to other ethnic groups. There was higher vaccine acceptance among migrant groups in Qatar and China than in the general population. However, migrants to the UK experienced barriers to vaccine access, mainly attributed to language and communication issues. Lack of confidence, mainly due to mistrust of government and health systems coupled with poor communication were the main barriers to uptake among Black ethnic minorities and migrants. CONCLUSIONS: Our study found that low confidence in COVID-19 vaccines among Black ethnic minorities driven by mistrust and safety concerns led to high vaccine hesitancy in this group. Such vaccine hesitancy rates constitute a major barrier to COVID-19 vaccine uptake among this ethnic minority. For migrants, convenience factors such as language barriers, fear of deportation and reduced physical access reduced access to COVID-19 vaccines. Building trust, reducing physical barriers and improving communication and transparency about vaccine development through healthcare workers, religious and community leaders can improve access and facilitate uptake of COVID-19 vaccines among ethnic minority and migrant communities.

The COVID-19 pandemic has had devastating consequences for health and the economy worldwide. There have been almost 5 million deaths, almost certainly an underestimate, by October 2021 (1) and virtually every country reported negative economic growth in 2020. (2) The emergence of the Omicron variant and its related lineages is a reminder that the pandemic is not over, with continued disruptions likely through 2022. There is now widespread agreement that vaccination against COVID-19 is critical to global emergence from the pandemic. It offers protection against transmission, protects against severe symptoms and reduces the risk of death in those infected with SARS CoV-2.(9-11) As of 13 December 2021, a total of 8,200,642,671 vaccine doses have been administered globally. (1) However, there are concerns that just as these groups have been disproportionately harmed by higher infection rates and worse COVID-19 outcomes, they continue to be disproportionately harmed by lower vaccination uptake as vaccine programs gather pace, leaving them further behind as the world recovers. Here we report a systematic review of the evidence on whether this is happening and what might be done to overcome it.

The WHO SAGE Working Group on Vaccine Hesitancy defines vaccine hesitancy as "delay in acceptance or refusal of vaccination despite availability of vaccination services, a complex phenomenon and is often contextually bounded, influenced by factors such as complacency, convenience and confidence." (12) However, whatever the reasons, the ability to control the pandemic in populations will ultimately depend on extending coverage to those least likely to receive vaccines.

We are unaware of any systematic review so far that has examined uptake of COVID-19 vaccines by ethnic minorities and migrants globally. We now seek to fill this gap by synthesizing the peer-reviewed literature on this issue, so as to provide an understanding of barriers and facilitators related to COVID-19 vaccine uptake in these groups with a view to identifying potential interventions. We do so by means of a systematic review and narrative synthesis of quantitative studies on COVID-19 vaccine access and acceptance among ethnic minority and migrant populations. Additionally, we conducted a framework synthesis using the best fit approach for qualitative studies that explored barriers and facilitators of COVID-19 vaccine access and acceptance among migrants and ethnic minority populations. (13) We define ethnic minorities "as a group of people who differ in race or in national, religious, or cultural origin from the dominant group of the country of study" and as such may face discrimination and other barriers to accessing health services. (14) "Migrants" include refugees, asylum seekers and internally displaced persons and often face administrative, financial, legal, and language barriers to access the health system. (15) 2 Methods

We electronically searched PubMed and Web of Science databases covering the period from prior to the COVID outbreak, 1 Jan 2020, through to the time of the search, 7 October 2021, following PRISMA guidelines. (16) The review was registered with PROSPERO (CRD42021278123) on 13 September 2021. (17) The search included three main keywords: migrants, ethnic groups and COVID-19 vaccine. For migrants, we searched for existing systematic reviews and operationalized those keywords, including various permutations of asylum seekers, refugees, and internally displaced persons.

For COVID-19 vaccines, a MeSH term has been created which we employed in our search. For ethnic groups, we recognize that this is an area that faces many terminological challenges because of the use of words that have particular meanings in different contexts or are in certain respects synonymous. Fortunately this has also been recognised by those developing the MESH term "Ethnic group", which includes groups such as "African Americans, Amish, Arabs, Asian

Americans, Hispanic Americans, Mexican Americans, Indigenous Peoples, Alaskan Natives, Jews, Roma". In addition, the term "Black Americans" is also indexed under "African Americans" in Pubmed. For PubMed our search was as follows: 

We applied a series of inclusion and exclusion criteria during screening and eligibility stages.

Articles were included if: i) they were peer-reviewed articles; ii) written in English; iii) they included data or estimates of migrants' access to vaccines; and iv) they were a qualitative, quantitative or mixed method study.

We excluded papers that were not research studies or were reviews, such as commentaries, editorials, correspondences, systematic literature reviews and preprint articles. We further excluded population studies which did not report outcomes on either migrants or ethnic minority populations or when such outcomes could not be disaggregated from the general population. Papers were also excluded if they only described or proposed vaccine access policies without reporting on our outcome of interest. Finally we excluded studies on access or participation in COVID-19 vaccines trials and studies reporting on migrants and ethnic minority   access to vaccines other than COVID-19 vaccines. Screening based on title and abstract was performed and reviewed independently by two authors (MA and DS). Any conflicts were resolved by consensus. The 2 reviewers screened titles and abstracts, removed duplicates and extracted data with Covidence 2.0 systematic review software. This excluded 133 studies, leaving 115 potentially eligible. Of these, 82 were excluded because they were not research studies (n=47); did not report outcomes pertaining to vaccine access (n=26); did not report data about migrants or ethnic minorities (n=8); or was a systematic review (n=1) (note: some articles had multiple reasons for exclusion; for brevity only the main one is included here). This left 33 articles in the final systematic review sample for data analysis and quality assessment. Figure 1 further describes the process of inclusion / exclusion.

[ Figure 1 about here]

We extracted main study parameters into a summary Excel Since there was considerable methodological and clinical heterogeneity across study populations, designs, and endpoints in the reviewed studies we did not perform a metaanalysis.

No ethics review was required as the study involved only secondary analysis of published studies. There was no direct funding source for this study.

Of the 33 studies included in the final sample, nearly all were conducted in high-income countries, including in the US (n = 17), UK (n = 10), Qatar (n = 2), Israel (n = 1) and France (n = 1). One study was in an upper middle-income country -China (n=1) and another covered multiple countries (n = 1). No study covered populations in low-or lower-middle income countries. Most of the studies were quantitative -cross sectional studies (n=24) and ecological (n=4). The remaining were qualitative (n=4) and mixed methods (n=1). Table 1 provides a description of included studies with a summary of their key findings.

[ (22) . Figure 2 summarises the studies by region and population.

[ Figure 2 Although they found more frequent negative attitudes among ethnic minorities, these attitudes did not influence intentions by these groups to accept COVID-19 vaccines. Their findings were not reported for different ethnic groups, so caution is needed when drawing conclusions given the potential for heterogeneity. In contrast, Sethi et al 2021 found that the BAME community were more likely to take an approved vaccine than Whites (OR=5.48), a finding that the authors attribute to the disproportionate COVID-19 mortality among the BAME population. (40) However, it should be noted that this study too did not disaggregate its findings according to different ethnic groups (Blacks, Asians and Mixed ethnicity), although the authors did suggest that there may be variations.

One study reported on acceptance of vaccines by Arab Israelis in a study of ethnic and sociodemographic factors associated with attitudes towards COVID-19 vaccines. The authors reported significantly higher rejection by Arabs (29.9%) compared to Jews (7.7%) (p<0.0001).

Although women in general showed more hesitancy than men, this was significantly higher in Arab (41.0%) than Jewish women (17.2%). (44) The authors suggest that the low willingness among Arab women could be related to a lack of confidence in COVID-19 vaccines, reflecting disinformation around the idea that the vaccines lead to infertility.

Next we summarise evidence from the 9 studies that examined vaccine access and acceptance among migrants. These were from the UK (n=4), Qatar (n=2), France (n=1), China (n=1) and multiple countries (n=1). ( 

Taken together the studies revealed a number of barriers to COVID-19 vaccine uptake. We synthesize them using the 3Cs Model of Vaccine Hesitancy namely; confidence, convenience and complacency. Confidence was the most frequently reported barrier (n=12), followed by convenience (n=4) and complacency (n=2). Some studies reported more than one barrier.

We will first present synthesized evidence of confidence barriers. The main drivers were mistrust in the healthcare system/government (n=9) and vaccine safety concerns (n=7). New Jersey counties severely affected by the pandemic. They found that the devastating effects of the pandemic did not translate into COVID-19 vaccine acceptance, with participants expressing a high level of distrust of the vaccine. Specifically, they did not trust the vaccine development process, expressing concerns that the process had been "rushed" and that the vaccines might have long-term adverse effects. They also expressed mistrust of the healthcare system and government, voicing fears that they might be unwilling subjects of experiments.

As in the US, mistrust was a key barrier to vaccine acceptance among Afro-Caribbeans in the UK. (37, 43) Even among those who were healthcare workers, suspicion and mistrust in the vaccine development process was especially salient, often reflecting concerns about poor and unethical past research.

Only a few investigated the role of mistrust in fueling hesitancy quantitatively. Thompson 

Next we turn to convenience barriers. The WHO SAGE working group on vaccine hesitancy has categorized factors such as physical unavailability, unaffordability and unwillingness-to-pay, geographical inaccessibility and inability to understand (language and health literacy) as convenience barriers. Of these, inability to understand (language and health literacy) (n=3) was the most commonly cited followed by geographical inaccessibility (n=2) and unaffordability (n=1).

Two qualitative studies in the UK conducted in person interviews with different categories of migrants in order to gain a deeper understanding on their perspectives on COVID-19 vaccine access. (49, 50) In the first study, Knights 

Only 2 studies reported complacency as a barrier to vaccine uptake among ethnic minorities and migrants. Olanipekun 

Most studies reported improving confidence as facilitator to COVID-19 vaccine uptake, 

There was consensus that more effective communication by health bodies is needed to facilitate COVID-19 vaccine uptake in ethnic minority/racial and migrant groups. Contextual factors, reflecting historical, environmental and health system factors have weakened migrants' trust in COVID-19 vaccines and ultimately their decision to accept/reject the vaccines. It was suggested that these were best addressed through influential leaders in the communities concerned, who could champion vaccine uptake within their local communities.(49,50,52)

There is evidence that improving physical access to vaccination sites also improves uptake Table 2 presents the results of the quality appraisal for cross-sectional studies. We assessed the cross-sectional studies (n = 24) using an adapted NOS protocol as outlined in the Methods section. Most studies were of moderate quality n=22. The average score was approximately 6 stars (range = 4-8 stars). The most common quality issues were failures to justify sample size and to describe the response rate or the characteristics of the responders and the nonresponders.

[ Table 2 about here] Table 3 presents the results of quality assessment for the qualitative studies. We assessed the studies using the CASP checklist . The checklist had 10 questions, each of which was given an answer, 'Yes', or 'No', or 'Cannot tell'. As suggested by CASP, we did not create a summary score of the appraised studies. We retain articles of seemingly poor quality but report our assessment of potential biases.

[ Table 3 about here]

This study is the first systematic review, to the best of our knowledge, to synthesize evidence on acceptance and access to COVID-19 vaccines among ethnic minorities and migrants. Most of the included studies were quantitative and assessed the acceptance of COVID-19 vaccines among ethnic minorities rather than migrants. There is consistent evidence that Black ethnic minorities in the UK and US report higher vaccine hesitancy than their White counterparts but, in the US, the picture with respect to Hispanics/Latinx populations and their White counterparts varies. Most studies that included Asians in the US found higher COVID-19 vaccine acceptance compared to Whites. The few studies that looked at migrants found higher vaccine acceptance compared to the general population. However, there was evidence that migrants face access barriers, due to a host of factors, the commonest of which related to a lack of confidence in COVID-19 vaccines, particularly due to mistrust of governments and health systems as well as lack of information particularly due to poor communication.

Vaccine hesitancy among ethnic minorities and migrants constitutes another barrier to uptake, largely driven by mistrust in the healthcare system that is widespread with ethnic minority and migrant communities. This can be traced to previous unethical research practices such as the There may be scope for explanation of the vaccine development process by religious and community leaders but this must recognize the challenges involved in overcoming past and current experiences.

A one size fits all approach risks excluding ethnic minorities and migrants. There is a need for culturally sensitive and context specific COVID-19 vaccine information that reflects their situation and beliefs, while reaching out to appropriate settings such as places of worship and community centers.

A key strength of our study lies in the fact that we assessed both demand-side barriers such as vaccine hesitancy and supply-side barriers such as vaccine access among two socially disadvantaged populations globally. Additionally, by including both quantitative and qualitative studies, we were able synthesize evidence on the extent of barriers to COVID-19 vaccination uptake as well its drivers. However, despite it being broad in scope, the review still had some weaknesses and limitations.

First, as noted above, we recognized the potential problems arising from the terminology employed-"ethnic group". However, we were reassured that our search strategy was sufficiently sensitive, capturing papers that used many different terms, such as "racial groups/ minorities" and "Blacks". Second, the methods and quality of the included studies varied substantially. Few studies focused primarily on ethnic minorities or migrants so these groups intentions. While there is some evidence that intentions mirror uptake trends, there is need for cautious interpretation as the decision to accept a vaccine is a result of complex interactions and influences that could change with time. Sixth, while we did not apply language restrictions, our search did not return eligible publications in any language other than English. This limits the generalizability of our findings. Although we have ensured fidelity to the strategy as set out in our PROSPERO submission, in response to a comment by a reviewer, we subsequently widened our search to include African Index Medicus and LILACS database but found no additional papers. Finally, we did not search for grey literature, nor did we consider pre-print publications.

Including these types of publications could have yielded additional relevant results but at the risk of being misled, a particular problem in a field where there is so much disinformation.

Reasons behind low vaccine acceptance among ethnic minorities are plausible and in keeping with previous vaccination uptake patterns.(69) However, there is the need for more qualitative studies to provide much deeper understanding of how these factors affect vaccine uptake among ethnic minorities and migrants. Such qualitative studies could be used to interpret subjective experiences of ethnic minorities and migrants to define strategies that will ensure equitable access and delivery of COVID-19 vaccines.

Only a few studies reported on migrants' access to and acceptance of COVID-19 vaccines, which is disappointing given estimated that there were over 270 million migrants in 2019.. (70) Consequently, caution should be applied when drawing conclusions from our findings on migrants. The heterogeneity of the populations and the methods employed limit the generalizability of these studies. There is therefore the need for more studies of migrant's access to COVID-19 vaccines. This is necessary due to the limited number of studies and the different contexts in which they were conducted.

There is consistent evidence that Black/Afro-Caribbean groups in the US and UK experience barriers to COVID-19 vaccine uptake associated with hesitancy. Conversely, the picture with 

COVID-19) Dashboard

A Long and Difficult Ascent [Internet]. IMF

Rising Caseloads, A Disrupted Recovery, and Higher Inflation

Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: A systematic review

Unequal impact of the COVID-19 crisis on minority ethnic groups: a framework for understanding and addressing inequalities

Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population

Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis. EClinicalMedicine

Vaccine hesitancy in migrant communities: a rapid review of latest evidence

COVID-19 vaccines and decreased transmission of SARS-CoV-2

Prevention of host-to-host transmission by SARS-CoV-2 vaccines. The Lancet Infectious Diseases

Vaccine effectiveness against SARS-CoV-2 transmission and infections among household and other close contacts of confirmed cases, the Netherlands

Vaccine hesitancy: Definition, scope and determinants

What is Qualitative Evidence Synthesis? : Methodologies and methods for qualitative evidence synthesis

Ethnic Minorities | Scholastic

Google Scholar

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Migrants and ethnic minorities' access to COVID 19 vaccines: a systematic review of barriers and facilitators

Covidence systematic review software, Veritas Health Innovation

The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses

CASP -Critical Appraisal Skills Programme

COVID-19 vaccine access and attitudes among people experiencing homelessness from pilot mobile phone survey in

A high rate of COVID-19 vaccine hesitancy in a large-scale survey on Arabs

Determinants of COVID-19 vaccine acceptance in the US

COVID-19 Vaccination Coverage Among Insured Persons Aged ≥16 Years, by Race/Ethnicity and Other Selected Characteristics -Eight Integrated Health Care Organizations, United States

Predictors of willingness to get a COVID-19 vaccine in the U.S. BMC Infect Dis

Individual and social determinants of COVID-19 vaccine uptake

Factors associated with the intention to obtain a COVID-19 vaccine among a racially/ethnically diverse sample of women in the USA

Factors influencing likelihood of COVID-19 vaccination: A survey of Tennessee adults

Factors Associated With Racial/Ethnic Group-Based Medical Mistrust and Perspectives on COVID-19 Vaccine Trial Participation and Vaccine Uptake in the US

Attitudes and Perceptions Towards Coronavirus Disease 2019 (COVID-19) Vaccine Acceptance Among Recovered African American Patients

COVID-19 Related Medical Mistrust, Health Impacts, and Potential Vaccine Hesitancy Among Black Americans Living With HIV

Prevention Interest, and Testing Among Sexual and Gender Minority Adults in a Diverse National Sample. LGBT HEALTH

COVID-19: Perceived Infection Risk and Barriers to Uptake of Pfizer-BioNTech and Moderna Vaccines Among Community Healthcare Workers

Vaccination patterns of the northeast Ohio Amish revisited. Vaccine

Assessment of Racial and Ethnic Disparities in Access to COVID-19 Vaccination Sites in Brooklyn

Uptake of COVID-19 vaccination in a medium secure psychiatric hospital population

Predictors of COVID-19 vaccine hesitancy in the UK household longitudinal study

Anti-vaccine attitudes and risk factors for not agreeing to vaccination against COVID-19 amongst 32,361 UK adults: Implications for public health communications

Parents' and guardians' views on the acceptability of a future COVID-19 vaccine: A multi-methods study in England. Vaccine

The UPTAKE study: a crosssectional survey examining the insights and beliefs of the UK population on COVID-19 vaccine uptake and hesitancy

COVID-19 vaccine hesitancy in the UK: The Oxford coronavirus explanations, attitudes, and narratives survey (Oceans) II. Psychological Medicine

The Catalyst Project Team. Social Patterning and Stability of Intention to Accept a COVID-19 Vaccine in Scotland: Will Those Most at Risk Accept a Vaccine? Vaccines (Basel)

Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. The Lancet Regional Health -Europe

A study of ethnic, gender and educational differences in attitudes toward COVID-19 vaccines in Israel -implications for vaccination implementation policies

Acceptance and Willingness to Pay for the COVID-19 Vaccine among Migrants in Shanghai, China: A Cross-Sectional Study. Vaccines (Basel)

Prevalence and Potential Determinants of COVID-19 Vaccine Hesitancy and Resistance in Qatar: Results from a Nationally Representative Survey of Qatari Nationals and Migrants between

COVID-19 vaccine hesitancy and attitudes in Qatar: A national cross-sectional survey of a migrant-majority population. Influenza Other Respir Viruses

COVID-19 vaccine hesitancy among persons living in homeless shelters in France

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

Impact of COVID-19 on migrants' access to primary care and implications for vaccine roll-out: a national qualitative study

ethnicity and COVID-19 vaccination: a qualitative study of UK healthcare staff

Black and Latinx Community Perspectives on COVID-19 Mitigation Behaviors, Testing, and Vaccines

COVID-19 Vaccine Administration, by Race and Ethnicity -North Carolina

Why African-Americans are Hesitant to Take the Newly Proposed COVID-19 Vaccines: Tuskegee Revisited

Beyond Tuskegee -Vaccine Distrust and Everyday Racism

How George Floyd Died, and What Happened Next. The New York Times

Trump leans into racist rhetoric and downplays police violence against Black Americans -CNNPolitics

Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. The Lancet [Internet]

Addressing Vaccine Hesitancy in BIPOC Communities -Toward Trustworthiness, Partnership, and Reciprocity

Does Diversity Matter for Health? Experimental Evidence from Oakland

A three-tiered approach to address barriers to COVID-19 vaccine delivery in the Black community

The biggest pandemic risk? Viral misinformation

How to fight an infodemic. The Lancet

The COVID-19 vaccine social media infodemic: healthcare providers' missed dose in addressing misinformation and vaccine hesitancy

Healthcare is not universal if undocumented migrants are excluded

What Do Core Obligations under the Right to Health Bring to Universal Health Coverage? Health Hum Rights

Safe surgeries network -Doctors of the World

Legal advocacy as a tool to advance Roma Health. Health Economics, Policy and Law

The role of trust in HPV vaccine uptake among racial and ethnic minorities in the United States: a narrative review

The number of international migrants reaches 272 million, continuing an upward trend in all world regions, says UN | UN DESA | United Nations Department of Economic and Social Affairs

Demographic Characteristics of Persons Vaccinated During the First Month of the COVID-19 Vaccination Program -United States

All Fields]) OR "internally displaced person"[All Fields] OR ("emigrants and immigrants"[MeSH Terms] OR ("emigrants"[All Fields] AND "immigrants"[All Fields]) OR "emigrants and immigrants"[All Fields] OR "emigrant

All Fields]) OR ("migrant s"[All Fields] OR "transients and migrants

covid 19 nucleic acid testing"[All Fields] OR "covid 19 nucleic acid testing"[MeSH Terms] OR "covid 19 serological testing"[All Fields] OR "covid 19 serological testing

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work

☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests