Vaccinating adult migrants: recognising barriers and increasing confidence

Nurse practitioner in asylum and refugee services, Victoria Bradley, explores the challenges and barriers to vaccination for adult migrants in the UK, and how nurses can help improve access, build trust, and deliver effective, inclusive immunisation services.

A migrant refers to someone who is residing outside of their country of origin, some of whom may have increased health needs because of experiences either before, during or after migration. The UK Health Security Agency (UKHSA) uses the term vulnerable migrants to describe these individuals, examples of which include:¹

• Asylum seekers and refugees
• People who have been trafficked
• Undocumented migrants
• Low paid migrant workers

There are a number of reasons why migrants may not have completed or started immunisation schedules. Adults in particular, may be at increased risk of under-immunisation for routine vaccination or left out of catch-up initiatives.²

Vaccination plays a crucial role in global health promotion, however evidence suggests that migrants have lower immunisation rates, and higher burdens of vaccine-preventable diseases (VPDs), compared with host populations of the country they are residing in.⁴

This article will review some of the key barriers to vaccination for adult migrants, how to overcome them, and provide vaccination resources for both clinicians and patients.

Barriers and special considerations

Barriers may exist for migrants accessing vaccinations both in their country of origin, and on arrival into a new country.

Migrants can be at risk of inadequate immunisation if healthcare has been disrupted in their country of origin, due to war or other sociopolitical challenges.⁵ Accessibility of vaccines also varies by country, with some having poor access to vaccine services⁶, and some countries not offering protection against all the antigens currently offered in the UK immunisation schedule.¹⁰

Due to overcrowded living conditions, and risks during and post transit, migrants can be at increased risk of harm from contracting VPDs.⁵

Some barriers that prevent migrants from accessing vaccinations on arrival into new countries include:^4,13

• Language and communication barriers
• Lack of information in relevant formats including translated information
• Blanket approaches to vaccine campaign outreach i.e. all vaccination reminders sent via letter/ text
• Distrust of healthcare systems or authorities
• Lack of knowledge from healthcare professionals around entitlement and catch-up vaccine guidelines
• Physical or practical barriers: inaccessible facilities or appointments for vaccinations

Overcoming barriers

Managing language barriers is essential. Its good practice to use a professional language interpreter, allow longer for the consultation, and if possible, facilitate patient preferences of interpreter, such as gender.⁷ Follow up appointments should also be relayed to the patient via an interpreter, and it can be useful to ask them to repeat back appointment details to ensure clarification.⁷

Healthcare professionals involved in providing vaccination services should receive specific training in providing inclusive and culturally sensitive vaccination services to migrants, with awareness of health needs, and risk of contracting VPDs.⁵

Adopting a more convenient approach with drop-in vaccine clinics or flexible appointments can also increase uptake.¹³

Make every contant count

The UK Health Security Agency (UKHSA) provides advice across their migrant health and vaccination of individuals with uncertain or incomplete immunisation status guidelines, that can aid healthcare professionals in using appointments and opportunistic contact effectively to support vaccination. Tips include:^3,8

• Migrants should always be asked about their vaccine history, and be assumed to be unimmunised unless they can provide records or other reliable vaccination history
• Plan catch up schedules with the aim to protect the individual in the shortest time frame possible, using the minimum timescale
• Give as many vaccines as possible at each visit, in case the patient does not return for subsequent appointments
• Ask family members who have attended with the patient about their vaccine histories, and update these at the same appointment if possible
• Opportunistically ask about future plans to travel to their country of origin, and arrange for provision of appropriate travel advice as necessary

Advise of entitlement – adult focus

Not having permanent UK citizenship should not be a barrier, as refugees, asylum seekers and refused asylum seekers can register for and receive primary care services free of charge in any nation of the UK.⁷ They should be advised of vaccines available to them, and how the UK’s primary care system works.⁷

Traditionally, vaccination campaigns have focused on children and under fives⁵, however gaps have been identified in the provision of vaccines to older migrants (adolescents and adults), and policies and planning should be put in place to ensure they have opportunities to access vaccinations they may have missed as children, with subsequent boosters and any additional vaccines they need to align them with their host country schedule.⁴

Although upper age limits apply to a few vaccines, for most, administering them late still provides protection against VPDs, and a better late than never approach should be used.⁴

Vaccine hesitancy

Vaccine hesitancy refers to a delay in acceptance, or a refusal of safe vaccines.¹² The reasons for which migrants may experience this can be complex.

Some contributing factors include levels of health literacy or limited proficiency in host country language, and institutional mistrust from experiences of discrimination and marginalisation.¹¹ Some migrants may also have worries about vaccine safety and side effects⁴, or have concerns around their confidentiality that require reassurance.⁷

Migrants may have different cultural, social or religious norms and values surrounding their perception of health and illness, which can influence decision making in regards to vaccines.⁹ Materials provided to migrants should therefore be culturally appropriate, including information on why vaccines are important, which diseases they prevent, and answer common concerns and misconceptions.⁵

Specifically monitoring for and addressing misinformation around vaccines is also an important tool in understanding and attempting to overcome vaccine hesitancy.⁴

Continued contact with migrants can help re-enforce the safety of health services and the need for vaccination¹⁴, and consideration should be given to different health seeking behaviours, such as the support of family, friends or health professionals in the decision making for vaccination.⁵

Victoria Bradley is a nurse practitioner – refugee and asylum seeker services.

Signpost to resources:

Below are some patient focused resources that can support informed decision making around vaccination.

www.gov.uk/government/publications/immunisation-information-for-migrants – Leaflet on vaccines for migrants who have moved to the UK, available in multiple languages

www.immunology.org/public-information/vaccine-resources/vaccine-resources-different-languages – Vaccine resources in different languages

www.publichealth.hscni.net/publications/measles-protect-yourself-protect-others – Information on measles and MMR vaccine for adults, translated in different languages

www.gov.uk/government/publications/menacwy-vaccine-information-for-young-people/a-guide-to-the-menacwy-vaccine#translate – MENACWY vaccine information translated

www.doctorsoftheworld.org.uk/translated-health-information/ – Translated health information, including vaccination and how to register with a GP

Healthcare professionals:

Useful resources for healthcare professionals:

WHO Immunization Data port www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-bookal – All Data – World Health Organisation (WHO) data on vaccination by country

www.sps.nhs.uk/articles/vaccines-and-immunisation-resources-for-answering-questions/ – A list of resources for primary care healthcare professionals on vaccinations, and answering questions around them

www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book – The Green Book immunisation against infectious diseases