Motives for COVID-19 vaccine hesitancy amongst marginalized groups, including homeless persons and migrants, in France: a mixed-methods study.

doi:10.21203/rs.3.rs-1662988/v1

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Motives for COVID-19 vaccine hesitancy amongst marginalized groups, including homeless persons and migrants, in France: a mixed-methods study.

https://doi.org/10.21203/rs.3.rs-1662988/v1

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Background: Persons experiencing unstable housing – including recently arrived migrants – are at elevated risk of contracting COVID-19 and suffer from high morbidity and mortality. In this context, the COVID-19 vaccine was foreseen as a promising way to control the pandemic and reduce social inequalities in this area. Understanding the motives of COVID-19 vaccine acceptability in people with unstable housing, including migrants, is therefore crucial to tailor public health communication and outreach. Thus, the main objective of our study was to investigate - both quantitatively and qualitatively – the motivations behind vaccine hesitancy in people experiencing unstable housing when vaccines became available in France.

Methods: A cross-sectional study was performed in Spring 2021, using convergent mixed-methods approach. Participants were recruited from homeless shelters and day centres and face-to-face interviews were offered, with help, where necessary, from phone-based interpreters. Factors associated with motives for COVID-19 vaccine hesitancy were explored using logistic regression models. Qualitative data – collected through semi-structured individual interviews - were analysed via an inductive thematic approach. Both quantitative and qualitative data were then integrated.

Results: Vaccine hesitancy was found to be at an elevated rate (58.0%). The three most reported motives of hesitancy were related to COVID-19 vaccine effectiveness, safety, and trust in information about the vaccine. Factors of elevated hesitancy comprised the interviewees’ age, level of education, French-language aptitude, feeling of worry about COVID-19, and time of residence in France. Generic distrust in official information was a shared associated factor for the 3 motives of hesitancy. This result was expanded upon by the interview data where participants described having differential trust depending on who is recommending the vaccination. Another emerging key theme related to hopes that the vaccine would release them from the burden of the pandemic.

Conclusions: Our mixed methods study provides a comprehensive understanding of COVID-19 vaccine hesitancy among persons with unstable housing in France in Spring 2021. Elevated levels of hesitancy remain a public health concern as “No one is safe until everyone is safe”. The already established role of trust in vaccine hesitancy is still to be adequately addressed as a potentially effective route of intervention.

COVID-19

Vaccine hesitancy

Marginalized populations

Immigrant

Homeless

Health inequalities

Mixed methods

Persons experiencing unstable housing – including recently arrived migrants – are at elevated risk of contracting COVID-19 (1–3) and suffer from high morbidity and mortality (4). Furthermore, their risk might be higher due to a high prevalence of factors associated with COVID-19, such as chronic diseases (e.g. diabetes, hypertension) (5, 6). In this regard, the pandemic has exacerbated pre-existing health inequalities (7). In this context, the COVID-19 vaccine was foreseen as a promising way to control the pandemic and reduce social inequalities in this area. However, data on elevated vaccine hesitancy in marginalized groups, collected during the early phase of the pandemic while the COVID-19 vaccine was not yet available, showered initial optimism (8). Indeed, prior to the diffusion of the COVID-19 vaccine, high vaccine hesitancy was observed in migrants compared to native populations (8). Understanding the motives of COVID-19 vaccine acceptability in people with unstable housing, including migrants, is therefore crucial to tailor public health communication and outreach, as claimed by the World Health Organization “No one is safe until everyone is safe” (9).

Prior to the introduction of the vaccine pass in France, levels of vaccine uncertainty and refusal were higher than seen in other countries. In Canada, for example, the rate of uncertainty during December 2020 was 11% of the adult population, with 4.7% refusing, compared to 30.1% uncertainty and 10.2% refusal in France (10). In this study, vaccine hesitancy was associated with living in a rural area; having lower levels of education; disinterest in information surrounding COVID-19; and reporting a lower level of concern regarding COVID-19 and its impact on one’s family.

Fewer studies have also investigated vaccine acceptability in marginalized population groups. The first round of investigation in the ECHO study, conducted in Spring 2020 when vaccines were not yet available (8), saw 40.9% of participants – homeless persons and migrants – show some degree of vaccine hesitancy. Elevated vaccine hesitancy associated with: being a woman (OR = 2.55; 95% CI 1.40–4.74), living with a partner (OR = 2.48, 95% CI 1.17–5.41), being undocumented (OR = 0.51, 95% CI 0.27–0.92), and having low health literacy (OR = 0.38, 95% CI 0.21, 0.68) (8). In a primary care medical facility in Rome, in February 2021, approximately 35% of homeless participants were hesitant to get vaccinated against COVID-19 (11). Another study, conducted during the same period among homeless persons in Los Angeles (California) found a prevalence of vaccine hesitancy of 48%. Associated factors were a low risk perception of COVID-19 (aOR = 0.25, p = 0.02) and engaging in COVID-19 protective behaviours (aOR = 3.63, p = 0.02) (12). Vaccine acceptability was also surveyed in homeless shelters in Washington (US) from Nov. 2020 to Feb. 2021 (13). Among the 632 participants, the majority were willing to get vaccinated (53.7%), 28.1% were reluctant, 17.6% were hesitant, and 0.6% were already vaccinated. Elevated levels of vaccine hesitancy or reluctance were observed among persons who were Black/African-American, and those with lower educational attainment.

Knight et al. (14) explored COVID-19 testing and vaccine acceptability among homeless populations through qualitative interviews from July to October 2020. While participants showed an overall willingness to receive the vaccine, hesitancy was also observed. Hesitancy was motivated by the possibility that the vaccine could cause illness, as well as concerns about being the first to get vaccinated and mistrust of the government. More recently, in February 2021, Meehan et al. (15) assessed COVID-19 vaccine acceptability and uptake among residents of homeless shelters in Detroit, Michigan. A total of 106 residents participated in the survey, among whom 57.5% were already vaccinated, 11.3% were unsure and 31.1% did not plan to get vaccinated. Motives of vaccine hesitancy were fears of potential side effects (66.4%) and unknown long-term health impacts (57.8%).

COVID-19 vaccine hesitancy among migrant or ethnic minority groups has been mostly investigated in comparison with native populations. Studies in the Qatari population, which is mainly (~ 80%) composed of migrants, showed higher levels of vaccine refusal in immigrants than in natives (16, 17). Vaccine hesitancy was associated with beliefs that: COVID-19 was not a real disease (OR = 1.09, p = 0.009), the vaccine was not fully tested (OR = 1.71, p < 0.001), and natural exposure to viruses gives the safest protection (OR = 1.20, p < 0.001) (16). In Canada, immigrants had a 2-fold higher rate of vaccine hesitancy than natives (aOR 1.99, 95% CI 1.57–2.52) (18). The motives of hesitancy reported by immigrants vs. natives were related to vaccine safety (71.3% vs. 49.5%), side effects (66.4% vs 47.3%) and mistrust in vaccinations (12.5% vs 6.6%). In Australia, Lidell et al. found that 28.1% of refugees were vaccine hesitant. In this study, factors associated with vaccine hesitancy were a younger age, information (lack of information, unavailability in one’s language) and trust (difficulty trusting healthcare providers administering the COVID- 19 vaccine) barriers, perceived lower logistical barriers (waiting time to access the vaccine, worry about cost, etc.), and, concerns about the safety and side effects of the vaccine; feelings of lack of control; and low perceived COVID-19 risk (19). In the United States, rates of COVID-19 vaccination in 43 states were assessed. When compared to the White population, the rate of vaccination was lower among Black Americans (49% vs. 56%), higher among Asian-Americans (72%), and equivalent to Hispanic populations (54%) (20).

Qualitative studies have also investigated vaccine hesitancy in ethnic and migrant populations. Before the vaccine roll-out, Crawshaw et al. pleaded for a concerted effort to include ethnic and migrant populations, alongside targeted community implementation approaches. They also called for research to explore risk factors for underimmunisation against COVID-19 and the extent to which vaccine hesitancy plays a role in these communities (21). A qualitative investigation by Ekezie et al. explored the barriers and facilitators to participation in vaccine trials amongst ethnic minorities and marginalized communities (i.e. homeless and Gypsy, Roma and Traveller (GRT) communities) (22). This article highlighted the lack of adequate information which, in turn, was associated with scepticism and distrust towards the vaccine. In another study, Knights et al. aimed to explore views on the pandemic and the COVID-19 vaccine among both primary care professionals and recently-arrived migrants to the UK (< 10 years) via semistructured interviews (23). They found that the digitalisation of xxx had exacerbated existing inequalities, due to a lack of digital literacy and language barriers. Migrants reported contradictory information from different sources, and different beliefs about the vaccine, from thoughts that the vaccine may be unsafe or ineffective, to concerns of conspiracy regarding the vaccine.

At the end of December 2020, the first COVID-19 vaccine became available in France to both the elderly and caregivers. Progressively, it was extended to adults aged over 50 years and experiencing comorbidities. From mid-May 2021, COVID-19 vaccination became available for all persons over 50 years of age, and from mid-June for all adults. Several COVID-19 vaccines have been validated for use by the WHO and national authorities over time. In this paper we use the generic term “vaccine”, independent of specific brands or manufacturers. Most studies that investigated COVID-19 vaccine hesitancy among marginalized populations were conducted in 2020, while vaccines were not yet readily available. However, vaccine hesitancy is usually defined as a “delay in acceptance or refusal of vaccine despite availability of vaccine services” (24). The interpretation of hesitancy while the vaccine was not yet accessible is therefore complex and should be performed with caution. Thus, our main objective was to investigate, both quantitatively and qualitatively, the motivations behind vaccine hesitancy in people experiencing unstable housing, primarily migrants, after vaccines were actually available. We also assessed vaccine hesitancy as a secondary objective.

Study design

This cross-sectional study was performed between March 9th 2021 and June 25th 2021 in the French metropolitan regions of Paris and Lyon, as part of the ECHO study (25). The study sample consisted of persons aged over 18 years experiencing housing instability. Participants were recruited from homeless shelters and day centres, with day centres defined as centres welcoming homeless persons up to a maximum of one night. Participating centres were selected using purposive and convenience sampling methods (26). We used a convergent mixed-methods approach, i.e. a concurrent conduct of both the quantitative and qualitative phases, independent analyses and subsequent integration of all the results together (27, 28). Study interviews were conducted face-to-face by trained interviewers, with help, where necessary, from phone-based interpreters. Approximately 20 different languages were employed, aside from French and English, most frequently Arabic, Pashto and Dari. The study protocol was approved by the Ethical Research Committee of the University of Paris (CER-2020-41).

Quantitative data collection and analysis

For the quantitative part of the study, data were collected via a standardized questionnaire. Regarding vaccination, participants were asked about the level of information they had, their willingness to get vaccinated, and associated motives, as well as actual vaccine accessibility. Vaccine hesitancy was defined as either having refused vaccination when offered or being unsure (do not know) or unwilling to get vaccinated (if vaccination had not yet been offered). Among unvaccinated participants, vaccine hesitancy rates were assessed - as a secondary objective of this study - by the question “Would you be willing to get vaccinated against COVID-19?” Participants who responded ‘no’ or ‘I don’t know’ were considered vaccine hesitant.

Vaccine hesitant participants were then asked to rank their agreement (yes, no, don’t know) with the following statements: (1) the vaccine is an ineffective measure against COVID-19; (2) the vaccine is dangerous for my health; (3) I don’t trust the information about the vaccine; (4) COVID-19 doesn’t exist; (5) the vaccine goes against my personal or religious principles. Participants who responded ‘yes or ‘I don’t know’ were considered vaccine hesitant for that particular motive.

Our study was conducted from March to June 2021, when the COVID-19 vaccine was first available to adults aged over 50 years experiencing comorbidities, and became available to all adults over 50. We therefore added a question on whether participants were actually vaccinated against COVID-19 – defined as having received at least one dose. This information was not available for the first 111 participants. However, 57 of them (51.4%) reported being either unwilling to get vaccinated or having refused vaccination when offered, and were thus categorized as unvaccinated. Among unvaccinated participants, vaccine hesitancy was assessed by the question “Would you be willing to get vaccinated against COVID-19?” Participants who responded ‘no’ or ‘I don’t know’ were considered vaccine hesitant.

Factors considered as being potentially associated with motives of vaccine hesitancy were the following: sex (male, female), age (18–29, 30–39, 40–49, 50 + years), region of birth (France, North Africa, Sub-Saharan Africa, Europe, Eastern Mediterranean, Other), being in a stable relationship (yes, no), having children (yes but living separately, yes and living with at least one of them, no), French-language aptitude (low, intermediate, high), highest educational level reached (no school/incomplete primary education; primary/high school education; College/higher education), administrative status (French citizenship or legal status, undocumented), health insurance (yes, no), time spent in France (< 1 year, 1 to < 3 years, 3 to < 5 years, 5 + years or native), centre type (day/night centre, longer stay shelter), centre location (Lyon or Paris), trust in official information (yes, no), seeing COVID-19 as a source of concern (yes, no, neither), declared previous COVID-19 infection (yes, no), COVID-19 infection along close friends/family (yes, no), number of COVID-19 tests taken (0, 1, 2 to 5, more than 5), and perceived sufficiency of information regarding the COVID-19 vaccine (yes, no). The following health related factors were also investigated: perceived health (bad, good, very good to excellent), having a chronic disease (yes, no), depressive symptoms (yes, no) and anxious symptoms (yes, no) assessed via the 4-item Patient Health Questionnaire (PHQ-4) (29), change in tobacco consumption since the beginning of the pandemic (no consumption, decreased, unchanged, increased), and change in alcohol consumption since the beginning of the pandemic (no consumption, decreased, unchanged, increased). Participants were also questioned using the Health Literacy Questionnaire (30) HLQ-4: social support for health (lower, higher), and HLQ-7: navigating the healthcare system (lower, higher).

After exclusion of participants who were not hesitant towards the COVID-19 vaccine, as well as those with missing data on vaccine hesitancy or motives behind vaccine hesitancy, missing values for the factors listed above were imputed using the SAS fully conditional specification method (MI procedure, FCS statement, NIMPUTE option) (31). Pooled effect estimates were computed using the SAS MIANALYSE procedure. Unadjusted logistic regression models were used for all bivariate analyses, using the SAS logistic procedure. Corresponding variables were selected for the adjusted analyses where p-values fell under 0.25 to prevent the exclusion of important ones (32–34). We then tested associations with factors considered potentially relevant in relation to motives for COVID-19 vaccine hesitancy using logistic regression models. Statistical significance was drawn from odds ratios’ confidence intervals rather than p-values (35).

All statistical analyses were conducted using SAS (version 9.4; SAS Institute Inc., Cary, NC).

Qualitative data collection and analysis

The qualitative part of the study was implemented through semi-structured individual interviews with participants recruited exclusively from day centres. The estimated threshold for data saturation was set at 30 participants (36). The interview guide covered the following dimensions: (1) daily life during the pandemic; (2) perceptions and experiences of lockdown; (3) beliefs regarding health and COVID-19; (4) attitudes towards vaccination (in general and COVID-19 specific); (5) trust in public authorities and access to information; and (6) views on the aftermath of the pandemic. In this study we focused the analyses on verbatim quotations regarding vaccination in general and COVID-19 specifically. The interviews - conducted by a researcher from the study team - were recorded and fully transcribed. Using NVivo© (release 1.3 535) software, transcripts were analysed via Braun and Clarke’s inductive thematic approach (37). Analyses were performed in six steps (methodology previously detailed (38)), although thematic development was iterative and guided by a constant comparative method (27). Theoretical saturation was reached and conclusive themes were identified from the coded data (37).

Quantitative results

The sample for all quantitative analyses was recruited from 22 accommodation centres. 635 persons were approached,of whom 82.0% (521) agreed to participate and answered questions on vaccine hesitancy. Among these participants, 43% (226) complete-cases were included in bivariate analyses to identify variables to be included in the multivariate model, and 54% (282) were included in the imputed adjusted analyses (Fig. 1).

Sociodemographic, health and COVID-19 related information on the study participants is available in Table 1. In brief, participants included in the current analyses (n = 226) were mainly male (65.9%), young (57.0% under 40 years), single (68.6%), and born abroad (87.6%), with low to average French-language proficiency (65.1%), and an up to high school level education (73.9%). Half (51.8%) were living in France for less than 5 years, and approximately half were undocumented (48.2%). Regarding health, 43.8% reported a chronic disease, 33.2% had symptoms of depression, 32.3% felt anxious, and 14.2% had no health insurance coverage. More than half (58.8%) reported being worried about the COVID-19 pandemic, 17.3% had previously been infected, and a large majority of them (83.0%) had already taken a COVID-19 screening test. Nearly half of the study participants (46.9%) expressed distrust in official COVID-19 information, and 58.0% presented some degree of vaccine hesitancy. At the time of the study, 63.3% indicated not knowing where or how to get vaccinated.

Table 1

Characteristics of ECHO study participants, France, Spring 2021 (n = 226; %).
		% (n)
Sex
	Man	65.9% (149)
	Woman	34.1% (77)
Age
	18–29 years	27.4% (62)
	30–39 years	29.6% (67)
	40–49 years	16.8% (38)
	50 + years	26.1% (59)
Region of birth
	France	12.4% (28)
	North Africa	19.0% (43)
	Rest of Africa	46.0% (104)
	Europe (excl. France)	11.9% (27)
	Eastern Mediterranean	9.3% (21)
	Americas	0.4% (1)
	South-East Asia	0.9% (2)
	Western Pacific
Relationship
	No	68.6% (155)
	Yes	31.4% (71)
Having children
	No	47.3% (107)
	Yes, not living with them	36.3% (82)
	Yes, living with them	16.4% (37)
French-language aptitude
	Low	42.5% (96)
	Average	22.6% (51)
	High	35.0% (79)
Highest educational level reached
	Up to primary school	22.1% (50)
	Primary/High school	51.8% (117)
	After High school	26.1% (59)
Administrative status
	French or legal status	51.8% (117)
	Undocumented	48.2% (109)
Health insurance coverage
	None	14.2% (32)
	Yes	85.8% (194)
Duration of stay in France
	<1 year	12.8% (29)
	1 to < 3 years	22.1% (50)
	3 to < 5 years	16.8% (38)
	5 + years	48.2% (109)
Type of centre
	Longer stay shelter	65.5% (148)
	Day/night centre	34.5% (78)
Region of centre
	Lyon	42.5% (96)
	Paris	57.5% (130)
COVID-19 – Trust in official information
	No	46.9% (106)
	Yes	53.1% (120)
COVID-19 - Worries
	None or almost none	34.1% (77)
	Average	7.1% (16)
	Completely or almost completely	58.8% (133)
COVID-19 – Previous COVID-19 infection
	No	82.7% (187)
	Yes	17.3% (39)
COVID-19 – COVID-19 infection among close friends/family
	No	65.9% (149)
	Yes	34.1% (77)
COVID-19 – No. of tests taken
	0	27.0% (61)
	1	27.9% (63)
	2	22.6% (51)
	3	7.5% (17)
	4	5.8% (13)
	5	3.5% (8)
	5+	5.8% (13)
COVID-19 – Perceived sufficiency of information on vaccine
	No	51.8% (117)
	Yes	48.2% (109)
COVID-19 – Vaccine hesitancy
	No
	Hesitant	25.7% (58)
	Reluctant	52.7% (119)
	Refusal	21.7% (49)
COVID-19 – Actual vaccination
	No	100% (226)
	Yes
COVID-19 - Vaccine hesitancy due to ineffectiveness of the vaccine
	Non-hesitant
	No	21.2% (48)
	Do not know	51.3% (116)
	Yes	27.4% (62)
COVID-19 - Vaccine hesitancy due to safety of the vaccine
	Non-hesitant
	No	15.5% (35)
	Do not know	32.3% (73)
	Yes	52.2% (118)
COVID-19 - Vaccine hesitancy due to mistrust in the vaccine
	Non-hesitant
	No	22.1% (50)
	Do not know	22.6% (51)
	Yes	55.3% (125)
COVID-19 - Vaccine hesitancy due to ‘COVID-19 does not exist’
	Non-hesitant
	No	66.8% (151)
	Do not know	16.8% (38)
	Yes	16.4% (37)
COVID-19 - Vaccine hesitancy due to ‘against one’s principles’
	Non-hesitant
	No	81.9% (185)
	Do not know	9.7% (22)
	Yes	8.4% (19)
COVID-19 – No. of motives of vaccine hesitancy
	0	3.1% (7)
	1	8.4% (19)
	2	16.8% (38)
	3	43.4% (98)
	4	21.2% (48)
	5	7.1% (16)
COVID-19 – Knowing how/where to get vaccinated
	No	63.3% (143)
	Yes	36.7% (83)
Perceived health
	Excellent or very good	38.5% (87)
	Good	45.6% (103)
	Deteriorated	15.9% (36)
Chronic disease
	No	56.2% (127)
	Yes	43.8% (99)
Depressive symptoms
	No	66.8% (151)
	Yes	33.2% (75)
Anxious symptoms
	No	67.7% (153)
	Yes	32.3% (73)
Tobacco use (change since last year)
	Non-user	65.3% (98)
	Reduced	7.3% (11)
	Stable	17.3% (26)
	Increased	10.0% (15)
Alcohol consumption (change since last year)
	Non-user	68.9% (102)
	Reduced	11.5% (17)
	Stable	14.2% (21)
	Increased	5.4% (8)
Health literacy – Navigating in the healthcare system
	Low	33.3% (49)
	High	66.7% (98)
Health literacy – Social support
	Low	33.1% (49)
	High	66.9% (99)

Vaccine hesitancy rates were assessed via bivariate analyses in a subsample of complete-cases (n = 372), including nonhesitant respondents. In our sample, 10.3% of participants were vaccinated (1 dose). Amongst participants who showed some degree of unwillingness towards the vaccine (overall 58.0%), 15.6% were hesitant, 31.6% were reluctant and 10.8% were opposed. As shown in Appendix 1, factors for overall vaccine refusal or reluctance, assessed by bivariate analysis in comparison with nonhesitancy, were being a woman (OR = 2.31, CI: 1.38–3.89) and not trusting official information (OR = 4.54, CI:2.73–7.55). Compared with nonhesitancy, no factor was significantly associated with being hesitant to receive the COVID-19 vaccine.

Motivations of COVID-19 vaccine hesitancy

In our sample, approximately two thirds of the participants (71.2%) agreed with 3 or more motives of vaccine hesitancy. A large majority of respondents did not support the motives “COVID-19 does not exist” or “the vaccine goes against my principles” (66.8% and 81.9% respectively). These two motives were therefore excluded from multivariate analyses.

Characteristics associated with the three remaining motives of vaccine hesitancy – regarding the effectiveness, safety and trust towards the COVID-19 vaccine – assessed via multivariate regression models, are shown in Table 2. Risk factors for COVID-19 vaccine hesitancy on the grounds of its ineffectiveness were: being 30–49 (aOR = 3.21, CI: 1.45–7.11) or aged over 50 years old (aOR = 5.81, CI: 1.96–17.26); having low French-language proficiency (aOR = 2.90, CI: 1.19–7.03); having completed primary school (aOR = 3.96, CI: 1.64–9.54) or high school (aOR = 5.53, CI: 1.88–16.30); and not trusting official COVID-19 information (aOR = 2.54, CI: 1.26–5.12). A decreased likelihood of hesitancy regrading this motive was seen among participants suffering from chronic illness (aOR = 0.43, CI: 0.19–0.96).

Risk factors for vaccine hesitancy due to its perceived health hazard were having completed primary school (aOR = 5.03, CI: 1.72–14.75), not trusting official COVID-19 information (aOR = 5.16, CI: 1.94–13.68), and being worried about the pandemic (aOR = 2.98, CI: 1.24–7.18). Having taken one COVID-19 test was associated with a lower hesitancy due to health hazard (aOR = 0.30, CI: 0.10–0.90).

Vaccine hesitancy due to distrust in vaccine information was higher in participants aged over 50 years old (aOR = 6.70, CI:2.16–20.79), who had completed primary school (aOR = 3.21, CI: 1.35–7.65), who had lived in France for 2–4 years (aOR = 2.71, CI: 1.13–6.48), and who did not trust official COVID-19 information (aOR = 2.48, CI:1.22–5.05).In contrast, a lower likelihood of owe one’s hesitancy to this motive was associated with having taken one (aOR = 0.35, CI: 0.13–0.93) or two or more COVID-19 tests (aOR = 0.39, CI: 0.15–0.99).

Table 2

Characteristics associated with motives for COVID-19 vaccine hesitancy, ECHO study, France, Spring 2021 (n = 282; multivariate logistic regression models, OR, 95% CI).
		Vaccine hesitancy due to ineffectiveness of the vaccine	Vaccine hesitancy due to health hazard associated with the vaccine		Vaccine hesitancy due to distrust in vaccine information
		Yes / Do not know*	Yes / Do not know*		Yes / Do not know*
Sex
	Man	[Ref]		[Ref]		[Ref]
	Woman	0.65[0.33;1.28]		1.45[0.58;3.60]		0.61[0.30;1.23]
Age
	18–29 years	[Ref]		[Ref]		[Ref]
	30–49 years	3.21[1.45;7.11]		1.18[0.41;3.42]		1.94[0.89;4.23]
	50 + years	5.81[1.96;17.26]		2.87[0.72;11.35]		6.70[2.16;20.79]
Relationship
	No	[Ref]		[Ref]		[Ref]
	Yes	0.66[0.31;1.38]		1.32[0.49;3.54]		0.79[0.36;1.75]
French-language aptitude
	Low	2.90[1.19;7.03]		1.03[0.32;3.27]		0.82[0.34;1.95]
	Medium	2.23[0.87;5.73]		0.39[0.13;1.18]		1.04[0.41;2.67]
	High	[Ref]		[Ref]		[Ref]
Highest educational level reached
	Up to primary school	[Ref]		[Ref]		[Ref]
	Primary/high school	3.96[1.64;9.54]		5.03[1.72;14.75]		3.21[1.35;7.65]
	After high school	5.53[1.88;16.30]		2.48[0.75;8.27]		1.44[0.53;3.88]
Administrative status
	French or legal status	[Ref]		[Ref]		[Ref]
	Undocumented	0.67[0.35;1.29]		0.54[0.24;1.23]		1.25[0.65;2.39]
Duration of residence in France
	< 2 years	1.26[0.49;3.20]		2.07[0.61;7.01]		2.32[0.90;5.99]
	2 to 4 years	1.73[0.74;4.06]		2.69[0.88;8.22]		2.71[1.13;6.48]
	5 + years or born in France	[Ref]		[Ref]		[Ref]
COVID-19 – Trust in official information
	No	2.54[1.26;5.12]		5.16[1.94;13.68]		2.48[1.22;5.05]
	Yes	[Ref]		[Ref]		[Ref]
COVID-19 - Worry
	Low	[Ref]		[Ref]		[Ref]
	Medium/high	0.91[0.46;1.82]		2.98[1.24;7.18]		0.91[0.45;1.82]
COVID-19 – Infection along close friends/family
	No	[Ref]		[Ref]		[Ref]
	Yes	1.31[0.64;2.68]		1.66[0.67;4.14]		1.12[0.55;2.26]
COVID-19 – No. of tests taken
	None	[Ref]		[Ref]		[Ref]
	1	0.71[0.28;1.77]		0.30[0.10;0.90]		0.35[0.13;0.93]
	2+	0.66[0.28;1.58]		1.03[0.33;3.24]		0.39[0.15;0.99]
COVID-19 – Perceived sufficiency of vaccine information
	No	0.53[0.26;1.07]		1.20[0.51;2.85]		0.83[0.41;1.66]
	Yes	[Ref]		[Ref]		[Ref]
COVID-19 – Know where/how to get vaccinated
	No	[Ref]		[Ref]		[Ref]
	Yes	1.28[0.62;2.68]		2.03[0.80;5.15]		1.65[0.78;3.47]
Perceived health status
	Very good or excellent	[Ref]		[Ref]		[Ref]
	Good	1.10[0.51;2.40]		2.72[0.98;7.59]		1.31[0.59;2.88]
	Bad	0.45[0.16;1.31]		0.61[0.16;2.31]		0.49[0.17;1.37]
Chronic illness
	No	[Ref]		[Ref]		[Ref]
	Yes	0.43[0.19;0.96]		0.59[0.21;1.64]		0.63[0.29;1.39]
Symptoms of depression
	No	[Ref]		[Ref]		[Ref]
	Yes	1.20[0.54;2.68]		1.39[0.48;4.05]		1.55[0.69;3.47]
Symptoms of anxiety
	No	[Ref]		[Ref]		[Ref]
	Yes	1.60[0.71;3.58]		2.39[0.78;7.31]		0.89[0.41;1.95]
*Participants who agreed with or did not know about each statement were considered vaccine hesitant for that particular motive.

Qualitative results

Thirty participants were interviewed in Lyon (n = 6) and Paris (n = 24). More than half of the participants (n = 16) had experienced homelessness at some point since the first COVID-19 related lockdown (March 2020). Twelve participants were sleeping roughly at the time of the interview, without formal or informal (friends/family) shelter. The majority of interviews were conducted in French (n = 21), and the average duration was 28 minutes. Participants were mainly male (n = 24), single (n = 26), without children (n = 20), born abroad (n = 25) and unemployed (n = 28). The median age was 38 years old (ranging from 20 to 75 years). Among foreign-born participants, 44% (n = 11) had arrived in France in the preceding five years, and 28% (n = 7) had arrived in the last 6–10 years. More than half of the participants (n = 16) did not have a residence permit. Twelve were vaccinated at the time of the interview.

Through thematic content analysis four themes were identified: 1) Purpose of the vaccine - knowledge, uncertainties and doubts, 2) Attitudes and influences surrounding vaccination, 3) Fears and hopes, and 4) Trust in authorities.

Purpose of the vaccine - knowledge, uncertainties and doubts

Participants reported what they knew and believed about vaccines, both in general and specific to COVID-19. The general principle of vaccination was often perceived as a medicine or treatment for a given disease, not as a preventative tool.

The vaccine... it's the medicine, isn't it? It's the medicine to fight the virus, right?

Man, 40–49 years old, immigrant from Sub-Saharan Africa, translated from Portuguese.

The different types of COVID-19 vaccines were not very well known by the study participants. The majority of respondents reported mistrust or worries about COVID-19 vaccines due to the perception that the vaccines were developed hastily, when compared to former existing vaccines against other diseases.

But I'm scared because here, the time it took unlike other vaccines which really took a lot more years. It's scary.

Woman, < 30 years old, immigrant from Sub-Saharan Africa, translated from French.

Notably, participants reported a lack of knowledge when questioned about vaccines, often associated with a feeling of being indifferent towards vaccines, a lack of interest, or a feeling of not being entitled to have an opinion. This lack of knowledge is associated with homelessness.

I don't know about public health in France. I am a foreigner. I'm not too aware of all that. For a start, I am homeless.

Man, 30–39 years old, immigrant from Europe, translated from French.

Attitudes and influences towards vaccination

Participants reported their attitudes regarding vaccination towards themselves and towards their inner circle, along with the attitudes of their relatives towards themselves. Nearly half of the respondents (n = 14) were reluctant to be vaccinated. Some respondents expounded their willingness to be vaccinated to protect their relatives.

In my inner circle, there are nevertheless people who have fragile health. I would vaccinate myself more to protect them.

Woman, < 30 years old, immigrant from Sub-Saharan Africa, translated from French.

The perceived social norm regarding vaccination influenced participants to get vaccinated or not. In this regard, most participants (n = 24) reported the attitude of their inner circle having various degrees of influence on their willingness to get vaccinated.

I only know people who are against it. And it's true, we deal with this subject extensively, we talk a lot about vaccines. I have not met a single friend who wants to be vaccinated.

Man, 40–49 years old, immigrant from Europe, translated from Polish.

For some, their relatives even directly recommended that they get vaccinated, this personal advice being received with trust.

I don't like getting vaccinated. It was my friend who advised me. It was a friend who motivated me to do it: ‘Get a vaccine, it will be fine.’ If it wasn’t her, me, never. She was the one who told me, get your shot. If I get vaccinated, I mustn't get vaccinated against that. ‘Get vaccinated with that!’ This is what I'm gonna do.

Man, < 30 years old, immigrant from Sub-Saharan Africa, translated from French.

Fears and hopes

Almost half of the participants (n = 12) expressed concerns and fears about the COVID-19 vaccination. Potential side effects and risk of death were mentioned by many. To a lesser degree some respondents also reported beliefs in conspiracies around the vaccine or the pandemic in general.

But now they want to do a ‘spring cleaning’ with the vaccine, ‘spring cleaning’. Many people die. There is a lot of people dying out there.

Man, < 30 years old, French, translated from French.

[The COVID-19 vaccine], it's for making money and killing people.

Man, 30–39 years old, French, translated from French.

Approximately one-third of participants (n = 9) discussed the potential for compulsory COVID-19 vaccination. Most of them reported that while they would not get vaccinated spontaneously, they would comply if compulsory. They also reported a willingness to get vaccinated for non-health related motives, in instances where a vaccination pass would be necessary to resume social activities (e.g. travelling, going to pools, museums, and theatres).

For example, to go to the cinema. If we are forced to have a vaccination pass, I would get vaccinated, I really like the cinema.

Man, < 30 years old, French, translated from French.

Motivations towards COVID-19 vaccination were also associated with hope for several participants (n = 9). The vaccine was seen as a means to return to one's life before the pandemic, or at least an opportunity to relinquish preventative measures (e.g. wearing masks, using hydroalcoholic gel and physical distancing).

I wish that the virus was eradicated, to find a vaccine, which can really put an end to this virus. I don't know like that, at least we'll get our lives back.

Woman, < 30 years old, immigrant from Sub-Saharan Africa, translated from French.

For some respondents the vaccine was seen as a tool or weapon against the pandemic:

It's a very good thing. It is a chance. It is a chance among all the chances. To be vaccinated is to be armed against COVID. Armed even more, we were already armed, but here we really have the weapon we need.

Man, 40–49 years old, French, translated from French.

A few respondents also referred to the vaccine as a definitive solution to the health crisis, expressing great enthusiasm and sometimes presenting it as a dream or utopia.

Well the future... that everyone is vaccinated, that everyone has their immunity so that we can be free from all this.

Man, 40–49 years old, immigrant from Sub-Saharan Africa, translated from Portuguese.

Trust in authorities

A large majority of the interviewees (n = 20) spoke about whether they trusted those who were perceived to be a form of authority during the pandemic, specifically: government representatives, policymakers, healthcare practitioners, or scientists. In particular, participants seemed to be very receptive to their general practitioner. Even when their knowledge of the vaccines was limited, they respected their doctor’s advice without question. Trust in the opinions of scientists was also frequently reported.

You have to go to your doctor, if your doctor says "take this one", I think you need to take this one.

Man, 40–49 years old, immigrant from Sub-Saharan Africa, translated from Portuguese.

With regard to participants’ trust in the government’s ability to handle the pandemic, opinions were divided. This trust was reported generically, and was not specific to the COVID-19 vaccine. Some believed that the government was doing its best to manage the sanitary crisis, while others believed that the political authorities were unable to handle the problem. Feelings towards the government ranged from doubts to more acute forms of distrust.

I don't really know who to trust because it's something big, it's bold. Saying that the government manages, no, the government does not manage [the pandemic].

Man, 30–39 years old, French, translated from French.

Table 3 presents the key results emerging from both quantitative and qualitative analyses on the three main motives of COVID-19 vaccine hesitancy. The quantitative findings for the effectiveness and safety motives of hesitancy were expanded meaningfully in the qualitative data, where interviewees described their views and attitudes towards the vaccine, as well as fears about the potential hazard of the vaccine, or strong hopes that the vaccine would release them from the burden of the pandemic. Both the quantitative and qualitative results show that trust as a motive of hesitancy is a key issue in the acceptance of the vaccine. The findings relating to trust were expanded upon by the interview data, where participants described having differential trust depending on who is recommending the vaccination.

Table 3

Motives of COVID-19 vaccine hesitancy, ECHO study, France, Spring 2021, quantitative and qualitative juxtaposed findings.
Declared motives of COVID-19 vaccine hesitancy	Quantitative investigation (n = 282)		Qualitative investigation (n = 30)
	Factors of elevated hesitancy	Factors of reduced hesitancy	(Themes and description)
"It’s an ineffective measure against COVID-19"	- aged 30 + years - lower French language aptitude - schooling above primary school - distrust in official information	- having a chronic disease	Purpose of the vaccine Respondents recognized a lack of knowledge, partly due to a perception that it is not their concern Vaccine perceived as a treatment Attitudes and influences Willingness to get vaccinated to protect one’s relatives, or when vaccination was perceived as the social norm Fears & hopes COVID-19 vaccine seen as a mean to return to pre-pandemic life, a release from preventative measures (e.g. wearing a mask) or a somewhat magical solution to the pandemic Conspiracy theories contributing to hesitancy (e.g. vaccine as a “spring-cleaning” to kill and control the population)
"It's dangerous for my health"	- aged 50 + years - schooling after middle school and before the end of high school - distrust in official information - an elevated feeling of worry about COVID-19	- having undertaken one COVID-19 test
"I don't trust the information about the vaccine"	- aged 50 + years - schooling after middle school and before the end of high school - having resided in France between 2–5 years - distrust in official information	- having undertaken one or more COVID-19 tests	Trust in authorities Trust expressed in doctors and scientists but doubts or distrust towards the government Purpose of the vaccine Mistrust towards the vaccine as its development was perceived as being too quick

This mixed methods study provides a comprehensive understanding of COVID-19 vaccine hesitancy among persons with unstable housing in France in Spring 2021. Our study found vaccine hesitancy to be at an elevated rate (58.0%); additionally, we found that the motives behind vaccine hesitancy are associated with distinct respondent profiles. The themes that emerged from the qualitative investigation, confirmed and expanded upon the quantitative findings, providing a better understanding of the respondents’ feelings, beliefs and attitudes towards the COVID-19 vaccine, in particular about trust in the vaccine and the different authorities, as well as hopes in the vaccine to get released of the pandemic burden and get back to the pre-pandemic life.

Distrust towards COVID-19 vaccine information was one of the main motives of vaccine hesitancy. Respondents who cited this as a personal motive tended to be older (50 + years), had an intermediate level of education (after middle school but before the end of high school) and had resided in France between 2 and 5 years. This distrust in vaccine information was also associated with a more general cynicism towards official information. Our qualitative investigation complemented the understanding of this feeling of distrust. Whilst respondents explained the doubts they felt towards government information, they retained confidence in their doctors or the scientific community. The general distrust in official information was a shared factor of vaccine hesitancy for both other motives (effectiveness and safety of the vaccine). Factors associated with a higher hesitancy due to the feeling of vaccine ineffectiveness were being aged over 30 years old, lower French language aptitude, and an education above primary school level. Being affected by a chronic disease was associated with a decreased hesitancy for this motive. Vaccine hesitancy on the basis of questions regarding vaccine safety was more common among respondents aged over 50 years, with an intermediate level of education, and an elevated feeling of worry about COVID-19. Qualitative data regarding these two motives for hesitancy – vaccine ineffectiveness and safety – were common. A perceived lack of personal knowledge regarding the vaccine, as well as a misperception regarding the purpose of the vaccine, may constitute part of this hesitancy to vaccinate oneself. Nevertheless, respondents were considering getting vaccinated, either if most of their entourage was vaccinated, or as a way to protect others. Finally, perceiving the COVID-19 vaccine as a definitive solution, either to return to a pre-pandemic life or to be released from the burden of safety measures, appeared to influence participants’ intentions to get vaccinated.

Strengths and limitations

This study provided unique insight into the motives of COVID-19 vaccine hesitancy in a marginalised population that is rarely studied and often underrepresented in general population surveys (39). Furthermore, many studies among homeless persons or ethnic minorities have investigated only the rates of COVID-19 vaccine hesitancy, regardless of the underlying motives (11–13, 16, 17, 20). The mixed-methods design allowed us to quantitatively assess factors associated with three motives of COVID-19 vaccine hesitancy while providing useful additional context from the qualitative component. Nonetheless, our study does not come without limitations. First, the nonprobabilistic quantitative sample is unlikely to be nationally representative of the populations in unstable housing situations. However, the use of translation services made it possible to include non-French speakers, thereby enriching the study with a wider set of profiles. Another important limitation is the period of data collection. During the first part of the quantitative study, the vaccine was not readily available to all the participants. Vaccine hesitancy might have therefore been overestimated, since overall vaccine hesitancy in the French general population decreased during the period under study (40, 41). Finally, due to the cross-sectional nature of our data, and the limited representativity of the ECHO study sample, the comparison of hesitancy rates with earlier data from the ECHO study is rather limited.

Comparison with body of evidence

Studies on COVID-19 vaccination in marginalized groups – including migrant and homeless persons – were scarce at the time of our study, as most of those now published were conducted during the same period. The overall COVID-19 vaccine hesitancy measured in this study was 17 points of percentage higher than that assessed one year earlier in the first wave of the ECHO study (58.0% vs. 40.9%, respectively) (8). This trend opposes that observed within the general population, where those not willing to get vaccinated represented about 40% at the end of 2020, compared to 25% in May 2021 (41). Furthermore, in July 2021, when the COVID-19 vaccine was available for the whole adult population, only 16% of the general population remained vaccine hesitant. Motives of hesitancy concerned the vaccine’s safety (77%), inefficacy of the vaccine to limit the spread of the virus (40%), and one’s preference for other preventative measures (38%) (42). Within our study, women expressed higher levels of refusal or reluctance towards COVID-19 vaccination (OR = 2.31, CI: 1.38–3.89). This is in line with findings described by Heyerdahl et al. (43), who observed that French women exhibited the highest COVID-19 vaccine hesitancy when compared to their European counterparts. Vaccine safety and mistrust of the authorities were again the most commonly reported motives of hesitancy.

One of the main findings from this study is the importance of trust in different authorities and the information surrounding COVID-19; which is in line with the current evidence on the role of trust barriers in COVID-19 vaccine acceptability (44). Our results showed the influential role of general practitioners’ recommendation to get vaccinated, as previously demonstrated in the literature for other vaccines. For instance, Charron et al. confirmed the primary role of the healthcare professional on one’s decision to be vaccinated (45). They also highlighted the need for quality information about vaccination on the internet, as those who get information through these sources appeared more likely to be vaccine hesitant. More specifically, for COVID-19, doctors’ recommendations to get vaccinated are also reported to positively influence the uptake of the COVID-19 vaccine (46). This study also confirmed that knowledge that the vaccine is safe and effective for oneself and for others contributes to vaccination uptake in the general population. The influence of the general practitioner (GP) on vaccine uptake was studied in France in July 2020 (ahead of vaccine accessibility), and showed no association between vaccination refusal and recommendation of vaccination by the GP (47). The authors hypothesised that the effect of the GP’s recommendation was probably attenuated by the increased vaccine hesitancy associated with mass vaccination centres compared with vaccination at GP practice (48).

From a research perspective, this study provides valuable insight into specific motives for COVID-19 vaccine hesitancy in specific marginalized groups. However, now in an advanced phase of the pandemic, with decreasing hospitalisation rates in France (source: data.gouv.fr) as in most European countries, updated figures of the groups still currently unvaccinated would be of major public health interest.

It has been shown that marginalized populations have been disproportionately impacted by the pandemic and related public health measures (e.g. lockdown) (38). It is therefore important to address further inequalities regarding COVID-19 vaccine uptake. Our results suggest that adherence to the COVID-19 vaccine could be improved for these groups, as they were not specifically targeted by the vaccine roll-out. The elevated vaccine hesitancy observed in our sample might be associated with the digitalisation of primary care services during the pandemic, which was shown by Knights et al. (23) to amplify disparities in access to healthcare among specific migrant groups. Furthermore, one’s chosen information source can potentially influence hesitancy towards the vaccine. In this regard, Mascherini and Nivakoski (49) demonstrated that heavy use of social media and using social media as a main source of news are significant factors (p < 0.05) of elevated COVID-19 vaccine hesitancy in European populations. Compared to traditional news sources (press/radio/TV), the likelihood of being vaccine hesitant is 20 percentage points higher among people who use social media as their main source of information (p < 0.01).

In addition, trust towards doctors or scientists – despite distrust towards government information, both in general and specific to the COVID-19 vaccine – should be taken into consideration while developing vaccine uptake interventions for these populations. The role of trust in vaccine hesitancy has been highlighted in the 3Cs model (Complacency, Convenience and Confidence model), which provides a framework for national intervention (24). This model highlights the point that vaccine hesitancy is complex and not driven by a simple set of individual factors. In this regard, we found ‘confidence’ to consist of trust in vaccine effectiveness and safety, the reliability of health services and health professionals, and the motivations of policymakers. Rather than general population-wide campaigns, targeted promotion of vaccination for marginalized population groups through the healthcare professionals or social workers they are in contact with might be an effective route of intervention. Empowering healthcare and social professionals, e.g. in one’s shelter, could also be a realistic alternative to address the misperceptions or lack of knowledge reported by our study respondents. To address health inequalities regarding vaccine hesitancy and uptake, COVID-19 vaccine distribution in shelters and day centres should be implemented in a culturally sensitive manner (50).

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations. The study protocol was approved by the Ethical Research Committee of the University of Paris (CER-2020-41). Informed consent was obtained from all subjects: written consent was obtained for participation in the quantitative part of the study, while oral consent was recorded prior to the qualitative interviews.

Consent for publication

Not applicable.

Availability of Data or Materials (ADM)

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This work was supported by the French National Research Agency (ANR, grant no. ANR-20-COV9-0005-01, project ECHO) and the European Commission Horizon 2020 H2020-SC1-PHE-CORONAVIRUS-2020-2 call (project PERISCOPE, grant no. 101016233).

Authors' contributions

S.D., N.F. and C.D. contributed to the design of the study, data collection, data analysis and interpretation, and drafting of the manuscript; S.D. and M.M. conceptualized and coordinated the study. All authors read and approved the final manuscript.

Acknowledgements

Firstly, we would like to thank the participants who agreed to take part in this study. We also thank the non-governmental organisations involved in this study: Médecins du Monde, Habitat et Humanisme, Aurore, the French Red-Cross, Empreintes, Groupe SOS, La Rose des vents, SIAO 67, and their managers, social workers and volunteers for their kind participation. We thank Laure Courret and Julie Ziegelmeyer from Médecins du Monde, who contributed to the preparation and implementation of the survey in Lyon. We also thank in particular Stéphanie Nguengang Wakap, head of Pôle Recherche et Apprentissages, Doctors of the World, for her feedback on the study questionnaire; and Julie Ziegelmeyer and Laure Courret, Doctors of the World, for their contribution to the development and implementation of the study. Finally, thank you to each of the members of the ECHO team.

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Motives for COVID-19 vaccine hesitancy amongst marginalized groups, including homeless persons and migrants, in France: a mixed-methods study.

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Abstract

Figures

Introduction

Methods

Study design

Quantitative data collection and analysis

Qualitative data collection and analysis

Results

Quantitative results

Motivations of COVID-19 vaccine hesitancy

Qualitative results

Purpose of the vaccine - knowledge, uncertainties and doubts

Attitudes and influences towards vaccination

Fears and hopes

Trust in authorities

Discussion

Strengths and limitations

Comparison with body of evidence

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

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