# Vaccine hesitancy among migrant populations in Europe: A mixed-methods systematic review

Erika Khuu, Sohela Moussaoui, Nicolas Vignier, Kim Bonello, Elise Archer

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Erika Khuu, Sohela Moussaoui, Nicolas Vignier, Kim Bonello, Elise Archer. Vaccine hesitancy among migrant populations in Europe: A mixed-methods systematic review. Vaccine, 2025, 68, 10.1016/j.vaccine.2025.127954. hal-05354621

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Review

# Vaccine hesitancy among migrant populations in Europe: A mixed-methods systematic review

<figure><img src="image_2.png" /></figure>

Erika Khuu<sup>a,*</sup>, Sohela Moussaoui<sup>a,b</sup>, Nicolas Vignier<sup>c,d,e</sup>, Kim Bonello<sup>a,1</sup>, Elise Archer<sup>a,1</sup>

ARTICLE INFO

Keywords:

Acculturation

Emigrants and immigrants

Immunization

Migrant health

Transients and migrants

Vaccination refusal

A B S T R A C T

**Objectives:** Among migrants, vaccine uptake is influenced by various factors including interrupted vaccination in origin countries, divergent schedules, and marginalization within host systems. Vaccine hesitancy is shaped by cultural, structural, and experiential factors that differ from native-born populations. This systematic review aims to synthesize qualitative and quantitative evidence on vaccine hesitancy among migrant populations in Europe.

**Methods:** Eight databases (PubMed/MEDLINE, PsycINFO, EMBASE, Scopus, CINAHL, Web of Science, ERIC, and Cochrane Library) were searched for primary studies published in English or French between January 2000 and December 2024. References from relevant non-primary studies were hand-searched. This review followed the Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews. Eligible studies explored vaccine attitudes among migrant populations in Europe. The quality of included studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Data extraction used JBI's Mixed Methods Data Extraction Form, and synthesis followed a convergent integrated approach.

**Results:** Forty-six studies were included (20 qualitative and 26 quantitative), most conducted in Western or Northern Europe and examining diverse migrant populations including legal and undocumented individuals. Evidence was synthesized under seven integrated findings: (1) acculturation, (2) distrust in authorities, (3) health literacy, (4) informal information networks, (5) sociocultural determinants, (6) sociodemographic characteristics and (7) vaccine-specific perceptions. No studies were excluded based on quality, but MMAT scores informed interpretation.

**Conclusion:** Vaccine hesitancy among migrants in Europe reflects the interplay of origin-country beliefs, host-society norms, and migration-related vulnerabilities, reinforced by gendered constraints, limited health literacy, informal information networks, and persistent institutional mistrust. Addressing these determinants requires culturally responsive, participatory interventions co-designed with migrant communities, tailored to health literacy needs, and attentive to institutional mistrust and gendered constraints. Further research should examine underrepresented groups, the interaction of gender, migration, and trust, and evolving attitudes across generations to guide sustainable confidence-building strategies.

# 1. Introduction

Vaccine hesitancy, defined by the Strategic Advisory Group of Experts on Immunization as the delay in acceptance or the refusal of

vaccines despite their availability [1], has been identified as one of the ten most significant global health threats [2]. Between 2016 and 2019, reported measles cases in Europe increased by 2282 %, reaching over 100,000 cases in 2019. This marked the highest number recorded in

<footnote><sup>a</sup> Sorbonne Université, Faculty of Medicine, Department of Education and Research in General Practice, F75012 Paris, France</footnote>

<footnote><sup>b</sup> Institute for Research and Information in Health Economics (IRDES), 21 rue des Ardennes, 75019 Paris, France</footnote>

<footnote><sup>c</sup> Infection, Antimicrobiens, Modélisation, Evolution, IAME, INSERM, UMR 1137, Paris, France</footnote>

<footnote><sup>d</sup> Université Sorbonne Paris Nord, Hôpital Avicenne, Hôpitaux universitaires Paris Seine-Saint-Denis, AP-HP, Department of Infectious and Tropical Diseases, Bobigny, France</footnote>

<footnote><sup>e</sup> French collaborative Institute on Migration, Institut Convergences Migrations, ICM, 93322 Aubervilliers, France</footnote>

<footnote>Abbreviations: JBI, Joanna Briggs Institute; MMAT, Mixed Methods Appraisal Tool.</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: erika.khuu@etu.sorbonne-universite.fr (E. Khuu).</footnote>

<footnote n="1">¹ Both authors contributed equally to this work.</footnote>
more than 25 years, with Ukraine alone accounting for more than 56,000 cases. This resurgence has been linked to declining vaccine uptake, with vaccine hesitancy undermining herd immunity and enabling measles transmission in areas where it had previously been eliminated. Growing distrust in immunization has made it increasingly difficult to sustain the 95 % coverage required for effective population protection [3,4].

According to the International Organization for Migration (IOM), migrants are individuals who move across international borders or within a country, away from their usual place of residence [5]. Migrants experience health challenges that are shaped by cultural, structural, and experiential factors distinct from those of native-born populations. These differences contribute to persistent disparities in health outcomes and access to care [6]. Consequently, migrants are disproportionately affected by vaccine-preventable diseases (VPDs), including measles and diphtheria [7], largely due to underimmunization stemming from disrupted vaccine access, differing schedules in countries of origin, and legal or logistical barriers in host countries [8]. Beyond these access-related barriers, vaccine hesitancy further undermines immunization uptake. Shaped by both systemic and attitudinal factors, vaccine hesitancy poses a critical challenge to the effectiveness of vaccination programs, and understanding its specific drivers is essential for the development of targeted, equity-oriented public health interventions.

A preliminary search conducted in May 2024 across eight databases (PubMed/MEDLINE, PsycINFO, EMBASE, Scopus, CINAHL, Web of Science, ERIC, and the Cochrane Library) did not identify any mixed-methods systematic reviews focused specifically on vaccine hesitancy among migrants in Europe. Crawshaw et al. (2022) explored underimmunization through uptake rather than hesitancy, following the 5As framework (access, affordability, awareness, acceptance, and activation) [9]. In contrast, the present review employs an inductive approach and focuses on the drivers of vaccine hesitancy, integrating qualitative and quantitative evidence while excluding access-related barriers.

The objective of this review is to identify and synthesize the determinants underlying vaccine hesitancy among migrants in Europe.

## 2. Methods

We conducted a mixed-methods systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [10]. The protocol was prospectively registered in PROSPERO (CRD420250517028) [11].

### 2.1. Search strategy

A search strategy combining MeSH and free-text terms related to vaccination, migrants, and Europe was developed following a scoping search in PubMed/MEDLINE and refined with input from a medical librarian. The final strategy was adapted for seven additional databases (PsycINFO, EMBASE, Scopus, CINAHL, Web of Science, ERIC, and the Cochrane Library) and extended to Google Scholar to identify grey literature. Searches were restricted to English and French publications from January 2000 to December 2024. References of included studies and relevant non-primary publications were also screened. Full search strategies are provided in **Appendix A**.

### 2.2. Study eligibility and selection criteria

Records were managed in Rayyan [12], and deduplicated. Titles and abstracts, then full texts were screened in duplicate against eligibility criteria (Table 1), with third-reviewer adjudication of conflicts. Reasons for full-text exclusions are detailed in **Appendix B**.

### 2.3. Data extraction

One reviewer (EK) extracted qualitative and quantitative data using

<table><caption>**Table 1**
Summary of eligibility criteria.</caption><thead><tr><th></th><th>Inclusion</th><th>Exclusion</th></tr></thead><tbody><tr><td>Participants</td><td>Migrants, as defined by the United Nations, regardless of age, legal status (e.g., refugees, asylum seekers, undocumented migrants), or country of origin. Healthcare workers (including physicians, nurses, public health staff, and community health workers) providing care to migrants.</td><td>Studies focused exclusively on ethnic minorities with no clear reporting of migration background.</td></tr><tr><td>Studies</td><td>Primary research studies using quantitative (e.g., cross-sectional, longitudinal), qualitative, or mixed methods designs. Published between January 2000 and December 2024. Published in English or French.</td><td>Studies limited to second-generation migrants.</td></tr><tr><td>Outcomes</td><td>Studies examining vaccine-related beliefs, knowledge, confidence, acceptance, hesitancy, attitudes, or uptake with subgroup analyses within migrant populations.</td><td>Non-primary sources (i.e., secondary sources such as reviews, commentaries, or other articles summarizing primary research). Studies for which full-text was unavailable. Studies conducted outside the WHO European Region. Studies not reporting outcomes related to vaccine beliefs, knowledge, confidence, acceptance, hesitancy, or attitudes.</td></tr><tr><td></td><td></td><td>Studies comparing vaccine uptake between migrants and native populations without subgroup analysis within migrant populations.</td></tr></tbody></table>

the JBI Mixed Methods Data Extraction Form for Convergent Integrated Reviews [13] with a second reviewer (SM) verifying all entries. Extracted fields included author, year, study design, population, setting, phenomena of interest, relevant findings, and author conclusions. Qualitative data comprised reported themes and supporting quotations, while quantitative data included numerical results, measures of association, and corresponding author interpretations. Data were extracted verbatim where possible, and disagreements were resolved by consensus or third-reviewer adjudication (EA).

### 2.4. Data transformation

Quantitative data were transformed into qualitized findings following Lizarondo et al. (2025) [14], converting numerical results and author interpretations into descriptive text. When available, both numeric values and accompanying narrative were extracted verbatim. If narrative was insufficient, additional contextual information was added. In the absence of interpretation, reviewers generated descriptive summaries from reported data.

### 2.5. Data synthesis

Data were integrated inductively following JBI's convergent integrated approach [15]. Qualitative findings and qualitized quantitative data were coded line by line and grouped by similarity of meaning into categories, which were then synthesized into integrated findings addressing the review question. This inductive process, rather than deductive mapping onto existing conceptual frameworks, allowed themes to emerge directly from the data. Disagreements were resolved by consensus or third-reviewer adjudication.

### 2.6. Methodological quality assessment

All studies were appraised with the MMAT [16]. One reviewer (EK) conducted the appraisal, a second (SM) checked all ratings, and disagreements were resolved by consensus or third-reviewer adjudication
(EA). Each criterion was rated ‘Yes,’ ‘No,’ or ‘Cannot tell.’ Studies were not excluded based on methodological quality to capture the full range of evidence and avoid overlooking perspectives that could inform future research. MMAT results guided cautious interpretation in the context of higher-quality evidence.

## 3. Results

We identified 350 records via databases. 47 duplicates were removed before screening, leaving 303 records screened, of which 225 were excluded. Twelve additional reports were identified by other methods (citation searching, *n* = 10; websites, *n* = 2). In total, 90 full-text reports were retrieved and assessed for eligibility (Fig. 1).

A total of 46 studies were included. Quantitative designs predominated (*n* = 26), comprising non-randomized observational studies (*n* = 24) and descriptive cross-sectional surveys (*n* = 2). Twenty studies used qualitative methods, primarily semi-structured interviews (*n* = 15) and focus groups (*n* = 5); one study used open-ended interviews and another combined interviews and focus groups. All studies underwent MMAT appraisal, with results reported in **Appendix C**.

Studies were conducted in 13 countries, plus one multi-country analysis. Most originated from the United Kingdom (*n* = 13), followed by Norway (*n* = 6), Sweden (*n* = 6), Germany (*n* = 4), Italy (*n* = 4), Denmark (*n* = 2), France (*n* = 2), the Netherlands (*n* = 2), and Poland (*n* = 2). Single studies came from Austria, Belgium, Finland, and Portugal. The multi-country study drew on data from Switzerland, Italy, and France; data from the United States (US) available in the source dataset were excluded. Quantitative data sources included surveys conducted in settings such as clinics, shelters, schools, and online, as well as registries, including national vaccination and health registries. Qualitative data were obtained in person or remotely within diverse community and healthcare environments.

Among the included studies, 35 focused on specific vaccines or diseases (including COVID-19, human papillomavirus [HPV], measles,

mumps and rubella [MMR], and influenza), while 11 examined routine vaccination or vaccination in general. The phenomena of interest included vaccine-related beliefs, knowledge, attitudes and uptake. Seventeen studies reported differences in uptake across migrant subgroups, which were interpreted as proxies for underlying drivers of hesitancy. Characteristics of included studies are summarized in Table 2.

### 3.1. Acculturation determinants

Acculturation refers to how migrants adapt to their host country while maintaining ties to their country of origin. In public health research, it is often operationalized by length of stay in the host country [17].

Lower acculturation was linked to incomplete childhood vaccination in Germany [18] and to less favorable COVID-19 vaccine attitudes in Norway, mediated by lower healthcare system trust [19]. Residence duration showed mixed effects: shorter residence predicted lower uptake in Finland [20], Denmark [21] and among migrants from low-coverage countries in Norway [22] whereas in France, longer residence predicted less favorable attitudes [23].

Evidence also covered acculturation-related behaviors. Vaccine-refusing Polish residents in Scotland more often used Polish-language media than those using English-language sources [24]. Unfamiliar vaccination schedules and procedures contributed to confusion and skepticism among Polish migrants in Norway [25] and Romanian migrants in England [26]. Transnational information flows reinforced hesitancy through origin-country narratives [27,28].

### 3.2. Distrust in authorities

Distrust in authorities refers to skepticism toward the spectrum of actors involved in vaccination and care delivery.

Suspicions of ulterior motives among governmental and public health actors [29–31] included profiteering [32], surveillance [29], and

<figure><img src="image_3.png" /><figcaption>**Fig. 1.** PRISMA 2020 Flow diagram [10].</figcaption></figure>
<table><caption>**Table 2**

Characteristics of included studies.</caption><thead><tr><th>First author (year)</th><th>Country</th><th>Vaccine(s)</th><th>Phenomenon of interest</th><th>Study Population</th><th>Sample size (N)</th></tr></thead><tbody><tr><td colspan="6"><strong>Quantitative Studies</strong></td></tr><tr><td>Aktürk (2021)</td><td>Germany</td><td>COVID-19</td><td>Knowledge, attitudes, behaviors, and COVID-19 vaccine hesitancy among people with migratory backgrounds</td><td>Turkish- and German-speaking patients of Turkish-speaking family doctors in Munich</td><td>420 (migrants n = 348)</td></tr><tr><td>Bastola (2023)</td><td>Finland</td><td>COVID-19</td><td>Incidence of SARS-CoV-2 infection, COVID-19 vaccine uptake, and factors associated with complete vaccine uptake among persons of migrant origin</td><td>Adults aged 18–64 years, foreign-born with both parents also foreign-born, living in mainland Finland, from seven regional origin groups</td><td>13,223 – FinMonik register-based sample (main analysis)<br>3668 – MigCOVID survey sub-sample (extended analyses)<br>N = 922 in 2016; N = 917 in 2017</td></tr><tr><td>Bielecki (2019)</td><td>Scotland</td><td>Influenza</td><td>Uptake of nasal influenza vaccine, consent form return, and declination rates by ethnicity</td><td>Primary school pupils aged 5–12 years in three Edinburgh schools with high proportions of Polish and other ethnic minority pupils</td><td>- Polish (n = 387 in 2016; n = 372 in 2017)<br>- Other identified ethnic minority (n = 171 in 2016; n = 192 in 2017)</td></tr><tr><td>Bielecki (2020)</td><td>Scotland</td><td>Influenza</td><td>Impact of a Polish-language influenza information pamphlet and role of social media in parental decision-making on vaccine uptake</td><td>Primary school pupils (years 1–7) in Edinburgh pilot and control schools, with analysis by ethnicity (Polish, UK, Other Identified Ethnic Minorities)</td><td>Pilot schools N = 855 (Polish n = 366)</td></tr><tr><td>Cacciani (2023)</td><td>Italy</td><td>COVID-19</td><td>Association between migrant status and COVID-19 vaccination uptake</td><td>Residents of Rome aged 18–64 years on 31 December 2020, including migrants, refugees, and asylum seekers from HMPCs and HDCs</td><td>Control schools N = 1913 (Polish n = 404)</td></tr><tr><td>Devroey (2013)</td><td>Belgium</td><td>General vaccines</td><td>Comparison of knowledge, attitudes, information sources, and barriers to vaccination between Belgian and immigrant adolescents</td><td>Adolescents aged 14–17 years from three secondary schools in Antwerp; immigrants defined as those not born in Belgium or with parents not born in Belgium</td><td>1,731,595 (HMPCs n = 269,075; HDCs n = 17,595; Italians n = 1,444,925)</td></tr><tr><td>Fabiani (2016)</td><td>Italy</td><td>Influenza</td><td>Differences in influenza vaccination coverage between adult immigrants and Italian citizens at risk for influenza-related complications</td><td>Adult residents (≥18 years) at risk for influenza-related complications (elderly or with chronic conditions) with free access to vaccination</td><td>186 (immigrants n = 88; Belgian n = 98)</td></tr><tr><td>Führer (2022)</td><td>Germany</td><td>COVID-19</td><td>Determinants of COVID-19 vaccination among migrants, focusing on barriers to access, general vaccine attitudes, and attitudes toward COVID-19 vaccines</td><td>Adults (≥18 years) with a migration background, residing in Germany, recruited via social media, online groups, and leaflets in asylum seeker shelters; survey available in German, Arabic, Persian, English, Spanish, and Turkish</td><td>42,048 (immigrants n = 885; Italian citizens n = 41,163)</td></tr><tr><td>Gorman (2020)</td><td>Scotland</td><td>Influenza</td><td>Comparison of vaccine hesitancy among Polish migrant parents who accepted or refused nasal influenza vaccination for their children</td><td>Polish parents of primary school pupils in three Edinburgh schools with the largest cohorts of Polish pupils, all having received a Polish-language influenza information pamphlet</td><td>204</td></tr><tr><td>Grandahl (2017)</td><td>Sweden</td><td>HPV</td><td>Association between catch-up HPV vaccination status and sociodemographic factors, beliefs, knowledge, and sexual behavior</td><td>Upper secondary school students aged 16 years in mid and western Sweden; analyses of vaccination status focused on girls; immigrant background defined as one or both parents born outside Europe</td><td>128 (vaccine accepters n = 45; refusers n = 60; non-consent form returners n = 18)</td></tr><tr><td>Hertzum-Larsen (2020)</td><td>Denmark</td><td>HPV</td><td>Differences in HPV vaccination uptake between immigrants, descendants, and native Danish girls</td><td>Girls born 1996–2003, resident in Denmark on date of eligibility for routine HPV vaccination; immigrants defined as foreign-born with foreign-born parents; descendants defined as Danish-born with foreign-born parents</td><td>751 (girls n = 391, boys n = 360; girls with non-European background n = 27, European background n = 364)</td></tr><tr><td>Holz (2022)</td><td>Germany</td><td>COVID-19</td><td>Relationship between migration background and COVID-19 vaccination intentions</td><td>Adults aged 18–65 years residing in Germany; 50 % first-generation migrants (foreign-born with foreign-born parents) and 50 % native Germans without migration background, recruited via online access panel with oversampling of migrants</td><td>260,251 (immigrants n = 5990; descendants n = 20,549; native Danes n = 233,712)</td></tr><tr><td>Hussaini (2023)</td><td>Norway</td><td>COVID-19</td><td>COVID-19 vaccination rates among adolescents by immigrant background, household income, and parental education</td><td>Adolescents aged 12–17 years residing in Norway with a Norwegian national identity number; immigrant category defined as Norwegian-born with foreign-born parents or foreign-born with foreign-born parents</td><td>1009 (migrants n = 477; native Germans n = 532)</td></tr><tr><td>Igreja (2019)</td><td>Portugal</td><td>General vaccines</td><td>Attitudes toward vaccination among Brazilian migrants and Portuguese travelers</td><td>Brazilian migrants living in Portugal for at least 6 months, recruited via anonymous web-based survey; comparison group of Portuguese travelers from a travel clinic in Lisbon</td><td>384,815 (Norwegian-born with foreign-born parents n = 31,207; foreign-born with foreign-born parents n = 34,374)</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td>77 (migrants n = 22; Portuguese travelers n = 55)</td></tr></tbody></table>

(continued on next page)
<table><caption>**Table 2 (continued)**</caption><thead><tr><th>First author (year)</th><th>Country</th><th>Vaccine(s)</th><th>Phenomenon of interest</th><th>Study Population</th><th>Sample size (N)</th></tr></thead><tbody><tr><td>Kraft (2022)</td><td>Norway</td><td>COVID-19</td><td>Differences in COVID-19 vaccination coverage by immigration category and country background, and the influence of socioeconomic and demographic factors</td><td>Adults aged ≥18 years residing in Norway with a Norwegian national identity number; immigrant categories: Norwegian-born with foreign-born parents, and foreign-born with foreign-born parents</td><td>4,264,370 (Norwegian-born with foreign-born parents n = 57,153; foreign-born with foreign-born parents n = 689,540)</td></tr><tr><td>Lajunen (2022)</td><td>Norway</td><td>COVID-19</td><td>Relationship between acculturation to Norwegian culture, trust in health authorities, and attitudes to COVID-19 vaccination among Polish immigrants</td><td>Adults aged ≥18 years; Polish immigrants in Norway (first-generation), compared with Polish in Poland and Norwegians in Norway; recruited via Facebook ads</td><td>670 (Polish immigrants n = 150; Polish in Poland n = 256; Norwegians in Norway n = 264)</td></tr><tr><td>Longchamps (2021)</td><td>France</td><td>COVID-19</td><td>COVID-19 vaccine hesitancy and associated factors among residents of homeless shelters</td><td>Adults living in short- and long-term homeless shelters in Paris, Lyon, and Strasbourg regions; migrants defined as foreign-born</td><td>235 (migrants n = 217; non-migrants n = 18)</td></tr><tr><td>Mikolajczyjk (2008)</td><td>Germany</td><td>MMR Hepatitis B</td><td>Association between acculturation level and vaccination coverage among preschool children</td><td>Preschool children aged 5–6 years in a rural district of Bavaria undergoing mandatory school entry examinations in 2004–2005; migrant background defined by country of birth, citizenship, language use, and parental migration history</td><td>1481 (more acculturated migrants n = 143; less acculturated migrants n = 122; indigenous population n = 1203)</td></tr><tr><td>Møller (2018)</td><td>Denmark</td><td>HPV</td><td>HPV immunization uptake among refugee girls compared with Danish-born girls, and predictors of uptake among refugee girls</td><td>Refugee girls obtaining residence permits in Denmark between 1994 and 2010, born 1993–1999, eligible for HPV vaccination between 2008 and 2012; matched 1:6 by age with Danish-born girls with Danish-born parents</td><td>22,848 (refugees n = 3264; Danish-born girls n = 19,584)</td></tr><tr><td>Moussaoui (2022)</td><td>France</td><td>General vaccines</td><td>Vaccine hesitancy among immigrants compared to native-born French citizens, and association with time since arrival</td><td>French-speaking individuals aged 15–75 years living in mainland France, from the 2016 Health Barometer survey; foreign-born classified by region of birth; native-born as reference group</td><td>15,216 (foreign-born n = 1524; native-born n = 13,692)</td></tr><tr><td>Napolitano (2018)</td><td>Italy</td><td>HPV</td><td>Knowledge and attitudes regarding HPV infection and vaccination, and determinants among immigrants and refugees</td><td>Immigrants and refugees aged 12–26 years or parents with at least one child aged 12–26 years, recruited from an ambulatory center in Naples between September 2016 and March 2018</td><td>427</td></tr><tr><td>Page (2022)</td><td>France, Italy, Switzerland</td><td>COVID-19</td><td>Perceived accessibility and demand for COVID-19 vaccination among undocumented migrants</td><td>Undocumented migrants aged ≥16 years, foreign-born, without valid residency permits, attending health facilities in Geneva, Milan, and Paris (Baltimore site excluded for review scope)</td><td>670 (Geneva n = 441; Milan n = 126; Paris n = 103)</td></tr><tr><td>Pollock (2019)</td><td>Scotland</td><td>HPV</td><td>HPV vaccine uptake among Polish girls compared to UK-born girls</td><td>Girls in S3 (aged 13–14) in school years 2014/15–2016/17 in Scotland; ethnicity estimated via Onemap from names, verified by Polish-speaking author</td><td>78,990 total over three cohorts (Polish n = 910; Eastern European non-Polish n = 1176; UK n = 71,582)</td></tr><tr><td>Svallfors (2023)</td><td>Sweden</td><td>COVID-19</td><td>COVID-19 vaccine hesitancy among first-generation immigrants</td><td>First-generation immigrants aged ≥16 years living in Sweden, from the Migrant World Values Survey, April–September 2021</td><td>2612</td></tr><tr><td>Vinjerui (2022)</td><td>Norway</td><td>COVID-19</td><td>Correlation between COVID-19 vaccination coverage among European-born immigrants in Norway and vaccination coverage in their countries of birth</td><td>Adults aged ≥18 years, foreign-born from 22 European countries with universal vaccine access by Aug 2021; analysis included coverage comparisons between migrant subgroups in Norway and by length of residence (&lt;6 years, ≥6 years)</td><td>276,506</td></tr><tr><td>Waxenegger (2018)</td><td>Austria</td><td>Childhood vaccines</td><td>Association between migration background and children's/adolescents' health status and use of vaccination scheme</td><td>Children and adolescents aged 0–17 years from the Austrian Health Interview Survey 2014; migration background defined by parent's country of birth (EU foreign, non-EU foreign)</td><td>5277 (EU foreign country n = 346; non-EU foreign country n = 286; no migration background n = 4645)</td></tr><tr><td colspan="6"><strong>Qualitative Studies</strong></td></tr><tr><td>Bell (2019)</td><td>England</td><td>Childhood vaccines</td><td>Vaccination attitudes, behaviors, and access to primary healthcare services among migrants</td><td>Polish- and Romanian-born community members and healthcare workers</td><td>50 (migrants n = 20; HCWs n = 30)</td></tr><tr><td>Bell (2020)</td><td>England</td><td>MMR</td><td>Factors influencing vaccination uptake among Romanian and Roma Romanian communities during measles outbreaks</td><td>Romanian and Roma Romanian community members and key vaccination/outbreak management providers in Birmingham, Leeds, and Liverpool</td><td>42 (migrants n = 9; providers n = 33)</td></tr><tr><td>Crawshaw (2024)</td><td>England</td><td>COVID-19</td><td>Contextual factors shaping COVID-19 vaccination decision-making among Congolese migrants</td><td>Congolese adult migrants (born in DRC or identifying as Congolese) living in or around Hackney, London</td><td>32 (asylum seekers n = 6; refugees n = 13; naturalised British n = 6; other visa n = 2; prefer not to say n = 5)</td></tr><tr><td>Deal (2021)</td><td>England, Wales</td><td>COVID-19</td><td>Views on COVID-19 vaccines, vaccine hesitancy, barriers to access, and strategies to improve uptake among precarious migrants</td><td>Recently arrived migrants (&lt;10 years in UK) with precarious immigration status (asylum seekers, refugees, undocumented migrants,</td><td>32 (asylum seekers n = 19; refugees n = 3; undocumented n = 8; limited leave to remain n = 2)</td></tr></tbody></table>

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<table><caption>**Table 2 (continued)**</caption><thead><tr><th>First author (year)</th><th>Country</th><th>Vaccine(s)</th><th>Phenomenon of interest</th><th>Study Population</th><th>Sample size (N)</th></tr></thead><tbody><tr><td>Ganczak (2021)</td><td>Poland</td><td>Childhood vaccines Influenza HPV</td><td>Vaccination concerns, beliefs, and practices among Ukrainian migrants</td><td>limited leave to remain) from 15 countries across 5 WHO regions<br>Ukrainian migrants aged 18–45 years living in Szczecin, Poland, for ≥6 months; recruited via snowball sampling</td><td>22 (men n = 12; women n = 10)</td></tr><tr><td>Ganczak (2024)</td><td>Poland</td><td>COVID-19</td><td>Determinants of COVID-19 vaccination decision-making among Ukrainian economic female migrants</td><td>Ukrainian-born females aged ≥15 years, residing in Poland for 6 months–10 years, living in Lublin or Zielona Góra; recruited via snowball sampling</td><td>45 (adults n = 33; adolescents n = 12)</td></tr><tr><td>Gleditsch (2024)</td><td>Norway</td><td>Childhood vaccines</td><td>Attitudes toward childhood vaccination among Polish immigrants</td><td>Polish parents (n = 15) living in Norway in 2022, all with at least one child; recruited via purposive sampling through Polish organizations, schools, and churches</td><td>15</td></tr><tr><td>Gorman (2019)</td><td>Scotland</td><td>Childhood vaccines Influenza HPV</td><td>Vaccination behaviors among Polish migrant women</td><td>Polish female migrants living in Edinburgh, Scotland; recruited via community health projects</td><td>13</td></tr><tr><td>Grandahl (2015)</td><td>Sweden</td><td>HPV</td><td>Immigrant women's experiences and views on cervical cancer prevention, screening and HPV vaccination</td><td>Immigrant women aged 18–54 years studying Swedish for Immigrants (SFI) in Uppsala; participants from Middle East, Africa, Asia, and Eastern Europe</td><td>50 (Middle East n = 24; Africa n = 16; Asia n = 6; Eastern Europe n = 4)</td></tr><tr><td>Harmsen (2015)</td><td>Netherlands</td><td>Childhood vaccines</td><td>Factors influencing vaccination decision-making among immigrant parents</td><td>Mothers of Moroccan, Turkish, and other ethnic backgrounds with at least one child aged 0–4 years, living in the Netherlands for ≥1 year; recruited via mother-baby group meetings in Utrecht</td><td>33 (Moroccan n = 14; Turkish n = 7; other ethnicities n = 12)</td></tr><tr><td>Herzig van Wees (2023)</td><td>Sweden</td><td>COVID-19</td><td>Perceptions and experiences of accessing the COVID-19 vaccine among ethnic minorities</td><td>Syrian- and Somali-born adults (≥18 years) living in Sweden; participants included health volunteers from minority communities and members of the two largest ethnic minority groups in Sweden</td><td>25 (health volunteers n = 14; ethnic minority participants n = 11)</td></tr><tr><td>Jama (2018)</td><td>Sweden</td><td>MMR</td><td>Factors influencing MMR vaccination decisions among Somali mothers</td><td>Somali-born mothers of at least one child aged 18 months–5 years living in Rinkeby and Tensta, Stockholm; recruited via snowball sampling</td><td>13 (timely vaccinators n = 6; delays n = 7)</td></tr><tr><td>Jama (2019)</td><td>Sweden</td><td>MMR</td><td>Nurses' perceptions of MMR vaccine hesitancy in Somali parents</td><td>Female child health clinic nurses directly responsible for vaccination programmes in Rinkeby and Tensta, Stockholm, districts with high proportions of Somali-origin residents</td><td>11</td></tr><tr><td>Knights (2021)</td><td>England</td><td>COVID-19</td><td>Impact of COVID-19 on migrants' access to primary care and implications for COVID-19 vaccination roll-out, vaccine attitudes and hesitancy</td><td>Recently arrived migrants (<10 years in UK), aged ≥18 years, recruited across England through migrant support groups, charities, and snowball sampling; asylum seekers and refugees from 14 countries across five WHO regions</td><td>17 (asylum seekers n = 15; refugees n = 2)</td></tr><tr><td>Mupandawana (2016)</td><td>England</td><td>HPV</td><td>Factors influencing HPV vaccine acceptability and refusal among African parents</td><td>African-born parents with at least one daughter aged 8–14 years, residing in a city in northern England; recruited via purposive snowball sampling from an African social club</td><td>10 (mothers n = 5; fathers n = 5)</td></tr><tr><td>Salad (2015)</td><td>Netherlands</td><td>HPV</td><td>Perceptions, barriers, and facilitators to HPV vaccination and Pap smears among Somali women</td><td>Somali women living in the Netherlands</td><td>Individual interviews: 20 (young women n = 14; mothers n = 6)<br>Group discussions: 26 (mothers only; group 1 n = 12; group 2 n = 14)</td></tr><tr><td>Sim (2011)</td><td>Scotland</td><td>Influenza</td><td>Decision-making about H1N1 vaccination in pregnancy among Scottish and Polish women</td><td>Pregnant women in Lothian during the first two weeks of the H1N1 vaccination programme in Nov 2009; Scottish women recruited from antenatal clinics, Polish migrants from a Polish-language parenthood class</td><td>10 (Scottish n = 5; Polish migrants n = 5)</td></tr><tr><td>Socha (2020)</td><td>Norway</td><td>General vaccines</td><td>Challenges in vaccinating migrant populations from the perspective of healthcare providers</td><td>Healthcare providers (nurses and physicians) working in general practice, public health, infectious disease, migrant health, and local public health institutes in South-Eastern and Western Norway</td><td>7</td></tr><tr><td>Tomlinson (2013)</td><td>England</td><td>Childhood vaccines</td><td>Health beliefs about preschool immunisations among Somali mothers</td><td>Somali-born mothers with at least one child under 5 years, living in Birmingham; recruited via purposive and snowball sampling at Somali community centres</td><td>23</td></tr><tr><td>Torre (2023)</td><td>Italy</td><td>COVID-19</td><td>Undocumented migrants' perceptions of COVID-19 vaccination</td><td>Undocumented migrants in transit</td><td>Not reported</td></tr></tbody></table>
N = total sample size; n = subgroup sample size; HMPC = High Migratory Pressure Country; HDC = High Developed Country; HPV = Human Papillomavirus; MMR = Measles, Mumps and Rubella.

experimentation [27,29,32,33]. Fears of receiving inferior or counterfeit products [32,34] were expressed, alongside beliefs that both COVID-19 and its vaccines were engineered to harm the population [29,30]. Official communications were described as propaganda, unclear, or unconvincing [29,35,36], fostering perceptions of coercion [29,34] as well as doubts regarding governmental competence and integrity [27,32,34,37]. Undocumented migrants feared identity or immigration-status checks at vaccination sites [27,36].

Dismissive treatment, hostility, and discrimination left participants feeling marginalized [29,34,36,38,39], with some linking these feelings to historical medical abuses [29]. Fears of exclusion from trials or delayed access to vaccines reinforced perceptions that their health needs were secondary [27,36]. Concerns about bribery and falsified records [32,34], together with unrealistic time constraints on consultations [26] and reliance on ad hoc interpreters [38] further eroded confidence in the health system's integrity and responsiveness.

At the provider level, participants raised concerns about healthcare professionals perceived as less competent in vaccine administration [26,28], questioned the quality of medical training in some countries [32], and reported poor clinical assessments [28,32,34]. In Sweden, some parents feared deceptive or coercive nursing practices for MMR vaccination [40].

Distrust of pharmaceutical companies focused on suspicions that vaccines were promoted primarily for profit [32].

### 3.3. Health literacy

Personal health literacy refers to the ability to find, understand, and use health information and services, and is typically categorized into functional, interactive, and critical domains [41]. No included studies reported findings related to interactive health literacy; results are therefore limited to functional and critical domains.

Low functional health literacy was associated with lower COVID-19 vaccination intention among Turkish immigrants in Germany [30] and increased vaccine hesitancy among individuals living in homeless shelters in France [42]. Language and literacy limitations impaired migrants' understanding of medical advice [26,29,33,36,38,43,44], and ability to make informed decisions [33,36,38], leading them to rely on family or community members for interpretation [33,34,38] and favor oral communication over written materials [27,33,38]. Knowledge gaps included unawareness of vaccine purposes or schedules and misconceptions about the existence of vaccines for non-preventable conditions [25,31,44-48]. Additional navigation challenges involved registering with general practitioners, using digital platforms and interpreting official correspondence [33,35,36].

Limitations in critical health literacy were linked to difficulties in assessing the reliability and relevance of vaccine information. Conflicting or unclear public health messages, coupled with the overwhelming volume of misinformation on social media and parent forums, were reported to contribute to confusion [26,29,36,39]. Challenges in evaluating source credibility further exacerbated uncertainties surrounding vaccine safety and the assessment of associated risks and benefits [29,32,49,50]. Some participants contrasted these experiences with vaccination systems in their countries of origin, where mandates were seen as streamlining decision-making by minimizing conflicting information [34].

### 3.4. Informal information networks

Informal information networks are non-institutional, socially embedded channels through which migrants access, interpret and act on health information [51].

Misinformation and rumors circulated via social media platforms,

social networks, and transnational channels [27,29,36]. Reliance on social media and community networks was associated with lower demand and higher refusal [24,52]. Reported content included conspiracy narratives [27] and claims linking vaccines to autism [28,40], disability [29], infertility, or even death [29,31,32,49].

Circulating anecdotes within personal and community networks were reported to reinforce mistrust in healthcare and wider governance systems [36] and, together with reports of adverse effects from relatives or community members, shaped vaccination decisions [40,45].

### 3.5. Sociocultural determinants

Sociocultural determinants refer to cultural values, social norms, and kinship structures that influence health perceptions and care decisions [53].

Cultural beliefs shaped perceptions of risk and the relevance of vaccination. Cervical cancer was described as linked to older age, high parity, or the use of traditional intravaginal remedies, while ancestral protection and moral upbringing were cited as protective. The disease was also portrayed as affecting “white girls” rather than “African girls,” reflecting assumptions about sexual behavior. Taboos around sexual health complicated communication, with mothers taking responsibility for these discussions after migration. In this context, HPV vaccination was framed as undermining moral purity or encouraging promiscuity [31].

Faith-related considerations were reported as barriers to vaccination through mechanisms including faith-based objections to vaccination [36], concerns about prohibited ingredients [45], and fatalistic beliefs about divine control of health [45]. A German study found religiosity indirectly reduced vaccination intention via lower fear of transmission [54], and, for HPV, religion was linked to lower perceived risk and a reason for refusal [31].

Peers and religious leaders were reported to provide guidance on vaccination, with some migrants seeking advice from these networks before, or instead of, healthcare professionals [27,33,35]. Social norms within community and religious settings exerted peer pressure that shaped vaccination decisions [27,34,39], and the normalization of refusal within some communities was described as reinforcing hesitancy [28,31].

Household norms also influenced decisions. Patriarchal family structures placed decision authority with fathers, particularly for HPV vaccination, while mothers reported limited influence [31]. In Norway, adolescent uptake among Eastern European migrants was higher when at least one parent was vaccinated [55]. Intergenerational input from extended family members also shaped decisions; family elders and trusted relatives were described as having a decisive role in specific cases, at times preventing uptake [31,33,40].

### 3.6. Sociodemographic determinants

Sociodemographic factors are commonly identified as determinants of health outcomes and access to care [56].

Lower uptake was reported among migrants from Eastern European countries such as Latvia, Bulgaria, Poland, Romania, and Lithuania [21,22,37,54,55,57-60], as well as among those from Sub-Saharan Africa [23]. In Denmark, HPV uptake was lowest for migrants and refugee girls from Afghanistan, Eastern Europe, Germany, Iraq, and Somalia [21,61]. Vaccine uptake and intention differed across countries. In Germany, migrants from European Union (EU) countries expressed lower intention to vaccinate than non-EU migrants [54]. Yet in Austria, children of EU-born parents were less likely to have been vaccinated than those of non-EU-born parents [62], while in Sweden, girls from European backgrounds had higher coverage than their European peers
[63].

Among socioeconomic factors, administrative status, employment, income and education also shaped vaccination behaviors. Undocumented migrants exhibited greater hesitancy [42], while unemployment [59], economic inactivity [20] and low household income were associated with lower uptake [55]. Lower education was linked to lower vaccination intentions [54], and higher levels of refusal or uncertainty [37]. When considering parental education as a determinant of child vaccination uptake, findings were mixed. In Sweden, higher maternal education was positively associated with HPV catch-up vaccination uptake among adolescent girls, independent of migrant background [63]. In contrast, in Germany, higher parental education was associated with an increased risk of children lacking MMR or hepatitis B vaccination [18].

In addition to socioeconomic position, demographic characteristics such as age, gender and household composition further influenced vaccine attitudes and uptake. Across studies in Finland, Germany, Sweden and multicountry European surveys, younger migrants were consistently more likely to refuse or delay COVID-19 vaccination, whereas vaccine hesitancy was markedly lower among older migrants [20,37,52,54]. Gender differences in vaccination attitudes and uptake were observed across European migrant populations, with women more likely to express COVID-19 vaccine hesitancy in France [42] and Sweden [37], whereas in Rome, migrant women had slightly higher uptake than men, except for those from central-western Asia [64]. In France, [42] living with a partner was associated with greater vaccine hesitancy among homeless migrants.

### 3.7. Vaccine-specific perceptions

Vaccine-specific perceptions capture migrants' beliefs about vaccine safety, effectiveness, necessity and risks, including misconceptions, that influence decision-making.

Low perceived necessity, shaped by perceptions of disease susceptibility and severity, was a recurrent barrier to uptake among migrants. Influenza and H1N1 vaccination were declined when illness was regarded as mild or vaccination unnecessary for those considered healthy or with limited exposure [26,28,32,35]. More broadly, adolescents reported that “not all vaccines are necessary,” citing low exposure or disease treatability [47], and Somali mothers questioned immunization based on past experience of remaining healthy without it [45]. HPV, meningococcal and pneumococcal vaccines were dismissed as irrelevant due to abstinence expectations, rarity of disease, or lifestyle factors [25,31,33,50]. For COVID-19, vaccination was rejected in favor of natural remedies, self-isolation, or reliance on natural immunity [36,65], dismissed as unimportant [37], or refused when seen as an obstacle to mobility [66].

Efficacy doubts frequently undermined trust in vaccination. In studies of influenza vaccination, parents questioned the ability of flu vaccines to prevent illness, and refusers were less likely to agree that vaccines were effective or that they protected their child and the wider community [28,50]. For COVID-19, concerns about effectiveness included doubts about protection levels, variant coverage, booster requirements, and perceptions of lower reliability compared to influenza vaccines [27,29,46,49]. Doubts also extended to HPV, where some women questioned whether the vaccine provided full protection [46].

Safety concerns were widespread, with general fears about side effects and unknown long-term effects [25,33,34,46-48,50,65,67], as well as personal health concerns from prior adverse effects [24,29]. Parents reported fears of febrile seizures and genetic susceptibility [39,44], while concerns about vaccine ‘overload’ led to preferences for spaced dosing [26,28] and postponement when children were considered too young [46]. Pregnancy-related concerns included fears of fetal harm and perceived risks to fertility [31,32,35,49]. Trust was further undermined by doubts about storage conditions [32,34], together with mistrust related to vaccine novelty, rapid development or perceived lack of trial

data [28,31,34-36,44,49].

Misconceptions included myths about neurological harm, such as claims that MMR causes autism or developmental disorders [28,39,40,45]. Physiological myths included beliefs that vaccines induced illness-like reactions [26], paralysis [28], or interfered with puberty [34], sometimes linked to suspected harmful ingredients [25,35]. Conspiracy narratives portrayed vaccines as surveillance tools or as weapons, including fears of microchips and beliefs about racial targeting [27,29]. In some accounts, natural infection was considered superior to vaccination [67].

### 4. Discussion

This review identified multiple intersecting determinants of vaccine hesitancy among migrants in Europe, with attitudes reflecting the interplay of origin-country beliefs, host-country experiences and shifting risk perceptions.

Many migrants retained origin-country health beliefs that continued to shape perceived necessity, safety and disease risk despite long-term residence abroad. Polish migrants in Norway echoed attitudes prevalent in Poland, mirroring findings among North African and South Asian migrants in the US, where uptake aligned with origin-country rates [19,68,69]. These cultural baselines intersected with moral frameworks centered on purity, dignity and family hierarchy, shaping interpretation of vaccine information. Such values influenced whether vaccination was seen as protective or as a threat to moral or social order, consistent with evidence linking hesitancy to concerns about purity, liberty and respect for traditional authority [31,70,71].

The evolution of these beliefs appears shaped by the interaction between acculturation and the host-country normative environment. Berry's model frames acculturation as a balance between maintaining origin-country culture and adopting host norms [72]. Our findings suggest that integration outcomes are influenced by the surrounding social and institutional climate. For instance, in Finland, where national vaccine confidence was 68 % in 2020 [73], longer-residing migrants were more likely to complete routine immunizations than recent arrivals [20]. In contrast, in France, with only 51 % of adults expressing high vaccine confidence [73], long-term migrants were more hesitant than both recent arrivals and native-born citizens [23], indicating that integration into a skeptical context may reinforce hesitancy. These contrasting outcomes highlight how acculturation pathways are context-dependent, and do not uniformly shape health behaviors.

Beyond integration into host norms, we observed separation trajectories, characterized by retention of origin-country beliefs and limited engagement with host health systems. This pattern was particularly pronounced among Eastern European groups, whose vaccination attitudes mirrored those of their countries of origin [22,37,54,57-59]. In Poland, vaccine refusal more than doubled between 2017 and 2022, especially for MMR [74], while regional confidence across Central and Eastern Europe declined from 70 % to 55 % between 2018 and 2022 [75]. These findings suggest that region of origin continues to influence vaccine behaviors long after migration, highlighting the need for subgroup-specific analyses to identify context-sensitive drivers of hesitancy.

Our review identified a consistent gender disparity, with women more often expressing hesitancy or refusal [37,42,54], reflecting broader trends in the European population, where lower confidence among women for certain vaccines such as HPV has been documented [73]. For HPV in particular, participants in one study frequently reported that patriarchal decision-making limited maternal influence [31]. Beyond origin-country norms, migration-related structural and contextual factors further shape gender dynamics, influencing power relations within households and communities [76]. Women may face overlapping disadvantages, including reduced autonomy, time poverty, informal employment, language barriers, and limited social support, which together narrow the scope for vaccination decisions [77]. Gender
disparities among migrants are therefore not simply carried over from countries of origin; rather, migration-related vulnerabilities can intensify them. These findings underscore the need for health interventions that are gender-responsive and sensitive to the social, structural and cultural barriers shaping women's vaccination decisions.

Low health literacy, often compounded by limited proficiency in the host language, constrained migrants' ability to understand vaccine guidance and navigate healthcare systems [29,31,34,38,39,43]. This reduced engagement limited exposure to acculturative supports, such as host-language use and familiarity with system norms, reinforcing separation from institutions. Early gaps in acculturation therefore create persistent health literacy barriers and cycles of disengagement. Evidence from Oslo illustrates this: 71 % of Somali women had inadequate health literacy linked to poor acculturation, limiting awareness of available services [78]. More broadly, cultural and linguistic barriers, combined with low health literacy, reduce knowledge of formal resources, discouraging preventive care [79]. Importantly, these barriers contribute to a gap between vaccination intention and actual uptake. For example, migrants from EU countries in Germany [54] reported lower intention, whereas in Sweden, girls from European backgrounds had higher vaccine coverage [63]. This shows that behavior does not always reflect intention, particularly when linguistic, organizational, or systemic obstacles exist, highlighting the need for interventions that address both attitudes and practical constraints. These migrant-specific cycles reflect longstanding shortcomings in health communication, documented since the Institute of Medicine's 2004 report [80], and help explain the continued reliance on informal information networks.

While informal networks provide culturally familiar channels for health information, they also act as conduits for misinformation [27,31,40]. Studies of online anti-vaccine content report emotionally charged personal narratives, appeals to natural immunity, civil-liberties rhetoric and conspiracy themes [81,82]. Repeated exposure increases acceptance of false claims, even when individuals recognize them as inaccurate, with a single repetition sufficient to enhance their perceived credibility [83,84]. Evidence from transnational networks demonstrates that misinformation can traverse borders through “broker” groups connecting otherwise unlinked communities, amplifying its reach and perceived credibility, and disproportionately affecting vulnerable populations [85]. Addressing this effect requires corrective strategies that include explicit forewarnings, repeated delivery, and the provision of clear and credible alternative explanations [86].

Institutional mistrust emerged as a central determinant. Participants linked hesitancy to cumulative experiences of discrimination, marginalization and perceived neglect, rather than isolated incidents [27,29,36]. Röder et al. similarly found that perceived discrimination and social exclusion significantly erode immigrants' trust in core institutions including the police, courts, parliament, and political leadership, even when institutional performance is objectively favorable [87]. This pattern is not limited to socioeconomically disadvantaged groups. High-skilled migrants also report unmet expectations, professional devaluation, and chronic marginalization, contributing to emotional distress and ultimately reinforcing institutional mistrust [88].

Comparable dynamics have been documented in other historically marginalized groups. In Black American and Roma communities, mistrust of health systems reflects the intersection of contemporary inequalities with long histories of structural discrimination [89–91]. A historically significant case is the Tuskegee Syphilis Study, in which hundreds of Black American men were enrolled by the US Public Health Service and withheld effective treatment without informed consent, even after therapy became available. The study ran from 1932 to 1972, with its full ethical violations acknowledged only years later. As Jones and Reverby [92] argue, the persistence of mistrust stems not only from the facts of the study but also from the enduring moral and institutional conditions that allowed such exploitation, rooted in systemic racism and the devaluation of marginalized populations.

While the Tuskegee study involved a specific racialized group in the

US, its relevance to migrant populations in Europe lies in structural parallels. Many migrants face systemic marginalization, exclusion and differential treatment in healthcare, with patterns of surveillance, neglect and unequal care. As with Tuskegee's legacy, migrants' mistrust of health institutions is frequently grounded in accumulated experiences of discrimination and structural disadvantage. In this context, public health messaging that directly acknowledges historical and structural injustices has proven more effective than generic campaigns, as shown in efforts to increase vaccine uptake among Black Americans [93]. These observations suggest that interventions for migrant populations should address structural and historical roots of mistrust rather than rely solely on information-based strategies or surface-level outreach.

Building trust therefore requires a shift toward approaches that are participatory, culturally grounded and responsive to the lived realities of marginalized communities. Community-led co-design has consistently demonstrated value in this regard. In the LISOLO MALAMU study, outreach initiatives developed in collaboration with Congolese migrants significantly improved vaccine acceptance [94]. In Canada, public health interventions informed by behavioral science and sustained engagement with community representatives aligned official messaging with community priorities and helped rebuild trust [95].

Across settings, co-created communication tools, including culturally and linguistically tailored infographics, improved health literacy and vaccine confidence [96]. User-tested print and digital materials helped migrant parents navigate complex catch-up vaccination schedules [97]. Bidirectional communication that engaged trusted community leaders and delivered services through accessible local clinics was effective in encouraging uptake [98]. Ethnographic work led by community health workers identified social and structural barriers, and enabled the co-development of contextually relevant immunization strategies [99]. Multicomponent programs that combined mobile outreach, care coordination and community leadership proved effective in strengthening vaccine acceptance and supporting the completion of vaccination schedules in underserved populations [100].

Improving vaccine acceptance and reducing inequalities requires more than technical measures. It demands authentic collaboration, cultural adaptation, and integration of community knowledge, alongside engagement with structural injustices and historical exclusions shaping migrant health experiences. The WHO SAGE “3C” model [1] conceptualizes vaccine hesitancy as a behavioral outcome shaped by three interrelated factors: confidence (trust in vaccines, health systems, and policymakers), complacency (perceived importance and necessity of vaccination), and convenience (accessibility, affordability). Situating the present findings within this framework helps illustrate how migrant-specific factors connect to broader behavioral drivers. Confidence was consistently influenced by institutional trust [19,26–28,30–40,94], perceived vaccine safety [24–28,31–36,39,40,44–50,65,67,94], and credibility of information sources [26,32,36,39,49,50,94]. Convenience was affected by linguistic [26,29,33,36,38,43,44], cultural [25,26], and cognitive barriers [25,31,44–48], while complacency varied with acculturation [27,28] and perceived disease relevance [25,26,28,31–33,35–37,45,47,50,65]. Migration-specific factors, including acculturation pathways [20–23], reliance on informal information networks [24,52], and experiences of discrimination [27,29,36], extend this framework by highlighting the sociocultural and structural conditions in which hesitancy emerges. Adapting existing models is necessary to fully capture the migration-related dimensions identified in this review.

## 5. Limitations

This review has limitations in scope, measurement, methods and generalizability. By focusing on first-generation migrants and parents of second-generation children, it does not capture how attitudes may evolve in later generations or within mixed heritage households.

In this review, we treated vaccine uptake as a proxy for hesitancy
when migrant specific subgroup data were available. While uptake may reflect attitudinal patterns, it remains an imperfect measure since non-uptake can result from factors unrelated to hesitancy, including logistical barriers, competing priorities, or structural constraints. Although studies dominated by access-related barriers were excluded from this review, residual influences on uptake may still be present, potentially leading to either overestimation or underestimation of hesitancy.

Language restrictions to English and French may have omitted relevant work in other European languages, and limiting inclusion to peer-reviewed sources, even after searching grey literature, may introduce publication bias. Quantitative studies varied in methodological quality, which may reduce the robustness of certain findings. Two studies [65,67] had markedly lower MMAT scores, but their findings generally aligned with higher-quality evidence. The perception that natural infection was superior to vaccination, reported only by Igreja et al., should be interpreted with caution. Heterogeneity in study design, population characteristics, and outcome measures also constrained direct comparability across studies.

Transforming quantitative results into qualitative form, coupled with reliance on a single primary extractor, may have introduced interpretive bias and increased the risk of error or subjectivity. Finally, most included studies were conducted in Western and Northern Europe, which may introduce geographic bias. Migrant populations in these regions may experience sociopolitical contexts, cultural norms, and public health messaging that differ from other parts of Europe. As a result, the determinants of vaccine hesitancy identified here may not fully reflect those affecting migrants in Southern, Eastern, or Central Europe, limiting the generalizability of the findings. Further research in underrepresented regions is needed to confirm and expand these results.

Despite these limitations, the review provides valuable insights into the determinants of vaccine attitudes among migrants.

## 6. Conclusion and recommendations

This review finds that hesitancy among migrants in Europe reflects the interplay of origin-country beliefs, host-country norms and migration-related factors shaping trust, information access and decision-making. Our synthesis highlights persistent origin-country attitudes, the role of acculturation pathways shaped by host-country norms, and region of origin as key predictors of vaccination behavior. Gender gaps were evident, with migration often intensifying constraints on women's agency. Low health literacy compounded by linguistic barriers fostered reliance on informal information networks which, while culturally resonant, could amplify misinformation. Institutional distrust emerged as a central driver, rooted in present-day exclusion and historical injustices.

Addressing these determinants requires culturally responsive, participatory interventions co-designed with migrant communities, tailored to health literacy needs, and attentive to the historical and structural conditions shaping vaccine attitudes. Evidence supports the value of community-led co-design, trusted community messengers, and communication strategies that acknowledge systemic inequities. Future research should assess interventions using longitudinal and participatory designs, including studies led by migrant organizations. Other priorities include examining underrepresented groups, subgroup heterogeneity, the interplay of gender, migration, and trust. The influence of informal and digital information networks, including transnational misinformation, and changes across generations should also be assessed. Comparative studies in under-researched European regions and evaluations of structural or policy-level interventions are warranted to inform sustainable confidence-building strategies.

### CRediT authorship contribution statement

**Erika Khuu:** Writing – review & editing, Writing – original draft, Visualization, Project administration, Methodology, Investigation,

Formal analysis, Data curation, Conceptualization. **Sohela Moussaoui:** Writing – review & editing, Validation, Supervision, Project administration, Conceptualization. **Nicolas Vignier:** Supervision, Project administration, Conceptualization. **Kim Bonello:** Supervision, Validation, Writing – review & editing, Methodology. **Elise Archer:** Validation, Supervision.

### Ethics approval

As this is a systematic review of published literature, ethics approval was not required.

### Declaration of competing interest

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.

### Acknowledgements

We thank the medical librarian who validated the search strategy.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.vaccine.2025.127954.

### Data availability

Data will be made available on request.

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