This key considerations brief outlines perceptions, understandings and experiences of COVID-19 vaccination among ‘people on the move’ in Italy. For an increasing number of such people, Italy is considered a transit destination to reach other European countries. Considerations in this brief are relevant to countries situated along Eastern and Central Mediterranean migrant routes.

EU policymakers have expressed concern about the vulnerability of mobile populations – a group which includes refugees, asylum seekers and undocumented migrants – in relation to COVID-19. Due to the extreme mobility of these populations, coupled with a fear of state authorities, public health experts have linked communities to a heightened risk of COVID-19 transmission within and across national borders. Yet, the same factors which link mobile populations to transmission of COVID-19 also make these individuals hard to reach through state-led vaccination campaigns. This brief highlights the complexities of this humanitarian situation and provides advice as to vaccination approaches which take account of people’s specific vulnerabilities and priorities.

This brief draws on research conducted along Italy’s Alpine border in 2021. This brief was developed for SSHAP by Costanza Torre (LSE) with support from Elizabeth Storer (LSE) and Sara Vallerani (Roma Tre University). Additionally, contributions and reviews were provided by Megan Schmidt-Sane (IDS), Eloisa Franchi (Université Paris Saclay – Pavia University), and Professor Federico Federici (UCL). This brief is the responsibility of SSHAP. The research was funded through the British Academy COVID-19 Recovery: G7 Fund (COVG7210058). Research was based at the Firoz Lalji Institute for Africa, London School of Economics. The brief is the responsibility of SSHAP.

KEY CONSIDERATIONS

Summary points

• People on the move’s calculations and decision-making processes around COVID-19 vaccination relate largely to their need to be mobile, which is continually prioritised above fears of COVID-19 infection. Whilst prioritising mobility does not necessarily make people resist vaccines, it does structure engagement with vaccination. People often accepted vaccination to access certification which would facilitate movement, or rejected it based on fears that side-effects of the COVID-19 vaccine would interfere with their mobility needs. While these effects are considered ‘mild’ in policy and medical literature alike, the context of the migratory journey heavily influenced the decision-making and perception of health risks of the research participants.
• The prioritisation of mobility among people on the move in Italy is a function of changing geopolitics and the cost of the journey. Trying to avoid the constraints and threats of the Dublin Regulation, migrants are attempting to pass through Italy quickly and undetected to declare asylum elsewhere. Migrant trips are costly, particularly for families travelling together. If interventions do not take account of priorities of movement, it is likely they will fail to reach migrants.
• In Italy, the introduction of the EU Digital COVID Certificate of immunization (in Italy known as ‘Green Pass’), which serves as an immunity passport, has presented issues for people on the move. Many understood COVID-19 as simultaneously a health and bureaucratic threat.

Tailoring communication

• It is essential that information is made available in multiple languages, or alongside clear infographics. Information about immunity passports should be provided alongside health information. It is also essential to place information within trusted spaces, such as safehouses.
• Migrants use social media more than government websites. It is important to develop tailored campaigns which are shared on WhatsApp, Facebook, Instagram and TikTok.
• Due to the extreme marginalisation of mobile populations, we suggest vaccine campaigns must be paired with wider advocacy for migrants’ rights. Vaccine information should be accompanied by clear information about nearby refuges, temporary housing options, health clinics, psycho-social support services, and asylum regulations.

Engaging solidarity infrastructures

• Following recognition of the risks posed to border-crossing migrants, networks of solidarity have formed along Italian borders. These networks offer shelter, food, mountain clothing to undertake the crossing and, crucially, medical care. These networks provide one of the only trusted entry points to dispatch vaccination information to people on the move.
• These are networks sprung from solidarity, which often rely on volunteers to function. At present, such infrastructures prioritise equipping migrants for border crossings, and associated medical care. If asking safehouses to administer vaccines, or information, it is essential to invest and fund these infrastructures. A solution could be funding an on-call resident doctor or nurse.

BACKGROUND

Italy is one of the European countries most heavily affected by the COVID-19 pandemic.  Since its onset in early 2020, there have been over 165,000 recorded COVID-19 related deaths (as of May 2022).³ Italy hosts an estimated 500,000-700,000 undocumented migrants,⁴ and serves as a transit destination for many more. These groups have been disproportionately affected by both the health and socio-economic burden of the pandemic.⁵ Undocumented individuals are over-represented in COVID-19 hospitalizations and deaths, and have faced reduced access to health and other welfare services under pandemic restrictions.⁶

Recent efforts to expand the coverage of COVID-19 vaccinations during the ongoing pandemic have brought concerns about groups labelled ‘hard to reach’ to the fore.² Undocumented migrants and people on the move have been described as being vaccine hesitant. This assumption is based on remarkably little evidence, since undocumented persons are largely excluded from government enumeration.¹²

Research informing this brief was conducted in December 2021 primarily at the Rifugio Fraternità Massi in the border town of Oulx, in northern Italy. This location is a well-known safehouse on the Italian side of the Alpine border and serves as a key stop for migrants to receive food, shelter, clothing, and medical assistance in preparation for border crossing. The age and origin country of research participants varied greatly; largely, participants originated from Afghanistan, Iran, Iraq, Kurdistan, Morocco, Algeria, Senegal, Ivory Coast, Cameroon, Guinea, and Sierra Leone. Many were travelling alone or with friends they met along the journey. All were transiting through Italy on their way to other countries in Europe such as Germany, France, the United Kingdom, and Scandinavian countries. Journeys ranged from forty-five days to several years. Some had been residing in Italy for a while before undertaking their journey through the Alps.

Italy’s Alpine Border Zone

The border between Italy and France has historically been relatively porous, but over the past seven years it has become one of the most policed on the European continent. This is largely due to France’s suspension of Schengen agreements following the Paris terror attacks of November 2015, and of the extension of a state of emergency in 2016. In an attempt to elude police controls, migrant routes shifted from coastal crossing points around the town of Ventimiglia, where most police patrols are located, to the Alpine border-zone north of the Italian town of Oulx, in the Susa Valley.¹⁵

Since late 2016, migrant flows through Oulx have increased. This is despite the fact that achieving the crossing presents as a dangerous journey, made particularly challenging by often extreme weather conditions and frequent police arrests and pushbacks. Usually people attempt the crossing several times before successfully arriving to the small town of Briançon, about eleven kilometres into French territory, where another well-known safehouse is located.

Over the years, several people have lost their lives during the crossing. The outrage that followed news of these incidents has resulted in extended networks of solidarity emerging on both sides of the border. The landscape of solidarity efforts is subject to changes, but generally includes:

• Safehouses, which rely both on volunteer efforts and on various sources of public and private funding. Through collaboration with religious and non-governmental organisations, safehouses can provide support to migrants in the form of shelter, food, clothing, legal counsel, and medical assistance, including COVID-19 vaccinations.
• More informal groups and/or networks of individuals, who are often engaged in political struggles against state border controls. These groups offer shelter and food to people on the move.
• Discrete mobilizations of groups of citizens called maraudeurs, who rescue migrants in distress on the mountains. Their action is often strongly criminalised by state and border authorities.

VACCINE HESITANT?: MIGRANTS’ PERCEPTIONS OF VACCINES

Contrary to existing assumptions which depict migrants as ‘vaccine hesitant’, our research found that many passing through the safehouse in Oulx prior to crossing the Alpine border had received a vaccination during their journey. Though individual circumstances varied greatly, people travelling in family groups where more likely to have been vaccinated against COVID-19, while people travelling by themselves (the totality of which in this study were men) more often reported resistance to vaccines.

People that had arrived in Italy after traveling across the Eastern Mediterranean route (the ‘Balkan route’) from Afghanistan, Iran, Iraq, Kurdistan etc, were often more likely to have been vaccinated in comparison to those originating from the Central Mediterranean route. This was sometimes related to the duration of people’s journeys, as the Balkan route usually entails prolonged stops and detention in refugee camps. Additionally, people who had spent extended time in one or more countries during their journey were more likely to have accepted a COVID-19 vaccine.

Vaccine acceptors

• Vaccines in the context of migratory journeys. People on the move who had accepted a vaccination against COVID-19 understood vaccination as another requirement, and often another obstacle, in their migratory journey. Vaccination was understood not just as a health-related choice, but rather one centred on mobility needs. Even voluntary decisions were driven by pragmatism. Health concerns related to COVID-19 were rarely mentioned. This partly relates to the need to complete journeys which, in addition to being exhausting and dangerous, are increasingly costly.¹⁶
• Complying with COVID-19 bureaucracy. Following the heavy lockdowns of 2020 and the subsequent waves of the COVID-19 pandemic, in most European countries the right to work, participation in public spaces and mobility are increasingly tied to the possession of a COVID-19 passport, obtainable through proof of vaccination/recovery or a negative COVID-19 test. In Italy, until 1st May 2022 the certificate was necessary to access buses, trains, and other forms of public transport. Between 6th December 2021 and 1st April 2022, the introduction of more stringent legislation further restricted access to transportation only to those with proof of vaccination or recovery from COVID-19. Transport authorities were instructed to deny boarding to anyone who cannot produce a pass. Similar regulations are common across Europe, and many research participants reported having accepted a COVID-19 vaccine to facilitate their journey

• Accepting a vaccine did not relate to trusting the state. Other participants explained they had accepted a vaccine to avoid additional problems with police. Along the route, people have usually experienced adverse encounters with police and border authorities. These interactions heavily inform people on the move’s decisions regarding vaccination, as explained by one young Afghan man: ‘For me, I got the vaccine in Greece, because I thought that if the police ask for vaccine certificate, at least I will have no problem.’ Frequent feelings of coercion were reported as people perceived they had been coerced to obtain a vaccine by law enforcement.
• Fears of COVID-19 are secondary to the pursuit of a migratory journey and leaving adverse circumstance in a country of origin. Many who migrate have done so after witnessing or experiencing violent conflicts, political oppression, and persecution. After fleeing exceptional violence, COVID-19 is not deemed to present a significant risk to people’s health. For example, one young man who had fled from Afghanistan said: ‘Only the Taliban are a big problem in Afghanistan’. Another added: ‘I had two cousins in the army, they were twenty and twenty-two years old. The Taliban killed both of them’. Whilst these orientations do not necessarily mean forced migrants are not aware of the health dangers of COVID-19, it shows that the conditions of deep uncertainty that people are fleeing fundamentally shape people on the move’s perceptions and experiences of risk.

Vaccine refusers

Whilst individual experiences towards vaccination varied greatly, our research found a significant trend underlying refusal being related to common side-effects of COVID-19 vaccines, such as  tiredness, headache, fever, muscle ache and generalised physical weakness.¹⁸ Many had chosen not to receive a COVID-19 vaccine based on pragmatic considerations related to side-effects of the vaccine in relation to their ability to undertake the physically demanding Alpine crossing. While these effects are considered and discussed as ‘mild’ in the medical literature, the circumstances were prominent among people on the move. Attitudes were more prominent among people traveling by themselves, and especially young men.

• Side effects of the vaccine as obstacles to the journey. The most reported reason for refusing COVID-19 vaccination was that the common and well-known side effects of the vaccine would affect the possibility of continuing the journey (see Box 3). The threat of physical illness, weakness, or discomfort in the aftermath of vaccination was especially relevant considering the physical demands of the Alpine crossing, which all people on the move who stop by Oulx plan on attempting. Vaccine side effects are therefore often seen as an obstacle to completing this crossing. These worries are particularly common among people traveling on their own, for whom the prospect of feeling unwell during the journey is particularly daunting. In this sense, rather than being misinformed, people were making pragmatic choices.
• The role of exhaustion. Upon reaching Italy, people often present with symptoms of extreme physical weariness (e.g., widespread infections, frequent injuries to legs and feet due to lack of medical care and overuse during travel), and psychological exhaustion resulting from dangerous travels, long periods spent in overcrowded and unsanitary conditions in refugee camps, and often experiences of torture, abuse, and intimidation at the hands of police and border authorities. People on the move are also unlikely to have been able to access meaningful healthcare during the journey, and are likely to present several co-morbidities, including severe psychological distress as a result of trauma endured during the journey. These factors increase people’s fears of exposing themselves to additional physical vulnerability such as the side-effects of the COVID-19 vaccines.
• Short-term exposure to assistance structures. People often transit through Italy within short periods of time. Upon arriving in Oulx, migrants stay in safehouses for brief periods, usually one day for people traveling alone, and a few days in the case of family groups. Crucially, safehouses are also only equipped for short stays, and until January 2022 only offered overnight shelter, with rare exceptions. These circumstances contrast to stays in camps where people have sometimes been stuck along the route for long periods of time.
• The role of masculinity. For young men traveling alone especially, the migratory journey often plays a major role in the performance and construction of identity and masculinity, of which physical strength is an essential component. Additionally, the search for a better life is frequently linked to family obligations and gender norms. One young Sierra Leonian man summarised: ‘I am the first son, I have to be the man of the family and support my five sisters and one brother to go to school, because for us in Africa when you are the first son you have to support…there’s your father and then there’s you.’

BARRIERS TO INCREASING COVID-19 VACCINE UPTAKE AMONG MOBILE GROUPS

In the context of highly mobile populations on known migratory routes, such as the ones transiting through northern Italy on their way to Europe, several factors contribute to pose challenges to vaccination efforts.¹⁹

Infrastructure limitations

• Until September 2021, COVID-19 vaccination in Italy was precluded to anyone not in possession of a National Insurance Number. This automatically excluded undocumented individuals from obtaining one. More recently, vaccination has been made available to undocumented individuals in possession of a code called ‘STP – Straniero temporaneamente presente’ (Temporary resident foreigner). However, applying for an STP code involves a lengthy bureaucratic process, and does not guarantee immediate access to vaccination, excluding those transiting through the country.
• The lack of dedicated regional/local infrastructures where people on the move can seek and receive information on COVID-19 symptoms, prevention and vaccination poses a significant obstacle. No structures or clinics have been put in place during the pandemic to assist undocumented migrants on the Italian-French border.
• Assistance to undocumented migrants in the area is left to networks of local volunteers and a few non-governmental organisations, whose resources are not sufficient to coordinate an extended public health effort. At present, the presence of doctors or nurses is not always guaranteed.

Mobility factors

• Migrants’ priority is to continue their journey undetected and within a short timeframe. Their quick transit through Italy also poses challenges to the establishment of long-term relationships with health facilities which are needed to undergo a full course of vaccination. Even if people decide to obtain a first dose of the COVID-19 vaccine, completing the vaccination would imply staying in the country for a minimum of four weeks. This is for many people an untenable requirement.
• People on the move in Italy prioritise mobility, which is characterised by long, exhausting and costly journeys. Side-effects of the COVID-19 vaccination, despite being understood as mild and not posing a significant threat to individual health, are central in people’s decision-making processes around accepting immunization, as vaccines are understood as a threat to the possibility of continuing the journey as quickly as possible.
• Undocumented migrants and people on the move may fear that approaching health facilities would result in being reported to the authorities as illegal, or quarantines which would delay journeys. Such perceptions are heavily shaped by previous violent encounters with police and border authorities along the journey. The perceived link between health and state authorities has therefore wide implications for people on the move’s health-seeking behaviours.

Limited information about access and vaccine effects

• Basic communication between volunteers, doctors, and people on the move at the facility is made possible through digital tools such as Google Translate. Yet, this kind of translation can often lead to misinterpretation or an incorrect assessment of important medical problems. The absence of intercultural mediators able to guarantee efficient and reliable communication with migrants poses a major challenge for doctors and nurses trying to offer or explain the benefits of COVID-19 vaccination.
• People on the move have limited access to information about different brands of the COVID-19 vaccine, where those are recognised within different countries in Europe, and the challenges that people may face with regards to mobility in this case. The lack of information in this sense puts migrants in a position of structural uncertainty, which adds to the multi-vulnerabilities of their circumstances.
• There is also a lack of information available on vaccination in the specific circumstances of interest to undocumented migrants, i.e., the effects of COVID-19 vaccination on bodies under severe stress and in conditions of extreme physical and psychological exhaustion. While research is available on the interaction of COVID-19 vaccination and other pre-existing conditions, data and information in this sense is thoroughly lacking, and may result in more people choosing to refuse COVID-19 immunization.

Misinformation about vaccines

• Attitudes towards COVID-19 vaccination in the country of origin may influence people’s decisions about whether to accept one. People on the move may have been exposed to misinformation or disinformation about COVID-19 vaccines in countries of origin or along their journey, as they are also frequently in touch with friends and relatives at home through phone and WhatsApp communication.
• Many people on the move, and especially young people, often heavily rely on social media as source of information (e.g., Instagram, TikTok), where often misinformation is spread.
• Many people on the move reported specific fears about the AstraZeneca brand of COVID-19 vaccine, which has been at the centre of widespread debate in the initial phases of immunization campaigns worldwide for its potential for adverse side effects.
• Undocumented migrants in Oulx sometimes reported fearing that the COVID-19 vaccine may be forbidden by their professed religion because the medical technology used for COVID-19 vaccines uses cell lines initially developed from aborted foetuses (for example). Worries persisted despite statements by several religious authorities declaring COVID-19 vaccination safe and admissible.²⁰

BOOSTING COVID-19 VACCINE UPTAKE AMONG MOBILE GROUPS

This research highlights several possible entry points which may improve vaccine acceptance and uptake among people on the move, without affecting the delivery of assistance vital for these groups.

Tailoring communication strategies

• Public health campaigns targeting people on the move must put people’s priorities and needs at the centre of their mandates. In addition to dispelling particular types of misinformation, health communication must integrate concerns about movement with health information.
• Clear and accessible information in multiple languages and multiple formats needs to be available around access to vaccination, the acceptance in different European countries of different brands of vaccines, and common and uncommon side-effects of COVID-19 vaccination. Information on side-effects of COVID-19 vaccination along border zones should include a map of infrastructure that people on the move can rely on in case they feel unwell (e.g., safehouses, emergency rooms, medical hotlines that offer help via phone).
• Language barriers represent a huge challenge for actors on the ground, working within infrastructures of solidarity and assistance to people on the move. The regular presence of intercultural mediators and interpreters in assistance and public health services, safehouses and solidarity infrastructures should be ensured to improve access to services.²¹

Engaging solidarity infrastructures

• The implementation of public health policies targeting people on the move needs to rely on health and social workers that are already embedded in solidarity spaces and safe havens. These include, among others, safehouses and potentially also, maraudeurs. Whilst investing in and supporting these structures may offer scope to reach migrants, building bridges will require concerted and long-term engagement.
• It is crucial that efforts to distribute vaccinations do not detract from urgent practices through which people on the move make plans for onward transit at refuge stops. Most do not plan to stay at the safehouse for more than one night, and their efforts are directed at the preparation for the Alpine crossing – resting, seeking urgent medical assistance, and obtaining good quality clothes for the journey. Many do not know the route across the Alps and rely solely on their smartphones or on maps distributed at the rail station by volunteers. It is important to consult volunteers and solidarity infrastructures on effective strategies for engagement of migrants.
• The provision of adequate funds for nurses and doctors to volunteer at safehouses may be a way to enhance capacity, so that they can also be supported to engage with COVID-19 vaccination. However, it is essential that medical practitioners are mindful of the cultural norms of assistance networks (as well as people on the move).

Harm-reduction approach

• Effective public health strategies aimed at preventing COVID-19 transmission need to be informed by their priorities and experiences. This may involve combining vaccine roll-out with COVID-19 tests and PPE. Tests require only minutes, and a negative result will provide documentation needed for travel. It is important to provide safehouses and assistance hotspots with COVID-19 tests, alongside adequate funds to cover quarantine costs, and to equip these structures with resources to create isolation zones where the space is lacking.
• To build long-term trust, it is important that vaccination campaigns be embedded within wider advocacy to address the structural marginalisation of people on the move. While it has been recognised that COVID-19 restrictions have exposed economic and health inequalities, public health policies need to consider and openly address the additional risks created by restrictions to mobility. Public health policy concerned with reaching people on the move needs to openly and actively engage with the contestation of borders and advocacy for humanitarian corridors. The lack of safe passage needs to be understood as a public health emergency in itself.

Further mapping of migrant trajectories

• Migratory routes and countries of origin of undocumented migrants are subject to frequent shifts, and depend on changing legislation (e.g., closures of borders and routes) and geopolitics worldwide (e.g., new conflicts and humanitarian crises). Dynamic responses and assistance infrastructures should be strengthened to adequately and promptly respond to the needs of people on the move.
• Further research is needed to better understand how to reshape public health policy so that it can be relevant to people on the move’s needs, and to counteract mainstream, stigmatising and often xenophobic narratives relating to vaccine hesitancy.

CONCLUSION

Policy documents have recently outlined the need to build inclusionary approaches to encourage migrants to take vaccines.²² These instruments recognise the need for tailored communication. We complement such approaches, urging for a consideration of the mobility-centred basis for vaccine engagement.  It is important to engage with trusted networks, and to adapt health information to contexts and concerns centred around mobility. Wider education is also needed, to reverse the stigma that exist against undocumented migrants and people on the move, and to shed light on the public health implications of a lack of safe migratory routes. These efforts must be combined with longer term endeavours to build trust with mobile groups, such as advocacy for safe passage and movement towards and within Europe.

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ACKNOWLEDGEMENTS

This brief was written by Costanza Torre ([email protected]) with support from Elizabeth Storer (LSE) and Sara Vallerani (Rome Tre). The research was funded through the British Academy COVID-19 Recovery: G7 Fund (COVG7210058). Research was based at the Firoz Lalji Institute for Africa, London School of Economics.

CONTACT

If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Olivia Tulloch ([email protected]).

The Social Science in Humanitarian Action is a partnership between the Institute of Development Studies, Anthrologica and the London School of Hygiene and Tropical Medicine. This work was supported by the UK Foreign, Commonwealth & Development Office and Wellcome Trust Grant Number 219169/Z/19/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of IDS, Anthrologica or LSHTM.

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Suggested citation: Torre, C. (2022). Key Considerations: Engaging ‘People on the Move’ to Promote COVID-19 Vaccine Acceptance in Italy. Social Science in Humanitarian Action (SSHAP) DOI: 10.19088/SSHAP.2022.011

Published May 2022

© Institute of Development Studies 2022

This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated. http://creativecommons.org/licenses/by/4.0/legalcode