Precarity, agency and trust: Vaccination decision-making in the context of the UK asylum system.

Background: Individuals living in initial asylum accommodation are at increased risk of vaccine-preventable disease, yet confidence in vaccination may be low in these settings. Our aim was to understand the influence of experiences within the UK asylum system on vaccine confidence and decision-making from a sociological perspective. Methods: In-depth semi-structured interviews were carried out on views and experiences around vaccination (09/2020-08/2021) with individuals seeking asylum or having recently been granted asylum (<10 years in the UK). Interviews were audio-recorded, transcribed and analysed in NVivo 12 using a reflexive thematic analysis through an inductive approach. Results: 25 participants were interviewed (mean age: 37 years, mean time in UK: 6 years, 72% female), of whom 13 were living in asylum accommodation at the time of interview. Analysis generated three main themes: 1) the detrimental impact of trauma and fear, both within the UK asylum system and prior, on perceptions of risk and vaccination decisions, 2) the effect of marginalisation, discrimination and neglect within the asylum system on an individual's trust and 3) the structural violence and restricted agency imposed on asylum seekers and its effect on ability and motivation to vaccinate. Past trauma or negative experiences since arriving in the UK, such as feeling forced to receive 'invasive' healthcare interventions in asylum accommodation may lead to distrust, increased perception of danger and avoidance of perceived 'risks' such as vaccination. Participants described how their struggle to cover basic necessities, social isolation and precarious living conditions imposed by the asylum system left them with more pressing priorities than vaccination. Participants who perceived that they had been cared for with empathy in the healthcare system or who described feeling empowered to make their own decision about vaccination often suggested they would be likely to accept vaccination if offered. Conclusions: Asylum seekers and refugees have often experienced substantial trauma and precarity and have a lack of agency directly imposed on them by the asylum system. These factors are likely to impact trust and decision-making around vaccination, with some also representing systemic or structural barriers to accessing services. Formative experiences in the UK are key to establishing trust in healthcare settings; a trauma-informed approach should be central in developing vaccination interventions for these groups, particularly in asylum accommodation.