Since there is (so far) no mandatory vaccination program for SARS-Cov2 for the entire adult population in most of the countries worldwide, herd immunity by vaccination is largely dependent on voluntary decision making of the people. The extensive literature on the topic has delivered a repertoire of explanations for vaccination attitudes and intentions. Individuals negotiate their evaluation of the option to get vaccinated by the degree they trust the vaccine and its providers, perceptions of risks, costs and benefits, understanding and beliefs about health, the body and disease (1–6). The role of sociodemographics has been widely assessed and led to findings of differences in vaccination intention in categories of age, gender, education, income and ethnicity (7–10). However, broader attitudinal and belief-related factors in the context of vaccination have not been focused on yet. While it has been shown that more general attitudes and beliefs seldomly have direct effects on concrete health behavior (11), it can be assumed that during a totalizing event like the COVID-19 pandemic, more global belief structures influence health behavior like the intention to get vaccinated. We therefore seek to further explore the role of wider contextual aspects and their mediated effects on the intention to vaccinate against SARS-Cov2.

Migrants in several countries have been shown to be a vulnerable group during the COVID-19 pandemic, having higher infection prevalence and death tolls (4, 12) even after controlling for socioeconomic status (13). At the same time, most elemental resources to cope with this hazard, such as information, are very limited. In a quantitative analysis of governmental websites of member states of the European Union (14), it was shown that not one member state employed campaigns in the early days of the pandemic regarding information for health care in the languages spoken by the majority of migrants. While in the meantime there is some information available in target languages, one cannot speak yet of a nationwide provision.

The present study tries to understand and explain COVID-19 vaccination intentions with respect to differences in migration background. This article contributes to the literature in two ways: firstly, we explore the effect of migration background on individuals' risk assessment in the context of vaccination intention, and the role of health and political attitudes as potential mediators. We seek to understand social mechanisms of vaccination intention beyond socioeconomic and sociodemographic predictors. Secondly, we calculate a separate, migrant-only model including specific aspects of acculturation (years since migration, media consumption, region of origin) exploring explanations of potential differences in the vaccination attitudes compared to Germans without migration background.

In this section we will outline briefly the way vaccination behavior can be understood through commonly applied behavioral models, but also through additional more general aspects. We further discuss the major elements of each in the context of migration and the consequences of having a migration background in Germany.

We do not seek to replicate the 5C model 1:1, since the literature on the topic is already quite extensive. Moreover, we seek to propose a model where certain aspects of both behavioral and sociocultural aspects are put in relation to one another, so we try to shed light on multiple pathways to vaccination intention. In addition, we contribute to the ongoing discourse with a perspective that is less dependent on vaccine specific aspects and gives special attention to broader facets. We propose two models, where the first one (Model 1) is aimed at estimating the effect of migration and the relation to general and vaccine-specific factors, and a second model (Model 2) considering migrants only, examining migration-specific aspects within this framework. By doing so, we seek to find possible explanations in Model 2 for potentially differing vaccination intentions of migrants in Model 1.

For both cases (see Figure 1), we argue that the migration and sociocultural background mainly influences general attitudes toward political/public institutions and health. For Model 1, we specify the migration and sociocultural background as the migration status and the degree of religiosity. In Model 2, we specify this background as factors of acculturation and the region of origin. Acculturation includes years since migration and the type of media consumption (German vs. foreign media). For region of origin we use the indicator for European country of origin.

These factors determine attitudes toward institutions and health, which in turn are expected to have an effect on the intention to vaccinate, mediated by the fear of infection. On the level of vaccine specific factors, we use fear of infection and fear of transmission as the main mediators, where the former represents the individual and the latter the collectivistic aspect in the perceptions of fear and risk regarding COVID-19. Fear has been shown to be a mediator between risk assessment and health preventive behavior (61, 62). We argue that vaccination intention can be explained by applying this model, where migration and sociocultural background have no direct effects on the vaccination intention, but influence the outcome merely through the formulated mediation pattern.

To control for socioeconomic mechanisms, we include net income and educational level as additional predictors in all models. This approach allows us to identify explanations of vaccinations beyond socioeconomic position.

To explore the rather complex structure of health preventive behavior, we test each model in two variants: Firstly, we apply a strict hierarchical mediated structure (Model 1 and Model 2 without dashed lines in Figure 1). Secondly, we allow effects that empirically skip the strict hierarchical order (Model 1+ and Model 2+; including dashed lines in Figure 1).

It is important to note that the intention to be vaccinated can be explained by the application of the hypothetical structure which we formulated in section 3. This is reflected in a sufficient model fit (see Table 2) for both Model 1 and Model 2, even without further loosening of correlational restrictions. Our findings contribute to the broad literature regarding the 5C Model and sociocultural perspectives in so far as we were able to formulate a “hierarchical” structure of the antecedents of vaccination intention. Vaccination intentions can therefore be understood as a result of effects of the migration and sociocultural background which are first mediated by general belief structures about health and institutions (comparable to confidence in the 5C perspective) and subsequently through fears of infection (both complacency and collective responsibility).

It could be shown that the vaccine specific part of the model is in line with previous research.

Higher perceived risk and thus fear (complacency in the 5C Model) of COVID-19 infection predicted higher intention of a COVID-19 vaccination (6, 9, 23). It is thought that fear causes defensive reactions (72) and in the specific case of infectious diseases, the feeling of being threatened by disease is thought to change preventive behavior. Our findings contribute to the state of research, that this fear or risk assessment can be both of individual and collectivistic nature, where fear of either individual infection and infection of others by oneself leads to a higher impetus to vaccinate. However, this is only true if the whole population is the unit of analysis. Looking only at the migrant sample, individual fear of infection has no effect on vaccination intention, i.e., only the collectivistic component of fear is relevant in the internal negotiation of views toward vaccination. It is conceivable that a cultural orientation directed more toward collectivism makes collectivistic components of fear/risk assessment more relevant. This might be the case since populations from typical migration countries score higher in collectivism than the general population of Germany (32). Future research should investigate the mechanism of collectivistic orientation in the context of migration in more detail.

The overall lower vaccination intention of migrants (when compared to native Germans without migration background) as found in Model 1+ replicates the results of the already extensive research on the issue (4, 6, 18). Beyond the current state of research, we offer an additional explanatory path concerning the origin of the lack of vaccine acceptance, which goes beyond socioeconomic characteristics, bearing in mind that the effect of socioeconomic position could not be explained away entirely (in fact, education is one of the strongest predictors in all models).

We found, in line with current research (39), that migrants tend to have a higher level of religiosity. This effect has two consequences: on the one hand, there is a negative effect of religiosity on the collectivistic fear perceptions regarding COVID-19 infections, which in turn leads to a lower intention to vaccinate. We interpret this finding as a sign for the earlier mentioned notion (35), that religiosity can shift individual and environmental responsibility for disease and protective behavior to the realm of the divine and therefore away from personal agency. On the other hand, the heightened degree of migrant religiosity has a health protective dimension as well. The positive effect of religiosity increases two significant antecedents for vaccine intentions: trust in authorities (or confidence) and health consciousness. For the former effect Browne et al. (73) suggested that religiosity is associated with social conservatism and therefore with more acceptance of advice from established and conventional authorities. The latter effect is in concordance with the finding that religiosity can lead to more health preventive behaviors such as screening and adverse preferences for smoking and drinking (37, 38). Yosef (74) delivers a relevant explanation by pointing out that beliefs concerning purity and the perception of the body as a divine gift within abrahamic theology, might lead to better diet, more preventive screening and abstinence of hazardous substances.

To better understand underlying mechanisms within migration groups we employed Model 2 with a variety of migration specific indicators. As already shown in the literature, the role of acculturation is a complex one. We found positive effects of acculturation in the sense that increasing years since migration leads to an increase in German media consumption, which in turn is a mediator for trust (confidence), health consciousness and thus vaccination intention.

On the other hand, consumption of media from the country of origin decreases with years since migration. Yet, country of origin media consumption has a positive effect on political trust and health consciousness. In Mikolajczyk et al. (53) lower levels of acculturation are linked to higher vaccination rates. The authors argue that protection of Hepatitis B is higher in less acculturated respondents, because the prevalence is higher in the countries of origin and therefore risk perception is still elevated. Perhaps the positive association between health consciousness and political trust can be explained by foreign media reporting on the higher rates of COVID-19 fatalities in the countries of origin compared to the reporting in German media on the German situation. To draw actual conclusions regarding this issue, international comparisons of media content regarding COVID-19 fatalities, as well as media consumption patterns between migrant and native populations have to be studied.

Similarly to Model 1+, religiosity has a direct negative effect on vaccination intention, but no effect on political trust and health consciousness in the migrant-only sample. Evidence from Wong et al. (5) suggests that there is a growing concern among Muslim communities as to whether the COVID-19 vaccines are produced in line with halal requirements. Further, within Christian and anthroposophic communities Fournet et al. (34) identified a reason for undervaccination in the belief of destiny when it comes to disease as well as that a theologically oriented lifestyle alone has protective power against diseases. Further, educational level was identified to be the strongest predictor in migrant religiosity, while the role of acculturation seemed to be negligible. How exactly religion functions within different religious groups in the context of COVID-19 vaccination has yet to be studied in detail. The non-significance of religiosity on political trust, contrary to the all-respondents Model 1, can be interpreted as a sign that the social conservatism that accompanies religiosity (73) only applies to native Germans, since we only measured political trust in the host country institutions. This raises the question as to whether migrant religiosity in turn increases political trust in institutions of the country of origin. It is necessary to bear in mind that migration can already be a sign of distrust in the country of origin institutions, since the dissolution of social infrastructure and lacking economic opportunities are factors that drive people out of the country (75). With our data this question cannot be answered, however future research can make use of direct comparisons of different objects of trust in the context of religiosity.

Another interesting finding is the significantly lower vaccination intention of European compared to Non-European migrants. In Sallam (57) there is evidence that in an international comparison of COVID-19 vaccine acceptance the general populations of the Russian Federation (54.9%) and Poland (56.3%) score among the lowest, whereas Turkey (66 %), for example, is slightly more accepting, yet less so than Germany (70%). These findings correspond with the effects found in our study, yet the effects in Sallam (2021) relate to attitudes in the general population of the respective countries and not their emigrates to Germany. Apart from the general lower vaccination intention, our model provided a parallel path through political trust and fear of infection, where European migrants score lower in both measures. The reason why Europeans have lower trust in German authorities than Non-Europeans cannot be answered with our data and implicate missing mediators. Further research is needed to give plausible explanations.

The strength of our study lies in the employment of a rigorous oversampling framework in the data collection process. In that way, the large share of first-generation migrants (50% of the sample) increases statistical power for the analysis and allows a more differentiated insight. Secondly, by using a Structural Equation Modeling framework, effect decomposition of multiple mediators on vaccine intentions helps to identify potentially differing paths to the outcome for different migration groups.

Beside our contribution, the generalizability of our results has some limitations. Firstly, due to the use of an online access panel sample, bias can be induced by varying degrees of participation probability in the general population. Further, access panel participation is already dependent on proficiency of the German language, which in turn leads to a skewed distribution toward more acculturated individuals. This is reflected in the distribution of the acculturation variables, where low scores in these measures were found only very rarely. To get a wider picture of the effects of acculturation, conventional face to face approaches and more survey translations are necessary to increase variance in acculturation indices.

Secondly, our sample is restricted solely to first generation migrants and Germans without any migration background. This was done in order to increase hard-to-reach groups like first generation migrants. In future studies, the inclusion of second generation migrants can shed light on more specific effects of acculturation.

Further bias is possible due to the sensitivity of the vaccination questions, since this issue has become a political issue as well. Opponents of vaccination might decline participation or respond in a socially desirable way. Approaches to reduce social desirability, like survey experiments, can be helpful in future studies.

Regarding the measures, it should be mentioned that we did not include attitudes toward vaccination or health beliefs in the context of culture or religion. Additionally, we did not investigate the role of media type, where it is conceivable that a potential reliance on a certain media type (e.g., print vs. television vs. online social media) can produce different effects on the outcome measures. Further research is needed to address the role of these factors.

Since we are using cross-sectional data in this study, no inferences can be made regarding causality, the results of our analysis are restricted to the nature of statistical associations.

In this study we estimated two separate models in a SEM approach with vaccination intention as the outcome variable and socio-cultural factors as independent and mediator variables. We found that migration background is negatively associated with COVID-19 vaccination intention. Through multiple mediation pathways the model suggests positive and negative effects of religiosity on vaccination intention. Positive effects are mediated by political trust and health consciousness, whereas negative effects are mediated by fear of transmission. To further understand migrant specific factors, we estimated a second “migrant only” model with additional variables. We found, in coherence with the literature, complex associations regarding acculturation. Acculturation (measured in terms of years since migration) increases antecedents of vaccination intention such as German and foreign media consumption and thus political trust and health consciousness.

Moreover, we found a disparity between European and Non-European migrants, where the former show lower levels of political trust and lower overall vaccination intention than the latter.

Our results mirror frequent demands by public health scholars that campaigns regarding vaccination need to be tailored according to the target population's features and predispositions. First and foremost, it is necessary to offer all kinds of public health information in the target languages, such as Russian, Polish, Arabic, Turkish, Farsi or Kurmanji, especially for official government websites (14). In the dimension of content, interventions integrating religious teachings (74) and emphasizing collective utility of vaccination (22) can further motivate health seeking behavior. Face to face approaches can also help to increase vaccination acceptance in hard to reach communities (76). Regarding communication, it may be possible to increase trust in institutions by restricting the public discourse about COVID-19 to health care professionals and experts (77) and include media presenters from relevant migration groups (e.g., Poland, Russia, Turkey, Syria). In general, those with minority status (13), as well as asylum seekers (78) need to be included in the category of vulnerable groups by health agencies and public health institutions.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: doi: 10.5281/zenodo.5795773.

MH, JM, HA, and BM had the idea of the research and conceptualized and designed the research. MH performed the statistical analysis, interpreted data, and drafted the initial manuscript. JM, HA, and BM supported the analysis and revised the manuscript critically. All authors contributed to the article and approved the submitted version.

The publication of this article was funded by Chemnitz University of Technology and by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) - 491193532.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.