Racial and Ethnic Inequalities, Health Disparities and Racism in Times of COVID-19 Pandemic Populism in the EU: Unveiling Anti-Migrant Attitudes, Precarious Living Conditions and Barriers to Integration in Greece

Abstract

The COVID-19 pandemic has had a significant impact particularly on the most vulnerable populations, including immigrants, asylum seekers and refugees in the EU. The article depicts the results of the comparative research project “Local Alliance for Integration (LION/GSRI/University of West Attica/81018): Migrant and Refugee integration into local societies in times of the COVID-19 pandemic in Spain and Greece” implementing a qualitative methodology. This article analyses via 32 in-depth interviews the experiences of immigrants, asylum seekers and refugees in Greece, the increased barriers towards integration due to racial and ethnic inequalities, precarity and health disparities during this period which function as a means of perpetuating exclusion in five sectors: (a) formal employment, (b) healthcare, (c) formal education and language training, (d) housing and social care/protection, and (e) intercultural coexistence as well as the new rise of a hostile rhetoric and anti-migrant attitudes under a COVID-19 pandemic populism. The unravelling of the narratives revealed perceptions and practices of inequality and uncertainty as well as of hope. The socioeconomic impact of the pandemic on immigrants, asylum seekers and refugees, similarities and differences that occurred and evidence of the ongoing obstacles they encountered during the pandemic are presented. Policy and practice implications include the implementation of prevention measures by the institutions that are tasked with the responsibility to remove hindrances, address unequal treatment, racial/ethnic and social inequalities and raise awareness on multiple ways in which the COVID-19 pandemic has intensified vulnerability.

1. Introduction: Racial and Ethnic Inequalities, Racism and Exacerbating Migrant and Refugee Health Disparities during the COVID-19 Pandemic

Racism entails practices and norms that allocate lower value and determine prospects according to the external looks or skin color of individuals. In the context of the COVID-19 pandemic, inequalities emerged particularly regarding marginalized and racialized populations [1,2,3]. Strong differences existed concerning mortality and infection rates by age, gender, ethnicity, work status and conditions, housing and geographic residence [4,5]. Racism involves a disadvantaged position in society where consistent disparities arise along with institutional exclusion [6,7] in employment, education, housing, healthcare and everyday interaction. It is articulated via xenophobic behaviours and discriminatory practices due to social identification of racial and ethnic origin with precarious, low/status/low wage work, poor housing and living conditions. Immigrants, asylum seekers and refugees are subject to aggression and false characterizations, negative behaviours, rejections for work advancement and access to education and healthcare. All these lead to poor life opportunities and unfavourable exclusion regarding healthcare, employment and housing, and place migrants on the receiving end of multiple forms of violence (verbal, physical and psychological) and increasing disparities [8,9]. Failure to deal with social determinants of health disparities increases vulnerability of these racial and ethnic groups to infectious diseases, thus combating social inequalities needs to be a priority in both policy and practice [10]. For example, there have been reports of racism against Chinese individuals and other groups in response to the way the origins of the virus were stated [11,12,13]. There are documented occurrences of xenophobic responses where racial and ethnic groups were marginalized. They are perceived by societies as ‘unwanted individuals’ or as a ‘threat’, a ‘health time-bomb’, ‘criminals and dangerous’, ‘invaders/intruders’, individuals who ‘alter the homogeneity of the host country’, people who are ‘uneducated, uncultured and do not want to attend school’, and who ‘take the jobs of native-born workers’, a threat to democracy, and draining of public resources and during COVID-19, a threat to public health [9,14,15,16,17,18]. All these descriptions have been used by political leaders and the media [19,20,21].

Once infected with SARS-CoV-2, individuals who have been marginalized are in greater need of hospitalization because they often have chronic comorbidities [22,23]. The prevalence of chronic diseases is higher among low-income, minority populations [24,25]. Racial or ethnic minority patients in the European Union (EU) often lack health insurance, suffer from comorbidities, live mostly in low-income and often unsafe neighborhoods, and are dependent on care from low-funded safety net institutions [26,27]. Patients with limited English language skills and especially limited health literacy, are more likely to have worse health outcomes [28]. Disparities in socioeconomic conditions across racial lines have intensified during the COVID-19 pandemic [29,30,31]. Amid the state pandemic measures, the rhetoric on pandemic uncertainty, anti-vaccination movements and vaccine hesitancy, migrants have been among the worst hit by the pandemic and migrant workers have been at a higher risk of infection. This is due to their precarious employment and legal status, while still being considered essential workers throughout the public-health crisis in both low- and high-skilled jobs in the EU [32,33,34,35]. Additionally, while residing in confined and crammed spaces in Accommodation Facilities, squalid housing and unsanitary conditions, with inadequate access to healthcare, migrants have been vulnerable to COVID-19 infection [8,36,37,38].

1.1. COVID-19 and Its Impact on Migrant and Refugee Integration

Racism and xenophobia against migrants in particular are on the rise [39,40,41]. Anti-migrant sentiments and mobilizations, social exclusion and xenophobia have intensified as governments, local societies, communities and individuals react to fears and challenges related to the disease, regarding migrants as a threat to public health [42,43,44]. This anti-migrant political and social media hateful rhetoric is targeted at migrants [45,46,47]. Xenophobia entails attitudes, prejudices and practices that cast-off, exclude and frequently denigrate individuals based on the belief that they are outsiders or foreigners [48,49]. Racism being a conceptual construct assumes a position of power over others based on physical and cultural attributes, e.g., skin colour, origin and language [50,51,52]. Although these are separate ideas, they overlap as phenomena since one triggers the other. The media plays a catalytic role in boosting racist and xenophobic narratives. During the pandemic, prejudice and disdain against migrants offer an emotional outlet for anxieties driven by fear and ignorance. Both racism and xenophobia against migrants have been established in clandestine and unconcealed ways (clearly visible verbal and physical abuse, hateful rhetoric, practices and behaviour) and varied forms at all levels, regenerating from each other [53,54,55].

During the COVID-19 pandemic, migrants experienced: (i) different frequency in testing or treatment, (ii) mobility restrictions, (iii) segregation or quarantine in overcrowded and unhygienic conditions; (iv) delays in vaccinations and exclusion from general response programmes; (v) delays in the issue of residence permits, applications as well as lack of access to migration/asylum services, driving them to precarity and vulnerability while experiencing covert ways in which racism and xenophobia operate in everyday interactions with nationals [8,56,57]. What was observed is a negative stereotypical association between migration and fear, an equation ‘migrants = dangerous individuals who bring or carry diseases and spread COVID-19′ was embedded in social consciousness, leading to erroneous suppositions [58,59]. These suppositions, often reinforced via the construction and standardization of otherness in discourse, are embedded in everyday discussions among nationals. As a consequence, they segregate and exclude migrants as a means of ‘protecting’ themselves, leading to negative characterizations, hatred, along with expulsions and quarantine measures [60,61,62]. The above thought process, formed the perception that migrants posed a risk and fear is weaponized in the name of spreading SARS-CoV-2 leading to restriction of their mobility in favour of protecting nationals [63,64]. However, administrative policy responses intensified the risk of exposure to SARS-CoV-2, as well as to violence, abuse and stress, thus impacting their physical and mental health beyond the pandemic. All these strengthened public perceptions that migrants pose a risk to public health, intensified their precarity and vulnerability to health risks, feeding a vicious cycle of precariousness and racism (see

Table 1. Precarity and racism during the COVID-19 pandemic.

Pre-existing precarity →	Increased precarity due to the pandemic →	Exclusion, exploitation and further precarity
← racism and xenophobia →

).

Integration describes an individual or group process that seeks to adapt to a new country and the reality of immigrants, applicants and beneficiaries of international protection [65,66,67,68]. It is a dynamic, two-way process of mutual accommodation by both immigrants and residents of EU Member States, and the promotion of fundamental rights, non-discrimination and equal opportunities for all are key integration issues [69]. One of the main indicators for examining the degree of integration of immigrants, asylum seekers and refugees is their access to healthcare services, both at the level of institutional framework and in challenges they face when accessing and utilizing health services [8,70]. Moreover, their concentration in precarious, low-status/low-wage jobs contributes to this, especially in the case of irregular migrants who are severely affected [71]. Precarious work is employment that lacks all the standard forms of labour security, typically takes the form of wage work, is characterized by exceptionally limited social benefits and legal rights, job insecurity, low wages and high risk of ill health [72] (pp. 3–4). Migrants are a social category with particular needs in the health sector, given their generally poor living conditions (both in sending and receiving countries), but also due to additional problems caused by difficulties adapting to a new social and cultural environment [73,74]. Thus, the relationship between social exclusion and the health status of migrants works in a bidirectional manner: on the one hand, the experience of social exclusion—as reflected via poor living conditions, low income, difficulties in communication, institutional or actual exclusion from health and other services and the phenomena of racism and xenophobia—has detrimental effects on the health of immigrants. On the other hand, a possible health disorder leads to social exclusion due to difficulty in finding formal employment since immigrants are mostly employed in casual, informal occupations, in precarious, low-status/low-wage jobs and experience deterioration of their real income.

1.2. COVID-19 Pandemic and Social Determinants of Migrant and Refugee Health

Social determinants of health contribute to racial and ethnic groups being disproportionately affected by COVID-19 [4]: (a) Living environment: They face difficulties finding inexpensive, quality housing [75,76]. This limits their options to neighborhoods and residences with other racial and ethnic groups, crowded conditions that may also lack access to reliable transportation. Under such conditions, illnesses, diseases, and injuries are more common and more severe. Access to nutritious affordable foods may be limited and they may be exposed to environmental pollution within their neighborhoods. Older adults are at increased risk due to living in over-crowded conditions. (b) Healthcare: They are disproportionately affected by lack of access to quality health care, health insurance, and linguistically and culturally responsive health care, resulting in their distrust of State healthcare systems and considering health, health promotion, preventive care and hygiene as unimportant [77]. (c) Occupational conditions: They are disproportionately represented in precarious, low-status/low-wage work due to the unequal division of labour. Hence, it entraps migrants almost exclusively into the informal sector of the economy, where employers benefit financially by avoiding social security contributions and hiring people without contracts. Migrants exercise manual labour in agriculture, construction, crafts, domestic work, restaurant and hotel services, personal care, nursing, factory work, fishery, food production, and public transportation and in itinerant trade. These jobs are not attractive, offer no social prestige and are socially inferior [78]. In such settings, they have increased risk to be exposed to COVID-19 due to close contact with the public or other workers, as they involve activities that cannot be done from a distance or lack benefits such as health insurance and paid sick leave. (d) Income: They face barriers in accumulating funds, have greater debts and are unable to send remittances to the country of origin, pay for health coverage in cases of uninsured individuals, cover medical bills and access housing, nutritious food and childcare. (e) Education: They are disproportionately affected by inequities in access to formal education. This can lead to lower literacy, limited school completion rates, barriers to university-level education, poor access to quality job training and language courses, thus restricting future job choices and leading to inferior pay or unstable jobs.

These results are disadvantageous for migrants, asylum seekers and refugees due to inequities in the above social determinants of health [79,80,81]. Racism impacts them mentally and physically and is deeply embedded in societies creating inequities in access to a range of social and economic benefits [82,83]. Racial and ethnic groups in the EU experience higher rates of ill health, including COVID-19 infection [84,85,86], and death compared to nationals. The pandemic has had an uneven impact among racial and ethnic populations deepening health disparities due to poverty and health and quality-of-life risks and are less likely to be vaccinated and unable to implement social distancing.

2. The Rise of the COVID-19 Pandemic Populism in the EU: Anti-Immigrant, Asylum Seeker and Refugee Attitudes and Mobilizations

The level of politicization of migration issues by political parties in the EU has been extremely significant, and remains so to this day. Since 1990, all aspects of the migration phenomenon have been a source of conflict and dispute, culminating in the 2015 “refugee reception crisis [20,87,88,89,90,91,92]. The management of the migration issue is at the centre of an ongoing political debate involving arguments that highlight the existence of mixed migration flows and the questionable conditions of the asylum system. The political controversy in the EU mostly concerns internal security, cultural issues and social welfare implications, focusing less on integration. Due to the politicization of migration, anti-migration rhetoric has become part of a process of enhancing the nation-state concept by differentiating citizens from immigrants, asylum seekers and refugees. Right-wing populists embed the will of the people—the so-called ‘silent majority’—while rejecting minority groups, especially migrants. In Greece, for example, the political party ‘Elliniki Lisi’ which ranked 5th in the 2019 national elections at 3.7%, in November 2019 called for the closure of the borders for refugees and the transfer of refugees and migrants to uninhabited island [93]. In July 2021 they did not attend the event for the anniversary of the restoration of the Republic at the Presidential Mansion due to the presence of representatives from migrant and LGBTI communities [94]. Thus, far-right and populism has been proven resilient within many countries’ political and electoral systems before and during the COVID-19 pandemic in the EU, e.g., Italy, France, Hungary, Spain, Germany and others supporting an anti-immigrant stance with stronger migration controls, expulsion and emphasis on a ‘nationals only’ welfare. Media representations and the political discourse regarding skepticism about COVID-19 and hesitancy regarding SARS-CoV-2 vaccination led to new polarization that coexisted with implemented measures such as in the case of Greece: (a) suspension of asylum applications, (b) extension of residents permits, (c) suspension of reception and administrative actions (recordings, interviews, filing of an appeal, etc.), (d) suspension of all special activities in the Accommodation Facilities, (e) forced lockdown and restriction on movement were implemented and were periodically extended. This approach was problematic as there was concurrently a lifting of restrictions for the public and for international visitors so this paved the way to anti-immigration discourse and right-wing populism similarly in the EU [95]. This section is mainly based on media coverage.

In Austria, on 7 December 2020 the Austrian Chancellor declared that individuals who had been in origin countries during the summer, brought COVID-19 back to the country [96]. In a press conference in 24 February 2021 the right-wing Freedom Party of Austria (FPÖ) mentioned that approximately 20% of irregular, third-country nationals (TCNs) who were apprehended by the border police -the Austrian state Burgenland- “bring coronavirus to Austria” [97]. In Belgium, TCNs have been severely affected by COVID-19; they not only face obstacles with their asylum applications but the State has also imposed more strict regulations for accessing housing. Living conditions for TCNs has become extremely precarious [98]. The State has maintained a more conservative position regarding EU recommendations on the opening of borders, and inflows from non-EU countries has been limited. When Belgium implemented a lockdown in mid-March 2020, the authorities evacuated half the accommodation centres, leaving hundreds of individuals without shelter. The state also ceased the operation of the reception centre in Brussels, making it impossible for TCNs to receive state support. Thus, some Belgian nationals intervened to provide assistance by offering food, shelter and protection from being detected by police when sleeping on the streets [99]. In the Czech Republic on 30 June 2021, the Ministry of Health informed the regional authorities that they could vaccinate migrants with no health insurance, but no aid was offered to organize and implement this [100]. In Cyprus there were incidents in which TNs reported that they had been fined because, unbeknownst to them, they had not received SMS approval of their request to leave their residences. Some were fined for giving a wrong reason for exiting, while others for remaining out for longer than allowed by law. In addition, employees of humanitarian organizations in Nicosia noted that in many cases during the lockdown, police gathered homeless TCNs and transported them to the Emergency Hospitality Center in Pournara in Kokkinotrimithia, despite many TCNs being officially registered as residing within the city of Nicosia. The government justified these actions by citing health reasons, claiming that the TCNs lived in conditions which promoted the spread of the virus [101].

In Denmark racism is considered to be a widespread issue. Recently, a racist attack was reported in Aarhus. The perpetrator punched and shouted racist slanders at an employee at a COVID-19 testing center. In addition, the Danish government itself has a reputation for pursuing a tough immigration policy [102]. The coronavirus pandemic has increased exposure of Asians and other minorities to hate speech in Denmark. An Asian woman who had been adopted by a Belgian family was in a grocery shop when a man approached her and said: “You should go back to where you come from”. He then spat on the ground in front of the lady and her son [103]. In France, for many migrants who are still camping out in Calais and Dunkirk, the pandemic worsened an already dire situation. In certain cases, supermarkets did not allow them entrance and the police removed their tents [104,105]. Additionally, irregular TCNs and those employed in the informal sector of the economy were severely affected [106]. In Germany, the far-right party Alternative für Deutschland (AfD) promised to implement a campaign to end the COVID-19 restrictions, a stricter policy on migration and an exit from the EU, in its pre-elections manifesto [107]. The pandemic has increased unemployment among TCNs faster than among German nationals, hindering previous successful efforts of the country to assimilate 1.1 million asylum seekers into the labour market since 2015 [108]. TCNs deal with increased racism due to the pandemic [109]. The COVID-19 lockdown has negatively affected the unemployed, the homeless and refugees in Berlin, and the lives of many individuals who feel unprotected and experience increasing precariousness for their future [110,111,112]. Since the COVID-19 pandemic more racist attacks have been reported [113] in Germany and German-based Asians, Germans with Asian migration history and people assumed to be Asian, have reported experiencing an increase in anti-Asian hate, as they are considered responsible for the origin and rapid spread of COVID-19. Irregular migrants fear deportation more than anything and the COVID-19 pandemic has added to their fears as they are obliged to be registered to receive healthcare [114]. Migrants have fewer job opportunities and German language courses have been cancelled [115,116] as COVID-19 measures restrict group gatherings [117]. Misinformation via electronic social media has created obstacles to vaccinations under crowded conditions [118].

In Greece on the Athens-Thessaloniki train route, when at the Lianokladi station, a legal migrant from Cameroon was forced off the train, because they believed that he had coronavirus. During the inspection of his ticket, it was found that he had purchased a ticket to Livadia and bore a document stating that he had contracted coronavirus in May 2020, four months previously. The passengers panicked and demanded he get off the train. The inspector asked him to sit on the floor until they reached the next station, where he left the train, while the police and the National Center for Emergency Care (EKAV) were informed [119]. In another incident that took place on the Athens-Thessaloniki route on November 2021, the train was stopped to disembark 27 Bangladeshi nationals as the rest of the passengers were disturbed by their presence and asked the specific people to be checked for the required health certificate [120]. In Kilkis there were intense protests and mobilization of parents against the integration of refugee and immigrant children in the first grade of Axioupolis High School, where out of 97 enrolled students, 51 were local citizens and 46 refugees and migrants. The mayor described the reactions of the parents as “justified”, pointing out that these are children who do not have the educational background to participate at an equal level in the educational process. “The justification is that they will bring them in to integrate and socialize and not to learn, sacrificing the learning future of our children and endangering public health as most COVID cases are detected in immigrant camps” the statement said [121]. At the port of Thermi in Lesvos Island [122] a group of citizens from the area blockaded the port, not allowing the disembarkation of refugees and migrants who had been taken there by the Coast Guard. There were approximately 50 people on the boat, including many children. The representative of the UN High Commissioner for Refugees, journalists and photographers were attacked and insults were directed towards a municipal councilor. In another incident that took place in Chios on 12 August 2020, a Greek citizen was arrested following a complaint by the Racist Crime Observatory about a racist post on social media calling to action against the refugees; in the post, the Greek stated that ‘they are destroying our land and property. Wanted Dead or Alive’ [123].

In Malta applications for residence permits in the country have been affected by the pandemic and the Maltese government has announced that residence permits will be revoked for TCNs found to be in violation of quarantine rules [124]. In Hungary, as part of these national measures in the field of migration under the COVID-19 pandemic, the State has strengthened its border guards with troops and police in collaboration with the Czech Republic, Poland and Slovakia. Barbed wire has been set up along the border with Serbia and Croatia to intercept the flow of asylum seekers, a state of emergency was declared in border areas and sanctions for illegal border crossings were increased. A law passed by the Hungarian Parliament made it mandatory for asylum seekers, including children, to be kept in Facilities set up at the border during asylum applications, and it was announced that those who did not adhere to the law and were arrested, would be expelled. These actions were taken as incoming populations were considered to be at high risk of spreading COVID-19 [125]. In Italy, the COVID-19 pandemic triggered a “Sinophobia” with Italians reporting acts of violence, assaults, sexual violence, insults and boycott of businesses, discrimination and harassment [126]. In Romania the government prevented most foreigners from entering the country on March 21st and tightened restrictions on travel within the country [127]. In Slovenia the COVID-19 quarantine cost migrant workers their jobs. Their rights had already been violated, and migrant workers in Slovenia stated that quarantine measures also cost them their jobs. When a migrant tested positive for COVID-19 in September, it cost him not only his health but also his job. As a Serbian truck driver employed in Slovenia, he would not be very useful to his employer during the quarantine and post-infection recovery period: “I resigned. My boss asked me to resign and that’s it” [128]. Building on these existing findings, this article will further investigate the experiences of immigrants, asylum seekers and refugees in Greece, the increased barriers towards integration due to racial and ethnic inequalities, precarity and health disparities during this period which function as a means of perpetuating exclusion in five sectors: (a) formal employment, (b) healthcare, (c) formal education and language learning, (d) housing and social care/protection, and (e) intercultural coexistence.

3. Materials and Methods

The COVID-19 pandemic has had a significant impact particularly on the most vulnerable populations, including immigrants, asylum seekers and refugees [129,130,131,132,133]. The article attempts to address the following central question: Has the COVID-19 pandemic raised barriers against integration and allowed space to anti-migrant attitudes? The results are based on findings from the project “Local Alliance for Integration” (LION/General Secretariat for Research and Innovation (GSRI)/University of West Attica (UNIWA)/81018): “Migrant and Refugee integration into local societies during the COVID-19 pandemic in Spain and Greece”, carried out by the Department of Public Health Policy at the School of Public Health of the University of West Attica and funded by the General Secretariat for Research and Innovation implementing a qualitative methodology under the National Funding 2019 with Scientific Director/Principal Investigator (PI) Theodoros Fouskas, Assistant Professor at the Department of Public Health Policy at the School of Public Health of the University of West Attica (UNIWA). The interviews were conducted in person during the first half of 2022 (between 18 March 2022 and 28 May 2022). In the current article, research results from Greece are presented.

3.1. Interviews

Thirty-two (32) in-person, semi-structured interviews were conducted in Greece with adult male and female TCNs (immigrants, refugees and asylum seekers) from Afghanistan, Congo, Iraq, Kuwait, Morocco, Somalia, Syria and Uganda (see

Table 2. The social and demographic characteristics of the sample.

Interview Code	Nationality	Gender	Age	Entry Year in Greece	Reasons for Entry	Way of Entry	Education	Family Status	Children	Employment	Residence	Community Association Participation	Healthcare via NHS	Healthcare via NGOs	COVID-19 Positive	COVID-19 Vaccinated
1	Syria	Male	23	2019	Warfare	Irregularly/Sea	ISCED 2: Lower secondary education or second stage of basic education	Married	1	No	Container in Open Accommodation Facilities for Migrants and Refugees	No	No	No	Νο	No
2	Congo	Male	36	2019	Warfare		ISCED 2: Lower secondary education or second stage of basic education	Single	0	No		No	No	No	Νο	No
3	Congo	Male	34	2019	Warfare		ISCED 1: Primary education or first stage of basic education	Single	0	No		Yes	Yes	No	Νο	No
4	Iraq	Female	55	2018	Warfare		ISCED 6: Bachelor’s or equivalent level	Married	3	No		No	Yes	No	Νο	No
5	Iraq	Female	21	2020	Warfare		ISCED 3: Upper secondary education	Married	1	No		No	Yes	No	Νο	Yes
6	Somalia	Female	28	2018	Warfare		ISCED 2: Lower secondary education or second stage of basic education	Married	1	No		No	Yes	No	Νο	Yes
7	Somalia	Female	20	2018	Warfare		No formal education/below ISCED 1	Married	0	No		No	Yes	No	Νο	Yes
8	Morocco	Male	44	2019	Economic		ISCED 6: Bachelor’s or equivalent level	Married	2	No		No	Yes	No	Νο	No
9	Congo	Male	21	2019	Economic		ISCED 5: Short-cycle tertiary education	Single	0	Yes		No	Yes	Yes	Νο	Yes
10	Syria	Male	30	2020	Warfare		ISCED 1: Primary education or first stage of basic education	Married	3	Yes		No	Yes	Yes	Yes	No
11	Somalia	Male	19	2021	Economic		No formal education/below ISCED 1	Single	0	No		No	No	No	Νο	Yes
12	Congo	Female	29	2017	Family		No formal education/below ISCED 1	Married	2	No		No	Yes	Yes	Νο	No
13	Kuwait	Male	57	2019	Economic		No formal education/below ISCED 1	Widowed	3	No		No	Yes	No	Νο	Yes
14	Congo	Female	39	2019	Economic		ISCED 2: Lower secondary education or second stage of basic education	Single	0	No		No	No	Yes	Νο	Yes
15	Iraq	Female	70	2018	Warfare		No formal education/below ISCED 1	Single	2	No		No	Yes	Yes	Νο	Yes
16	Congo	Male	41	2018	Political		ISCED 6: Bachelor’s or equivalent level	Married	3	Yes		No	Yes	Yes	Νο	No
17	Congo	Female	36	2019	Political		ISCED 1: Primary education or first stage of basic education	Single	1	No		No	No	Yes	Νο	No
18	Congo	Male	20	2019	Economic		No formal education/below ISCED 1	Single	0	No		No	Yes	Yes	Νο	Yes
19	Congo	Male	29	2019	Warfare		ISCED 6: Bachelor’s or equivalent level	Single	2	No		No	No	Yes	Νο	No
20	Syria	Female	23	2019	Warfare		ISCED 3: Upper secondary education	Married	2	No		No	Yes	Yes	Νο	No
21	Syria	Male	24	2019	Warfare		No formal education/below ISCED 1	Married	3	No		No	Yes	Yes	Νο	Yes
22	Somalia	Female	19	2019	Warfare		No formal education/below ISCED 1	Single	0	No		No	Yes	Yes	Νο	No
23	Uganda	Male	28	2018	Warfare		ISCED 2: Lower secondary education or second stage of basic education	Married	2	No		Yes	Yes	Yes	Νο	Yes
24	Syria	Male	20	2019	Warfare		ISCED 2: Lower secondary education or second stage of basic education	Married	1	Yes		No	Yes	Yes	Νο	Yes
25	Somalia	Male	19	2020	Political		No formal education/below ISCED 1	Single	0	No		Yes	No	Yes	No	Yes
26	Congo	Female	39	2019	Economic		ISCED 2: Lower secondary education or second stage of basic education	Single	0	No		No	No	Yes	Νο	Yes
27	Kuwait	Male	37	2019	Economic		No formal education/below ISCED 1	Widowed	4	No		No	Yes	Yes	No	Yes
28	Congo	Female	29	2020	Economic		ISCED 2: Lower secondary education or second stage of basic education	Separated	2	No		No	No	Yes	No	No
29	Syria	Male	30	2020	Warfare		ISCED 1: Primary education or first stage of basic education	Married	3	Yes		No	Yes	Yes	Yes	No
30	Afghanistan	Female	43	2019	Warfare		ISCED 1: Primary education or first stage of basic education	Married	3	No		No	Yes	Yes	Νο	No
31	Afghanistan	Male	37	2019	Warfare		ISCED 3: Upper secondary education	Married	2	No		No	Yes	Yes	Νο	Yes
32	Afghanistan	Female	29	2019	Warfare		No formal education/below ISCED 1	Married	3	No		No	Yes	Yes	Νο	Yes

) living in Open Accommodation Facilities for Migrants and Refugees in the wider region of Attica (Greece). Additionally, fifteen (15) semi-structured interviews were conducted in Spain with adult male and female TCNs from Colombia, Venezuela, El Salvador, Romania and others in the greater Andalusian region. Via 47 in-depth interviews regarding the experiences of immigrants and refugees in Spain and Greece the research unveils increased barriers towards integration during the COVID-19 pandemic which function as a means of perpetuating exclusion in five sectors: (a) formal employment, (b) healthcare, (c) formal education and language learning, (d) housing and social care/protection, and (e) intercultural coexistence as well as unravelling the impact of the COVID-19 pandemic on migrants in the EU, which caused polarization, racism and new forms of populism and obstacles to their social integration. The unravelling of the narratives revealed perceptions and practices of inequality and uncertainty but also hope. The socioeconomic impact of the pandemic on immigrants and refugees, similarities and differences and evidence of the continuous obstacles they encountered during the pandemic are presented. Policy and practice implications include the implementation of prevention measures by the relevant institutions to remove obstacles, address unequal treatment, and raise awareness that the COVID-19 pandemic has intensified vulnerability.

Applying this technique allowed the researches to delve into the TCNs own vision of their migration path and their integration/inclusion process in the country of arrival. It also helped in identifying possible “success stories” of their integration and inclusion. The main constraint during the research were the COVID-19 pandemic restrictions. In order to minimize these limitations, researchers provided a flexible availability on their part and extended the planned time of the research.

3.2. Data Analysis

The transcribed interviews underwent a coding procedure. Data broken down into parts and labels to identify recurrences of coded text within the cases and links between codes. Thematic Analysis was implemented.

3.3. Research Ethics

Interviewees were given an informed consent form, which guaranteed confidentiality. In the context of ethical issues and anonymity, names or personal details of participants would not appear in the interview transcript. The methodological design and the information collection instruments were designed by the Scientific Director and approved of by the Research Ethics Committee of the University of West Attica (UNIWA) (approval ref. no. 22354/08-03-2022). Participants were informed of the procedure and purpose of the study, participation of the sample and continuation in the research has been voluntary, the investigation was carried out under the principle of confidentiality of data provided, ensuring the correct use of the same and the research participants signed the informed consent. All personal data obtained in the study is confidential and will be treated in accordance with Law 4624/2019 on data protection.

4. Migrants Experiencing Inequality and Precarity, Racism and Populism in the Midst of the COVID-19 Pandemic: Barriers against Integration of Immigrants, Asylum Seekers and Refugees in Greece

4.1. Health Care

The majority of interviewees report that, while in Greece, they have visited a public hospital at least once—for themselves or their children and have received medical care and/or medication. One of them (interviewee 15, female from Iraq) reported taking medication for hypertension and diabetes, while one participant (interviewee 9, male from the Congo) admitted being treated by a psychiatrist to whom he was referred to by a psychologist, as he had previously been residing under stress in Moria (Lesvos). They usually make an appointment with the assistance of officials of the Facility in which they live. However, two participants (interviewee 2, male from the Congo, interviewee 19, male from the Congo) reported that since they do not possess Tax ID (AFM/Tax Identification Number and/or Medical ID/National Insurance Number (AMKA)/PAAYPA) they have limited access to medical services and/or have to pay for the medication they need. Similarly, another participant (interviewee 5, female from Iraq) stated that she could not afford the prescribed medication. Additionally, the same participant stated that the absence of interpreters when in the presence of medical staff hindered communication and created difficulties. In fact, even though she spoke a little English, she could not communicate with to the medical staff. Another issue that was mentioned was the tendency of health issues to be downgraded by the medical staff: one participant (interviewee 4, female from Iraq) said that she went to hospital not feeling well, but the doctors insisted she was healthy: “I went to the hospital because I was not well; there they told me “There’s nothing wrong with you”. In fact, she added that officials of the refugee Facility have formally complained to a hospital about this practice, but receive the answer that the patient was well in their health or that they should visit the hospital again: “She has nothing” and “Come next week”, something not always feasible due to family obligations: “I cannot leave the girl alone [her minor daughter] every day to visit doctors”. On the other hand, when asked about it, none of the participants reported discriminatory behavior towards them by the medical staff—some said that the behavior of the staff towards them was “good”. Regarding the protective measures against the spread of the coronavirus pandemic, almost all participants stated that they adhere to the personal protection measures and specifically the use of masks and antiseptic lotion, adding that they are provided with these items within the Facility. However, it seems that the provision of information on COVID-19 is not the same in all the Facilities: for example, as one participant (interviewee 26, female from the Congo) reported, while in the refugee Facilities in the Aegean islands, the executives informed the refugee population about the COVID-19 protective measures, which apparently is not the case in the Facility he currently resides. There was also a difference in the reports by the participants regarding the provision of personal protective equipment as some of them stated that they are given “only” masks within the Facility, while others stated that they have access to other materials such as antiseptic hand lotion. One possible explanation is that the relevant items of personal protection are not sufficient to cover the needs of the entire refugee population living in the Facility. An interviewee from Kuwait (interviewee 27, male) said:

“I was in fear. I did not have a mask. Later they gave me a few. We did not have many doctors”.

Additionally, 3 participants (interviewee 15, female from Iraq and interviewees 6, 7 two females from Somalia) had already been vaccinated against coronavirus. Of the others, 1 participant (interviewee 4, woman from Iraq) stated that her vaccination had been scheduled, 1 participant (interviewee 10, male from Syria) stated that he did not wish to be vaccinated, 1 participant (interviewee 16, male from the Congo) stated that he intended to be vaccinated while another (interviewee 2, male from the Congo) wondered how he could be vaccinated while not having a National Insurance Number (AMKA or PAAYPA/Provisional Social Security and Health Care Number). The lack of adequate or effective information is also highlighted by reservations expressed recently by some of the participants regarding the safety of coronavirus vaccines. In particular, one participant (interviewee 1, male from Syria) stated that, despite the fact that he fears the coronavirus pandemic, he does not intend to be vaccinated because he does not know what the vaccine contains, while to strengthen his argument, he referred to the corresponding refusal or reservations of several Greek citizens: “[I am not vaccinated] because I do not want to be injected with something [the vaccine] that I do not know. “Not all Greeks have been vaccinated”. Another participant (interviewee 18, male from the Congo) reported that, although initially afraid, he finally decided to get vaccinated because his friends had done so. One (interviewee 29, male from Syria) participant also expressed the view that the coronavirus pandemic and the consequent restrictive measures are simply an excuse to justify his poor living conditions. Specifically, when asked how the pandemic and the restrictive measures affected his life, he replied:

“Excuses! Everyone talks about coronavirus. I have not seen a [case] of coronavirus. I have not had it either; and I undergo tests regularly. I have nothing”.

Another interviewee (19, male from the Congo) added that the problems he faced before the pandemic are the same as those he faced during the pandemic. As for the other participants, one participant (interviewee 32, female from Afghanistan) focused mostly on the effects of the pandemic and the resulting restrictive measures on mental health: as she characteristically stated, because of the pandemic (and the consequent restrictive measures) “we are like prisoners”, “It has deeply affected us psychologically”, “we are afraid to go out”, “our already aggravated psychological condition has been affected”. In the same vein, another participant (interviewee 7, female from Somalia) noted that their daily lives are difficult as they have been under “too much pressure” and are forced to wear masks. An interviewee from Syria (interviewee 24, male) highlighted:

“One day I couldn’t find my mask. I looked everywhere. I was afraid to go out”.

Another participant (interviewee 6, female from Somalia) focused on the difficulty of meeting daily needs while he dwelled on the conditions of confinement, but also expressed the hope for better days: “I cannot go to the supermarket, I cannot go out on the street, I cannot buy anything, but now we have had the vaccinations and I hope things will change”. Finally, another participant (interviewee 23, male from the Uganda) generally stated that he is having a “difficult” time due to the restrictive measures, adding however “I thank God that I am alive”. An interviewee from the Congo (interviewee 26, male) emphasized:

“Now, when we meet, we will be able to talk with each other, because we have been vaccinated. Before, it was difficult because we were afraid to approach one another and spend time together because of COVID-19”.

Overall, 17/32 (53.13%) were had been vaccinated and 2/32 (6.25%) were positively tested in COVID-19.

4.2. Employment

Some Congolese men, one Iraqi woman and two Somali women have had work experience in their home country: house painters, an English teacher, a housekeeper and a street vendor, respectively. One participant (interviewee 6, female from Somalia) stated that she has never worked in her life, while one participant (interviewee 24, male from Syria) stated that he has never worked in his country but has worked part-time in Greece. Others have worked in Greece, one in low-skilled and informal work (interviewee 30, male from Syria) and two as female volunteers (interviewee 26, female from the Congo, Red Cross volunteer in Facility on an Aegean Island and interviewee 4, female from Iraq, volunteer English teacher at a refugee Accommodation Facilities on an Aegean Island). Participants reported finding it difficult to find work in Greece or lacked access to employment for a variety of reasons, unrelated to the pandemic. An interviewee from the Congo (interviewee 3, male) said:

“I lost my job at the moving company. My boss said we don’t have work now. It’s the pandemic. It’s difficult to find a job now”.

Another interviewee, a male from Afghanistan (interviewee 31) said:

“I was in Athens, looking for a job in a restaurant and the man asked me “Are you vaccinated? Show me proof”, “Is everyone vaccinated at the place you live?” He had asked me if I was staying in a camp. I felt strange like being interrogated again”.

Another interviewee from Morocco (interviewee 8, male) said:

“He (my employer) told me that I have to work 4 h not 8 h. He said he cannot pay more. But I agreed. I could not stop as I needed the money also due to the pandemic”.

For example, one participant (interviewee 2, male from the Congo) stated “I do not have the Tax ID (AFM) number, I do not have the documents I need to [find] a job (…) but I want to work”. Another participant (interviewee 15, female from Iraq) focused on language barriers: “In order to work I have to know the [Greek] language and they do not offer us language classes”. One participant (interviewee 6, female from Somalia), focused on her family responsibilities and the lack of a relevant support network that would allow her to work: “I am not able to look for a job—who will take care of my child? “I do not feel safe; I feel very unsettled”. Finally, another participant (interviewee 22, female from Somalia) gave a gender dimension to barriers in accessing employment, noting that as a woman it is even more difficult to find a job. Finally, in terms of job seeking, most participants seemed to have given up due to insurmountable obstacles, some of which have been mentioned above. One of the participants (interviewee 19, male from the Congo) stated that many migrants were actively seeking for informal work: specifically, he has sought to find a job by approaching his Greek colleagues who are in the house-painting business, giving them his personal telephone number (mobile) to call him, but “so far nothing”.

4.3. Education

Some participants noted that there are no opportunities for educational activities for the children in the Accommodation Facilities. They also mentioned the inhospitable living conditions that children in the Accommodation Facilities and/or in the country in general are subject to. An interviewee from Somalia (interviewee 7, female) added:

“I remember once, when I left my child at school some parents kept staring at me. One man came and asked me where I was from, if I was fully vaccinated, where I lived and if my son had been sick. I felt I was being interrogated”.

In particular, one participant (interviewee 1, male from Syria) stated that his child is “not at all happy” with life in the refugee Facility as they “have no money”, and his material and other needs cannot be met. Another participant (interviewee 7, female from Somalia whose child passed away in Greece) noted “this refugee camp is not good for children; it is not good for people”. An interviewee from the Congo (interviewee 12, female) said:

“In the camp my daughter did not have access to online lessons because we had a weak WIFI signal while others did not have a tablet. She was disappointed”.

Another interviewee from Congo (interviewee 28, female) mentioned:

“When I went to pick up my daughter from school a woman, a parent, asked me if I and my child are vaccinated. I said, we were not, but were planning to. She responded: Why? Are you not afraid? How can you bring your child to school? I said: We wear masks and my husband and I will be vaccinated.

Regarding educational, recreational or creative adult employment opportunities, only one participant (interviewee 6, female from Somalia) referred to such activities within the Facility, which are not provided by the Facility staff but by a well-known humanitarian organization: in particular, an NGO organizes “activities” in which they participate, such as painting and art classes, “they take us on excursions out of the camp, we are given sewing machines and we sew”. The rest of the participants noted the complete absence of such opportunities: as one participant (interviewee 29, male from Syria) bluntly stated “there is nothing for us to do here!” while, in the same spirit, a participant (interviewee 25, from Somalia) stated “We do not have a job, we do not have a school, we just sit here”. Finally, once again there is a difference between the opportunities provided by different Accommodation Facilities: in particular, one participant (interviewee 2, male from the Congo) mentioned that in the Accommodation Facility where he was originally located on an Aegean Island, Greek lessons were held, but not at the Accommodation Facility where he now lives. Another participant (interviewee 18, from the Congo) argued that, despite the existence of such options in the Moria Facility where he was located, the conditions of confinement and the insecurity he experienced did not allow him to participate in educational or recreational activities:

“It was like a prison there [in Moria]. We were not free; the place was not very safe. I want to learn something, to do something. But it was a confined space and the situation on the island was not good. Everyday life was so stressful, it was not good to learn anything”.

4.4. Housing

All participants lived in metal containers within the Accommodation Facilities. Almost everyone expressed their strong dissatisfaction with the living conditions in the facility, the majority of whom focused on the quality of the meals: “the food is not edible” (interviewee 21, male from Syria), “I either give it to someone else or throw it away [the food]” (interviewee 15, woman from Iraq), “Honestly, the food we are given is not edible! I do not eat it. It’s cold and the fruit [given to us] is rotten” (interviewee 4, female from Iraq), “the food has gone off by the time it reaches us” (interviewee 22, female from Somalia). In addition, other participants also mentioned: (a) lack of room in the cooking and showering facilities; one must take turns (interviewee 9, male from the Congo), (b) the absence of heating—it is so cold and they are not allowed to have an open fire heater for safety reasons (interviewee 19, male from the Congo), (c) power outages or reduced meals (interviewee 18, male from the Congo), d) lack of cleanliness (interviewee 5, woman from Iraq). One of the participants (interviewee 1, male from Syria) described the living conditions in the Accommodation Facility he had originally been placed (Facility of Moria, Lesvos), in the worst possible terms: typically, he referred to the presence of rats and water inside his tent, concluding that “My wife and I lived on the island. It was like a Syrian prison”. Once again, there are differences between the Accommodation Facilities, this time in terms of living conditions: in particular, a participant (interviewee 4, woman from Iraq) stated that, in the Accommodation Facility in Samos where she was originally located, the living conditions were better and sanitation was satisfactory: “now [in the Facility] I cannot walk inside the camp”. At the level of State social protection and/or support from other bodies and services, three participants (interviewee 21, male from Syria, interviewee 9, male from the Congo, interviewee 25, female from Somalia) pointed to the pre-pandemic termination of the financial “allowance” for asylum seekers/refugees, a development that resulted in the deterioration of their living conditions. As one participant (interviewee 29, male from Syria) characteristically stated:

“My wife will have a caesarean section in two days. I do not have 100 euros in my pocket for the child; he may need milk—who knows? She [the mother] may not have milk to breastfeed. I only have the blessings of God. I have no money, no salary. Life is very difficult”.

Additionally, one participant (interviewee 14, female from Iraq) stated that she cannot afford to buy her medication. Finally, only one participant (interviewee 18, male from the Congo) reported that another non-State body, promised to help him improve his living conditions.

4.5. Community Participation

The majority of participants mentioned the existence of a friendly environment and lack of participation in organized collectives, either of the same ethnic community or different ones. One participant (interviewee 4, female from Iraq) claimed that because of the pandemic she severed social contacts with people from her community, while one participant (interviewee 16, male from the Congo) stated that he has no friends. They perform their religious duties—when they do—within the Facility. When they need information or advice on key issues (such as jobs, healthcare, housing, paperwork, education, etc.) they turn to either NGOs operating within the Facility or the Facility staff. One participant (interviewee 5, female from Iraq) referred positively to the staff of the Facility, noting “thank God [the staff of the Facility] helps”. However, not all participants have the same opinion (or experiences): in particular, another participant (interviewee 4, female from Iraq) stated that when she asks for information/advice on key issues she is told “that is not within our responsibilities”. Finally, another participant (interviewee 2, male from the Congo) claimed that he does not seek advice and information and focuses his efforts on finding a job through his Greek colleagues (house painters).

4.6. Intercultural Coexistence

The pandemic resulted in some participants being forced to remain within the Facility and to cease their social contacts. Indicatively—and as mentioned above—due to the coronavirus pandemic, a participant (interviewee 15, female from Iraq) stopped socializing with members of her community while adding that the fear of the pandemic has kept them constantly within the Facility, where they felt like “prisoners”. Even in the case of one participant (interviewee 29, male from Syria) who refuses to get the coronavirus vaccine and regards the pandemic and the restrictive measures as an excuse to cover up other problems, the “fear” of the pandemic—as he argued—has kept him inside the Facility. Regarding the possible existence of discriminatory attitudes towards them during their stay in Greece, one participant (interviewee 19, male from the Congo) clearly referred to racist attitudes: in particular, after initially stating that Greece, in general, “is not [considered] good” and that “the country has not helped him”, he added that, in Lesvos (Facility of Moria) where he was initially, he had faced racist behavior due to the color of his skin. An interviewee from Somalia (interviewee 11, male) mentioned:

“One time I feared for my life; there was a guy, I don’t know where he was from, but I know he was someone in charge of the camp, who asked me: Why are you here? I don’t see any refugee who seeks asylum. He said “this is my country! Go back to your country! I don’t want to see you again”. I told him he was right and then I left; I was scared for my life”.

An interviewee from Iraq (interviewee 4, female) stated:

“I have often experienced racism on public transport. When I sit next to someone, they don’t want her to be so close. Once there was an elderly lady and I was on the train, with my baby, and she started shouting at me to get up and give her my seat. Everybody was looking at me. I gave her my seat”.

An interviewee from Syria (interviewee 24, male said:

“One day, while I was at the bus stop with lots of people, I removed my mask for a minute and a woman told me put it back on. “You carry diseases! Do you want to get us all sick?“

Two other women from Somalia reported harassment by Facility staff without any clear evidence of racist motive or some other need (“they do not even talk to you”, “they do not help you”)—behaviors that may be due to skin color. Along the same lines, another participant argued that within the refugee Facility, the staff is often rude to them. Finally, one participant (interviewee 3, male from the Congo) reported armed attacks (with a knife) and muggings (theft of his mobile phone) by refugees/asylum seekers of different nationalities, without the existence of a racist motivation.

5. Discussion

Some participants reported feelings of fear, insecurity and isolation as a result of the pandemic and the restrictive measures that were implemented. In addition to the effects of the pandemic and the restrictive measures on participants’ mental health, they have had a negative impact on their lives at multiple levels. For example, one participant (interviewee 5, female from Iraq) referred to the lengthy postponement of her asylum application process (interview): “[The pandemic] changed my life 100%. I waited two years for my interview [examination of an asylum application]. When the interview date came, it was postponed for 1–1.5 years. That was very difficult for me”. Another participant (interviewee 7, female from Somalia) referred to the cessation of educational and creative opportunities within the Refugee Facility: in particular, before the outbreak of the pandemic, there was an “English-language school” in the Facility which closed down at the outbreak of the pandemic. Other participants expressed their dissatisfaction with the required use of masks (interviewee 7, female from Somalia, interviewee 23, male from Uganda, interviewee 25, male from Somalia, interviewee 32, female from Afghanistan), the inability to visit shops (e.g., supermarkets) for basic necessities (interviewee 6, female from Somalia, interviewee 25, male from Somalia). In two cases (interviewee 19, male from the Congo, interviewee 21, male from Syria) it was pointed out that pre-existing problems and challenges still existed. The life of TCNs (immigrants, asylum seekers and refugees) in Greece is full of challenges: living in Accommodation Facilities under often unsuitable conditions, time-consuming procedures for international protection applications or appeals, job and education prospects for themselves and their children, lack of access to even basic services (e.g., healthcare) and finally limited or non-existent alternative support networks. The coronavirus pandemic and the application of restrictive measures aimed at preventing its spread, has had an additional negative impact on their life in the country: exacerbation of their mental health (widespread feelings of fear and/or isolation due to segregation), additional delays in asylum applications, restriction of their daily activities. Pandemic containment policies include, albeit with difficulties or shortages, refugees and asylum seekers. Despite these adversities, many of them take an active stance against the pandemic threat and the difficult conditions of their lives: they are vaccinated or have scheduled vaccination, adhere to the individual protection measures and, above all, make plans for the future, both for themselves and their children, even in the same country that has not always been hospitable to them.

6. Conclusions

What emerges in the post-COVID-19 era is the prevalence of the image of migrants as a threat to Public Health which is reinforced by the relevant policy measures. There has been an extension of the Joint Ministerial Decision on emergency measures to protect public health from the risk of further spread of COVID-19 throughout the territory to 14 November 2022 [134]. It includes Reception and Identification Centers (RICs), Closed Controlled Structures (CCS), Controlled Facilities for the Temporary Accommodation of asylum seekers, as well as any kind of structure and place of reception and accommodation for TCNs. Entry and exit options are being implemented by taking into account the particularities of the location of the Facilities or structure. Based on the identified needs of the participants in this research and in order to promote the social inclusion of third country nationals, the following are proposed: (i) the acceleration of procedures for requests for international protection but also for appeals and the issuing of the relevant documents in cases of positive outcome, (ii) the learning of the language (e.g., in cooperation with civil society organizations, adult educational institutions, etc.), (iii) the design and implementation of targeted promotion programs in employment and vocational training (e.g., through the Manpower Organization and/or in the context of corporate social responsibility of private companies/enterprises and vocational training providers). Regarding the improvement of living conditions, the following are proposed: (i) the re-granting of a Medical ID/National Insurance Number (AMKA), (ii) the improvement of living conditions in Accommodation Facilities (e.g., through the improved utilization of the relevant European funds, the participation of private sponsors when and where possible and the active—and voluntary—involvement of the guests themselves, through which they will put to use any technical knowledge they have, will improve skills and abilities, acquire new ones and possibly earn a basic income as compensation for their work), (iii) provision of special care for the needs of mothers and children in the Accommodation Facilities (e.g., opportunities for creative employment and entertainment, parallel support for refugee children so that their parents can participate freely in training/education activities or work), (iv) continuous training and awareness of the Accommodation Facility staff in order to better function, (v) provision of information on the coronavirus pandemic among the refugee population in order to address misinformation or fears that act as deterrents to vaccination.