This study found significant differences among patients with and without migratory backgrounds in the studied sample concerning COVID-19. While 82.8% had a migratory background, 42.1% preferred the German questionnaire. Furthermore, while 42.3% of the participants with a migratory background were considering becoming vaccinated, this proportion was 76.5% for non-immigrant Germans. On the other hand, this group’s mean knowledge, attitude, and behavioral scores were relatively high. After correcting for potential confounders, migratory background, increased attitude scores, male sex, longer schooling, and higher age positively affected vaccination intention.
This study approached patients of Turkish-speaking general practitioners (GPs) in Munich. Hence, its interpretation should consider this context. Slight differences could be expected if the sample had been selected from all GPs, including native German physicians, which might limit the generalizability of the results. As another potential limitation, we may mention that the survey questionnaire was not validated before. However, as described in “Methods” section, an effort was given to standardizing the items. Furthermore, all three subscales revealed reasonable internal consistency findings.
People originating from Turkey constitute the highest proportion of citizens with foreign origin in Germany, followed by Poland and Syria . However, they often find themselves not so highly appreciated and accepted [23, 24]. Considering the participants’ mean age of 42.2 years, attention is needed for those with immigrant backgrounds and who were born in Germany but still did not obtain German citizenship. The relatively high proportion of this group (40.9%) confirms a lack of successful integration even in the third generation.
Although there was a recent influx of immigrants from Turkey (around 40,000 within 5 years) , they constitute a minor proportion; the majority are the offspring of the first immigrants after 1961 . Hence, the healthy immigrant effect [10, 11] seems to be negligible here. Our study demonstrated significant shortcomings among people with migratory backgrounds concerning the intention to be vaccinated as well as knowledge, attitudes, and behaviors concerning COVID-19. Thus, interventions are highly required to close the health-related gap in this group of citizens. Besides the efforts of the German state, projects initiated by the Turkish-speaking community may accelerate the integration process .
People of Turkish origin make up the largest migration group in Germany, so their different social, political, and health aspects have been widely studied. Therefore, we would like to present some more information on the situation of Turkish migrants and their descendants in Germany to understand the broader social dynamics that could explain the distrust of vaccines. This segment of the German population experiences particular social disadvantages and displays a decline in some aspects of health across generations . Examples of health-related disadvantages include the lack of infrastructure for religious practices, gender-specific treatment options, and nutritional preferences in hospitals . In addition, policies such as the test for Muslim citizenship applicants  may have contributed to the introversion of Turkish immigrants and their rejection of Western values.
People’s acceptance of immunization against COVID-19 was a concern even before specific vaccines became available. In particular, nursing staff in Germany have been reported to be hesitant to get vaccinated. Although they are in the highest priority group, only 46.6% had been vaccinated as of April 2021 . It is worth mentioning that 23.2% of these healthcare workers have a migratory background .
Presently 70% of the German population is expected to accept the COVID-19 vaccination . Disagreements among health professionals and politicians  as well as fake news  account for a substantial part of the confusion in public. However, research shows a high degree of hesitation rather than direct opposition to COVID-19 vaccination , which is similar to the results from our case: Of the 52% who intended not to be vaccinated or were not sure, 33.3% were hesitant to make a decision, while 18.7% were refusers. At this point, the reasons for vaccine refusal should be noted.
Access to healthcare was proposed as another barrier to vaccination, especially for unregistered immigrants . Lack of access combined with a lack of information about the contents and side effects of the vaccine could lead to a low perceived need, causing vaccine hesitancy. Therefore, hesitation should be addressed with clear, accessible, and individualized information campaigns. Furthermore, ethnic minorities and insecure migrant populations have low intent and uptake of vaccine services . The mistrust might have its origins in the sporadic racist attacks on immigrants, particularly those with Turkish roots. From this perspective, involving trainers from the same community could increase the possibility of acceptance and help people embrace the information that is transferred.
The proportion of participants with an immigrant background who refused vaccination in our study was similar to figures reported from Turkey. In a study conducted on 272 women and 156 men, 66.1% considered not getting vaccinated against COVID-19, and women were less likely to be willing to get a vaccine than men . Lower vaccination rates among women compared to men have been reported by other researchers .
As to our findings regarding the motives for accepting or rejecting vaccination, it can be speculated that the rapid developmental process of the COVID-19 vaccines and the global immunization campaigns without satisfying information transfer to the public has contributed to the concerns about the safety of vaccines or raised mistrust in vaccines and the perception that vaccines have not been sufficiently studied. Looking at the distributions of the reasons for accepting or rejecting vaccination in our study, negative news, conflicting information, and conspiracy theories rank in third place. Of the people with a migratory background, 12.6% believed that COVID-19 does not exist, compared to 5.6% among the non-immigrants. An even higher number of immigrants (30.6%) assumed that COVID-19 was purposely created to control the world.
Combining the above information with integration tardiness, we may deduct that Turkish immigrants in Germany are substantially affected by external negative factors. It was reported that 6.17% of adults in Western Turkey received no lifetime vaccination at all and anticipated a further decline in vaccination rates . In fact, vaccine hesitancy proportions in Turkey are growing dramatically. The number of families who signed a vaccine rejection form increased from 183 in 2011 to 12,000 in 2016 and 23,650 in 2017 . As of the 12th of September 2021, the complete (two doses) vaccination rates of Germany and Turkey were 62.3% and 49.6%, respectively . The comparatively lower vaccination readiness of the Turkish immigrants in Germany might be attributed to experiences of discrimination and racism as well as a mistrust in public authorities. Although it is possible that Turkish migrants are exposed to information sources from Turkey rather than Germany, it could also be that they are more exposed to the type of German information sources that spread misinformation on vaccines because they rely more on social media and have less trust in the government.
Bearing in mind that a significant number of participants were critical or suspicious against vaccination, the relatively high knowledge scores suggest an informed decision. Participants scored 21.5 points out of a maximum of 25. In other words, those who are against COVID-19 vaccination or have reservations devised their opinions possibly not because of a lack of knowledge but rather due to their attitudes shaped by factors not addressed in our study. A multivariate analysis endorses this conclusion. After correcting for potential confounders, the most significant two variables affecting the decision to be vaccinated were the migratory background (OR 3.1) and attitude scores (OR 2.9). Qualitative studies could ascertain the reasons behind the negative attitudes concerning the COVID-19 vaccination.