Unequal access in a universal health system: COVID-19 vaccination and health services utilization among international migrants in Brazil.

BACKGROUND: The COVID-19 pandemic has intensified existing health inequities, particularly among international migrants, who often face barriers to healthcare access and vaccination. In Brazil, where the Unified Health System (SUS) provides universal coverage, little is known about COVID-19 vaccination coverage and healthcare utilization among international migrants. This study aimed to analyze COVID-19 vaccination coverage, associated factors, and the use of SUS services among international migrants in Brazil during the pandemic.  METHODS: A cross-sectional study was conducted through face-to-face interviews with 374 international migrants residing in Brazil for at least six months. Participants were recruited between May 2022 and October 2023 through community networks and organizations in 26 of Brazil's 27 federative units. COVID-19 vaccines were provided exclusively through SUS infrastructure and facilities. Data were collected via face-to-face interviews using a culturally adapted questionnaire covering sociodemographic characteristics, vaccination status, healthcare utilization, and trust in health services. Descriptive statistics and binary logistic regression were used to identify factors associated with COVID-19 vaccination and SUS utilization. Analyses were conducted using RStudio software. RESULTS: Among participants, 82.4% reported receiving a COVID-19 vaccine, and 93.0% reported using SUS services during the pandemic. Lower likelihood of vaccination was observed among migrants who identified as White (adjusted odds ratio [aOR]: 0.42; 95% CI: 0.21-0.89) and those with completed elementary education (aOR: 0.39; 95% CI: 0.19-0.86). Migrants living with older adults (aOR: 2.54; 95% CI: 1.12-6.64) and those tested for COVID-19 prior to vaccination (aOR: 3.67; 95% CI: 2.00-6.96) were more likely to be vaccinated. Increased utilization of the SUS was positively associated with trust in hospitals and healthcare professionals (aOR: 3.22; 95% CI: 1.25-8.89), while higher educational attainment (aOR: 0.24; 95% CI: 0.06-1.09) and residing in the Northeast (adjusted OR: 0.31; 95% CI: 0.09-0.99; p = 0.047) were associated with lower utilization of the SUS. CONCLUSIONS: International migrants in Brazil experienced significant barriers to COVID-19 vaccination and healthcare access, influenced by race, education, household composition, and trust in health institutions. These findings reveal critical gaps in universal health coverage during pandemics and highlight the need for targeted, culturally sensitive public health strategies to promote equity in vaccination and healthcare delivery for migrant populations.