Equity challenges in public health responses during the COVID-19 Pandemic: mixed-methods study of Travellers’ experiences in Nouvelle-Aquitaine, France

BACKGROUND: During the COVID-19 pandemic, socially disadvantaged populations in France faced higher risks of infection and severe forms of COVID-19, particularly among marginalized groups such as Travellers, a population predominantly composed of nationals residing in either static or mobile caravans. In France, few studies have investigated Travellers' experiences and preventive behaviours, with existing research limited to a small number of epidemiological outcomes prior to the pandemic. This study addresses this gap by exploring how living conditions and social exclusion shaped Travellers' experiences of the pandemic and their responses to government measures. METHODS: We conducted a sequential explanatory mixed-methods study, combining questionnaires and semi-structured interviews among Travellers in the region of Nouvelle-Aquitaine, France. Quantitative data assessed health status, prevention practices including COVID-19 vaccination and living conditions. Qualitative data provided deeper insight into Travellers' experiences, perceptions and attitudes towards the government' handling of the health crisis. Questionnaire data were analysed using descriptive statistics and multivariable logistic regression to identify factors associated with COVID-19 vaccination (≥ 1 dose). Interview data were analysed using Braun and Clarke's six-phase thematic analysis framework. RESULTS: Among 406 participants, 52.6% reported probable COVID-19 infection (based on a positive test or clinical symptoms) since the onset of the pandemic, of whom 9.2% reported to have been hospitalized. 30.0% of participants reported COVID-19 vaccination compared with 85% in the French general population. Vaccination was associated with being a woman, older age, living in stable housing, prior measles-mumps-rubella vaccination, receiving clear information from health authorities, and trust in the French government's pandemic response. Interviewees reported that overcrowded, underserved living conditions hindered adherence to preventive measures, while fear of infection disrupted social interactions, increased feelings of confinement, and heightened psychological distress. CONCLUSIONS: The COVID-19 pandemic disproportionately impacted Traveller communities in France, with structural vulnerabilities increasing both exposure and severe outcomes. These findings highlight the need for inclusive public health responses to avoid increasing preexisting health inequalities in future pandemic crisis. Effective strategies should integrate community perspectives, engage healthcare and social professionals, and tailor vaccination approaches to the specific vulnerabilities and socio-historical contexts shaping behaviours in marginalised populations.