Multidimensional vulnerabilities and health inequities among migrants in Tunisia: a qualitative study

Abstract Background Migrant vulnerability is increasingly recognised as a multidimensional and dynamic condition shaped by interacting structural, social, and individual determinants. However, evidence remains largely derived from high-income countries, limiting understanding of how vulnerabilities manifest in resource-constrained transit settings. As both a transit and destination country, Tunisia provides a unique middle-income context to examine how structural barriers intersect with health equity. This study explored how multidimensional vulnerabilities are produced and experienced among migrants in Tunisia and how they influence healthcare utilisation. Methods This qualitative secondary analysis was conducted using data collected between May and December 2023 across four Tunisian cities (Tunis, Sousse, Sfax, and Medenine). Using purposive sampling, 163 participants were recruited, comprising migrants and refugees (n = 87), migrant community leaders (n = 33), and non-governmental organisation (NGO) staff (n = 43). Data were collected through 33 semi-structured interviews and 16 focus group discussions conducted in participants' preferred languages (French, Arabic, and English), with recruitment continuing until thematic saturation was achieved. Thematic analysis followed a hybrid inductive-deductive approach informed by the International Organization for Migration's Determinants of Migrant Vulnerability (DoMV) framework. Results Vulnerability emerged as a dynamic and cumulative process driven by interacting structural, socioeconomic, and social determinants. Irregular legal status functioned as a key upstream determinant, restricting access to employment, social protection, and healthcare. Economic precarity, housing instability, family obligations, racial discrimination, gendered power asymmetries, and language barriers contributed to unmet health needs and eroded trust in public services. Participants reported a dual burden of infectious and chronic conditions alongside substantial unmet mental health needs. NGO staff corroborated these findings, highlighting systemic failures including administrative exclusion, lack of interpreter services, and the absence of culturally competent care. These intersecting vulnerabilities prompted coping strategies, including self-medication, informal support networks, and delayed healthcare utilization, which paradoxically exacerbated health risks and reinforced structural inequities. Conclusions Healthcare inequities among migrants in Tunisia are driven less by individual behaviours than by structurally embedded forms of legal and socioeconomic exclusion. Addressing upstream legal, administrative, and financial barriers is essential to promote equitable access to healthcare.