Improving vaccination rates among people experiencing homelessness

Patient encounter

“I am definitely not getting vaccinated—no one is putting that stuff in me!” was John’s response to our team at one of the COVID-19 vaccination outreach clinics at a large shelter for people experiencing homelessness in Toronto. After sharing his stance, John provided numerous reasons why he was opposed to receiving the immunization and stated his preference to trust the advice being shared by the local health food store instead. As our conversation continued, we learned that John was concerned about unknown side effects, was distrustful of the government, and had had unfortunate experiences with health care providers in the past. Although John was initially hesitant to speak with us, as we continued to listen he became increasingly transparent about his beliefs and perspective. When he had finished sharing his thoughts, I (K.S.) asked his permission to speak with him again the next time I visited, and he agreed.

John’s concerns are common among unvaccinated populations and are not exclusive to communities of people experiencing homelessness. During our team’s conversations with individuals in this vulnerable population, we uncovered many challenges and fears, including a mistrust of the government and policy makers and uncertainty regarding whom to trust. These fears tend to be rooted in conflicting messages; negative experiences or perceived stigma in interactions with health care workers; mental health conditions and substance use disorders; low health literacy; not having an immediate, regular, and trusted primary care provider; lack of understanding regarding COVID-19 infection and potential sequelae; a collective mindset around antivaccination; alternative health providers offering COVID-19 cures; and lack of a trusted support network.

To my surprise, John approached me during the team’s next visit to the shelter. He eagerly showed me alternative health articles that offered cures for COVID-19. While he shared his concerns and questions, I showed genuine care and empathy while gently dispelling misinformation. Although this conversation did not result in John receiving the vaccination, it sowed the seeds for something that may have been missing in our previous conversation—trust. When asked if he was prepared to be vaccinated, his answer had shifted from a firm “no” to “maybe.”

Populations of people experiencing homelessness tend to have lower vaccination rates than the general population, and our team’s vaccination efforts at the shelter had plateaued after the early adopters had received their doses. We had been offering vaccinations in a method similar to how the general population was receiving theirs, but this was resulting in a vaccination rate much lower than 50%. Our observations showed us that we were missing patient trust, something that could come only from offering a more personal experience. For our next visits, we pivoted to a more patient-centred strategy and started offering door-to-door vaccination service. While this process took much longer, the resulting conversations built rapport and resulted in a surge of new vaccine recipients. As a team, we also changed our availability to meet patients’ needs more easily. Within a few visits, we had quadrupled our pervisit vaccination numbers, and we had noticed a positive shift in the way the residents of the shelter welcomed us. Box 1 lists lessons we have learned and strategies we have adopted to address vaccine hesitancy and improve vaccination rates in our population of patients experiencing homelessness.