key: cord-1055544-ugl38qar
authors: Knight, K. R.; Duke, M. R.; Carey, C. A.; Pruss, G.; Garcia, C. M.; Lightfoot, M.; Imbert, E.; Kushel, M. B.
title: "This is about the coolest thing I've ever seen is that you just showed right up." COVID-19 testing and vaccine acceptability among homeless-experienced adults: Qualitative data from two samples
date: 2021-03-20
journal: nan
DOI: 10.1101/2021.03.16.21253743
sha: f0e7d04b798a33075ac5ac013ff3765f650794a5
doc_id: 1055544
cord_uid: ugl38qar

Background: Homeless-experienced populations are at increased risk of exposure to SARS CoV-2 due to their living environments and face increased risk of severe COVID-19 disease due to underlying health conditions. Little is known about COVID-19 testing and vaccination acceptability among homeless-experienced populations. Objective: To understand the facilitators and barriers to COVID-19 testing and vaccine acceptability among homeless-experienced adults. Design: We conducted in-depth interviews with participants from July-October 2020. We purposively recruited participants from 1) a longitudinal cohort of homeless-experienced older adults in Oakland, CA (n=37) and 2) a convenience sample of people (n=57) during a mobile outreach COVID-19 testing event in San Francisco. Participants: Adults with current or past experience of homelessness. Approach: We asked participants about their experiences with and attitudes towards COVID-19 testing and their perceptions of COVID-19 vaccinations. We used participant observation techniques to document the interactions between testing teams and those approached for testing. We audio-recorded, transcribed and content analyzed all interviews and identified major themes and subthemes. Key Results: Participants found incentivized COVID-19 testing administered in unsheltered settings and supported by community health outreach workers (CHOWs) to be acceptable. The majority of participants expressed positive inclination toward vaccine acceptability, citing a desire to return to routine life and civic responsibility. Those who expressed hesitancy cited a desire to see trial data, concerns that vaccines included infectious materials, and mistrust of the government. Conclusions: Participants expressed positive evaluations of the incentivized, mobile COVID-19 testing supported by CHOWs in unsheltered settings. The majority of participants expressed positive inclination toward vaccination. Vaccine hesitancy concerns must be addressed when designing vaccine delivery strategies that overcome access challenges. Based on the successful implementation of COVID-19 testing, we recommend mobile delivery of vaccines using trusted CHOWs to address concerns and facilitate wider access to and uptake of the COVID vaccine.

Approximately 550,000 people are homeless each night in the United States; Black and Native Americans are overrepresented. [1] Adults experiencing homelessness, particularly those living in congregate shelters, are at high risk of acquiring SARS-CoV-2 infection due to environmental conditions (i.e. crowded spaces, poor ventilation). [2] Behavioral conditions common in homeless populations (i.e. mental health disorders) can interfere with preventive behaviors (e.g. mask wearing, social distancing) that reduce the risk of SARS-CoV-2 transmission. There have been multiple large outbreaks of COVID-19 in homeless shelters. [2] Homeless-experienced adults have a high prevalence of conditions associated with severe COVID-19 illness, including chronic lung and kidney disease, and cancer. [3] They have low rates of insurance, low use of primary care, and high rates of Emergency Department use and hospitalization. [4, 5] They face barriers to early intervention if they are infected. For these reasons, some states have prioritized people experiencing homelessness for COVID-19 vaccination. [6] Many factors (i.e. inability to travel far distances, lack of primary care physician, transient movement) contribute to homeless populations being difficult to reach for COVID-19 testing and vaccination, and reportedly could decrease acceptability of these interventions. [5] Due to experiences of stigma and racism in health settings, homeless populations may also mistrust health care interventions. [7, 8] Limited internet access [9] may decrease their ability to receive information about or register to receiver testing and vaccines. Little is known about homeless-experienced adults' attitudes towards and willingness to accept COVID-19 testing or vaccination. We conducted in-depth interviews with currently and formerly homeless . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 20, 2021. ; https://doi.org/10.1101/2021.03. 16 .21253743 doi: medRxiv preprint individuals (homeless-experienced) to understand their experience with and attitudes towards testing and vaccination to inform strategies to improve the delivery and uptake of testing and vaccination in this population.

We recruited from two separate homeless-experienced samples. For one, we recruited 37 participants from the Health Outcomes in People Experiencing Homelessness in Older Middle agE ("HOPE HOME") study, a longitudinal study of people ≥50 years old who were experiencing homelessness at enrollment (July 2013 to June 2014 and August 2017 to June 2018) in Oakland, CA. [10, 11] We used purposive sampling to recruit HOPE HOME participants from three current living categories: congregate shelters or unsheltered settings (n=12), pandemic-response non-congregate shelters ("shelter-in-place" (SIP) hotels) (n=12), or housed (n=13). [10] For the second sample, we recruited 57 participants during a two-day COVID-19 mobile testing event in October 2020 for unsheltered individuals in San Francisco, CA. We used convenience sampling to recruit individuals who did (n=50) and did not (n=7) test. Before the event, Community Health Outreach Workers (CHOWs) advertised the event to unsheltered individuals. CHOW-led testing teams spread out throughout the geographic areas with the highest number of homeless-experienced adults. [12] The teams offered testing in homeless encampments, on street corners, and in front of a large homeless services organization. All who tested received an incentive of a cloth mask, snacks, and $10 gift card.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) We provided participants with gift cards ($25 for HOPE HOME and $20 for testing event). All interviews were audio-recorded and professionally transcribed. We developed a codebook for the HOPE HOME interviews through an iterative, consensus process, and coded interview transcripts via Dedoose. We repeated this process for the shorter mobile testing interviews with a condensed codebook. We conducted content analysis on interviews and fieldnote observations. The University of California, San Francisco's Institutional Review Board approved all study procedures for both projects.

Of the 94 participants, two-thirds (65%) were cis-men and 3% were transgender. Over half (56%) identified as Black, 24% as white, 7% as Latinx, and 4% as Native American, . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted March 20, 2021. ; https://doi.org/10.1101/2021.03.16.21253743 doi: medRxiv preprint Asian/Pacific Islander, and other, respectively. Participants ranged in age from 20-71 with a median age of 59. (Table 1) Facilitators for testing were the convenience of mobile testing, support for incentives, recognition of COVID-19's severity, and support for universal testing. Barriers to testing were fears of shelter disruption and concerns about the accuracy and safety of testing. (Table 2 ) For COVID-19 vaccine acceptability, we found the desire to reunite with family and work, and a sense of civic responsibility to be motivating factors, and a desire to see safety and efficacy data, prior negative experience with vaccines, desire to wait for others to be vaccinated first, and mistrust of the government as reasons for vaccine hesitancy. (Table 3 )

Many participants noted that mobile testing was convenient and acceptable.

"This is about the coolest thing I've ever seen is that you just showed right up. On-thespot testing...on the sidewalk like that, it was just a good idea." [Testing event participant] Mobile teams were convenient because they reached people who did not want to abandon their belongings or leave their neighbors to participate. Study ethnographers observed community members thanking the teams for bringing incentivized testing to where they lived.

Ethnographers documented that CHOWs initiated conversations and built rapport with participants before and during the event. CHOWs' familiarity with participants aided in managing expectations and resolving tensions between participants waiting to test.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 

Participants noted that they were concerned about the severity of COVID-19 and its interaction with their underlying health conditions. This concern motivated some to seek out testing.

Some participants noted that they would test if they had COVID-like symptoms.

Conversely, participants who declined to test cited their lack of symptoms as a reason. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 20, 2021. Participants expressed concerns that the vaccines made people sick. This stemmed from observing reactions to other vaccines and believing that vaccine side effects (e.g. sore arms, low grade fevers) or other seasonal illnesses were signs that vaccines led to illness. Some expressed beliefs that vaccines contained a live virus that led to these symptoms. Some connected this mistrust to experiences of racism.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 

In this qualitative study of two samples of homeless-experienced adults, we found that although homeless-experienced individuals face numerous barriers to accessing health services, offering low-barrier mobile testing mediated by CHOWs and incentivized by a small monetary gift and food led to testing acceptability and uptake. Despite conducting the interviews prior to the release of vaccine trial efficacy data and subsequent EUA by the Food and Drug Administration [13] , we found a general willingness to receive the vaccine. This was motivated by an awareness of COVID-19's severity, the desire to return to regular life, and a sense of civic responsibility. Many participants expressed the need to see safety data and trusted community members' acceptance of the vaccine prior to agreeing to be vaccinated. Those who expressed hesitancy noted several concerns, similar to those about testing: the possibility that the vaccine could cause illness, skepticism about safety of the vaccine, and mistrust of the government.

Participants recognized the importance of testing but faced barriers to receive it. For example, there is a no-cost walk-in testing site in the neighborhood where we did our mobile testing. Despite this, participants still expressed the importance of the mobile outreach, which didn't require them to leave belongings unattended or make appointments. People experiencing homelessness face numerous barriers to COVID-19 information, testing, and vaccination, including transportation impediments and lack of engagement in routine . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 20, 2021. ; https://doi.org/10.1101/2021.03.16.21253743 doi: medRxiv preprint healthcare. [4, 5] Thus, the use of mobile COVID testing teams was a welcomed testing facilitator for individuals because it can mitigate these barriers. [14] Participants noted incentives were an important factor in their decision to test.

Participants noted that incentives counteract the cost of lost time due to testing when they have competing demands for basic survival. Incentives are an accepted strategy to nudge people who are hesitant about vaccinations. [15] We found support for the use of homelessexperienced CHOWs with neighborhood familiarity to facilitate outreach and increase testing uptake. Trained by, and working in partnership with, healthcare providers, the CHOWs brought evidence-based recommendations to the population and relayed questions to the healthcare team. This model offers an effective strategy for vaccinating this population. The CHOWs can extend the health care providers' role by serving as trusted health messengers. They can identify concerns that need to be addressed, reduce operational barriers by guiding mobile outreach, and share their own narratives of vaccination to increase acceptability.

Concerns about testing mirror those about vaccinations and provide lessons. Some expressed concern that testing could transmit SARS-CoV-2; others had the same concern about vaccination. These concerns may be due to misinformation or prompted by a lack of trust in the healthcare system. Trusted messengers, such as CHOWs, should provide information to counteract these concerns. Others expressed the concern that testing could incur negative consequences. Vaccine campaigns should be cautious about unintended negative impacts, such as losing access to COVID19-response long-term non-congregate shelter. Policies should disconnect vaccinations from decisions to scale back these interventions, to reduce the chance that individuals sense that vaccine acceptance is tied to negative consequences.

. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 20, 2021. ; https://doi.org/10.1101/2021.03. 16.21253743 doi: medRxiv preprint Our study has several limitations. We conducted our interviews prior to the release of vaccine study data and the resultant EUA. [13] We were not able to assess whether these events changed views. Additionally, in the testing sample, we were only able to interview a small number of those who chose not to be tested, so we may have understated objections to testing among the target population. Lastly, we reported data from two different studies whose populations were distinct in terms of age, testing accessibility and housing situation. This could also be a strength, since the similarity of responses between the two samples increases generalizability.

In a qualitative study of homeless-experienced individuals, we found that participants were interested in COVID-19 testing and vaccines and found CHOW-mediated mobile outreach to be effective and acceptable. Participants' concerns about the vaccine mirrored those of the US general public.

[19] However, homeless individuals face structural barriers stemming from a lack of housing coupled with a disproportionate burden of structural racism and discrimination based on social status and behavioral health characteristics. Our data suggest that providing mobile testing, incentives, and trusted members of communities (CHOWs) to provide information and answer questions can mitigate barriers to access and uptake of both COVID testing and vaccines. HOME Study: St. Mary's Center, Allen Temple, and Lifelong Medical Care. We could not do this work without the leadership and assistance of our Community Advisory Board. We would like to thank the hundreds of volunteers who helped us complete the mobile testing. Finally, the authors would also like to thank Deborah Yip and Ali Zahir for interviewing the HOPE HOME participants and Ashley Smith for coding the interviews.

The authors report no conflicts of interest. All authors have seen and approved this manuscript. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 20, 2021. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted March 20, 2021. ; https://doi.org/10.1101/2021.03.16.21253743 doi: medRxiv preprint

The 2019 Annual Homeless Assessment Report (AHAR) to Congress, The U.S. Department of Housing and Urban Development

Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters -Four

Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey

The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations

Defining hard-to-reach populations for vaccination. Vaccine

Kaiser Family Foundation, State COVID-19 Vaccine Priority Populations. 2021

Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters

Stigma at every turn: Health services experiences among people who inject drugs

Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study

Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study

Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study

San Francisco Point-in-Time Count and Survey

14. National Association of Community Health Centers

Beyond Politics -Promoting Covid-19 Vaccination in the United States

What to Expect after Getting a COVID-19 Vaccine

The authors would like to thank the participants for telling their stories. The authors would like to thank the CHOWS who worked with us and our community partners for their generous support during our testing events: Code Tenderloin, Glide Foundation, Larkin Street Youth Services, St. Anthony's Foundation, and Urban Alchemy, and our partners for the HOPE