Structural violence as a driver of COVID-19 vaccine hesitancy and low vaccine uptake among people experiencing homelessness in Toronto, Canada: A qualitative study

J I R Jenkinson; J Wigle; L Richard; T Tibebu; A M Orkin; N S Thulien; T Kiran; E Gogosis; F Crichlow; A P Dyer; M D Gabriel; S W Hwang

doi:10.1016/j.socscimed.2024.117588

Structural violence as a driver of COVID-19 vaccine hesitancy and low vaccine uptake among people experiencing homelessness in Toronto, Canada: A qualitative study

Soc Sci Med. 2024 Dec 6:365:117588. doi: 10.1016/j.socscimed.2024.117588. Online ahead of print.

Authors

J I R Jenkinson¹, J Wigle², L Richard³, T Tibebu³, A M Orkin⁴, N S Thulien⁵, T Kiran⁶, E Gogosis³, F Crichlow⁷, A P Dyer³, M D Gabriel⁸, S W Hwang⁹

Affiliations

¹ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada. Electronic address: jesse.jenkinson@unityhealth.to.
² Department of Health and Society, University of Toronto Scarborough, Toronto, Ontario, Canada.
³ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada.
⁴ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
⁵ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
⁶ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada; Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
⁷ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada; South Riverdale Community Health Centre, Toronto, Ontario, Canada.
⁸ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada; Well Living House, Unity Health Toronto, Toronto, Ontario, Canada.
⁹ MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

PMID: 39671768
DOI: 10.1016/j.socscimed.2024.117588

Abstract

Background: People experiencing homelessness are at increased risk of contracting SARS-CoV-2 and of severe complications of COVID-19. Vaccination is promoted as a key strategy to protect against severe illness from SARS-CoV-2 infection, but rates of vaccination among people experiencing homelessness are lower than the general population. Studies suggest lower uptake is a result of vaccine hesitancy, but few theoretically engage with the structural drivers of vaccine hesitancy. We explore the role of structural violence in shaping COVID-19 vaccine decision-making among people experiencing homelessness.

Methods: We conducted this critical qualitative study in Toronto, Canada. Thirty-one adults of diverse races, genders, and vaccination status participated in in-depth interviews between November 2021 and February 2022. Ecosocial Theory shaped the study focus, interview guide, and analysis. Analysis employed an abductive thematic approach guided by the Framework Method analytic approach.

Findings: Participant experiences were shaped by multiple forms of structural violence. Analytic themes included: i) challenges navigating income generation and 'placelessness' during lockdowns; ii) perceived and enacted stigma and discrimination, and feeling 'othered' as a result of vaccine mandates; and iii) a disruption in the continuity of access to healthcare; all were housed under the domains of economic and social deprivation, social trauma, and inadequate medical care. These shaped participant's description of their agency and subsequent vaccine decision-making, concerns related to COVID-19 vaccination, and ultimately (re)produced health inequities.

Interpretation: Multiple pathways of structural violence experienced prior to and during the COVID-19 pandemic influenced vaccine decision-making and represent critical mechanisms by which health inequity becomes embodied by people experiencing homelessness.

Keywords: COVID-19; Ecosocial theory; Ill-housed persons; Qualitative; Structural violence; Vaccine.