A paper published in Nature Communications Medicine in February 2023 examines the results of a study investigating how a person’s housing situation might factor into their vaccination status. With limited global data on this relationship, the authors concluded from the study in France that “taking housing into consideration plays a major role in vaccination campaigns”.  

The paper establishes that “vulnerable populations”, including “people experiencing homelessness”, are less likely to have received a COVID-19 vaccine. The authors aimed to identify possible reasons for this through interviews with “homeless/precariously housed people in France”. Although many had been vaccinated, the vaccination rate was lower than the general population, with the least likely to be vaccinated living on the streets.  

COVID-19 and vaccines in France 

Evidence from early COVID-19 waves across the world suggests that groups such as “people experiencing homelessness (PEH) or precariously housed (PH)” are “disproportionately exposed to infection” and “severe forms of the disease”. Not only this, but the social and mental health consequences are believed to be worse. The risk of transmission is increased by factors such as: 

  • Precarious living conditions 
  • High population density 
  • Need to access food distribution services 
  • Poor access to sanitation and hygiene 
  • Difficulties accessing care 

Furthermore, preventative measures such as social distancing or self-isolation are “challenging to maintain”.  

With the introduction of “highly efficacious” vaccines in 2021 we saw “strong protection against severe disease, hospitalisation, and death.” However, it was “already known” that PEH/PH “tend to uptake vaccination” for other diseases to a “lower degree than the general population”. Thus, attempts to prioritise “residents of migrant workers’ hostels and homeless people over 55” began in the first round of vaccinations in France. However, this was “nullified” by “lack of vaccines and of actors able to perform vaccination”.  

Obstacles and barriers 

As we explored in a previous post on reporting on vaccine hesitancy, there are many factors that influence or determine a person’s vaccination status. For PEH/PH these include “practical barriers and service limitations”, “suboptimal experiences with vaccines or health services”, and hesitancy or confusion about medicine or vaccines.  

Other factors include “structural obstacles” such as “inadequate medical coverage and access to care” or “not considering disease prevention a priority”. For migrants and refugees in particular, “language barriers” or “lack of access to information” might be preventing vaccination in a host country.  

“Moreover, migrants and refugees may also be reluctant to take up vaccination, for fear of deportation while waiting for the right to reside.”  

PEH/PH population in France 

The authors estimate that around 250,000 people in France comprised the PEH/PH population in 2021. In the specific regions of consideration, Ile-de-France and Marseille, the number is believed to have been around 150,000.  

Some are housed in workers’ hostels, some in centres for asylum seekers or emergency shelters, and some in social hostels. An estimated 2,800 are understood to be “permanently living rough” in Paris, with 1,500 in Marseille. Despite these numbers, the authors found “no official French data” for COVID-19 vaccination coverage in “migrants, homeless, or roofless populations”. Additionally, data from other European countries with “similar migration and homelessness profiles” are neglected.  

What does the study show? 

The cross-sectional study took place from 15th November to 22nd December 2021 in the Ile-de-France region and the city of Marseille. Inclusion criteria were “to be aged >18 and in full capacity to give consent”. Inclusions were performed at the place where each participant last slept the night. 

The study finds that “PEH/PH in France are less likely to receive COVID-19 vaccination than the general population (79.9% vs 91.1%)”. However, it also suggests that “vaccine uptake varied massively according to precariousness and social integration”. For example, those living in the streets, camps, or squats, were less likely to be vaccinated (42% with at least 1 dose) than “Accommodated (75%) and Precariously Housed participants (85%)”. 

“Housing is thus the most important factor linked with vaccine uptake.”  

The analysis reveals that “older people, undocumented migrants and refugees, people needing the vaccine certificate, people with medical coverage, and people followed by a GP and/or social workers” are more likely to be vaccinated. Vaccine uptake was “undoubtedly increased” by on-site vaccination by mobile teams.  

Unfortunately, individual factors such as “negative influence by peers” or a “fear of the vaccine” were likely to dissuade a person from vaccination.  

“Practical or physical obstacles to vaccine uptake were rare, as compared to personal motivations.” 

The main factors associated with low coverage were “vaccine hesitancy or negative views on vaccination”. However, people who opposed vaccination “comprised a minority” in comparison with “hesitant people”, with 54% of non-vaccinate participants being “afraid of vaccine effects”. 

Why is this so important? 

As the study notes, the dangers to PEH/PH from COVID-19 are greater than faced by the wider population. Thus, it is important to encourage vaccine uptake to lower this threat. The data also demonstrate the importance of “awareness-raising and sensitisation by trusted third parties”.  

As structural barriers reportedly play a “more minor role”, the authors identify “national policies” such as “free vaccination” and “increased access” as critical. To complement this, the “deployment of mobile teams” and “site-based vaccination activities” by various organisations may have helped overcome access issues.  

Although “social and humanitarian actors” have played a role in reaching PEH/PH populations, “substantial effort is still needed to reach the most excluded, street-sleeping individuals”. What, then, do the authors recommend?  

  • Outreach activities and onsite vaccination programmes should be extended and tailored  
  • Sensitisation activities should take place early to address barriers like vaccine hesitancy or complacency 
  • Policies ensuring free, universal access to vaccination and the support of field actors achieve high coverage 

Although the study “cannot easily be extrapolated to other contexts”, the paper concludes with a call for further data on “vaccine uptake and its drivers”. Furthermore, the “lessons” it reveals “could be of use in countries with a similar migration and/or homelessness profile”.  

What lessons do you think we can take from this study? How would you better approach vaccination across PEH/PH populations in a future global health crisis, or what efforts could be made to encourage more positive attitudes towards vaccinations and health interventions in general? 

For more on COVID-19 vaccination policies and outreach efforts at the World Vaccine Congress in Washington this April, get your tickets here.