November 2021

Pop-ups, podcasts and public libraries

Why are some PWUD hesitant to take up the vaccine?

They are suspicious or concerned about the specific vaccine or the rollout of it.

Prior experiences of stigma and discrimination make them distrust government systems.

Prior experiences including feeling alienated make them distrust accessing more mainstream options for healthcare.

COVID-19 restrictions/lockdowns and related job loss/the lack of stability may mean they have minimal income, ability or mobility to access healthcare and vaccination if they need to travel to do so.

How different programs are reaching and vaccinating PWUD against COVID-19

As COVID-19 vaccination rates increase in the mainstream, authorities and services around the world continue to grapple with the question of how best to engage with some of our most vulnerable populations.

“You go where the people are,” Elizabeth Holliday says of responding to the COVID-19 vaccination needs of people who use drugs (PWUD) in her part of Canada.

In February this year, Elizabeth’s team at the Overdose Emergency Response and Harm Reduction Program vaccinated 9,000 people in Vancouver’s Downtown Eastside area.

They offered immediate on-the-spot vaccination via pop-up and mobile clinics.

This is one strategy different jurisdictions are trying in order to reach and vaccinate PWUD and the communities they’re a part of.

PWUD are a high-risk group if COVID-19 is contracted, due to potential long-term health complications and issues. This is further complicated by a lack of trust in government systems and potential transience and other factors.

It’s also a group that’s not immediately thought of and that’s often stigmatised; all of this makes reaching them, informing them and overcoming vaccine hesitancy a difficult challenge.

So what does it take to have some success at vaccinating the community?

A community-led approach

For both Elizabeth and US-based Jessica Hulsey, founder of the Addiction Policy Framework, whichever program or initiative is put in place has to be community led.

“It’s critical that we get this right and that our patient population is not left behind,” Jessica says.

It’s critical… that our patient population is not left behind.

Jessica Hulsey

“We’ve found our greatest successes in working in partnership with people with lived experience, community members and service providers who are the closest on the ground to those folks.”

Danny Jeffcote, AOD West Program Facilitator at cohealth in Victoria, agrees.

“It’s important that we keep doing what we do best, and that’s working with marginalised communities employing people from the community to work with the community and marrying that up with skilled clinicians,” Danny says.

How is this set up?

In some jurisdictions, this means using existing services and programs to reach out, inform and deliver vaccinations. In others, it’s being the point of connection and access for PWUD.

Jessica’s Vaccine Navigator Initiative was set up to communicate, advise and answer queries on vaccines for the community, overcoming vaccine hesitancy and connecting people to the different existing vaccination programs and services.

To date, the program has had more than 172,000 conversations with people in the community.

“We worked with a foundation for a small grant to really establish a way for people with substance use disorder and in recovery or receiving treatment and their family members to ask questions to tackle vaccine hesitancy head-on and then to really work with people to find them appointments or make sure they’re staying as safe as possible on an ongoing basis,” she says.

Victoria’s cohealth – which pre-pandemic offered a range of health services to not just the PWUD population but the rest of the local community as well, including mental health, general practice, counselling and support sessions – pivoted to cope with COVID-19 restrictions.

“In COVID times when we’ve had to adjust the way we’re working, we’re still providing essential services face to face – things like the needle syringe program,” Danny says.

“Some services such as some of the counselling and nursing GP services have switched from all face-to-face to a combination of some face-to-face with the more complex and pressing situations.”

For the Overdose Emergency Response and Harm Reduction Program, improving people’s access to vaccination is key as the team works with external organisations to provide vaccines.

What does all this look like?

In Vancouver, this means walking the streets and making it easily available for people.

“We’ve really focused on keeping it very mobile, going to where people are in terms of either where they’re placed as residents or where they spend their days,” Elizabeth says.

“The reason our [February] campaign was a success is that we really tried to grab people when they were ready. We didn’t rely on people being able to get to a place and a time when they could make an appointment.”

Pop-up and mobile clinics are important, especially in the context of lockdowns and restrictions, limited work and therefore limited income, and mobility to access healthcare.

“We ran a pop-up clinic here where we brought in the nurses and set up the clinic for two weeks and got as many people through the door as we could,” Danny says.

“That was quite successful because when you bring [the clinic] to the places where people normally go to, then that’s much easier for them to access.”

Peer education is key

One common thread is that who delivers the message is as important as the message itself.

For Jessica, it’s key that when people call, text or contact the Vaccine Navigator Initiative online they’re speaking to someone they trust who has been part of the community. As a result, the initiative’s social workers and counsellors are all from the community itself.

“A ‘trusted messenger’ approach is important. Trusted messengers are a really key component of how we get the word out, both in actual services and also in addressing these actions,” she says.

Elizabeth agrees.

“We rely heavily on peer engagement: folks with lived and living experience who we pay to do outreach and education and bring folks in to the clinics,” she says.

For Elizabeth’s team this means partnering with organisations that work with PWUD and the overlapping and intersecting communities.

“We have a lot of existing relationships with community service providers, of which there are many in this neighbourhood, many of which serve specific segments of the population,” she says.

“When we are trying to reach specific intersected communities… we work with those service providers that typically support those individuals in those communities because they have the best relationships. We come in as sort of like the vaccine experts.”

It’s easier to trust a friend than it is to perhaps trust the government, especially if you’ve had a lifetime of stigma and discrimination from other government services.

Danny Jeffcote

Danny says: “It has a certain amount of gravity and it’s easier to trust a friend than it is to perhaps trust the government, especially if you’ve had a lifetime of stigma and discrimination from other government services.”

The community is not homogenous

The PWUD population covers many different cultural, socio-economic, political and other groups, each with its own specific needs for accessing both information and vaccination.

This varies geographically.

In British Columbia, Canada, undocumented people are one of the groups within the population: a group often reluctant to be vaccinated if they worry the government may identify them.

Giving these people a safe means of accessing vaccination and a vaccination card is key in overcoming their hesitancy.

We say: “We won’t be asking people for ID. You know, if you don’t have a provincial health number, if you don’t have Canadian citizenship, let’s not worry about those things. Everybody is entitled to this vaccine. We will support you.”

Elizabeth Holliday

“We say: ‘We won’t be asking people for ID. You know, if you don’t have a provincial health number, if you don’t have Canadian citizenship, let’s not worry about those things. Everybody is entitled to this vaccine. We’ll support you’,” Elizabeth says.

Participants can get a temporary PHN (personal healthcare number) through the program without identification and then call a hotline to make it permanent.

Public libraries can also help the elderly or those who don’t have devices to register for PHNs, print off and laminate their vaccination cards and ensure they have proof of vaccination for accessing non-essential services.

Different language and cultural groups are also a key concern.

“We engage translators, and if we’re working with service providers that have those translation abilities, then they do that,” Elizabeth says.

“Big service providers could do that work with Chinese seniors so we made sure there were folks who spoke both Mandarin and Cantonese and were able to keep things safe and comfortable.

“We worked with a huge number of activists in the Chinatown community because it borders the Downtown Eastside,” she says.

Jessica also faces this. “We’re working to translate many of our materials into Spanish. We can refer any of our patients with other language barriers best to the CDC [Centers for Disease Control], which has a lot of this information already translated,” she says.

Obstacles and mistakes

It isn’t all smooth sailing.

The vaccine rollout caused a few hiccups for Elizbeth’s team when it started vaccinations in December 2020.

“It was so early in the campaign that there were a lot of questions from the community: ‘Why us and why now, when we’re left behind for lots of other reasons – why are we getting it first?’,” she says.

Australia’s vaccine rollout also caused concern.

“First we had to wait for the vaccines to be developed,” Danny says.

“The pandemic had a huge impact on us and our clients, right from the very start, as we had to reorganise how we how we worked.

“A lot of services shut their doors, which had a huge impact on clients.”

The different messaging around the AstraZeneca vaccine in Australia didn’t help either.
“There was only limited supply, and with AstraZeneca being reclassified there were a lot of things that came along that didn’t help sell the message and interrupted the trust the public had in both vaccines and supply,” Danny says.

Mistakes were made early on in Canada as well, with Elizabeth’s team initially running larger fixed-site clinics that didn’t target the most vaccine-hesitant people.

Thinking outside the box

The answers lie not only in pop-up and mobile clinics or a hotline.

In the Downtown Eastside campaign’s early days, a podcast called Crackdown featured key vaccinated community members talking about their experience.

The Vaccine Navigator Initiative has put out animated cartoons and videos to try to reach and educate people.

Future plans include training people to have the conversations the initiative has already had so that more people can be reached across the US.

Elizabeth is focusing on vaccinating anyone moving into the very transient Downtown Eastside community.

Future concerns

Other systemic and structural issues are making things even more complicated.

“Given the fact we’re creating a situation where there’s a lot riding on whether or not you’re vaccinated, it’ll be interesting to see how that impacts on people who use drugs,” Danny says.

There’s agreement that people need support in other areas as well.

“COVID really has exposed where we’re falling short in the supports we provide to people: the cracks in the system,” Elizabeth says.

“We really try to shore it up as best we can but any kind of pressure causes those things to be exposed again.

“If you see disruption in the fundamental things that people need in their lives then that’s going to have an effect on substance abuse and their status and recovery.”

Elizabeth says the community must be at the heart of any initiative.

“It’s about being responsive to the community,” she says. “So, letting go of the expectation that we as healthcare providers know best how to reach the communities.”

Jessica offers one final piece of advice at the most practical of levels: “Don’t vaccinate in the rain or in extreme sun, and have juiceboxes – people will get dehydrated.”

– Marisa Wikramanayake