Predictors of COVID-19 Vaccination among Veterans Experiencing Homelessness

The effect of a financial incentive on COVID-19 vaccination uptake, and predictors of uptake, in people experiencing homelessness: A randomized controlled trial

People who are homeless are at increased risk of COVID-19 infection, and of poorer associated outcomes. Delivering vaccinations to, and ensuring uptake of multiple doses in, people who are homeless is complex. Financial incentives may improve vaccination uptake, particularly in people who have not received routine vaccinations previously, though evidence about the effect of incentives is limited and variable. This randomized controlled trial (ANZCTR 383156) assessed the effect of a financial incentive (an A$10 grocery voucher) on uptake of the second COVID-19 vaccination in Australian adults who were homeless, and who had received their first dose. Participants were recruited through a vaccination program for people experiencing homelessness between September 2021 and January 2022. They were followed-up for a minimum of 6.5 months. Uptake was measured 'on-time' at 6 weeks, and at any time during the trial period. Vaccination status was checked on the Australian Immunisation Register. Demographic and vaccination program characteristics associated with uptake were also investigated. Eighty-six people consented to participate, and 43 were randomly allocated to each of the 'incentive' and 'no incentive' groups. The incentive slightly increased the likelihood of a participant receiving a second vaccination on-time (risk difference (RD), 11.6 % [95 %CI, -9.0, 32.2 %]; p = 0.27), and at any time during the trial (RD, 14.0 % [95 %CI, -2.2, 30.1 %], p = 0.09). The incentive had a significant positive effect on uptake in people with no previous vaccination history, increasing their likelihood of receiving a second vaccination on-time (RD, 42.3 % [95 %CI, 15.7, 68.8 %]; p = 0.002) and at any time during the trial (RD, 38.7 % [95 %CI, 16.1, 61.3 %], p < 0.001). Financial incentives may increase COVID-19 vaccination uptake in people who are homeless, and particularly those who have no previous vaccination history. Future research should consider alternative incentive values, types, and cost-effectiveness.

The Association of Vaccination for Common Adult Infectious Diseases and Uptake of COVID-19 Vaccines among 5,006,851 Veterans, 20 December 2020-31 October 2021

Disparities in vaccination coverage for coronavirus disease 2019 (COVID-19) in the United States (U.S.) are consistent barriers limiting our ability to control the spread of disease, particularly those by age and race/ethnicity. This study examines the association between previous vaccination for common adult infectious diseases and vaccination for SARS-CoV-2 among a cohort of veterans in the U.S. Sociodemographic and clinical data were utilized from three databases within the Veterans Health Administration included in the electronic health record. We examined the association of previous vaccination for common adult vaccinations through six separate multivariable logistic regression analyses, one for each previous vaccine exposure, adjusting for demographic and clinical variables. We also examined the association of receiving any one of the six common adult vaccinations and vaccination against SARS-CoV-2. Adjusted models indicate higher odds of vaccination for SARS-CoV-2 among those who received each of the previous vaccinations. Significant differences were also noted by race/ethnicity and age. Veterans who recorded receiving any one of the previous vaccinations for common adult infections had significantly greater odds of receiving any vaccination against SARS-CoV-2. Understanding veterans' previous vaccination status can assist researchers and clinicians in impacting the uptake of novel vaccines, such as vaccination against SARS-CoV-2.

COVID-19 vaccination uptake and receptivity among veterans enrolled in homelessness-tailored primary health care clinics: provider trust vs. misinformation

BACKGROUND

Compared to the general population, individuals experiencing homelessness are at greater risk of excess morbidity and mortality from COVID-19 but have been vaccinated at lower rates. The U.S. Department of Veterans Affairs (VA)'s Homeless Patient Aligned Care Team (HPACT) program integrates health care and social services for Veterans experiencing homelessness to improve access to and utilization of care.

METHODS

This study explores the vaccination uptake behavior and attitudes through a qualitative comparative case study of two HPACT clinics, one in California (CA) and one in North Dakota (ND). Semi-structured telephone interviews were conducted with Veterans enrolled in the two VA HPACT clinics from August to December 2021 with 20 Veterans (10 at each clinic).

RESULTS

Four themes emerged from the interviews: (1) Vaccination uptake and timing- While half of the Veterans interviewed were vaccinated, ND Veterans were more likely to be vaccinated and got vaccinated earlier than CA Veterans; (2) Housing- Unsheltered or precariously housed Veterans were less likely to be vaccinated; (3) Health Care- Veterans reporting positive experiences with VA health care and those who trusted health providers were more likely to vaccinate than those with negative or nuanced satisfaction with health care; (4) Refusers' Conspiracy Theories and Objectivity Claims- Veterans refusing the vaccine frequently mentioned belief in conspiracy theories while simultaneously asserting their search for objective information from unbiased sources.

CONCLUSIONS

These findings amplify the importance of improving access to population-tailored care for individuals experiencing homelessness by reducing patient loads, expanding housing program enrollment, and increasing the provider workforce to ensure personalized care. Health care providers, and housing providers, social workers, and peers, who offer information without discrediting or criticizing Veterans' beliefs, are also key to effectively delivering vaccine messaging to this population.

SARS-CoV-2 incidence, seroprevalence, and COVID-19 vaccination coverage in the homeless population: a systematic review and meta-analysis

Objectives

SARS-CoV-2 infection and COVID-19 vaccination of homeless people are a serious public health concern during COVID-19 pandemic. We aimed to systematically assess SARS-CoV-2 incidence, seroprevalence, and COVID-19 vaccination coverage in homeless people, which are important to inform resource allocation and policy adjustment for the prevention and control of COVID-19.

Methods

We searched PubMed, Web of Science, and the World Health Organization COVID-19 database for the studies of SARS-CoV-2 incidence, seroprevalence, and COVID-19 vaccination coverage in the homeless population. Subgroup analyses were conducted to pool SARS-CoV-2 incidence and seroprevalence in sheltered homeless, unsheltered homeless, and mixed population, respectively. Potential sources of heterogeneity in the estimates were explored by meta-regression analysis.

Results

Forty-nine eligible studies with a total of 75,402 homeless individuals and 5,000 shelter staff were included in the meta-analysis. The pooled incidence of SARS-CoV-2 infection was 10% (95% CI: 7 to 12%) in the homeless population and 8% (5 to 12%) for shelter staff. In addition, the overall estimated SARS-CoV-2 specific seroprevalence was 19% (8 to 33%) for homeless populations and 22% (3 to 52%) for shelter staff, respectively. Moreover, for the homeless subjects, the pooled incidence was 10% (4 to 23%) for asymptomatic SARS-CoV-2 infections, 6% (1 to 12%) for symptomatic SARS-CoV-2 infections, 3% (1 to 4%) for hospitalization for COVID-19, and 1% (0 to 2%) for severe COVID-19 cases, respectively while no COVID-19-related death was reported. Furthermore, the data derived from 12 included studies involving 225,448 homeless individuals revealed that the pooled proportion of one dose COVID-19 vaccination was 41% (35 to 47%), which was significantly lower than those in the general population.

Conclusion

Our study results indicate that the homeless people remain highly susceptible to SARS-CoV-2 infection, but COVID-19 vaccination coverage was lower than the general population, underscoring the need for prioritizing vaccine deployment and implementing enhanced preventive measures targeting this vulnerable group.

Assessing the coverage and timeliness of coronavirus vaccination among people experiencing homelessness in Wales, UK: a population-level data-linkage study

BACKGROUND

People experiencing homelessness have elevated morbidity, increasing their risk of COVID-19 related complications and mortality. Achieving high vaccination coverage in a timely manner among homeless populations was therefore important during the mass vaccination programme in Wales to limit adverse outcomes. However, no systematic monitoring of vaccinations among people experiencing homelessness in Wales has been undertaken.

METHODS

Retrospective cohort analysis was conducted using de-identified administrative data. Study cohort members were adults (≥ 18 years old) living in Wales on the 2 December 2020 and who had recently experienced homelessness, defined as experiencing homelessness between 1 July 2020 and 2 December 2020. The outcome of interest was first coronavirus vaccine dose. Follow-up started on 2 December 2020, and ended if the participant died, had a break in address history > 30 days, reached the end of follow up (30 November 2021), or had the outcome of interest. Median-time-to-vaccination was used as a crude measure of 'timeliness' of vaccine uptake. To account for competing risk of death prior to vaccination, vaccine coverage was described using cumulative incidence at 350-days, and at 50-day increments over follow-up (2 December 2020 to 17 November 2021). As a benchmark, all time-to-event measures were generated for the adult population in Wales with similar baseline individual and residential characteristics as the study cohort.

RESULTS

1,595 people with recent experiences of homelessness were identified and included in analysis. The study cohort were disproportionately male (68.8%) and concentrated in the most deprived areas in Wales. Median time-to-vaccination for the study cohort was 196 days (95% CI.: 184-209 days), compared to 141 days (95% CI.: 141-141 days) among the matched adult population in Wales. Cumulative incidence of vaccination after 350-days of follow-up was 60.4% (95% CI.: 57.8-62.8%) among the study cohort, compared to 81.4% (95% CI.: 81.3-81.5%) among the matched adult population. Visual analysis of cumulative incidence over time suggests that vaccine inequality, i.e., difference between study cohort and matched adult population, peaked after 200-days of follow-up, and declined slightly until last follow-up at 350-days.

CONCLUSIONS

Despite being prioritised for vaccination, people experiencing homelessness in Wales appear to have been under-engaged, leading to lower vaccination coverage and greater time unvaccinated, potentially increasing their risk of COVID-19 complications and mortality.

[Health of homeless individuals during the COVID-19 pandemic]

The living situation and health of homeless people differs from the general population in many ways. It is reasonable to assume that the homeless population has been particularly vulnerable during the coronavirus disease 2019 (COVID-19) pandemic. This narrative review will summarize the current literature on the health and care of homeless people during the COVID-19 pandemic. The literature research was performed between December 2022 and February 2023. In addition to the current national and international literature, findings from the "National Survey on the Psychiatric and Somatic Health of Homeless Individuals" (NAPSHI study) will be synopsized, examining psychiatric and somatic diseases as well as the care for homeless people in Germany.Homeless individuals are often mentally and physically ill and have limited access to the regular medical care system. Facilities with group rooms and dormitories pose a risk for outbreaks during the COVID-19 pandemic. As suspected, evidence of Severe Acute Respiratory Syndrome Coronavirus Type 2 (SARS-CoV‑2) infections emerged more frequently in homeless individuals than in the general population during the pandemic. Many of the infected individuals were asymptomatic. High rates of those unknowingly infected homeless individuals may have contributed to the spread of the viral disease. However, uncontrolled COVID-19 outbreaks, as feared by some researchers at the beginning of the pandemic, were not observed.

Estimating COVID-19 vaccine uptake and its drivers among migrants, homeless and precariously housed people in France

BACKGROUND

Migrants, people experiencing homelessness (PEH), or precariously housed (PH) are at high risk for COVID-19 infection, hospitalization, and death from COVID-19. However, while data on COVID-19 vaccine uptake in these populations are available in the USA, Canada, and Denmark, we are lacking, to the best of our knowledge, data from France.

METHODS

In late 2021, we carried out a cross-sectional survey to determine COVID-19 vaccine coverage in PEH/PH residing in Ile-de-France and Marseille, France, and to explore its drivers. Participants aged over 18 years were interviewed face-to-face where they slept the previous night, in their preferred language, and then stratified for analysis into three housing groups (Streets, Accommodated, and Precariously Housed). Standardized vaccination rates were computed and compared to the French population. Multilevel univariate and multivariable logistic regression models were built.

RESULTS

We find that 76.2% (95% confidence interval [CI] 74.3-78.1) of the 3690 participants received at least one COVID-19 vaccine dose while 91.1% of the French population did so. Vaccine uptake varies by stratum, with the highest uptake (85.6%; reference) in PH, followed by Accommodated (75.4%; adjusted odds-ratio = 0.79; 95% CI 0.51-1.09 vs. PH) and lowest in Streets (42.0%; AOR = 0.38; 95%CI 0.25-0.57 vs. PH). Use for vaccine certificate, age, socioeconomic factors, and vaccine hesitancy is associated with vaccination coverage.

CONCLUSIONS

In France, PEH/PH, and especially the most excluded, are less likely than the general population to receive COVID-19 vaccines. While vaccine mandate has proved an effective strategy, targeted outreach, on-site vaccinations, and sensitization activities are strategies enhancing vaccine uptake that can easily be replicated in future campaigns and other settings.

COVID-19 Vaccine Hesitancy among U.S. Veterans Experiencing Homelessness in Transitional Housing

Little is known about COVID-19 vaccine hesitancy and acceptance among individuals experiencing homelessness, despite their higher risk for morbidity and mortality from SARS-CoV-2. This study examines COVID-19 vaccination attitudes and uptake among U.S. military Veterans experiencing homelessness enrolled in transitional housing programs funded by the U.S. Department of Veterans Affairs (VA). Telephone interviews were conducted with 20 Veterans in California, Florida, Iowa, Kentucky, and Massachusetts, USA (January-April 2021). A rapid analysis approach was used to identify and enumerate commonly occurring themes. Although 60% of interviewed Veterans either received the COVID-19 vaccine or were willing to do so, one-third expressed hesitancy to get vaccinated. COVID-19 vaccination attitudes (e.g., belief that the vaccines were inadequately tested), military experience, beliefs about influenza and other vaccines, and sources of information emerged as influential factors for COVID-19 vaccination uptake or hesitancy. Veterans in VA-funded homeless transitional housing programs are generally willing to be vaccinated. However, a substantial minority is reluctant to take the vaccine due to concerns about the COVID-19 vaccine and distrust of authority. Recommendations for increasing uptake include utilizing Veteran peers, homeless service providers, and healthcare providers as trusted messengers to improve confidence in the vaccine.

Military Culture and Cultural Competence in Public Health: U.S. Veterans and SARS-CoV-2 Vaccine Uptake

As part of the U.S. effort to encourage vaccination for SARS-CoV-2, scholars have emphasized the importance of culture and identity in vaccine uptake decisions. The culture and identity of military service are poorly understood in the context of understanding Veterans’ acceptance of COVID-19 vaccines. In analyzing data from semi-structured interviews with Veterans in homeless transitional housing, this article examines their willingness to get vaccinated for COVID-19. Themes invoking military culture included (a) mandatory vaccinations in the military; (b) cynicism and mistrust toward the government; and (c) trust of and reliance on Veteran peers with shared military culture in decision-making. To further understand how military culture influences vaccine uptake and explore avenues for building culturally competent, trust-based health care interventions with Veterans, a previously published case study of Veterans volunteering in Team Rubicon (TR) disaster relief is examined. Veteran participants in TR described the experience of being in a Veteran-centric organization as an empathetic context wherein they were able to: (a) address their reintegration struggles; (b) gain a new appreciation of their Veteran status; and (c) connect with trusted peers. Given TR’s credibility, Veteran-serving health care organizations could collaborate with Veteran-led organizations to expand shared efforts to address Veterans’ distrust of government-promoted vaccines.

Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021

Introduction

Achieving high COVID-19 vaccination coverage in homeless shelters is critical in preventing morbidity, mortality, and outbreaks, however, vaccination coverage remains lower among people experiencing homelessness (PEH) than the general population.

Methods

We conducted a cross-sectional study to retrospectively describe attitudes and identify factors associated with change in COVID-19 vaccination intent among shelter residents and staff during March 2020 - August 2021. To identify factors associated with change in COVID-19 vaccine intent becoming more positive overall compared to other attitudes, we utilized a Poisson model to calculate Risk Ratios with robust standard errors, adjusting for confounding by shelter site and demographic variables determined a priori.

Results

From July 12 - August 2, 2021, 97 residents and 20 staff participated in surveys across six shelters in Seattle King County, Washington. Intent to be vaccinated against COVID-19 increased from 45.3 % (n = 53) when recalling attitudes in March 2020 to 74.4 % (n = 87) as of August 2021, and was similar among residents and staff. Many participants (43.6 %, n = 51) indicated feeling increasingly accepting about receiving a COVID-19 vaccine since March 2020, while 13.7 % (n = 16) changed back and forth, 10.3 % (n = 12) became more hesitant, and 32.5 % (n = 38) had no change in intent. In the model examining the relationship between becoming more positive about receiving a COVID-19 vaccine compared to all other attitudes (n = 116), we found a 57.2 % increase in vaccine acceptability (RR 1.57; 95 % CI: 1.01, 2.45) among those who reported worsening mental health since the start of the pandemic.

Conclusions

Findings highlight opportunities to improve communication with residents and staff about COVID-19 vaccination and support a need for continued dialogue and a person-centered approach to understanding the sociocultural complexities and dynamism of vaccine attitudes at shelters.Clinical Trial Registry Number: NCT04141917.

Exploring COVID-19 vaccine uptake, confidence and hesitancy among people experiencing homelessness in Toronto, Canada: protocol for the Ku-gaa-gii pimitizi-win qualitative study

INTRODUCTION

People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lower than the general population. This study aims to characterise reasons for COVID-19 vaccine uptake and hesitancy among people experiencing homelessness, to identify strategies to overcome hesitancy and provide public health decision-makers with information to improve vaccine confidence and uptake in this priority population.

METHODS AND ANALYSIS

The Ku-gaa-gii pimitizi-win qualitative study (formerly the COVENANT study) will recruit up to 40 participants in Toronto who are identified as experiencing homelessness at the time of recruitment. Semistructured interviews with participants will explore general experiences during the COVID-19 pandemic (eg, loss of housing, social connectedness), perceptions of the COVID-19 vaccine, factors shaping vaccine uptake and strategies for supporting enablers, addressing challenges and building vaccine confidence.

ETHICS AND DISSEMINATION

Approval for this study was granted by Unity Health Toronto Research Ethics Board. Findings will be communicated to groups organising vaccination efforts in shelters, community groups and the City of Toronto to construct more targeted interventions that address reasons for vaccine hesitancy among people experiencing homelessness. Key outputs will include a community report, academic publications, presentations at conferences and a Town Hall that will bring together people with lived expertise of homelessness, shelter staff, leading scholars, community experts and public health partners.

COVID-19 Vaccine Coverage and Sociodemographic, Behavioural and Housing Factors Associated with Vaccination among People Experiencing Homelessness in Toronto, Canada: A Cross-Sectional Study

People experiencing homelessness were prioritized for COVID-19 vaccination in Toronto, Canada, due to the high risk of infection and associated complications relative to the general population. We aimed to ascertain COVID-19 vaccine coverage in this population and explore factors associated with the receipt of at least one dose. We collected survey and blood sample data from individuals ages 16+ recruited by random selection at 62 shelters, hotels and encampment sites between 16 June 2021 and 9 September 2021. We report vaccine coverage by dose number and explored sociodemographic, behavioral, health and housing factors associated with vaccination using multivariable modified Poisson regression. In total, 80.4% (95% CI 77.3–83.1%) received at least one vaccine dose, and 63.6% (CI 60.0–67.0%) received two or more doses. Vaccination was positively associated with age (every 10 years adjusted rate ratio (aRR) 1.05 [95% CI 1.03–1.08]), and receipt of influenza vaccination (aRR 1.19 [95% CI 1.11–1.27]). Factors negatively associated with vaccination included female gender (aRR 0.92 [95% CI 0.85–1.0]), Black racial self-identification (aRR 0.89 [95% CI 0.80–0.99]) and low frequencies of masking in public places (aRR 0.83 [95% CI 0.72–0.95]). COVID-19 vaccine coverage is very high among people experiencing homelessness in Toronto, suggesting advocacy and outreach efforts may have been effective.

COVID-19 vaccine coverage and factors associated with vaccine uptake among 23 247 adults with a recent history of homelessness in Ontario, Canada: a population-based cohort study

BACKGROUND

People experiencing homelessness face a high risk of SARS-CoV-2 infection and transmission, as well as health complications and death due to COVID-19. Despite being prioritised for receiving the COVID-19 vaccine in many regions, little data are available on vaccine uptake in this vulnerable population. Using population-based health-care administrative data from Ontario, Canada-a region with a universal, publicly funded health system-we aimed to describe COVID-19 vaccine coverage (ie, the estimated percentage of people who have received a vaccine) and determinants of vaccine receipt among individuals with a recent history of homelessness.

METHODS

We conducted a retrospective, population-based cohort study of adults (aged ≥18 years) with a recent experience of homelessness, inadequate housing, or shelter use as recorded in routinely collected health-care databases between June 14, 2020, and June 14, 2021 (a period within 6 months of Dec 14, 2020, when COVID-19 vaccine administration was initiated in Ontario). Participants were followed up from Dec 14, 2020, to Sept 30, 2021, for the receipt of one or two doses of a COVID-19 vaccine using the province's real-time centralised vaccine information system. We described COVID-19 vaccine coverage overall and within predefined subgroups. Using modified Poisson regression, we further identified sociodemographic factors, health-care usage, and clinical factors associated with receipt of at least one dose of a COVID-19 vaccine.

FINDINGS

23 247 individuals with a recent history of homelessness were included in this study. Participants were predominantly male (14 752 [63·5%] of 23 247); nearly half were younger than 40 years (11 521 [49·6%]) and lived in large metropolitan regions (12 123 [52·2%]); and the majority (18 226 [78·4%]) visited a general practitioner for an in-person consultation during the observation period. By Sept 30, 2021, 14 271 (61·4%; 95% CI 60·8-62·0) individuals with a recent history of homelessness had received at least one dose of a COVID-19 vaccine and 11 082 (47·7%; 47·0-48·3) had received two doses; in comparison, over the same period, 86·6% of adults in the total Ontario population had received a first dose and 81·6% had received a second dose. In multivariable analysis, factors positively associated with COVID-19 uptake were one or more outpatient visits to a general practitioner (adjusted risk ratio [aRR] 1·37 [95% CI 1·31-1·42]), older age (50-59 years vs 18-29 years: 1·18 [1·14-1·22], ≥60 years vs 18-29 years: 1·27 [1·22-1·31]), receipt of an influenza vaccine in either of the two previous influenza seasons (1·25 [1·23-1·28]), being identified as homeless via a visit to a community health centre versus exclusively a hospital-based encounter (1·13 [1·10-1·15]), receipt of one or more SARS-CoV-2 tests between March 1, 2020, and Sept 30, 2021 (1·23 [1·20-1·26]), and the presence of chronic health conditions (one condition: 1·05 [1·03-1·08]; two or more conditions: 1·11 [1·08-1·14]). By contrast, living in a smaller metropolitan region (aRR 0·92 [95% CI 0·90-0·94]) or rural location (0·93 [0·90-0·97]) versus large metropolitan regions were associated with lower uptake.

INTERPRETATION

In Ontario, COVID-19 vaccine coverage among adults with a recent history of homelessness has lagged and, as of Sept 30, 2021, was 25 percentage points lower than that of the general adult population in Ontario for a first dose and 34 percentage points lower for a second dose. With high usage of outpatient health services among individuals with a recent history of homelessness, better utilisation of outpatient primary care structures might offer an opportunity to increase vaccine coverage in this population. Our findings underscore the importance of leveraging existing health and service organisations that are accessed and trusted by people who experience homelessness for targeted vaccine delivery.

FUNDING

The Public Health Agency of Canada.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Vaccinating Veterans Experiencing Homelessness for COVID-19: Healthcare and Housing Service Providers' Perspectives

This study examines challenges experienced during COVID-19 vaccination efforts, facilitating factors that increased vaccination, and lessons learned from healthcare providers and housing program staff who delivered healthcare and services to Veterans experiencing homelessness during the SARS-CoV-2 pandemic. Qualitative, semi-structured interviews were conducted with seven transitional housing program staff in northern California, southern California, Florida, Iowa, Kentucky, Massachusetts, and New Jersey (January-April 2021) and six primary care providers serving Veterans experiencing homelessness, four from clinics in California and two from a clinic in North Dakota (July-August 2021). Interviews were transcribed and analyzed using a rapid analysis approach. COVID-19 vaccination rates were between 40 and 60% among Veterans who received care from the primary care providers and between 20 and 90% among Veterans who were enrolled in the transitional housing programs. Barriers that providers and housing staff encountered when getting Veterans vaccinated for COVID-19 included lack of eligibility, the vaccine appointment scheduling process, transportation and communication challenges, Veterans' distrust in the government, vaccine mandates, and vaccine hesitancy among organization staff. Recommendations to increase COVID-19 vaccine uptake included making vaccination more convenient, using trusted sources such as homeless program staff or Veteran peers to provide educational information about the safety and efficacy of COVID-19 vaccines, and encouraging rather than mandating vaccination. These lessons will enable entities providing care to people experiencing homelessness to develop more effective policies and educational campaigns to improve vaccine acceptance and uptake among this vulnerable population.