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Building Vaccine Confidence
Weekly COVID-19 Vaccine Update for Homeless Service Providers – March 4, 2021

Racial Equity and Vaccine Distribution

The United States cannot successfully plan to vaccinate people experiencing homelessness without focusing on racial equity. It is important for homeless service providers to ensure engagement of Black, Indigenous, and People of Color in planning for vaccine rollout in communities. We are pleased to bring you the first of a series designed to prepare homeless service providers with knowledge of the historical background of medical distrust that may lead to vaccine hesitancy. Note that Black, Indigenous, and People of Color are not a monolith, and we should not assume that all are vaccine hesitant or that there aren’t white people who are also hesitant for a variety of reasons. Continuums of Care (CoCs) and homeless service providers should educate, inform, and engage all persons with empathy and understanding. We look forward to engaging with you in this extremely important dialogue.

HUD Message

Goals and Objectives for Equitable Vaccine Distribution to People Experiencing Homelessness

The COVID-19 pandemic has amplified the historical and current discrimination experienced by racial and ethnic minority groups and people experiencing homelessness. Underlying health and social inequities have resulted in Black, Indigenous, and People of Color being disproportionately impacted by the disease. Vaccination against COVID-19 can significantly reduce severe morbidity and mortality among people experiencing homelessness, which will require confronting racial inequities and building vaccine confidence.

HUD is working in partnership with the CDC to provide guidance and planning support to homeless response systems with the goal of ensuring the equitable distribution of the vaccine to people experiencing homelessness and essential homeless services staff, based on community prioritization strategies.

To achieve this goal, HUD sets out clear objectives, which includes calling on communities to:

  1. Ensure the demographics of people experiencing homelessness who have been vaccinated mirrors the demographics of the population of people experiencing homelessness.
  2. Strive for an overall vaccination rate of people experiencing homelessness that is comparable to or better than the vaccination rate of the general population.
  3. Lead with a race equity lens by focusing on: a) establishing vaccine confidence in historically marginalized communities; b) developing meaningful engagement strategies for these populations; and c) continuously examining our data to determine if we are making measurable improvements.
  4. Create engagement strategies that focus on the intersection of race and other historically marginalized populations who are overrepresented in the population of people experiencing homelessness, such as people with disabilities and people who identify as LGBTQ.

See the COVID-19 Vaccination: HUD Message at HUD.gov for key policy issues.

Equity Series Part I: Understanding the Historical Roots of Public Health and Medical Institution Mistrust

The devastating impact of COVID-19 on Black, Indigenous, and People of Color communities is bringing to the forefront the historical inequities that have existed in the United States since its inception. Near the end of 2020, over 170 cities, counties, state legislatures, and other governmental leaders declared racism a public health crisis. In their Joint Statement on Racism in America, the National Medical Association and American Psychiatric Association stated, “We must do more than speak out in the moment, we must act to ensure that systemic racism is exposed and eliminated throughout our country and its institutions.”

The homeless response system continues to design strategies and resources that align with public health guidance in response to the pandemic. In order to do that effectively, it is critical that stakeholders and providers understand the root causes of mistrust and uncertainty that Black, Indigenous, People of Color hold about public health and healthcare systems. In gaining this understanding, communities are better equipped to lead with equity and approach vaccine distribution efforts with cultural humility.

Cultural humility gives us a greater understanding of cultures that are different from our own and helps us recognize each person’s unique cultural experiences. Practicing cultural humility involves having a humble and respectful attitude toward people of other cultures and ongoing self-exploration combined with a willingness to learn from others. This practice helps us recognize our cultural biases and realize that we can’t know everything about a culture – that there is always more to learn about one another.

Medical professionals and other works wearing masks and discussing strategies

History of Reproductive Health Injustice Against Black, Indigenous, and People of Color

Reproductive health disparities have existed in marginalized communities for generations. Maternal mortality rates continue to overwhelm women of color, particularly Black women. In addition, the post-partum needs of Black, Indigenous, and Women of Color continue to be disproportionately met1. This historical reality has amplified uncertainty during the COVID-19 pandemic and is one that marginalized women who are pregnant and experiencing homelessness may be grappling with as well. Concerns may include: the impact of the vaccine on reproductive health, what consent forms or information provided about vaccination may really mean, and how data collected will be used and stored.

When having vaccine discussions with Black, Indigenous, and Women of Color who are pregnant and experiencing homelessness, the historical experiences below may impact or inform conversations.

Information presented in the following two sources shows how traumatic experiences can adversely impact an individual and their community across a lifespan. It also reaffirms the importance of transparency and information sharing, in culturally competent terms, about procedures.

History of Biomedical Research Injustice Against Black, Indigenous, and People of Color

The involuntary use of DNA from marginalized populations to further biomedical research has contributed to broader vaccine hesitancy circulating within the communities of Black, Indigenous, and People of Color. The experiences below provide insight into some of the many origins of distrust among these communities. It reinforces why homeless response systems providing as much information as possible to persons experiencing homelessness and staff about vaccine safety, efficacy, side effects, and other aspects is critical in order to build confidence.

  • Genomic Justice for Native Americans: Impact of the Havasupai Case on Genetic Research
    This article details the misleading study conducted on the Havasupai Tribe. The Havasupai “Diabetes Project” was an effort led by a group of Arizona State University researchers. Its original and sole intent was to assist the tribe in addressing the diabetes epidemic the community was experiencing. However, the collected DNA samples were used in ongoing genetic and mental health related studies without consent. The article shows how trust for medical providers was impacted in the community, and why, similar to the Tuskegee experiments, these types of incidents have long-lasting effects. It talks about the importance of intentionally and consistently creating opportunities for individuals to express their concerns and to have them addressed. In addition, it discusses why there can be complexity in building trust with communities.
  • Lessons from HeLa Cells: The Ethics and Policy of Biospecimens
    This article details the story of Henrietta Lacks, the 30-year-old African American women whose cervical cancer tissue samples were used, without her knowledge or consent, from 1951 to the present, in order to further biomedical research. Ms. Lacks’ cells were proved to be especially valuable and used in research for a variety of fields including the development of the polio vaccine, developing treatments for blood disorders, and understanding the infectivity of HIV/AIDS and Tuberculosis. The article also highlights the discriminatory impact on her family’s socioeconomic status. The Lacks family never received any financial benefit from the use of Ms. Lacks’ cells and continued to live in poverty with limited access to healthcare. Additionally, the article discusses issues around data confidentiality, as Ms. Lacks’ tissue samples continue to be shared and commoditized for public and private research without her family's consent.

Reproductive health and biomedical research injustice are only two examples of historic medical racism with present day implications. It is pivotal that communities equip themselves with both this historical knowledge as well as information about the current experience of inequities, bias, and lack of access to quality healthcare that marginalized communities face. This will help providers initiate conversations with marginalized people experiencing homelessness, especially those who may be vaccine hesitant. The COVID-19 pandemic has only heightened existing inequities that Black, Indigenous, and People of Color face in both healthcare and homelessness. Visit Health Leads USA to learn more about the challenge of the trust gap and its collaborative approach to equity-oriented vaccine demand.

Reproductive Health and Biomedical Research Injustice

HUD has provided guidance for homeless response systems on racial equity. Please review these key foundation documents as part of planning for equitable vaccine distribution:

Building Vaccine Confidence

In continuing to focus on ways to build vaccine confidence in persons experiencing homelessness and service provider staff, we are sharing the following community spotlight about the Benioff Homeless and Housing Initiative on the Community Health Outreach Worker (CHOW) approach and their recommendations for adapting it for local vaccine ambassador programs.

As you engage with people experiencing homelessness and staff who are vaccine hesitant, paying attention to the language you use is crucial. This cheat sheet from Health Leads USA Equitable COVID-19 Vaccination Initiative provides a quick guide to language that is more effective.

In previous newsletters we identified many other tools to support vaccine confidence, which you can access on the HUD Exchange COVID-19 Homeless System Response: Vaccine Planning and Distribution Page.

Domestic Violence/Sexual Assault/Human Trafficking Considerations for Survivors

As CoCs plan with public health partners for vaccine access for survivors of domestic violence, sexual assault and human trafficking, the highest levels of confidentiality and safety must be maintained. The following guidance identifies key planning considerations.

Data Considerations

The previously released Data Collection Options document recommended data that communities could collect in, and extract from, their Homeless Management Information Systems (HMIS) or other data collection systems to record COVID-19 vaccination screening and vaccine status information. The purpose of this companion document is to discuss a framework for analyzing and improving your vaccine distribution to people experiencing homelessness.

Additional Tools and Helpful Resources

View the recordings and slides from previous Office Hours.

Please Remember

The COVID-19 Pandemic has been challenging for everyone, including staff. The National Alliance to End Homelessness has provided an excellent toolkit to assist you in caring for homeless services staff during the pandemic and vaccination rollout.

Be safe and take care of yourself!

1. Racial and Ethnic Disparities in Postpartum Depression Care Among Low-Income Women, Kathy Backes Kozhimannil, Ph. D., M.P.A., Connie Mah Trinacty, Ph.D., Alisa B. Busch, M.D., MS., Haiden A. Huskamp, Ph.D and Alyce S. Adams, PhD.

The contents of these materials, except when based on statutory or regulatory authority or law, do not have the force and effect of law and are not meant to bind the public in any way. These materials are intended only to provide clarity to the public regarding existing requirements under the law or agency policies.

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