Covid-19 vaccinations at our homelessness engagement hub

The vaccination clinic is positioned alongside the meals take away service at the front of our property. Every day there are people we have not seen before, there are also regulars and the pattern of use is varied. There are those who come once or twice a month, right up to people who attend almost daily.

The clinic ran twice a week for three hours per session from a large white marquee in the middle of our front courtyard.

We have privileged a consistent, single worker to act as a vaccine ambassador. This has enabled consistent messaging and allowed the worker to become a familiar and trusted source of information.

This worker does a range of things including meeting and greeting arrivals, inviting people to have a vaccination, answering questions, and providing written information. A major part of the role has been listening to people’s fears and concerns. Having a single worker present for each session has been a key part of this project’s success.

I’d like to also acknowledge the work of STAR Health and particularly the team who have been coming to our service, who have demonstrated great flexibility and patience and an openness to working in a spontaneous way.

We know that in our four residential services, vaccination uptake has been high (above 80%). This is primarily because workers have increased opportunities and time to engage with residents. At a drop-in service like ours, with an ever-renewing community of transient and marginalised people, the fully vaccinated rate remains low and (at the time of writing) is still under 50%.

While many people in the homeless community are mindful of their health, we know that homelessness itself has a diversity of presentations. There are groups of people within this community who do not often engage with services. Experiences of trauma are probably at the heart of this.

We generally see between 12 to 25 people attending for each 3-hour session.

There was a lag in numbers at the end of 2021 where we had only 3 or 4 people, but that was unusual.

Across the year l, we provided:

• 862 vaccinations – the vaccinations are spread across first vaccinations (268), second (289), third (270) and fourth shots (35).
• Up to 25 people accessed the on-site clinic per day.
• 41 individuals identified as Aboriginal community members.
• We estimate that a further 100 people have been able to access vaccinations off site at other clinics offered in Melbourne. Some of these our workers have helped to facilitate.

In all of this, it might be useful to remember that our engagement hub is a high-volume, open access service – we do not keep files on everyone who comes in, and we don’t know everyone’s name. If someone seeks specific help then we get consent and open a file. Our model is to encourage people who may not be help seeking to come to us, with as few barriers to access as is possible.

It should be noted that in recent weeks the need for booster shots has been received with some suspicion and irritation, even from fully vaccinated people. “When is this going to end? Is this really necessary?” have been a common reactions. Enhancing the messaging about why boosters are needed must be a key part of vaccination communication going forward.

We have identified 4 cohorts of people:

1. People who are ‘vaccination ready’
   A group of people who are likely to be in stable social housing – they are typically older (40 plus) and more proactive regarding their own health.
2. People who are hesitant
   This includes people who have had significant negative experiences with authorities, with hospitals and institutions and, as a consequence, lack trust in services. A combination of fear and a lack of access to clear and reliable information on vaccinations seems to fuel hesitancy.
3. People who are unwilling to accept vaccination
   Some people have a range of reasons for not accepting the reality of Covid. To some extent this response to vaccination reflects views held by some in the broader community. Fear can quickly turn to anger and our approach with this cohort has been through gradual and supportive conversation.
4. People who are living in crisis situations
   This includes people who may have an untreated mental illness and use substances and find it difficult to wait and do an intake, even when the process is fast-tracked and streamlined. We took the view that rough sleepers and people who identify as Aboriginal and Torres Strait Islanders, should be fast-tracked in the clinic and this has worked reasonably well. But some people will walk if they can’t be seen within three minutes. Where possible, we allocate a case worker to keep someone engaged with a drink and a chat.

Central to our approach has been having one dedicated worker whose job it is to educate, answer questions and provide clarification. Sometimes this has included being yelled at.

It’s not always the bad thing when someone loses their temper. I can think of several occasions where a client has been very angry about vaccinations, and about the pandemic in general, has vented and this has eventually led to a fruitful conversation.

A number of people have actually made the decision to be vaccinated from an initial position of verbal resistance, but it takes time and a nuanced response.

There have been many reactions to on-site vaccinations. One man, Peter, is a 55 year-old who identifies as an Aboriginal community member. Nine months after he was eligible, he decided to have his first shot.

We had a chat about why he finally agreed to go ahead after weeks of hesitation. Peter said that he came to our site for several weeks and watched the people coming in and out for their shots. In Peter’s words, “I saw no one was taken away on a stretcher, no one seemed to get sick. I saw the same workers here each time. People were friendly. I decided, based on what I could see it was probably safe.”

This goes to the heart of predictability and consistency.

I’m aware that other vaccination clinics have also been set up alongside vulnerable communities and that they have not always had a significant uptake of vaccinations. Perhaps what was missing was an element of predictability and a dedicated worker to provide that important transfer of trust, to act as a conduit.

We think there are 8 key lessons that are worth sharing.

1. That people who appear to be against vaccinations may well end up changing their mind. It is not easy to say how this process works but it requires an ongoing, supportive dialogue.
2. People need time to come to the decision to be vaccinated. They require significant time to deal with their fear, to hear about vaccination (in manageable increments), to push back, and to make up their mind. We know there are people who have taken 10-15 weeks to get to this point.
3. People need to enter into a conversation in order to make up their mind. Running a clinic is not just about if you build it they will come. They will not necessarily come… They need encouragement and tailored information.
4. It is important to have workers who can help build a bridge of trust from the service site to the vaccination clinic. This is where an ambassador or key worker comes into their own. They make it possible for the client to feel safe and prepared when walking into the vaccination tent.
5. Working from a consistent and predictable approach are critical. These are two important aspects of trauma-informed work and they assist in running a successful clinic. People see the same workers at the same times and this builds confidence and trust. One client who made the decision to be vaccinated said – “I saw your clinic there every day at the same times and realised after a couple of months that it was not going away and that vaccination was something I should take seriously.”
6. There have also been some surprises – the few people who have been most vocal against having vaccinations on site turned out to be clients who had been fully vaccinated. We can only guess why they have been so vocal – possibly this resides in how they feel about government and society.
7. Our space has worked for us. People coming through for a meal can see the clinic right next to them. People wave and say hello. This provides a feeling of safety and transparency. It’s not some sinister medical operation in a hidden back room. A number of clients have said to us that after seeing it did not look scary, they decided to go ahead. This is critical.
8. In talking to clients about vaccinations it is often helpful not to ask a direct question such as, “Have you had a Covid vaccination yet?” It might be seen that there is an implicit judgement built into this question and it’s very direct. We find it more useful to say, “A lot of people are having Covid vaccinations right now. What do you reckon?” And then gradually get more specific about it. Or, “We have Covid vaccinations here twice a week if you are anyone you know is interested.”

This article was first published in Parity Magazine, Australia’s national homelessness publication. The outcome statistics mentioned in this article were updated in October 2022.