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Dr. Audrey Steenbeek is an Epidemiologist in the School of Nursing at Dalhousie University; Dr. Jeff Karabanow is a professor in the School of Social Work, Dalhousie University

Optimal COVID-19 vaccine delivery faces many challenges and barriers such as vaccine hesitancy, availability, access, and scheduling. Among those experiencing homelessness, these issues are magnified considerably. Research indicates that the origin of factors leading to homelessness, while diverse and complex, are deeply rooted in poverty, prior and current traumas, addiction and mental health experiences, inadequate formal and informal support mechanisms, lack of employment and affordable housing and problematic discharge planning for those leaving hospital, correctional and mental health facilities.

The majority of Canadians experiencing homelessness are improperly housed or on the verge of eviction: sleeping in temporary spaces (couch surfing) with friends and relatives; in church basements; welfare motels; abandoned buildings and vehicles. For Canada, to achieve equity of COVID -19 vaccine access and to control this pandemic, individuals who experience homelessness must not be left out, nor last to gain vaccine access.

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Youth are especially vulnerable. Approximately 20 per cent (or up to 40,000) of Canadians experiencing homelessness are youth between 13 and 24 years of age. Most youth who experience homelessness are victims of poverty and neglect, child abuse and/or violence. In Canada, these circumstances are often due to system failures, with more than 50 per cent of youth having a long history in the child welfare system. Additionally, 12 per cent of youth who experience homelessness have a physical disability, 18 per cent suffer from addictions and 39 per cent have mental health issues. Homelessness is disproportionately higher among LGBTQ2S, Indigenous and black youth.

Youth who experience homelessness also experience a high incidence of infectious diseases, some of which are vaccine preventable. However, early departure from school, limited access to public health services, few youth- focused shelters, and being a more mobile population, makes these youth a vulnerable and extremely hard to reach group compared to other Canadians. Additionally, immunization may be seen as a low priority for these youth who tend to exist within a day-to-day survival mode consistently seeking out food, clothing, safety, shelter and income.

Given the current state of the COVID-19 pandemic, and since youth who experience homelessness are more vulnerable due to their age, more limited ability to practice COVID-19 infection mitigation steps (social isolation, frequent handwashing, masks), experiences of trauma, risky behaviours for survival, limited supports and abilities to find housing, making a vaccine both available and accessible to this highly vulnerable population should be considered a public health priority. Additionally, those working with all individuals who face homelessness should also be prioritized.

There are a multifold of challenges in COVID-19 vaccine delivery among youth who experience homelessness such as limited access to healthcare services (often due to a distrust of formal health systems), perceived discrimination by healthcare workers, lack of identification, worries of confidentiality breeches and fears of being reported to law enforcement authorities.

Given these challenges, how do we create opportunities for accelerated COVID-19 vaccine delivery among youth who experience homelessness? We recommend five strategies.

First, co-creation brings benefits to all. Involving youth in the design of vaccine rollout strategies is likely to lead to increased take-up. Peer- youth support at shelters, health clinics, drop-in centres, and supportive housing structures can be an engaging mechanism for youth buy in. Art-based dissemination (e.g., short, animated clips, street art, and spoken word) can also be ways to engage this population and share messages.

Second, enhanced collaboration between public health and those providing services to youth who experience homelessness. It is key to combine ease of access, vaccine education, self-esteem and coping strategies and incentives (like food). In order to achieve this goal, public health providers need to develop or deepen their collaborative partnerships with non-profit organizations that assist youth in order to reach them where they are. Innovative vaccine delivery sites will also assist in increasing the likelihood that individuals will return for a second dose, which is required for the two vaccines authorized to date. Consideration needs to be given to also offering catch- up doses of routine immunizations such as human papilloma virus vaccines that may have been missed. Research has shown that street youth often develop a positive and healthy relationship with informal, non-profit support services like youth shelters and drop-in centres, especially when it comes to health matters. Other options for youth-friendly, vaccination delivery include street vaccination, bottle collection facilities and public libraries. Providing multiple and easy-to access opportunities to get the vaccine, integrating reminders into routine interactions, and conducting outreach to connect with individuals who might otherwise be lost to follow-up are essential for COVID-19 vaccine delivery among youth who experience homelessness.

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Third, in reaching out to youth the medium as well as the messages are key. Communication needs to be targeted to this group, and different than other more traditional approaches used with the general population. For example, using social-media outlets popular among youth such as tiktok to convey vaccine information and locate sites for vaccine access, hosting street youth friendly events and distributing flyers in youth shelters, on buses, in bus shelters and other venues that these youth frequent are tactics likely to enhance success.

Fourth, vaccine education and delivery for youth in correctional facilities may also be an opportunity for some youth to accept the vaccine.

Finally, those administering the vaccine and tracking uptake must bear in mind that some street youth may not want to give a formal name and date of birth but may be willing to supply a street name and “age”. Street outreach teams dedicated to vaccine outreach, and the use of mobile aps, could be ways to reach more youth who experience homelessness.

These same principles for street youth also need to be applied to adults who experience homelessness- co-creation of roll out strategies to grow trust, enhanced collaboration with public health and organizations that work with individuals who experience homelessness are needed to develop targeted messages with tools that reach this population.

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