Guy Felicella says a small cash honorarium or coffee gift card always helped draw him into in a research study or public-health campaign during the two decades he spent living on Vancouver’s Downtown Eastside, where he once struggled to fuel a heroin and cocaine addiction.
So he had no issue last week handing $5 each to the roughly 100 people a group of public-health nurses vaccinated as part of a COVID-19 immunization team that blitzed the neighbourhood looking for those who had missed recent pop-up clinics.
Mr. Felicella, who left the Downtown Eastside eight years ago to get sober and now is a clinical peer adviser with Vancouver Coastal Health’s regional addiction program, said he would walk up to people, chat for a bit and convince them the vaccine was worth it. Then he would explain they would get some cash as they waited 15 minutes to see whether they had an allergic reaction to the jab.
“When they found out on top of it there was five bucks, they were laughing,” he said.
The involvement of peer advisers such as Mr. Felicella is one of the ways vaccination teams are reaching out to a population that is transient, has often experienced trauma and discrimination in the health care system, and is at high risk of death and severe COVID-19. To vaccinate as many people as quickly as possible, public-health agencies are adapting their strategies. This means relying on shelter providers and community workers to build trust and rapport, setting up mobile clinics instead of fixed locations, and using incentives, such as cash or gift cards – a measure some say raises ethical issues.
“We need to actually have approaches that actually go to where people are, rather than waiting for them to come to us,” said Linda Jackson, senior clinical director of community and primary care at Unity Health Toronto. Her hospital network has so far delivered at least one vaccine dose to more than 600 people living in or entering the shelter system.
In various cities across the country, homeless people have been prioritized in the vaccine rollout, since many are older adults, have existing chronic health issues and often live in shelters with little space for physical distancing.
But delivering vaccines to them poses a challenge, in part, because there are so many shelters serving different groups, Ms. Jackson said. According to the City of Toronto’s most recent data from January, an estimated 7,829 people experiencing homelessness used the city’s shelter system at least once in the past three months.
Moreover, owing to the transient nature of this population, “people might not be there for the second dose, so how do we actually follow them?” she said. She added there are individuals experiencing homelessness who have jobs to go to, and are not always available during regular work hours.
To address these challenges, Unity Health Toronto has developed a “playbook” with guidelines similar to those developed for long-term care and retirement homes. It provides recommendations such as partnering with shelter providers and community agencies, and educating and communicating with shelter residents in advance.
By holding educational sessions beforehand, vaccination teams have seen a fair amount of willingness from shelter residents to roll up their sleeves, Ms. Jackson said. At one shelter, they gave vaccines to more than 85 per cent of residents, she said.
Going out into the communities has been a key part of Montreal’s strategy to vaccinate its homeless population, said Annie Dufour of the city’s south-central health district. Between mid-January and late February, public-health teams gave an initial dose to more than 1,080 individuals experiencing homelessness and nearly 400 community workers and volunteers in close contact with them.
When vaccination teams visit shelters, it’s important to create a buzz and make the event special to ensure a good turnout, said Toronto street nurse Cathy Crowe. That’s where incentives play a crucial role, she said. B.C.’s Health Minister Adrian Dix said at a news conference this week that the $5 honorarium or a coffee card for Downtown Eastside residents replaces food or coffee that is often provided during other immunization campaigns, such as annual flu shots, and it reduces contact with shared surfaces.
“It’s very practical … it’s consistent with what we do all the time and we want to be effective because we want to stop the transmission of COVID-19,” Mr. Dix said.
So far, he said, more than 5,000 people living in the Downtown Eastside have been immunized as well as a further 2,000 people working in cheap dorm-style rental apartment buildings, social housing complexes and health and social services organizations.
But the practice of offering incentives does present an ethical quandary. On one hand, it’s important, not just for the health of individuals but others in the community, to make COVID-19 vaccines as attractive and accessible as possible, said Maxwell Smith, a bioethicist and assistant professor at the University of Western Ontario. Nevertheless, he said, this is already a vulnerable population. And like paying homeless people to participate in health research, “there’s a risk that there is some sort of undue inducement – that they wouldn’t actually take the vaccine had they not had this incentive,” he said.
There is also the risk some may erroneously think cash or gift card incentives reflect a nefarious or ulterior motive behind public-health authorities’ push for vaccinations, he added. “We need to be very careful about vaccine hesitancy and ensuring that people are confident and trust the vaccine.”
In the United States, CalOptima, a community-based health plan for low-income people in California’s Orange County, is offering its members a US$25 gift card for each COVID-19 vaccine dose they receive. Some companies are similarly encouraging their employees to get COVID-19 shots, such as Florida-based grocery chain Publix Super Markets, which is offering US$125 gift cards to vaccinated employees.
In Toronto, Ms. Jackson said her hospital network is discussing the use of incentives for COVID-19 vaccines with shelter providers. When doing outreach COVID-19 testing, some of its partnering community agencies offered Tim Hortons gift cards and toiletries. And at a managed alcohol program, where participants with alcohol-use disorders are given controlled amounts of alcohol, beer was made available as an incentive to get tested, Ms. Jackson said.
Ms. Crowe said while more affluent groups can comfortably make informed decisions without having “a zillion other crises in their lives, the homeless population is very, very different. They’re so deprived, they are living day by day in such stressful conditions that this is kind of a nice, decent thing to do to provide an incentive.”
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