One of the many harms of the stigma society inflicts on marginalized people who use drugs is destruction of trust in the medical system and government advice. The COVID-19 pandemic exacerbated racism, xenophobia, classism, fear and hate already experienced by these populations—who have paid the price with their lives, due to soaring overdose deaths and heightened vulnerability to COVID. A large proportion of people who use drugs, in our experience, remain unvaccinated.
This raises critical questions about the barriers involved, and how harm reduction workers and other service providers can approach the issue in conversations with clients.
Vaccine hesitancy is as old as vaccines themselves. And it’s increased by structural inequalities like incarceration, housing insecurity and a hazardous unregulated drug supply. Misinformation about COVID-19, for example on social media, is a further complication that has impacted the wider public’s vaccine uptake.
For people who have been routinely mistreated by policymakers and the health care field, distrust is natural. Why should they be ready and willing to get a government-recommended vaccine? And what can we do to support them in making the best decision for themselves?
A team of researchers set out to explore such questions around COVID vaccine hesitancy among people who use drugs. Through a Canadian Institutes of Health Research grant, they conducted semi-structured qualitative interviews with people who use drugs from across the country, followed by a thematic analysis. All aspects of the study involved people with lived and living experience to support design and implementation.
Senior author and principal investigator Dr. Tara Elton Marshall is an associate professor at the School of Epidemiology and Public Health at the University of Ottawa. Dr. Farihah Ali, the study’s co-investigator, is a scientific lead at the Centre for Addiction and Mental Health for the Ontario Node of the Canadian Research Initiative in Substance Misuse.
“We are very passionate about advancing research regarding the health outcomes of people with lived and living experience of drug use,” they told Filter over email, and “to ultimately explore how concerns and barriers of the COVID-19 vaccine can be addressed to encourage uptake” in promoting better health outcomes. The study has been submitted to the Harm Reduction Journal, where it is currently under review.
“What really stuck out is the importance of peer involvement in delivering messaging around vaccination.”
It recruited a total of 78 participants from all over Canada, although over 90 percent lived in urban settings: 19 people from Ontario, 18 from Quebec, 17 from the Atlantic provinces, 14 from the prairies provinces and 10 from British Columbia. There was an even gender balance and just over 60 percent identified as white. More than half identified as polysubstance users, and more than half said they used drugs daily.
Forty-nine of the participants were fully vaccinated at the time the interviews were conducted between March and October 2022, while 29 were either only partially vaccinated (received one dose) or not vaccinated at all.
After conducting the interviews, the main themes of the qualitative thematic analysis were vaccine-related concerns, factors facilitating vaccination, barriers to getting vaccinated, boosters, addressing vaccine hesitancy, and ways to improve COVID-19 messaging.
In analyzing the responses, “what really stuck out is the importance of having peer involvement in delivering messaging around vaccination,” Ali and Elton-Marshall said. “This is something that we haven’t been doing enough.”
Aside from questions of availability, the researchers encountered responses expressing reluctance to get both initial vaccinations and booster shots, which the Canadian government has continued to prioritize for vulnerable populations.
Reservations reported by study participants included fears about side effects, dangers they believed were associated with particular brands, the speed with which COVID vaccines were created, and conspiracy theories and distrust of elites.
“I kind of had that worry about the population control, like you know, they could be injecting anything into us,” one participant told the researchers. “Like, we don’t know what’s going on in the upper government, and stuff like that.”
Past negative experiences when accessing health care and broader stigmatization of people who use drugs played a major role.
Despite Joe’s hesitancy, he was not completely against the idea—something that aligns with many responses received by the study.
Joe* is a person who uses drugs in Canada, who was not a participant in the study. He has not been vaccinated against COVID, and he spoke with Filter about his decision.
“Honestly, the whole vaccination thing, there were times that I was about to get vaccinated, whether it was a job I was applying for, or I just felt the pressure from society,” he said. “I feel the government … they have an ulterior motive, so I felt I should rebel against the vaccine. So half of me was gonna do it, and half of me wants to rebel against the secret agenda that I feel the government has.”
Joe’s feelings about the government are easy to understand when he has experienced being criminalized for his drug use.
Still, at one point, Joe related, he even traveled to a pharmacy to get a vaccine. But when he arrived, he was told they didn’t have any in stock.
His story underlines the importance of the government organizing the supply to meet demand. But it also illustrates that despite Joe’s hesitancy, he was not completely against the idea of getting vaccinated—something that aligns with many of the responses received by the study.
The research team also referred to the World Health Organization’s Tailoring Immunization Programs to think of ways to support marginalized people who use drugs in making these decisions. They concluded that utilizing Motivational Interviewing techniques would be a natural and appropriate intervention.
First developed in the 1980s, Motivational Interviewing is a counseling approach that has been defined as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” It has been used in other forms of engagement and service provision for people who use drugs, including, for example, support for individuals receiving hepatitis c treatment.
“Motivational interviews have been demonstrated to be effective to address vaccine hesitancy,” Ali and Elton-Marshall told Filter. “But they are also important because they encourage people to have respectful dialogues where individuals’ concerns are listened to.”
Would Motivational Interviewing, or at least access to a health care provider with whom he had a positive relationship, have encouraged Joe to get vaccinated?
“Yeah, I probably would’ve,” he replied.
“I just really wanted to, you know, get my proper information,” he continued. “Even my mother did it, right? But at the same time, my mother’s elderly, she’s like 80 years old. She sort of just followed the way of society, right? And most people do, and I could understand.”
Most other people in Joe’s personal network got vaccinated, too—including his former girlfriend, for whom it was mandated by her work. “But, yeah, I don’t know. I was just always a little bit reluctant, right?”
Joe doesn’t know if he ever caught COVID. He thinks he might have once, but it could have been flu and he never got tested.
Both health care providers and policymakers have a responsibility to foster the dialogue—not just one-way messaging—that can build trust.
There’s something admirable about how he held out, despite social pressure, when he didn’t feel convinced. But it’s also frustrating to think how he couldn’t get a vaccine when he once chose to do so, how he wasn’t listened to, and how nobody sat down with him to talk through his doubts.
He needed different ways of being told about the importance of getting vaccinated, whether through peers or formal counseling, and in that respect, he was let down.
“We recognize that there are concerns and systemic reasons as to why some people may not feel comfortable getting vaccinated,” Ali and Elton-Marshall said. “Motivational interviewing can facilitate such conversations and shed light on how to appropriately engage.”
Access to health care is a fundamental human right—and this should mean more than just physical access. Both health care providers and policymakers have a responsibility to foster the dialogue—not just one-way messaging—that can build trust.
That takes time and effort. But if we don’t make the effort for the most vulnerable people in our society, what is our society worth? The trust that can be built when people are genuinely listened to can have many benefits beyond COVID vaccination.
*Name has been changed to protect source’s privacy.
Matthew Bonn is a coauthor and co-investigator of the study described in this article.