Structural violence as a driver of COVID-19 vaccine hesitancy and low vaccine uptake among people experiencing homelessness in Toronto, Canada: A qualitative study

People experiencing homelessness are at increased risk of contracting SARS-CoV-2 and of severe complications of COVID-19. Vaccination is promoted as a key strategy to protect against severe illness from SARS-CoV-2 infection, but rates of vaccination among people experiencing homelessness are lower than the general population. Studies suggest lower uptake is a result of vaccine hesitancy, but few theoretically engage with the structural drivers of vaccine hesitancy. We explore the role of structural violence in shaping COVID-19 vaccine decision-making among people experiencing homelessness. We conducted this critical qualitative study in Toronto, Canada. Thirty-one adults of diverse races, genders, and vaccination status participated in in-depth interviews between November 2021 and February 2022. Ecosocial Theory shaped the study focus, interview guide, and analysis. Analysis employed an abductive thematic approach guided by the Framework Method analytic approach. Participant experiences were shaped by multiple forms of structural violence. Analytic themes included: i) challenges navigating income generation and ‘placelessness’ during lockdowns; ii) perceived and enacted stigma and discrimination, and feeling ‘othered’ as a result of vaccine mandates; and iii) a disruption in the continuity of access to healthcare; all were housed under the domains of economic and social deprivation, social trauma, and inadequate medical care. These shaped participant’s description of their agency and subsequent vaccine decision-making, concerns related to COVID-19 vaccination, and ultimately (re)produced health inequities. Multiple pathways of structural violence experienced prior to and during the COVID-19 pandemic influenced vaccine decision-making and represent critical mechanisms by which health inequity becomes embodied by people experiencing homelessness. Highlights : • Low vaccination for homeless groups is often explained by vaccine hesitancy. • We connect the lived experience of homelessness with COVID-19 vaccine decision-making. • Low vaccination can be partly explained by experiences of structural violence. • Examples include placelessness, income challenges, stigma, and service disruption. • Pandemic responses must address social isolation, income, service access and housing.