A comfortable, semi-structured discussion was facilitated among the focus group participants, with probing to elicit the following areas of research interest: knowledge about infectious diseases, vaccines and healthcare, attitudes towards immunization and healthcare system, beliefs that pose potential obstacles to immunization, experiences conducive to contracting infectious diseases and precluding immunization, as well as suggestions to improve immunization. Common themes emerged and are discussed below:
1. Knowledge of infectious diseases, vaccines and healthcare
(a) Identifying infectious diseasesMost of the 29 participants had a good general knowledge about infectious diseases, recognizing that they are contracted from other people. They had a more vague understanding of modes of transmission (i.e. coughs and sneezes, by contaminated hands or objects, and sexually). They were highly aware of STI and of conditions that were receiving wide coverage in the press (e.g. H1N1 pandemic influenza received significant publicity during the late summer of 2009). Although nobody spontaneously identified meningitis as an infectious disease, as the conversation progressed and examples of less common infectious diseases were introduced into the discussion, several individuals proved to have had personal experience and some basic knowledge of meningitis.Those most aware of meningitis had either contracted it personally, had been diagnosed with suspected meningitis or received medication as a result of exposure.Lack of knowledge about meningitis was common.
(b) Perceived risk factors for infectious diseasesRespondents recognized a number of infectious disease risks they encounter daily. They discussed the details and consequences of living in poverty, such as having little access to clean washing facilities, eating irregularly and sharing close personal space with other people.They recognized sub-standard accommodations as an infectious disease risk factor, providing accounts of “cardboard apartments”, “boarding houses”, “garbage cans”, “open grassy fields”, “alleyways”, “abandoned cars” and “couch surfing” [temporarily staying with friends or family].They spontaneously cited hepatitis, mononucleosis and influenza as the diseases putting them at most risk. While the conversation began with general comments about their vulnerability to these more common infections, later other infectious diseases were incorporated into the discussion among the participants.
(c) Prevention strategiesParticipants were well aware that infectious diseases can be harmful and expressed concern about prevention.Knowledge of prevention strategies was congruent with perceived risk factors.While possible prevention practices were known, limited ability to employ these strategies was recognized as a barrier. The more urgent need to survive the contingencies of life on the streets took priority and varied with the degree of homelessness.
(d) Knowledge about vaccines and immunizationParticipants acknowledged that vaccines were protective.Our participants lacked information about the different types of vaccines and frequent confusion concerning preventative antibiotics occurred.When asked about which vaccines they had received, the majority of participants mentioned hepatitis B and influenza. Most individuals remembered vaccines received in schools and two participants recounted being immunized in jail. There were frequent misconceptions and confusion between seasonal and “swine” influenza (H1N1 pandemic influenza).Consistent with the lack of general awareness of meningitis disease, noted in section 1 (a), nobody mentioned meningitis vaccine without prompting.
2. Attitudes towards immunization and healthcare
(a) Attitudes towards vaccinesThere was an ambiguous expression of attitudes pertaining to vaccines. The majority of the study participants said they would be willing to be immunized despite having reservations about whether the vaccine actually worked. They were active compliers of health professional advice, responding positively to immunization decisions when such opportunities were made available.While some side effects of vaccination including fever, rash, swelling, nausea, headache and feeling faint or anxious were identified, nobody mentioned anaphylaxis.Many youth mentioned that safety of vaccines depends on individual factors.Only a few explanations were provided about why youth would not have a vaccine. Among them were fear of needles and concerns about its effectiveness.
(b) Attitudes towards healthcareParticipants expressed mixed feelings about the health care system, in common with many Canadians, especially concern about the availability of family doctors. Several said that the health care system “sucked”, citing limited access.There was a concern among those who travelled that provincial health insurance plans do not provide medical coverage in other provinces without bureaucratic hassles. Among some, there was a lack of understanding about how the health system works, e.g., how to get a provincial health insurance card.Balancing the negative comments, several participants made positive statements about the health care system and how they were treated.Several homeless youth valued the added security of the “ability to sleep in the hospital” as a good thing.
(c) Intention to get immunizedParticipants indicated that they would get immunized if it was readily available and easily accessible, but they would not go to lengths to get a shot.
(a) Caring for youth is not a priority for the health care systemMany participants self-identified as social pariahs. They believe that providing healthcare for them is not high on the agenda of healthcare professionals and services.Others saw their homelessness as largely invisible, and therefore not presenting any barriers when they sought medical attention at a walk-in clinic or hospital emergency, for example.
(b) Getting immunized is not a priority for homeless youthParticipants mentioned that other aspects of their personal lives take precedence over getting proper health care including vaccination.
4. Experiences associated with infectious diseases and their prevention
(a) Living conditionsParticipants recognized that their living conditions and lack of affordable accommodation placed them at a higher risk for contracting infectious diseases.
(b) Incarceration and immunizationTwo youth acknowledged being immunized while incarcerated.
(c) Irregular school attendanceSome recalled being immunized in schools; others became homeless during their school years or had irregular attendance and were missed by immunization programs. Homeless youth had a history of truancy, precluding them from the usual sites for vaccination programs.
(d) Opportunities to get vaccinatedMany said that they take advantage when vaccines are made available, regarding it as an opportune event.
5. Barriers to immunization
(a) Lack of communication and informationWhile it is widely held that homeless youth rely on information from their “inner circle” rather than from health professionals [39
], study participants said that they readily comply with health care providers’ advice. They emphasized that lack of communication from their health providers was the reason they did not get immunized.
(b) CostCost was seen as a major deterrent to immunization to the homeless youth. They felt that immunization should be free irrespective of their ability to pay, and they said they would not be able to afford vaccines if they had to pay.Several youth, particularly females discussing the HPV immunization, mentioned that they would pay a nominal fee (“up to $20”) for a vaccine that they really wanted. There were persistent misunderstandings, however, as to which vaccines were free.
(c) Vaccination policy and lack of access to immunization servicesMany travellers and those without family doctors said that they did not have access to immunization facilities. The only options open to them were walk-in clinics and Phoenix House.Uncertainty among some health care providers concerning vaccine access, demographic targeting and immunization campaigns contributes to public uncertainty. Youth reported being told that they were not eligible for free influenza immunization.
6. Solutions to improve immunization
(a) Better outreach using appropriate mediaOur study participants recommended that better advertisement of time and location of free immunization sites would improve their awareness of what is available to them. They suggested advertising in public and commercial locations, including on buses and beverage containers (commonly mentioned in humor), and pamphlets in grocery stores and added to grocery bags.Participants had extensive awareness and access to e-mail, citing Phoenix House, Public Archives and the local university libraries for example, and many use social networking media such as “Facebook” or “My Space”.Media savvy, they insightfully suggested that advertisements should be conducted in a positive rather than threatening fashion.
(b) Health care system should be more homeless youth friendlyMany youth felt that health professionals should do more to accommodate the needs of the homeless and wanted to see more health care options open to them.
(c) Improved accessParticipants suggested shelters such as Phoenix House as an access point for vaccines.