Secondary Logo

Journal Logo

Increasing influenza vaccination acceptance in the homeless

A quality improvement project

Beers, Lorraine MSN, RN, FNP-BC; Filter, Marilyn PhD, RN, CNM; McFarland, Marilyn PhD, RN, FNP-BC, CTN-A

doi: 10.1097/01.NPR.0000586012.31046.c9

Abstract: The US homeless population is predisposed to serious complications of influenza with increased likelihood of hospitalization and death. This quality improvement project sought to increase influenza vaccination in the homeless population of a rural area in the Midwest and improve provider knowledge of risks and preventive care responsibilities.

The US homeless population is predisposed to serious complications of influenza with increased likelihood of hospitalization and death. This quality improvement project sought to increase influenza vaccination in the homeless population of a rural area in the Midwest and improve provider knowledge of risks and preventive care responsibilities.

Lorraine Beers is a volunteer FNP at Traverse Health Clinic, Traverse City, Mich.

Marilyn Filter is an associate professor at the University of Michigan-Flint, Flint, Mich.

Marilyn McFarland is a professor at the University of Michigan-Flint, Flint, Mich.

The authors have disclosed no financial relationships related to this article.



In 1919, over 500,000 Americans died in the influenza pandemic, and this viral pathogen has caused multiple outbreaks since then.1 The World Health Organization (WHO) identified both the risks of an influenza pandemic and vaccine hesitancy as 2 of the top 10 global health risks of 2019.2 Influenza, a viral infection of the respiratory tract, has three viral types, but only types A and B can cause human illness. The virus spreads from person to person via large-particle droplets that require close contact between the source and exposed individual, with indirect transmission occurring when a person touches his or her face after contact with a contaminated surface.3 Acute influenza causes a whole-body inflammatory reaction, with an increased risk of heart attack and stroke during the first 2 to 4 weeks of recovery.4 The US Preventive Services Task Force recommends an annual influenza vaccination for all eligible individuals age 6 months and older.5

Influenza is the most frequent cause of vaccine-preventable death in the US.6 Despite the current Advisory Committee on Immunization Practices recommendation of a 70% influenza vaccination rate for eligible individuals 6 months and older, the influenza vaccination acceptance rate for the 2017–2018 influenza season was 37.1%, a decrease of 6.2 percentage points from the previous influenza season.7

Patients with heart, lung, or kidney disease; asthma; certain underlying immunologic diseases such as cancer; or who are age 50 and older are considered high-risk and prioritized to receive vaccination. The homeless population in the US also has high levels of chronic health problems that predispose its members to serious complications of influenza with increased likelihood of hospitalization and death.8 In 2018, the number of unsheltered individuals increased by 3%, with increased homelessness also evidenced in the small Midwestern city in which the authors conducted their study.9 The authors' studied homeless shelter, built in 2017, needed to increase bed capacity from 65 to 82 beds in 2018 to accommodate a growing homeless population. Many of the shelter residents lacked an identified healthcare provider, and respiratory illnesses were prevalent in the 2017–2018 influenza season. Limited on-site healthcare was provided by a physician and a volunteer FNP. Shelter residents needing further care were referred to either a local health clinic, a walk-in clinic, or the ED, depending on symptoms. Because of the continued risk of influenza in the local homeless population, and because community members including those who provide services for the homeless also were at risk, a quality improvement project was planned and implemented to increase influenza vaccination acceptance in the homeless population.

This article outlines the quality improvement project aims, methods, and results. The influenza vaccination rate of homeless clinic patients did not improve, but the influenza vaccination rate improved by 115% in the nontraditional shelter and meal site settings. Influenza vaccination refusal remained high in all settings. Barriers to influenza vaccination acceptance for marginalized populations must be identified before recommended national influenza vaccination rates can be met.

Back to Top | Article Outline

Homelessness and healthcare

Although the homeless population lacks prioritization for influenza vaccination, the living conditions of people residing on the streets is considered a violation of international human rights.10 Homelessness is considered a key social determinant of health; homeless patients have twice the risk of unmet health needs as housed patients.11,12 Homeless patients may list the address of a shelter, friend or family member's house, or a fictitious residence as a primary address, so evaluating their true living situation may be difficult.13 One recent study found that the homeless have a mortality five times greater than the general population.14 Many homeless people with modifiable risk factors, such as smoking, obesity, and at-risk drinking, express no desire to address them.15 Lack of a consistent source of healthcare predisposes the homeless to seek treatment at EDs or urgent-care facilities, often with minimal or no follow-up care.

Distrust of the healthcare system and providers, the stigma associated with homelessness, and care processes that limit access to healthcare are three main reasons that homeless people delay healthcare. Identifying a place for care, having depression, and having at least one medical condition were associated with the willingness of the homeless to receive care. A previous history of not being involved and included in personal healthcare decisions was associated with decreased willingness to receive care.16 Homeless individuals may feel healthcare providers lack compassion for the homeless, and negative past experiences can deter healthcare access.17 A retrospective study of ED patients demonstrated that homeless Medicaid patients, compared with housed Medicaid patients, were 7.65 times more likely to return to the ED within 30 days of their previous visit and 11 times more likely to return to the ED in 2 years.18 The strongest correlation of hospital readmission was discharge location, which is often a shelter or transient housing.19 Mental illness, substance use disorder, lack of primary care, and distrust of the healthcare system all predispose the homeless to lack the resources to participate in preventive care.20

Vaccination resistance. Two types of nonadherence to vaccination recommendations exist: intentional nonadherence, an active decision to not follow prescribed therapy; and unintentional nonadherence, a passive process that includes forgetfulness, scheduling conflicts, or lack of knowledge about vaccine efficacy and safety.21 If a patient does not make an active choice to be vaccinated the default is to do nothing.22 The Strategic Advisory Group of Experts organized by the WHO identified three determinants in defining resistance to vaccination: complacency, or low-risk perception; confidence, trust in the effectiveness and safety of the vaccine; and convenience, the extent of vaccine availability.23 Homeless individuals often lack access to understandable, relevant information about influenza vaccination. Vaccination refusal may also be a route to assert one's right to make choices when opportunities to make choices are otherwise limited.

Effective vaccination programs and limitations. Best vaccination practices are well defined in recent studies.24,25 Following these guidelines for the homeless is difficult. Few homeless shelters have the economic resources to have a vaccine-compliant storage system on site.26 Although provider recommendation is the strongest predictor of patient vaccination, if the patient has no regular provider, patients default to receiving influenza vaccinations at EDs and urgent-care clinics.27 Without a phone, patient communication is limited. If the patient has a phone, it may be out of minutes, damaged, or stolen. In these situations, telephone reminders are not often useful. The library or the homeless shelter may be patient's the only available telephone and internet access sites. Until the community identifies, acknowledges, and provides needed resources, this quality improvement project provides a means to improve homeless patient access to preventive care.

Back to Top | Article Outline


The purpose of this quality improvement project was to increase influenza vaccination acceptance in the homeless population of a regional rural area in the Midwest; to increase provider knowledge about influenza incidence, risks, and provider responsibility in providing preventive care that includes influenza vaccination; and to explore reasons for influenza vaccination hesitance and refusal. After comparing the national influenza vaccination rate of 37.1% for 2017–2018 with the clinic vaccination rate of 30% and unknown vaccination rate for the homeless population treated outside the clinic, planning was initiated to develop improved influenza education and increase vaccination rates in both the clinic and shelter settings.

Back to Top | Article Outline


Sample. The patient sample was a convenience sample of 54 homeless individuals from ages of 18 to 80 who either resided in the homeless shelter or attended a meal site for the homeless. Fourteen women and 40 men participated in the study. All participants were offered influenza vaccination. Potential participants were verbally invited to participate in the intervention during a 3-month period extending from December 2018 through February 2019.

The provider sample included individuals employed by a single primary care clinic, a designated patient-centered medical home (PCMH) that provides primary healthcare to a high percentage of low-income individuals and families. Providers were defined as clinic employees who had direct contact with and provided service to patients; and included one physician, six NPs, four mental health professionals, four social workers, eight RNs, one lab aide, two LPNs, four medical assistants, seven front-desk registration and phone triage individuals, one benefits coordinator, and one quality assurance coordinator. The executive director, a computer support analyst, and four other clinic personnel also participated in the interventional educational program. The role of the providers was to increase vaccination rates for the homeless population seen at the clinic, with the outcome measured though chart review by the quality assurance nurse analyst.

Setting. The provider intervention was conducted at the PCMH, which provides health services to some of the local homeless population. Patient participants in the study were seen at the local homeless shelter and a single church site that provides meals for the homeless.

Ethical considerations. Patient participants who verbally agreed to participate in the project received either individual education on influenza vaccination or viewed basic influenza vaccination information provided at the shelter and meal site. All participants were offered influenza vaccination. No personally identifying variables were collected. This quality improvement project was deemed exempt by the University of Michigan-Flint Institutional Review Board. The medical director and CEO of the federally qualified health clinic and the medical director of the homeless shelter approved the implementation of the project.

Influenza vaccination costs not covered by patient insurance were covered by either the local health department or the medical clinic. The local health department provided RNs to administer influenza vaccinations for the three scheduled influenza clinics.

Back to Top | Article Outline

Provider intervention

Clinic vaccination records for the 2017–2018 influenza season were reviewed with the quality assurance NP. Thirty percent of the clinic's patients received the influenza vaccine in the previous season compared with the overall national average of 37.1%. The goal of this project was to increase the influenza vaccination rates of the clinic's homeless population to 40% within a 3-month period. Clinic information on previous vaccination rate and influenza information was summarized on a two-sided handout, and a single 20-minute influenza educational program was presented at a monthly all-staff meeting in November 2018. The summary information sheet was given to each attending staff member. The goal of increasing influenza vaccination rates at the clinic was supported by all staff. Potential reasons for limited influenza vaccination rates for patients were identified by the providers, and clinic policy was modified to specify that all patients would be offered influenza vaccination, regardless of ability to pay.

Back to Top | Article Outline

Patient intervention

The project director had volunteered at the shelter and meal site for 6 months and 12 months, respectively, prior to the intervention. The homeless population has a unique culture that shares values, habits, perceptions, beliefs, and often mutual support. The Theory of Culture Care Diversity and Universality, often referred as the Culture Care Theory, considers culture to be the blueprint for guiding actions and decisions.28 This theory was used to guide the project in gaining gradual acceptance and trust from the homeless population group. The Culture Care Theory uses enablers or facilitative guides that help practitioners identify patients' core beliefs and cultural practices. This approach helps define and structure healthcare that is culturally appropriate for the patient. Gatekeepers, who are highly trusted group members, helped the practitioner gain credibility by association and their support. Use of the Stranger–to–Trusted-Friend enabler assisted the practitioner to become known as a healthcare provider who was committed to improving healthcare for group members. With this approach, the NP worked with several homeless group members to develop an influenza information sheet, using graphics developed by a previously homeless group member.

The goal of the project was to increase influenza vaccination acceptance to 40% in this population. The influenza vaccine acceptance rate for the previous year was unknown, as the number of vaccinations were recorded without a population denominator. A population-tailored information sheet was used for patient education during the 3-month period from December 2018 through late February 2019. The patient intervention occurred at both the local homeless shelter and a single homeless meal site. Homeless participants either viewed the information without discussion or were approached individually and invited to participate in the project.

During the planning stage of this project, a meeting was held with the local health department's medical director and public health RNs in December 2018. The health department agreed to staff three influenza vaccination clinics during the project's intervention. During the initial project implementation, the refusal rate for influenza vaccinations was high, so a brief, six-variable, qualitative questionnaire was developed by the NP to help identify reasons for influenza vaccination refusal. The questionnaire was used if the influenza vaccine was refused but the patient agreed to participate in the project. Most of the shelter residents in the study participated in the homeless meal program.

Back to Top | Article Outline


Vaccination rates for both the medical clinic overall and homeless patient population were calculated by the medical clinic's nurse quality analyst, and percentages were compared with the previous year's vaccination rates. The number of influenza vaccinations given at the shelter during the previous year was compared with influenza vaccinations given at the shelter and nontraditional meal site during the project period. Results of the project were summarized and an executive report was presented to the medical health clinic's administrative staff and the homeless shelter's board of directors.

SPSS Statistics version 25 was used for data analysis. Cross tabulations were performed for chi-square and Fisher's exact results.

Although the influenza vaccination rate improved for study participants at the nontraditional meal site, the influenza vaccination rate for homeless clinic patients decreased from 24.77% in 2017–2018 to 23.85% during 2018–2019. The percentage of homeless patients seen at the clinic also decreased from 6.98% to 6.58% of the clinic population during the same period.

The number of influenza vaccinations given at the meal site and homeless shelter increased 115%. A total of 13 influenza vaccinations were given in 2017–2018, which increased to 28 vaccinations given during the 2018–2019 study period. This number did not include homeless patients who were vaccinated at a health fair prior to the initiation of the project.

The vaccination refusal rate for participants who were included in the intervention was 39.47%, and the refusal rate for patients not included in the intervention was 51.9%. For all individuals evaluated in the study, 6% stated they had never received an influenza vaccination.



Chi-square and Fisher's exact tests showed no statistical significance for gender (P = .362), age (P = .883), intervention (P = .749), or positive history of vaccination (P = .236) with vaccine acceptance (alpha level = .05). (See Results: Demographics and vaccine acceptance [N=54].) Although the number of influenza vaccinations for the homeless increased at the nontraditional site, overall vaccination numbers remain low. With increased opportunities for convenient vaccination, vaccination refusal rates remained high for study participants. The authors found no significant correlation between study variables (age, gender, history of previous vaccination, participation in intervention) and vaccination acceptance. Although overall clinic influenza vaccination rates improved 2%, the vaccination rate for the homeless clinic patients decreased, despite the educational program developed for clinic staff on the increased risks of influenza for the homeless.

Back to Top | Article Outline


This quality improvement project provided increased and convenient opportunity for influenza vaccination, but resistance to vaccination remained high. Vaccine hesitancy and resistance remains problematic and has a significant impact on public health. A recent study demonstrates that confidence and hesitancy has a statistically significant relationship to influenza vaccine uptake: influenza vaccine is viewed differently from other vaccines, and having confidence in other vaccines is not enough to overcome resistance to flu vaccinations.29 If available information about flu vaccination focuses on lack of effectiveness and adverse reactions, social media can effectively publicize negative information and dispute the need for annual vaccination. For the homeless population, concern about vaccine adverse reactions often leads to the default choice of not being vaccinated.

Receipt of influenza vaccine at the medical clinic was delayed until late October 2018, which eliminated the possibility of early vaccination and affected overall clinic vaccination rates. Clinic staff did not receive regular feedback about influenza vaccination rates, which could slow the impetus to promote influenza vaccination. Increased census and differing or new priorities could affect vaccination promotion. It is possible that medical and social acuity levels of homeless patients prevented provider and staff focus on preventive care. Homeless patients who lack a regular healthcare provider may mistrust providers who interact with them on an irregular or a limited basis. If trust in the healthcare system is lacking, misinformation about influenza is prevalent and available, and peers decline vaccination, there is a normal disinclination to follow recommendations.

Back to Top | Article Outline


The single NP was unable to access all possible patient participants, which limited the sample size. The study was initiated after the annual influenza season began, which also limited the number of unvaccinated participants. Differing prioritization of influenza vaccination by clinical and support staff may have impacted the study results. Consistently updated information on influenza incidence and risks was not available for shelter residents because of restrictions on posting information, so results of the study may have been impacted by lack of current information. Many homeless patients lacked regular preventive care, including influenza vaccination, so promotion and recommendation by established providers was limited to the single practitioner and shelter's medical director.

Back to Top | Article Outline


Educational interventions require bilateral communication to meet the needs of the population being educated. Information must be readily available and updated regularly. With increased on-site convenient vaccination opportunities, the acceptance rate increased at the nontraditional site. The medical clinic's homeless vaccination rate did not improve despite education, so consistent emphasis on the necessity of vaccination for all patients is needed.

Prior experiences with and misconceptions about influenza vaccination need to be identified. Lack of updated influenza vaccination information, complacency, and lack of confidence in the vaccination process all contributed to influenza vaccination hesitance and refusal in the participating homeless population.

Homeless patients who lack a designated provider often default to episodic care and lack follow-up that focuses on wellness. To increase influenza vaccination rates to the CDC's recommended rate of 70% for all eligible individuals, vaccine information and the vaccine need to be available at multiple sites. Further studies are needed to determine the reasons for vaccination resistance in marginalized populations, such as the homeless. Finally, collaboration of multiple health and community resources is necessary to support and implement effective influenza vaccination for the homeless. Homelessness occurs in communities of all sizes, and the need for effective influenza vaccination programs is necessary regardless of location.

NPs have multiple roles in providing healthcare to many cultures. It is important that we identify personal and societal prejudices as well as dominant stereotypes. Not making generalized assumptions about individual patients from marginalized populations is essential, as each patient is different in background, beliefs, and fears. The homeless are often traumatized and feel stigmatized. Seeking direction from the homeless about their beliefs and values regarding vaccination assists healthcare providers in understanding how to care for this group and to better understand the helpless and hopeless feelings of homelessness. There is a need to seize the opportunity to advocate for underserved members of our society through lobbying, collaboration, and creative provision of culturally congruent care.

Back to Top | Article Outline


1. Barclay W, Openshaw P. The 1918 influenza pandemic: one hundred years of progress, but where now. Lancet Respir Med. 2018;6(8):588–589.
2. World Health Organization. WHO announces top ten threats to global health in 2019. 2019.
3. Centers for Disease Control and Prevention. Influenza vaccination: a summary for clinicians. 2016.
4. Splete H. ID experts urge widespread flu vaccination for 2018–2019 season. Internal Medicine News. 2018.
5. Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 influenza season. MMWR Recomm Rep. 2018;67(3):1–20.
6. Immunization Action Coalition. Ask the experts: influenza. 2019.
7. Centers for Disease Control and Prevention. 2016–2017 Estimated influenza illnesses, medical visits, and hospitalizations averted by vaccination in the United States. 2018.
8. Story A, Aldridge RW, Gray T, Burridge S, Hayward AC. Influenza vaccination, inverse care and homelessness: cross-sectional survey of eligibility and uptake during the 2011/12 season in London. BMC Public Health. 2014;14:44.
9. U.S. Department of Housing and Urban Development. The annual homeless assessment report (AHAR) to congress, part1: Point-in-time estimates of homelessness. 2018.
10. Gee A. San Francisco or Mumbai? UN envoy encounters homeless life in California. The Guardian. 2018.
11. Kushel M. Homelessness: a potent risk factor for readmission. Med Care. 2018;56(6):457–459.
12. Lebrun-Harris LA, Baggett TP, Jenkins DM, et al Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey. Health Serv Res. 2013;48(3):992–1017.
13. Feldman BJ, Craen AM, Enyart J, et al Prevalence of homelessness by gender in an emergency department population in Pennsylvania. J Am Osteopath Assoc. 2018;118(2):85–91.
14. Stenius-Ayoade A, Haaramo P, Kautiainen H, Gissler M, Wahlbeck K, Eriksson JG. Mortality and causes of death among homeless in Finland: a 10-year follow-up study. J Epidemiol Community Health. 2017;71(9):841–848.
15. Taylor EM, Kendzor DE, Reitzel LR, Businelle MS. Health risk factors and desire to change among homeless adults. Am J Health Behav. 2016;40(4):455–460.
16. O'Toole TP, Johnson EE, Redihan S, Borgia M, Rose J. Needing primary care but not getting it: the role of trust, stigma and organizational obstacles reported by homeless veterans. J Health Care Poor Underserved. 2015;26(3):1019–1031.
17. Nickasch B, Marnocha SK. Healthcare experiences of the homeless. J Am Acad Nurse Pract. 2009;21(1):39–46.
18. Amato S, Nobay F, Amato DP, Abar B, Adler D. Sick and unsheltered: homelessness as a major risk factor for emergency care utilization. Am J Emerg Med. 2019;37(3):415–420.
19. Doran KM, Ragins KT, Iacomacci AL, Cunningham A, Jubanyik KJ, Jenq GY. The revolving hospital door: hospital readmissions among patients who are homeless. Med Care. 2013;51(9):767–773.
20. Fraino JA. Mobile nurse practitioner: a pilot program to address service gaps experienced by homeless individuals. J Psychosoc Nurs Ment Health Serv. 2015;53(7):38–43.
21. Gadkari AS, McHorney CA. Unintentional non-adherence to chronic prescription medications: how unintentional is it really. BMC Health Serv Res. 2012;12:98.
22. Buttenheim AM, Asch DA. Leveraging behavioral insights to promote vaccine acceptance: one year after Disneyland. JAMA Pediatr. 2016;170(7):635–636.
23. Jarrett C, Wilson R, O'Leary M, Eckersberger E, Larson HJ. Strategies for addressing vaccine hesitancy: a systematic review. Vaccine. 2015;33(34):4180–4190.
24. Wright WL, Bruns DP, Feeney AS, Strowman SR. Improving vaccination rates in older adults: a quality improvement project. Nurse Pract. 2019;44(4):40–49.
25. Tan L. Adult vaccination: now is the time to realize an unfulfilled potential. Hum Vaccin Immunother. 2015;11(9):2158–2166.
26. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: standards for adult immunization practice. Public Health Rep. 2014;129(2):115–123.
27. Sevin AM, Romeo C, Gagne B, Brown NV, Rodis JL. Factors influencing adults' immunization practices: a pilot survey study of a diverse, urban community in central Ohio. BMC Public Health. 2016;16:424.
28. Leininger MM, McFarland MR. Culture Care Diversity and Universality: A Worldwide Nursing Theory. 2nd ed. Sudbury, MA: Jones and Bartlett; 2006.
29. Quinn SC, Jamison AM, An J, Hancock GR, Freimuth VS. Measuring vaccine hesitancy, confidence, trust and flu vaccine uptake: results of a national survey of white and African American adults. Vaccine. 2019;37(9):1168–1173.

Culture Care Theory; homeless; influenza; patient-centered medical home; preventive care; vaccination; vaccination refusal

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.