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People who inject drugs are disproportionately impacted by SARS-CoV-2 and COVID-19, yet they do not frequently accept vaccination against SARS-CoV-2 when offered.
This study aimed to explore why people who inject drugs decline free vaccines against SARS-CoV-2 and how barriers to vaccination can potentially be addressed.
We conducted semistructured qualitative interviews with 17 unvaccinated adult persons who inject drugs during August and September 2021 at a New York City syringe service program, where approximately three-fourth of participants identified as Latino (55%) or African American (22%). Interviews lasted roughly 20 minutes. The interview guide examined reasons for declining vaccination, participants’ understanding of COVID-19 risks, and how messages could be developed to encourage vaccine uptake among people who inject drugs.
Participants acknowledged that they faced increased risk from SARS-CoV-2 owing to their injection drug use but feared that long-term substance use may have weakened their health, making them especially vulnerable to side effects. Fears of possible side effects, compounded by widespread medical mistrust and questions about the overall value of vaccination contributed to marked ambivalence among our sample. The desire to protect children and older family members emerged as key potential facilitators of vaccination.
Community-developed messages are needed in outreach efforts to explain the importance of vaccination, including the far greater dangers of COVID-19 compared to possible unintended side effects. Messages that emphasize vaccines’ ability to prevent inadvertently infecting loved ones, may help increase uptake. Community-focused messaging strategies, such as those used to increase HIV and hepatitis C virus testing and overdose prevention among people who inject drugs, may prove similarly effective.
People who inject drugs face drastically increased risk of exposure to SARS-CoV-2, the virus that causes COVID-19, and are far more likely to experience severe complications, including death, if they develop COVID-19 [
People who inject drugs are frequently homeless [
At the same time, owing to stigma [
For African American and Latino people who inject drugs, the disproportionate impact of COVID-19 can be especially deadly [
There is a rich history of messaging guided by evidence-based theories of behavior change (eg, Social Cognitive Theory [
A purposive sample of unvaccinated people who inject drugs (n=17) was recruited in August and September 2021 from individuals receiving services at a community-based syringe service program (SSP) with a participant base of mostly African American and Latino people who inject drugs in New York City. Staff from the SSP recruited participants in a drop-in-center at SSP headquarters. Participants were recruited from the population of people who come to the organization for a host of services on a weekly or daily basis. Eligibility criteria for interviewees included injection drug use within the past 90 days, and not having received a vaccination against COVID-19, both assessed via self-report. Once it was determined they were eligible, they were referred to members of our research team who explained details of the study. To ensure both anonymity and to prevent duplicate responses, we used program participants’ existing SSP anonymous identifiers as their study identification. After participants provided verbal informed consent, 1 of 2 project staff members—who are coauthors of the current paper—conducted interviews on site in private rooms at the SSP. Interviews lasted approximately 15-30 minutes and were audio-recorded and transcribed verbatim by a third-party service. Participants received US $20 cash at the end of the interview as compensation for their time.
Interviews were conducted in English and Spanish by project staff, using an interview guide developed by the principal investigator (PI) with input from the full project team, including members of the partnering organization. Preliminary interview topics were developed from an exhaustive literature review on vaccine hesitancy and COVID-19. Two members of the study team who were experienced qualitative interviewers and researchers conducted semistructured interviews that explored both barriers to and facilitators of COVID-19 vaccination including the following: COVID-19 knowledge, sources of information, perceptions of vaccine risk, vaccine uptake, vaccination settings, stigma, medical mistrust, and policy-related barriers to and facilitators of vaccination. As part of the discussion of potential facilitators, interviewers asked participants to suggest messages our team could share with other people who inject drugs to increase vaccination rates. The study team also collected demographics from study participants, including race and ethnicity, gender, and primary language spoken at home.
Transcripts were analyzed through thematic analysis. Following completion of each audio-recorded interview, the digital file was promptly transcribed by external transcription services: REV.com for English language interviews and Datagain Services for interviews conducted in Spanish. The PI made sure interview files did not contain any identifying data before submitting them for transcription. Coding was conducted using MAXQDA qualitative analysis software.
Our team met weekly to conduct preliminary analysis of the interview transcripts to identify broad thematic categories addressed in each interview and to discuss these identified thematic categories which consisted of both a priori constructs (based on the aims of the study and the interview guide) and emerging themes (that were related to the study aims but not specifically anticipated). An initial code list was developed from the interview guide and project aims. To expand this preliminary code list, a small subset of interviews was jointly analyzed by 3 team members, and codes and coding strategies were then discussed by the larger team.
Three team members, including 2 who also conducted interviews, used an inductive or deductive approach to analyzing the interviews using a combination of a priori and emergent code categories to identify some of the barriers to and facilitators of COVID-19 vaccination [
To characterize the range of reasons for declining a vaccination and the most salient ones, we calculated the frequency with which themes were endorsed by study participants. This is not to imply that our qualitative data can be generalized to larger populations of people who inject drugs or to vaccine decliners, but to better characterize the range of themes that emerged among a population of people who inject drugs in New York City. As other qualitative studies have suggested, infrequently endorsed themes can be as important for designing public health interventions as frequently endorsed ones [
All procedures, including the interview guide, were approved by a single governing institutional review board, BRANY (protocol number 21-039-524), and the study participants provided informed consent.
Seventeen people who reported injection drug use in the past 90 days and had not been vaccinated were interviewed for this study. Participants identified as male (n=11, 64.7%) and female (n=6, 35.3%). The majority of participants identified as Hispanic or Latino (n=11, 64.7%), 5 (29.4%) identified as Black non-Hispanic, and 1 (5.9%) identified as White non-Hispanic. A chief goal of our research was to keep interviews brief and focused on why participants declined vaccination and how potential barriers to vaccination could be addressed. An additional important goal was to protect the privacy of respondents. As a result, we did not include questions about participants’ backgrounds beyond self-reported race and gender.
Participants described multiple reasons for not getting vaccinated, ranging from a fear of side effects (both known and as of yet undiscovered), to misinformation and medical mistrust, as well as questions about whether the vaccines were even needed. Participants also reported understanding they faced increased risk of SARS-CoV-2 exposure because of their injection drug use, but said they feared long-term drug use could have weakened their immunity and overall physical condition, rendering them especially vulnerable to negative vaccine side effects. Details of related findings, accompanied by specific quotes illustrating each emerging theme, appear below.
This fear of side effects included not only immediate reactions, but also reports of people who took the vaccine and within days or weeks developed other health problems or died. These fears appear compounded by concerns the vaccine was released only a short time after the first cases of COVID-19 were reported: “six months later, we got a vaccine. How did they do that?” [Interviewee 6, Hispanic man]. Accordingly, a number of participants reported a desire to wait and see if additional negative effects would emerge over time.
I don't want to get it, and then, you know, three months from now, all of a sudden, um, people who are 40 and under are dying because they, they're, something with the vaccine, how it interacts with our, our brain chemicals as we reach the age of 40. … I've been waiting to see. You know? I'd say five years would be a good period of time to get all the ducks in a row, to know if it's worth it or not.
I'm like wait a minute … there's a chance I'm taking. I know it's a- it's a better thing for me, like just do it and get it out the way and- and hope not to catch the virus. But it's another thing for me to think “Wait a minute, but if I do it what will happen to me?” I'm not sure I might get a side effect, a bad side effect, some- you know, detrimental to my life or whatever.
I literally seen somebody caught a reaction next to me on the bus, just came off from getting the Johnson & Johnson. They never made it out of the bus without the paramedics. So, um... I don't know. I want to, but I don't want to. I don't know how it's gonna look in the future. I don't know how the future will be. I was gonna... I was just gonna put that to the future, but... I'm pretty sure they're gonna come up with something better, with vaccines.
As highlighted by the last quote, many participants claimed firsthand knowledge of someone who became ill after vaccination. However, it remains unclear how many of these incidents are attributable to the vaccine, and which might still have happened (eg, a person getting sick on a bus) even if the person had not vaccinated.
Interview data indicate that other theories are circulating and spread by social media and television, as well as by close friends and family members, and they have created strong barriers to vaccination.
You see the TV. You have Farrakhan, Minister Farrakhan. “Don't take this vaccination. It killed this one, it killed that one.” … “Oh, the government is putting a chip inside you” and so on and so on.
Lotta people don't vaccinate because they say, “Oh,” 'scuse my language, “Oh, that's bullshit,” you know. 'Scuse me for expression. You know, “That's, that's, it's a lie or it's the fake. It's just the government, you know, trying to, another way of keeping track of you,” you know, and stuff like that.
Two additional themes that emerged through our interviews appear specific to people who inject drugs. Some participants indicated that maintaining a relatively healthy lifestyle, combined with steps they take to protect themselves from HIV—such as only using new syringes and not sharing injection equipment—would protect them from COVID-19 just as well as vaccination:
I've been doing good with my own regimen. You know, washing my hands, eating right, so on and so on. I've been doing good so far and I figure I don't need it.
Other participants recognized that the close contact of social interactions related to drug use made them increasingly vulnerable to COVID-19 and therefore required additional safeguards. At the same time, some within our sample questioned whether the toll that years or decades of drug use had taken on their physical health made them even more susceptible to potential vaccine side effects.
Especially as drug users … it attacks us first. Because we come in contact with all different kind of people and they be high and they don't take care they life … They don't take, medicate, nothing … So we are high risk. So therefore as, as us being high risk, we should be at the door, knocking at the door like bang, bang, bang, let me in.
Well I've been a drug user for a lot of years, number of years, and I don't know if my body will be able to take- I'm not- I'm not sure about catching certain side effects that can be detrimental to my life. You know? … I'm scared of that fact that I don't know what to expect. I mean I know I have a better chance at surviving from getting at if I am vaccinated. However … if I do take the vaccination I'm not sure what might happen to me. You know? I'm not sure if I might get a side effect … or die. Die from it because of my drug use over the years.
Interviews with our sample of unvaccinated people who inject drugs also established a number of potential vaccination facilitators. Participants spoke of wanting to protect family members from inadvertent exposure, especially children who were too young to receive vaccination and older adults who, in general, faced greater risk from COVID-19. Participants also reported that simply discussing the increased risk of COVID-19 exposure among substance users might facilitate vaccination uptake, if handled correctly. Interview data underscore the value of phrasing intervention messages in positive terms (eg, “getting vaccinated will help you because…”), and the importance of not making intervention recipients felt as though vaccination is being forced upon them.
Children, mothers, and grandmothers all emerged as potential facilitators of vaccination among our sample. As noted earlier, participants expressed a strong desire to protect their families. In addition, participants noted that mothers could prove to be excellent messengers for and models of vaccination uptake.
I would tell them to do it, that they should think about their children, they wouldn't want that to happen to their children, or anybody else.
If my mother tells me. She has told me so many times too. She is vaccinated too. My mom. Thank God. And she is fine. … And my grandma. Thank God, they are already fine, and they are vaccinated.
Similar to concerns about vaccination among people who inject drugs, which emerged among our sample, themes about messages that would facilitate vaccination among people who inject drugs emerged as well. These included messaging about the increased dangers of injection drug use during the pandemic, which again underscore the risks stemming from the close personal contact associated with injection drug use:
I recommend vaccination to any person using drugs on the streets. They should be vaccinated, because they are on the streets, and they don't know who they may infect if they are infected. You don't know … When you use drugs, you interact with many people, and you may infect many people. So, I would tell them to get vaccinated as soon as possible. That's what I say.
Suggested methodologies to increase vaccination among people who inject drugs also included simple reassurance as a facilitator, including telling people that they would not be left alone in their time of need.
Something like that, “If you're afraid, I'll go with you.” Yeah … just to encourage them by saying that it does- I, I, it doesn't hurt, you know. Only take a couple of seconds, and, and it's over. And you're good.
Lastly, although our sample only included people who had not vaccinated against COVID-19, some participants indicated that the process of discussing their resistance to vaccination during study interviews and describing how they might explain the importance of vaccination to someone else left them more likely to accept a vaccination if one were offered.
I would say, “Listen ... with me, myself, I never got the vaccine.” I will try 'cause, you know, really, I, I'm scared, but ... I'm sitting here with you, so that's why I'm try- I would like to get the vaccine.
In many ways, our sample may be described as more “vaccine ambivalent” than “vaccine hesitant” or “vaccine resistant.” Interview data show participants are clearly aware of their increased risk of COVID-19 exposure, and that participants understand the importance of vaccination to prevent illness. At the same time, participants expressed concerns about the vaccines’ safety, and whether a possible weakening of their bodies owing to injection drug use has intensified the danger of possible vaccine side effects. In addition, participants in our sample, like others in our society, describe a seemingly endless stream of social media misinformation, often repeated by close friends and family members, which actively discourages vaccination. Together, these issues have left our participants unsure what steps they should take to protect themselves and what sources of information they can trust.
This ambivalence becomes more important to address as the danger of COVID-19, specifically among substance users, is increasingly well documented. According to a large, nationwide study conducted by the National Institutes of Health and researchers at Case Western Reserve University [
Participants repeatedly mentioned that they feared their history of drug use would exacerbate the dangers of potential side effects, possibly to the point that vaccination might prove deadly. These concerns may be particularly difficult to dispel among people who inject drugs, who are contemplating vaccination and, in fact, appear to have scientific merit. Clinical trials for the approved COVID-19 vaccines did not explicitly include participants with SUD, and there are no current systematic studies examining the real-world effectiveness of COVID-19 vaccines among SUD or populations of people who inject drugs [
Some interviews suggest participants became more amenable to vaccination during their discussions with our team. This may indicate that simply allowing interviewees to voice their concerns about vaccination without being judged or silenced encouraged participants to consider the benefits of vaccination and left them feeling empowered to make positive decisions about protecting themselves. A similarly supportive and noncoercive approach could potentially encourage vaccination—and health care utilization in general—on a wider scale among people who inject drugs and other members of marginalized, high-risk populations, especially if paired with messaging designed to address known barriers to vaccination and emphasize facilitators (eg, “No matter what you do we want you to be safe, and the best way to keep yourself, your kids, and people you care about safe from COVID is to vaccinate”). This type of strategy, rooted in the idea of low-threshold access to health care via harm reduction services [
Building upon our team’s participatory methodology, we now plan to create a series of digitally delivered intervention messages based on the aforementioned findings, including short videos and SMS text messages to encourage vaccination among people who inject drugs, who initially decline. All steps of intervention development and evaluation will include continued involvement among people who inject drugs, including ongoing monthly meetings with a community advisory board who we have consulted since August 2021.
This study is not without limitations, the first one related to the generalizability of a fairly small sample recruited at a New York City SSP. Owing to the relative saturation of area harm reduction services, participants may feel less stigma and may therefore be more open to discussing substance use and related health issues, including decisions to decline vaccination. This may also be a strength of our study, as interviews conducted in a supportive SSP environment may have resulted in more detailed, and possibly more honest, participant responses. Additionally, our analyses show the themes discussed in this study emerged among a number of interviews. This suggests current data may represent larger topics of concern among people who inject drugs in the New York City area. Further research is warranted to examine whether similar themes would be present among additional populations of people who inject drugs nationwide.
Effectively encouraging vaccination among people who inject drugs remains a public health priority. If members of populations of people who inject drugs, who are generally already greatly underserved by health care, do not get vaccinated in adequate numbers, SARS-CoV-2 can continue to spread and mutate into potentially more dangerous variants. Appeals to protect the health of loved ones and the safety of the larger community have been successfully employed to encourage important health behaviors among populations of people who inject drugs, such as HIV or HCV testing and prevention along with overdose prevention and reversal. Developing intervention materials that depict trusted community members (eg, recognizable peer educators and individuals with compelling personal stories) delivering clear, nonjudgmental messages may prove especially helpful now. Similarly, organizations that currently offer services to people who inject drugs, including SSPs or other community-based organizations, can facilitate vaccination by offering easy access to vaccines on site (people may be more likely to accept a vaccine offer from someone they already know and trust, especially if they do not have to travel to an additional location).
Importantly, data from this study show that people who inject drugs often remain reluctant to get vaccinated even when they understand the dangers posed by COVID-19, and the increased safety vaccines can offer to them and their families. Given historic vaccine hesitance and medical mistrust among people who inject drugs, combined with pervasive concern about possible side effects, interventions are urgently needed to effectively offer vaccines in ways those most in need will actually accept them.
hepatitis B virus
hepatitis C virus
opioid use disorder
principal investigator
syringe service program
substance use disorders
This work was supported by the National Institute on Drug Abuse of the National Institutes of Health (award R01DA054990). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Additional research support was provided by National Institute on Drug Abuse grants (P30 DA029926 and P30 DA011041).
None declared.