Vaccines, Military Culture, and Cynicism: Exploring COVID-19 Vaccination Attitudes among Veterans in Homeless Transitional Housing

Abstract

Veterans experiencing homelessness are particularly at risk from infection and transmission from COVID-19, and vaccines offer a promising avenue toward reducing that risk. However, little is understood about vaccine acceptance within the homeless population, particularly Veterans experiencing homelessness, who comprise a disproportionate share of that population. The cultural roots of vaccine hesitancy among active-duty military members and Veterans are even less understood. This study used semi-structured interviews to explore the role of military identity in shaping the vaccination attitudes of 20 Veterans experiencing homelessness enrolled in U.S. Department of Veterans Affairs’ (VA) transitional housing programs. Over half of the Veteran respondents mentioned their military experience during interviews about the COVID-19 vaccines. In these discussions, they cited mandatory vaccines in the military, military identity, and distrust of the military or government. Distrust was cited by most refusing the vaccine, while mandatory vaccines in the military were cited by most accepting the vaccine. Military identity, culture, and experience influence the risk-benefit reasoning that man Veterans in VA homeless programs undertake when deciding whether to accept the COVID-19 vaccine. A more nuanced understanding of military culture’s effect on Veterans experiencing homelessness is vital in designing messages and strategies that encourage vaccine uptake.

Keywords:

• Military culture
• Veteran homelessness
• COVID-19 vaccination
• military experience
• military identity
• homelessness
• peer education
• health behavior
• distrust
• mandatory vaccines

Introduction

The COVID-19 pandemic poses a particular risk to individuals experiencing homelessness due to the high rate of health conditions in this population, the inherent challenge of maintaining hygiene, masking, and social distancing in highly dense congregate living environments, and their inherent lack of trust and access to mainstream sources of health care information (National Academies, 2021; Leung et al., 2008; Pixley et al., 2021; Tsai & Wilson, 2020; Zlotnick et al., 2013). COVID-19 vaccines offer a promising avenue for reducing transmission and offering protection from serious illness for these vulnerable populations. However, data suggests that individuals who are unhoused are being vaccinated at about half the rate of the general population (Kendall, July 19, 2021). Limited research on vaccine hesitancy among people experiencing homelessness suggests high vaccine refusal rates for hepatitis (Buechler et al., 2020; Nelson, 2018), influenza (Beers et al., 2019; Kong et al., 2020), and COVID-19 (Balut et al., 2021; Meehan et al., 2022; Montgomery et al., 2021; Rogers et al., 2022; Shariff et al., 2022), underscoring the need to better understand the vaccination behavior of people who are homeless during the pandemic.

People experiencing homelessness may have other unique experiences and identities, such as prior military service, that can powerfully shape worldviews and influence their vaccination behavior. As former military members, Veterans have a complex relationship with the government, and their military experience may uniquely affect vaccination attitudes (Elwy et al., 2021; Jasuja et al., 2021). Veterans’ levels of trust in their local health departments has been found to be markedly different from those of non-Veterans (Heslin et al., 2013). Veterans often share cultural values of self-reliance or “a bootstrap mentality” instilled during military service, which can sometimes hinder their willingness to adopt recommended health behaviors (Kranke et al., 2016). Castro et al. (2015) conceptualizes Veterans’ self-reliance and military experience mindset as a larger paradox, distinct from civilians’ worldview. Within this paradox, Veterans are often happy with the individual health care received from the U.S. Department of Veterans Affairs (VA), despite high levels of general mistrust and cynicism toward the VA. “Military culture” is a distinct subculture within American civilian society that Veterans often continue to hold after separating from the military (Weiss & Coll, 2011).

However, COVID-19 vaccine uptake, attitudes, and behavior within the Veteran population in general (Elwy et al, 2021; Jasuja et al., 2021), and in Veterans experiencing homelessness specifically, has been a neglected research topic (Gin et al., under review). Prior work examining influenza vaccination has found Veterans were more likely to get vaccinated than non-Veterans (Der-Martirosian et al., 2013), pointing to structural advantages that enable Veterans to access care as a rationale. However, research and media reports of lagging COVID-19 vaccine uptake among active-duty military members during the vaccine rollout also suggest differential vaccine attitudes and behaviors. COVID-19 vaccine refusal among active-duty military members has been elevated by the spread of misinformation fueling perceptions that the vaccines were unsafe and developed too quickly (Steinhauer, 2021; Stewart & Ali, 2021). In August 2021, only 64% of active-duty military members voluntarily received the COVID-19 vaccine, though vaccination rates have since increased to 95% by early October 2021 due to the U.S. military vaccine mandate (Aker, 2021; Geppert, 2021; Liebermann & Kaufman, 2021; Mitchell, 2021; Stewart & Ali, 2021). However, as one leader noted, a military mandate may strengthen distrust and cynicism in the military (Geppert, 2021), and possibly reinforce resistance among those not covered under the military mandate, such as Veterans and the public. Early research on Veteran attitudes toward the COVID-19 vaccines have found multifaceted factors behind vaccine hesitancy, with military experience emerging as a potential inhibitor and peer encouragement as a potential facilitator to vaccine uptake (Elwy et al., 2021). Veterans have a complex relationship with the government compared with the general population (Elwy et al., 2021; Jasuja et al., 2021), underscoring the importance of better understanding how Veterans’ military experience and reliance on peers affects vaccination behaviors.

This study explores the role of military experiences and identities in shaping COVID-19 vaccine perceptions of Veterans experiencing homelessness living in residential transitional housing, and how these attitudes, in turn, shape their vaccine uptake behavior. If Veterans, a major segment of the U.S. adult population experiencing homelessness, respond differently to health authorities due to some aspect of their military experience, identity, or culture, this may affect whether they heed those authorities’ vaccine recommendations during health emergencies (Heslin et al., 2013; Kranke et al., 2016; Weiss & Coll, 2011). Understanding how military experiences and identities shape Veterans experiencing homelessness’ attitudes toward the COVID-19 vaccines may assist the VA and other homeless service providers in identifying additional avenues to improve vaccine uptake and curb the spread of the increasingly transmissible virus.

Methods

Study design & data collection

Interviews were conducted with 20 Veterans residing in five organizations funded by the VA Grant and Per Diem (GPD) Program. The VA GPD program funds entities outside the VA to provide transitional housing and services to Veterans experiencing homelessness (McGuire et al., 2011; Perl, 2015; Tsai et al., 2013; U.S. Department of Veterans Affairs, July 19, 2018). Study sites included five GPD organizations located in California, Florida, Iowa, Kentucky, and Massachusetts. The five GPD organizations were in both urban and rural areas and represented a broad range of both politically “liberal” and “conservative” areas of the country. The GPD programs were facilities exclusively serving male Veterans. Researchers invited GPD grantee organizations to participate in the study through a monthly webinar hosted by the National VA GPD Office for these organizations and VA program staff. Seven organizations contacted the research team and volunteered to recruit their Veteran residents to participate in one of two ways: (1) distributing a recruitment flyer to Veterans with a phone number for contacting researchers to schedule an interview; (2) collecting the contact information of Veteran residents who were interested, and with their consent, sharing that information with researchers who contacted the Veterans directly. Five of the seven organizations successfully recruited Veterans for interviews. GPD staff members at all seven organizations were also interviewed about their experiences facilitating COVID-19 vaccination.

Between two to six Veterans from each site participated in qualitative, semi-structured telephone interviews lasting approximately 30 minutes between January and April 2021. Veteran participants were recruited until data saturation was reached (Guest et al., 2020), resulting in interviews with 20 Veterans. All interviews were conducted by the same two research team members. All Veterans currently enrolled in GPD programs were eligible for inclusion in the study. Veterans did not receive compensation for study participation.

The interview guide consisted of 20 open-ended questions covering a wide range of topics related to Veterans’ attitudes toward the COVID-19 vaccine, including their willingness or refusal to get vaccinated and their reasons for their intentions either way. Interviews also asked about Veterans’ sources of information about the COVID-19 vaccine, their trust in healthcare providers, their vaccination history, and their sociodemographic characteristics. Notably, Veterans were not asked about their military experience, nor were they prompted to consider their identity as military Veterans. Military experience and identity were emergent themes solely brought up by Veterans. Consequently, this article reports the findings from these emergent military themes and their impact on COVID-19 vaccination attitudes and uptake.

Data analysis

All interviews were audio recorded and professionally transcribed verbatim. A rapid analysis approach was used to analyze the interview transcripts (Gale et al., 2019; Taylor et al., 2018), employing both an inductive grounded theory approach of identifying themes that emerged as highly salient to Veterans’ expressed views toward vaccination and within the deductive domains covered in the interview guide (Corbin & Strauss, 1990; Strauss & Corbin, 1990). Military experience and identity themes discussed here were identified through the inductive grounded theory approach. Transcripts were independently read and summarized by two team members. Interview summaries were then combined into a single document to identify commonly occurring themes across all interviews. The significance of themes was based on their substantive significance (Patton, 2014), referring to the extent to which they speak to the extant literature.

Ethical considerations

This study was reviewed by the VA Greater Los Angeles Healthcare System Institutional Review Board and determined to be a quality improvement study. All methods were carried out in accordance with relevant guidelines and regulations. Verbal informed consent was obtained from each participant prior to study inclusion.

Results

Table 1 displays the sociodemographic and health-related characteristics of the 20 study participants by GPD location. All 20 Veterans in the study were male, and ranged in age from 29 to 65 years, with the majority in their 50s. Most were white, though five were racial minorities and four did not disclose their race/ethnicity. Seven considered themselves to be in a “medically high-risk” category due to their age or health conditions they may have (e.g., heart disease, diabetes, high blood pressure, asthma, etc.). Half of the participants (n = 10) received a flu vaccine in either the 2019/2020 or 2020/2021 flu season.

Table 1. Sociodemographic and health-related characteristics of homeless Veterans enrolled in GPD programs, by COVID-19 vaccination status (n = 20).

		Yes—Vaccinated or willing	No—Refused or hesitant
Age	20s	–	1
30s		1	1
40s		3	–
50s		7	1
60s +		2	1
Unknown/Did not disclose		1	2
Race/Ethnicity	White	7	4
African American		1	–
Hispanic or Latino		2	–
Asian or Pacific Islander		–	–
Native American or Alaskan Native		1	–
Biracial or Multiracial		1	–
Unknown/Did not disclose		2	2
Medically high-risk	Yes	4	4
No		9	1
Unknown/Did not disclose		1	1
Received flu vaccine	Yes	9	1
No		5	4
Unknown/Did not disclose		–	1
Total		14	6

Table 2 presents the number of Veterans who mentioned any military theme, broken down by their willingness (Yes/No) to be vaccinated for COVID-19. Veterans at all five sites mentioned this theme as a factor informing their vaccination decisions. The military theme was mentioned by Veterans of all racial and age group categories. Of the 20 Veterans, 11 of them mentioned military themes during the interview, alluding to its salience among Veterans enrolled in the VA’s GPD program. Results from the broader study, which found that COVID-19 vaccination attitudes (e.g., belief that the vaccines were inadequately tested), beliefs about influenza and other vaccines, and sources of information emerged as influential factors for COVID-19 vaccination uptake or hesitancy, are available elsewhere (Gin et al., under review). In addition, previous military experience and military identity emerged in over half of these discussions about vaccination. This analysis explores those themes further, and how they impact their vaccination decisions.

Table 2. Number of veterans mentioning military themes during interviews (n = 11).

	Military themes
Willingness to receive COVID-19 vaccine	Any military experience & identity theme	Mandatory vaccines in military	Mistrust of gov’t/Military	Military background
Already vaccinated or definitely yes	7	4	1	6
Definitely or probably no	4	2	3	2
Total	11	6	4	8

Within the broader overarching military experience and identity theme, three distinct subthemes emerged: (1) Mandatory vaccines in the military; (2) Mistrust of government or military-related institutions; and (3) Military background (their own or others’). Several of the 11 Veterans who mentioned the military experience and identity theme mentioned more than one of the three subthemes.

Subtheme 1: Mandatory vaccines in the military

When asked about their willingness to accept the COVID-19 vaccine, six of the 20 Veterans noted that they had received mandatory vaccines in the military. Four of these six Veterans had either received the vaccine or wanted to receive it, while two were reluctant. Of the Veterans who mentioned mandatory military vaccinations and were willing to be vaccinated for COVID-19, two of them mentioned that they had also received the anthrax vaccine as part of the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) cohort that served in the U.S. wars in Afghanistan and/or Iraq that began in 2001 and 2003, respectively. The anthrax vaccine, mandatory for personnel serving in the Middle East, became controversial, as it was found to cause severe adverse reactions in 85% of U.S. Air Force members who were vaccinated and led to a 16% attrition rate among those required to receive it (U.S. Government Accountability Office, September 20, 2002). “Massachusetts4,” who eagerly received the COVID-19 vaccine in January 2021, recounted the widespread cynicism and distrust that the anthrax vaccine generated from himself and other military members:

What they did is they gave everybody this vaccine to test it out…. They give it to prisoners and military members to see what exactly is gonna happen over a period of time because they’re government property….

After weighing the benefits of being vaccinated for COVID-19, he noted he was able to separate his past distrust around the anthrax vaccine from his decision.

“Iowa1,” an OEF/OIF-era Veteran who was also willing to get the COVID-19 vaccine, expressed similar views about receiving mandatory vaccines, such as anthrax, in the military:

The way in which the military treats vaccines is you get desensitized to the idea of the government putting things in your body. I’ve had anthrax, Hep A, Hep B … things I can’t even pronounce, pumped into me. And I’m still alive. I just don’t worry about vaccines.

He emphasized a view that he and his peers developed in the military: thinking of vaccines not as much a means to prevent disease and illness as they are a requirement to be fulfilled to gain access to certain benefits. Iowa1 repeatedly referred to all vaccines as: “a box to check.”

While in the military, in order to be promoted or to get any type of favorable actions, you have to … get all of your vaccines and immunizations.

Interviewed six weeks before vaccines became widely available to the entire broader U.S. public, “Iowa1” had already anticipated a future wherein access to desired benefits would be contingent on COVID-19 vaccination.

Subtheme 2: Mistrust of government and military-related institutions

Four of the 20 Veterans expressed personal mistrust of government and military institutions, including the VA. Three of the four Veterans reporting mistrust refused the COVID-19 vaccine, while one, “Massachusetts4,” received the vaccine despite his distrust.

Exposure to environmental health hazards during military service was mentioned by two Veterans when asked about their views on vaccines in general. “Massachusetts1,” who was adamantly opposed to getting the vaccine, cited his own experience with being stationed at Camp Lejeune, a Marine base where drinking water was contaminated with toxic chemicals for 30 years, Veterans’ exposure to Agent Orange during the Vietnam War, and conspiracy theories regarding U.S. government origins of COVID-19, as reason for mistrust:

So, I don’t really trust the government when it comes to saying everything is all right when it comes to medicine for patients. I’m also in the study of the Camp Lejeune… And they’re … still refusing to step up … and they’re not taking care of people that were exposed to it.

Having served in the Middle East during OEF/OIF, “Massachusetts4” mentioned burn pits, another source of environmental exposure that he believed contributed to cynicism and distrust:

There were consequences… Just like the heavy metals we all ingested from the burn pits when we were deployed. Raised the rates of cancer. Stillbirth with children.

Agent Orange, water contamination at Camp Lejeune, and the Middle East burn pits, are all military service hazards whose long-term health impacts the VA is following (U.S. Department of Veterans Affairs, September 14, 2021).

Veterans refusing the vaccine also cited mistrust of the VA health care system. Although “Kentucky2” had never used VA health care, he distrusted both government vaccines and the VA in general:

I wouldn’t go to the VA for anything, even if they were the last resort.

“Massachusetts4,” who had specific negative experiences with VA health care in the past, shared his decade-long experience of initial dissatisfaction with the VA before witnessing improvements:

I don’t trust the information [the VA] gives me. Because I understand their track record… The VA was made to mend the broken toy soldiers that the military made. And for a very long time they were not good at their job. They’re getting better. The amount of care that they’re offering now because of the Gulf War and OEF/OIF Veterans. The VA is forced to become better at their job. …. that’s why I don’t trust the VA.

To him, the VA and the military are one and the same, both emblematic of perceived substandard care and an institutionalized disregard for quality in the interest of cost saving. Despite his detailed description of his reasons for mistrusting the military, “Massachusetts4” was, notably, the only Veteran expressing mistrust who received the vaccine.

Subtheme 3: Military background

Military background was a broad subtheme. It included Veterans mentioning their own military experience, trusting the word of others with a shared military background or connection about vaccines, or ways that their military training influenced their view on COVID prevention measures such as vaccines. Of the 20, eight Veterans mentioned their or others’ military background. Six of these accepted the vaccine, whereas two refused.

When asked about their opinion about COVID-19 vaccines, some Veterans brought up their military service, noting which branch of the military they served in or where they were stationed. Both Veterans and GPD staff members noted that peer influence also played a strong role in Veterans’ decisions whether to get vaccinated. Others mentioned that talking to fellow Veterans who were vaccinated helped alleviate their concerns about whether they should get the vaccine. “Florida1” noted that his GPD counselor was a trusted source of information about the vaccine, because the counselor had a father who was a Vietnam Veteran and thus was “military-connected,” underscoring the power of military identity as a signal of whom he could trust. “Iowa1” described detailed conversations with fellow Veterans about the vaccine, prefacing his comments with “every Veteran I’ve talked to is like this.” He also framed compliance with future vaccine mandates within the context of Veterans as an identity group:

But it’s not that we’re seeking the vaccine because we’re scared of contracting COVID. It’s that society wants us to have the vaccine, so we’re happy to get it.

Veterans mentioned their military training in explaining their response, either to the risk of COVID-19 or how they felt about COVID-19 vaccination. “California3” noted that the safety measures he adopted (wearing gloves and sanitizing) to protect himself from contracting COVID-19 were closely aligned with the mindset that the military acculturated within him:

In the military, the number one thing is safety because you could die in a moment. You have to wear a bullet proof vest. You have to wear a gas mask. You have to wear combat boots and a helmet.

Military background covered a vast typology of disparate subthemes. They included mentioning the branch of the military one served in, looking toward peers and others with military or Veteran identities as trusted cues on vaccine uptake behavior, and military training that influenced responses to COVID-19.

Discussion

These data illustrate the nuanced and multifaceted influence of military identity and experience on the attitudes and behaviors toward vaccines of Veterans’ experiencing homelessness, confirming Elwy et al.’s (2021) suggestion of the influence of military culture on vaccine decisions. To some Veterans, military life was structured in a way that led them to grow accustomed to accepting vaccines without question, while others decided that once they no longer had compulsory vaccination, they would avoid vaccines perceived as new and unknown. However, most Veterans who mentioned mandatory vaccinations in the military accepted the COVID-19 vaccine.

One striking aspect of the mandatory vaccination theme was the remarkable consistency of “Massachusetts4” and “Iowa1,” who both served in OEF/OIF and received the anthrax vaccine and were both willing to get the COVID-19 vaccine. Both Veterans exhibited the paradox of cynicism described by Castro et al. (2015), in both expressing trust in their VA health care providers while expressing strong cynicism about the VA and the military. In contrast to two other Veterans of their same age cohort who were reluctant to be vaccinated (“Florida2” and “Kentucky2”), “Massachusetts4” and “Iowa1” both willingly accepted the COVID-19 vaccine despite their shared skepticism. Both “Massachusetts4” and “Iowa1” had hopeful narratives in their interviews, while the other two Veterans in their age group who refused the vaccine were either unhappy with, or did not receive, VA health care. When asked about the vaccine, Veterans who refused to get vaccinated cited information they heard through the media but either did not receive information about the vaccine from their health care providers or had not interacted with health care providers during the pandemic. If positive experiences with VA health care could help mitigate their distrust of the military and government institutions they associate with the military, expanding VA health care to cover more Veterans and utilizing VA health care providers as trusted messengers to foster trust in vaccines could be critical to improving uptake.

Mistrust of government and military institutions was mentioned by most Veterans rejecting the COVID-19 vaccine. “Massachusetts4” was the only one who got vaccinated despite being distrustful of the VA and the military. He observed that the VA had been forced to improve quality of care, which may have led him to accept the vaccine. All four Veterans expressing mistrust were either in their late 50s/early 60s, the generation who came of age during the Vietnam War, or in their mid-30s and therefore of the OEF/OIF generation. Veterans who came of age during the Vietnam War were found to have lower levels of trust in local public health departments than other age cohorts (Heslin et al., 2013). However, in the 21 years since those data were collected, the OEF/OIF Veteran generation has grown and many report levels of cynicism toward government paralleling those of the Vietnam Veteran cohort. The mistrust expressed by these Veterans should not be overlooked in public health messaging, specifically. Moreover, changing perceptions toward quality of care in health care systems used by Veterans could eventually overcome the mistrust that can hinder health behavior adoption.

The prevalence of military background in interviews where respondents were not asked questions about their military experience underscores the high salience of this identity to these Veterans. The strong influence of trusted peers is consistent with research about Veterans’ tendency to select services and make major decisions based on peer word-of-mouth (Alenkin, 2015). The wide array of military-connected themes: branch of military, arming oneself against risks, deployment related hazards exposures, trust in one’s fellow peers, and even military vaccines, all align with research suggesting that military service is an all-encompassing experience that continues to shape individuals and mold service members’ worldview long after separation from the military (Weiss & Coll, 2011). The denotation of “we” and “us” by “Iowa1” in summarizing his belief in a shared Veteran perspective on vaccines, based on his conversations with fellow Veterans, evokes the concept of a shared identity among military Veterans suggested by Weiss and Coll (2011) and Castro et al. (2015). This article suggests that this shared culture influences attitudes and behaviors toward vaccination.

Limitations

The salience of military themes in vaccine decision-making among GPD-enrolled Veterans may not apply to the general Veteran population for various reasons. First, being enrolled in VA Homeless Programs may reflect self-selection bias in this Veteran population. Veterans with stronger military cultural identities could be more likely to enroll in VA homeless services when in need, although this does run somewhat counter to the observation that some of these Veterans refused vaccination because of the stated military themes. It is possible though that these individuals are more willing to accept housing services and other benefits from the VA than health care. Secondly, Veterans who become homeless may disproportionately reflect individuals who experience challenges in reintegrating to civilian life after the military (Mares & Rosenheck, 2004), possibly due to posttraumatic stress disorder, substance use disorders, or other psychological disorders. These conditions, while not necessarily caused by military service but that might reflect lifelong mental health concerns (Mares & Rosenheck, 2004), may have contributed to their current homeless status, and would also lead them to mention cynicism, fatalism, or other negative perceptions of distrust toward the military or government. Mental health concerns have long been associated with homelessness among Veterans (O’Toole et al., 2016; Tsai et al., 2016; Tsai & Rosenheck, 2015). Thus, it is important to recognize that these findings among Veterans experiencing homelessness in GPD programs may not be generalized to the overall U.S. Veteran population. This study did not inquire about Veterans’ political affiliation, which has been shown to heavily influence COVID-19 protective measures, including vaccination (Albrecht, 2022). However, Veterans living in both “liberal” and “conservative” states mentioned military themes and did not identify political affiliations as factors influencing their COVID-19 vaccination decision. Due to the sample size and several non-responses to the sociodemographic questions, the study team could not effectively make associations between age, race/ethnicity, and COVID-19 vaccination status. COVID-19 vaccine mandates had not yet been discussed in early 2021 when the interviews were conducted, but such ordinances could shape individuals’ attitudes and behavior. The convenience sampling recruitment method may have led to selection bias, although Veteran respondents represented diverse localities and age groups. Lastly, the study team did not ask about military experience, Veterans’ branch of service, years of service, or rank, all of which may impact vaccination uptake behavior. Future research should explore military themes in vaccine decision-making among other groups of Veterans.

Conclusions and implications

This study has implications for understanding how Veterans experiencing homelessness perceive COVID-19 vaccination efforts through a military lens, given the urgency of vaccinating this population. Research on military vaccination acceptance, and the mixed record of current U.S. active-duty military in receiving COVID-19 vaccines, suggests that a more nuanced understanding of how military experiences, culture, and identity is invaluable to developing pro-vaccine strategies and messages that resonate with active-duty military service members and Veteran communities. If Veterans experiencing homelessness respond to health behavior recommendations in ways heavily influenced by their military identity (Heslin et al., 2013), understanding these perspectives and accounting for them in messaging and outreach strategies is vital to successfully persuading hesitant group members. Given the strong mistrust and cynicism present in narratives of Veterans in VA Homeless Programs refusing the vaccine, fellow Veterans engaged in peer education could consider acknowledging their reasons for mistrust stemming from past military experiences and the inability to refuse vaccines and other drugs in the military (Rein, 2021; Rettig, 1999). The VA is uniquely well positioned to alter the calculus of vaccine uptake given its focus on serving Veterans experiencing homelessness. A vaccination campaign that resonates with their shared values and culture by, for example, using Veteran patients and providers who can speak to these military themes, is ultimately vital to protecting their health and safety during this global pandemic.

Ethics approval and consent to participate

This study was reviewed by the VA Greater Los Angeles Healthcare System Institutional Review Board and determined to be a quality improvement study. All methods were carried out in accordance with relevant guidelines and regulations. Verbal informed consent was obtained from each participant prior to study inclusion. Involvement in the study was voluntary and there were no repercussions for nonparticipation. Anonymity and confidentiality of the information was maintained by removing personal identifiers from the data. The notes and audio tapes are kept in secured password protected electronic device accessible only to the first author and the coauthors.

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available. They are available from the corresponding author on reasonable request, subject to approval from the ethics committee that approved the study.

Disclosure statement

The authors declare that they have no financial conflicts of interests.

The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Department of Veterans Affairs nor the U.S. government.

Funding

This study was funded by the U.S. Department of Veterans Affairs. The funder did not participate in the design of the study, collection, analysis, and interpretation of data or writing this manuscript.