It is no secret that the COVID-19 pandemic has altered the way we live. The pandemic has brought to light a number of critical challenges in the delivery of care and services.
As one example, the deployment of the COVID-19 vaccine highlighted the barriers and disparities among different cultures and age groups, especially among older adults. Older people, especially those living in long-term care settings where infections can spread easily, belong to this high-risk group. The impact of the pandemic and distribution is now under review and investigation in various countries.
In 2021, the Global Ageing Network, the world’s only network of ageing service providers, in partnership with Standards Wise International, embarked on qualitative research in the report, ‘The COVID-19 Vaccine Distribution in Elder Care: A cross cultural snapshot’, to examine the challenges providers were facing in accessing vaccines and deploying vaccinations. The study focused primarily on residential settings such as nursing homes, group homes and assisted living communities. However, information was also gathered from providers about the vaccine-related experiences of community-dwelling elders who receive home and community-based care.
The research was conducted by Dr Emi Kiyota, an Environmental Gerontologist. In addition to interviews conducted with aged care leaders in 12 countries, Dr Kiyota reviewed published data. Most of the selected providers also participated in a previous study, ‘Elder Care Providers & COVID-19: Cross-cultural perspectives’.
- Vaccine supplies and vaccination schedules were unreliable. Many of the surveyed providers reported challenges related to shortages of COVID-19 vaccines and frequent changes in vaccination schedules.
- Strong leadership was critical. Vaccination rates increased when national governments exercised strong leadership in securing vaccines and issuing policies, which prioritised residents of elder care settings
- Community-dwelling elders faced greater challenges. Elders living in their community, rather than in a congregate setting, had more difficulty obtaining vaccinations than elders living in long-term care settings. Community-dwelling elders had limited access to the help they needed to navigate web-based appointment systems and had more trouble accessing vaccination sites.
- Rationales behind vaccination priority categories were often unclear and sometimes inconsistent. Several countries excluded elder care workers from the ‘health care worker’ category, causing significant delays in staff vaccinations.
- Preparing residents for vaccination was challenging. Government agencies had difficulty co-ordinating vaccination logistics and often gave last-minute notice about the schedules for vaccination clinics. This created challenges for providers seeking to prepare residents to be vaccinated.
- Staff vaccinations caused care-related challenges. Worker shortages made it more difficult for staff members to provide sufficient care to residents and clients while also obtaining vaccines or recovering from vaccine side effects. These shortages were particularly problematic when staff members could not obtain vaccinations at work.
- Staff members were receptive to misinformation. Misinformation and rumours about COVID-19 vaccines, spread mainly through social networks, made it more difficult to reach high vaccine uptake rates among staff members.
- National health care systems influenced vaccination success. Countries with a national health care system achieved high vaccination uptake at a faster rate than countries without such a system. The COVID-19 vaccination rollout was swiftly co-ordinated in countries like Israel and the United Kingdom, while other countries struggled to acquire enough vaccines and/or to co-ordinate logistics.
- Inequities were real. Stark inequities emerged between high- and middle-to-low-income countries. Those inequities were particularly evident when comparing the relatively generous amount and variety of vaccines available for distribution in high-income countries, and the shortages of vaccines in lower-income nations.
The report highlighted six major themes. First, all providers that participated in the study had some level of experience with vaccination planning before the pandemic began. However, the plans focused primarily on influenza vaccinations. The COVID-19 rollout proved to be more challenging at a national or regional level and exposed issues around confidentiality, public perceptions and confidence in the efficacy of the vaccines. Countries such as the United Kingdom and Israel, which managed their vaccine rollouts through their national health care systems, were able to co-ordinate vaccine administration through primary doctors.
The second theme that emerged focused on vaccine availability. Regional differences in vaccine availability and other logistics affected vaccine scheduling within countries. Community-dwelling older people were vaccinated later than older adults living in long-term care settings. Hospital systems in the United Kingdom and Israel did not rely on community-dwelling elders to make their own vaccine appointments on a computer or by phone, which often involved long waits. Instead, the systems reached out to these individuals by phone to set up their vaccination appointments.
All 12 countries gave health care workers first priority for vaccination over other workers. Most countries included long-term care workers as part of that first-priority group. In the few countries that did not follow this protocol, including Australia, Mexico and some of the European countries, staff members had to wait until their age group was eligible for vaccination. This delay caused many infection-control and staffing challenges for providers. High-income countries were able to start vaccinations quicker than middle- to low-income countries. Providers in the 12 study countries did not have access to all eight types of vaccines available worldwide (Table 3). It appears that higher-income countries administered Pfizer, Oxford/AstraZeneca, Moderna, and Johnson and Johnson vaccines, while middle- to lower-income countries used these vaccines but added the Chinese and Russian vaccines when they could not obtain adequate vaccine supplies.
Third, providers followed the same process for vaccine delivery and administration. All the providers participating in this study assigned either one person or a team to co-ordinate vaccination delivery. Vaccines could only be administered by personnel assigned by the Government, which created challenges in co-ordination, unclear communication, confusion around web-based appointments and logistical challenges. In some countries, such as South Africa, Singapore and the United Kingdom, in-house nurses were allowed to administer vaccinations.
The fourth theme focused on vaccine acceptance. Vaccine acceptance among residents was high in most of the countries. Vaccine refusals came primarily from family members who had concerns about side effects, the frailty of their relatives, and rumours and misinformation that had been spread through social media. However, the vaccination acceptance rate was initially lower among staff members, due mainly to fears spurred by misinformation, religious objections and their own existing medical conditions.
In some study countries, including the Netherlands, Spain and the United Kingdom, providers did not know the vaccination status of staff members due to privacy laws. Almost one year after the vaccine rollout started, Australia and Canada made vaccinations mandatory for health care and elder
Fifth, communication with staff, families and national and local authorities was of upmost importance to address rumours and misinformation about vaccines. The goal of the communication was to inform family members about an organisation’s vaccination plans and to obtain informed consent signatures. Many providers conducted in-person meetings and education sessions with staff to explain the safety of vaccines. During the national vaccine rollout, providers communicated regularly with national and local authorities. Many providers reported that their communication with the Government during the infection-control phase of the pandemic made it easy to establish effective communications during the vaccine rollout. The responsibility of providers to send reports to the Government was varied.
Elder care associations played an important role in distributing vaccine-related resources in the Netherlands, the United Kingdom and Spain. However, widespread vaccine misinformation caused the most common communication challenges encountered by providers. Providers had to rebut rumours about the efficacy of different vaccine products, side effects and the rationale behind how groups of staff members were prioritised for the vaccine.
The final theme revolved around policy-related challenges. Most providers reported that their governments issued policies and guidelines for vaccinating elders in long-term care settings, but that these policies were not effective for community-dwelling elders who do not reside in those settings. A provider from the United Kingdom discussed the need to make vaccine-related educational materials more sensitive to cultural issues that might affect vaccine acceptance. All 12 countries in the study established priority groups for vaccinations; however, the rationale behind these priorities was not well communicated to providers or the public. Providers agreed that these criteria should have been presented in a clear and logical manner. As knowledge about COVID-19 evolved, messages from policymakers kept changing. Moreover, multiple layers of Government (federal, state and city) and various disciplines (health, social services and ageing services) were involved in the decision-making and communication about the vaccine rollout. The messages from these entities often conflicted.
The report identified six key lessons and associated action items that emerged from the participating providers and stakeholders:
- National governmental leadership was key to an effective COVID-19 vaccine rollout.
- Elders living in long-term care settings were able to access vaccinations more easily than community-dwelling elders, due to the support offered by care settings.
- Staff members in long-term care settings had lower vaccine acceptance rates than elders living in those settings.
- COVID-19 revealed a troubling inequity in vaccine distribution and choice around the globe.
- The COVID-19 vaccine rollout shed light on the ethical tension between personal choice and public health.
- Communications with a designated contact point were key to an effective vaccine rollout.
Almost two years after COVID-19 first appeared in the world, we are still facing challenges related to COVID-19. Providers, policymakers and researchers must now turn their attention to measures that can be put in place to avoid the mistakes of recent months. Providers have a unique perspective that can’t be overlooked as they are responsible for the wellbeing of many older adults in a variety of settings. The knowledge and insights that can be gleaned from conversations with an even larger group of providers will be invaluable as the pandemic continues, the status of vaccinations evolves and new variants possibly emerge. In addition, leaders around the world should focus attention on critical issues that emerged, including equity, ethics, mental health and the need for collaboration.
Thank you to the partner of the Global Ageing Network report, Standards Wise International.
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