Abstract
Background
People with substance use disorder are at high risk of harms from COVID-19 infection. Vaccine hesitancy is common in this population and compounds pre-existing barriers to accessing health care. A drug and alcohol service in Sydney, Australia introduced strategies to enhance COVID-19 vaccination in people receiving opioid agonist treatment (OAT). We report vaccination outcomes and staff experiences of this.
Methods
This mixed methods study (i) retrospectively evaluated vaccine uptake in people accessing OAT and (ii) explored perceptions of staff who delivered vaccination interventions through surveys and semi-structured interviews.
Results
Of the 984 patients receiving OAT on 9 December 2021, 90.9% had received the first COVID-19 vaccination and 86.7% the second. Australia wide vaccination rates on that date were 93.1% and 88.7% for first and second doses, respectively. Staff commented that having a deep knowledge, understanding and connection with the patient group drove implementation and success of vaccination interventions. This was further supported by staff engagement with the vaccination interventions, and communication and sharing information, both between staff and with patients.
Conclusion
High rates of COVID-19 vaccination can be achieved in a vulnerable population. Engaged staff providing information and facilitating access to healthcare underpin this success.
Keywords: addiction, COVID-19, vaccination
Introduction
Substance use disorder (SUD) is associated with high rates of physical health comorbidities such as cardiorespiratory diseases that are risk factors for poor outcomes with COVID-19 infection.1 This risk was realized early in the COVID-19 pandemic, with studies demonstrating that people with SUD were at higher risk for COVID-19 infection, morbidity and mortality.1 Unstable housing, need for frequent attendance at dosing points and dependence on public transport increase risk of transmission and are practical barriers to vaccination.2
Vaccine hesitancy in the general population preceded the pandemic but has been particularly apparent with COVID-19, underpinned by mis/disinformation and mistrust.3 COVID-19 vaccine hesitancy is more common in people who inject drugs (PWID).4,5 Mistrust, fear of adverse events and complacency regarding disease severity are reported reasons.5–7 Barriers to accessing healthcare experienced by PWID also impede vaccine uptake in this population, including logistical barriers such as cost and transport, and de-prioritization of health care.8 Stigma is one of the most frequently reported barriers.8
COVID-19 vaccination rates ˂50% are reported in Australian needle syringe exchange program (NSP) attendees.9 While there have been calls for programs that facilitate vaccination in vulnerable populations with SUD, implementation and outcomes of such programs have not yet been reported.2,4,10
The Australian national COVID-19 vaccination program was commenced on 22 February 2021 and implemented in phases.11 Phase 1A was immunization of high-risk populations such as healthcare workers. Phase 1B began on 22 March 2021 and included people with SUD. At this time, vaccine rollout in Australia was disrupted by vaccine safety concerns.12 Communicating the risk–benefit of the Astra-Zeneca vaccine, the only product then widely available in Australia, was challenging. Vaccine complacency was also likely exacerbated by low rates of COVID-19 infection.13 On 22 March 2021, there had been 5077 total cases and 56 deaths reported in New South Wales (NSW),14 markedly different to the global experience.15 The apocryphal statement ‘it’s not a race’ by the then Prime Minister reflected the prevailing policy environment.16
By 2 August 2021, the percentage of adult Australians who had received two doses of the COVID-19 vaccine ranged between 8.6% and 27%, varying by local government areas (LGA), whereas 67.2% of the eligible United Kingdom population had two vaccines at this time.17 In the two LGAs in which the opioid treatment program (OTP) clinics of Drug and Alcohol Services in Western Sydney Local Health District (DAWS) are situated, rates of double dose vaccination in the general population were 17.9% and 19.8%.18
Routine measures to reduce COVID-19 transmission were introduced across NSW Health, including DAWS, in April 2021. These applied to all attendees and included screening for signs or symptoms of COVID-19, physical distancing, use of hand sanitizer and facemasks. In September 2021, recognizing both the population and individual health risk of COVID-19 infection, and the challenges in vaccinating this population, DAWS developed multiple focused interventions to enhance COVID-19 vaccine uptake in people attending OTP and NSP services (Table 1). Changes were initially overseen by the executive committee of DAWS. With increasing complexity of the pandemic, a group of four clinicians (nursing, allied health and medical) convened on 20 September 2021 to provide ongoing co-ordination of all COVID-19 related service issues. This group monitored and facilitated patient vaccination processes, monitored infected and close-contact patients requiring home dosing, managed COVID-19 related furloughed staff, personal protective equipment stock levels and responded to enquiries from staff.
Table 1.
Interventions to enhance vaccination uptake of those attending DAWS
| Interventions implemented in DAWS | Month commenced |
|---|---|
| Local strategic actions | |
| Drug and alcohol services met with Local Health DistrictPublic Health Unit to: -assist with development and delivery of vaccination clinics at the NSP and OTP clinics -provide staff with up-to-date information to ensure the correct public health response to complex clinical scenarios -assist with securing funding for financial incentives for vaccination uptake |
June 2021 April 2021 October 2021 |
| Administrative support provided for a COVID-19 co-ordinators group | September 2021 |
| Database developed by DAWS of all OTP patients created to: -capture vaccination status -record date(s) of vaccination(s)a -record product receiveda |
October 2021 |
| Patient facing activities developed and delivered | |
| Facilitate access to electronic or paper-based proof of vaccination | May 2021 |
| Based on readiness to vaccinate: -provide information about vaccine types and dosing intervals -book vaccination appointments -discuss vaccine hesitancy concerns and provide evidence-based information |
May 2021 July 2021 March 2021 |
| Implement and actively recruit patients to out-reach vaccination clinics at: -OTP sites -NSP sites In these clinics, external vaccination providers attend these services at pre-agreed times. DAWS provided nursing and administrative support and co-ordinated patient attendance. |
July 2021 October 2021 |
| Provide details of specific vaccination clinic times and dates and other vaccination sites, which included: -Aboriginal and Torres Strait Islander health services with targeted vaccination clinics -GP and pharmacy details -Vaccination clinics on-site at dosing sites |
July 2021 May 2021 June 2021 |
| Remind patients when their booster was due | July 2021 |
| Inform patients about vaccine availability and vaccine shortages | May 2021 |
| Provide financial incentives (supermarket gift cards) for vaccination at NSP clinics | November 2021 |
| Staff focused actions | |
| Update staff regularly about vaccine coverage of patients attending services | September 2021 |
| Acknowledge ongoing efforts of staff to achieve outcomes via email and at staff meetings | September 2021 |
LHD, local health district; NSP, needle syringe exchange program; OTP, opioid treatment program.
aConfirmed by reviewing the Australian Immunization Register record, review of the NSW state government vaccine certificate or record of vaccination on site at DAWS.
We therefore sought to describe the outcome of these interventions on vaccination rates and staff experiences of implementing these interventions. This mixed methods study aimed to report the vaccination rates of patients attending DAWS outpatient clinics up to the 9 December 2021 and to capture the experiences, perspectives and learnings of staff who developed and implemented the interventions.
Methods
This study was undertaken in a Drug and Alcohol service in Western Sydney (DAWS), in an outer metropolitan local health district (LHD) in NSW, Australia. Western Sydney LHD services a population of 1.1 million people. DAWS provides OTP clinics, NSP, court diversion programs, inpatient and ambulatory withdrawal programs, and longer-term alcohol abstinence treatment. There are four OTP clinics in DAWS providing daily supervised dosing of methadone or sublingual buprenorphine, and weekly or monthly buprenorphine depot injections. Some patients receive opioid agonist treatment (OAT) dispensed in community pharmacies but prescribed through the OTP clinics. Clinics A and B are physically distant from each other and are located in LGA1. The other two clinics are co-located on a site in LGA2 and are nominated as Clinic C for this study.
There were two arms to this mixed methods study.
Part 1: a retrospective audit of vaccination status assessing:
(i) first and second vaccination uptake in patients in all OTP clinics on 9 December 2021,
(ii) second vaccination uptake by patients of clinic A, which was recorded on 13 October, 1 December and 9 December 2021 and
(iii) LGA1, LGA2, state and national vaccination data on the same dates.
A vaccination database of all patients attending the four OTP clinics was created as part of the vaccination intervention. Vaccination status was recorded in the database through confirmation of the Australian Immunization Registry record, visualization of the NSW state government vaccine certificate or record of vaccine administration provided on site at DAWS. Data on vaccination status were extracted from this database. Demographic data were extracted from routinely collected administrative data.
Vaccination rates of the population of LGA1 and LGA2, NSW and Australia were extracted from publicly available NSW Health14 and national19,20 datasets.
Part 2: a staff survey and semi-structured interviews with clinic staff.
All staff (n = 130) of DAWS were invited via two separate general emails 4 weeks apart to participate in an anonymous online survey, hosted on REDCap.21,22 The survey comprised five questions to capture staff experiences of the vaccination interventions: two fixed choice (Yes/No) and three open-ended questions (Table 2). The survey questions were developed through an iterative process until the research team reached consensus. The survey was available for 8 weeks in June to July 2022.
Table 2.
Questions of the anonymous online survey
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On completion of the online survey, participants were invited to participate in a face-to-face semi-structured interview. Interviews sought to explore experiences of the vaccination intervention, including barriers and facilitators to implementation and uptake. The study took an interpretive approach to this health services research. Interviews were recorded and transcribed verbatim. Interviews were conducted by investigators MT and MJ between 15 July 2022 and 8 August 2022 at a DAWS premises.
Reflexivity statement
Both MT and MJ are staff members of the service who were part of the activities described and known to participants. Neither MT or MJ have supervisory roles and both are experienced researchers and conducted interviews and subsequent analysis cognizant of these factors. The researchers took an etic perspective to the study question. The implications of the interviewers’ roles were discussed among the research team.
Data analysis
Statistical analysis was undertaken with Excel and GraphPad Prism (version 9 for Windows, GraphPad Software, San Diego, California, USA, www.graphpad.com). Descriptive statistics were used for demographic data. Risk ratios were calculated to compare vaccination rates in different populations.
For qualitative data, deidentified open-ended survey responses and interview transcripts were analyzed independently by three researchers (MA, JC, MT). Transcripts were first read and re-read to familiarize researchers with the data. Using QSR NVivo and line-by-line coding, potential codes were then identified within and across transcripts by using an inductive approach. Themes were generated by group discussion.23 Researchers met on multiple occasions during data analysis to ensure consistency of interpretation. Discrepancies in interpretation were resolved by consensus.
The study was approved by Western Sydney LHD Human Research Ethics Committee (2022/ETH00029). Waiver of consent was granted for the retrospective audits. Electronic informed consent was obtained from participants for the survey and qualitative study. STROBE guidelines were followed in reporting these data.24
Results
In December 2021, DAWS OTP clinics provided care to 984 people, with an average age of 44.4 years, 71.3% of whom were male. The principal drug of concern was heroin for 74% and pharmaceutical opioids for 12%. The majority (55%) of people were treated with methadone, with the remainder receiving buprenorphine.
Vaccination coverage
Of the 984 patients attending DAWS OTP clinics on 9 December 2021, 90.9% had received the first COVID vaccination and 86.7% the second. National coverage on that date was 93.1% and 88.7% for first and second dose, respectively. Corresponding NSW coverage was 94.7% and 93%. Both first and second dose coverage in LGA1, and first dose in LGA2 were greater than 95%. In LGA2, the rate for the second dose was 94% (Fig. 1a).
Fig. 1.
(a) Percentage of patients vaccinated in OTP clinics in DAWS, and percentage of population in LGA1, LGA2, NSW and nationally vaccinated on 9 December 2021. (* = Risk ratio (CI) < 1 compared to DAWS first dose. ** = Risk ratio (CI) < 1 compared to DAWS second dose). (b) Time trend of percentage of attendees at DAWS Clinic A who had received two doses of vaccine between October and December 2021. Clinic A is located in LGA1. Data for LGA1, state (NSW) and national double vaccination rates are shown. (* = Risk ratio (CI) < 1 compared to Clinic A).
Temporal trends of double vaccination for Clinic A, which is located in LGA1, between September and December 2021, are shown in Fig. 1b. The proportion of the population vaccinated in Clinic A, LGA1, NSW and Australia increased over time, although the percentage fully vaccinated at Clinic A and at a national level was consistently lower.
Staff experiences
A total of 23 completed surveys were analyzed (response rate = 17.7%). The survey was completed by 11 nurses, six allied health professionals, three administrative staff, two medical staff and one not stated. Eight survey participants participated in semi-structured interviews—five nurses, one allied health professional, one administrative staff and one medical staff member.
Three main themes describe the data from the interview and survey responses; having a deep knowledge, understanding and connection with the patient group, communicating and sharing information and that the success of the program was driven by staff (Table 3, Supplementary Tables S1 and S2). Expanded sub-themes from the three major themes and representative quotations are reported in Supplementary Table S1.
Table 3.
Summary of the three major themes and subthemes from staff interviews
| Theme 1: Having a deep knowledge, understanding and connection with the patient group | |
|---|---|
| |
| Theme 2: Communication and sharing of information | Theme 3: The success of the program was driven by staff |
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Having a deep knowledge, understanding and connection with the patient group
Staff expertize and connectedness with patients with SUD was identified as a unique skillset that allowed staff to engage and encourage this often-stigmatized population to accept vaccinations. One participant commented that ‘It’s not just official. We understand. And we empathize with them. So, when you talk to them about things like this, then they listen to you.’(P4) Understanding the need for continuity of care from the service was considered important ‘…and as you know that our patients are not ready to go to the GP or any vaccination hub’(P3) along with non-judgmental staff behavior and attitudes ‘they didn’t feel humiliated, they didn’t feel shunned.’(P2) This continuity was also seen to contribute to the trust that patients had in the staff that had developed over previous positive interactions; ‘And I think also our daily contact with people does make a difference and those then strengthen those relationships so that we were a trusted source of information for our patients eventually.’ (P1).
Communicating and sharing information
Communication was seen as a significant factor in the success in vaccinating this community, both between staff, as well as between staff and patients. Staff described the benefits of the clear information provided to them by DAWS and knowledgeable colleagues, both in its generosity and timeliness. ‘Emails and I think I mean I think the LHD did really well with emails and information, but I also think Drug Health (DAWS) did a very good job like you know we got, I think I felt like we got updates on every new thing, umm, as they came out.’(P2) In turn, this information was shared with patients attending the service who were reported to have been greatly influenced by mis- and dis-information via social media and others in the community. One participant commented that education sessions ‘…gave the staff the confidence to talk to patients about the vaccination and also trying to get some of the untruths out of that population.’(P1).
Participants described nuanced communication skills that appreciated where patients were in their readiness to vaccinate. A staff member described that, ‘They need days to digest and need days to think about it. Then they will come back and that’s why we keep asking them.’(P6) The need for persistent messaging and reminders to facilitate attendance at in-house vaccination clinics was recognized; ‘And even if it was, you know, it might have taken three or four conversations before we actually got them back for vaccination.’(P3) The Staff was highly aware of the communication and information needs of patients and how this was frequently not met outside the service.
The success of the program was driven by staff
The engagement of staff in supporting delivery of the vaccination program was viewed as central to its success. This took many forms in practice: advocacy by staff at all levels of the service e.g. in organizing vaccination clinics on site; sharing personal vaccination status and stories; and assisting patients to overcome physical barriers to vaccination e.g. reminders in person and/or via text messaging (SMS), accessing identification documents, providing proof of vaccination. It was acknowledged that all of this was outside the usual remit of drug and alcohol services, but participants were acutely aware this public health intervention would not reach the patients with mainstream approaches. Participants felt that the goal of maximizing the vaccination of patients was successful due to a co-ordinated effort from all staff. One staff member described that ‘…we had a very short time… to make it happen,... We didn’t have enough people and then we, you know, we, it seemed all against us. But very quickly we’re able to, with as a group, as a team, and we’re only a small team, try to see it happen.’(P7).
In addition to themes identified above, several suggestions to improve the service were made. These included scheduling vaccination clinics on busy clinical days so more patients were present, and to coincide with booster dose timing. Having more clinics and extending access to other household members was also suggested. Developing in-house capacity to provide such services by upskilling clinic and administrative staff on site was also proposed (Supplementary Table S2).
Discussion
Main findings of this study
In this study, we have demonstrated that high vaccination rates against COVID-19 can be achieved in a marginalized population of opioid dependent people receiving treatment. A multifaceted intervention introduced to support vaccination was effectively delivered by engaged and committed staff members who understood the needs of this population.
What is already known on this topic
Although the dual vaccination rate achieved in this study of 86.7% was slightly lower than the general population, they are substantially higher than national and international rates. In total, ~50% of Australian NSP attendees have received dual vaccination,9 while 69.4% of people with Opioid Use Disorder (OUD) in France25 and 71% of people attending a Spanish OTP clinic had double vaccination.6
Vaccine hesitancy preceded the pandemic, and its determinants can be categorized in domains of confidence (in the vaccines, health systems and policy environment), convenience and complacency, risk calculation and collective responsibility.26 With COVID-19, concern about side effects is the main contributor to hesitancy globally.27 The exposure to misinformation and disinformation throughout the pandemic has also reduced vaccination participation.13 People who use drugs can experience additional barriers of stigma, mistrust of health systems, mistrust of COVID-19 vaccines, as well as financial and organizational barriers in accessing vaccination.9,28,29 These barriers were recognized by staff in this study, reflecting the deep understanding the staff has of this patient population. Provision of timely, accurate vaccination information to staff, which could then be disseminated to patients in an accessible way was perceived as important. Overcoming the practical and stigma-related barriers by providing on-site vaccination was also considered by the staff as a key to the effectiveness of the vaccination drive. While providing a vaccination service is outside the usual scope of work of drug and alcohol services, the need to adopt novel strategies to facilitate vaccination in vulnerable populations is recognized.2,10,29 Overcoming the barriers faced by this population by providing information from credible sources and facilitating access to treatment have been successfully applied to address other important issues such as Hepatitis C.30
What this study adds
We have demonstrated that when vaccination, information and practical support are provided in a culturally safe way by engaged staff, high vaccination rates result. Most of the interventions introduced were evidence-based strategies for enhancing COVID-19 vaccination.3 However, patients with SUD need particular communication strategies.28,29 This finding was reinforced in this study, and staff being aware and responsive to the unique needs of the population was seen as a driver of success in the interventions.
Further work is needed in this area; future studies could prospectively evaluate the interventions in NSP and should also collect patient experiences to identify which aspects are most effective, and acceptable. Expanding such programs to other preventive health measures such as seasonal influenza vaccination or breast cancer screening should be investigated. In addition, consumers were not formally involved in the design of interventions due to the urgent need to address the issue of preventing COVID-19. Given the increasing recognition of the importance of co-design with consumers in research and clinical service development, further studies should include consumers in the design of interventions.
Limitations of this study
There are several limitations to this study. As a retrospective review of data with multiple contemporaneous interventions, causality cannot be inferred. External factors such as government mandated ‘vaccine passports’ may have impacted on the rate of vaccination, although this applied to the entire population. While the intervention was also delivered in the NSP, no information was gathered on vaccination status there because of the anonymous nature of the service provided. Interviews were conducted by research staff who work in DAWS, which may have influenced participant responses in the face-to-face interviews. There may be sampling and recall bias in both survey and interview respondents.
Conclusion
This study demonstrates high levels of COVID-19 vaccination in opioid dependent people attending OTP clinics. The engagement of staff with the multiple interventions and their commitment to those attending the service was integral to success of these interventions to maximize COVID-19 vaccination rates in this vulnerable population.
Supplementary Material
Bridin Murnion, Associate Professor
Jane E. Carland, Associate Professor
Meryem Jefferies, Dr
Michael Au, Dr
Marguerite Tracy, Dr
Contributor Information
Bridin Murnion, Drug and Alcohol Services, Northern Sydney Local Health District, St Leonards, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
Jane E Carland, Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
Meryem Jefferies, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Drug Health Services, Western Sydney Local Health District, Wentworthville, New South Wales, Australia.
Michael Au, Drug Health Services, Western Sydney Local Health District, Wentworthville, New South Wales, Australia.
Marguerite Tracy, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Drug Health Services, Western Sydney Local Health District, Wentworthville, New South Wales, Australia.
Conflict of interest
The authors declare no conflicts of interest.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.