COVID-19 vaccination in high-risk communities: Case study of Brampton, Ontario

Abstract

Background:

The Peel region in Southern Ontario is among the most ethnoculturally diverse and fastest growing areas in Canada. During the COVID-19 pandemic, the multicultural community of Brampton suffered one of the highest infection rates in Canada, in part because of the demographic and socioeconomic characteristics of the community. The role of pharmacists in supporting vaccine uptake in this linguistically, ethnically and religiously diverse community has not been adequately characterized.

Methods:

A qualitative case study approach was used, focusing on one of the major communities in Peel (Brampton). Interviews with community pharmacists and pharmacy staff directly involved in COVID-19 vaccine administration during the pandemic were undertaken to identify common experiences and trends related to providing care and support to this high-risk community. Constant comparative coding was used to identify common themes that can inform ongoing public health supports in future pandemics.

Results:

A total of 29 interviews were completed. Key themes that emerged included 1) the impact of operational, organizational and logistical issues on vaccine uptake in the community; 2) the negative influence of inconsistent messaging from public health and other experts during the pandemic; and 3) the identification of an emerging typology of “vaccine hesitancies” describing different reasons/motivations for avoiding COVID-19 vaccination and approaches taken by pharmacy staff to address these within a multicultural, multilingual practice context.

Discussion:

The COVID-19 vaccination campaign was unprecedented in its size, scope and speed, and community pharmacists were integral in this effort. The unique needs of ethnoculturally, linguistically and socioeconomically diverse communities like Brampton require further studies to examine ways in which the pharmacy profession can positively influence greater vaccine uptake, by increasing understanding of the diverse proliferation of vaccine hesitancies that emerged.

Peel Region (Ontario) is one of the fastest growing suburban communities in Canada, consisting of the cities of Brampton, Mississauga and Caledon. ¹ Located to the west and northwest of Toronto, Peel emerged as one of the “hotspot” locations for COVID-19 transmission throughout the pandemic, with unusually high rates of infection, hospitalization, morbidity and mortality compared with other suburban Toronto jurisdictions.^1,2 In part, this reflects the unique demographic characteristics of Peel: owing to its location adjacent to the busiest international airport in Canada,^1,3 Peel has one of the highest concentrations of recent immigrants in Canada. ³ Sixty-five percent of Peel residents are visible minorities, and more than 80% speak a language other than English. ³ A large proportion of households in Peel are multigenerational, heightening risks of transmission as younger family members at school or at work live with elderly relatives. ³ Much of the workforce in Peel was categorized as “essential” during the pandemic, including the trucking, manufacturing, supply chain/logistics and warehousing sectors that continued to supply grocery stores, pharmacies and online retailers during lockdowns.^1,3 A major concern throughout the pandemic has been the higher-than-average incidence of workplace-based COVID-19 outbreaks across the large employers of Peel Region, with more than 900 workplaces identified and restricted since March 2020.^1,2 Since the start of the pandemic, more than 79% of COVID-19 infections occurred within this visible minority population, most likely transmitted through essential workers. ² Overall, Peel was identified as among Canada’s most vulnerable and affected regions during the pandemic, with particular and unique public health needs compared with other regions with different demographic characteristics.^1-3

Knowledge into Practice.

• The COVID-19 mass vaccination campaign relied heavily on pharmacy personnel with connections to local, diverse communities.

• Communities most adversely affected during the pandemic were frequently those with high concentrations of ethnoculturally diverse, new Canadians working in essential service roles and living in multigenerational households.

• Pharmacies played a pivotal role in reaching out to these most vulnerable individuals but experienced barriers related to operational/logistics issues of vaccine procurement and unclear/inconsistent communication and messaging from public health and other experts.

• Recognition that “vaccine hesitancy” is not a single problem but is due to a wide variety of different reasons helped pharmacists customize and individualize approaches to encourage and support patients in making decisions to accept immunization.

Mise En Pratique Des Connaissances.

• La campagne de vaccination de masse contre la COVID-19 s’est largement appuyée sur le personnel pharmaceutique qui avait des liens avec les diverses collectivités locales.

• Les collectivités les plus touchées par la pandémie étaient souvent celles qui comptaient une forte concentration de nouveaux Canadiens d’origines ethnoculturelles diverses travaillant dans des services essentiels et vivant dans des ménages multigénérationnels.

• Les pharmacies ont joué un rôle essentiel pour tendre la main à ces personnes les plus vulnérables, mais elles se sont heurtées à des obstacles liés à des problèmes opérationnels et de logistiques d’approvisionnement en vaccins et à une communication et des messages peu clairs et inconsistants de la part de la santé publique et d’autres experts.

• La reconnaissance du fait que « l’hésitation à se faire vacciner » n’est pas un problème unique, mais est attribuable à une grande variété de raisons a aidé les pharmaciens à personnaliser et à individualiser les approches visant à encourager et à soutenir les patients dans leur décision d’accepter la vaccination.

The economic importance of Peel for greater Toronto and Canada is significant: without the warehouses and fulfilment centres that spread through this region, stores and online retailers could not function. The extraordinarily diverse and multiethnic workforce consisting primarily of new Canadians was among the most affected and at highest risk for COVID-19 infections during the pandemic. Especially during the first 3 waves, community pharmacies delivered significant primary health care services to Peel residents, and community pharmacists were among the only front-line health professionals available for unscheduled or immediate consultation. In particular, as vaccines became available and the first line of defence against COVID-19, community pharmacies played an outsized role in managing vaccine distribution and administration, countering false information and providing outreach to multilingual, multiethnic community members who may be harder to reach through traditional communication pathways. ⁴ Given the relative youth of the Peel community, public health clinics and family physicians administered a relatively low percentage of vaccines, with community pharmacies emerging as a primary vector for vaccine administration. ⁴ As pandemic conditions evolve, Peel Region provides a unique case study for exploring how community pharmacists can support high-risk, demographically vulnerable communities more effectively during times of urgent universal vaccination.

Research Objective

The objective of this case-study research was to characterize the vaccine management and distribution practices of community pharmacies in Brampton, Peel Region, during the COVID-19 pandemic. For the purposes of this research, the time frame covered the administration of the first 2 required injections and the first booster shot (approximately January 2021 to March 2022); at the time of writing, a second booster shot was being discussed, but this was not included in this study.

Methods

This research was exploratory and used a qualitative method to understand and characterize the experiences of community pharmacies involved in COVID-19 vaccine administration in Peel Region. Inclusion criteria for this study included any pharmacy staff member (pharmacist, technician, assistant, learner) involved in some element of the vaccination process, including procurement, storage, administration and documentation. All pharmacies in Brampton offering COVID-19 vaccinations (n = 61 as of April 2021) were identified through a government website ⁵ ; researchers contacted these pharmacies via email (or phone, if email was not available) to provide information about this study and an invitation to participate. Efforts were made to interview multiple staff members with different roles in the vaccination process, although interviews were undertaken on an individual (one-on-one) basis, not in a group setting. As social distancing conditions were in place for much of the study period, all interviews were undertaken via Zoom, Microsoft Teams or telephone; 1 researcher led the interview while the other assisted through note taking. All interviews were voice recorded; verbal consent was taken prior to each interview. After each interview, transcription was undertaken using Otter.ai with manual corrections. No remuneration or honorarium was available for participation in this study.

Analysis and coding were undertaken using a constant-comparative method ⁶ ; all transcripts were reviewed by a minimum of 2 research team members who came to consensus on themes after independent analysis. Interviews were conducted until saturation of common themes emerged. Spot checking of analysis and coding by a third research team member was also undertaken as a quality assurance measure. This study was approved through the University of Toronto Research Ethics Board.

Findings and Discussion

A total of 29 participants (representing different roles in community pharmacy) were interviewed for this study (Table 1). These participants came from a total of 18 different pharmacies, meaning some individuals from the same pharmacy workplace were interviewed. In all but 1 case in which individuals from the same pharmacy workplace were interviewed, participants had different roles (e.g., a pharmacist and a regulated technician). Interviews lasted approximately 25 to 30 minutes. The finalized version of the semistructured interview protocol used in this study emerged after the 17th interview (see Appendix 1, available with the online version of the article).

Table 1.

Demographic profile of participants (N = 29)

Mean age, years	40.2 (range: 26-71)
Sex
Female	65.5% (19/29)
Place of graduation
Canada or United States	44.8% (13/29)
International pharmacy graduate	55.2% (16/29)
Practice type
Chain/banner	37.9% (11/29)
Independent/medical centre	27.6% (8/29)
Grocery/big box	34.4% (10/29)
Average self-reported daily prescription volume
<200	10.3% (3/29)
200-300	13.8% (4/29)
300-400	34.4% (10/29)
400-500	34.4% (10/29)
>500	6.9% (2/29)
Role and qualification
Pharmacist (BScPhm or equivalent)	55.2% (16/29)
Pharmacist (PharmD or equivalent)	13.8% (4/29)
Regulated pharmacy technician	13.8% (4/29)
Pharmacy assistant or other	17.25 (5/29)

Three major themes emerged:

• 1. Operational and organizational challenges undermined the success of the vaccination effort in community pharmacy.

A universal theme in this research was the frustration with the logistics of vaccine delivery, a problem that persisted during the initial rollout and into the first booster phase more than a year later. Poor and miscommunication between pharmacies, head offices, Public Health Ontario and other groups involved in distribution meant that pharmacies often had no clear indication when they would be receiving shipments or vaccines, which vaccines would be delivered and how many doses would be available. This was particularly problematic given that Peel was identified as a “hotspot” requiring priority vaccination among its essential workers and multigenerational households, and supply could not keep pace with demand. Participants in this study understood the reasons for this during the initial rollout but expressed increasing frustration a year later when the booster phase began. The lack of control over supply created confusion and significant unnecessary additional work within the pharmacy. Further, as online reservation systems became more prominent and pharmacies became embedded within government reservation systems, this produced additional workload and confusion. Worse, this occurred at a time of significant workload increase, as walk-in requests, general drug information queries and additional pharmacy-specific demand for renewals, adaptations or modifications of prescriptions were spiking, as well as (in some cases) COVID testing services that were simultaneously being introduced. Regardless of role, all participants in this study spoke about the unrelenting workload and stress that was emerging as the “new normal.” This was further exacerbated by an increasingly conflict-prone and fractious public demanding more and more from community pharmacies, without a commensurate increase in staff or support. Many participants spoke frankly about the personal mental health burdens and toll associated with the vaccine rollout, despite feeling a sense of pride at how important pharmacy was in tackling the most significant public health emergency of our lifetime. Most participants felt that this toll could have been avoided had operational/organizational issues been better managed initially and procurement/distribution practices more effectively implemented. An unanswered question in this research relates to the mid- and long-term consequences for the pharmacy workforce as pandemic conditions evolve: despite rhetoric suggesting workload and stress were unique/time-limited events related to vaccine campaigns, there was a pervasive belief that pharmacy workplace conditions have irrevocably changed for the worse in a psychologically unsustainable manner, which may in the months ahead lead to recruitment, retention and mental health problems across the workforce.

• 2. Lack of clear/coherent messaging from experts, media and public health interfered with community pharmacies’ ability to best manage vaccinations.

Participants in this study expressed pride in being a member of a profession that was front and centre in the vaccination effort. They noted that the prominence of community pharmacy in the public eye had never been greater and that this provided psychological energy to endure many of the hardships discussed above in theme 1. A significant nonoperational issue that interfered with the success of vaccine rollouts related to unclear and incoherent messaging in both mainstream and alternative (including ethnic- and culture-specific) media, producing confusion for both members of the public and pharmacy staff. At the core was the observation that pharmacies were among the first places members of the public would, or could, go to ask questions: during the study period, family doctors’ offices were available only for phone-based consultations (producing significant time lags/delays) and public health/government phone lines were all but inaccessible due to the volume of calls. For example, early in the pandemic, when the AstraZeneca (AZ) vaccine’s risk of triggering blood clots in certain patients emerged in the media, the National Advisory Committee on Immunization (NACI) released a statement suggesting mRNA vaccines were preferred rather than the AZ generally available in community pharmacy. This messaging, which appeared to occur with minimal input from community pharmacies, created havoc and chaos in terms of questions from patients but also resulted in excess supply of AZ, which blocked the ability to procure mRNA vaccines. The absence of support from community pharmacy leaders in providing consistent messaging on this point was also noted as a failure, producing significant additional workload for front-line pharmacists and staff in managing patients’ concerns and questions.

• 3. A proliferation of different kinds of “vaccine hesitancies” among the multilingual, multiethnic population of Brampton presented challenges and opportunities for community pharmacy.

One of the unique features of this study was the opportunity to explore the complex phenomenon of vaccine hesitancy in vulnerable communities from a community pharmacy perspective. A key finding of this study related to the notion that the convenient label of “vaccine hesitancy” oversimplifies a complex and multifactorial issue without sufficient nuance to account for the experiences of a multilingual, multiethnic working-class suburban population such as that found in Brampton and Peel Region. Importantly, the multilingual capabilities of pharmacists, technicians and other staff allowed them to interact with the multiethnic populations of Brampton more authentically and potentially achieve a deeper understanding of root causes of behaviours generically labelled as “vaccine hesitancy.”

Participants in this research delineated a diverse array of hesitancies, each with different root causes, supportive interventions and potential solutions. Importantly, throughout the pandemic, vaccine hesitancy has been characterized by many as a deficiency—everything ranging from a lack of education to an indication of mental illness. As pharmacy staff on the front lines of vaccination, participants highlighted the many ways in which they contributed to their communities to address misunderstanding, misinformation or misapprehension regarding COVID vaccines. Six different subtypes of vaccine-hesitant patients were described by participants in this study:

1. The vaccine-unaware represented a group of patients who (usually due to issues of language or culture) were cut off from most mainstream and alternative media. Often these individuals were elderly or adherents of a religious group. While public health officials made extraordinary efforts to reach these groups in different languages and through different means, pharmacists in this study reported some patients simply not being aware of vaccines or aware of how to go about booking and receiving a dose. Interventions by pharmacy staff cited as being most impactful for the vaccine-unaware included communication in the language of the individual by a member of that community or mobilization of religious or other community leaders to communicate effectively. In some cases, written communication would be ineffective due to literacy issues or to the inability to actually produce the specific/unique script of a dialect. Pharmacies reported developing a sophisticated network of colleagues across the profession with specific cultural backgrounds or language skills that could be called upon when needed to communicate with vaccine-unaware individuals; success was generally described as very high once contact and communication was undertaken: the vaccine-unaware appeared to be relatively adherent to medical expertise if it was presented in a culturally appropriate, linguistically accurate context.

2. The vaccine-disorganized represented one of the largest groups most directly affected by pharmacy staff in this study. The centralized vaccine-scheduling system was described by some as “the Hunger Games”: a ruthless competition to gain a precious appointment. Accessing this online system or navigating the requirements to get a place in the queue is complex and requires technical skills and persistence. The vaccine-disorganized were a group of patients who were open and (in many cases) highly motivated to receive vaccines but could not navigate the system for diverse reasons including language, technical skills, or a lack of patience or persistence. Haphazard, stop-start attempts to find bookings caused frustration and eventually resulted in people giving up. Participants in this study highlighted the invaluable role of multilingual, multiethnic pharmacy staff in helping the vaccine-disorganized gain access to systems allowing them to book appointments.

3. The vaccine-irritated represented another large group of patients assisted by participants in this study; this group generally had previous experiences with a COVID vaccine, other vaccines or the health care system and found the experience difficult or annoying. For example, many individuals experienced moderate side effects to a first vaccine dose and that reduced their desire for subsequent doses. The vaccine-irritated responded well to pharmacy staff providing guidance on symptom management/mitigation as well as gentle encouragement to persist with second and booster doses. Similarly, individuals in essential services jobs with limited sick time provisions feared losing work (and pay) if they had to take time off work to recover from a vaccine dose and would therefore prolong time between doses or avoid second and booster doses entirely in order to avoid having to lose work. Individualized attention and empathy, coupled with practical suggestions to minimize consequences of side effects, were important interventions provided by participants in this study that resulted in greater uptake of vaccine doses.

4. The vaccine-phobic were patients who had limited previous exposure to vaccines of any type and who had strong negative views of vaccines due to a fear of side effects. Importantly, the vaccine-phobic were rarely opposed to the concept of vaccines per se but were personally afraid of how these would interfere with their day-to-day lives. Participants in this study described the vaccine-phobic as a difficult group to reach; traditional education that worked for the vaccine-irritated seemed less effective for this group. One technique described by some participants as being somewhat effective involved attempts at peer referencing: finding members of that individual’s ethnocultural, religious or linguistic community to act as role models and champions for vaccination. While the logistics of this was cumbersome and time-consuming, when operationalized it did appear successful.

5. The vaccine-skeptical were patients who asserted strong personals beliefs regarding the value and need for vaccination in general. For example, adherents of certain Ayurvedic traditions dismiss use of nonnatural products including mRNA vaccines. The vaccine-skeptical were typically relatively well educated, had access to mainstream media and were often young and employed but had little faith in medical expertise. This group of patients was among the most challenging group to work with, and many participants in this study expressed their belief that these patients were “unreachable” and as a result spent little time or energy focused on this group.

6. The anti-vaxxers represent a group of particularly strong-minded and aggressive individuals, whose views were often rooted in misinformation or conspiracy. Some participants spoke of active harassment and intimations of violence received from this group, particularly as boosters were deployed and general aggressiveness of the anti-vaccination movement in Canada grew. Though small in number, those pharmacies that experienced the wrath of anti-vaxxers described harrowing situations involving the need for police intervention and increased store security. Those who experienced anti-vaxxers firsthand frequently framed the issue as a mental health problem, aligned with conspiracy theories and in most cases felt that any attempt to actually engage and educate anti-vaxxers might only breed violence and should therefore be avoided.

Participants in this study described internally constructed schema that allowed them to rapidly assess and label individual patients who were “vaccine-hesitant” in a more precise/individualized way aligned with the 6 subtypes described above once they were able to overcome certain communication barriers related to English as a second language. This was a widely adopted strategy allowing for pharmacy staff to identify how to best reach patients and help them—or whether to simply ignore them and hope they would go away. Participants clearly noted that some patients (particularly the anti-vaxxers and vaccine-skeptical) were simply “not worth” even trying to help, for fear they would become violent/belligerent or because it was thought nothing pharmacy staff could do would work. Alternatively, the vaccine-unaware and vaccine-disorganized were described as the most rewarding to work with, as the results were generally rapid and appreciated. Not all participants articulated or identified the 6 subtypes described above, although most participants did discuss a process of triaging and prioritizing who among their patients merited additional attention and interest to support vaccine uptake.

The findings of this case study present interesting questions for pharmacy as pandemic conditions evolve. Clearly, greater emphasis on logistics and supply chain organization will be necessary in the future to reduce stress on and burnout of pharmacy staff. Equally, ensuring community pharmacy representation and active input in the “expert messaging” of groups such as NACI could prevent significant problems on the front line. Further exploration of the different forms of vaccine hesitancy identified in this study is required to support more customized interventions by pharmacy staff who can communicate in a variety of different languages.

Although the context for this study was 1 diverse community in 1 province, there are many similar communities across Canada where similar issues will arise. This study can provide pharmacists and managers with tactics for supporting more extensive vaccine uptake through more careful differentiation of root causes of “vaccine hesitancy” and use of more individualized patient care and education approaches. The logistics/supply chain issues identified in this study may persist with future waves and future vaccine rollouts; proactive strategies to manage these issues and communicate more effectively with patients will be necessary. Reliance on public health or government-run portals/websites alone may not provide sufficient support for patients seeking vaccines, so pharmacy-specific outreach and booking procedures should be developed that are aimed at diverse, multilingual communities. Further, inadequate staffing levels were identified as a barrier that interfered with vaccine rollout; managers need to reexamine staffing levels and determine methods for aligning staff member skills related to language and cultural understanding with the demographics and needs of the pharmacy’s community.

As a qualitative study, there are limitations to this work, particularly with respect to generalizability beyond the study group itself. The final version of the interview protocol emerged after 17 interviews, meaning earlier interviews and later interviews differed somewhat in terms of content and specific questions asked. In large part this was due to the emergence of the theme describing the proliferation of vaccine hesitancies encountered; this was not initially conceptualized as part of this study, but as the data emerged and was analyzed, this became a particularly important theme to capture and required changes to the original versions of the interview protocol. As a result, those who participated earlier in the study cycle had fewer opportunities to elaborate on “vaccine hesitancies” than those who participated later in the study cycle. The study focused on a unique and highly impacted community, but some findings may be of value beyond this group. Further work in this area is necessary to better prepare pharmacy for whatever comes next in this pandemic or the next one.

Conclusions

The experience of community pharmacy in Brampton, Ontario, emphasizes the ways in which the unique demographic, sociocultural and other determinants of health also affect the practice of pharmacists. Further work in exploring the proliferation of different variants of “vaccine hesitancies” among multicultural, multilingual communities in Canada is required to help equip pharmacists with the tools they need to address public health issues. Emphasizing operational and logistical efficiency and effectiveness to minimize unnecessary—and potentially life-threatening—delays in vaccine distribution will be essential to support pharmacists in their important and evolving public health roles. ■