Make it a Double

Thursday, December 30, 2021

Rural Canada needs to catch up as government urges all to get fully vaccinated.

By Becky Dumais

Winter is coming and we're still struggling through the fourth wave of COVID-19 and its new variants, yet some of the population remains either unvaccinated, or has had only their first dose of the vaccine. Many of these Canadians live on farms and in rural regions where it's not so convenient to drop by the pharmacy and roll up your sleeve; other reasons include hesitancy or complacency.

If health officials are pushing for higher vaccination rates in farm country, is there a way to get more eligible people immunized?

Urban barriers

Rural Canada has always faced barriers when it comes to healthcare, and is access to COVID-19 vaccination any different? It may explain, at least partially, why rural residents are being vaccinated at lower rates than those in urban areas. "That's still generally true," says Dr. Finola Hackett, rural locum in family medicine and outreach volunteer leader with 19 to Zero.

19 to Zero was launched at the University of Calgary in August of 2020 and is a coalition of academics, public health experts and behavioural economists working to understand and shift public perceptions around COVID-19 behaviours and vaccination.

Dr. Adam Vyse, a rural family physician in High River, Alta. who has worked on vaccine hesitancy and vaccine clinics for groups in the area, as well as involvement in 19 to Zero, agrees that rates are low. "For example, in the 20-39 age group, 75-80 per cent in Calgary have at least one shot. It's 30-50 per cent in most rural areas of Alberta."

Hackett noted that Alberta is currently at a 70 per cent vaccination rate (83 per cent of those eligible) for at least one dose in most of the province when she most recently spoke to Better Farming on Sept. 30.

Outside of urban areas, rates vary from 20-80 per cent. "However, an equivalent proportion of rural counties are sitting in the 40-60 per cent range as those in the 60-80 per cent range (i.e., rates are overall lower than in urban areas which are all around 70-80 per cent). Also, most rural counties that are in the 60-80 per cent range are actually sitting at 60-70 per cent, not 70-80 per cent," she says when noting that shaded orange areas on the government of Alberta's coverage map "are slightly misleading."

Apart from the 83 per cent rate of eligible people mentioned above, these percentages apply to the whole population – "hence why no county is above 80 per cent, due to the under-12 population that is not yet eligible."

Hesitancy is more prevalent rurally. "My information is that rural Albertans are more hesitant than urban Albertans. I think that is similar across the country," says Vyse.

"In April and May, access was a huge barrier in many parts of Canada, but now, in September, with abundant vaccine supply, access should be less of a problem. Hesitancy is likely more of a barrier than access for most of the unvaccinated. Rural Alberta has some of lowest vaccination rates in the country. Most of my unvaccinated patients are capable of sourcing a vaccine, but they are definitely hesitant."

There are several reasons for a gap in numbers comparing rural and urban communities. "The rural populations tend to be underserved," explains Dr. Roman Pabayo, a social epidemiologist and associate professor, school of health and Canada research chair in health equity at the University of Alberta. "In urban centres you can walk down the street and get vaccinated, but if you're in a rural setting or you have a certain amount of time where you have to work, fitting that all in your schedule can be difficult. The solution to that could be public health units going out to places to where people are so they can make it easier and more accessible for people to get vaccinated," Pabayo suggests.

Vyse has been involved in developing a Vaccine Hesitancy Toolkit for physicians to help identify types of hesitancy and to have strategies to address their patients effectively. Information can be found at www.albertadoctors.org. "From personal experience in the past couple of months, this is successful on a case-by-case basis, but we have about a million Albertans to reach," he says.

Politicization of the vaccine in the media is another factor where there can often be a "rural-urban split in terms of political affiliation," Pabayo says, adding that on top of that are people's political beliefs they were raised with. "We have individual rights versus what's good for society, etc., so there's that political divide. I'd like to think that if we improve access that will improve vaccination in rural ridings."

Pabayo also has anecdotal evidence that people in rural ridings don't see the pandemic hitting them as hard as in cities. "It may not be a pressing issue. I do think that increasing vaccination is key in order to fight this pandemic," he notes.

Early in the beginnings of the pandemic, the Ontario Federation of Agriculture (OFA) fielded many inquiries from members about vaccination availability, clinic locations and where they could learn more about the vaccines. "There was tremendous call for vaccine availability for farm families and employees, as well (as the food processing industry across the province)," says Cathy Lennon, general manager for the OFA.

"OFA has been a strong supporter of all public health measures recommended throughout the pandemic including sharing information and raising awareness about vaccine clinics across the province and in particular in rural areas."

Former OFA board member Patrick Jilesen believes firmly in a patient approach. "I'm interested in showing compassion and empathy towards those that are being hesitant, rather than the name-calling or shaming," he says. "And farmers should be very familiar with the peer-to-peer strategy of encouragement."

One of Hackett's colleagues from 19 to Zero chalks the gap up to three Cs: convenience, complacency, and conspiracy.

Convenience

The more readily available the vaccine is, the more convenient it is for anyone to get immunized. "If something is inconvenient and it's easier to opt out than to opt in, it has to (become more) convenient. It's definitely more convenient in an urban centre than in some rural areas," explains Hackett. "One of the things 19 to Zero did this summer was starting a mobile vaccination bus clinic to address some of that."

Alberta's first mobile vaccination clinic is a joint effort between 19 to Zero, Alberta Health and industry partners to extend the vaccination campaign. The clinic on wheels focuses on rural communities, hard-to-reach populations or those working in remote camps where vaccinations may be harder to access, or where uptake may be low. The clinic provides onsite immunization for those communities and workplaces across Alberta. Check online: www.19tozero.ca/mobile-vaccine-clinic-map. People can also fill out a form online to request a stop in their community.

Saskatchewan temporarily offered a mobile clinic over the summer. On June 20 the La Ronge Public Health Nurses partnered with the La Ronge EMS paramedics to drive around the communities of La Ronge, Air Ronge and Lac La Ronge Indian Band Reserves.

Ontario retrofitted two GO busses for its mobile clinic and began delivering doses on Aug. 7. "This innovative partnership with Metrolinx will ensure Ontarians have even easier access to a first or second dose of the COVID-19 vaccine," says Solicitor General Sylvia Jones. "By bringing vaccines directly to the people, we are helping more residents get the protection they need for themselves, their families and their communities."

Visit www.ontario.ca/vaccinebus, or email GOVAXX@ontario.ca to book a bus stop in your community.

Any forward movement in getting the population vaccinated should be positive, but Vyse notes "it's a good idea in principle, but in isolation I do not believe it is enough. Mobile clinics need to coincide with multidisciplinary public outreach to build public trust in the process."

Complacency & conspiracy

The second C is complacency. If people feel like COVID hasn't – and won't – affect them in any way, why bother? "Different rural areas at different times have had quite low rates (of outbreak) so complacency results, and also feeling like it's not a concern or an immediate concern to your life," says Hackett. "Some of the ways to address that is by education around the fact that even if rates are low now, they can change, as well as the fact that protection's not just for your own individual risk but protecting the community at large and helping us move on with the economy."

The third C: conspiracy. Misinformation and theories are thrown around social media and in the media itself – Hackett feels this is the biggest factor why some people don't get vaccinated. A solution would involve "trying to address the misinformation in a way that actually listens to what people's concerns are and doesn't dismiss them.

You need to start from an empathetic position and say ‘I just want you and your family to be healthy, and that is the same as what your goals are. Our goals are not different, but we're using different information to make decisions around this and here's the scientific information that I'd like you to consider...' and try to understand what other information it is they're considering – which is sometimes fear-based. A lot of fear is what drives the emotions: fear of loss of livelihood, fear of change, fear of a lot of things. So, getting out those ideas and emotions in an empathetic way is what we try to do in approaching that third C."

Closely related to the topic of conspiracy is fear. Hackett does feel that some people can be "swayed" by what they are told by medical professionals, but information on why one should get vaccinated "needs to be coming from your neighbour, your family member, a friend. You need to have a family member say, ‘hey I got the vaccine, and this is my experience, because I wanted to protect myself and others.' That is what tends to sway peoples' decisions.

I think it's positive because we all have more power than we think we do. And just being willing to have that conversation in a productive way but things are so polarized now, whether it's on social media or in person, these things can turn into arguments with friends or family. But if you try to approach it in that empathetic way and just have a discussion, you as a family member/friend/colleague can have a bigger impact than any medical professional."

Pabayo also agrees there are ways to reach out to unvaccinated Canadians. Disseminating information, talking to a healthcare professional, having leaders in the community help advocate for vaccination. "I think that could be key to it as well. In public health, I've always been trained that shaming isn't the way to go. There are other possible ways that are more grassroots, more community capacity building where you're working with community leaders, stakeholders, etc. to try to get their vaccinations up and to help advocate."

More outreach

Outreach does work to inform and educate. "I think what's interesting is that it's not usually an immediate thing – even if I have a visit with a patient and we have the discussion it's not often someone will say ‘ok now I'm going to get it,'" Hackett illustrates. "They might have 10 conversations with their doctor and their friends and others, and it might be weeks or months and they'll eventually (say they're ready)."

It's important to have an open-door policy, says Hackett, "because people need a lot of that support. But it's hard – I think for a lot of health practitioners it's hard seeing the rates go up and knowing we have this very safe and effective vaccine. It's hard to keep that patience but you have to understand where people are coming from, and access to health information and to healthcare has been an issue in rural areas for a long time in general."

Proof of vaccination passports is yet another issue that has many people balking, but recent data from the non-profit Angus Reid Institute indicate there's increased support for needing to show proof of vaccination to enter certain public spaces. According to a related report, "support for proof of vaccination in public spaces is now a majority opinion in both Alberta and Saskatchewan, where Premiers Jason Kenney and Scott Moe have denounced the idea. In fact, 54 per cent of Albertans now support proof of vaccination in public spaces, up from just 40 per cent in late July."

Producer encouragement

In August, more than 30 U.S. state and national agricultural organizations representing farm, commodity and agribusiness communities banded together to promote vaccination among farmers and rural Americans. An open letter to association members reiterated the important need to get vaccinated and the vital connection between ag, science and health.

"Many rural communities have been hit hard by the Delta variant," says an article on the National Milk Producers Federation website, "which has stressed healthcare systems and threatens to greatly impact those we depend on for a safe food system. Agricultural leaders are asking farmers to protect their health and their communities by getting vaccinated saying, ‘Farmers make science-based decisions every day to protect their farms and their communities – they should make these same decisions to protect their health as well.'"

We won't know if the fourth wave will continue to rise or crest and ICU rates continue to be high – the highest they've ever been in Alberta, according to Hackett. "I'm quite worried. Healthcare workers are quite burnt out. It's been a long couple of years, and we don't have the same capacity we used to to deal with things. It's important to say that nobody wants more lockdowns and to avoid that, the higher the vaccination rates the better."

Rural Albertans – many farm and ranching folks – "are the most kind, generous and community-minded people I have ever been around," Vyse articulates. "The issue they face now is trusting an individual process (getting vaccinated) that contributes to the community well-being." The irony, he says is that it's such a natural rural community theme: ‘many hands make light work.'

"More ironic is that we know that they trust their physicians more than anyone for health information, yet they don't ask us, or if they do, our advice is often trumped by internet personalities. This is keeping them unvaccinated, susceptible to COVID, and this Delta variant is finding them." BF