He Aroka Urutā. Rural health provider perspectives of the COVID-19 vaccination rollout in rural Aotearoa New Zealand with a focus on Māori and Pasifika communities: a qualitative study

Sampling was purposive with the aim of recruiting a broad span of healthcare providers involved in the COVID-19 vaccination rollout at each study site, including those involved across managerial, clinical, administrative and community support areas. Health providers were invited to participate in focus group or individual interviews. The research team was guided by local healthcare leaders in choosing the approach, whether in-person or virtual interviews or a combination of both.

Demographic information was collected from participants during the consent process.

Semi-structured interviews were conducted between February and May 2023. The interview schedule (see Supplementary File S1) was developed with input from the entire research team and explored participants’ views of the vaccine rollout in their locality, including their personal experience, how usual business was affected and suggestions regarding future vaccine rollouts.

Interviews were a mix of individual and focus group, in-person and virtual. Focus group size ranged from two to six members. All interviews were recorded and auto transcribed using Zoom (2023, https://www.zoom.us/) or Otter.ai (2022, https://www.Otter.ai) transcription tools, except for one in which recording failed. To facilitate rapid analysis, notes were taken at the end of each interview. Interview playback listened for accuracy and a summary (memo) was completed for each interview. Average length of individual interviews was 52 min and for focus group interviews, it was 88 min.

Rural health providers knew the fragility of rural health having experienced erosion of their services and worsening workforce shortages over many years. With the COVID-19 pandemic well underway as the vaccination rollout began, there was no surge capacity. Yet, resilience was evident for rural health providers who discussed strong community commitment, connectedness, and accustomed ways of working.

Some Māori health providers had long established Kaimanaaki Tangata (KMT) (Māori community worker) roles, to provide whānau support and navigation through the wider health system. In [site 4], despite a growing Pasifika community, there had been no consideration of, and no prior investment in, a rural Pasifika-focused health service approach.

Where rural health services were dependent on centralised national (MOH) and district (District Health Board (DHB)) organisations, established external relationships were generally reliant on one or two key people. Rapid staff turnover in these national and district-level organisations throughout the pandemic impeded these relationships.

For rural health providers, being more aligned to community than a centralised and hospital-led approach, continual adapting and pivoting to make centralised systems fit the community was familiar. Centrally imposed solutions, developed without adequate consultation (particularly with rural providers and community) resulted in poorly informed decisions, wasted resources and culturally incompetent vaccine delivery models.

Despite MOH rhetoric regarding reaching vulnerable populations, it was participants’ experience that in the emerging situation, equity was not considered a priority.

Rural health providers described being ‘bombarded’ with rapidly changing, and often contradictory information. They were left to convert this ‘guidance’ to fit their context. Valuable staff time was spent travelling to access training located in towns and cities.

Many rural health providers, particularly those who were more remote, were delivering not just on vaccination, but the entire COVID-19 pandemic response. Separate response strands (eg vaccination, testing, supported isolation quarantine (SIQ)) each with their specific processes and protocols did not fit for small closely interconnected teams. For example, it made no sense for a team to travel out to a remote household or marae and address only the vaccination aspect when clinical care, testing and/or SIQ also needed attention.

Rural health providers felt alone, disconnected, and uncertain on ‘next steps’. With respective DHBs focusing on their central vaccination rollouts, there was scant consultation and lack of a collective plan.

In adapting guidance to make rural vaccination delivery workable, participants felt closely scrutinised. There was an expectation on rural services to do more, but without added resource to account for the context, including travelling long distances. The piecemeal nature of funding restricted anything but short-term planning and limited capacity building.

Complexities in vaccine delivery protocols, including cold-chain logistics, multiplied in the rural context. Although a multi-pronged delivery approach was needed, this was hindered by staff shortages and poor roading and infrastructure. Initially, regardless of vaccination volumes (eg 100, 20 or just 2) the same number of staff were needed. Thus, a large team was required to travel out from a central site where vaccines were stored to remote communities to administer perhaps just one or two vaccines, and this could take the whole day.

Participants described the reality on the road, including trying to record and draw up vaccines in the back of mobile clinics on unsealed roads and dealing with flooded rivers, all the while keeping to strict time limits for vaccine use.

Participants discussed assumptions made by central urban organisations regarding connectivity. Centralised COVID-19 vaccination-specific IT systems were initially unworkable and meaningful assistance was unavailable. Staff resorted to paper recordings on the road and at peripheral sites, which then had to be uploaded on their return, often working late into the evening.

The COVID-19 Immunisation Register (CIR) system required log-in registration that expired after a 2-week period. This was problematic in the context of a small workforce not solely focused on vaccinating. Staff would repeatedly get ‘kicked out’ of the system and be required to re-register. Similarly, the national vaccination website and social media information regarding rural clinic locations and opening times were frequently inaccurate causing immense frustration for health providers and their communities.

Rural health providers all held the view that each vaccine given was ‘one more than before,’ and found individual solutions whenever needed, such as taking the vaccine out to just one person and ensuring flexible hours of operation. Well-intentioned large, urban-based organisations (including DHBs, PHOs (Primary Health Organisations) and Māori health providers) wanting to collaborate or assist with the rural vaccination rollout, did not always understand this concept. Arriving in remote areas expecting many people, they perceived the low numbers as an abysmal response to their efforts and resources and were subsequently reluctant to return.

As vaccinations ramped up, providers were under increasing pressure managing vaccination clinics, providing COVID-19-related clinical care, and trying to keep on top of ‘business as usual’. Existing staff shortages escalated as staff themselves contracted COVID-19 and needed time off to isolate and recover. For a rural non-clinical organisation [in Site 4], becoming a vaccination provider meant everything, including workforce, needed to be built from scratch. Many staff faced difficult personal conflicts in being pulled away from their normal community work to vaccinate.

Rural health providers recognised early on the potential of training their unregulated staff as vaccinators to support the workforce shortfall. However, the initial rigid protocols set up by central organisations delayed progress in this area.

Rural health providers went about actively removing barriers and opening opportunities wherever they could. They reset to a locally appropriate, culturally aligned approach, drawing on established ways of working. Through strong community relationships, formal and informal engagement with local leaders, and staff embedded in the communities they worked, rural health providers and communities were able to engage and mobilise.

Having built capacity during the COVID-19 pandemic, trained their unregulated workforce, and strengthened community and external collaborations, rural health providers called for central organisations (MOH, DHBs) to commit to long-term sustained investment in rural health services, starting with rural voices having representation at the highest decision-making levels.

It was the participants’ view that successful rural vaccine rollouts should not be built on specific immunisation programmes, but rather on strong resilient rural health services. This fundamental principle they perceived as applying equally to any emergent health crisis. Strengthening rural health services was seen by participants to require recognition of the unique rural context (Table 1), as well as trusting partnerships between central health organisations, Māori and Pasifika networks and rural health providers.

Participants voiced that handing control to local rural health services and communities, as experts in their specific context, would avoid the failed ‘one stop shop’ approach and ensure responses were geographically tailored and culturally anchored.

Established in their knowledge of their place and communities, rural health providers from an organisational perspective were agile, showed flexibility, built capacity and were rapidly responsive to their communities’ needs, highlighting the known unique strengths and assets of rural health providers.^30,31

The complexity and multifactorial nature of accessing health services in rural and remote settings shown in our findings, and the interaction between them, is internationally recognised.³² Our study found three overarching factors influencing the vaccine rollout rurally: geographical tailoring, cultural anchoring, and local control. Our findings suggest the interaction between these three factors is as important as the role played by each single one.

Although geographical access to health services (including financial access associated with travel) has been identified as the major issue for Rural Health internationally,²³ our findings emphasise the importance of other dimensions of access to health services when considering the NZ rural context, particularly the role of cultural factors or ‘acceptability access’.^32,33 These findings concur with previous NZ research regarding the success of the COVID-19 overall response in Māori and Pasifika communities, including the value of identity and relationships and by-Māori, for-Māori or by-Pasifika for-Pasifika approaches.^17,18,34,35

For rural health providers in this study, incorporating Māori or Pasifika cultural values and principles into the COVID-19 vaccine rollout was paramount; their communities were more empowered taking a collective approach to managing the vaccine rollout. Our findings showed that established and trusted relationships and networks mattered. National and regional Māori and Pasifika networks,which are not defined or confined by urban–rural categories but rather span them, can facilitate progress for rural health providers, especially when relationships between central health system organisations (MOH and DHBs) and rural health providers falter.

Alongside cultural anchoring and geographical tailoring, the study findings draw attention to the importance of local control in rural vaccine delivery, which concurs with research findings of COVID-19 vaccine hesitancy in rural communities internationally.^36–38 Local ownership of health initiatives ensures people can access health services through a model they recognise and trust from individuals they know and can relate to, but it requires adequate support and resources from funding bodies and effective collaborations. Conversely, by-passing local health providers (eg with separated outreach programmes), can create more barriers and further disadvantage rural health providers and their communities.

The rural COVID-19 vaccine rollout relied on reprioritisation of care and redeployment and training of staff, with study findings emphasising the key role of community workers and the unregulated workforce. Our study concurs with previous research regarding the importance of retaining and valuing workforce/human resources in rural areas^23,26,39 and signals that an alternative approach to rural workforce shortages is needed.⁶ Considering bottom-up community development approaches to strengthening the rural health workforce,^6,39 recognising and accepting that non-clinical groups can support national immunisation programmes and other health initiatives are solutions worthy of investment.

Our study highlights the importance of context in delivering health initiatives rurally. The smaller and more remote the community, the higher the importance of integrated health services requiring bundled rather than fragmented administrative and regulatory frameworks and resources. Bundling requires a move away from siloed funding for strands of activity to a whole-of-service, community-led approach. Sustained investment in rural health services will ensure that, not for just the next vaccination rollout, but any health initiative will succeed for rural communities.