The contribution of rural primary health care to the coronavirus (COVID-19) vaccination program

Introduction

The Australian health system requires an effective, equitable, and sustainable capacity for surge response for when emergency situations present, such as the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to explore the contribution of service providers to the COVID-19 vaccination program in Victoria, Australia, to gain insight into the role of primary health care to the consumer during surge response and determine if this differs with rurality. The COVID-19 vaccination program is the surge response used for this investigation and a program overview is provided in Box 1. The outcomes of the research will be relevant for planning future health system surge responses that are increasingly needed for emergency situations including natural disasters.

The COVID-19 vaccine program in Australia offers a valuable lens for analysing a surge response because the existing healthcare system was leveraged for population immunisation. Initially, the COVID-19 vaccine rollout operated separately to the National Immunisation Program and vaccines were rolled out in tranches based on supply and prioritisation (Box 1). As vaccine supplies increased, vaccines were prioritised to high risk groups,¹ distributed through Commonwealth and Jurisdictional (state and territory) Government channels.²

Across all service providers, vaccinations were provided free-of-charge, therefore out-of-pocket costs were not a factor in determining where people chose to obtain their vaccine.¹ Primary care vaccine providers were renumerated through additions to existing national funding schemes, including the Medicare Benefits Schedule for general practice settings, and the Pharmacy Programs Administrator (COVID-19 Vaccination in Community Pharmacy program) for community pharmacists. It was expected that the contribution of vaccine providers may vary by rurality because of location of vaccine providers and travel distances.

Primary care providers had a choice whether to opt-in to the COVID-19 vaccination program. A survey of GPs during the first COVID-19 infection wave in April 2020 (with over half being rural and regional respondents) noted concerns about staff and patient safety and risk of exposure to COVID-19 at work, reduced billable time and income due to outbreaks, difficulties accessing personal protective equipment, and increased workload for disinfecting procedures, triage, and administration³ – all factors that could affect practice viability and influence them not to opt-in.

Likewise, at the commencement of the rollout, a further research survey of GPs (about one-quarter being rural and regional respondents), found many had concerns about patient acceptance of vaccines and about half of patient queries about COVID-19 were to ask for vaccine information.³ In this survey, many GPs felt they had an important role in administering and increasing uptake of COVID-19 vaccines by providing credible information and correcting misunderstandings.⁴ Some had concerns about adding COVID-19 vaccinations to an already heavy workload.⁴

Research on health system surge response is needed to build evidence of the varied roles of rural primary care providers. Recent research on the COVID-19 response in the Aboriginal community controlled sector in Australia demonstrated the important role of Aboriginal health practitioners as COVID-19 immunisers in primary healthcare sites.⁵ In New Zealand, research on general practice contributions to the pandemic have described specific contributions of rural versus urban general practice sites and explored how rural providers coped with strain and staff shortages, demonstrating resilience and coping capacity.⁶ In the USA, rural models of care were developed for vaccination administration and COVID-19 treatment, demonstrating this can be effectively managed by rural health teams and systems.⁷ This growing body of research provides important learnings for policy makers for planning a health system surge response that is effective for rural contexts.⁷

Methods

Data analysis

Quantitative descriptive analysis was completed in Microsoft Excel to determine the quantity and proportion (percentage) of vaccine administrations reported by postcode, which was further grouped into categories based on MMM and provider type category. Data are presented using total and percentage of totals to represent the contribution of provider type categories by MMM and overall. Provider types were categorised and grouped, and findings are presented in Table 1 and Fig. 1.

Table 1. COVID-19 vaccine administration in Victoria, Australia, by provider type, recorded in Australian Immunisation Register.

Provider type	Metropolitan	Regional centres	Large rural towns	Medium rural towns	Small rural towns	Remote communities	Total by provider
	1	2	3	4	5	6
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
Primary care – Aboriginal health service – Aboriginal health worker – General practice – General practitioner – Flying Doctor Service – Nurse practitioner – Pharmacy	4 387 283 (50.50%)	332 393 (42.70%)	296 254 (50.10%)	304 831 (54.55%)	380 675 (57.86%)	3713 (70.15%)	5 705 149 (50.58%)
General practitioner only (% of total vaccinations)	3 811 490 (43.87%)	283 287 (36.39%)	232 857 (39.38%)	261 116 (46.73%)	322 931 (49.08%)	3518 (66.47%)	4 915 199 (43.57%)
State government – Public health unit – Public hospital – State health department	3 651 987 (42.03%)	361 591 (46.45%)	253 662 (42.90%)	194 428 (34.79%)	232 558 (35.35%)	1417 (26.77%)	4 695 643 (41.63%)
Other – CommercialA – Community health centreB – CouncilB – Private hospital	649 207 (7.47%)	84 452 (10.85%)	41 359 (6.99%)	59 567 (10.66%)	44 683 (6.79%)	163 (3.08%)	879 431 (7.80%)
Total by MMM	8 688 477	778 436	591 275	558 826	657 916	5293	11 280 223

Note: vaccination administrations recorded by provider type in the Australian Immunisation Register as of 31 December 2021. Grouped by primary care, state government, and other to support comparison and to comply with data suppression requirements that require values less than 10 to be suppressed to avoid re-identification. N = number of vaccine administrations recorded, and the percentage is the proportion of the provider type for each Modified Monash Model (MMM) geographic classification of the patient’s address registered with Medicare: 1 – metropolitan, 2 – regional centres, 3 – large rural towns, 4 – medium rural towns, 5 – small rural towns, 6 – remote communities. The total by provider reflects the contribution across the state of Victoria, the total by MMM reflects the total for each geographical classification.

^ACommercial providers completed vaccinations in residential aged care and disability facilities.

^BVaccinations administered in community health centres and council were included in the other category because they were likely to represent vaccination services contracted by the State and Commonwealth Government for specialist programs for high-risk groups, but this could not be confirmed for accurate categorisation.

Fig. 1. 

Contribution of primary care to the COVID-19 vaccination program 2021 by MMM classification. Note: the contribution of primary care vaccine providers by rurality of patient residential address registered with Medicare. MMM categories: 1 – metropolitan, 2 – regional centres, 3 – large rural towns, 4 – medium rural towns, 5 – small rural towns, 6 – remote communities.

Results

The contribution of vaccine provider types by rurality is presented in Table 1.

Overall, primary care providers completed 50.58% (n = 5 705 149) of total COVID-19 vaccination administrations in Victoria during the study period, reflecting half of total vaccination administrations for the population.

The contribution of primary care was higher than state government and other in MMM category 1 – metropolitan cities where 50.50% of vaccinations were administered by primary care vaccine providers. Similarly, primary care vaccine providers provided more vaccinations to patients residing in rural and remote regions defined by MMM categories 3 to 6 compared to state government and other.

The largest difference was observed for patients in MMM category 6 – remote communities where 70.15% of COVID-19 received vaccinations by primary care vaccine providers compared to 26.77% by state government and 3.08% by other.

Overall, outside of major cities and regional centres, the contribution of primary care vaccine providers to the COVID-19 vaccine program appears to increase with patient rurality.

The contribution of primary care vaccine providers was lowest for patients residing in MMM category 2 – regional centres at 42.70%, compared to 46.45% administered by state government and 10.85% administered by other.

Within the primary care category, GPs administered the majority of vaccines in all MMM categories ranging from 36.39% of all vaccinations in MMM 2 – regional communities to 66.47% of all vaccinations in MMM 6 – remote communities.

Discussion

The contribution of service providers to the COVID-19 vaccine program highlights the critical importance of rural primary care providers, specifically GPs, to the delivery of population health interventions for rural people during a surge response. This key finding demonstrates that current and future policy initiatives, and reforms that aim to strengthen and build sustainability of rural primary health care and general practice, are critical for maintaining and building the Australian health systems’ capacity for surge response.

The contribution of primary care vaccine providers was less than state providers in regional centres, which was likely due to the presence of state vaccination centres delivering mass vaccination programs in or near regional hospitals. Vaccinations completed by primary care providers increased with patient rurality, being highest in remote communities. This is likely to reflect travel distances and the greater accessibility of primary healthcare settings within remote communities, in comparison to state vaccination centres. The time period (February to December 2021) was selected to examine the surge response required to reach population immunisation coverage (over 90% of people fully vaccinated), however, the COVID-19 vaccination program is ongoing, and the high number of community pharmacies that opted in by end of December 2021 (n = 3472) would have further improved rural community access and uptake. These findings suggest that rurally distributed primary care providers were essential for COVID-19 vaccine access for people living in rural and remote communities.

Primary healthcare professionals in small rural towns and remote communities are well situated to plan and deliver equitable vaccination strategies because of their local leadership roles and knowledge of healthcare barriers. Previous research has recommended that GPs work with community leaders from different sectors and backgrounds to enhance vaccine outreach and acceptance.¹¹ Primary healthcare professionals are recommended to be vaccine ambassadors; being trusted sources of factual vaccine information, they can instil confidence in communities, provide credible and trustworthy health information, and discuss fears and safety concerns.¹² In the USA, rural generalist medical professionals were identified as critical to the rural COVID-19 response,⁷ were driven by altruism, and were willing to work long hours in the absence of specialists. Additionally, researchers in New Zealand suggested that rural general practices were more adaptive and better able to cope with changed conditions during the COVID-19 pandemic in comparison to urban practices due to their ability to operate in a resource constrained environment.⁶

Workforce shortages, however, pose a major challenge for sustaining rural primary healthcare services in small rural and remote communities with thinner markets and longstanding recruitment and retention issues. For a primary healthcare based surge response to work as effectively as it did for the COVID-19 vaccination program, State and Commonwealth Governments must prioritise rural workforce strategies and reforms, such as those initiatives that would increase and sustain community access to primary health care. In current reforms this includes nurse practitioner candidate scholarships and rural generalist training pathways for medical, nursing, and allied health professionals that include advanced skill training. Investment in innovative rural primary healthcare models is also recommended with multidisciplinary rural health teams including community pharmacists who provide critical supports for GPs.

Further research is needed that determines optimal primary care availability and accessibility in rural communities for surge response, including workforce and services mix.¹³

Study limitations

Factors that might have limited primary care providers’ vaccine administration could include fluctuations in vaccine supply and the alignment of community sociodemographics to vaccine priority groups, which determined the timeline of availability. In Australia, vaccine uptake was also influenced by public concern about vaccine side effects and efficacy relating to vaccine brand Vaxzevria (AstraZeneca).¹⁴ Between 25 July and 20 August 2021, vaccine safety concerns were the most common reasons for not being vaccinated or intending to be vaccinated in Victoria, Australia,¹⁴ and other studies have shown that rural communities are more likely to report vaccine hesitancy compared with urban communities.^15–18 Additionally, previous research has demonstrated that vaccine hesitancy also increases with social, economic, and educational disadvantage, which are all factors known to increase with rurality.^15,16,18 Vaccine administrations in rural communities could have potentially been higher if these social determinants of health were addressed alongside and within vaccination programs.

Geographic location was the primary factor of interest in this study. We did not extend this study to explore other factors that are known to influence vaccine uptake in communities and that would provide further valuable insights,¹⁹ including age and Aboriginal and Torres Strait Islander identity, which are available in AIR, or disability/ability, political beliefs, and socio-economic status, which are not currently available in AIR.^11,18 Postcode data used for MMM categorisation was based on the patient’s home postal address registered in Medicare at time of vaccination. Postcodes were used to extract COVID-19 vaccination administration data because suburbs cannot be extracted from AIR and postcodes are more sensitive for exploring rurality compared to local government areas. However, MMM is applied at suburb level, therefore a postcode may include multiple suburbs and have more than one MMM classification. The postcode and suburb map were overlayed, and the MMM classification was selected based on the classification of the suburb that usually preferenced the lower MMM category to reduce risk of bias, i.e., where MMM category 1 and 2 were relevant for the postcode, category 1 was selected reflecting higher density geographic location/lower rurality.

The strengths of this study is that a national immunisation register was used that has combined data across all vaccine channels providing an accurate representation of total vaccine administrations by geography. All vaccine providers were required to report COVID-19 vaccinations to AIR by Australian Government legislation and conditions of the Commonwealth Government COVID-19 vaccine program participation.¹⁹ However, there may be inaccuracies resulting from under-reporting due to data entry errors.²⁰

Conclusion

This study contributes to existing literature by exploring the contribution of service providers to the COVID-19 vaccination program in Victoria, Australia, providing new insights into the importance of rural primary health care for surge response and showing that this importance increases with patient rurality. Overall, primary care providers completed half of total vaccination administrations for the population across the state of Victoria, and the majority were completed by GPs. Study results demonstrate that the number and proportion of vaccine administrations completed by primary care provider types increased with rurality when compared with state government and other channels. This research can guide health policy makers and planners tasked with strengthening health systems in preparation for a future health system surge response.

The contribution of rural primary health care to the COVID-19 vaccine program highlights the importance of establishing policy around the needs and interests of rural primary care providers, specifically general practice, ACCHOs, and community pharmacies. Further research is needed to understand the full scope of the multifaceted role of primary care providers in rural communities in surge response and recovery, during and beyond pandemics.

Data availability

This research uses the Australian Immunisation Register data set de-identified for primary health networks, which is managed by the Australian Government, Department of Health and Aged Care.

Conflicts of interest

The authors were employed by Murray PHN and had a role in coordinating the primary care COVID-19 vaccination roll out.

Declaration of funding

The research did not receive any specific funding.