We conducted 8 focus groups with a total of 39 participants. Focus groups were organized based on provider groups (i.e., physicians, nurses, executive directors, quality improvement decision support specialists) when possible; however, we conducted 3 focus groups comprised of interprofessional healthcare providers (IHPs) when we did not have enough participants to run provider-specific focus groups. The largest focus group included six participants, although there was an overall average of five participants per focus group. The participants (N = 39) represented geographic diversity across each of the six Ontario Health regions West (n = 10), East (n = 9), North East (n = 6), Central (n = 5), Toronto (n = 5), and North West (n = 4). In terms of geographical representation, there was a similar representation of participants from urban (n = 21), rural (n = 16), and mixed (n = 1) settings, with n = 1 unknown. Table 1 provides an overview of each of the 8 focus groups, while Table 2 provides details of the professional roles represented by study participants.
Table 1
Overview of Eight Focus Groups
Focus Group # | Types of Providers | Number of Participants |
1 | Executive Directors | 6 |
2 | Quality Improvement Decision Support Specialists | 5 |
3 | Nurses | 5 |
4 | Nurses | 4 |
5 | IHPs | 5 |
6 | IHPs | 4 |
7 | IHPs | 5 |
8 | Family Physicians | 5 |
Table 2
Professional Roles Represented by Study Participants (N = 39)
Professional Roles | Number |
Nurses | 8 |
Executive Directors | 6 |
Family Physicians | 5 |
Quality Improvement Decision Support Specialists | 5 |
Nurse Practitioners | 4 |
Pharmacists | 4 |
Clerical | 3 |
Health Promoter | 2 |
Dietitians | 1 |
Respiratory Therapist | 1 |
TOTAL | N = 39 |
With respect to understanding PHC teams’ participation in the different phases of the COVID-19 vaccination rollouts, we identified five themes: i) supporting long-term care, ii) providing leadership in mass vaccinations, iii) integrating vaccinations in PHC practice sites, iv) reaching those in need through outreach activities; and v) PHC’s contributions being under-recognized.
1. Supporting Long-Term Care
Family physicians, holding multiple roles in their communities, explained that they were instrumental in facilitating the vaccination roll-out in long-term care facilities: “A few of us in [name of city] approached Public Health, to find out if they needed help getting into long-term care homes” (FG8, P5, Physician). Similarly, “With regards to long term care, we facilitate getting doses over to long-term care homes, all of us who work on the Family Health Team are the medical directors of long-term care home…if they need doses, we use the max vax clinic to get the doses over there” (FG8, P3, Physician). The focus group of Quality Improvement Decision Support Specialists (QIDSS) shared, “We started with long-term care, so we had clinics set-up for long-term care residents and like PSW's and so on working there, so it started with the people working there first” (FG2, P4, QIDSS).
PHC provided a range of human resources to assist with vaccinations in long-term care. As explained by a respiratory therapist, “You just basically tell the ED and supervisor what day you prefer…there's only few went to the long-term care, mostly it's the doctor and the nurses…mostly again, it's the nurses, nurse practitioners and the doctor going to, to those institutions” (FG5, P1, Respiratory Therapist). Participants representing rural communities highlighted the essential role that PHC teams played in all phases of the vaccination rollout, including in long-term care. According to the focus group of QIDSS: “I'd say for some of the more rural FHTs where they are the only shop in town, I mean, they were definitely more involved in all aspects of the rollout. So in long-term care, they helped with the rollout there” (FG2, P2, QIDSS).
Not all PHC teams participated in long-term care vaccinations, highlighting the regional nature of the rollout across the province. Focus groups indicated that members of their PHC team were not involved with the vaccination distributions in long-term care: “For us, for the (FHT Name) Family Health Team we didn't do much in long-term care. That was mostly driven by Public Health” (FG8, P4, Physician). The focus group of nurses noted: “with our team specifically I don't believe we helped out at long-term care” (FG3, P4, Nurse Practitioner).
2. Providing Leadership at Mass Vaccination
Across focus groups, participants emphasized the leadership role that PHC teams played in organizing and operationalizing mass vaccination efforts across Ontario. Focus groups described at length the engagement PHC providers and teams had in mass vaccination clinics: “The Family Health Team, we've done all of the mass immunization clinics, the entire time” (FG5, P1, respiratory therapist). Similarly, the family physician focus group noted:
Mainly driven by the county and the Family Health Team, we set up a mass vaccination clinic in our largest town center….we organized and ran mass clinics there from April 2021 onward…now with the new wave, we had just sundowned it and now it's back up and running, delivering over 26,000 doses in our, in our rural community (FG8, P3, Physician).
Similarly, the focus group comprised of nurses and nurse practitioners highlighted the leadership role of PHC in organizing and running mass vaccination clinics: “In January…we actually set up and ran our own mass clinics at one of the local sports centers and we did that, over the course of a two and a half week period, doing it every day except for Sundays” (FG3, P1, Nurse Practitioner). Some mass vaccination clinics were run at the PHC site itself, yet extended to all members of the community: “We're rural, and so what we brought to the table was, we did mass clinics out of our site, and so we expanded the access to the rural communities out here, and not all people were patients of ours, they were just across the community” (FG1, P1, Executive Director). The interprofessional healthcare providers focus group noted, “We did large scale drive through clinics, we kind of repurposed our vaccine committee to replan how a drive through clinic would work” (FG5, P4, Health Promoter).
Multiple team members contributed to mass vaccination clinics run in partnership with public health and other local organizations:
Our mass clinic was similar. We had 12 immunizers, 1 physician for monitoring of patients with AEs [Adverse Events], approximately 4–6 pharmacy students, pharmacists, technicians for vaccine preparation, 5–10 staff members for check-in/out, and multiple volunteers to guide patients through the clinic and monitor after receiving the vaccine. Staffing was a strength of our clinic given the relationship with the Family Health Team. (FG5, P3, Pharmacist)
Running the mass vaccination clinics required significant human resources, with some of the human resources provided by PHC as explained in the QIDSS focus group: “In terms of mass vaccination…Public Health asked the Family Health Team to join in the effort, to basically be the, participate in mass vaccination, as staff, so the staff was seconded, some of the staff was seconded to do that” (FG2, P1, QIDSS). Across all focus groups, participants overwhelmingly spoke about the contributions that PHC made by staffing the mass vaccination clinics: “Within the Family Health Team we have nurse practitioners, we have pharmacists and registered nurses, and RPNs…and so a lot of us did…get called upon to help out at the mass vaccination clinics in [city name]” (FG3, P4, Nurse Practitioner). The nurse focus group also noted the role that PHC played in staffing the mass vaccination clinics: “We have 15 physicians on staff, so our physicians went out to the arena, and vaccinated there, from probably April to…November 2021. We had some staff go vaccinate as well, some nurses who are seconded from the FHT and went over to vaccinate a couple days here and there” (FG4, P3, Nurse). Several focus groups highlighted that the PHC nurses played a particularly central role in administering the vaccinations: “The mass clinics…we had a pharmacist helping draw up, but basically it was always the nurses and the NPs…primarily providing the shots” (FG6, P2, clerical staff). PHC contributed a range of staff to support the operations of mass vaccination clinics in their communities, including clerical staff as explained by in the focus group of executive directors: “Public health was actually doing the process, doing the ordering, online booking…was a nightmare, so we asked if we could help by…giving some of my reception staff who are working evenings, they actually got the rights to actually do booking, into the booking clinics of public health, because they were overwhelmed” (FG1, P5, Executive Director). The family physician focus group also highlighted the staffing contributions to the mass vaccination clinics:
What we decided to…donate time to the mass clinic…that was at the…community center…So, the way we did that is, we spoke to the physician that…was running the clinic and we basically said, ‘How many tables are you going to need at each time?’ Turned out it was 14, each table having one vaccinator. We would give two tables consistently throughout the rollout. So if we had 14 tables required, two of them would come from our Family Health Team” (FG8, P5, Physician).
Some PHC teams opted to participate in mass vaccination clinics instead of hosting vaccinations on-site due to their own space limitations: “Starting in March of 2021, we started with the mass clinics because we just didn't have space here to do the numbers” (FG1, P3, Executive Director). It is important to note that not all PHC teams participated in the mass vaccination clinics. One challenge that prevented some teams from participating had to do with a lack of PHC providers: “I’m just very impressed that some of the teams were able to supply staffs seconded to mass vaccination clinics...I have more rural teams and there were just no staff to send out, like it was just impossible” (FG2, P3, QIDSS).
3. Integrating Vaccinations in PHC Practice Sites
Across all focus groups, participants noted that they distributed vaccinations within their PHC practice sites:
In November of 2021 we were asked to start vaccinating in clinic, when the big push for getting people vaccinated came along, so we started doing vaccination clinics here. We vaccinated probably about I would say, close to 3000 people so far, in our clinic, both patients and non-patients…we vaccinate all populations, we can do boosters. We do it all. (FG4, P3, Nurse)
Some vaccination clinics made the COVID-19 vaccination available to their patients as well as members of the public: “What the Family Health Teams did were…scheduled clinics. As the mass vaccination clinics were winding down the Family Health Teams were asked to take up the slack, and they actually scheduled clinics, not just for their patients but also for the general public.” (FG2, P3, QIDSS). The family physician focus group discussed implementing vaccination endeavours at their practice sites: “For our Family Health Team, we have a clinic of four docs…so we did run full pop-up clinics, and did most of our population here, which I think they appreciated” (FG8, P1, Physician). One of the FHTs offered drive-through vaccinations to patients to enhance patient safety: “Our Family Health Team ran some drive-through vaccination clinics, which were very successful, and patients absolutely love it - especially the older folks... So that was a lot of the focus of our Family Health Team, in terms of getting our own patients done” (FG8, P4, Physician). A medical receptionist in a different focus group noted, “We evolved to where we were offering clinics within our clinics…and that worked out well for us because of the patients, for whatever reason…it was easier for them to come here, we were able to provide that for them” (FG5, P2, medical receptionist). She further elaborated by saying, “We've done now 45 clinics since June and our nurse practitioner, she ran it…and we didn't have to go outside of the building for anything…we just did it and away we went and did the best we could” (FG5, P2, Medical Receptionist). Similarly, the executive director focus group noted:
[We were] trying to serve those whose needs weren’t…best met in a mass clinic type site…we had private rooms, we had primary care nurses and physicians on-site, we also offered pure counselling appointments, so people that weren't quite ready for the shot yet they could do either in-person, drop-in, or telephone counselling only to try to address any hesitancy (FG1, P4, Executive Director).
Additionally, the nurse focus group indicated that regularly scheduled vaccination clinics occurred at her site: “for first and second doses…we just concentrated on our patients here at the Family Health Team…we ran clinics Monday to Friday alongside the regular clinic that was running (FG3, P2, Nurse). There were variations in the vaccination initiatives across the various PHC teams because of space restrictions:
There were also vaccination happening at the clinics themselves…some clinics did have vaccination at different volumes. So [Name of FHT]…had run a drive-through before, so they had a really well-oiled system to do that…but some other teams, some other teams it was maybe less volume…and some teams downtown it was not drive-through because they did not have a parking lot (FG2, P1, QIDSS).
Across focus groups, participants explained that the vaccine initiatives were aimed at their patients as well as the general community:
Those targeted emails that we send out, we really only administered vaccines to patients of our clinic. We have about 20,000 patients…so we felt kind of accountable for serving our patients needs first. The only time that we really reached out outside of our clinic was when the clinics weren't filling up, and so there's an elementary school right across the street, so we went to the administrators, and said if there's any teachers, if there are staff that want to come to the clinic. And then we also went to the local pharmacy who we knew was maintaining a waitlist, and said, if anyone on your waitlist wants to come to our weekend clinic. (FG5, P4, Health Promoter)
PHC facilitated opportunistic vaccination, as described by the focus group with QIDSS: “There were opportunistic doses of vaccines given out - this was when people with COPD or something like that came in for a visit for their chronic condition, and they were just vaccinated if they weren't vaccinated” (FG2, P3, QIDSS). The focus group of executive directors showcased the importance of integrating opportunistic vaccinations that facilitated patient-centred access that aligned with the patients’ readiness for a vaccination:
We were allowed to have supply on hand, and we were able to catch - like when the physicians would have someone in that was anxious about the COVID vaccine, they would chat with them and then all of a sudden they'd say, ‘Well, if you had a dose, I would maybe take it’…and then they'd run down the hallway, and we'd get them vaccinated right while they're here (FG1, P1, Executive Director).
Similarly, participants noted that PHC was efficient by integrating the COVID-19 vaccination with the larger vaccination framework:
As time went on, we were encouraged to give other vaccines with the COVID vaccine. So we gave lots of flu shots as well. We would offer flu shots. And so the immunizations, even if they were due for, let's say for a Shingrix, or a Pneumovax, and all these other things - we didn't give them all, at the same time, obviously - but we would book them for another appointment later on in the year for those other vaccines (FG4, P4, Nurse Practitioner).
For some teams, this approach facilitated the commitment to routine PHC. The family physician focus group noted, “We felt very strongly that that was a good contribution, and that it allowed us to maintain our office practices of seeing patients, and not get bogged down by doing the vaccine. So that's how our FHT did it” (FG8, P5, Physician). This was also reflected in the executive director focus group which highlighted how COVID-19 vaccinations within PHC provided an opportunity to do opportunistic vaccinations for the flu: “Our building is big enough to probably do 80 people on a Wednesday afternoon and we were able to do flu shots at the same time, so we thought this would be an opportunity to do both, we jabbed you on both sides and that worked well” (FG1, P5, Executive Director). Across focus groups, participants explained the commitment that PHC had to ensure that patients had access to the COVID-19 vaccinations: “The doctors themselves…they wanted to make sure we had vaccine available for our patients, really wanted to be sure that that's available” (FG6, P2, Clerical Staff).
Some participants noted that not all PHC practices distributed vaccinations but still contributed to vaccinations by supporting patients in booking appointments. In a focus group of nurses, it was shared that even though vaccinations were not being done at her PHC clinic, the team was instrumental in helping some patients obtain access to vaccinations: “We weren't doing vaccines clinics at those times. We would spend a lot of time trying to do that for them. So searching for openings…So yeah, we spent a lot of time doing the searching and booking” (FG4, P2, Registered Nurse). However, not all PHC teams opted to distribute the COVID-19 vaccination, as explained in the family physician focus group:
There was a lot of noise throughout the pandemic about whether family physicians should be doing this in their offices. There were a lot of people that were very pro, there were a lot of people that were against. Wherever you landed was up to you. But unfortunately there was a lot of noise about it and a lot of complaining that there were too many roadblocks for some to do it in their office. Our FHT looked at it. We decided not to do it, simply because we didn't feel it could be done during the day, like we do flu shots, because of the COVaxx - the amount of time, you had to put people into COVaxx. And also you had to do a lot of people, because once you open up the bottle of vaccine, it can only stay for so long. That being said, we felt very strongly that we should be supporting the community. (FG8, P5, Physician)
4. Reaching Those in Need through Outreach Activities
Across focus groups, some participants described a range of outreach activities that members of the PHC team engaged in to support vaccination distribution efforts. One of the outreach efforts extended to schools: “We've done a few of them in the schools. We did - we have two high schools - so we did some clinics at the high schools, we've gone to the elementary schools” (FG5, P1, Respiratory Therapist). The executive director focus group similarly illustrated outreach activities to schools: “We ran a special three-day, just recently during Omicron, vaccination event for teachers and daycare workers, where we called all the schools and they booked their teachers - schools and daycare workers - and they brought their families” (FG1, P4, Executive Director).
In all the focus groups, participants explained that members of PHC teams did outreach to ensure vaccinations reached homebound persons: “[We] also did home visits for the few people that could not get in” (FG1, P6, Executive Director). The QIDSS focus group also highlighted outreach activities: “The Family Health Teams also conducted outreach to patients who were at home…who couldn't get into the clinic, potentially because of COVID issues, but also because they were so seriously ill they were homebound” (FG2, P3, QIDSS). In one of the IHP focus groups, outreach was also mentioned: “Some of our physicians did home visits to immunize their homebound patients” (FG5, P5, Health Promoter). The family physician focus group also emphasized the outreach activities for homebound persons, “We also created a homebound vaccination program taking the vaccine to homebound patients of all ages” (FG8, P2, Physician). Although not all teams engaged in outreach to homebound patients, “We had less access to do home-based vaccinations. It was one of the frustrations that a lot of us had [about] some homebound seniors. We had no idea how we were going to get to them” (FG8, P5, Physician).
PHC also conducted outreach activities to distribute COVID-19 vaccinations to unhoused persons. As described in the nurse focus group, “Shelter clients were one of the first populations after kind of frontline healthcare, I think, back in February 2021, started doing shelters. So our team was helping with that” (FG4, P2, Registered Nurse). While other teams conducted outreach activities to support a range of specialty clinics that required extra support:
We also did some…cancer clinics specialty clinics, either mobile or on site just on demand, in partnership when public health was just exceeding their capacity to do some of these outreach, they reached out to us and said, ‘Can your team go out and support some of those other populations?’ So we participated in that way. (FG1, P4, Executive Director).
Some outreach activities targeted areas with lower vaccination rates, as explained in the family physician focus group: “We even took a bus out…and we took it along some areas that were lower in vaccination rates, and took our bikes…and just tried to drop in on some establishments, letting them know where and when we would be vaccinating. So really trying to be as patient or person-centered as possible” (FG8, P2, Physician). There were also outreach activities that targeted areas most frequented by the general population: “We did a number of pop-up clinics in the small town halls…and in some of our parks, as well as…the Giant Tiger parking lot…just to be able to grab people opportunistically…we did popups at the construction sites which had some good uptake there” (FG8, P3, Physician).
Notably, some PHC teams undertook informal outreach activities to prevent having to discard unused vaccines. The QIDSS focus group explained, “We'd have leftover vaccines, at one point…we were out on the sidewalk asking if people wanted vaccines, just so wasn't getting wasted” (FG2, P4, QIDSS). One of the IHP focus groups described how PHC conducted informal outreach activities to pedestrians on nearby streets: “A few days we were in downtown [city name] and myself, and some of the nurses were literally just walking the streets and asking people if they wanted vaccines” (FG5, P4, Health Promoter). Similarly, informal outreach was utilized to engage hard-to-reach populations: “There is this quite large population of…IV drug users…that maybe would be a higher risk of developing complications from COVID, homeless population…in the last two months I would always kind of walk the intersection, and just flag people down and ask them if they wanted to come in” (FG5, P3, Pharmacist).
Not all PHC teams participated in outreach activities, however. Some of the administrative responsibilities deterred outreach activities: “The main reason for that is just because we had to register every patient manually in our system where we documented it there, and so it was pretty time-consuming to get those patients registered in, so not huge outreach beyond our patient population” (FG5, P4, Health Promoter).
5. PHC’s Contributions Being Under-Recognized
Many focus groups expressed concerns and frustrations that PHC’s contributions to the vaccination distribution was not widely recognized. There was concern about the perception that PHC was not actively involved in the vaccination distribution and was closed altogether: “There was something in one news article…that primary care is closed! It stuck. People think that we were closed…that just stuck despite what was actually happening” (FG5, P1, respiratory therapist). Despite being actively involved, some focus groups expressed frustrations about the lack of recognition regarding PHC’s leadership and participation in intersectoral planning: “They set up a vaccine rollout task force…Primary care was represented from…every FHT in the region. So that's why I kept getting very frustrated when I would hear people say that primary care was not, was being ignored – that was happening in some places, it was not happening in [Central Region Name]” (FG8, P5, Physician). One of the focus groups with IHPs also explained that the perception in the medical community that PHC was not actively participating in the vaccination efforts has a lasting impact on providers: “Within the medical community as well…I would hear comments of primary care being not as proactive, or not doing much, and physicians not seeing their patients, and it was so far from the truth that I think it was challenging…at the end of the day it does kind of weigh on you over time” (FG5, P3, Pharmacist). Many focus groups expressed concerns that the extent of PHC’s involvement in the vaccination efforts went unrecognized: “We did a couple clinic days at the arena…and we vaccinated the city staff, the firefighters [using] our own stuff, basically. And we ran through like double the amount of people that a Health Unit clinic would have ran through in the same amount of time…they don't recognize that at all!” (FG4, P3, Nurse).