Abstract

Background

Communities have an important role to play in disaster and emergency planning and response. Yet community members are not typically engaged in official planning activities, including plans for mass immunization clinics during infectious disease emergencies, such as the COVID-19 pandemic. This qualitative study explores one case of a community driven effort to implement a COVID-19 mass vaccination clinic in Cobourg, Ontario, Canada. Operational between mid-March 2021 and late February 2022, the Cobourg Community Centre (CCC) clinic involved 600 community volunteers, and at its peak completed approximately 700 vaccinations a day. The development and operation of the clinic was largely grassroots, spearheaded by local non-profits and volunteers. Drawing on insights from the various actors involved, this study seeks to understand the factors that made this collaborative effort a success.

Methods

Semi-structured interviews and focus groups were conducted between September 2022 and July 2023 with 34 individuals involved in coordinating and operating the CCC mass vaccination clinic including volunteer community members, members of local community organizations and businesses, public health unit and hospital staff and city employees. Data was analyzed utilizing an inductive thematic analysis.

Results

Four major themes were identified that contributed to the clinic鈥檚 success and enabled the team鈥檚 ability to navigate challenges including, a collaborative model, leveraging community knowledge and networks, flexibility and autonomy, and volunteers as an asset.

Conclusion

The findings of this study indicate the importance of community engagement in strengthening emergency planning and response for future public health emergencies.

Background

The importance of community engagement in emergency, crisis, and disaster management is increasingly being acknowledged for its potential to build community resilience and enable surge capacity [1,2,3,4] in response to more frequent disasters and large-scale emergencies, such as the COVID-19 pandemic. In particular, the United Nations Sendai Framework for Disaster Risk Reduction, which has been adopted by 187 member states, including Canada, advocates a collaborative, whole of society approach to disaster and crisis prevention, mitigation, response and recovery [5]. This includes a shared responsibility for building resilience to emergencies and disasters across all levels of society, including governments, the private sector, civil society, individual citizens, and communities. However, responses to the COVID-19 pandemic were largely top-down and adopted a command-and-control approach [6鈥�7].

In Canada, planning and guidance for pandemic preparedness is developed at the government level. This includes guidance on planning for mass immunization clinics, which is the responsibility of local/regional and provincial/territorial health departments and federal health departments [8]. Implementation of mass immunization clinics requires coordination among stakeholders across multiple sectors, and the mobilization of significant human resources, which often exceed the capacity of public health agencies. In addition to coordinating supplies and location set up, developing and operating a mass vaccination clinic requires the recruitment and management of health care professionals to administer vaccines as well as support staff and volunteers to fill non-health health care provider roles needed to ensure efficient clinic operation [9]. Studies on COVID-19 mass vaccination have provided guidelines for designing and operating clinics [10,11,12]; identified potential vaccination sites [13]; and have documented the effective use of pharmacists [14], front-line worker volunteers [15], pharmacy [16] and medical students [17] to administer vaccines. Much of this work provides guidelines but not details or real examples, and few approach this from a community, grassroots level.

Research that has explored community engagement in COVID-19 mass vaccination efforts tends to focus on its potential in improving vaccine uptake [18鈥�19], targeted outreach [20] and on volunteer motivation [15] and role satisfaction [21], but not on community involvement and collaboration in the design and implementation of mass immunization clinics. This study seeks to contribute to this literature by exploring one case of a bottom-up, community driven effort to establish a mass vaccination clinic during the COVID-19 pandemic in Cobourg, Ontario, Canada. The community of Cobourg took a unique approach to the development and operations of their COVID-19 mass vaccination clinic. It was largely grassroots 鈥� with non-profits and volunteers spearheading its development and operation. It was also largely deemed a success 鈥� so successful that members of government visited to see what made this site so effective [22]. Lessons learned from this collaborative partnership can provide support for mass vaccination clinics in response to future public health emergencies.

Methods

Informed by a constructivist interpretivist paradigm [23], this qualitative study explored the successes and challenges of a collaborative effort to develop and operate a mass vaccination site for the Haliburton, Kawartha, and Pine Ridge District Health Unit. Semi-structured interviews and focus groups were conducted with 34 people involved in various capacities in the design and implementation of a mass vaccination clinic in Cobourg, Ontario. Cobourg is a city located within Northumberland County and approximately 95听km east of Toronto. Northumberland County has a population of 89, 365 [24]. The population is mainly English speaking with a higher proportion of residents aged 65 and up compared to Ontario as a whole [24]. This region is geographically diverse, with suburban and rural communities, and communities of varying population sizes. The town of Cobourg is the largest municipality in Northumberland with a population of approximately 20, 519 [25]. Cobourg has a legacy of community engagement with a strong, highly skilled, and committed volunteer base as well as established community service organizations including the Rotary Club. Therefore, when vaccines first became available to health care workers in December of 2020, concerns were already emerging within the community about how to design and implement mass vaccination for the area, and community members were looking for ways to get involved.

Participants were recruited from among those involved in the Cobourg Community Centre (CCC) clinic using purposive and snowball sampling [26]. Most study participants were community volunteers (n鈥�=鈥�20), hospital nurses and physicians (n鈥�=鈥�5), public health and hospital leaders (n鈥�=鈥�3), and Rotary Club members (n鈥�=鈥�2). In addition, participants included local businesses and non-profits (n鈥�=鈥�3) and city employees (n鈥�=鈥�1). Interviews and focus groups lasted between 60 and 90听min and were conducted virtually between September 2022 and July 2023. All interviews were conducted using a semi-structured interview guide, audio recorded, and transcribed verbatim. Ethics approval for this study was granted by Western University鈥檚 Health Sciences Research Ethics Board.

Interviews were analyzed using an inductive thematic analysis to identify major themes across the dataset. Thematic analysis is a method 鈥渇or identifying, analysing and reporting patterns within the data鈥� [27 p. 79]. Our approach sought to provide a rich description of the entire data set to gain an understanding of the factors that contributed to the success, as well as the challenges of the CCC clinic. First, the study team read the entire data set from the semi-structured interviews independently and took notes for initial codes. Following this, the team met to develop an initial coding framework. The initial coding framework was then used to code the entire data set of semi-structured interviews line by line using NVivo data analysis software. In line with our constructivist approach, throughout the coding process, the team met multiple times to review and refine this framework until consensus was reached (every 5鈥�10 transcripts). The entire coded dataset (semi-structured interview data) was then reviewed to identify overarching themes that included multiple codes. From here, the research team developed a thematic map. The results from this analysis were presented to study participants during three separate focus group sessions to ensure rigor and add conceptual depth to the themes [28]. Subsequently, a final review of the codes was conducted by the team. A total of four overarching themes were identified encompassing the strategies that contributed to the clinic鈥檚 success.

Results

In this section we focus on how a collaborative partnership was developed between the local hospital, Cobourg Rotary Club, and later the Public Health Unit to establish and operate the CCC clinic, including the challenges faced and the strategies that made it a success. Four major themes were identified that contributed to the clinic鈥檚 success and enabled their ability to navigate challenges including, a collaborative model, leveraging community knowledge and networks, flexibility and autonomy, and volunteers as an asset.

A collaborative model

The establishment of the CCC clinic in Cobourg, Ontario was the result of collaboration between the local hospital and an existing non-emergency service organization, Rotary Club, that was able to extend its capacity to set up the clinic and mobilize and coordinate volunteers in the day-to-day operation of the clinic.

When vaccines first became available to healthcare workers in December 2020, the community was already focused on what the rollout would look like when they were made available to the general public. Growing concerns emerged that planning was not progressing quickly enough. In response, the hospital created a taskforce in collaboration with the local family health team to develop an initial plan and design for the mass immunization clinic. In the early planning stages, it became clear that hospital capacity to administer the vaccines would be a challenge, as the amount of people needed to successfully support a mass vaccination site far outpaced the number of staff available. Based on their already established relationships, the Rotary Club offered to support the taskforce鈥檚 efforts. While initially an unusual collaboration, the Rotary Club鈥檚 connections and relationships within the community proved critical in the physical construction of the clinic and the mobilization of volunteers, whose help quickly became apparent.

Leveraging community knowledge and networks to build the clinic and mobilize volunteers

Converting the CCC to a mass vaccination site was a significant undertaking which involved draining the ice rink and creating secure vaccine storage sites, as well as coordinating with emergency services (such as the fire department and police). Despite global shortages in the supply chain, particularly for plastics, local businesses donated the materials to build the physical structure, while local contractors volunteered their time so that the clinic was ready for operation within a few days. Moreover, through networking with Rotarians in other communities, the taskforce learned about the hockey hub model as an effective approach that should be used for the delivery of vaccines. As the hospital clinic lead explained, the design called for 鈥減eople sitting and the vaccinators moving as opposed to people moving and the vaccinators sitting鈥� (P30). While it was tiring for vaccinators, later it was regarded as efficient. Subsequent research by the Ontario Ministry of Health found that this model allowed for the highest number of people to be vaccinated per staff member [29].

As the physical structure of the clinic was built, volunteer recruitment and logistics began to take place. Given the magnitude of the endeavor, the Rotary Club began reaching out to the community at large through its networks and various social media platforms, to help with the effort. That鈥檚 how鈥墌鈥�600 volunteers from all walks of life joined the effort and became key players in the mass vaccination clinic. With such a large volunteer response, the Rotary Club developed an informal organizational structure: purple shirts and orange shirts. The orange shirts were the volunteers who assisted with daily activities such as door greeting or walking people to their seats. The purple shirts were the volunteer leads who acted as liaisons between orange shirts, hospital leaders, and vaccinators. For instance, before the start of each clinic, the purple shirt would talk to the floor lead and then relay information to the orange shirts about what vaccine was being used that day, how many people were booked, and the timing of the first and last appointments as well as any other daily updates. Additionally, the leaders of the purple shirts met regularly with the floor lead where they would pass on the concerns and insights shared by the orange shirts.

Realizing that this organizational structure would require logistics, a member of the Rotary Club contacted the president of a clinician scheduling software company, which was offering free use of their service to health care units during the pandemic. The software was adapted to meet the needs of a much larger team, which enabled the coordination of hundreds of volunteer shifts and saved valuable time and human resources.

Flexibility and autonomy

Innovative thinking, which drove decision making throughout the planning and operation of the clinic, enabled flexibility in responding to different needs and challenges. For example, in the early planning stages, a leader of the Rotary Club reached out to the chair of a community agency to provide transport for clients who could not travel to the clinic on their own. With funding from Rotary, this agency agreed to use their transportation services by utilizing existing personnel from the agency, as well as volunteers who were also brought on as drivers. This adaptation required some risk planning to ensure the safety of the drivers, as well as strategizing to speed up the process by, for example, negotiating to get police checks done as quickly as possible. Ultimately, the collaboration of the community agency and the police department allowed for the transportation of many community members to the clinic for their vaccine appointments.

A willingness to listen, learn, and adapt strategies 鈥� while maintaining safety 鈥� in response to suggestions from volunteers enabled success. The hospital clinic leader, who was a former emergency room nurse, adopted a crisis management approach that proved very effective through the various strategies she used. An orange shirt volunteer described this approach,

鈥淪he would call everybody at the end of the shift. We would go off to a place in this whole arena where we weren鈥檛 in the lines of people coming in. And she had a flip chart on an easel, and her marker in her hand and her big smile on her face that you could see. Because even though she wore a mask, it was in her eyes. And she鈥檇 be like, 鈥淭ell me. Tell me. How did today go? What was good? What wasn鈥檛 so good? What could you change?鈥� That鈥檚 the kind of debrief鈥� (P7).

These strategies allowed for changes to be implemented more easily. However, this kind of approach can take a toll during transition periods if floor leads lack the authority, experience, and/or confidence to make decisions. This was the case initially when the Health Unit took over leadership of the clinic. As one purple shirt explained, 鈥渢he lead would often be a young nurse who had to take all her decisions to somebody above her or strictly abide by the rules. So, if I said, 鈥渨e will be slow between 1-2pm because no one is coming in, can we take walk ins?鈥� She鈥檇 say 鈥渘o, absolutely not, those are the rules鈥濃�� (P16). And while expected from more top-down organizations, it created the perception that the opinions of volunteers were not valued anymore. This dynamic improved overtime as the Health Unit identified leads who worked well with the volunteers and assigned them to the floor more frequently. For both purple and orange shirts, this resulted in a level of confidence in decision making that was highlighted as invaluable to the success of the clinics after the transition.

Volunteers as an invaluable asset

Volunteers possessed a range of relevant skills, knowledge, and resources that contributed to the success of the clinics. Purple shirt volunteers were tasked with screening and learning about the skills 鈥� both professional and non-professional 鈥� of other volunteers before assigning them roles as orange shirts. Many volunteers were retired and their previous education and employment backgrounds often led to innovative and creative solutions. Strategically utilizing volunteer鈥檚 skills proved especially effective in dealing with people鈥檚 concerns and anxieties. For example, volunteers who were social workers put their skills to use in ensuring the comfort of clients. Similarly, volunteers who had experience as teachers were stationed in the clinic for children aged 5鈥�11. Working with community partners, they provided markers, puzzles, and paper for the children, as well as a seven-foot bear named Normandy who could sit with them while they received their shot.

Creative operational solutions from volunteers also boosted efficiency. Very quickly, it became apparent that outlying communities were struggling to access COVID-19 vaccinations. For some, this was due to mobility issues, transportation limitations, or work schedules that made travelling to the CCC challenging. With financial support from local government, the hospital began setting up mobile clinics. While partners in the community facilitated the clinic鈥檚 set up, the staff did not know how to use the vaccination management system. Therefore, a group of mostly female volunteers emerged as the IT resources to document vaccinations at those mobile clinics. And that鈥檚 how the 鈥渂omb girls鈥� materialized, named after the Canadian women who worked in munitions factories during WWII. The term 鈥渂omb girls鈥� was used by a participant as an analogy to describe the strategy adopted by the CCC clinic leadership of relying on volunteers to perform tasks usually done by paid workers, such as IT duties, that could be easily learned. Just as the 鈥渂omb girls鈥� stepped in during the war to fill critical jobs left by enlisted men, volunteers in Cobourg filled essential gaps in the vaccination effort due to limited resources.

Ultimately, it was the work of the volunteers that enabled the CCC clinic to function so efficiently. From mid-March 2021 to late February 2022 some 600 volunteers dedicated their time to serve Northumberland in the fight against COVID-19. After over a year of intensive efforts, the CCC closed its mass vaccination site on February 26th, 2022, having vaccinated 85.8% of its residents with their first dose, and 82.4% with their second dose [30].

Discussion

A number of lessons can be taken from the example of the CCC clinic for community engagement in response to future public health crises or disasters. Overall, the dedication, commitment, knowledge, passion, and sheer number of community members involved was integral to the successful functioning of the CCC clinic. Volunteers鈥� skills and knowledge proved critical in identifying what strategies were working, areas that were being underserved, and in driving creative solutions to issues that arose in the day-to-day operation of the clinic. Our findings echo those of other studies on community engagement in disaster/emergency planning and response [3, 31] which highlight the limits of top-down bureaucratic approaches and emphasize the importance of developing inclusive models that regard existing social networks, volunteer skills, and knowledge as valuable resources that can drive creative and innovative approaches to problem solving during times of crisis.

Importantly, capitalizing on community knowledge, skills, and resources is not possible without the relationships and networks that community organizations can facilitate [6]. In the case of Cobourg, a strong relationship between the hospital and the Rotary Club facilitated the rapid mobilization of the CCC clinic. As a well-established service organization with a track record of involvement in the global effort to eradicate polio, members of the Rotary Club of Cobourg were motivated early on to get involved in the vaccination effort. Given Rotary鈥檚 previous involvement in community event planning and volunteer recruitment, they were able to extend their role to build the clinic and successfully mobilize and integrate 600 volunteers into the mass vaccination effort. Key to their success was establishing an informal structure with clear roles for volunteers and open lines of communication; effective strategies that have been identified in other studies on COVID-19 mass immunization clinics [17, 21]. Furthermore, the crisis management approach adopted by the hospital and Rotary Club enabled them to better adapt to the challenges they faced in operating the mass vaccination clinics amid constantly shifting vaccination guidelines and supplies. It was their relative autonomy and flexibility that allowed them to implement innovative and creative strategies in response to issues that arose and needs that were identified in the community. This affirms the benefits recognized in the literature of integrating non-emergency organizations and volunteers into emergency management responses, given the flexibility they can enable [31].

As this unique collaboration illustrates, partnerships in public health emergency response can involve groups outside of official agencies, including non-emergency volunteers as well as local organizations and businesses that can expand or extend their capacities to assist in response efforts [31鈥�32]. Therefore, nurturing relationships with and including community partners in formal emergency planning can enable ongoing conversations about the potential role they can play in crisis management.

Likewise, given the critical role volunteers can play during emergencies and disasters [3], the example of the CCC clinic underscores the value of identifying willing volunteers in the community and keeping track of their skills on an ongoing basis. Of particular benefit would be for community organizations to establish a database of the professional and non-professional skills available in their communities and ensure it remains updated as community members move in and out. During crisis, this can facilitate decision-making regarding distribution of tasks among volunteers and enable the identification of unique skills that otherwise might be overlooked. The potential benefits of skill inventories during crises or disasters have been identified by other communities and organizations [3, 33]. In this study, the creation of a skill database was deemed actionable by the community who in their informal efforts to keep track of volunteers鈥� relevant skills indicated the need for a more robust system. As we and others have shown, effective utilization of volunteer skills, knowledge, and resources can enhance the adaptive capacity of communities, organizations, and public health agencies to respond to emergencies and disasters [34].

Overall, the lessons drawn from the CCC clinic may have applicability in a variety of settings. However, it is important to note that conditions that enable or constrain collective responses to crises can vary widely across communities, influenced by factors such as population size, socioeconomic status, culture, and the environment [6]. For instance, Cobourg is a smaller, predominately English-speaking community with a legacy of volunteerism and sizable retired population, which facilitated community engagement in the vaccination effort. In contrast, larger, more culturally diverse, and marginalized communities may encounter different factors that enable and/or constrain utilization of the community鈥檚 existing capabilities and skills [6].

Conclusion

The successful establishment of the CCC clinic serves as an instructive example of the role that community can play even in emergencies that require a very specialized response. Although the CCC clinic was the result of a collaborative effort, the impetus initially came from the community. As was acknowledged by healthcare leaders, while healthcare and public health organizations might have had the expertise to lead, they lacked the personnel. With its legacy of volunteerism, the residents of Cobourg had a strong sense of commitment to community service and were motivated by the desire to help, which allowed them to meet the need for additional human resources.

If other communities strive to do the same, it is important to realize that a legacy of volunteerism is not an innate feature of any community; it must be cultivated. In the case of the CCC, it was the existing relationships between community members, community organizations, the local hospital, and local businesses that enabled such an effective and dynamic vaccine administration effort. And those existing relationships, developed over time, are what enable communities to play a key role in responding to crises.

As is becoming increasingly clear, community engagement is a critical component in the response to any major crisis or disaster. Therefore, community involvement should be built into the development of any formal emergency response plan. When community involvement is driven by community organizations, like the Cobourg Rotary Club, relationships can be leveraged, and community members can feel empowered to know they can be involved in making a difference. As a result, government organizations and expert groups will likely have at their disposal a more effective channel to influencing the public. In Cobourg, the Rotary Club played a key role in organizing the CCC clinic. Other communities can benefit by identifying local organizations with the capacity and connections to lead an effective response. Champions exist in every community, and it is crucial to identify them and build relationships during non-crisis periods.