Rural Responses to COVID-19 Survey Findings (Summary) – May 2021


The Rural Evidence Review (RER) – a Centre for Rural Health Research research project – works together with rural patients to provide high-quality and useful evidence for rural health care planning in British Columbia (BC). The project recognizes the importance of rural patient voices in health planning and supports this through research. The RER is jointly funded by the BC SUPPORT Unit and the Rural Coordination Centre of BC.

The RER is built on regular and reciprocal engagement with rural patients across BC. Three Rural Citizen Advisory Committees (RCAC) bring together rural patients to support the project to understand and to action rural health care priorities through research. The Committees were instrumental in conceptualizing the ‘Rural Community Responses to COVID-19’ survey study, a project done in collaboration with the BC Rural Health Network. During Committee meetings in March 2020, members spoke about their communities’ experiences of COVID-19 and identified a gap in available information and knowledge: the experiences of other rural communities across BC during the pandemic.


To address this knowledge gap, the RER in partnership with the BC Rural Health Network (BCRHN) – a network of rural health care advocates across BC – launched an online survey to learn f rom rural BC patients and communities about their experiences of and responses to COVID-19. The survey was shared with Rural Practice Subsidiary Agreement(1) communities through local newspapers and radio stations, community-specific Facebook groups, and local elected council and Chambers of Commerce. We heard f rom 562 patients across 144 communities, between April 17 and June 23, 2020 (i.e., the end of Phase 2 of BC’s Restart Plan). The data were analyzed using quantitative and qualitative methods, led by the RER and in collaboration with BCRHN key stakeholders

The impacts of the pandemic on participating rural communities were physical, emotional, social and financial: A number of participants expressed an increased interest in gardening as a pastime and to grow their own foods. “Yards and gardens are looking beautiful, more people growing food.” Participants expressed fear, stress and frustration at the threat of the virus, and reported feeling lonely and isolated because of public health measures, especially physical and social distancing. These feelings were heightened by the financial consequences of the pandemic protocols and travel to the rural communities by nonresidents who were said to add strain to local supply chains (e.g., food availability at grocery stores) and health care services.

Out-of-Pocket Costs for Rural Residents When Travelling for Health Care: Results From a Province Wide Survey in British Columbia – July 2020

“This report presents findings from a rural citizen-patient survey on the out-of-pocket costs incurred while traveling to access health care in BC. To our knowledge, it is the first primary research study to systematically document the financial consequences of traveling for care for rural residents in BC and, as such, provides important information for health care planners.”

The results of this survey provide a starting place for discussions on the role of public support for rural residents who need to travel for health care. These discussions must involve key stakeholders from rural communities but also regional representatives and government ministries beyond the Ministry of Health (e.g., Transportation and Highways, the Ministry of Child and Family Development). Bringing the right group together will provided a starting place for developing a system response to ensure all residents have access to the health care they require, without financial barriers.

Respondents were asked to complete the survey for the most recent health care issue that required travel (e.g., a surgical procedure, cancer care). The most recent travel for this issue must have occurred within the last two years. Respondents were instructed to include travel for that one health issue and not to include separate travel for other health issues. However, responses indicate that a few respondents likely included trips for multiple issues in one survey response. Nonetheless, in this report, the use of the phrase ‘per person’ refers to the average cost per survey participant for one health condition. All costs are reported in Canadian Dollar as of 2020.

This study is co-funded by the Health Economics Simulation Modelling Methods Cluster, BC SUPPORT Unit and the Joint Standing Committee on Rural Issues, through the larger context of the Rural Surgical and Obstetrical Networks program, which works to stabilize and enhance surgical and obstetrical services in rural communities across BC.

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Rural use of health service and telemedicine during COVID-19: The role of access and eHealth literacy

Kathy L Rush, Cherisse Seaton, Eric Li, Nelly D Oelke, Barbara Pesut

First Published May 27, 2021


The COVID-19 pandemic has driven a greater reliance on telemedicine, yet rural access, use, and satisfaction with telemedicine and the role of eHealth literacy are unknown. Using a cross-sectional design, 279 (70.6% female) western rural Canadians completed an online survey. The majority of participants reported access to telemedicine, but nearly 1/5 lacked access to online or virtual mental health services. The majority of participants had used health care services following the declared COVID-19 pandemic in North America, and just under half had used telemedicine. Telemedicine satisfaction scores were higher among participants who had used video (M = 4.18) compared to those who used phone alone (M = 3.79) (p = 0.031). Telemedicine satisfaction and eHealth literacy were correlated (r = 0.26, p = 0.005). Participants did not want telemedicine to replace in-person consultations. Telemedicine practice requires that rural residents have the resources, ability and willingness to engage with remote care.


Well known health and health care disparities characterize at-risk populations in rural settings. Poor mental health, unhealthy behaviors (e.g. smoking), obesity, chronic diseases (e.g. cardiovascular disease, diabetes), lower life expectancy, and potentially avoidable mortality are higher in rural and remote areas than urban areas.1 Despite these greater needs, rural populations/communities face disparities in their access to health care such as physician (primary, specialist) shortages, lack of health care facilities, services and equipment, and inadequate infrastructure.2,3

Prior to the COVID-19 pandemic, telemedicine was touted as a promising solution to address these rural inequities and increase the quality and accessibility of health care. For our purposes, and following the World Health Organization, telemedicine is used interchangeably with telehealth and defined according to four elements: provides clinical support; connects users from different locations; uses information and communication technologies; and orients to health outcomes.4 Developments in remote monitoring and sensor technology have further advanced telemedicine practice providing applications for diagnosis, disease surveillance and treatment support.5 Indeed, the benefit of using technology in the delivery of mental health services to rural areas has been well documented.6 So too, cloud-based solutions have been effectively used to link rural patients with medical consultants through intermediary health care and community clinic workers.7

Despite its potential, pre-COVID-19 telemedicine uptake was slow and below expectation.8 Pre-COVID-19 evidence indicates that rural residents have lowered amenability and preference for telehealth services when local services are available (e.g. hospitals, clinics).911 How COVID-19 imposed restrictions on access to these services, and disruptions in usual rural primary care with the abrupt switch to telemedicine, have influenced rural residents’ satisfaction with telemedicine is unknown.

Although rural uptake was low, pre-COVID-19 satisfaction with telemedicine has been found to be high among patients from rural and remote areas.12 Orlando et al.,12 found high levels of satisfaction (system experience, information sharing, consumer focus and overall satisfaction) with telehealth videoconferencing among patients and caregivers living in rural and remote communities who had outpatient appointments from their local health care center with a health care provider at another center. Harkey et al.13 found patients living in rural areas had high levels of satisfaction with telehealth services for occupational therapy, physical therapy or physiotherapy, and speech-language therapy compared to in-person care. These telemedicine uses were largely for specialist care and did not necessarily reflect the massive shift that occurred with the COVID-19 pandemic that catalyzed telemedicine into all areas of practice including primary care where it had not been routinely used.

It is important to understand rural citizens’ use of, and satisfaction with telemedicine during COVID-19, especially as some have projected that post-pandemic, telemedicine will become the new normal in health care delivery.14 A recent survey suggested that patient satisfaction with telemedicine was high following COVID-1915; however, this finding was not specific to rural communities who face different challenges than their urban counterparts. For example, reliance on telemedicine used to its full capacity (e.g. video) requires adequate broadband access, which is often limited in rural and underserved settings.16 In urban Canadian communities high-speed internet doubled to 51.5 Mbps in 2020, while in rural communities it plateaued at 5.5 Mbps,17 potentially impacting the type and quality of telemedicine care rural people receive and influencing their satisfaction with this care modality.

Another factor that impacts users’ ability to use, and satisfaction with, telemedicine is electronic health (eHealth) literacy (defined as the ability to find, use and apply health information from electronic sources18). In their study of the eHealth literacy and communication technology use of remote Hawaiian community members, Witten and Humphry19 found that the eHealth literacy of this population appeared insufficient for proper understanding and utilization of technology. Although not rural-centric, a systematic review of telemedicine adoption suggested that low eHealth and/or a lack of computer literacy prevailed as barriers to widespread implementation.20 Indeed, eHealth literacy has largely been overlooked in the development of technology-based health interventions, limiting accessibility.21 Despite the fact that the COVID-19 pandemic has driven a massive shift to telemedicine to decrease person-to-person contact, and slow the spread of the virus,22,23 no research could be found examining the association between eHealth literacy and telemedicine satisfaction among rural patients. Overall, more research is needed examining rural access, use of, and satisfaction with telemedicine during the COVID-19 pandemic, as well as exploring the role of e Health literacy in patient satisfaction with telemedicine.

The purpose of this study was to describe rural health service and telemedicine usage and satisfaction in rural communities during COVID-19 as well as to explore the role of eHealth literacy in telemedicine satisfaction and gather participants suggestions for improving rural telemedicine delivery.

Research questions

  1. What proportion of rural community participants accessed health services, mental health services, and telemedicine during COVID-19?
  2. How satisfied are rural community members with telemedicine?
  3. How is telemedicine satisfaction related to eHealth literacy?
  4. What suggestions do participants have for improving telemedicine in rural areas?



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The Fourth Wave Is Crushing Nurses and Other Health-Care Workers

Exhausted and overworked, they’re fleeing the sector. Unless we act now, we’ll pay a price for decades.

By Marilou Gagnon and Damien Contandriopoulos 

Marilou Gagnon, PhD, is a professor in nursing at University of Victoria. Damien Contandriopoulos, PhD, is a professor in nursing at the University of Victoria.

COVID-19 — and the way it has been managed — ‘has resulted in an unprecedented mass exodus of nurses.’ Photo from Shutterstock.

[Excerpt] Two indicators have profoundly shaped the COVID-19 response in B.C. — the estimated potential burden on the health-care system and hospitalization data.

In fact, these two indicators were paramount in justifying the implementation of the most restrictive public health measures before the availability of vaccines. 

But coming out of the third wave, we learned these measures were largely insufficient in preserving the capacity of our health-care workers and our health-care system. 

Furthermore, we learned that the pressure, demands and moral distress generated by the management of COVID-19 in the health-care system exacerbated an already dire shortage of health-care workers.

In the first quarter of 2021, the health-care sector experienced the most significant increase (39 per cent) in job vacancies in Canada. In June, those vacancies represented about 20 per cent of the job vacancies in the country. That’s 98,700 vacant jobs, half of which are nursing positions.

Nurses have been particularly impacted by COVID-19 and the way it was managed. This has resulted in an unprecedented mass exodus of nurses, which continues today and will continue for the rest of 2021 — and beyond.

Throughout the summer, there have been numerous reports of closures of acute care beds and emergency departments due to the nursing shortage. Alarms have also been raised about the unsafe working conditions resulting from severe understaffing of nurses in acute care settings.

These reports only scratch the surface of what is happening in our health-care system. The full extent of the nursing shortage and its impact on the health-care system has remained largely hidden from the public despite rising COVID-19 cases.

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Nanaimo doctor warns B.C.’s critical care is reaching capacity

August 25, 2021

As COVID-19 cases continue to climb in B.C. due to the highly infectious delta variant, the province is bringing back mandatory masks.

“We are reintroducing a mask requirement across British Columbia for all indoor public spaces,” said Dr. Bonnie Henry, B.C.’s provincial health officer.

Anyone 12 years and older will have to wear a mask in any retail store, on public transit, in community centers including fitness centers unless working out, in restaurants, pubs, bars unless seated, in offices which serve the public, in common areas of post-secondary schools, for students in grades 4-12, and staff K-12.

The masks are a temporary intervention for now, as the province waits for the vaccine mandate to kick in next month.

But doctors are warning B.C.’s critical care is already reaching capacity.

“The concern I have is that I don’t think people recognize the degree at which we are in big trouble here from a health care standpoint. Interior [Health] is totally overwhelmed. Nanaimo General is the only hospital at the moment that is able to take cases,” said Dr. David Forrest, an infectious disease specialist on Nanaimo General Hospital’s critical care team.

“And this is only August. We’re yet to get into the fall months where there are more people indoors, where kids are back in school. There will be more transmission, there will be more disease. So I am very worried we are on the cusp of seeing much higher cases in hospital.”

Dr. Forrest’s comments come as new data shows hospitalizations, which typically lag behind spikes and dips in new cases, are up 100 per cent from two weeks ago. The number of patients in intensive care is up by over 50 per cent.

“There are about 13 patients across Vancouver island who are in the ICU right now, critically ill with COVID-19. Not one of those people has been vaccinated,” said Dr. Forrest.

Making it not only critical to get vaccinated but because of the possibility of breakthrough cases, but to also wear a mask.

“There are those amongst vaccinated people who are still at risk of developing the disease, because the vaccine doesn’t work as well in the elderly, in people who are immune-compromised, certainly in children,” said Dr. Forrest.

“So, without doubt, we will see breakthrough cases with vaccinated people who will become ill.”

For now, a mandatory thin piece of fabric will be our ticket to freedom, keeping social areas safe, and open.

Florida doctor: This devastating Covid surge didn’t need to happen

By Jennifer Caputo-Seidler 

August 24, 2021

Three Rivers Medical Center in Grants Pass, Ore., like many hospitals in Florida and other hard-hit states, is running out of room to take more patients.MIKE ZACCHINO/KDRV VIA AP, POOL

I recently came across a photo of myself in late December 2020 getting my first dose of a Covid-19 vaccine. I was ecstatic. Many of my colleagues posted similar images. Even though we were all wearing masks, no one could miss the smiles on our faces. This vaccine was the hope we’d been waiting for. In that moment of jubilation, I could not imagine the tragedy to come.

In the hospital in Tampa where I work as a hospitalist, the daily number of Covid-19 patients held steady in the 20s between January 2021 and July. While some of those patients were incredibly sick, and some died, the work felt doable after the crushing summer surge in 2020.

Then everything changed. Beginning in late July, the number of Covid-19 patients we are caring for has skyrocketed. The hospital went from fewer than 20 patients with active Covid-19 to more than 200 today. When the two floors of our Global Emerging Disease Institute quickly filled with Covid-19 patients, we scrambled to convert other areas of the hospital to treat them. The inpatient rehabilitation facility was closed and reopened as a Covid-19 unit. Every three to five days another unit was emptied to make room for the Covid-19 patients flooding the hospital’s emergency department.

As I write this, 13 of the hospital’s wards are now dedicated to caring for people with Covid-19.

It’s not just the number of patients that’s worse this time around. They are also sicker. I’ve gotten used to seeing a patient during morning rounds on minimal supplemental oxygen who ends up in the ICU before the day is over. I cared for one patient who, in 24 hours, went from being on a small amount of supplemental oxygen — 4 liters — to being on a ventilator. When even maximal ventilator support couldn’t provide him with the oxygen he needed, I called his wife and told her I didn’t think he would make it. She broke down on the phone and asked if we could arrange a call for their 9-year-old son to say goodbye to his dad.

I made eight similar phone calls that day.

While the hospital has plenty of ventilators to meet the growing number of people who need them, there aren’t always enough qualified physicians available to perform the delicate intubation procedure needed to connect a patient to the machine. It’s easy to go online and look at hospital or ICU capacity statistics and see that open beds are available. But those numbers don’t account for the health care workers needed to care for the patients in those beds. An ICU bed cannot save a life. It takes a team of doctors, nurses, respiratory therapists, pharmacists, environmental services workers, and others. And we are stretched too thin.


A lucky few seem ‘resistant’ to Covid-19. Scientists want to know why

All of us have been showing up for 18 months, caring for people with this disease, risking our health and risking exposing our families to it. We’re exhausted, physically and emotionally. We’re traumatized by the phone calls we must make telling families their loved one isn’t going to make it.

For me, the most devastating part of this surge is that it didn’t have to happen. The hope that I and other health care workers felt when Covid-19 vaccines arrived was real. Vaccines have since become easy to get — at the corner pharmacy, pop-up vaccination center, on the job, and elsewhere — which makes it unfathomable that nearly all of my current Covid-19 patients haven’t been vaccinated.

Vaccines save lives and reduce the risk of serious illness and hospitalization. In the face of this surge of Covid-19-related hospitalizations and deaths, I can’t understand why some people still don’t want to get vaccinated against a virus that is killing their family members, friends, and neighbors. Their decisions have pushed the health care system, and me and my colleagues who will care for them when they get Covid-19, to the breaking point.

Jennifer Caputo-Seidler is a hospitalist on the Covid-19 unit at Tampa General Hospital and an assistant professor of medicine at the University of South Florida.

B.C. acting to improve ambulance response times, support emergency workers

Wednesday, July 14, 2021 

The Province is strengthening B.C.’s ambulance system to ensure it is faster and more responsive to British Columbians, a better place to work for paramedics and dispatchers, and able to rapidly meet changing demands and needs through focused and direct leadership.

“When we call for help, we need to know help is on the way, and that it will arrive quickly,” said Adrian Dix, Minister of Health. “Immediate action on operations, as well as stronger leadership and increased investment at BC Emergency Health Services, will deliver a more effective ambulance service for patients and families who depend on it. Better support for paramedics and dispatchers will help them do the vital work we count on every day.”

To ensure direct leadership of ambulance services, Dix is reconstituting the BC Emergency Health Services board of directors to focus solely on ambulance services. It will be directly accountable to the minister of health with a clear mandate to ensure better service for patients and families who rely on the services — and better supports for workers who deliver the service.

Dix has appointed Jim Chu, former chief constable of the Vancouver Police Department, to chair the board.

“Jim Chu has extensive experience leading front-line emergency services in British Columbia. I am confident he will provide the focused governance leadership BC Emergency Services needs to be an effective and high performing ambulance service,” Dix said.  

Chu said: “I am enthusiastic to bring what I have learned from my time as chief constable of the Vancouver Police Department to this important role. I look forward to working together with the Ministry of Health, BC Emergency Health Services management, paramedics and dispatchers to ensure the ambulance service provides timely and exceptional help for British Columbians, and that it’s an outstanding employer for workers.”

Darren Entwistle, president and CEO, Telus, will serve as a special adviser to the board.

As well, Dix has directed that BC Emergency Health Services now be led by a chief ambulance officer responsible for the day-to-day management of the BC Ambulance Service.

Dix has appointed Leanne Heppell to serve as B.C.’s new chief ambulance officer on an interim basis. She is a trained clinical nurse specialist, currently serving as chief operating officer for acute care and chief of professional practice and nursing at Providence Health Care. Heppell has 20 years experience in senior leadership at Vancouver Coastal Health, Fraser Health and the BC Ambulance Service.  

The Province is also acting immediately to reinforce ambulance operations by providing funding for:

  • 85 new full-time paramedics;
  • 30 full-time dispatchers;
  • 22 new ambulances; and
  • converting 22 rural ambulance stations to 24/7 ALPHA stations to enhance ambulance coverage for these communities.
    • Six are scheduled to be running by October 2021.
    • Plans for up to an additional 16 stations will be ready by October 2021.

To get paramedics and ambulances back on the road to respond to patient calls more quickly, the Province is directing health authorities to add additional staff to receive patients and care for them when they arrive at emergency departments.

The Province is taking immediate action to support workers. This includes a direction that BC Emergency Health Services is to contract a team of mental health and wellness professionals to work directly with dispatch staff and paramedics to address chronic stress, fatigue and support wellness among staff (including access to trauma-informed therapy).

The new board chair, working with the BC Emergency Health Services Board and chief ambulance officer, will ensure the BC Ambulance Service has the vision and strategy to secure its renewal, and will present the approach to the minister of health for consideration of additional action for 2022-23 and beyond.

To ensure British Columbians who call for help get the quickest and best possible emergency health response, the Province will return to the pre-COVID-19 first-responder dispatching practices for 911. The Province is also directing the Emergency Medical Assistants Management Licensing Board to examine expanding firefighters’ scope of practice. The deadline for recommendations is Sept. 6, 2021.

These measures will benefit from continued collaboration between the BC Emergency Health Services and the Ambulance Paramedics of BC. They are working together to identify a range of measures to address employee wellness, operational performance, workload, response times, recruitment and retention, and public engagement. The Province recognizes the importance of this work and strongly supports this constructive and co-operative approach.

These measures build on the government’s record of investment in provincial ambulance services. Since 2017, the BC Emergency Health Services annual budget has increased from $424.25 million to $559.12 million a year, doubling the average annual spending increases compared to the previous year.

This has meant more paramedics, more dispatchers, and more ambulances on the road. Between 2017 and 2019, B.C. added 115 paramedic positions to support direct patient care, improve service and response times, and modernize dispatch operations. Since January 2021, 271 paramedics have been hired by BC Emergency Health Services.

Biographies of Jim Chu and Leanne Heppell
Jim Chu

Jim Chu is senior vice-president with the Aquilini Group. He joined Aquilini after he retired from the Vancouver Police Department in May 2015 where he served 36 years, including eight years as chief constable. He holds a bachelor of business administration from Simon Fraser University and a master of business administration from the University of British Columbia.

He was elected president of the Canadian Association of Chiefs of Police and served from 2012 to 2014. He has received an honorary doctorate from the Justice Institute of BC, an Outstanding Alumni award from Simon Fraser University, a Queen’s Diamond Jubilee medal and was invested into the Order of Merit of Police Services by the Governor General. He has previously served on the boards of the Streetohome Foundation, the Justice Institute of BC, the Richmond Public Library, and TransLink.  

Leanne Heppell

Leanne Heppell was appointed as chief operating officer, acute care and chief of professional practice and nursing at Providence Health Care in April 2015. Prior to this role, she was Providence’s vice-president, patient safety and innovation, and chief of professional practice and nursing, having been appointed in May 2013. Heppell brings to her role over 20 years of senior leadership experience, including with Vancouver Coastal Health, Fraser Health and the BC Ambulance Service.

Heppell is a registered nurse with a bachelor of science in nursing from the University of Victoria. She graduated from UBC as a clinical nurse specialist in the masters in nursing program, and completed a masters in leadership from Royal Roads University in 2003. She is also an academic supervisor of leadership studies at Royal Roads University. She completed a doctorate of business administration in 2016.