Buggy websites and complex online tools are being used to schedule COVID-19 vaccine appointments across the United States. The systems are hard to navigate for many people, but they’re particularly inaccessible for older adults. People over the ages of 65 and 75 are prioritized for early waves of vaccination and are most at risk from COVID-19 — but they’re also often uncomfortable and unfamiliar with technology.
“The most vulnerable people are left behind even more so than if we hadn’t used more of a technology-oriented solution,” says Ethan Basch, a medical oncologist at the University of North Carolina at Chapel Hill and physician-in-chief at the North Carolina Cancer Hospital.
Across the country, registration websites for vaccine appointments have been slammed with demand as soon as they launch, filling up within minutes. Many Florida county health departments turned to the event management platform Eventbrite to schedule appointments. New York City has multiple registration websites, some of which have dozens of fields to fill out and ask people to upload attachments. Navigating those platforms quickly enough to secure an appointment slot may be challenging for anyone not comfortable with computers or the internet and impossible for someone who doesn’t have access to those tools.
Only around half of people over the age of 75 use the internet at all, says Susan Nash, a visiting scholar at the Stanford Center on Longevity studying digital literacy options for older adults. “The great irony of this problem is that the people we need to reach with the vaccine and get information to are the ones who are least likely to be online,” she says.
Through the pandemic, gaps in internet access and digital literacy have made other aspects of health care delivery challenging for people who struggle to use technology. Many doctors moved to telehealth, but people without internet access — who tend to be older, non-white, and low income — are less likely to schedule telehealth appointments and are at risk for cracks in their care. They were left out of other services as well: someone without internet access wouldn’t have been able to order groceries through an online service, for example, Nash says.
“There have been these equity issues all the way through with older people. As we’ve experienced the pandemic, some of the easiest fixes have been to go online — and that leaves this whole population behind,” she says.
During the vaccine rollout, the need for speed and scale pushed officials toward digital scheduling tools. But local health departments around the US have been underfunded for the last decade, and they haven’t been given the funding over the past few months to create vaccine distribution systems. When the shots first became available, many scrambled to set up platforms to allocate the doses to people who were eligible.
Many small departments, particularly in rural areas, are overwhelmed, says Charles Wallace, an associate professor of computer science at Michigan Technological University who runs digital literacy programs. “Some poor person has had to take some time out of what’s got to be an incredibly busy schedule to put this information on the web, and designing a good interface takes time,” he says.
Quickly developed, jury-rigged digital registration platforms are likely to have elements that are challenging or stressful to people less familiar with technology, Wallace says. One local Michigan health department, for example, sent people to a second webpage through a pop-up warning users that they were leaving the health department’s website. “These pop-ups and warnings are exactly the kind of thing that throws people off when we’re dealing with newcomers,” he says.
Many registration sites in Florida and New York City forced people to move as quickly as possible to input their information or they’d lose a selected appointment slot.
“We can easily lose sight of how thin people’s competencies are,” Wallace says. “There’s a false sense of accomplishment. We put everything on the website and can say, great, we’re done. For a lot of people, the assumptions that people are up for adding attachments and things like that are wildly off.”
Asking people to use these complex systems to schedule something as important as a COVID-19 vaccination appointment compounds the anxiety, Nash says. “There’s more to be worried about, and there’s more reason for someone to talk to a human to find out, ‘Do I really have an appointment? Tell me about the side effects,’” she says.
Basch and his colleagues recognized that problem for their patients at the North Carolina Cancer Hospital — a public facility that serves a rural population and groups with low levels of education and health literacy. The state just opened up vaccination to people over 75, and their patients in that age bracket who have cancer are especially in need of vaccination.
The hospital planned to contact patients through their electronic health records and patient portals, but many patients don’t use that system to communicate with their physicians. “We realized that we would leave people behind,” he says. They’ve started compiling a list of every patient over 75 that doesn’t use the portal, and they plan to call them by phone to schedule vaccination appointments.
Outsourcing to doctors to contact patients directly is one way to sidestep the problem of the digital divide, Nash says. But that puts the burden on already overtaxed health care providers. “It’s another thing to place on them, but it does work,” she says.
Older adults are also turning to children or grandchildren to navigate webpages or schedule appointments on their behalf. That’s another temporary solution, Nash says — but it only solves the problem for people who have relatives who can access the internet.
In the chaos and inconsistency of the initial vaccine rollout, there isn’t a defined group taking responsibility for connecting people with vaccine resources. Guidelines are changing quickly, and there isn’t clear communication to support people who need help. Instead, many of the people who would benefit most from the vaccine are being left to figure out how to get one on their own.
“Is it on the patient to make themselves aware, and get themselves connected? Or is it the health system, or the state?” Basch says. “There’s a lack of clarity about whose responsibility it is.”