As Ontario prepares to launch its online COVID-19 vaccination portal for priority target groups, many Canadians still don’t have the broadband internet access or digital literacy skills they need to successfully navigate such a process. Once again, the pandemic has shown us that access and adoption of internet services is no longer a luxury: the ability to navigate online services has become a key determinant of health outcomes.

Lessons learned from American states that already have online vaccination portals in place should help inform our vaccination strategy and uncover potential vaccine distribution inequities before it’s too late. Early evidence from California’s Skedulo vaccine registration portal (which Ontario’s system will reportedly follow) show older adults, low-income individuals and people of colour (including Black and Latino) are being vaccinated at a disproportionately lower rate, with many underserved groups citing long wait times, technology troubleshooting and digital literacy challenges as their greatest hurdles to booking a vaccine appointment.

Here in Canada, the situation is unlikely to veer far from the U.S. experience. Based on what we know about the unequal distribution of home internet adoption and digital literacy skills in Canada, older adults, low-income individuals, remote residents and people with disabilities will find it difficult to book vaccination appointments online if proactive measures are not taken to correct Canada’s digital divides. While online vaccine registration is certainly needed in Canada, its effectiveness is limited if the people who need vaccination the most are the same people facing the most difficulty accessing and navigating these portals.

Allowing the highest priority target groups to effectively access vaccines requires proactive programming and policy approaches that recognize Canada’s digital divides.

Older adults

Lower internet connectivity rates and digital literacy skills among older Canadians present a significant hurdle to securing online vaccine appointments, particularly for those living alone. For the 28 per cent of those aged 65 and older in Canada who do not have home internet, online vaccination portals will simply be ineffective. Moreover, even among older adults with home internet access, lower internet speeds continue to present a problem: 48 per cent of those aged 60 and older in Toronto report home download speeds below the CRTC’s 50 megabits per second (Mbps) target, compared to only 38 per cent overall. Particularly for vaccine portals in high demand, those with better internet quality are most likely to secure the limited vaccination slots.

Equally important for navigating vaccine portal pages is having the right digital literacy skills. A Statistics Canada study shows older adults are less likely than younger Canadians to be exposed to the internet through close acquaintances or social networks, and a larger proportion do not rely on consistent access to the internet for work or personal use. Lack of familiarity with basic navigation skills is particularly a problem given online vaccine portals have been fraught with errors and delays. In Florida and Alberta, online vaccine registration sites crashed upon their launch due to a much higher-than-anticipated volume of people trying to book appointments. Older adults without sufficient digital literacy skills are less likely to be able to troubleshoot their way around technical difficulties.

Low-income communities

Low-income households in Canada also report lower internet access rates and quality: as of 2017, 31 per cent of households in the lowest income bracket did not have a computer and internet service at home, compared to only 1.5 per cent of households with the highest incomes. Moreover, almost half of households with an annual income of $30,000 or less did not have high-speed internet in 2018.

Ontario’s vaccine distribution plan does not explicitly designate low-income individuals as a priority group, although it does recognize those living in congregate settings, such as supportive housing and emergency homeless shelters. However, we know that low-income individuals face a disproportionately high chance of contracting COVID-19. The most recent numbers from Toronto Public Health show that people living in households with an income less than $30,000 make up 14 per cent of the city’s population, but nearly a quarter of its COVID-19 cases. By contrast, households with incomes above $150,000 represent 21 per cent of the population but only nine per cent of cases. Low-income communities also report more pre-existing health conditions that could aggravate risks associated with COVID-19.

Home internet access is more crucial than ever now that access to the internet in public spaces has been limited by the closure of libraries, recreational facilities and cafés. Without equitable access to online public health services, many low-income Canadians will not get the help they need.

Making it easier for digitally underserved communities to access and navigate online vaccine portals requires preemptive solutions that bring the right technology tools and skills directly to communities in need.

People with Disabilities

Individuals with intellectual or developmental disabilities are a priority group eligible for vaccination in Phase 2 of Ontario’s vaccine rollout plan, set to begin next month. With more than 6.2 million people in Canada over the age of 15 living with a disability, critical public health services such as vaccine portals must provide a completely accessible, barrier-free process.

In 2018, about one-fifth of people with disabilities did not use the internet, compared to only 10 per cent overall. When asked about equity concerns by the Toronto Star, an executive from Skedulo said the company was committed to working with the provincial government to address accessibility needs. With 2.1 million Canadians with a disability at risk of facing barriers in accessing information and communications technology, there should be no compromising on website accessibility, particularly for those who have been excluded from digital services in the past.

Moving forward: Policy recommendations for a more equitable vaccine distribution

Allowing the highest priority target groups to effectively access vaccines requires proactive programming and policy approaches that recognize Canada’s digital divides.

  1. Narrow age cut-offs for vaccine distribution phases: Online vaccine portals face high demand, especially upon launch, with the most tech-savvy users swiftly seizing available booking times. Phase 1 of Ontario’s vaccine distribution strategy designates those aged 80 and older as a priority target group, followed by those aged 75 and older in Phase 2, and decreasing in five-year increments over the course of the vaccine rollout. Alberta’s plan allowed those aged 75 and older to book a vaccine appointment upon the launch of their online portal, leading to a much greater than anticipated number of older Canadians competing for limited slots. The vaccination plan received criticism for failing to provide adequate age limits to ensure the oldest citizens get the vaccine first. Having a plan that limits age group access more narrowly will allow those most at risk to receive the vaccine first, with other priority groups following consecutively.
  2. Amplify community voices and consult equity-focused health experts: Making it easier for digitally underserved communities to access and navigate online vaccine portals requires preemptive solutions that bring the right technology tools and skills directly to communities in need. Ontario’s Operation Remote Immunity initiative is a step in the right direction: the provincial government delivered the first doses of the vaccine directly to all 31 fly-in, remote Indigenous communities. Identifying where access to the online portal is lacking, and what specific impediments prevent populations in need from booking appointments online, will inform where technology resources can be delivered and what administration changes would be helpful — such as reserving specific time slots for certain groups or for appointments scheduled by phone, family physicians or community groups.
  3. Send advance notice of new appointment availabilities: U.S. technology and health experts note that many people, particularly low-income and working individuals, do not have the time to continuously check appointment availabilities that appear unpredictably. The process could also overload websites unnecessarily as individuals continue to check back for updates. Instead, Washington, D.C., has experimented with notifying people of a specific, predetermined time when new availabilities will be released so that individuals in need can plan to log on well ahead of time.
  4. Simplify the online process by requiring less information to register: Managing high portal demand requires streamlining the online process to ensure individuals can complete registration as quickly as possible and make room for other incoming users. After Alberta’s website crashed, technology fixes now allow the vaccine portal to handle more than 5,000 bookings per hour — a rate that will be too slow for Ontario, which is home to almost three times Alberta’s population. To streamline the portal, the government should require users to only input personal information that is strictly necessary. New York City’s two-step verification process sends time-limited codes to an email address, and many seniors have complained that the process of re-entering information while flipping through different browser windows is too cumbersome. Verification could be most efficiently conducted during face-to-face appointments rather than through overly complicated processes using high-demand online portals.

Creating an online vaccine registration portal that effectively distributes limited vaccine supplies to those most in need must take into account at-risk priority groups that cannot easily access internet services. In the short term, policy-makers must proactively target digitally excluded groups by providing alternative registration methods or direct assistance to those without the digital skills or resources to connect online.

But we must also remember that these issues won’t go away after our current crisis is over, as more critical public health information and services have shifted to online-only or online-first. In the long term, closing Canada’s digital divides should be a top priority for policy-makers if they are serious about establishing a more equitable delivery of government services in an increasingly online world.