Testing behaviour may bias observational studies of vaccine effectiveness (preprint)

Background Recent observational studies have suggested that vaccines for the omicron variant of SARS-Cov2 may have little or no effect in preventing infection. However, the observed effects may be confounded by patient factors and preventive behaviours or vaccine-related differences in testing behaviour. To assess the potential degree of confounding, we aimed to estimate differences in testing behaviour between unvaccinated and vaccinated populations. Methods We recruited 1,526 Australian adults for an online randomised study about COVID testing between October and November 2021, and collected self-reported vaccination status and three measures of COVID-19 testing behaviour. We examined the association between testing intentions and vaccination status in the cross-sectional baseline data of this trial. Results Of the 1,526 participants (mean age 31 years): 22% had a COVID-19 test in the past month and 61% ever; 17% were unvaccinated, 11% were partially vaccinated (1 dose), 71% were fully vaccinated (2+ doses). Fully vaccinated participants were twice as likely to report positive COVID testing intentions than those who were unvaccinated (p

COVID-19 testing and vaccine willingness: Cross-sectional survey in a culturally diverse community in Sydney, Australia (preprint)

Objective The current study examined patterns in COVID-19 testing and vaccination intentions across multiple language groups in Greater Western Sydney, Australia. Methods Participants completed a cross-sectional survey available from March 21 to July 9, 2021 in Sydney, Australia. Surveys were available in English or translated (11 languages). Participants could complete surveys independently or with support from bilingual staff. Logistic regression models using post-stratification weighted frequencies identified factors associated with testing and vaccination intentions. Results Most of the 708 participants (88%, n=622) were not born in Australia; 31% reported that they did not speak English well or at all (n=220); 70% had no tertiary qualifications (n=497); and 41% had inadequate health literacy (n=290). Most participants reported high testing intention (77.2%, n=546), with differences observed across language groups (p<0.001). The most frequently reported barrier to testing was concerns about infection at the clinic (26.1%). Half (53.0%) reported willingness to get a COVID-19 vaccine if recommended to them (n=375); 18% were unwilling (n=127), and the remainder unsure (29%, n=205). These proportions varied significantly by language group (p<0.001). Participants were more likely to be unwilling/hesitant if they were female (p=0.02) or did not use Australian commercial information sources (p=0.01). Concerns about side effects (30.4%, n=102) and safety (23.9%, n=80), were key reported barriers to vaccination. Conclusion Different language groups have unique and specific needs to support uptake of COVID-19 testing and vaccination. Health services must work collaboratively with culturally and linguistically diverse communities to provide tailored support to encourage COVID-19 testing and vaccination. Lay summary 708 adults living in Sydney, Australia, who did not speak English as their main language at home took part in a survey about COVID-19 vaccination and testing. Participants could complete the survey online (English/translated) or with support from bilingual staff. The survey was available in 11 languages. Three quarters of participants (77%) reported they would get tested for COVID-19 if they had symptoms ‘no matter what.’ The most common barrier was concern about getting infected at the testing clinic. 53% of participants reported that they would get a COVID-19 vaccine if it was recommended to them. 18% reported that they wouldn’t get the vaccine, and 29% were unsure. The main barriers were concerns about vaccine side effects and safety. Intentions to get tested for COVID-19 or to get vaccinated varied significantly across language groups. Participants who were female, or who did not use Australian commercial information sources were more likely to be unwilling or unsure about getting a COVID-19 vaccine. Different language groups have unique and specific needs to support uptake of COVID-19 testing and vaccination. Health services must work collaboratively with culturally and linguistically diverse communities to provide tailored support to encourage COVID-19 testing and vaccination.

Main COVID-19 information sources in a culturally and linguistically diverse community in Sydney, Australia: A cross-sectional survey (preprint)

BackgroundLittle is known about COVID-19 information-seeking experiences for culturally and linguistically diverse groups in Australia. MethodsParticipants were recruited using a cross-sectional survey from March 21 to July 9, 2021, translated into 11 languages, and with supporting bilingual staff. Linear regression models identified factors associated with difficulty finding easy-to-understand COVID-19 information. ResultsAcross 708 participants (88% born overseas, 31% poor English proficiency), difficulty finding easy-to-understand COVID-19 information was rated 4.13 for English materials (95%CI: 3.85 to 4.41) and 4.36 for translated materials (95%CI: 4.07 to 4.66) (1 easy to 10 hard). Participants who were older (p<0.001), had inadequate health literacy (Mean Difference (MD)=-1.43, 95%CI -2.03 to - 0.82, p<0.001), or poor English proficiency (MD=-1.9, 95%CI-2.51 to -1.29, p<0.001) found it harder to find easy-to-understand English-language COVID-19 information. Those who had greater difficulty finding easy-to-understand translated COVID-19 information were younger (p=0.004), had poor English proficiency (MD=-1.61, 95%CI -2.29 to -0.9, p<0.001), university education (MD=0.77, 95%CI 0.00 to 1.53, p=0.05), and had spent longer living in Australia (p=0.001). They were more likely to rely on friends and family for COVID-19 information (p=0.02). There was significant variation in information-seeking experiences across language groups (ps<0.001). ConclusionsEasy-to-understand and accessible COVID-19 information is needed to meet the needs of people in culturally and linguistically diverse communities. This approach should involve working alongside these communities to tailor messages and leverage existing communication channels.

Collateral positives of COVID-19 for culturally and linguistically diverse communities in Western Sydney, Australia (preprint)

Issues addressed: To investigate whether culturally and linguistically diverse communities in Western Sydney have experienced any positive effects during the COVID19 pandemic, and if so, what these were. Methods: A cross sectional survey with ten language groups was conducted from 21st March to 9th July 2021 in Sydney, Australia. Participants were recruited through bilingual multicultural health staff and health care interpreter service staff and answered a question, In your life, have you experienced any positive effects from the COVID-19 pandemic? Differences were explored by demographic variables. Free text responses were thematically coded using the Content Analysis method. Results: 707 people completed the survey, aged 18 to >70, 49% males and 51% females. Only 161 (23%) of those surveyed reported any positive impacts. There were significant differences in the proportion of those who reported positives based on age (p=0.004), gender (p=0.013), language (p=0.003), health literacy (p=0.014), English language proficiency (p=0.003), education (p=<0.001) and whether participants had children less than 18 years at home (p=0.001). Reporting of positive impacts ranged from 12% for people aged seventy years or older to 30% for the 30-49 year age group. Reporting of positive impacts for different language groups ranged from 9% to 42%. 18% of men reported positive impacts compared to 27% of women, and 18% of people with inadequate health literacy reported positive impacts compared to 26% with adequate health literacy. Content Analysis of open ended responses showed that, of those that did report positives, the top themes were Family time (44%), Improved self care (31%) and, Greater connection with others (17%). Conclusions: From 21st March to July 9th, 2021, few surveyed participants reported finding any positives because of the COVID19 pandemic. This finding is in stark contrast to related research in Australia in a population dominated by adults with English as their first language, carried out in June 2020, in which many more people experienced positives. So what: The needs of people from culturally and linguistically diverse backgrounds must inform future responses to community crises to facilitate an equitable effect of any collateral positives that may arise.

Psychological, social and financial impact of COVID-19 on culturally and linguistically diverse communities: a cross-sectional Australian study (preprint)

Objective: This study aimed to explore the psychological, social, and financial impacts of COVID-19 on culturally and linguistically diverse communities in Australia. Design: Cross-sectional survey informed by the Framework for Culturally Competent Health Research conducted between March and July, 2021. Setting: Participants were recruited from Greater Western Sydney, New South Wales, Australia. Participants: 708 community members who speak a language other than English at home participated (mean age: 45.4years [range 18 to 91]; 88% [n=622] born outside of Australia). Outcome measures: Fifteen items regarding impacts of COVID-19, adapted from validated scales, previous surveys or co-designed in partnership with Multicultural Health and interpreter service staff. Logistic regression models (using post-stratification weighted frequencies) identified factors associated with psychological, social, and financial impacts. Surveys were available in English or translated (11 languages). Results: Even prior to the COVID-19 outbreak in Sydney, 25% of the sample reported feeling nervous or stressed most/all of the time and 22% felt lonely or alone most/all of the time. One quarter of participants reported negative impacts on their spousal relationships as a result of COVID-19 and most parents reported that their children were less active (64%), had more screen time (63%), and were finding school harder (45%). Mean financial burden was 2.9/5 (95%CI=2.8 to 2.9). Regression analyses consistently showed distinct impact patterns for different language groups and more negative outcomes for those with comorbidities. Conclusion: Culturally and linguistically diverse communities experience significant psychological, social and financial impacts of COVID-19, with distinct impact patterns across language groups. A whole-of-government approach with policy and sustainable infrastructure is needed to co-design innovative, tailored and culturally-safe COVID-19 support packages.

Behavioural barriers to COVID-19 testing in Australia: Two national surveys to identify barriers and estimate prevalence by health literacy level (preprint)

BackgroundCOVID-19 testing and contact tracing has been crucial in Australias prevention strategy. However, testing for COVID-19 is far from optimal, and behavioural barriers are unknown. Study 1 aimed to identify the range of barriers to testing. Study 2 aimed to estimate prevalence in a nationally relevant sample to target interventions. MethodsStudy 1: National longitudinal COVID-19 survey from April-November 2020. Testing barriers were included in the June survey (n=1369). Open responses were coded using the COM-B framework (capability-opportunity-motivation). Study 2: Barriers from Study 1 were presented to a new nationally representative sample in November to estimate prevalence (n=2869). Barrier prevalence was analysed by health literacy level using Chi square tests. ResultsStudy 1: 49% strongly agreed to get tested for symptoms, and 69% would self-isolate. Concern about pain was the top barrier from a provided list (11%), but 32 additional barriers were identified from open responses and coded to the COM-B framework. Study 2: The most prevalent barriers were motivation issues (e.g. dont believe symptoms are COVID-19: 28%, few local cases: 18%). Capability issues were also common (e.g. not sure symptoms are bad enough: 19%, not sure whether symptoms need testing: 15%). Many barriers were more prevalent amongst people with low compared to high health literacy, including motivation (preference to self isolate: 21% vs 12%, pain: 15% vs 9%) and capability (not sure symptom needs testing: 12% vs 8%, not sure how to test:11% vs 4%). ConclusionEven in a health system with free and widespread access to COVID-19 testing, motivation and capability barriers were prevalent issues, particularly for people with lower health literacy. This study highlights the important of diagnosing behaviour barriers to target public health interventions for COVID-19 and future pandemics.

Comparison of reported main COVID-19 information sources in national and culturally and linguistically diverse communities in Australia (preprint)

BackgroundTo manage the COVID-19 pandemic effectively, governments need clear and effective communication. This is a challenge for culturally diverse communities as groups may have different informational needs and information-seeking behaviours. In this paper we present the frequency of information sources for COVID-19 in a culturally diverse area of Sydney, Australia. MethodsThis study reports findings from two surveys. The first recruited participants across 10 languages between March 21 and July 9, 2021. The second provides a point of reference, and was an Australian, nationally-representative sample of English-speaking participants between November 4 - 18, 2020. ResultsFor the survey in culturally and linguistically diverse communities, of 708 participants, mean age was 45.4 years (SE 0.78), and 51% of respondents were female. Across all language groups, 54.7% of participants used Australian official or public broadcasters to find out about COVID-19 (n=421). Australian commercial information sources (54.1%, n=417), social media (51.6%, n=397), and family and friends in Australia (32.7%, n=252) were common sources. Patterns varied substantially across language groups. In the nationally representative survey (n=2313), 67% of participants (n=1540) used Australian official or public broadcasters, with lower proportions for social media (31.9%, n=738) and friends, family or other personal sources (23.1%; n=533). ConclusionAlmost 50% of participants from culturally and linguistically diverse communities did not report using Australian official or public broadcaster as main sources of information. Instead Australian commercial information sources, friends and family, overseas sources and social media were common. Though a crude comparison of the two datasets, this data can guide policy decisions for communication to different community groups. Further analysis is needed to interpret this data. Better understanding of how diverse communities seek and receive COVID-19 health information is imperative as we manage the current COVID-19 outbreak in the Sydney region.

Perceived public health threat a key factor for willingness to get the COVID-19 vaccine in Australia (preprint)

Background: Vaccination rollout against COVID-19 has begun across multiple countries worldwide. Although the vaccine is free, rollout might still be compromised by hesitancy or concerns about COVID-19 vaccines. Methods: We conducted two online surveys of Australian adults in April (during national lockdown; convenience cross-sectional sample) and November (virtually no cases of COVID-19; nationally representative sample) 2020, prior to vaccine rollout. We asked about intentions to have a potential COVID-19 vaccine (If a COVID-19 vaccine becomes available, I will get it) and free-text responses (November only). Results: After adjustment for differences in sample demographics, the estimated proportion agreeing to a COVID-19 vaccine if it became available in April (n=1146) was 76.2%. In November (n=2034) this was estimated at 71.4% of the sample; additional analyses identified that the variation was driven by differences in perceived public health threat between April and November. Across both surveys, female gender, being younger, having inadequate health literacy and lower education were associated with reluctance to be vaccinated against COVID-19. Lower perceived susceptibility to COVID-19, belief that data on the efficacy of vaccines is largely made up, having lower confidence in government, and lower perception of COVID-19 as a public health threat, were also associated with reluctance to be vaccinated against COVID-19. The top three reasons for agreeing to vaccinate (November only) were to protect myself and others, moral responsibility, and having no reason not to get it. For those who were indifferent or disagreeing to vaccinate, safety concerns were the top reason, followed by indecision and lack of trust in the vaccine respectively. Conclusions: These findings highlight some factors related to willingness to accept a COVID-19 vaccine prior to one being available in Australia. Now that the vaccine is being offered, this study identifies key issues that can inform public health messaging to address vaccine hesitancy.

COVID-19 prevention behaviour over time in Australia: Patterns and long-term predictors from April to July 2020 (preprint)

BackgroundIn Australia in March 2020 a national public health directive required that non-essential workers stay at home, except for essential activities. These restrictions began easing in May 2020 as community transmission slowed. PurposeThis study investigated changes in COVID-19 prevention behaviours from April-July 2020, and psychosocial predictors of these behaviours. Methods1,843 participants in Australia completed a national COVID-19 survey in April, with monthly follow-up over four months. Principal components analysis (PCA) combined self-reported adherence across seven prevention behaviours. Multivariable regression models explored baseline (April) correlates of behaviour in June (a period of low community transmission) and July (a period of increasing community transmission). ResultsOn average, participants agreed with statements of adherence for all behaviours (means all above 4 out of 7). PCA identified two behaviour types: distancing (e.g. staying 1.5m away) and hygiene (e.g. washing hands), explaining 28.3% and 24.2% of variance, respectively. Distancing declined each month (ps<.001), whereas hygiene remained relatively stable. For distancing, stronger perceptions of societal risk, self-efficacy to maintain distancing, and greater perceived social obligation at baseline were associated with adherence in June and July (ps<0.05). For hygiene, the only significant correlate of adherence in June and July was belief that ones actions could prevent infection of family members (p<.001). ConclusionsHigh adherence to COVID-19 prevention behaviours were reported; however, distancing behaviours tended to decrease over time. Belief in social responsibility may be an important aspect to consider in encouraging distancing behaviours. Different policy approaches may be needed for different behavioural categories.

What positives can be taken from the COVID-19 pandemic in Australia? (preprint)

ObjectiveTo investigate whether Australians have experienced any positive effects during the COVID-19 pandemic, despite the disruption to society and daily life. MethodsNational online longitudinal survey. As part of a June 2020 survey, participants (n=1370) were asked In your life, have you experienced any positive effects from the COVID-19 pandemic (yes/no), with a free-text explanation if yes, and also completed the WHO-Five well-being index. Differences were explored by demographic variables. Free-text responses were thematically coded. Results960 participants (70%) reported experiencing at least one positive effect during the COVID-19 pandemic. Living with others (p=.045) and employment situation (p

Impact of COVID-19 Restrictions on People with Hypertension (preprint)

Objectives: It is unclear how people with hypertension are responding to the COVID-19 pandemic given their increased risk, and whether targeted public health strategies are needed. Design: This retrospective case-control study compared people with hypertension to matched healthy controls during COVID-19 lockdown, to determine whether they have higher risk perceptions, anxiety and prevention intentions. Methods: Baseline data from a national survey were collected in April 2020 during COVID-19 lockdown. Of 4362 baseline participants, 466 people reported hypertension with no other chronic conditions, and were randomly matched to healthy controls with similar age, gender, education and health literacy. A subset (n=1369) was followed-up at 2 months after restrictions eased, including 147 participants with hypertension only. Risk perceptions, prevention intentions and anxiety were measured. Results: At baseline, perceived seriousness was high for both hypertension and control groups. The hypertension group had higher anxiety than controls; and were more willing to have the influenza vaccine. At follow-up, these differences were no longer present in the longitudinal sub-sample. Perceived seriousness and anxiety had decreased, but vaccine intentions for both influenza and COVID-19 remained high (>80%). Conclusions: Anxiety was above normal levels during the COVID-19 lockdown. This was higher in the hypertension group, who also had higher vaccination intentions. Locations with prolonged restrictions may require targeted mental health screening for vulnerable groups. Despite a decrease in perceived risk and anxiety after 2 months of lockdown restrictions, vaccination intentions for both influenza and COVID-19 remained high, which is encouraging for future prevention of COVID-19.

Behavioural barriers to COVID-19 testing in Australia (preprint)

Background: The current suppression strategy for COVID-19 in Australia is dependent on people getting tested and self-isolating while they have COVID-19 symptoms. However, there is very little research on the behaviours and behavioural barriers involved in getting tested, both in Australia and worldwide, despite there being some evidence that these barriers do exist. Methods: The Sydney Health Literacy Lab (SHeLL) has been conducting a national longitudinal survey in Australia since April 2020. A list of testing barriers was included in Wave 3 in June 2020 (n=1369), along with intentions to test and self-isolate if symptomatic. Open responses were also collected. The test barriers identified were categorised using the COM-B framework. Results: Only 49% of people strongly agreed they would get tested if they had COVID-19 symptoms, but most people agreed to some extent that they would get tested (96%). The most common barriers selected from the list provided were that testing is painful (11%), not knowing how to get tested (7%), and worry about getting infected at the testing centre (5%). Many participants (10%) indicated other reasons, and open responses included many additional barriers to testing than those provided in the initial list. These covered all components of the COM-B model. Conclusion: We identified a wide range of barriers using both quantitative and qualitative methods, which need to be addressed in order to increase COVID-19 testing behaviour.

Lessons from the COVID-19 pandemic: People's experiences and satisfaction with telehealth during the COVID-19 pandemic in Australia (preprint)

Objectives: To determine how participants perceived telehealth consults in comparison to traditional in-person visits, and to investigate whether people believe that telehealth services would be useful beyond the pandemic. Design: A national cross-sectional community survey. Participants: Australian adults aged 18 years and over (n=1369). Main outcome measures: Telehealth experiences. Results: Of the 596 telehealth users, the majority of respondents (62%) rated their telehealth experience as "just as good" or "better" than a traditional in-person medical appointment. On average, respondents perceived that telehealth would be moderately to very useful for medical appointments after the COVID-19 pandemic is over (M=3.67 out of 5, SD=1.1). Being male (p=0.007), having a history of both depression and anxiety (p=0.037), or lower patient activation (individuals' willingness to take on the role of managing their health/healthcare) (p=0.037) were associated with a poorer telehealth experience. Six overarching themes were identified from free-text responses of why telehealth experience was poorer than a traditional in-person medical appointment: communication is not as effective; limitations with technology; issues with obtaining prescriptions and pathology; reduced confidence in doctor; additional burden for complex care; and inability to be physically examined. Conclusions: Telehealth appointments were reported to be comparable to traditional in-person medical appointments by most of our sample. Telehealth should continue to be offered as a mode of healthcare delivery while the pandemic continues and may be worthwhile beyond the pandemic.

COVID-19: Beliefs in misinformation in the Australian community (preprint)

Objectives: To investigate prevalence of beliefs in COVID-19 misinformation and examine whether demographic, psychosocial and cognitive factors are associated with these beliefs, and how they change over time. Study design: Prospective national longitudinal community online survey. Setting: Australian general public. Participants: Adults aged over 18 years (n=4362 baseline/Wave 1; n=1882 Wave 2; n=1369 Wave 3). Main outcome measure: COVID-19 misinformation beliefs. Results: Stronger agreement with misinformation beliefs was significantly associated with younger age, male gender, lower education, and primarily speaking a language other than English at home (all p<0.01). After controlling for these variables, misinformation beliefs were significantly associated (p<0.001) with lower digital health literacy, lower perceived threat of COVID-19, lower confidence in government, and lower trust in scientific institutions. The belief that the threat of COVID-19 is greatly exaggerated increased between Wave 1-2 (p=0.002), while belief that herd immunity benefits were being covered up decreased (p<0.001). Greatest support from a list of Australian Government identified myths was for those regarding hot temperatures killing the virus (22%) and Ibuprofen exacerbates COVID-19 (13%). Lower institutional trust and greater rejection of official government accounts were associated with greater support for COVID-19 myths after controlling for sociodemographic variables. Conclusion: These findings highlight important gaps in communication effectiveness. Stronger endorsement of misinformation was associated with male gender, younger age, lower education and language other than English spoken at home. Misinformation can undermine public health efforts. Public health authorities must urgently target groups identified in this study when countering misinformation and seek ways to enhance public trust of experts, governments, and institutions.

Disparities in COVID-19 related knowledge, attitudes, beliefs and behaviours by health literacy (preprint)

ObjectivesTo explore the variation in understanding, attitudes and uptake of COVID-19 health advice during the 2020 pandemic lockdown by health literacy. Study designNational cross sectional community survey. SettingAustralian general public. ParticipantsAdults aged over 18 years (n = 4362). Main outcome measuresKnowledge, attitudes and behaviours related to COVID-19; health literacy and socio-demographic factors. ResultsPeople with inadequate health literacy had poorer understanding of COVID-19 symptoms (49% vs 68%; p<0.001), were less able to identify behaviours to prevent infection (59% vs 72%; p<0.001), and experienced more difficulty finding information and understanding government messaging about COVID-19 than people with adequate health literacy. They were less likely to rate social distancing as important (6.1 vs 6.5, p<0.001) and reported more difficulty remembering/accessing medication since lockdown (3.6 vs 2.7, p<0.001). Importantly there was higher endorsement of misinformation beliefs related to COVID-19 and vaccination in people with lower health literacy. Similar results were observed among people who primarily speak a language other than English at home. ConclusionOur findings show important disparities by health literacy and language in COVID-19 related knowledge, attitudes and behaviours that have the potential to undermine efforts to reduce viral transmission and may lead to social inequalities in health outcomes in Australia. Those with the greatest burden of chronic disease are most disadvantaged, and most likely to experience severe disease and die from COVID-19. Addressing the health literacy needs of the community in public health messaging about COVID-19 must now be a priority in Australia.

Protocol for a systematic review of qualitative and quantitative effects of cardiovascular disease risk communication using heart age concepts (preprint)

Introduction: The concept of heart age is increasingly used for health promotion and alongside clinical guidelines for cardiovascular disease (CVD) prevention. These tools have been used by millions of consumers around the world, and many health organisations promote them as a way of encouraging lifestyle change. However, heart age tools vary widely in terms of their underlying risk models and display formats, the effectiveness of these tools compared to other CVD risk communication formats remains unclear, and doctors have raised concerns over their use to expand testing of healthy low risk adults. Methods and analysis: We aim to systematically review both qualitative and quantitative evidence of the effects of heart age when presented to patients or consumers for the purpose of CVD risk communication. Four electronic databases will be search until April 2020 and reference lists from similar review articles will be searched. Studies will be considered eligible if they meet the following criteria: (1) published from the inception of the database to April 2020, in peer-reviewed journals, (2) used an adult population (over 18 years of age) or, if not explicit regarding age, are clear that participants were not children, (3) present the concept of heart age to patients or consumers for the purpose of CVD risk communication, (4) report qualitative themes or quantitative outcomes relating to psychological and/or behavioural responses to heart age. Two reviewers will perform study selection, data extraction and quality assessment. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis guidance. Ethics and dissemination: Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations.