Addressing Behavioral Barriers to COVID-19 Testing With Health Literacy-Sensitive eHealth Interventions: Results From 2 National Surveys and 2 Randomized Experiments.

BACKGROUND: Polymerase chain reaction (PCR) testing for COVID-19 was crucial in Australia's prevention strategy in the first 2 years of the pandemic, including required testing for symptoms, contact with cases, travel, and certain professions. However, several months into the pandemic, half of Australians were still not getting tested for respiratory symptoms, and little was known about the drivers of and barriers to COVID-19 PCR testing as a novel behavior at that time. OBJECTIVE: We aimed to identify and address COVID-19 testing barriers, and test the effectiveness of multiple eHealth interventions on knowledge for people with varying health literacy levels. METHODS: The intervention was developed in 4 phases. Phase 1 was a national survey conducted in June 2020 (n=1369), in which testing barriers were coded using the capability-opportunity-motivation-behavior framework. Phase 2 was a national survey conducted in November 2020 (n=2034) to estimate the prevalence of testing barriers and health literacy disparities. Phase 3 was a randomized experiment testing health literacy-sensitive written information for a wide range of barriers between February and March 2021 (n=1314), in which participants chose their top 3 barriers to testing to view a tailored intervention. Phase 4 was a randomized experiment testing 2 audio-visual interventions addressing common testing barriers for people with lower health literacy in November 2021, targeting young adults as a key group endorsing misinformation (n=1527). RESULTS: In phase 1, barriers were identified in all 3 categories: capability (eg, understanding which symptoms to test for), opportunity (eg, not being able to access a PCR test), and motivation (eg, not believing the symptoms are those of COVID-19). Phase 2 identified knowledge gaps for people with lower versus higher health literacy. Phase 3 found no differences between the intervention (health literacy-sensitive text for top 3 barriers) and control groups. Phase 4 showed that a fact-based animation or a TikTok-style video presenting the same facts in a humorous style increased knowledge about COVID-19 testing compared with government information. However, no differences were found for COVID-19 testing intentions. CONCLUSIONS: This study identified a wide range of barriers to a novel testing behavior, PCR testing for COVID-19. These barriers were prevalent even in a health system where COVID-19 testing was free and widely available. We showed that key capability barriers, such as knowledge gaps, can be improved with simple videos targeting people with lower health literacy. Additional behavior change strategies are required to address motivational issues to support testing uptake. Future research will explore health literacy strategies in the current context of self-administered rapid antigen tests. The findings may inform planning for future COVID-19 variant outbreaks and new public health emergencies where novel testing behaviors are required. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000876897, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382318 ; Australian New Zealand Clinical Trials Registry ACTRN12620001355965, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380916&isReview=true.

COVID-19 Vaccine Misperceptions in a Community Sample of Adults Aged 18-49 Years in Australia.

Central to a successful population vaccination program is high uptake of vaccines. However, COVID-19 vaccine uptake may be impeded by beliefs based on misinformation. We sought to understand the prevalence and nature of misbeliefs about COVID-19 vaccines, and identify associated factors, shortly after commencement of Australia's national vaccine rollout. A cross-sectional survey was administered to unvaccinated young adults (n = 2050) in Australia aged 18-49 years (mean age 33 years), 13 July-21 August 2021. This sample was previously under-represented in COVID-19 research but shown to have less willingness to vaccinate. Two thirds of participants agreed with at least one misbelief item. Misperceptions about COVID-19 vaccines were found to be significantly associated with lower health literacy, less knowledge about vaccines, lower perceived personal risk of COVID-19, greater endorsement of conspiracy beliefs, and lower confidence and trust in government and scientific institutions. Misbeliefs were more common in participants with less educational attainment, in younger age groups, and in males, as per previous research. Understanding determinants and barriers to vaccination uptake, such as knowledge and beliefs based on misinformation, can help to shape effective public health communication and inform debunking efforts at this critical time and in the future.

Interventions to improve media coverage of medical research: a codesigned feasibility and acceptability study with Australian journalists.

OBJECTIVES: Although the media can influence public perceptions and utilisation of healthcare, journalists generally receive no routine training in interpreting and reporting on medical research. Given growing evidence about the problems of medical overuse, the need for quality media reporting has become a greater priority. This study aimed to codesign and assess the feasibility of a multicomponent training intervention for journalists in Australia. DESIGN: A small pragmatic feasibility study using a pre- and postdesign. SETTING: 90 min online workshop. PARTICIPANTS: Eight journalists currently working in Australia, recruited through the study's journalist advisor and existing contacts of the researchers. INTERVENTION: The training intervention covered a range of topics, including study designs, conflicts of interest, misleading medical statistics, population screening and overdiagnosis. The intervention also provided tools to help journalists with reporting, including a Tip Sheet and list of expert contacts in health and medicine. Preworkshop and postworkshop questionnaires were administered via Qualtrics. MEASURES: Acceptability and feasibility of the intervention, and journalists' knowledge of overdiagnosis and common issues with health stories. Quantitative results were analysed descriptively using SPSS. Qualitative data were thematically analysed. RESULTS: All participants completed preworkshop and postworkshop questionnaires, and 6 completed the 6-week follow-up (75% retention). Feasibility findings suggest the intervention is acceptable and relevant to journalists, with participants indicating the workshop increased confidence with reporting on medical research. We observed increases in knowledge preworkshop to postworkshop for all knowledge measures on overdiagnosis and common issues with media coverage of medicine. Analysis of free-text responses identified several areas for improvement, such as including more examples to aid understanding of the counterintuitive topic of overdiagnosis and more time for discussion. CONCLUSIONS: Piloting suggested the multicomponent training intervention is acceptable to journalists and provided important feedback and insights to inform a future trial of the intervention's impact on media coverage of medicine.

COVID-19 challenges faced by general practitioners in Australia: a survey study conducted in March 2021.

Limited studies at the beginning of the COVID-19 pandemic found GPs have been negatively affected by increased workload, reduced income and major concerns about staff and patient safety. This study aimed to investigate the challenges of COVID-19 in general practice 1 year since it was declared a pandemic. A national cross-sectional online survey was conducted in March 2021 of a convenience sample of 295 Australian GPs attending an online educational webcast. Twenty-five multipart and free-text questions collected information regarding GPs' main COVID-19-related issues and concerns, including COVID-19 vaccines, useful sources of information, information needs and their perceived role as GPs in COVID-19 management. Descriptive statistics were calculated for all quantitative variables. Content analysis was used to analyse text data from open-ended questions. Of the 596 eligible attendees of the online educational webcast, 295 completed the survey (49.5% response rate). One year since COVID-19 was declared a pandemic, GPs still have concerns regarding patients ignoring prescreening and presenting with flu-like symptoms, the safety of their colleagues and family and catching COVID-19 themselves, as well as concerns about the effect of the pandemic on their patients and patients delaying essential care for non-COVID-19 conditions. More education and resources about vaccines was identified as the top information need, which will assist with what GPs' perceived to be their key roles in managing the COVID-19 pandemic, namely educating the public, correcting misunderstandings and providing the COVID-19 vaccine. These findings highlight gaps in communication and information, particularly regarding COVID-19 vaccines. GPs need high-quality information and resources to support them in undertaking complex risk communication with their patients.

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

BACKGROUND: Vaccination rollout against COVID-19 is underway 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 (very few 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 76.3%. In November (n = 1941) this was estimated at 71.5% 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.

Contextualising COVID-19 prevention behaviour over time in Australia: Patterns and long-term predictors from April to July 2020 in an online social media sample.

BACKGROUND: In 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. OBJECTIVES: This study investigated changes in COVID prevention behaviours from April-July 2020, and psychosocial predictors of these behaviours. METHODS: An Australia-wide (national) survey was conducted in April, with monthly follow-up over four months. Participants who were adults (18+ years), currently residing in Australia and who could read and understand English were eligible. Recruitment was via online social media. Analysis sample included those who provided responses to the baseline survey (April) and at least one subsequent follow-up survey (N = 1834 out of a possible 3216 who completed the April survey). 71.7% of the sample was female (n = 1,322). Principal components analysis (PCA) combined self-reported adherence across seven prevention behaviours. 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 and hygiene behaviours were analysed individually using multivariable regression models. RESULTS: On average, participants agreed with statements of adherence for all behaviours (means all above 4 out of 7). Distancing behaviours declined each month (p's < .001), whereas hygiene behaviours 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 (p's<0.05). For hygiene, the only significant correlate of adherence in June and July was belief that one's actions could prevent infection of family members (p < .001). CONCLUSION: High adherence to COVID prevention behaviours were reported in this social media sample; however, distancing behaviours tended to decrease over time. Belief in social responsibility may be an important aspect to consider in encouraging distancing behaviours. These findings have implications for managing a shift from government-imposed restrictions to individual responsibility.

The Psychological Impact of Hypertension During COVID-19 Restrictions: Retrospective Case-Control Study.

BACKGROUND: 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. OBJECTIVE: This retrospective case-control study compared people with hypertension to matched healthy controls during the COVID-19 lockdown to determine whether they have higher risk perceptions, anxiety, and vaccination intentions. METHODS: Baseline data from a national survey were collected in April 2020 during the COVID-19 lockdown in Australia. People who reported hypertension with no other chronic conditions were randomly matched to healthy controls of similar age, gender, education, and health literacy level. A subset including participants with hypertension was followed up at 2 months after restrictions were eased. Risk perceptions, anxiety, and vaccination intentions were measured in April and June. RESULTS: Of the 4362 baseline participants, 466 (10.7%) reported hypertension with no other chronic conditions. A subset of 1369 people were followed up at 2 months, which included 147 (10.7%) participants with hypertension. At baseline, perceived seriousness was high for both hypertension and control groups. The hypertension group reported greater anxiety compared to the controls and were more willing to vaccinate against influenza, but COVID-19 vaccination intentions were similar. At follow-up, these differences were no longer present in the longitudinal subsample. Perceived seriousness and anxiety had decreased, but vaccination intentions for both influenza and COVID-19 remained high across groups (>80%). CONCLUSIONS: Anxiety was above normal levels during the COVID-19 lockdown. It was higher in the hypertension group, which also had higher vaccination intentions. Groups that are more vulnerable to COVID-19 may require targeted mental health screening during periods of greater risk. Despite a decrease in perceived risk and anxiety after 2 months of lockdown restrictions, vaccination intentions remained high, which is encouraging for the future prevention of COVID-19.

Positive outcomes associated with the COVID-19 pandemic in Australia.

ISSUE ADDRESSED: To investigate whether Australians have experienced any positive effects during the COVID-19 pandemic. METHODS: National 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) and also completed the World Health Organisation-Five well-being index. Differences were explored by demographic variables. Free-text responses were thematically coded. RESULTS: Nine hundred sixty participants (70%) reported experiencing at least one positive effect during the COVID-19 pandemic. Living with others (P = .045) and employment situation (P < .001) at baseline (April) were associated with experiencing positive effects. Individuals working for pay from home were more likely to experience positive effects compared to those who were not working for pay (aOR = 0.45, 95% CI: 0.32, 0.63, P < .001) or who were working for pay outside the home (aOR = 0.40, 95% CI: 0.28, 0.58, P < .001). 54.2% of participants reported a sufficient level of well-being, 23.2% low well-being and a further 22.6% very low well-being. Of those experiencing positive effects, 945/960 (98%) provided an explanation. The three most common themes were 'Family time' (33%), 'Work flexibility' (29%) and 'Calmer life' (19%). CONCLUSIONS: A large proportion of participants reported positive effects resulting from changes to daily life due to the COVID-19 pandemic in Australia. SO WHAT: The needs of people living alone, and of those having to work outside the home or who are unemployed, should be considered by health policymakers and employers in future pandemic preparedness efforts.

Health literacy and disparities in COVID-19-related knowledge, attitudes, beliefs and behaviours in Australia.

OBJECTIVES: To explore the variation in understanding of, attitudes towards, and uptake of, health advice on coronavirus disease 2019 (COVID-19) during the 2020 pandemic stage 3 restrictions ('lockdown') by health literacy in the Australian population. STUDY DESIGN: National cross-sectional community survey. SETTING: Australian general public. PARTICIPANTS: Adults aged over 18 years (N = 4362). MAIN OUTCOME MEASURES: Knowledge, attitudes and behaviours related to COVID-19; health literacy and sociodemographic factors. RESULTS: People 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. People with inadequate health literacy were less likely to rate social distancing as important (6.1 vs 6.5; p < 0.001) and reported more difficulty with remembering and accessing medicines since lockdown (3.6 vs 2.7; p < 0.001). People with lower health literacy were also more likely to endorse misinformed beliefs about COVID-19 and vaccinations (in general) than those with adequate health literacy. The same pattern of results was observed among people who primarily speak a language other than English at home. CONCLUSION: Our findings show that there are important disparities in COVID-19-related knowledge, attitudes and behaviours according to people's health literacy and language. These have the potential to undermine efforts to reduce viral transmission and may lead to social inequalities in health outcomes in Australia. People with the greatest burden of chronic disease are most disadvantaged, and are also most likely to experience severe disease and die from COVID-19. Addressing the health literacy, language and cultural needs of the community in public health messaging about COVID-19 must now be a priority in Australia.

COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey.

BACKGROUND: Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined. OBJECTIVE: This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time. METHODS: This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020. RESULTS: Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation. CONCLUSIONS: The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.

People's Experiences and Satisfaction With Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study.

BACKGROUND: In response to the COVID-19 pandemic, telehealth has rapidly been adopted to deliver health care services around the world. To date, studies have not compared people's experiences with telehealth services during the pandemic in Australia to their experiences with traditional in-person visits. OBJECTIVE: This study aimed to compare participants' perceptions of telehealth consults to their perceptions of traditional in-person visits and investigate whether people believe that telehealth services would be useful after the pandemic. METHODS: A national, cross-sectional, community survey was conducted between June 5 and June 12, 2020 in Australia. In total, 1369 participants who were aged ≥18 years and lived in Australia were recruited via targeted advertisements on social media (ie, Facebook and Instagram). Participants responded to survey questions about their telehealth experience, which included a free-text response option. A generalized linear model was used to estimate the adjusted relative risks of having a poorer telehealth experience than a traditional in-person visit experience. Content analysis was performed to determine the reasons why telehealth experiences were worse than traditional in-person visit experiences. RESULTS: Of the 596 telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was "just as good as" or "better than" their traditional in-person medical appointment experience. On average, respondents perceived that telehealth would be moderately useful to very useful for medical appointments after the COVID-19 pandemic ends (mean 3.67, SD 1.1). Being male (P=.007), having a history of both depression and anxiety (P=.016), and lower patient activation scores (ie, individuals' willingness to take on the role of managing their health/health care) (P=.036) were significantly associated with a poor telehealth experience. In total, 6 overarching themes were identified from free-text responses for why participants' telehealth experiences were poorer than their traditional in-person medical appointment experiences, as follows: communication is not as effective, limitations with technology, issues with obtaining prescriptions and pathology results, reduced confidence in their doctor, additional burden for complex care, and inability to be physically examined. CONCLUSIONS: Based on our sample's responses, telehealth appointment experiences were comparable to traditional in-person medical appointment experiences. Telehealth may be worthwhile as a mode of health care delivery while the pandemic continues, and it may continue to be worthwhile after the pandemic.