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

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.

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

BackgroundVaccination 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. MethodsWe 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). ResultsAfter 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. CONCLUSIONSThese 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. HIGHLIGHTSO_LIPerceived public health threat is associated with intentions to vaccinate C_LIO_LIThose believing the efficacy of vaccines is made up were less willing to get vaccinated C_LIO_LITo protect myself and others was the top reason for getting the vaccine C_LIO_LISafety concerns was the top reason against getting the vaccine C_LI

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

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?

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<.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). Age and education were not associated with positive effects when controlling for employment and household numbers. There was an overall effect of gender (p=.001), where those identifying as female were more likely than males (aOR=1.62, 95%CI: 1.25, 2.09) to report experiencing a positive effect. 54.2% of participants reported a sufficient level of wellbeing, 23.2% low wellbeing and a further 22.6% very low wellbeing. Of those experiencing positives, 945/960 (98%) provided an explanation. The three most common themes were Family time (33%), Work flexibility (29%), and Calmer life (19%). ConclusionA large proportion of surveyed Australians reported positive effects resulting from changes to daily life due to the COVID-19 pandemic in Australia. Enhancing these aspects may build community resilience to cope with future pandemic responses. The needs of people living alone, and of those having to work outside the home or who are unemployed, should be considered by health policy makers and employers in future pandemic preparedness efforts, as these groups were least likely to report positive experiences and may be more vulnerable.

Impact of COVID-19 Restrictions on People with Hypertension

ObjectivesIt 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. DesignThis 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. MethodsBaseline 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. ResultsAt 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%). ConclusionsAnxiety 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

BackgroundThe 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. MethodsThe 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. ResultsOnly 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. ConclusionWe 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

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

ObjectivesTo 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 designProspective national longitudinal community online survey. SettingAustralian general public. ParticipantsAdults aged over 18 years (n=4362 baseline/Wave 1; n=1882 Wave 2; n=1369 Wave 3). Main outcome measureCOVID-19 misinformation beliefs. ResultsStronger 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. ConclusionThese 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

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.