Introduction by Croakey: Clear recommendations for improving public health communications with culturally diverse communities emerged from a recent online forum hosted by researchers at the School of Population Health, UNSW Sydney.
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Governments and policymakers need to do better at engaging culturally diverse communities with public health responses to the pandemic as Australia moves towards easing COVID-19 restrictions, according to leading experts.
Researchers from the School of Population Health, UNSW Sydney recently held an online Think Tank forum to hear from community leaders, health service providers, government agency representatives and health researchers about what strategies have worked to date and to ensure best practice is followed going forward.
For effective engagement, it was critical to put community leaders at the centre of consultations, keep messaging simple and timely, provide information in multiple formats, and avoid a one-size-fits all, the webinar was told.
Think Tank organiser Associate Professor Holly Seale said it was important to privilege the voices of diverse communities as Australia moves into the next phase of the pandemic, with double dose vaccination rates of 70 and 80 per cent to trigger an easing of restrictions.
“We need to ensure all levels of government and those who provide services to culturally and diverse (CALD) communities continue to speak to communities to understand the reasons impacting COVID-19 vaccine acceptance,” she said.
“It is also critical that learnings are shared across communities about the strategies that are supporting uptake, and those that are not working. It is not just about having translated materials on a website but having a tailored immunisation approach.”
The webinar highlighted key barriers to effective engagement during the pandemic including: the use of confusing and complicated language in health messaging, a lack of translated information and inaccuracies in translations, hard-to-navigate websites, and taking a one-size-fits-all approach to diverse cultural groups.
Evaluation studies from Queensland and NSW health researchers highlighted the diversity that exists within community groups and the importance of tailoring messages to target audiences.
The studies found community members used multiple sources for information – social media, family and friends, community leaders, and government websites – and revealed marked differences across generations, language groups, and those with low health and digital literacy and English proficiency.
Founder of the Somali Women’s Development Association (SWDA) Sainab Sheikh told of early efforts to inform the community about COVID-19. SWDA organised hundreds of Zoom sessions, WhatsApp group chats, conference calls and group emails to relay information.
Sheikh said the Victorian Health Department website was difficult to navigate, with the association working quickly to relay information in language, tweaking messaging in consultation with the community, and setting up Q and A sessions with health professionals – something that’s continued throughout the pandemic.
When a group of Somali women were turned away from a vaccine clinic because they weren’t part of the target group, Sheikh linked up with the clinic manager via the Victorian community health service cohealth to get them vaccinated. She now regularly contacts clinic managers to arrange bookings.
In central Victoria, the Bendigo Community Health Service (BCHS) has used its bicultural staff as a critical part of the COVID-19 messaging to Karen (Myanmar), South Sudanese and Afghan communities.
Among its successful initiatives is a Karen COVID hotline staffed by the bicultural team and health professionals five days a week, providing public health information, countering misinformation and organising vaccination bookings.
The leader of the cultural diversity team at BCHS, Kaye Graves, highlighted the need to understand communities, saying many have poor health, digital and service literacy.
Graves said many families – most with low English proficiency – have struggled with homeschooling during the pandemic, exacerbating feelings of loneliness and a sense of failure.
She said there was a real challenge with service providers trying to support people to access the MyGov website last year, with workers “standing on verandahs shouting through masks – it was very difficult”.
The webinar heard concerns that communities will be left behind, with the President of the Refugee Communities Advocacy Network (RCAN), Atem Atem, saying some in government agencies view the challenge of catering to multiple language groups as “too hard”.
Randa Kattan, CEO of the Arab Council Australia, agreed, saying the NSW Government left south-west Sydney and western Sydney behind at the start of the pandemic.
“We are always engaged after there is a problem – never upfront. The damage that has been done (through heavy-handed policing and the use of the military) is quite severe on the ground and there is a lot of feeling that this is racist,” she said.
Kattan questioned whether the new roadmaps would present a different approach, saying more financial stimulus was needed after months of hard lockdown and that communities needed to be consulted, not overlooked and left behind.
Early and sustained engagement
Dipti Zachariah is Multicultural Health Services team leader at Western Sydney Local Health Department (WSLHD) – which services a population where 50.3 percent of people speak a language other than English at home and 46.8 percent were born overseas.
She explained that community was always at the centre of the service’s response to COVID-19.
With diverse languages, nationalities, low literacy and health literacy, and socio-economic disadvantage adding to the complexity, Zachariah said community co-design was used from the outset.
The webinar heard of the importance of acknowledging and working with the existing resilience and knowledge of CALD communities, including new arrivals.
One example was to listen to those from countries which had dealt with serious infectious diseases such as Ebola, dengue and malaria, saying their lived experiences could help inform best practice going forward.
Use plain English
The need to use plain, simple English and concepts came through repeatedly during the Think Tank, with a Communication and Co-ordination breakout session hearing that public health and government material is still too complex, there’s a need for bite-size, easy-to-understand ‘chunks’, and that some terms don’t translate into another language.
It heard that demands on translation services are enormous and unrealistic, such as a request to translate thousands of words into 40 languages overnight, and that there is a lack of qualified translators.
There was also a need to get simple, plain English information out to community groups as quickly as possible, with the Queensland evaluation study finding community leaders very effective in picking up, simplifying and translating material for wider use.
Don’t rely on websites alone
Among the multiple channels used by communities to disseminate and receive COVID-19 information were official government websites, social media, audio/visual (YouTube and Facebook), WhatsApp, Zoom, email and the phone calls.
The Bendigo Community Health Service (BCHS), which delivers refugee services to Karen, Afghan and South Sudanese refugees, worked with Karen, Dinka and Dari speakers to co-design fact sheets, crafting simple English scripts.
Each was checked by two other language speakers for accuracy, then translated into fact sheets and audio-visual segments, before being disseminated using platforms including YouTube and Viber. Between July 2020 and July 2021, the BCHS online resource hub had 20,000 hits.
Local community champions and bilingual staff
Trusted local messengers were at the heart of effective engagement with diverse communities.
SWDA founder Sainab Sheikh used her own experience of twice having COVID-19, once last year and again in 2021, to spread the word to her community of the seriousness of the illness and press the need for testing and vaccination.
In western Sydney, the WSLHD created COVID safety champions and used bilingual members of its own team – some speaking 20-plus languages – to engage with communities.
With the message having to be tweaked repeatedly and the translation service under the pump, the WSLHD worked with community members to provide information that was clear, made sense and was accessible.
WSLHD also worked with trustworthy messengers – ordinary people, doctors, religious leaders and pharmacists – to drive calls to action and empower the message.
Reinforcing the importance of local champions, the Queensland engagement study found that each community leader reached an average of 200 people while for some it was thousands: evidence of how one trusted community leader can supercharge messaging.
Break down silos between service providers
Dr Nadia Chaves, an infectious diseases specialist at a Victorian community health service provider, cohealth, chaired a session on ways to break down silos between service providers working with culturally diverse communities on COVID-19.
It heard of frustration over the duplication of work across states, and of community members having to repeat themselves in meetings because of a failure to share information across government agencies.
There were also concerns raised about confusing messages and an overload of information, with community groups left wondering what to read and what to leave.
Kaye Graves, of Bendigo Community Health Services, spoke of the time spent building up service providers’ knowledge of the pre-settlement experiences of migrant communities.
BCHS began the work in 2012, working with the local hospital and other main services, building their understanding of the refugee journey, culture and faith of the Karen, Afghan and South Sudanese migrant communities.
Graves said understanding the risk and protective factors, such as poor health literacy, are central to creating an optimal settlement environment, and the region now has a refugee settlement network of major providers. This enables increased service coordination, understanding of unmet needs and gaps and identification of professional development needs in working with these communities.
Promote digital inclusion
Difficulties in navigating health department websites, especially for vaccination bookings, were common across diverse communities, according to service providers engaged in the Think Tank.
Community groups such as the Somali Women’s Development Association and the Bendigo Community Health Services underlined concerns with stories of community members being unable to access bookings due to confusing websites.
There were also issues with finding relevant information on local outbreaks, with local postcode searches being difficult, and particularly challenging for those with low digital literacy and little English.
Access to technology such as smart phones and the internet was also highlighted as a barrier for CALD communities, with one social media provider pointing out that digital transformation had not yet taken place in his small, typically face-to-face community, leading to challenges in disseminating information.
One suggestion was the engage tech-savvy international students and young tertiary students to help community members. The idea was to train these students to explain information or processes to community members, with the session told the students could be a great asset for government agencies.
Associate Professor Ben Harris-Roxas, a lecturer at the School of Population Health at the University of NSW, who chaired a session on enhancing communication, said governments are expecting people to navigate increasingly complex systems, such as MyAgedCare, the Carer Gateway and the NDIS which have a large digital component.
Harris-Roxas called for simple innovations such as the appointment reminder translation tool developed by the NSW Multicultural Health Communication Service and private initiatives such as the covid19nearme.com.au website set up by Ken Tsang to track exposure sites that now also maps vaccination clinics.
Harris-Roxas wants critical discussion on low health and digital literacy, saying it shouldn’t be implied as a deficit on the part of people and communities, when it’s a deficiency in the way health professionals and services respond to varying needs.
Evaluations of engagement with CALD communities in Greater Brisbane
For more information, see here.
- Surveyed 51 CALD community members, 31 community leaders
- Community members received information from multiple sources, but mostly from own communities and via social media
- Leaders and Queensland Government seen as trustworthy/credible sources
- Having access to audio/visual and information in their own language important
- Barriers for community members: lack of information in their own language, information overload, dealing with fake news
- Key supports for community members: simple, translated audiovisual material, community leaders/groups, regular information from authorities and access to information via social media
- Most had good knowledge of COVID-19
- Suggested improvements: access to translations in a range of formats, personalised information sharing, support of more CALD leaders and bicultural workers
- Community leaders reported broad adoption of information sharing
- On average, each leader passed on information to 200 community members
- Most translated and adapted information for community members
- Similar barriers to community members. Supports included technology/smart phones, existing relationships and networks, regular information sharing and simple visual messaging for sharing
- Remunerating, training and supporting leaders, as well as early and continued outreach and engagement
- Translated material created and shared early in as many formats as possible
- Engagement of more community leaders and bicultural workers
- Authentic engagement with CALD community and leaders to be built on over time, using an embedded community
Sydney Health Literacy Hub: Survey of Knowledge, Beliefs and Behaviours. Community Survey (conducted before the latest outbreak)
- Surveyed 708 people from 10 language groups in Greater Western Sydney who didn’t speak English at home
- 88% born overseas, 41% inadequate health literacy, 31% no or little English, 30% had university degree
- Top sources of information: public health sources (60%); Australian commercial services (59%) and social media (56%), family and friends (34%), community (28%) and overseas sources (36%)
- Under 30s relied more on social media (70%)
- Over 70s and those with low health literacy tended to use friends and family, and more reliant on information in their native language
- 55% got information in English but this much lower in older age groups
- Had difficulty finding information that was easy to understand – both in English and in native language
- 77% said they would be tested if they had symptoms, and 53% said they’d be vaccinated if this was recommended
- Cited concern about getting infection at testing site and vaccine safety
- High variability across language groups on most variables
- People with low English proficiency and low health literacy found it harder to find understandable COVID-19 information
- People using diverse information sources – pointing to further channels to target
- Barriers to testing and vaccination are often related to safety or information needs
- Even before the outbreak in western and south-west Sydney, one-quarter felt nervous or stressed most of the time; and almost as many felt lonely
Key take-out messages from the Think Tank included the importance of understanding communities – including the pre-settlement journey of migrants, their faith and cultural needs – consulting early and often and making vaccination easy by simplifying on-line booking procedures and taking vaccination hubs to the people, where they are.
Cohealth’s Dr Nadia Chaves said “capability, opportunity and motivation” were essential in supporting those in diverse communities to get the jab.
Much of the communication is “please get vaccinated” but if you have a family of seven children, you need the capability to do this – to make this easy, she said.
SWDA’s Sainab Sheikh wants more pop-up clinics in communities, an easier booking system, and more government funding for community groups to support their work.
The call for funding is backed by the Queensland evaluation study, which called for the engagement and remuneration of more community leaders. It stressed the need to invest and collaborate ahead of time, to ensure a strong base was built before the next pandemic or disaster.
Chaves wants more data on CALD communities, saying: “To provide any sort of health or social service, we need to know who the people are. We need to be informed by data.”
She pointed out that – after years of having no migrant or cultural diversity standards – the Australian Commission on Safety and Quality in Health Care, recently launched a user guide for people who work with diverse communities, recommending data collection and specific action within organisations.
Think Tank organiser Associate Professor Holly Seale said the experiences of the 2009 H1N1 pandemic were a wake-up call on the need for infectious disease outbreak plans to be inclusive and tailored to the diverse communities in Australia.
As an outcome, planning was tailored to capture the needs of Aboriginal and Torres Strait Islander people into the pandemic plans.
“This current pandemic again highlights that there is a critical need to ensure services, communication and efforts and other pandemic strategies are designed and delivered in a culturally responsive way,” she said.
Seale stressed collaboration with people from CALD backgrounds, including refugee communities, was critical to improving future pandemic plans as well as continuing ongoing COVID-19 activities.
This article was written by Cate Carrigan and edited by Dr Melissa Sweet, on behalf of Croakey Professional Services. It is sponsored by the Associate Professor Holly Seale of the School of Population Health, UNSW Sydney.
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