THE early stages of the Delta outbreak in the Greater Sydney region had disproportionate impacts on culturally and linguistically diverse (CALD) communities, many of whom are of a refugee background.
This outbreak is a testament to the complex interplay between social determinants of health and communicable diseases, and demonstrates the need for implementation of strategies that adequately address them. The ability to access and understand COVID-19 vaccine-related information is one of the key factors that determine vaccine acceptance and uptake, as it empowers individuals to make informed decisions on vaccines.
However, there is a variability of literacy levels among CALD communities, with groups with low health literacy likely to be more vaccine hesitant. Focusing on health literacy as one of the key determinants of vaccine uptake, this article discusses GPs’ roles in addressing health literacy barriers and offers insights on how GPs can be better supported to address COVID-19 vaccine literacy needs of CALD communities in New South Wales.
Achieving high immunisation coverage as a key public health strategy
The latest national COVID-19 response plan includes phases achieved through reaching > 70–80% immunisation coverage of eligible adults aged 16 years and over to control COVID-19 and ease lockdown restrictions and other measures. As at 9 September 2021, approximately 31.50% of people over the age of 16 years have been fully vaccinated with two doses. While the Australian Immunisation Register does not capture ethnicity, postcodes with high migrant populations have lower immunisation coverage. Achieving high immunisation coverage in these communities is one important strategy in controlling COVID-19. Misinformation and disinformation are fuelling vaccine hesitancy and refusal. Compounded by limited access to COVID-19 vaccine-related information for CALD communities, this may pose a significant challenge in achieving equitable immunisation coverage.
Low health literacy as a key barrier
According to a recent study that assessed readability of public health information on COVID-19 vaccines, Australia scored poorly in readability metrics, with most COVID-19 vaccine-related information deemed hard to read and understand and failed to meet the health literacy needs of diverse communities.
Addressing health literacy necessitates coordinated capacity building approaches at an individual level to empower individuals to make informed choices, and at the health system level to support health care providers to facilitate individual empowerment. Considering the complexities around COVID-19 vaccines, addressing the substantial health literacy needs of CALD communities calls for whole-of-system approaches involving stakeholders at various levels, including the individual, the community, health service providers, and the health system in general. While there have been laudable efforts in engaging communities at the grassroots level and dissemination of translated public health information on COVID-19 vaccines targeting various language groups, little attention has been given to GPs, who are key stakeholders in the current COVID-19 vaccine rollout plan.
GPs face barriers in cross-cultural care
According to a recently published report (based on data collected before the current Delta outbreak) by the NSW Council of Social Service that examined issues, barriers and perceptions about COVID-19 vaccines among CALD communities, GPs were cited to be among the most trusted and credible sources of information on COVID-19 vaccines for culturally and linguistically diverse communities.
Evidence from the literature affirms GP recommendation to be a significant predictor for vaccine uptake among individuals and is even more pertinent for CALD communities. As the most trusted advisors and influencers of vaccine decision making, particularly among hesitant individuals, GPs can play a crucial role in addressing the existing health literacy barriers among CALD communities.
However, the NSW Council of Social Service report found that 42% (78/199) of culturally and linguistically diverse communities would not get vaccinated against COVID-19 due to conflicting information from trusted sources, including GPs. These findings could be attributed to the constantly changing public health recommendations by the government, and reiterate the need for not only improved public communication from government officials but also more support for GPs in their role as risk communicators.
Even before the COVID-19 pandemic, GPs faced several logistical and administrative challenges at the client–provider interface that impeded provision of high quality of care for CALD communities.
At the provider level, these include structural complexities around provision of quality health care such as the lack of readily available interpreter services, particularly for some population groups; logistical issues, such as long waiting times; and sociocultural differences occurring during client–provider interactions affecting communication and trust between CALD groups and service providers.
At the client level, barriers affecting the quality of care include language barriers, limited literacy and health literacy, different cultural lenses for understanding health in general, and norms and practices that may negatively influence health-seeking behaviour among this group.
With the ongoing COVID-19 risk and restrictions and considering the novelty of the COVID-19 vaccines, the cross-cultural communication challenges are likely to be amplified, with consultations potentially taking longer than other general consultations. Without a Medicare item that appropriately remunerates GPs for their time when consulting with CALD communities on COVID-19 vaccines, cross-cultural care will remain a challenge.
Support for GPs in their role as risk communicators
GPs are best placed to contextualise risk communication about COVID-19 infection and the vaccine with their patients, conversations that are pivotal in instilling confidence in the vaccines and potentially uptake among hesitant individuals. To facilitate these conversations, evidence-based resources such as decision aids have been shown to be useful in providing invaluable assistance for psychologically and computationally complex decisions including immunisation, reducing decision-making conflicts related to immunisation, and may help to address vaccine hesitancy. However, while there are existing COVID-19 decision aids for GPs to contextualise risk communication at an individual level, these resources may not adequately cater to the needs of these groups due to various levels of literacy, health literacy, English proficiency, and unique health needs, such as higher burden of pre-existing medical issues in refugees.
The COVID-19 glossary, recently launched in over 30 languages, can be a useful resource for GPs when communicating risk with CALD communities and can help overcome the existing literacy and health literacy barriers by providing simple definitions to complex concepts and in their own languages (even more pertinent for bilingual GPs). The COVID-19 decision aids complemented by the glossary may be instrumental tools in the contextualisation of the risk–benefit analysis of COVID-19 vaccines at an individual level, enabling patients to make informed decisions about the vaccines.
Considering the current climate, bilingual GPs also have the potential to address the health literacy needs of targeted communities at a population level by leveraging social media and other mainstream media platforms to communicate about COVID-19 vaccines.
To overcome the language barriers, access to a readily available pool of interpreters for all language groups and training for GPs on how to effectively use interpreters during a consultation will be critical, as risk communication is a two-way process that needs to take into account individual values and preferences. Finally, ongoing cultural competency and sensitivity training for GPs, and patience when dealing with a group who already have trust issues with the government in the current climate, will be of utmost importance.
Achieving high immunisation coverage has been reiterated to be a key public health strategy in controlling the current Delta outbreak and easing lockdown restrictions and other measures. However, misinformation about COVID-19 vaccines, potentially fuelling vaccine hesitancy, and limited access to COVID-19 vaccine-related information among CALD communities with limited literacy and health literacy pose significant challenges and put Australia’s diverse communities at risk.
Addressing the high health literacy demands for this group is therefore an urgent imperative. While there are ongoing community engagement efforts at the grassroots level aimed at equipping CALD communities with knowledge on COVID-19 vaccines, a whole-of-system approach is of paramount importance. It must involve various stakeholders, including health care providers, to ensure no groups are left behind.
As the most trusted sources of vaccine information and predictors of vaccine uptake, GPs need to be better supported to effectively communicate COVID-19 vaccine-related risk–benefit analyses with CALD communities.
Dr Abela Mahimbo is a Lecturer in Public Health at the University of Technology Sydney.
Ikram Abdi is a Senior Research Officer in Social Science, with the National Centre for Immunisation Research and Surveillance.
Associate Professor Anita Heywood is an infectious disease epidemiologist, and Director of Teaching at UNSW Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.