All levels of government could be doing more to help protect medically vulnerable people in Australia from COVID-19.
The coronavirus disease 2019 (COVID-19) pandemic has been the most serious global public health crisis in a generation.
In May, the World Health Organization officially declared the public health emergency over, and instead identified COVID-19 as an “established and ongoing heath concern”.
This declaration follows significant worldwide declines in hospitalisations and deaths due to increased population immunity from widespread vaccination and infection and declining surveillance reporting, among other factors.
This declaration also comes after relaxation of public health measures in most countries. In Australia, few preventive measures remain, and public health messaging now almost exclusively focuses on vaccination uptake.
When other advice is provided (eg, around masks, isolating, or physical distancing), the emphasis is on personal risk assessment and choice.
Affecting the most vulnerable
We know that the COVID-19 pandemic disproportionately affected people who were already most vulnerable, including those with lower health literacy, social or economic disadvantage, or from culturally diverse backgrounds.
One group that has been particularly affected but remains largely invisible in public health communications are people who are medically vulnerable (including the chronically ill, immunocompromised and elderly).
This medically vulnerable group is not a negligible few — almost half of Australians have at least one chronic condition, and almost one fifth have at least two – meaning that even if only a fraction are also more vulnerable to COVID-19, the issue affects many.
Despite us being in an environment of heightened personal responsibility for COVID-19 risk management, governments of all levels could be doing more to keep medically vulnerable people safe from COVID-19.
Medically vulnerable people are forced to make difficult choices to protect their health because of this new era of personal responsibility. This is despite research showing that the impacts of COVID-19 are still affecting relatively healthy people; even after mild infection, many people are experiencing serious long term impacts of the disease (here and here).
Strikingly, high quality, tailored, evidence-based information to support this decision making is almost entirely missing for people at more severe risk from COVID-19.
The importance of public communications
Although it can be challenging for governments to communicate complex public health information in emergency situations, it formed an essential part of the COVID-19 pandemic response.
Before the COVID-19 pandemic there was extensive research on public health pandemic communication.
The experiences of COVID-19 are only adding to this evidence. We know that to best support the population to act on preventive advice, information must be clear and up-to-date, from trusted sources, accessible, consistent, able to be acted upon, and to reach all members of the community equally, regardless of preferred language or access to different forms of media (here).
We also know that that many groups within the community are less likely to be reached by public health messaging, or less able to take up certain measures.
Within Australia, for instance, COVID-19 communications were sometimes poorly tailored to people of non-English-speaking backgrounds, meaning they were not always accessible, understandable or actionable.
Early pandemic approaches
Early pandemic measures necessarily focused on physical distancing measures to counteract severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in the absence of vaccines or treatments.
The success of these measures depended on population-wide uptake, and were therefore supported by extensive public health communications conveying the importance of adherence, combined with concrete, actionable messaging about what people needed to do to stay safe (here).
Navigating the “return to normal”
With life returning to “normal” for much of the community, the situation is now very different.
Schools and workplaces are open, and hospitality, entertainment and travel are thriving.
This return to near-normal activity has come with high rates of COVID-19 in the community that would have been unimaginable in Australia in the early days of the pandemic (here).
For medically vulnerable people, who arguably have the most stake in protecting themselves against severe disease, worsened disability or death, this has created a riskier situation than ever in which to live. However, these same people are also living without acknowledgement of this personal decision-making burden or the concrete, actionable messaging that characterised the early pandemic response and enabled protective actions to be taken.
The uncertainty of life for the most vulnerable
Living with COVID-19, therefore, continues to be uncertain for medically vulnerable people.
A largely invisible but growing disparity now exists between people able to participate in normal life with high circulating SARS-CoV-2 levels and those needing to carefully navigate their own heightened risk against this backdrop.
Without tailored, evidence-based information about risk and protective measures, medically vulnerable people must therefore often make decisions without information or support.
True informed decision making can only happen when people can access accurate, evidence-based information about what they can, and cannot, safely do.
In the absence of this, medically vulnerable people must continue to navigate life in parallel, relatively isolated from the wider community, with the now well documented negative effects of doing so.
With the recent WHO declaration, it is clear that COVID-19 will not simply end, and requiring vulnerable people to isolate indefinitely to protect themselves is no longer a reasonable public health approach.
Addressing the lack of tailored information
Almost four years into the pandemic, the lack of tailored information to support everyday decisions about risk can only be viewed as a failure of public health policy and needs urgent attention so that medically vulnerable people can apply public health advice to live safely.
The WHO has put out guidelines on public communications.
We believe current advice in Australia is too generic and does not address the day-to-day information that people need when they are at higher risk.
The good news is that communication research during and before the COVID-19 pandemic tells us there are clear ways to address this gap.
First, there needs to be recognition that medically vulnerable people are not a homogeneous group, and so encounter a range of different issues and behaviours that could expose them to SARS-CoV-2.
Decisions for an older person are, for instance, not the same as those for a working mother with school-aged children, or a university student working and studying.
Public health messaging needs to recognise that the medically vulnerable are a diverse range of people across the lifespan and across life circumstances, and tailor public health messaging so it is accessible and acceptable to people with different needs.
Second, public health messaging needs to be actionable, and provide medically vulnerable people with accurate, up-to-date, accessible and tailored information to support decision making about COVID-19.
These messages need to speak to the real-world risks that people encounter in their lives and provide evidence-based strategies and solutions to manage these risks, potentially also including development of tools to support decision making around common risks.
Providing evidence-based information to aid decision making also means clearly acknowledging uncertainty (when information is not yet available), and must include plans for updating advice as research into COVID-19 risks for medically vulnerable people evolves.
Third, engaging with medically vulnerable people can help us to understand their main concerns in living with COVID-19, and learn how they are already managing risk in a high COVID-19 environment.
The most vulnerable need to be visible
Medically vulnerable communities also have a role in collaborating with public health researchers, clinicians, and policy makers to collect and better understand individualised risk data.
These collaborations should also be used in developing, testing, disseminating and evaluating public health messages to medically vulnerable people.
Finally, communication to the entire community about public health measures, in addition to messages around vaccination, needs to continue so that everyone understands what they can do to protect the medically vulnerable and why this is important.
The need for accurate, timely, up-to-date information to support protective public health measures has been highlighted since the very earliest days of the pandemic.
Vulnerable groups, including the medically vulnerable, are disproportionately disadvantaged by COVID-19 with, unsurprisingly, worsened social, economic and health impacts.
As we work to control the pandemic’s effects in Australia, we cannot say we are successfully “living with COVID-19” while medically vulnerable people remain isolated from many activities of daily life.
There is urgent need for leadership and public health action that squarely recognises and works to address this huge unmet need within the Australian community.
We all have a responsibility to keep the most vulnerable in the community safe, as there is only so much they can do on their own to prevent COVID-19, even with the right public health communications.
For example, the most medically vulnerable are under-represented in hospitals and health care settings, so low burden interventions such as mask wearing and improving indoor air quality in these places can only help the most vulnerable (here).
Dr Rebecca Ryan is a Senior Research Fellow and Head of the Centre for Health Communication and Participation at La Trobe University.
Dr Louisa Walsh is a Research Fellow at the Centre for Health Communication and Participation at La Trobe University.
This article is based on an article published in the Australian and New Zealand Journal of Public Health (10.1016/j.anzjph.2023.100049). The authors would like to acknowledge the contributions of their co-authors (Sophie Hill, Rebecca Jessup and Brian Oldenburg) in developing the ideas presented here.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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