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.
This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time.
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.
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.
The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.
Guidance to address health literacy often focuses on health education rather than tools to facilitate action, despite action being important for self-management. This study evaluated an online ...intervention informed by health literate design principles and behavior change theory to reduce unhealthy snacking.
440 participants were recruited online and randomized to an intervention: 1) Health-literate action plan (guided implementation intention); 2) Standard action plan (self-guided implementation intention); 3) Education (healthy snacking fact-sheet). The primary outcome was self-reported unhealthy snacking. Follow-up was at 1 month.
373 participants (84.8%) completed follow-up. Half the sample had adequate health literacy (52%), and the other half had low (24%) or possibly low (25%) health literacy, as measured by Newest Vital Sign (NVS). At follow-up, lower health literacy was associated with more unhealthy snacks and there was no overall difference between intervention groups. However, participants with lower health literacy who used the health-literate action plan reported less unhealthy snacking compared to the standard action plan; the reverse was true for those with higher health literacy scores (b = 1.7, p = 0.03). People scoring 2 points below the mean NVS (M = 3.4, SD = 2.0) using the health-literate action plan reported eating 8 fewer serves of unhealthy snacks, whereas people scoring 2 points above the mean NVS reported eating 6 more serves of unhealthy snacks using the same tool.
These findings suggest that the universal precautions approach currently recommended for health information may be less effective for facilitating action than tailoring to health literacy level.
ANZCTR identifier: ACTRN12617001194358.
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.
National cross-sectional community survey.
Australian general public.
Adults aged over 18 years (N = 4362).
Knowledge, attitudes and behaviours related to COVID-19; health literacy and sociodemographic factors.
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.
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.
Issue Addressed: Health behaviour change can be difficult to maintain. Action plans can address this issue, however, there has been little qualitative research to understand how to optimise action ...plan interventions. This study explored how people engage with a specific type of action plan intervention, the "volitional help sheet," in a cardiovascular disease (CVD) prevention context.
Methods: Twenty adults in the target age for CVD risk assessment (45 to 74 years) with varying health literacy participated in interviews and created an action plan to change their behaviour. Transcripts were analysed using framework analysis.
Results: Participants described how engagement with plans was related to how personally relevant the target behaviour and the options within the plan were. Also important was participants visualising themselves enacting the plan when deciding which option to choose. Amongst participants who already engaged in a target behaviour, some did not perceive the plan was useful; others perceived the plan as a helpful prompt or a formalisation of existing plans. For some, the barriers to behaviour change were out of the scope of an action plan, highlighting the need for alternative supports. Conclusion: This study provides qualitative insights into unanticipated ways that people with varying health literacy use action plans, providing new guidance for future developers.
So What?: Not all action plans are created equal. Careful selection of behavioural targets and plan options and encouraging users to imagine the plan May enhance user engagement. Alternative behaviour change strategies should be available if key barriers cannot be addressed by the plan.
Low health literacy is associated with poorer health outcomes. A key strategy to address health literacy is a universal precautions approach, which recommends using health-literate design for all ...health interventions, not just those targeting people with low health literacy. This approach has advantages: Health literacy assessment and tailoring are not required. However, action plans may be more effective when tailored by health literacy. This study evaluated the impact of health literacy and action plan type on unhealthy snacking for people who have high BMI or type 2 diabetes (Aim 1) and the most effective method of action plan allocation (Aim 2).
We performed a 2-stage randomised controlled trial in Australia between 14 February and 6 June 2019. In total, 1,769 participants (mean age: 49.8 years SD = 11.7; 56.1% female n = 992; mean BMI: 32.9 kg/m2 SD = 8.7; 29.6% self-reported type 2 diabetes n = 523) were randomised to 1 of 3 allocation methods (random, health literacy screening, or participant selection) and 1 of 2 action plans to reduce unhealthy snacking (standard versus literacy-sensitive). Regression analysis evaluated the impact of health literacy (Newest Vital Sign NVS), allocation method, and action plan on reduction in self-reported serves of unhealthy snacks (primary outcome) at 4-week follow-up. Secondary outcomes were perceived extent of unhealthy snacking, difficulty using the plans, habit strength, and action control. Analyses controlled for age, level of education, language spoken at home, diabetes status, baseline habit strength, and baseline self-reported serves of unhealthy snacks. Average NVS score was 3.6 out of 6 (SD = 2.0). Participants reported consuming 25.0 serves of snacks on average per week at baseline (SD = 28.0). Regarding Aim 1, 398 participants in the random allocation arm completed follow-up (67.7%). On average, people scoring 1 SD below the mean for health literacy consumed 10.0 fewer serves per week using the literacy-sensitive action plan compared to the standard action plan (95% CI: 0.05 to 19.5; p = 0.039), whereas those scoring 1 SD above the mean consumed 3.0 fewer serves using the standard action plan compared to the literacy-sensitive action plan (95% CI: -6.3 to 12.2; p = 0.529), although this difference did not reach statistical significance. In addition, we observed a non-significant action plan × health literacy (NVS) interaction (b = -3.25; 95% CI: -6.55 to 0.05; p = 0.054). Regarding Aim 2, 1,177 participants across the 3 allocation method arms completed follow-up (66.5%). There was no effect of allocation method on reduction of unhealthy snacking, including no effect of health literacy screening compared to participant selection (b = 1.79; 95% CI: -0.16 to 3.73; p = 0.067). Key limitations include low-moderate retention, use of a single-occasion self-reported primary outcome, and reporting of a number of extreme, yet plausible, snacking scores, which rendered interpretation more challenging. Adverse events were not assessed.
In our study we observed nominal improvements in effectiveness of action plans tailored to health literacy; however, these improvements did not reach statistical significance, and the costs associated with such strategies compared with universal precautions need further investigation. This study highlights the importance of considering differential effects of health literacy on intervention effectiveness.
Australia and New Zealand Clinical Trial Registry ACTRN12618001409268.
•Perceived public health threat is associated with intentions to vaccinate.•Those believing the efficacy of vaccines is made up were less willing to get vaccinated.•To protect myself and others was ...the top reason for getting the vaccine.•Safety concerns was the top reason against getting the vaccine.
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.
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).
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.
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.
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. This study investigated changes in COVID prevention behaviours from April-July 2020, and psychosocial predictors of these behaviours. 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. 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). 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.
Health information is less effective when it does not meet the health literacy needs of its consumers. For health organisations, assessing the appropriateness of their existing health information ...resources is a key step to addressing this issue. This study describes novel methods for a consumer-centred large-scale health literacy audit of existing resources and reflects on opportunities to further refine the method.
This audit focused on resources developed by NPS MedicineWise, an Australian not-for-profit that promotes safe and informed use of medicines. The audit comprised 4 stages, with consumers engaged at each stage: 1) Select a sample of resources for assessment; 2) Assess the sample using subjective (Patient Education Materials Assessment Tool) and objective (Sydney Health Literacy Lab Health Literacy Editor) assessment tools; 3) Review audit findings through workshops and identify priority areas for future work; 4) Reflect and gather feedback on the audit process via interviews.
Of 147 resources, consumers selected 49 for detailed assessment that covered a range of health topics, health literacy skills, and formats, and which had varied web usage. Overall, 42 resources (85.7%) were assessed as easy to understand, but only 26 (53.1%) as easy to act on. A typical text was written at a grade 12 reading level and used the passive voice 6 times. About one in five words in a typical text were considered complex (19%). Workshops identified three key areas for action: make resources easier to understand and act on; consider the readers' context, needs, and skills; and improve inclusiveness and representation. Interviews with workshop attendees highlighted that audit methods could be further improved by setting clear expectations about the project rationale, objectives, and consumer roles; providing consumers with a simpler subjective health literacy assessment tool, and addressing issues related to diverse representation.
This audit yielded valuable consumer-centred priorities for improving organisational health literacy with regards to updating a large existing database of health information resources. We also identified important opportunities to further refine the process. Study findings provide valuable practical insights that can inform organisational health actions for the upcoming Australian National Health Literacy Strategy.
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.
Background
Health literacy interventions and research outcomes are not routinely or systematically implemented within healthcare systems. Co‐creation with stakeholders is a potential vehicle through ...which to accelerate and scale up the implementation of innovation from research.
Methods
This narrative case study describes an example of the application of a co‐creation approach to improve health literacy in an Australian public health system that provides hospital and community health services to one million people from socioeconomically and culturally diverse backgrounds. We provide a detailed overview of the value co‐creation stages and strategies used to build a practical and sustainable working relationship between a University‐based academic research group and the local health district focussed on improving health literacy.
Results
Insights from our experience over a 5‐year period informed the development of a revised model of co‐creation. The model incorporates a practical focus on the structural enablers of co‐creation, including the development of a Community of Practice, co‐created strategic direction and shared management systems. The model also includes a spectrum of partnership modalities (spanning relationship‐building, partnering and co‐creating), acknowledging the evolving nature of research partnerships and reinforcing the flexibility and commitment required to achieve meaningful co‐creation in research. Four key facilitators of health literacy co‐creation are identified: (i) local champions, (ii) co‐generated resources, (iii) evolving capability and understanding and (iv) increasing trust and partnership synergy.
Conclusion
Our case study and co‐creation model provide insights into mechanisms to create effective and collaborative ways of working in health literacy which may be transferable to other health fields in Australia and beyond.
Patient and Public Contribution
Our co‐creation approach brought together a community of practice of consumers, healthcare professionals and researchers as equal partners.
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