Objective: To consider the challenges of communicating COVID-19 directives to culturally and linguistically diverse (CALD) communities in Australia, and present evidence-based solutions to influence policy and practice on promoting relevant health behaviours; to advance participatory research methodologies for health behaviour change.
Type of program or service: We present a case study of a participatory research collaboration between CALD community leaders and health behaviour change scientists during the COVID-19 crisis. The goal was to better understand the role of community leaders in shaping health behaviours in their communities and how that role might be leveraged for better health outcomes.
Methods: This article is the culmination of a series of dialogues between CALD community and advocacy leaders, and health behaviour change scientists in July 2020. The academic authors recruited 12 prominent CALD community leaders, conducted five semi-structured dialogues with small groups, and worked with all participants to develop insights that were applicable to the many different CALD communities represented in the research collaboration.
Results: Three key findings emerged: 1) partnerships between CALD leaders, communities and government are critical for effective health communication; 2) shifting behaviour requires moving beyond disseminating information to designing tailored solutions; and 3) the diverse needs and circumstances of people and communities must be at the centre of health communication and behaviour change strategies.
Lessons learnt: The collaborative process we undertook in this study enabled us to identify key challenges experienced and solutions offered by CALD leaders in communicating health information throughout the COVID-19 pandemic. Partnering with communities that are subject to health messaging can reduce inequalities in healthcare communication by enabling the development of strategies that help align human behaviour with the recommendations of health experts. This – along with sustained partnership and collaboration with CALD communities, understanding the cultural context, and the appropriate tailoring and delivery of communications – will ensure health-related messages are not lost in translation. The lessons provided in this paper are applicable not only to the current pandemic but also to post-pandemic social and economic recovery.
Australia documented its first confirmed case of coronavirus disease 2019 (COVID-19) on 25 January 2020, and nearly 500 cases were being reported daily by late March. The Federal Government promptly adopted a controlled adaptation strategy and, as of July 2020, every state and territory in Australia appeared to have contained the virus, except for Victoria. After Victoria relaxed restrictions in late May, metropolitan Melbourne and the Mitchell Shire located north of Melbourne experienced a second wave of COVID-19 in July 2020 and restrictions were reintroduced. The experiences during the second wave highlighted the need to engage culturally and linguistically diverse (CALD) communities. Widespread outbreaks of COVID-19 in several public housing towers, populated largely by people from CALD backgrounds, suggested that attempts to communicate the recommendations of the Chief Medical Officer may not have reached and/or been understood by all CALD community members.
It is often assumed that providing people with information and explaining why people should perform a behaviour will result in compliance.1 However, behavioural science has demonstrated that achieving desirable behaviours in a target population is accomplished by understanding the needs of the population and the barriers and enablers to behaviour change. Effective services and interventions draw upon evidence-based practices while taking local context into account. However it is not just what goes into the program, but how it is delivered that matters: implementation science offers techniques to embed evidence-informed strategies into frontline delivery. Designing and implementing successful health promotion interventions requires collaboration with communities.1,2,3 Thus, collaboration was formed between health behaviour scientists and CALD community leaders, advocates and bicultural workers (hereafter referred to as ‘community leaders’) to discuss the challenges faced by CALD communities in communicating COVID-19 health messages, and to develop evidence-based strategies to inform and empower CALD communities to adapt their behaviours in line with COVID-19 recommendations.
CALD community leaders, advocates and bicultural health workers have a wealth of knowledge and experience working across diverse communities in Australia. Developing research collaborations with those who have lived experience of the issue being studied is now a well-established method in health research, under the banner of ‘participatory research’.3 Using methods of participatory research, this paper has been co-produced by academics and CALD community leaders from end to end: from data collection through to the co-production of an academic manuscript. Purposive and snowball sampling were used to invite CALD community leaders to collaborate. The academic authors initially invited leaders known to them and those contributing to the public conversation about the issue in the media to take part. They then asked the core sample of seven who had agreed to participate to invite other CALD community leaders with relevant experience to take part.
Five semi-structured dialogues were held online via Zoom teleconference in July 2020 with various combinations of CALD community leaders (12 in total), focusing on the following three questions:
After completion of the audio-recorded dialogues (mean length 60 minutes), transcripts of the dialogues were analysed by AW and HS using inductive, interpretivist qualitative methods to identify key themes.4 This grounded-theory approach was used to identify key themes which were circulated to all in the research collaboration for further refinement before finalisation.
A ‘live’ online document was created to allow for multiple authors to contribute to the paper in conjunction with email consultations at four points: first, a draft prepared by AW, AK, DG, and HS was shared with all co-authors for further input/comment; next, initial feedback was incorporated into the paper by AW, and a revised draft was circulated for three more rounds of comment and approval. This iterative process allowed for collaboration throughout analysis and interpretation. The following describes the insights gleaned from this process.
While CALD community leaders commended the efforts of the federal and state governments to combat COVID-19, they suggested that challenges remain when communicating public health messages about the pandemic. Challenges may occur due to a lack of the following:
1. Translation of information into all of the various languages spoken by community members
2. Testing of translated materials by CALD groups to ensure that messages are understood by people who might also have limited health literacy
3. Tailoring translation and messages to specific communities, thereby contextualising messages
4. Using trusted messengers to deliver information (e.g. community leaders, advocates)
5. Communication methods that are appropriate to and accessible by CALD communities (e.g. ethnic radio, newspapers, videos delivered via social media platforms)
6. Engagement and collaboration with CALD communities and CALD advisory groups representing CALD communities at a state and federal level
7. CALD voices being represented and embedded in government and healthcare decision making.
These challenges demonstrate the complexity of developing and implementing mass public health communication strategies during public health crises.5,6 Messages need to be tailored when developed, so they are presented in a meaningful, relevant and applicable way to all population groups. This will be most effectively achieved by codesigning solutions with consumer and community involvement.7
Below we outline solutions offered from CALD community leaders, advocates and bicultural health workers that have been synthesised from the participatory process. In order to see what insights applied across the varied experiences of CALD communities, community leaders’ responses were recorded for three topics that were the focus of the dialogues: 1) disseminating messages; 2) designing messages; 3) building trust between communities and government.
Solutions were synthesised through an iterative mapping exercise using Miro, a collaborative online whiteboard tool (San Francisco, CA: Miro). Community leaders generated a range of recommendations, for example, about how COVID-19 messages could be disseminated more effectively, and these recommendations were sorted by AW in an initial map (Figure 1a, available from: xx). The second phase of mapping added explanations community leaders provided about why each of these recommendations would be effective, and drew connections between specific examples and the principles underlying their effectiveness (Figure 1b, available from: xxx). This mapping process was repeated with community leaders’ responses regarding how messages could be designed more effectively (Figure 2, available from: xxx) and how trust could be built between communities and government (Figure 3, available from: xxx).
To arrive at practical recommendations, authors then prioritised principles of effectiveness according to three criteria: 1) how many specific examples were linked to an explanatory principle (as indicated by arrows in Figure 1b); 2) the generalisability of a principle across CALD communities; 3) consistency with relevant research evidence. Five recommendations for health officials were distilled from this prioritisation process: 1) partner with communities to tailor messages; 2) use trusted messengers; 3) communicate via appropriate channels; 4) avoid blame and stigma and 5) establish structures for meaningful partnership, such as an advisory body. These recommendations are described below.
Translating COVID-19 health information and prevention strategies into different languages is necessary, however information alone does not lead to behaviour change.1 The process of language translation must also consider the audience’s frame of reference, and the context in which the translated material will be used, which can be done by partnering with community leaders to understand the barriers to understanding and adopting the information.8 For example, working with CALD representatives will ensure that information is translated into the most appropriate dialects and that it addresses common misconceptions (e.g. the cost of testing) and that difficulties in adhering to disseminated health information can be identified.
Translated information should be delivered using trusted messengers, as the effectiveness of any message depends upon how an audience perceives the credibility of its source.9,10 For many of the CALD communities in Australia, religious practice is important, and faith leaders can have great impact when promoting and modelling desired behaviours.11
Recognising that health communicators are competing for the attention of their audience, information should be delivered in ways that are accessible and appropriate to the target community.12,13 For example, the WeChat platform plays an important role in disseminating COVID-19 information to the Chinese community in Australia, providing up-to-date information in Chinese languages. Similarly, other CALD communities rely on community message boards, ethnic language print, radio and TV media.
Infectious disease outbreaks create feelings of fear that can exacerbate racist and xenophobic behaviour, as has been documented during the COVID-19 pandemic.14 Care should be taken to ensure that extra efforts to reach and support communities that are disproportionately affected by COVID-19 are not interpreted as singling out particular groups as more likely to spread disease. Not only could this increase instances of racism, it would be counterproductive to health efforts, as stigma is a well-documented global barrier to people seeking testing, health treatment or preventive strategies.15,16
COVID-19 presents an opportunity to bring together diverse communities and establish meaningful partnership between CALD communities and health officials. Creating a national advisory body is a way to formalise these connections and use them to support successful communication with CALD communities now and in the future. A CALD advisory group would provide a recognised source from which the government could seek advice and guidance on matters of health pertaining to CALD communities and would also provide a practical and efficient way to streamline communication with multiple CALD communities. A group could be quickly established by drawing on the membership of existing groups like the Federation of Ethnic Communities Councils of Australia (FECCA), as well as being publicised at all community consultations, taking particular care to include members of newer migrant groups which may not have membership in existing networks.
Drawing upon the principles recommended above, the authors considered how the barriers to effective communication identified at the beginning of this article might be overcome. A number of solutions were generated during the dialogues, which were refined during collaborative writing, to arrive at the following possible solutions:
1) Providing CALD community leaders with effective channels for contacting health authorities, to ask questions or request additional messaging support when needed (e.g. how to adjust behaviour during religious ceremonies or community events)
2) Preceding any major announcement by convening a diverse group of CALD representatives that could flag any major logistical and cultural considerations in advance and suggest solutions (e.g. importance of sending female health workers for door-to-door swab testing; culturally appropriate food support for migrant families in lockdown)
3) Deputising and resourcing community leaders and health advocates to take the lead on translation and health communication within their communities
4) Collaboration with ethnic language media to convey important health, safety and community messages
5) Reporting measures of ethnicity to the National Notifiable Diseases Surveillance System
6) Having proactive solution-focused consultations, rather than reactive consultations in response to a crisis, to create opportunities for ‘collective sensemaking’ and codesign of strategies that foster prevention.
Bringing together CALD community leaders and health behaviour researchers enabled us to synthesise recommendations that draw on insights from behavioural and implementation science, as well as the lived experience and professional expertise of community members. A participatory, collaborative research approach enabled us to identify barriers to communicating COVID-19 directives to CALD communities in Australia, and to codesign possible solutions to overcome those barriers through an iterative process of dialogue, analysis and synthesis. The research found that sustained partnerships and collaboration with CALD communities, both directly and through respected leaders and organisations, will enable more effective communication strategies. Working in this way provides the opportunity for timely responses to urgent public health needs, such as those experienced during the COVID-19 pandemic.
Externally peer reviewed, not commissioned.
© 2021 Wild et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.