A comparison of rural Australian First Nations and Non-First Nations survey responses to COVID-19 risks and impacts: implications for health communications

Globally, rural populations have experienced significant impacts from COVID-19. While infections spread more rapidly in highly populated areas, once the virus arrived in rural areas, mortality rates were higher, and economic and social impacts were more serious [1, 2]. Impacts on rural communities were attributed to generally poorer health, including chronic conditions, an older population, lower education, and employment that had to be undertaken in person [3].

Australia has reported low numbers of COVID-19 infections compared to many places in the world. Geographic isolation and good infection control have resulted in a small proportion of the population being affected by the disease [4]. At the beginning of the pandemic with limited experience of similar health crises, the government scrambled to identify and protect the country’s most vulnerable groups, including people with chronic illnesses, those in aged care and First Nations Australians. The phrase ‘First Nations Peoples’ refers to Indigenous peoples worldwide but especially in colonised nations of Australia, Aotearoa/New Zealand, Canada, and the United States. In this paper, the phrase ‘First Nations Australians and First Nations’ refers to the Aboriginal and Torres Strait Islander peoples in Australia [5]. First Nations Australians were found to be at greater risk of morbidity and mortality during past influenza pandemics [6], and gaps had been identified in existing disaster response plans, including a lack of information targeted to First Nations Australians [7].

People in rural and remote Australia were not specifically included as a vulnerable group in COVID response plans even though they were likely more at risk from COVID-19 for the same reasons as rural populations in other countries. First Nations Australians are a higher proportion of the population in rural areas compared to urban areas, and due to widespread racism, structural disadvantage and dispossession of land are disproportionately affected by poor physical and mental health, lower incomes and crowded housing prior to COVID-19 compared to non-First Nations Australians [8, 9]. COVID-19, converging with existing social and health conditions, including an epidemic of poor mental health, has the potential to cause a syndemic for First Nations Australians [9, 10]. Limited access to rural health care was further reduced during the pandemic due to service closures and fear of disease contagion. A move to virtual healthcare delivery was constrained in many rural areas because of unreliable connections and poor coverage [11]. This has been a more significant impact of COVID-19 on First Nations Australians who already had poorer access to digital devices and outcomes from virtual healthcare [12, 13].

While a NSW pandemic preparedness guideline released in July 2019 was based on extensive consultation with First Nations stakeholders, there was a notable absence of empirical research informing the strategy [14]. In addition, there was an absence of research examining rural First Nations Australian’s perceptions of COVID-19 risks and information and communication needs to better inform culturally safe community management and COVID recovery plans [15, 16].

Education level is a key factor in accessing and interpreting pandemic information and should be considered in the development of health communications. However, few studies examine the education level of respondents when assessing risk perceptions about COVID-19 [17, 18]. Studies of the current COVID-19 pandemic and previous Swine flu pandemic have found that health messaging has been confusing and difficult to understand, with written materials requiring above average reading ability and with limited attention paid to providing targeted messages to marginalized communities [18, 19]. However, it is not just education levels that are a factor in understanding pandemic information and responses. All infectious diseases disproportionately impact poor populations, women and First Nations peoples who experience health inequality because of these demographic characteristics [19]. Different consumer populations require nuanced communications that address their cultural milieu, including for First Nations Australians, a distrust of government and poor health care experiences that reduce access to healthcare and also acceptance of health communications [20, 21].

Risk perception and resultant behaviour are strongly influenced by personal, social and cultural contexts [22]. Two Australian studies have identified differences between First Nations and non-First Nations respondents in relation to COVID-19. One study found that non-Caucasian people were more likely to engage in protective health behaviours and included First Nations Australians in that group [23]. The other study found that the First Nations Australians perceived a greater risk from people who were not vaccinated [24]. However, there has been no investigation of the COVID-19 risk perceptions of First Nations Australians living in rural areas compared to those of non-First Nations rural populations. In particular, there is an absence of research examining rural First Nations people’s concerns about COVID-19 and its likely impacts to describe and compare factors that could better inform culturally safe communication strategies [15, 6]. To address this gap, this study investigated differences between rural-dwelling First Nations and non-First Nations survey respondents’ perceptions of COVID-19-related risks during the first COVID-19 lockdown in Australia and analysed other variables that could predict an exacerbation of anxiety related to COVID-19 harms.

A cross-sectional online and paper survey of rural residents from the western regions of NSW was conducted.

The research team included two First Nations researchers (a Wiradjuri Woman and Ngiyampaa Man). A First Nations Reference Group was convened with members of the western NSW community and met monthly for the life of the project. This group oversaw the cultural safety and sensitivity of the project [25]. For example, they reviewed and amended the survey (e.g., changing problematic language and including additional socio-demographic questions about household types, living arrangements, the role of community leaders and the types of health services available). They also recommended data collection methods and advised on the implications of the results.

There were 701 completed surveys collected. Paper-based surveys were completed by seven First Nations Australian respondents. The remaining 694 surveys were completed online. There were more female (n=447) than male respondents (n=254). Table 2 reports the survey respondents’ demographic characteristics. There were significant differences between First Nations (n=60) and non-First Nations (n= 639) respondents across all categories. First Nations respondents were significantly more likely to be female, to have a postgraduate degree, to live in a rural town more than 20 kilometres away from a health service and to be looking after children in their home compared to non-First Nations respondents.

Having compared the demographic characteristics of the First Nations respondents with non-First Nations members of the sample, in the next section, the groups are compared in terms of their perceptions about COVID-19. Table 3 includes five measures related to COVID-19 perceptions where there was a significant difference between the two groups: perceived likelihood of contracting COVID-19 in the next 12 months, perceived harmfulness of the virus, how often people felt afraid because of COVID-19, perceptions about respondents’ ability to do something about the virus and perceived economic impacts of the pandemic.

The results reflect a significantly higher level of anxiety among the First Nations group in the sample: they felt afraid more often, felt it was highly likely they would catch the virus and if they did catch the virus perceived that it would be very harmful.

The significant differences in other demographic characteristics included in Table 2 suggested that there may be more than First Nations status influencing the perceptions of each group, for example, education, age, gender, and population where people live and whether children were present in the household. The following section reports the results of two multinomial regression analyses examining the predictive relationship between the demographic characteristics of respondents and 1) how often they felt afraid of COVID-19 and 2) how harmful they perceived the virus to be.

In the first regression (Table 4), how often people reported feeling afraid about the virus was considered. Non-First Nations respondents were 60% less likely to report feeling afraid sometimes than First Nations respondents, illustrating a very different level of affect between these groups. Compared to those living in rural and remote areas, those living in towns were less likely to feel afraid sometimes (51.1%) and all of the time (79.6%). Males were six times more likely than females to report feeling afraid all of the time, and those with children under 18 in their household were 1.8 times more likely to report feeling afraid sometimes (when compared to those who did not feel afraid). Finally, those with a trade certificate or a diploma were 71.6% less likely to say they sometimes felt afraid than those with a postgraduate degree.

In the second regression, the perceived harmfulness of the virus was examined (Table 5). First, Nations status was the only variable that was significantly related to perceptions of harmfulness. When compared to those who thought COVID-19 was not harmful, Non-First Nations respondents were 66% less likely than First Nations respondents to perceive COVID-19 as moderately harmful and 93% less likely than First Nations respondents to report that the virus was very harmful. Education level does not make a difference in this model.

Overall, these findings reflect a much higher level of anxiety and fatalism amongst the First Nations respondents. There were some significant differences in risk perception and impacts of COVID-19 between First Nations and non-First Nations survey respondents and several demographic variables that predicted responses to COVID-19. First Nations respondents perceived COVID-19 to be more harmful than non-First Nations respondents to perceive a higher danger and vulnerability from the virus. . At the time the survey was conducted, there was no COVID-19 reported in Western NSW. Therefore, the finding of high perceptions of vulnerability from COVID-19 may reflect the media discourse about the high level of risk that First Nations people face in relation to COVID-19 and the potential impact on First Nations communities in other parts of Australia as well as confused messaging about risks to different places and sectors of the population [19, 21, 24].

There were significantly higher levels of anxiety among First Nations respondents (based on perceptions of fear and the harmfulness of the virus). Significantly higher levels of fatalism and a huge disparity in the perceived likelihood of catching the virus in the next 12 months point to the impact of COVID-19 anxiety on top of existing high levels of mental distress and social disadvantage [16]. All factors are consistent with a syndemic [10] indicating a much more serious impact of COVID-19 on First Nations Australians compared to non-First Nations Australians. First Nation’s survey respondents’ fears were justified because the Delta variant of COVID-19 quickly took hold in small communities with limited healthcare services, reflecting the pattern seen in other countries [16, 2]. Limitations in accessing healthcare services are also reflected in the results. Excluding rural populations from risk groups at the start of the pandemic was a dangerous oversight by the Australian government. The high proportion of First Nations people in Western NSW was not taken into account in vaccine rollout plans or the limited availability of healthcare services.

Other factors influencing perceptions of COVID-19’s harmfulness were also characteristic of many First Nations communities. Residing in a small rural town and living with children under the age of eighteen years were significantly predictive of concerns about COVID-19 harms. First Nations peoples typically live in larger extended family groups, including children, and in Western NSW, they are more likely to live in small rural communities than on farming properties [27, 34]. Frequently changing advice about the risks both to and from children directly impacts First Nations communities and likely heightened fear and concern about COVID-19 risks.

A high proportion of First Nations survey respondents had a post-school qualification (78% in the study compared to 42% of First Nations Australians nationally) [35]. However, most of the non-first Nations respondents only had school or vocational qualifications. High levels of education are likely to be consistent with good health literacy and better adherence to COVID-19 protective measures [15, 17, 19]. Lower levels of fear and perceptions of COVID-19 harmfulness among non-First-Nations respondents with lower education levels indicate a potentially blasé response to COVID-19 risks. Lower education levels are correlated with lower levels of concern about pandemic risks and typically result in less adherence to infection control measures, putting vulnerable groups at risk [36, 37, 17].

Education level is not the only issue at play in the effectiveness of health communications [18]. The levels of fear and perceptions of harmfulness found in the survey results should be expected when distrust of government and previous poor health care experiences are widespread for First Nations people [20]. There were no First Nations representatives in the daily government press conferences that delivered health advice even though there were frequent mentions of risks to ‘the regions’ [16, 20]. Heterogeneity of the population means diverse capacity to understand and apply pandemic related information [19]. Health messages could better target their intended audience by directly addressing the specific concerns and healthcare experiences of distinct populations such as First Nations communities in rural areas, via co-design of health communications and dissemination strategies [9]. The Aboriginal Community Controlled health sector worked hard to inform First Nations communities about COVID-19 risks, including closing remote Northern Territory communities and developing localised social media campaigns for these sites where subsequently no COVID-19 cases were reported during 2020 [21].This approach was not applied nation-wide. As the pandemic continues, the development of specific health communications for rural people in NSW is required with tailored options for First Nations Australian communities in the region.

Health communications for First Nations Australians in rural areas should be designed and delivered by First Nation’s Australians from those areas because they understand the rural context in which people live. This principle of First Nations-led design is critical to all health policy and planning. The Australian Government should include rural areas in planning pandemic responses, recognising that First Nations populations are a significant proportion of the rural population with different risk factors and concerns than those of non-First Nations peoples, creating syndemic conditions.