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Of the ten service providers invited, six agreed to participate. Of the 17 influential members invited, nine agreed to participate. Of the 24 community members invited, 15 agreed to participate. Two of the six service providers self-identified as also being influential community members. Five of the nine influential members self-identified as having had a refugee-like background themselves. Demographics of the community member participants are shown in Table 1.
We identified three major themes and several subthemes (Table 2). 1) Experience as a refugee uniquely influences COVID-19 message communication; 2) Refugee groups use diverse practices when accessing and sharing COVID-19 messages; 3) Official government messages could be improved by listening and tailoring to community needs.
Experience as a refugee uniquely influences COVID-19 message communication
Community members expressed how the ongoing lived experience as a refugee influenced access to COVID-19 health messages.
Educational background and English language proficiency
Community respondents described how fractured opportunities for education during times of war and escape led to reduced ability in general literacy. Furthermore, poor education coupled with low English proficiency contributed to feelings of inadequacy and low self-confidence. One Afghan community member explained that: ‘ … it’s really embarrassing if I go and ask….It’s like I’m saying I don’t have knowledge…’ A Congolese influential member reported that community members with lower English proficiency avoided attending COVID-19 information sessions because ‘ … they feel as if they are not good enough for that meeting, or not good enough to show themselves up … and speak there’. A Syrian influential member observed that people in her community with lower levels of education were more likely to rely on others for information and respond to rumours than those who were educated to seek information for themselves.
Community members interpret the same English messages differently. One Afghan influential member said: ‘some people confused to be honest … most people English word have different meaning. Even I myself struggle with some of the words what exactly is that meaning and the content.’ Community members also reported that people had varying abilities in digital literacy, information and media literacy. Seeking out and determining accuracy of information was difficult to many in the community. One Afghan community member explained: ‘ … we have laptop- I don’t know what I should type, or what I should put. I don’t want to make mess or any mistake. So, I just leave it. And I’m not confident enough. And if I don’t know anything, I’m going to say “I don’t know it”. Just leave it…’ Another Afghan community member explained that: ‘Sometimes when you pass information from this person to the other, it’s like second hand news. You don’t know if it’s been altered or amended somewhere in between, and you don’t know how true it is.’
On the other hand, influential and community members also reported that proficiency in English and baseline education were helpful in COVID-19 information seeking. Likewise, having access to an English-speaking family or friend was reported as beneficial for understanding health information provided in English. This was especially notable for Afghan community women, whose husbands had worked as interpreters for the Australian Defence Force.
Mental health
Some influential and community members also reported that anxiety and trauma, resulting from the refugee experience impacted interpretation and reactions to important information, such as COVID-19 messages. A Syrian influential member said: ‘Sometimes they [former refugees] may not get and understand the message sent to them … So sometimes we go to them, “okay, this is good for you, this is healthy”. Because sometimes, still they suffer from the trauma, and sometimes they may not take the [COVID-19] message in a straight way. Still they have, “we are still scared to get our citizenship … this [COVID-19] may be harmful for us”.’ Ongoing concerns about family overseas and the homeland COVID-19 situation were reported to contribute to panic and fear amongst communities. Apart from confusion and uncertainty, rumour was a source of anxiety and destabilisation, as one Syrian community member said: ‘Some people say the rumours and this make us like panic, get panic and get scared … we don’t like rumours. Rumours affects us.’ Furthermore, one Congolese influential member suggested that rumour might affect health seeking behaviour: ‘misinformation [rumour] itself is also making people not actually seek health advice if you’re ill because they are worried … [that] they might have Corona [virus-19] and that is a problem.’
Trust
Service providers, influential and community members explained that trust was fundamental to relationship building and subsequently, was a major driver of message sharing. Community members reported great trust in their community leaders, as an Afghan community member reported: ‘ … the reason is that person being honest, and the past history shows that person did not do any mistake to put them under any question … and people they trust them, whatever things that they say.’ Similarly, a Congolese influential member reported that ‘community leaders are the actual people where multicultural people get information about COVID-19, because that’s their trusted system- their community leaders, their elders…’ Many community members also reported trusting their friends and family members to receive and understand COVID-19 messages, particularly those of their own sect who were educated or had proficiency in English. Community members described trusting known staff from service agencies with whom they had established relationships, such as: settlement agency case workers, refugee health nurses and English teachers. Settlement agency staff were particularly trusted by community members, described as having the means and experience to communicate trustworthy COVID-19 messages directly to community members. Some community members said they felt safe in Australia, having assurance of the health system and trust in official government messages.
Connectivity and social cohesion
Community members described how connectivity was vital for their new and emerging population, although at times, this was difficult during COVID-19 lockdown periods. A service provider reported that newly arrived refugees were limited in social connections due to the restrictions of lockdown and quarantine. Several community members agreed that connections to family, community and religious groups created a network for people to share information easily using their own language. A Congolese influential member commented on how connections were achieved: ‘We care about relationships. We reach out to these people … we mourn with them, we feast with them, we celebrate with them, we are really in their space.’
Multilingual and educated community and influential members reported having a sense of social responsibility and obligation to connect and share important COVID-19 health information with others. Connections within family, such as school children who were fluent in English, helped translated messages to reach parents. Overseas connections to self-educate about COVID-19 were maintained by community members, by watching foreign television news and connecting through social media. Sometimes, being well-connected to overseas family, friends and media was noted to cause confusion and distress. A Congolese influential member explained: ‘So they just hear the news here [in Australia] and that side [overseas] … and then they [are] just more panicking. So I try to make [tell] them “… you need first to know what is happening here”’. A Syrian influential member described how the social connection within refugee communities impacts message transmission: ‘they [former refugees] came from their country, it’s very social. [Here], they visit each other, and they help each other, and if someone knows an information, surely the others will get the information … ’.
Heterogeneity of culture, language and religion
Some community members explained the inherent diversity within refugee groups, including languages, religious beliefs and cultural backgrounds. Many participants reported that official COVID-19 messages did not respond well to that diversity. For example, community and influential members explained that people of minority languages had limited access to official COVID-19 information. There was also variation in the preference of message tone- one Syrian influential member passed on messages in everyday friendly language; whilst another Syrian influential member said that the tone should be more formal, reporting that ‘when it’s friendly, they [community members] don’t follow it [message] up.’
Refugee groups use diverse practices when accessing and sharing COVID-19 messages
Participants indicated that past experiences of trauma and persecution, life opportunities and relationships all influence the sources and types of COVID-19 messages accessed by refugees.
Preferred sources of COVID-19 messages
Many community members noted that they preferred sources that had a simple message provided in language using a device that was easily accessible. Community members also preferred an audio-visual format, which did not contain text. An Afghan community member reported: ‘Reading news is really difficult. I always watch or listen. Listening and watching, because my reading is not as strong as others’.
All groups agreed that the smartphone was a commonly used tool for community members to access COVID-19 related information. Smartphones provided access to numerous platforms such as social media, text messages, phone-calls, emails, government websites and applications. Community reported that social media (especially WhatsApp and Facebook), were commonly used to network with trusted friends and family, both locally and overseas. Social media updates and messages were also provided by trusted service providers and officials, such as religious groups, settlement agencies, English teachers and government health sector in addition to influential members. Many participants noted that social media was popular with refugee communities because the platform provided the opportunity to communicate with hundreds of contacts instantly and affordably. Social media platforms also provided the added option of relaying voice-messages, thereby appealing to those who were not confident with written language. Many community members also described how important the mobile phone was in sharing COVID-19 related information. A Congolese influential member reported: ‘ … it [telephone] was the only material available to use, whether you’ve been to school or not, or whether you’re rich or poor.’
Some community members learnt about COVID-19 from pictorial signs or posters e.g., at shopping centres or other official organisations. Community members also reported trusting visual messages from overseas, especially television.
Some community members observed that settlement agencies were a useful and trusted source of COVID-19 information- particularly for newly arrived refugees who benefited from regular access to caseworkers providing active support and advice. Some community members also reported trusting information delivered by English language teachers and school teachers, staff from familiar non-government organisations and charities. Service providers and community members explained how Refugee Health staff delivered messages by telephone and face-to-face during medical consultations. All groups of participants, especially community members, praised Refugee Health staff as a trusted source of COVID-19 information. One Syrian influential member explained why this was so:
‘when they [community members] have a message from the doctor or [RH nurse], they think it very serious issue. They feel it’s interference from the health professional, it’s something big, something massive happening … That is what they received back in Lebanon, or Jordan, and the orientation which they have from the United Nation [overseas] which they have, that ‘there will be a clinic called Refugee Clinic- it responsible for you there [in Australia]’.
Ways of message sharing
Some community members reported accessing COVID-19 information opportunistically as opposed to intentionally. For example, some communities heard news from the radio or passengers whilst working as taxi or delivery (Uber) drivers. Some participants said that word of mouth was a common method of sharing information, for example during religious congregation, or with neighbours or friends attending English classes. One Afghan influential member explained that: ‘Any social gatherings, they share … they heard something, and it goes … viral after this’. Some community members reported that face-to face presentation of information was easier for sharing messages, others preferred digital formats, as one Syrian community member reported: ‘Face to face is difficult, because some people are working, some people at home. But by message you can reach us … Even if they are at home, they can get it.’ Community members critiqued that lockdown inhibited opportunities for formal and informal sharing of COVID-19 news.
Official government messages could be improved by listening and tailoring to community needs
Participants suggested various ways in which official information sharing about COVID-19 with refugee communities could be improved (Table 3). We describe them below in greater detail.
Improved message content, delivery and format
All three groups of participants suggested that official government messages could be improved by using a visual format in the appropriate language, providing outreach face-to-face demonstration sessions at familiar locations, and using trusted people and staff to distribute messages. Community and influential members added that regular updates and direct contact by telephone or in-person would be helpful for those with low written and digital literacy. Influential members and service providers suggested to simplify messages, pitching them to reach those at a basic education level, with accurate translation. As one service provider remarked: ‘if the English copy is academic and terrible, then the translation will be academic and terrible’. One Afghan influential member summarised that: ‘I like the idea, when you post video [on social media] … in all languages. 1 minute, weekly, twice, something like that, it would be more helpful. And good thing is to pick people from communities itself. Religious leaders, doctors, GP [general practitioners], people know, and it will be good.’
Some influential participants reported that governments need to mutually respect and acknowledge inherent diversity within communities, to provide acceptable COVID-19 messages. One Afghan influential member expressed the significance of respecting and recognising different sects:
‘Let me tell little thing about Afghan- you know Afghan, we have different tribes, like hundreds different tribes. Each tribe, this is in an Afghan’s DNA, ok- “first respect me, then I respect you for my entire life”. If we came up with interpreter and doctor to interpret in Pashto and if I send that video to Pashto tribe, they would love it. They would say, “they are respecting us, they are interpreting in our own language”. Which means they feel respect. And also if we do the same thing in Dari, that would be nice as well.’
Greater cooperation and collaboration between communities and services
Community members also noted that communication about COVID-19 could be improved if service providers, such as settlement agencies, government organisations and charities, worked collaboratively with community and their influential members to share accurate and up to date COVID-19 information. All participant groups recommended enhancing the role and response of Refugee Health and other public health organisations. Service providers and influential community members reported a desire to collaborate closer with government health services and had confidence that this would result in a better service for community. One Afghan influential member remarked:
‘Look, this is a really nice work when people say ‘let’s work together’, and if we work together, we can pass this message to the community. You can pass it through me, through other community members, and that is really easy. I honestly do my job, I will share, and the community will take the benefit of that …. If you have 3 or 4 active members, who is connected with you guys, then I’m sure we would cover all the community with the accurate news and important news.’
Enhanced role of trusted service providers
Influential members and service providers encouraged Refugee Health to extend their advocacy and research roles to assist communities. One Congolese influential member put it this way: ‘you [refugee health staff] are also dealing with the most difficult people that are even finding it hard to get the message by themselves … You guys are probably the perfect people in the centre of all this.’ One service provider suggested increasing the visual presence of the Refugee Health Team in promoting COVID-19 related educational material. Similarly, community members reported that information distributed by the settlement services would be well accepted, due to established trust.
Research as a medium for mutual learning and community empowerment
Some community members identified research as an opportunity to voice their experiences and improve current services. One Congolese influential member said: ‘ … doing something like this [research group], in a meeting, face to face, I think it’s sort of like, giving us also the chance of saying, we can do better’. Another Congolese influential member suggested that: ‘One of the thing [problem] I think of is the lack of research. And those top government organisation how to work with these community members in order to spread the information’. Some community members took the opportunity of the research interview to clarify COVID-19 information, by directly asking interviewers. One community member said: ‘Even you telling me about how far the COVID has gone, from sitting here, that can help me understand’.
Supporting the messengers
Some service providers reported feeling unsupported by government agencies to deliver COVID-19 messages, particularly at the start of the pandemic. Influential members and service providers indicated that government services could consider a ‘train the trainers’ approach- providing official educational sessions to influential people who could distribute that message to the broader community. A Congolese influential member explained: ‘I would suggest training the trainers and also having people who will deliver those programs into the community. And knowing those communities who have the capability to deliver the message, it would be under that addendum’. An Afghan influential member explained that governments can assist by improving communication with influential members by directly providing up to date information: ‘… they [community members] are asking me “what we should do about this, what we should do about this” and I’m sitting for hours and hours googling that. If I get that directly information from you guys [government health service], then I can send that video-link to them, “ok, see this” and it’s easy for me, easy for them’.
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