Rural populations globally 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 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 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 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. NSW Ministry of Health 2020]. 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]. Already limited access to rural health care was 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 an additional impact of COVID-19 on First Nations Australians who already had poorer access to digital devices and virtual healthcare [12].
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 [13]. 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 [14]. The COVID-19 Delta variant’s spread through Western NSW communities has highlighted limited access to vaccination and health workforce shortages adding to vulnerability of First Nation’s communities [15]. Redistribution of vaccines from rural NSW to non-First Nations school children in Sydney reinforced long-held views of First Nations Australians being treated as second class citizens.
Health literacy is a key factor in accessing and interpreting pandemic information. Studies of the current COVID-19 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 marginalised communities [16, 17]. Different consumer populations require nuanced communications that addresses their cultural milieu including for First Nations Australians, a distrust of government and poor health care experiences [18]. The Aboriginal Community Controlled health sector worked hard to inform communities around Australia about COVID-19 risks including closing remote communities and developing localised social media campaigns for these sites [19]. As the pandemic continues development of specific health communications for rural and remote people in NSW is required with tailored options for First Nations Australian communities in the region.
Risk perception and resultant behaviour is strongly influenced by personal, social and cultural contexts [20]. Two Australian studies have identified differences between First Nations and non-First Nations respondents in relation to COVID-19. One found that non-Caucasian people were more likely to engage in protective health behaviours and included First Nations Australians in that group [21]. And the other found the First Nations Australians perceived a greater risk from people who were not vaccinated [22]. 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 and remote 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 community management and COVID recovery plans [14, 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 lock down in Australia; and analysed other variables that could predict an exacerbation of anxiety related to COVID-19 harms.