How can we improve health messaging to reach all Australians?

Gretchen: Hello, this is Prevention Works, the podcast of The Australian Prevention Partnership Centre. I’m Gretchen Miller, and we’ve often reflected on Prevention Works how culturally and linguistically diverse people in Australian are neglected in most academic research, and health is not exempt. In this episode we’re discussing how Australian health messaging reaches this cohort and how it might be done better. Our research example is mid-life women, those entering perimenopause and menopause, with all the associated preventable health risks. Our guest today is Dr Mridula Bandyopadhyay, working in translation and knowledge transfer for the Centre of Research Excellence on Women and Non-communicable Diseases, CRE WaND for short, and CRE WaND is part of CERI, the Collaboration for Enhanced Research Impact. Mridula is also a research fellow in obstetrics and gynaecology at Melbourne’s Royal Women’s Hospital, and she looks into how Australians discover information about health issues. It’s no surprise that half our population searches online to inform themselves, but how does that work for you when English is not your first language? Mridula Bandyopadhyay, welcome. Can you describe the situation in Australia for communicating health issues to the broad community, what’s the status quo?

Mridula: Look, what I have found through my research over the years and recently through the CRE WaND program, most of the information which is out there is mostly text-based and it is very dense to understand, and people with low levels of education or from culturally and linguistically diverse backgrounds have difficulty understanding the messages which are out there, and then employing them to improve their situation, or using those health promotion messages to improve or self-manage their condition.

Gretchen: So there’s a real issue of accessibility, what does Australia look like, what proportion of people in Australia are culturally and linguistically diverse, for example?

Mridula: The recent census data which I looked at quite recently is populations who came into Australia, migrant population, between 2016 and 2021, out of that 14%, 14.57% have very, very poor knowledge of English and can speak limited English only, and of that 4% doesn’t speak any English at all.

Gretchen: And if you expand out from that and look at the overall population what do we see?

Mridula: Again, the data which I got from census from 2011 to 2016 shows that 22.5% of Australian population who arrived in that period between 2011 to 2016 had very poor knowledge of English or very limited English or didn’t speak English at all.

Gretchen: That’s an enormous percentage, isn’t it, when you then look at what proportion of people living in Australia are Anglo Australians, only a third are actually Anglo, so the assumption that Australia is this 1950s picture is just completely wrong, and yet I wonder whether the research community, perhaps, has had a hard time catching up on that.

Mridula: Look, again, according to 2021 Census, 28% of Australia’s population spoke a language other than English at home, so that’s a large proportion of Australian population whose English is not the first language for them, and to answer your question, I think prior to the last decade or in the last five years there was a lack of understanding and training in Australia in communicating with regard to diversity of migrant populations, the way Australian society engaged with migrant population was only from English-speaking countries like the UK or New Zealand or Canada. The policies didn’t talk about ethno-diverse population that there are a variety of people coming from different countries and Australia is facing an ever increasing ethnically diverse population, and I think COVID has put a spotlight on this. There was lack of understanding in communication, how to communicate with these communities.

Gretchen: Do you think that there’s been much of a learning about that in the health community since then?

Mridula: I think so, definitely here in Victoria the Health Department is working with the communities now and trying to put messages in their language ensuring that their cultural practices and traditions are respected and be very culturally sensitive. So inviting those community leaders to have a dialogue with the Health Department helped them do the proper messaging about how to avoid COVID, how to take care of yourself, how to sanitise and everything else, so that is changing and researchers are also engaging with the communities in a big way. Previously they did but it was all the social scientists or the anthropologists or the sociologists who were doing that work, and to be very honest it was not considered as academic work when people were working with those groups because every time you did apply for any grants they would say oh, the evidence is not very clear because you did a small study with a small sample and it doesn’t translate to the wider population group. So that has been a block. So I think it is changing for the better now.

Gretchen: Before we kind of get to the meat of your work, I wanted to draw in another factor, and talk about the way most people get their health advice in the 2020s. As we know, doctors, GPs, are becoming more expensive, bulkbilling is harder to access, and so the internet, Dr Google, perhaps, has been a great way to inform yourself and a great place to start, but I’m wondering what the benefits of using the internet are to at least initially inform yourself of what might be going on, and how those benefits might intersect with language issues?

Mridula: Right, that’s a very good question and like you said, everyone is on social media platforms, they’re using Google, Google knows it all, but because it’s not monitored by any health practitioner or health department, so the sites, some of the sites can be quite shady, quite shonky, so you don’t know the information you’re getting is right or not. So it needs to be taken with a pinch of salt. The first port of call is okay, if you are able to read and understand what is on the internet, but you need still see your GP.

Gretchen: One of the issues is being able to tell what is a valid website and what is a dodgy website and having a good command of English is important there, isn’t it?

Mridula: Yes, sometimes the information provided, let’s say for menopause health, it’s a long list of things and densely written, but…

Gretchen: And you raise menopause and that’s no accident because that’s where you’ve been working, and it is a challenging time of life with physical and psychological symptoms that are rarely only just being talked about in public forums in English, in the media and online, without shame and with reduced discrimination in the past five years or so. It’s a vulnerable time of life for a significant proportion of the population, you’re often caring for children, teenagers, ageing extended family, it is a demanding time of life and so it’s an important time of life to be able to get clear health messaging across.

Mridula: Yes, and actually we started doing this research messaging for culturally and linguistically diverse people as well as people with low health literacy in Australia, and when we embarked on this work with CRE WaND, because we had just got this grant and we were looking at what we could translate, what was out there already, I mean the lead investigators from WaND, they were working on certain issues and menopause came up time and time again, and it was felt that it’s an important area and we need to target the population, middle-aged women, and look what information is available out there for women to understand the menopause health, what happens at menopause and how you can maintain your health to be able to care for your family, your children, yourself, and also then enjoy your life, basically.

Gretchen: Before I ask you for more detail on your study, why was it that menopause was coming up so often for CRE WaND?

Mridula: It was coming up because there are quite a number of factors which is related with non-communicable diseases as you’re getting older and if you have natural menopause, so you have surgical menopause and how then it elevates your chances of getting, for example, heart disease, diabetes, or osteoporosis, so those are the issues linked with menopause because the oestrogen is reducing in a woman’s body so many women do not know that, and what you need to do to stay on top of your game, and many women also are diagnosed at that time that may be breast cancer, ovarian cancer, so all these multi-morbidities occur around this time.

Gretchen: So CRE WaND decided to do a study, what did you set out to do?

Mridula: So I’ll just tell you how we went about this, because we collated all the studies that were done pre-2020 by the investigators and we found menopause was number one as women’s heath issue which came up time and time again, not only with CRE WaND but with the National Health Framework, Australian National Health, and also Jean Hailes reports that women wanted information on menopause health, so that was the top one. The second one was on bone health, joint health, so leading into osteoporosis, so that was the second one, and the third one was mental health. So that’s why we started with menopause, then we moved onto osteoarthritis, osteo health, bone health, and now we are looking into mental health, and they are connected in some way or the other. So when we had these meetings and we had this conversation about what should be our first translation work, so we all collectively thought that we should look at what is out there on menopause health and go from there.

Gretchen: So bringing together what we were talking about at the beginning of this conversation with the issue of menopause, what you wanted to look at was how to reach this very significant proportion of the population that needed more assistance to understand menopause better.

Mridula: Well, it was my push because I’m interested in culturally and linguistically diverse background women and refugee health, so because when I was hired to do this job, and that’s my expertise or speciality, I said that most of the literature out there is very focused to white Australian women with western lifestyle, western outlook, but there’s hardly anything on diverse communities, so can we look at Australia per se, but also concentrate on these women, and also there are Australian women, white women, who are not as highly educated as everyone else, and their understanding, their health literacy is pretty low at times, so can we concentrate on that, and that’s how we embarked on this journey. Because the health promotion tool, resource that we have come up with I think it’s easy to understand and relate to, though it’s very simplistic, but for women from culturally diverse backgrounds and for women with poor health literacy it would be very, very beneficial in our view, but we are still in the process of evaluating these videos, health promotion tools, so I can’t comment on that.

Gretchen: We’ll get to a bit more detail on those in a moment but with the study, what did you set out to do? I think you looked at and assessed 16 different websites to measure their accessibility, their readability, their searchability, and how findable and how useable they were, and how acceptable they were in terms of cultural sensitivity, right?

Mridula: Yes, what we set out to do, initially I thought I’ll just systematically review what is out here available in Australia, and the only ting we decided is we will focus more on internet-based information that is available because in today’s day and age people hardly look at anything written on a piece of paper, everyone is looking at Google, like you said, so that was a conscious decision by us that we will limit our study to, but it should be on Australian-hosted health websites, how reliable are these health websites, and what kind of information is available, is it easy to first access if you type in menopause, multiculturalism, what comes up in the first three pages of the search engine, so those are the first eight websites which come, and then evaluate it on searchability, findability, useability, whether the information in there was useful to the masses who is reading that information.

Gretchen: How many offered information in languages other than English?

Mridula: Just two websites we found, one was Better Health Channel and one was Jean Hailes. Jean Hailes is the national gateway of health information for women, but again, I think most of the women who are aware of Jean Hailes’ website are again white Australian, educated professional women, though it’s a national gateway to women’s health information, quite a few people are quite unaware of it, but they are widening their rate and they are talking to culturally and ethnically diverse women and they ware increasing their reachability.

Gretchen: And working, I think, with you to do this?

Mridula: Yes, they are working with us. So Jean Hailes had in a few community languages some information on mental health, I’m just going to talk about the menopause because this paper is basically on menopause and bone health.

Gretchen: So just two languages other than English, what other ways did the websites offer to communicate?

Mridula: Just fact sheets, basically, you can download the fact sheet and read it in English, and Department of Health Better Health Channel had in a few different languages specifically in Vietnamese, Arabic, simplified Chinese, so those were the standard languages and they are including more and more. So when I did the research last year in 2021 Census the largest group of overseas born were from England and India-born was the second group with the largest increase since 2011. So they are now translating in a few Indian languages as well because many Indian migrants who are coming, especially from Punjab and other parts of India are not very fluent in English.

Gretchen: Not only did you do this research into these websites but then CRE WaND went about practically addressing some of these problems, so tell me about the videos that you did?

Mridula: So what our research showed was that the information, yes, it is available there but it is not accessible, like you said, it’s not easy to find, it’s not easy to search within the website, and also if it is available you cannot use the information which is available to improve your own health, so self-manage.

Gretchen: So you can start off just by understanding your own body to begin with and then you can start to understand when things are more serious and might need a GP visit.

Mridula: They’re not saying that you don’t need to see a doctor but if certain symptoms persist over a week or two it is time you do contact your GP and go and see your GP.

Gretchen: So you made some videos, what languages did you…?

Mridula: We started with the idea of doing videos but it needed to be done in 90 seconds. So we started out with writing the script and all academics getting together our language wasn’t very simple to be very honest, so it took a long time for us to even come to this stage to simplify the language, to ensure that the community is able to understand, get people’s views about it, and then we connected with a company called EthnoLink, and they work with ethnic populations and do translation services, so  they were quite helpful in guiding us and simplifying our language further and further and not using technical terminologies. So then we did the storyboard, we chose the characters, animations, we thought we didn’t want people talking, just animated characters, and a voiceover talking about your health, and so we did that and we looked at the census data which was available then, 2016, and the Vietnamese and Chinese community were topping at the time, we wanted to do it in Arabic too but the costs were escalating, because we had to do everything from scratch. Jean Hailes has already put it on their channel and I think it’s quite a hit. From the top of my head I think the Vietnamese one had nearly 33,000 views, and the Chinese one had about 25,000 views, and the English one had about 70,000 views on Jean Hailes website, if you go you can see those videos.

Gretchen: So the proof is in the pudding there that they have proved to be really useful. So the intention of the research was firstly to understand what’s currently out there, and secondly to offer a model for what these websites could do.

Mridula: Exactly, and also we will be talking to the government department health websites if they would be happy to host it on their website, and also once we do finish with the evaluation we will be approaching quite a few organisations and also healthcare practitioners to run in their GP clinics on a loop, because when you visit GP clinics you see some videos that run on a loop, so this is all after the evaluation is done and we get the results of our effort and see whether people think it is really useful or not.

Gretchen: Such a great idea to put them in GP’s offices.

Mridula: From Jean Hailes where it is hosted, because Jean Hailes, they have their own YouTube channel, you can download the videos on your smart phone and watch it. If you forget that okay, what was I supposed to do if I had X, Y, and Z, so you can watch, because it’s such a short video it’s just a minute and a half, you can just watch it quickly and say okay, this is what I need to do. So you can download it on your phone, and that was our intention, actually, make it really widely available.

Gretchen: As well as these videos can we talk further about what CRE WaND is doing with respect to knowledge translation?

Mridula: For knowledge translation what we are doing is whatever research this program of work is producing we are trying to promote through either the development and creation of these videos or providing input into clinical guidelines for practitioners, or having policy dialogues or dialogues with clinicians and practitioners, even giving them the guidelines, the health promotion tools, the protocols which we, these are evidence-based, which we create or develop to be shared with these agencies to prevent onset of non-communicable diseases and detection and time to be able to get proper treatment and care.

Gretchen: So what follows next?

Mridula: So next is policy dialogue. So once these are evaluated we will be talking with the health departments and disseminating and distributing it as widely as possible so that people are able to use it, it is distributed through every channel possible, not only through our CRE WaND investigators via the program, but through the health departments because we think it is very essential and important for health departments to be involved in prevention.

Gretchen: That’s Mridula Bandyopadhyay from the Centre of Research Excellence on Women and Non-communicable Diseases. More information of course on the Prevention Centre’s website. I’m Gretchen Miller, catch you next time.