Eligible but missing out: a qualitative study of access to COVID-19 antivirals in Australia

Abstract

Background

Oral antiviral medication is available free of charge to Australians with SARS-CoV-2 infection who meet specific eligibility criteria. Health services and systems are targeted to support vulnerable populations, but not all eligible people received antivirals prior to hospitalisation. To expand the evidence base of social and behavioural insights in infectious disease emergencies and inform future pandemic responses, we sought to understand why people at high risk of hospitalisation with COVID-19 did not access antivirals.

Methods

We conducted 29 semi-structured interviews with people who were eligible for antivirals but did not receive them, and who were subsequently hospitalised with COVID-19. Interview questions explored all levels of influence on antiviral uptake from intrapersonal to policy, via the patients’ perspective. Analysis blended deductive and inductive approaches and resulting themes were categorised into the factors of the Capability-Opportunity-Motivation-Behaviour (COM-B) model.

Findings/results

Most participants lacked the capability to access antivirals through primary care. The key impediment was a lack of awareness about their existence or availability. In addition, many did not have sufficient opportunity, usually due to an inability to access primary care services in a timely manner. Almost all participants were highly conscious of their health and risks posed by their pre-existing conditions. Of those who were motivated to seek antivirals, reasons included preventing severe symptoms and limiting their time off work. Participants described situational mistrust in the provision of primary healthcare as structural changes made it harder or more expensive to access.

Conclusion

To improve antiviral uptake during an infectious disease emergency, policy makers need to ensure medication access to those eligible but also provide good motivations to take them by promoting them as a preventative measure. This can be done by targeted government communication and measures that address healthcare system inequities through better access to and quality of primary care for vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14392-7.

Introduction

Nirmatrelvir-ritonavir (Paxlovid) or molnupiravir (Lagevrio) are oral COVID-19 treatments, developed rapidly in response to the pandemic [1]. Both can reduce hospitalization and death from COVID-19, particularly for those at risk of severe disease [2]. In early 2022, both medications were made available free of charge to Australians with SARS-CoV-2 infection who met specific eligibility criteria [3]. Because early supplies of antivirals were limited, general practitioners (GPs) were instructed to examine patients’ risk of severe disease and develop individualized plans in the eventuality of a positive COVID-19 test. After several adjustments, at the time of this study the eligibility criteria for antiviral access were: 70 years of age or older, or 50 to 69 years of age with 2 risk factors, or Aboriginal and Torres Strait Islander of 30 to 69 years of age with 1 risk factor, or 18 years of age or older and moderately to severely immunocompromised, or previously hospitalized from COVID-19 [4]. These criteria reflect the disproportionate burden of disease and mortality rates for the elderly, Aboriginal and Torres Strait Islander peoples and those living with a disability or comorbidity [5]. The criteria were implemented in order to ensure the community members most vulnerable to serious disease were able to reduce their risk. Complementary processes were put in place to further ensure this, including antiviral stock being placed in aged-care facilities and Aboriginal Community Controlled Health Services to ensure access, and increased telehealth services to help alleviate demand for GPs [6].

Policy measures and systems to make antivirals available and free at point of care in Australia are designed to support the most vulnerable, but in practice not all eligible people are receiving them. Originally polymerase chain reaction (PCR) tests were used to diagnose all COVID-19 infections in Australia, allowing public health systems to assess a patient’s eligibility for antivirals and align them with appropriate health care [7]. However, with the introduction of rapid antigen tests (RAT), timely access to antivirals became dependent on people notifying their primary healthcare provider of a positive result. GP shortages, a decrease in free and affordable clinics, increasing demands for appointments and wait times have exacerbated difficulties in accessing primary care [7]. These barriers push people towards hospital emergency care facilities [8]. Against this background, when compared to the national average there were reductions in antiviral use for those in remote areas (37%), Aboriginal and Torres Strait Islander peoples (25%), and people from culturally and linguistically diverse communities (13%) [5]. These patterns in suboptimal intervention uptake are not unique to antiviral medications. The same groups have lower vaccination levels, against COVID-19 and other vaccine preventable diseases, as demonstrated by a rich research literature focusing on vaccine access and related behaviours [9].

Vaccine access and related behaviours are well studied but factors affecting use of oral antiviral agents in community settings are also important to public health, especially during a pandemic and/or when no vaccine is available. There is much less available literature regarding the facilitators and barriers to the uptake in Australia of antivirals through primary care [10]. Various antiviral treatments have been widely available for more than 60 years [11]. In previous pandemics, e.g. 2009 H1N1 swine flu pandemic, studies indicate lower antiviral use by those who have a lower socio-economic status and an increased distance to medication collection points [12]. Recent experiences during the COVID-19 pandemic provide an opportunity to understand patterns of use, and strengths and weaknesses of antiviral access. Self-diagnosis using Rapid Antigen Tests (RATs) means we also aim to present a better understanding of the decision-making process surrounding medication uptake on an individual level, as antiviral access has become dependent upon patient-initiated contact with a GP to receive a prescription. With regular calls for effective and equitable allocation of antivirals in future public health responses [13], our more nuanced understanding of access as separate from allocation can determine barriers and enablers to antiviral use to prevent hospitalization and deaths. To expand the evidence base of social and behavioural insights in infectious disease emergencies and inform responses to future pandemics, we set out to understand why people who were hospitalized with COVID-19 did not access antivirals even though they were eligible.

Methods

Participants

We sought interviews with a sample of 25–30 members of the Australian public who had been hospitalised with COVID-19 and had not accessed antivirals through the primary healthcare system, despite being eligible to do so. This sample size is consistent with the interview range recommended to reach data sufficiency in qualitative research exploring complex, behavioural, or experiential topics [14]. Recruitment was undertaken by a specialised research recruitment agency (Taverner Research) using advertisements on their website and social media (Facebook). Whilst eligibility for antivirals was limited to specific populations and demographics, we sought a diverse sample within eligible groups with regard to their rurality, age, and cultural background (Table 1). Potential participants responded to advertisements through an expression of interest with eligibility to take part in the study determined by a screening survey. Inclusion criteria were those who tested positive for COVID-19 and were consequently admitted to hospital and were eligible to access antivirals however did not receive them prior to hospitalisation. Participants received a $100 grocery voucher for their time.

Table 1.

Participant Characteristics

Age Bracket	18–29	30–39	40–49	50–59	60–69	70+
	1	1	6	11	3	7
State	NSW	Vic	WA	Qld	NT	SA
	14	8	3	2	1	1
Rurality			Urban		Regional
			21		8
Gender			Female		Male
			20		9
English is Second Language			Yes		No
			7		22

Data collection

JW and CD conducted semi-structured interviews with 29 people who met eligibility requirements for oral antiviral medications but did not receive them and were subsequently hospitalised with COVID-19. Interviews took place on the telephone or via a videoconferencing platform and lasted between 20 and 45 min. Participant consent was sought and obtained prior to each interview, as per our Human Research Ethics Approval [University of Wollongong, 2024/099]. Based on an interview schedule used to explore sub-optimal childhood vaccine uptake [15], the interview guide was developed by the research team in consultation with experts in researching infectious disease-related health behaviours. The guide was structured around Michie’s Theory of Behaviour Change [16], alternatively known as COM-B, capabilities, opportunities, and motivations to manage COVID-19 diagnosis and access and use of antiviral medications [See supplementary files]. To extend our analysis we also developed question probes that sought to capture any barriers or enablers of antiviral access that aligned with the Social Ecological Model of Health (SEM) [17]. Small changes were made to the guide after the first few interviews to improve clarity. Interviews were recorded and, once complete, transcribed in a naturalistic style for analysis. Data were deidentified and pseudonyms were used to replace participant names. Data collection took place between 25 July 2024 to 9 October 2024.

Data analysis

We employed the framework method to organise and analyse interview data, adopting a blended inductive-deductive approach [18]. The COM-B model [16] and SEM informed the deductive components of our coding framework and analysis. COM-B captures individualised responses and experiences on intrapersonal and interpersonal levels (Fig. 1). It provides a structured approach to understanding a specific behaviour (B), in our case (not) accessing antivirals, as being dependent upon the interaction between three interrelated properties of individuals – their capability (C), opportunity (O) and motivation (M). According to the model capability refers to an individual’s psychological and physical ability to complete a behaviour, whilst opportunity refers to external environmental and social factors that facilitate a behaviour, and motivation refers to the conscious and unconscious factors that enable or prevent a behaviour occurring [19]. The components of the COM-B model exist in a flexible dynamic with one another, interrelated by each impacting the extent to which the other can promote or inhibit a specific behaviour [16]. To choose to engage in a behaviour, an individual must sufficiently have each component of the model present. Therefore, it is possible for one or two components of the COM-B model for an individual to be satisfactory, however if one is lacking it will impede the potential for the behaviour to occur. For example, for an eligible individual to access antivirals through primary care, they might have the opportunity to request antivirals but lack capability and motivation because they are unaware of the existence of this medication or their eligibility for it, or don’t think it will help.

Fig. 1.

The COM-B model which proposes that behaviour (B) is influenced by three core components: Capability (C), Opportunity (O), and Motivation (M)

Questions and deductive codes based on the SEM were intended to assist us in developing an understanding of how participant behaviours and choices (captured by COM-B) reflected a wider social, economic and political context shaped by relationships between individuals, communities, and institutions. To complement and enhance insights from our deductive approach inductive codes were developed during analytic processes. The interviewers (CD and JW) discussed the interviews as they progressed, identifying similarities and differences, new information and repetitive themes. The lead author (EC) then conducted line by line, deductive and inductive coding of the transcripts, consistent with framework methodologies [18]. This highlighted themes and patterns in people’s understandings and experiences of health services around COVID-19 antivirals. We also explored recurrent themes that did not fit the COM-B framing [20]. Confidence in data sufficiency (where no new insights or themes are emerging from analysis) was attained after the first 18–20 interviews, with the final 10 interviews providing validation [21].

The research team was compromised of an empirical bioethicist and two health social scientists, one of which has a background in clinical medicine. The second and third authors have been involved in numerous interview studies about different aspects of COVID-19 and have a sound understanding of and appreciation for the variation in people’s experience of the virus and the pandemic. Reflexivity was maintained through frequent discussions among the research team of perspectives and emerging insights following each interview and by ensuring analysis was derived directly from the data. This process of iterative data gathering and discussion, followed by additional coding and thematic analysis, was combined with the COM-B model to understand the reasons for circumstances and patterns in antiviral use.

Results

Participant characteristics

Participants were over 18 and eligible for antivirals but did not receive them. Eligibility was determined by the Australian criteria at the time data were collected which included: (1) testing positive for COVID-19 and (2) being 70 years of age or older, or 50 to 69 years of age with 2 risk factors, or Aboriginal and Torres Strait Islander of 30 to 69 years of age with 1 risk factor, or 18 years of age or older and moderately to severely immunocompromised, or having previously been hospitalized from COVID-19. We sought a diversity of age, state, rurality, gender and cultural background as tabulated below.

Capability

Most participants had high levels of health literacy and proficiency at navigating the healthcare system. Yet despite their frequent engagement with healthcare professionals, some participants were unaware of the existence of antivirals or their eligibility for them prior to the interview. When the COM-B framework is applied to the interview data, more than half of the participants described experiences and circumstances that indicate they lacked the capability to access antivirals through primary care. When asked, very few participants reported having seen public health messaging regarding antivirals.

BEN: That was news to me. I’ve never known what antivirals were, so to speak, or, you know, who was able to get them or not get them… not really knowing, you know what they were, the names of them, and what they specifically do.

Highlighting the importance of community in effective health communication, participants who knew about antivirals usually reported learning about them via interactions with family or friends. All participants told us they trusted health care providers and organisations including their GPs and the government helpline service. However, government messaging around antiviral use missed most of them entirely, and therefore, in their view, was totally ineffective.

Even when participants described themselves as having some knowledge of antivirals, many did not seek them out or declined a prescription because of confusion or misunderstandings about their eligibility. It was not uncommon for participants to conflate antivirals and vaccination or to indicate that they thought that only vaccination or antivirals were indicated for protection from severe illness.

JEMIMA: I was thinking, you know, I should be pretty stable, I have, my vaccination, so I shouldn’t get into trouble.

Most participants were highly health literate and skilled at navigating the healthcare system when it came to their regular care, but many were not prepared for the possibility that they could have severe illness from COVID-19. In regard to this, the extent to which the people we spoke to sought information about what to do if they caught COVID-19 and antiviral medications varied. The most active information seekers utilised their GP, Google searches, the government helpline service Health Direct, or all three to inform their decisions. Others did not seek information about what was available to them if they caught COVID-19 beyond what was provided to them by their GP. Some participants knew about the medication through word-of-mouth from family members who already accessed antivirals, particularly those who had a positive experience. Several participants did not access antivirals within the recommended timeframe because they did not become severely ill until four to five days after the onset of symptoms. This was the result of a ‘watch and wait’ approach that many participants said they preferred. A result of this was that by the time they became severely ill it was too late for them to benefit from oral antivirals. In some cases, this indicated an underlying misunderstanding about how the medications prevent, rather than treat severe disease. Other participants understood that antivirals worked best if taken within 5 days of testing positive, even if symptoms were mild, but still preferred not to take them before they knew they needed them. The decision to watch and wait undermined their capability and opportunity to use them effectively.

Opportunity

Insufficient opportunity was a mix of individual and institutional barriers. Our analysis of the interview data identified that most of the people we spoke with did not have sufficient opportunity to access antivirals through the primary healthcare system. The effectiveness of antivirals depends on patients starting the medication within the first 5 days of symptom onset. Therefore, any delay in accessing primary care becomes an obstacle to the optimal management of COVID-19 infection in those most at risk of severe disease and hospitalisation. The most common barrier was being unable to access primary care services in a timely manner once participants became unwell. This was a problem both for those who were unaware of antivirals and for those actively seeking them. There were a range of reasons for this – the lack of availability of near-term GP appointments, not being aware of telehealth services, having to cover the cost of a consultation, or not being able to gain physical access or travel to a GP clinic. Many of these barriers were experienced simultaneously, requiring someone who was unwell with COVID-19 to develop and then coordinate a suite of different measures in order to be able to be seen by a GP and access the medication.

GILLIAN: One of the barriers [to accessing GP] is availability of time to see him. The other barrier is, because they used to bulk bill [be free of charge], but they don’t now, is having the finance. And for me my biggest barrier is I can’t drive anymore.

For other participants living with long term conditions, the rapid onset of severe symptoms (in one case less than 4 h) meant they did not have time to see a GP before needing critical care. Participants told us of finding out they had COVID-19 in ambulances and emergency departments on a day where they woke up feeling normal but then later collapsed or suddenly experienced acute respiratory difficulties. Others still faced unexpected issues, with some participants denied appointments with their regular practitioner due to their positive COVID-19 diagnosis. In these cases, some participants were offered alternate appointments with other GPs. This was not always an optimal solution as participants said they had difficulty trusting they would receive appropriate care that would also accommodate the complexity of their chronic conditions.

SPIROS: [When can’t see regular GP], That makes a bit difficult because you build up that relationship with the one doctor. If you see another doctor, then you’ve got to kind of sit there and talk about your all your problems and stuff.

Some of our participants found that even if they managed to get an appointment with their primary care provider, this clinical encounter did not always result in the receipt of antivirals. Several participants told us their impression was that some doctors lacked knowledge of eligibility criteria and prescribing guidelines, particularly during the initial roll out of the medication. These missed opportunities in the primary healthcare system potentially had a significant impact on some participants’ health, leading them to present at the emergency department with severe disease. Others decided to bypass the primary healthcare system and seek immediate emergency care. These participants indicated that this was what they always did when their trusted regular health care providers were not available.

TRACY: I went to my doctors to talk about antiviral, and they didn’t think it was a good idea. I think it had just come out, and I said, I really should have the antiviral. They said, see how you go in the next 24 h, and we’ll give it to you. I was in hospital by the end of the day, so I wasn’t offered it, so I had the antiviral once I was in hospital.

Interactions between individuals and institutional actors were important factors in participants’ opportunities to access antivirals. Healthcare provider availability and accessibility, along with their understanding of and willingness to prescribe antivirals, meant that many aspects of opportunity were to some extent out of the hands of the individuals we interviewed.

Motivation

Almost all participants were highly conscious of their health and risks posed by their pre-existing conditions. During interviews they sought to emphasise how they followed their healthcare team’s advice on managing their long-term conditions, with many also describing how they had adopted practices to protect themselves from COVID-19 infection. For these participants, the idea of preventing severe symptoms, limiting their time off work, or both, was motivation to seek out antivirals, despite ultimately not having done so.

GINNY: If I had a lot of issues on the first day where I was fairly confident that I had COVID and I was having issues with, like the chest pain and the blood pressure and things like that, the kind of more, severe symptoms it would be something that I’d consider.

However, during interviews almost half of the people we spoke to indicated that they were not interested in accessing or taking antivirals if they caught COVID-19. A key concern among this group was the need to take a new medication. Some simply did not want to increase the number of pills they needed to take – even if only for a limited time. Drawing on past experiences of being prescribed new medication by locums and doctors unfamiliar with their medical history, many feared potential side effects from unanticipated drug interactions. Or, for similar reasons, they were cautious about safety because of the relatively rapid development and testing of the new antiviral drugs.

TOMMY: Unfortunately, the situation, I have to take 15–20, pills every day. Yeah. 15, 12, yeah. So, it just feels like adding to the burden of pills.

Others spoke of how they did not feel motivated to try and access antivirals because they found it hard to justify the cost of the GP appointments necessary to be prescribed the medication. Others still described themselves as being highly reliant on and compliant with the directions and advice given by their GP or specialist – and were therefore not especially interested in seeking out or following the advice of other available health care providers.

JANET: I would notify my GP. Ask for her advice first. If she said, look, I’m going to send you an e-script of antivirals again. I would take the [Paxlovid] if that’s what she suggests. Or if she says you need to present to hospital to be re-examined or even come in and see me. Then I would follow her orders.

Motivations were a complex mix of personal factors that, for some, involved weighing up harms. Motivating harms included avoiding lost income or experiencing serious COVID-19 symptoms. Demotivating harms included worry about side effects and drug interactions, along with the burden of additional medications. They were personal in nature in contrast to opportunities. However, even where motivation was strong, capabilities and/or opportunities meant the drugs were not accessed.

Future motivations

As part of the interviews, we asked participants about their antiviral intentions in the event of a future COVID-19 infection. Their answers ranged from immediately requesting antivirals upon a positive COVID-19 result, to unequivocally rejecting them. Some participants said they would take them only if recommended by their primary healthcare practitioner. As part of this line of questioning the interviewers explained the window of effectiveness for taking antivirals (i.e. a maximum of 5 days post symptom onset, and ideally much sooner). Despite this, most participants still wanted to wait and see how severe their symptoms became before seeking them out or taking them. Once again concerns about drug interactions, side effects and taking potentially unnecessary medicines were key demotivators. During the interviews individuals provided us a range of things that they might do in the future, including relying on antivirals to treat COVID-19 infections instead of having a yearly vaccination, or presenting to the hospital to receive better care than they could receive at home.

The role of trust

Separate to the COM-B analysis, an inductive finding through thematic analysis was the role of trust. Trust was a cross-cutting theme across interviews in ways that do not neatly fit into the categories above. Participants described situational mistrust. They described diminished trust in the provision of primary healthcare as structural changes made it harder or more expensive to access. Related, they did not trust healthcare providers they didn’t know, such as GP locums or newer or unfamiliar doctors at their familiar practice. Many said they viewed their regular GP as a trusted source of healthcare information but also talked about untrustworthy information related to COVID-19 infection and treatment. Despite the high level of health literacy in this participant group, some demonstrated clear misunderstandings about the role of vaccination and its connection with antivirals and viewed them as interchangeable or alternative options.

SONYA: If the injection hasn’t helped, well, why would I turn around and get take more medication.

For them, the fact that they had caught COVID-19 meant that the vaccine had not worked (i.e. they thought the vaccine would prevent infection), and that antivirals were therefore similarly untrustworthy. Some lack of trust in antivirals was related to their perceived novelty, and likely similarly entangled with widespread discourses about undertested COVID-19 vaccines. Because these antivirals were new to market, participants worried that testing of interactions between drugs was insufficient and were not sure if the drugs could be trusted not to harm people with already complex health needs.

Discussion

Antivirals are most effective for those at higher risk of severe disease, with the Australian eligibility criteria reflecting the need to prioritise access for these populations [4]. However, because service delivery can fail to meet the needs of these groups they often face inequities within the healthcare system and beyond. The frequency of GP visits has been found to be a positive indicator of access to antivirals [5], suggesting that people who see a doctor regularly are more likely to receive appropriate care. Yet the experience of many of our participants, whose long-term conditions mean they have regular patterns of care, was an inability to access a primary care provider within an appropriate timeframe after a positive test. The Australian eligibility criteria for antiviral prescription reflect groups likely to be at greatest need of their benefits. Healthcare needs are complex and multifactorial, however, and Breadon and Chan’s analysis of antiviral access points to important interrelated social disadvantage that means that the people with highest need also face the highest access barriers [5]. This means that those populations that stand to gain the most benefit from antivirals have difficulty accessing them, raising even more concerns about how structures and systems can compound and amplify health inequities. It is also important to note that people in priority populations often do not see themselves as such, potentially limiting the effectiveness of public health communications [22]. Several participants were not motivated to access medications. They chose to wait and see how their symptoms progressed, believing antivirals were potentially unnecessary, despite having a strong desire to protect their health. This further highlights the difficulty of not only ensuring access to antivirals for those eligible, but giving them good reasons and motivations to take them.

Participants described reluctance to access care from unfamiliar doctors. Rubinstein showed that adherence is improved under specific advice from doctors [22]. Previous research also indicates that patients with long-term complex conditions may postpone care if the only available care providers are locums [23, 24]. Patients with long term conditions value and expect individualized care but this is not always possible, especially during a public health emergency. Potential strategies to mitigate a lack of patient trust in unfamiliar providers could include public transparency and education on variations in physician practices and the benefits of team-based collaborative approaches to healthcare [25, 26].

Some participants similarly lacked a sense of agency in their care, content to remain passive consumers who aligned all their health decisions with their doctors’ recommendations, supporting the literature [27]. Studies show word of mouth can positively influence Tamiflu adherence, specifically speaking firsthand to someone with a positive experience of the medication [22, 28]. We saw similar comments from participants, with most also being proactive information seekers. Value was placed on how other people had benefited from antivirals through first-person referrals, gaining information from GPs or online, via government websites and resources. Being aware of antivirals from any of these information sources increased the likelihood of seeking access to antivirals, but did not guarantee it.

Whilst our participants were highly experienced in navigating the healthcare system, it was common for this to be from necessity, having no other choice but learn how manage their own pathways. As most participants had comorbidities, they are regularly treated by multiple doctors and dependent upon their GP to coordinate care. However, care co-ordination and clear handovers between medical specialties does not always happen. Lun echoes that this is common for patients with multimorbidity and that some professionals do not want to meddle with patients’ medication when multiple professionals are involved, particularly when the patient is stable [29]. McNamara and Ho reinforce this point, showing that patients with multimorbidity are not only at greater risk of fragmented care and unsuitable polypharmacy but also the corresponding consequences, including an increased risk of hospitalization [30, 31]. Salisbury suggests that treating multimorbid patients is an emerging imperative that jars with the current single disease model of medicine [32]. In this case those who stood to benefit most from antiviral access had the most reason not to trust new medicines prescribed by unfamiliar health care providers. More needs to be done to address this gap in trust to better protect these groups in future infectious disease emergencies.

Whilst dependent upon the healthcare system due to their complex conditions, people still make decisions by perceiving their self-efficacy, potential personal consequences and social influence of others’ experiences with antivirals [33, 34]. Franklin and Lun highlight the need for individuals to understand the importance of their therapy as, without it, they cannot weigh up the potential benefit against competing factors such as medication cost, transport difficulties and the cost of a GP [13, 27, 29]. Our results reflect this finding, with cost impeding both opportunity and motivation to seek antivirals. Antiviral side effects also impacted participant motivation. Some ceased their course due to discomfort. Relief of symptoms prior to starting antivirals was also a reason for the delay as patients perceived risk of severe disease was lowered, echoed in literature [35]. Most participants framed antivirals as a treatment for COVID-19, rather than the prevention of severe disease.

Strengths and limitations

Our study has several strengths and limitations. The use of in-depth interviews is a strength as we were able to capture each participant’s social context and how it shaped their perspectives and experiences with antivirals. This allowed us to understand facilitators and barriers to antiviral uptake in detail from a patient-centred lens. Participants came from a range of backgrounds and geographic locations with participants from different states and metropolitan locations facing different experiences and challenges. Many participants had multiple and different co-morbidities. As this is a qualitative interview study, we do not claim that our findings are generalisable, but we believe they offer helpful insights. The majority of our participants were women. This reflects the epidemiological data on prevalence of comorbidities in Australia, with females more likely to be diagnosed with at least one chronic condition than males (52.3% vs. 47.4% respectively) [36]. Online recruitment meant we were limited to people with access to digital platforms, but it also meant that we were not geographically constrained in our sample. We acknowledge that the experiences and barriers to antiviral uptake of groups without access to digital communication are likely to be different to those of participants in this study, an avenue which has potential for further exploration. Finally, we note the COM-B model has limitations when interpreting the complexity of behaviour, especially in relation to systemic, cultural, and social dynamics, especially when applied to vulnerable groups. The COM-B model is intended to be exploratory such that future research could employ the Theoretical Domains Framework to provide greater specificity in designing interventions [37].

Implications for policy and practice

The 2009 H1N1 pandemic proved that trust in government was a predictor of adherence to medication prescribed in an emergency setting [38]. As priority populations are highly dependent upon primary care, they need strong trust in their GP, particularly when they face regular difficulties from the healthcare system. Participants spoke frequently of being let down by the healthcare system, often beginning from being unable to access their regular GP, forcing them into the emergency system. Based on our findings it is clear that more targeted government messaging is required if antivirals are rolled out in future pandemics. This should include leveraging existing peer-support networks for groups most at risk (e.g., community organisations and disease specific consumer advocacy groups) to increase awareness about the availability and efficacy of these medications. Medical specialists who attend to high-risk conditions also have a role in increasing patient awareness. In these communications it is vital to frame antivirals as a strategy to prevent severe disease, rather than a treatment of such. It is clear that GPs also need to attend to the specific needs of patients when prescribing, anticipating concern about drug interactions and additional burdens. This will assist in amplifying the perceived benefit to priority populations and countering the common ‘watch and wait’ attitude, an attitude that continued to be articulated when participants were asked about future intentions. By increasing patient motivation and subsequent antiviral uptake to limit severe disease, hospitalization rates can decrease. There is also a need for better training of GPs in how to have conversations regarding antivirals, including normalising the development of individualized care plans for patients during emergencies, by liaising with specialists and initiating standing prescriptions at pharmacies for eligible patients [39]. Finally, any measure that lessens inequities within the healthcare system should improve antiviral access and uptake among populations most likely to benefit.

Conclusion

Our study highlights barrier to accessing antivirals in a timely manner. Many of them lacked appropriate knowledge, access and motivation to seek the medication. To improve antiviral uptake during an infectious disease emergency, policy makers need to ensure access to GP appointments and frame messaging around antivirals being a preventative measure to improve patient motivation. Trusted care providers and medical specialists should work with their patients to prepare plans and pathways for antiviral access in case they are unavailable when needed. Targeted government communication and measures that address healthcare system inequities through better access to and quality of primary care for vulnerable populations are required.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

GP

General Practitioners

RAT

Rapid Antigen Test

Author contributions

CD and JW conceptualized and designed the study. CD and JW undertook data collection. EC, JW and CD conducted the analysis. EC, JW and CD wrote the main manuscript text and E.C. prepared the figure. All authors reviewed the manuscript.

Funding

Department of Health and Aged Care, Commonwealth Government of Australia [IG8ZXS].

Data availability

Access to data is restricted by human research ethics conditions.

Declarations

Ethics approval and consent to participate

This study was approved by the University of Wollongong, Human Research Ethics Committee [2024/099]. Our study complied with the Helsinki Declaration. Informed consent was obtained from all the participants.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.