Search results and article selection
A total of 104 papers were included in our critical interpretive synthesis of migrants’ experiences of the Australian health system (see Fig. 1). The electronic bibliographic database search yielded 1272 records and, after the removal of duplicates (n = 389), the titles and abstracts of 883 records were screened. Based on our initial board exclusion criteria, 664 records were excluded. Following further refinement of the exclusion criteria and additional searches, 104 papers were included in the CIS. Details of the included papers and policy documents are presented in Additional file 2.
How are migrants’ experiences of the Australian health system conceptualised?
We began this CIS by first aiming to examine how the literature conceptualised migrants’ experiences of the Australian health system. This was with a view to ultimately propose how the Australian literature could better conceptualise migrants’ care encounters. In many papers, the migrant patient was reduced to their “cultural identity” and this led to an overwhelming focus on how culture shapes migrants’ care encounters. Other papers reduced migrant patients to specific language groups, conveying a sense of “linguistic homogeneity” and emphasising the impact of language barriers on the care experience. Finally, some studies reduced and homogenised migrants’ geographic origins, discounting the diversity and heterogeneity within and across regions and countries.
In the following sections we present our critique of the Australian literature on migrants’ care along these three broad lines which represent the key findings of our CIS. Additional file 3 presents a detailed account of how these three lines of critique were identified and arrived at, and how the overall synthesising argument was developed – it provides the empirical and theoretical basis of each critique.
Critique 1: Reduction of the migrant patient to ‘a’ cultural identity
The influence of culture on migrants’ experiences of the Australian health system was widely reported and discussed in the literature. Cultural mores, beliefs, and the stigma associated with these beliefs, influenced various aspects of migrants’ care encounters. In particular, culture shaped migrant patients’ decisions and ability to access care, their trust in healthcare providers (as well as interpreters), and their need for confidentiality during the healthcare encounter. This was particularly the case when accessing health services for mental health and sexual and reproductive health – this being linked to a preference among migrant patients for being treated by culturally and linguistically concordant healthcare practitioners. However, we noted that in articulating these influences, migrant patients were often homogenised and reduced to broad cultural groups. For instance, Alzubaidi et al. , suggest that “collectivistic Arabic cultures” can have some “problematic aspects”, specifically, that significant others are often involved in decision-making processes, including those related to health. In another study, it was found that Asian migrant women were at times reluctant to express their childbirth-related needs or preferences. When Hoang et al. (p.7, ) explain the nature of doctor-patient interactions they contend that “most Asian cultures teach people to be unassertive and inhibited from childhood”. In examining the health needs of migrant mothers from different cultural backgrounds, Renzaho and Oldroyd  report that Chinese, Middle Eastern and African mothers, more so than Afghani mothers, experienced differences between their traditional antenatal practices and those in Australia. Within these studies, the assumption is that migrant patients view themselves as “members” of specific cultural groups and therefore adhere to the common practices and beliefs of these groups . In this way, categorising migrant patients according to their cultural identity led to an inordinate focus on ‘a’ culture as the key factor shaping migrants’ experiences of the Australian health system. However, there were exceptions which recognised the limitations of such a culturalist approach and appreciated the importance of considering the “individuality” of migrant patients. For example, in Broom et al.’s  study, healthcare practitioners described culture as “part of the complexity” and emphasised the need to manage the “reduction of personhood to cultural abstractions”.
Given the above, it was therefore unsurprising that Australian policies on migrant health were also framed within a broad, cultural frame – which paradoxically was rather narrow. Healthcare policies across the board recognised and emphasised that culture, in particular, influences how individuals experience and manage health and illness [33, 34]. The “cultural responsiveness framework” has emerged as the guiding principle for Australian health services to provide care that is “respectful of, and relevant to, the health beliefs, health practices, culture and linguistic needs” of diverse communities . Recent health policy documents tend to argue and demur that ‘cultural responsiveness’ should be understood as being a broader concept than ‘cultural competence’ (this was the focus of policies before 2005) as it better encompasses the diverse needs of migrant populations . However, despite this claim, we found that definitions of cultural responsiveness, within multiple Australian health policies, were centred predominantly on addressing some particular, almost titular, cultural, and linguistic needs of migrant communities [33,34,35,36]. In fact, several studies highlighted the shortcomings of the cultural competence/responsiveness premise within healthcare policies. For instance, in the study by Broom et al. , one healthcare professional confessed, “I’ve come across too many cultures to be competent in all of them…”. This reflects a common feeling among healthcare professionals of being overwhelmed and unprepared for encounters with patients from diverse backgrounds which was exacerbated by a lack of cross-cultural training [37,38,39].
These findings echo current debates within the broader global literature around the over reliance on cultural approaches to examine and understand migrant health outcomes and disparities [2, 3, 5]. Central to cultural explanations is the concept of acculturation, the individual-level process through which one sheds the cultural characteristics of one’s country-of-origin and adopts those associated with the host country [2, 5]. The acculturation framework underpinned several studies included in our analysis and also features in certain policy documents [30, 34, 40, 41]. Such explanations have been critiqued as they risk identifying culture as the “problem”, as well as promoting a static definition of culture which homogenises entire populations . It is argued that this reduction to and problematic treatment of culture can perpetuate racial/ethnic stereotypes and inadvertently promote “victim-blaming explanations”. An individual-level cultural change-based approach also overlooks the impact of structural factors on migrant health disparities, such as the influence of migrant policies, racialisation processes, as well as economic and social integration . To Brah (, p. 24) such approaches reduce and present migrants as “‘culturally encapsulated’ – as if ‘culture’ was something entirely separate from lived experience”.
Critique 2: Reduction to and of language
A consistent finding within the literature is that migrants’ experiences of the Australian health system were shaped and defined by language- and communication-related barriers. Studies overwhelmingly noted that migrants, who were unable to speak and understand English, were unable to comprehend and/or effectively communicate their needs to healthcare practitioners, as well as understand English-based education resources. Often adding that as a result, some migrants were often unaware of their diagnosis or prognosis and would even undergo procedures without fully understanding the reasons for it [42, 43]. Though interpreters did, at times, facilitate communication during a care encounter, there were issues regarding confidentiality, the accuracy of the translation, as well as their “humanity” when communicating sensitive information [41, 44]. Moreover, accessing an interpreter, in the first instance, was often an issue particularly in under-resourced or rural and regional communities; requesting an interpreter could delay access to care, prolonging waiting times for appointments [45, 46]. As a result, family members, even children, would often act as interpreters for migrants. These reported issues are despite several State and Federal government health policies and strategies advocating for the effective provision of language services and supports [33, 36, 47].
Eight studies specifically examined the impact of language- and communication-related barriers on the migrant care experience. Two of these studies compared the experiences of non-English speaking migrants with Australian-born or English-speaking individuals [48, 49]. Almost all studies categorised migrants according to specific language groups, labelling migrants as, for example, “Arabic speaking” or “Chinese speaking”. In summary, such an articulation of language and communication barriers experienced by migrant patients dominates the Australian literature and health policies. Accordingly, Australian health policies overwhelmingly stress the importance of recognising the “linguistic affiliation” of migrants and the moniker ‘CALD’ appears extensively in policy documents, in empirical research and in the mainstream healthcare discourse, and CALD communities are approached based on language, as well as culture and/or religion [33, 34, 35]. The literature however conveys a sense of “linguistic homogeneity”; that is, it seems to assume that migrants originate from distinctly bounded, homogenous societies sharing the same language . The importance of recognising the heterogeneity within language groups has, in fact, been noted in some studies discussing interpreter services. For example, Alananzeh et al.  report the instance of a patient from Egypt who was unable to understand the Lebanese Arabic dialect of the translator and found it difficult to convey the “meaning of the conversation”. Similarly, Blignault et al. , talk about a Mandarin-speaking patient who was unable to understand the Cantonese-speaking bilingual worker that the health professional had organised for a home visit. The extensive examination of language and language-related barriers in research, and the importance accorded to language in healthcare policies is perhaps understandable given the established wisdom that language is a medium for or “proxy” for culture. In a general sense, language is the symbolic representation of a people, comprising their historical and cultural background [52, 53]. Therefore, language and culture are inextricably linked, and this could indeed explain why, within the examined literature, we identified a notable focus on how both language and culture shape the migrant care experience. We argue that such reduction of migrants en-masse to their ‘linguistic affiliation’ or broad language group is problematic as it prejudicially anticipates their English-language ability and also wrongly presents migrant populations as homogenous. In doing so, migrants’ experiences of the Australian health system are narrowly defined by the ‘inevitable’ language barriers they encounter.
Critique 3: Homogenisation and reduction of migrants’ geographic origins
The assumption that migrants originate from geographically bounded, homogenous societies was also widely evident in the literature. Apart from categorising migrants according to broad language groups or “cultural identity”, one sees migrants’ origins being referred to in broad geographic locational terms, such as Sub-Saharan Africa or South-East Asia [17, 29, 32, 40, 41, 43, 50, 54,55,56,57,58], for example, compared the commonalities and differences in experiences of sexual health related help-seeking and discrimination between Sub-Saharan African and South-East and East Asian migrants. Other the other hand, Hoang et al.  reveal that Vietnamese, Chinese and Korean women shared similar maternity care cultural practices of confinement during pregnancy. While there are notable differences, as well as similarities in the care experiences of migrants from such broad geographies, the issue is that these studies do not recognise and engage with the vast differences within these groups. That is, how diversity (in terms of language, religion, and cultures) across these vast geographic regions shapes the migrant care experience. There can also be considerable diversity within large countries, such as India, which has over 22 recognised languages with only 125 million people speaking English as a first, second or third language. While the majority of the population is Hindu, there are variations between and within states. For instance, North-Eastern states have a Christian majority, whereas Sikhism is the major religion in Punjab . Similarly, China has at least 55 ethnic groups (other than the Han majority) – each with their unique language, culture and often religion. Moreover, while Mandarin is recognised as the national language, dialects vary widely and can be mutually unintelligible with southern varieties of Chinese . This diversity is not reflected, or engaged with, in studies which described individuals’ care experiences as that of an Asian, South-East Asian, or East Asian migrant [29, 41, 54, 57].
Though much of the literature did not appreciate the problems associated with such homogenisation and reduction, some studies did offer valuable insights into and some reflections on how such a reduction and homogenisation is problematic – both on research and policy fronts. Abdelmessih et al.  reveal how categorising individuals as “Arab migrants” can be problematic as cultures can significantly vary between Arabic countries, as well as different regions within the same country. Due to this, Arab migrant patients suggested that there was no need for written information on cardiovascular disease that is tailored to specific cultural needs . Wamwayi et al.  also described how cultural differences between various ethnic African groups can, in turn, equate with different beliefs and healthcare practices. We argue that homogenising migrants and reducing them to broad geographies is problematic; doing so ignores the heterogeneity within and across countries and regions, and the impact such diversity can have on migrants’ interactions with and experiences of the Australian health system.