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Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications

Representations and coverage of non-English-speaking immigrants and multicultural issues in three... Background: No recent Australian studies or literature, provide evidence of the extent of coverage of multicultural health issues in Australian healthcare research. A series of systematic literature reviews in three major Australian healthcare journals were undertaken to discover the level, content, coverage and overall quality of research on multicultural health. Australian healthcare journals selected for the study were The Medical Journal of Australia (MJA), The Australian Health Review (AHR), and The Australian and New Zealand Journal of Public Health (ANZPH). Reviews were undertaken of the last twelve (12) years (1996-August 2008) of journal articles using six standard search terms: ‘non-English-speaking’, ‘ethnic’, ‘migrant’, ‘immigrant’, ‘refugee’ and ‘multicultural’. Results: In total there were 4,146 articles published in these journals over the 12-year period. A total of 90 or 2.2% of the total articles were articles primarily based on multicultural issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention. Conclusions: The quantum and range of multicultural health research and evidence required for equity in policy, services, interventions and implementation is limited and uneven. Most of the original multicultural health research articles focused on newly arrived refugees, asylum seekers, Vietnamese or South East Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies has implications for evidence-based health and human services policy. Background culturally diverse social contexts, and, in a healthcare Mainstream healthcare research can be perceived as environment increasingly committed to evidence-based being neglectful of cross-cultural research. It is fre- policy, may ultimately produce poor policy. quently seen as methodologically difficult to do with sig- Representations of immigrants have shifted consider- nificant interpretative problems [1,2]. Resources may be ably in the period since the end of World War Two. inadequate for the translation of study instruments or Thirty years ago cross-cultural health researchers would the employment of bicultural researchers and inter- have studied ‘migrant patients’, or, a little later, ‘patients preters. Concepts do not always have semantic or lin- from non-English-speaking backgrounds’-at that time, a guistic equivalence across languages or cultures [3,4]. definable (constructed) field of study, which assumed Sampling methods, subject recruitment, achieving ade- that the similarities within these groups allowed them to quate sample sizes and representative samples may pose be neatly categorised, labelled and understood as one additional challenges [5,6]. However, it can equally be entity. From the post-World War Two period to the argued that to ignore populations with limited English 1960s, the presence of immigrants was basically ignored. proficiency may result in poor study validity and gener- They were expected to be invisible and assimilate into alisabilty, could be considered discriminatory in the dominant society as quickly and as fully as possible [7]. Research studies indicate that, in the 1960s, doctors * Correspondence: Pam.Garrett@sswahs.nsw.gov.au and psychiatrists developed an interest in exotic migrant Simpson Centre for Health Services Research, University of New South ‘diseases’ or pathologies and the ‘culture-specific’ health Wales, 2-4 Speed St Liverpool, BC1871, Sydney, Australia © 2010 Garrett et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 2 of 13 http://www.anzhealthpolicy.com/content/7/1/1 problems of migrants [8]. In the 1970s, the developing the state indicates continued attention to people who interest in social justice led to a desire to build social have migrated to Australia in the past several decades. capital (including universal health insurance and The changing representations reflect the ongoing pro- migrant participation) to overcome the poverty and duction and re-production of social understandings inequity experienced by, amongst others, migrant groups about immigrants. [9]. Lobby groups advocated for healthcare access and No recent Australian studies or literature provide evi- migrant rights in the 1980s [7,10]. Most recently, multi- dence of the extent of coverage of multicultural health cultural health services have operated as targeted strate- issues in Australian healthcare research. A series of lit- gies to address the specific needs of specific groups of erature reviews in major healthcare journals were under- people with limited English proficiency [11]. In other taken to discover the level, content, coverage and overall words, conceptions (and re-conceptions) of the field of quality of research on multicultural health. immigrant health study are a product of history, are relational, and have associated socially constructed Results meanings. Search Results: Medical Journal of Australia Congruent with these shifts in constructions of immi- In the MJA, over this 12-year period, there were 7,176 grant health problems and issues has been a shift in the publications, of which 2,227 were articles. The Scopus language for representing and describing immigrants. search, using six search terms, yielded 80 articles, after Immediately post-war, the official term for immigrants exclusions, and the Medline search yielded 69 articles, was ‘new Australians’, indicating a sense of differentness, after exclusions. Three hundred and fifty articles were of welcome, but also an expectation of assimilation. This accessed through the eMJA search. A further two arti- changed to ‘ethnic’ or ‘migrant’ in the 1970s and to cles accessed through the other two search strategies ‘non-English speaking background’ (NESB) in the 1980s and not accessed by the eMJA search were added to and 1990s. These terms reflected the cultural pluralism those included in the study [15,16]. After exclusions (N that was current at the time, with a person’scultural = 205), 184 articles were studied in depth. Thirty-one of and linguistic origins and migration status being viewed theseweresubsequentlyexcludedastheycontained no as constants, rather than evolving in dynamic interaction mention of multicultural health-related issues, leaving with the host country. In 1996, the federal government 153 MJA articles in the final analysis. formally replace the term ‘NESB’. The House of Repre- Thirty-four original articles, or 1.5% of the articles sentatives Standing Committee on Community Affairs published in the MJA over the 12 year period, directly Inquiry into Migrant Access and Equity [12] argued that related to multicultural health concerns. Twenty-one being from a non-English-speaking background did not articles were original research articles, 10 more were indicate disadvantage; an increasingly valid observation policy issues, guidelines or case studies and three were as the class and educational background of immigrants related to medical workforce issues. Figure 1 outlines had shifted by that decade. the strategy and results of the search. However, the agreed replacement term, ‘culturally and The 31 articles which were excluded at this final stage linguistically diverse (CALD)’ was taken up by federal are worthy of examination. There were 10 clinical guide- authorities in Australia (but not unilaterally by the pre- lines or workforce articles that did not mention non- dominately Labor state government authorities). It English-speaking populations or groups. A further 21 asserted and highlighted the difference between immi- original research articles in the MJA explicitly excluded grants and mainstream Australians, and emphasised cul- the participation of people with limited English. These ture, rather than language. The new term’s emphasis on articles, which knowingly excluded the participation of being different from the Australian cultural norm people with limited English proficiency, included articles implied a marginalising attribute-a distinction from the concerning: women’s understanding of their breast can- majority, the Australian-born. This representational cer diagnosis [17]; a prevalence study of domestic vio- change was undertaken within a context where there lence [18]; a random sample of young people to was increasing national questioning about the ideology determine their ability to identify depression and psy- of multiculturalism, immigration levels, and contestation chosis [19]; a random sample testing the intentions of over what it meant to be Australian. The changing dis- young people should they experience mental health pro- course on immigrants has frequently served to define blems [20]; a random sample of South Australian house- non-immigrants as legitimate and immigrants as differ- holds to determine the extent of self-reported ent, and therefore marginal, and potentially less legiti- medication [21]; predictors of participation in screening mate: ‘The Other’ [13,14]. Interestingly, CALD has also programs or cancer tests [22,23]; pathways to care for come to convey a sense of being ‘up-to-date’ or current. cancer patients [24]; health status during treatments The naming and re-naming of this population group by [25]; co-morbidity studies [26]; and, studies of post- Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 3 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Figure 1 Medical Journal of Australia literature search method and results. operative or post-treatment complications [27,28]. Gen- intravenous drug use and Human Immunodeficiency erally, these articles simply listed their exclusion in the Virus in Indochinese communities [48]. methods section or in a section on the study’s limita- A further 71 original MJA research articles took some tions. In explanation, one said that lack of funds for account of patients with limited English, ethnic groups translators restricted the study to people who could or multicultural health. These articles were further cate- speak English. Others noted that the questionnaire was gorised as having a high (11 studies), moderate (23 stu- in English only or that the study required consent to be dies) or minor (37 studies) treatment of multicultural signed in English. One study [29] did not provide the health issues within the study. program of outpatient stabilisation of newly diagnosed The 11 original research articles categorised with a Type 1 Diabetes patients to patients without English. high level of consideration of multicultural health Of the 153 included articles, 21 were original research included, for example, a study showing that overseas- studies that specifically focused on immigrant groups. born men were more likely to commit domestic homi- Five articles provided descriptive information on African cide and that NESB women in arranged marriages were or refugee medical and physical health derived from on- particularly at risk [49]; a case study of an immigrant arrival screening or related services [30-34]; three dis- patient negatively affected by herbal medicine usage cussed Vitamin D deficiency in veiled and dark-skinned [50]; a study of the use of complementary medicines women and their babies [35-37]; five were concerned [51]; a study reporting mainstream community concerns with the mental health of refugees [15,38-41]; one with about refugees bringing diseases to Australia [52]; a pre- iron depletion in Arabic-speaking toddlers [42]; one valence study of tuberculosis (TB) in Melbourne sec- examined the hospital utilisation of refugees based on ondary students, which found that being born overseas their source country [43]; one examined the differential was a predictor for contraction of TB [53]; an analysis access rights of Temporary Permit Visa holders, as com- of the differential death and disability risk factors in pared with refugees [44]; one studied the primary care developed and developing countries [54]; a study of the utilisation patterns of 341 asylum seekers in Melbourne efficacy of intramuscular cholecalciferol injection for [45]; one studied the effectiveness of outpatient malarial Vitamin D deficiency [55]; and, a study finding non- treatment with African refugees [46]; one looked at the English-speaking (NES) patients, in comparison with barriers to healthcare access for newly arrived African English-speaking patients, were more likely to consult a refugees [47]; one studied shared antenatal care by bilingual GP, attend a solo metropolitan practitioner women of non-English speaking backgrounds [16]; and and to consult a GP for respiratory, endocrine and one studied the positive relationship between digestive problems [56]. Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 4 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Examples of the 23 original research articles that were rights to healthcare of asylum seekers [76,77]; and an rated as having a moderate consideration of multicul- article detailing the trauma experienced by children and tural health included: a study of young women and risk their families held in detention [78]. taking, which found young women from non-English- Seven MJA articles related to medical workforce speaking backgrounds (NESB) were more likely to be issues, mainly focused on the stresses associated with involved in car accidents [57]; a study of snorkelling being a doctor [79-82]. Birrell et al. [83] discussed the deaths, which found 10 out of 27 were ‘NESB tourists’ lack of national standards and variable standards and [58]; a study of homicides during psychotic episodes, knowledge of overseas trained doctors (OTDs); Arkles which found that 19% (an over-representation) were et al. [84] outlined similar issues associated with health- from a ‘NES background’ [59]; a study predicting deaths care provided by OTDs in remote Aboriginal popula- among young offenders, which found that having a tions; McGrath [85] discussed the importance of drug-related offence was a major predictor and that the integrating OTDs into the medical workforce. The latter risk of drug-related offences was 13 times greater for three articles are considered to be based on multicul- ‘Asian’ young offenders and two times greater for those tural health issues. from other non-English-speaking backgrounds [60]; a Search Results: Australian Health Review study of cosmetic surgery and health status noting that In the AHR over this 12-year period there were a total NESB women were less likely to undergo cosmetic sur- of 866 publications. Of these, 751 were articles. Eighteen gery [61]; a study of the spread of Hepatitis C, finding articles relating to multicultural health issues were iden- that Vietnamese migrants and prisoners were more tified initially from the Medline and Scopus searches- likely to share needles [62]; a study of the help-seeking two of these were excluded as they were New Zealand behaviour of men with erectile dysfunction finding that articles. A verifying manual search through the journal NESB men with this problem were less likely to seek website yielded a further five articles [86-90]. Of these help [63]; a study of gestational diabetes noting a gen- final 21 articles, eight were original research based on eral prevalence of 3.6% ‘north east Asian’ and ‘south multicultural health, six were health workforce articles east Asian’ women having prevalence rates of 13.7% and based on multicultural health issues and two were arti- 12.5% respectively [64]; a study of obesity and over- cles concerned with cross-cultural research methods. weight in an obstetric population noting increasingly Fifteen original articles, or 1.9% of the articles published high body mass index (BMI) associated with ‘minority over the 12-year period, directly related to multicultural ethnic descent’ [65]; a study of Type 2 Diabetes in youth health concerns. One further workforce article had a finding ‘ethnic’ young people were over-represented moderate consideration of multicultural issues and three [66]; and an epidemiological study and discussion of original research articles had a minor inclusion of multi- child health in Australia, which noted the particular vul- cultural health issues. Figure 2 outlines the AHR search nerability of asylum seekers and the problems of institu- strategy and the results of the search. tional racism [67]. The AHR contained eight original research articles Fifty-four MJA articles were clinical guidelines, policy based on multicultural health issues. Tran et al. [91] issues, or case study articles rather than original profiled 829 clients of the Ethnic Obstetric Liaison Offi- research articles. Of these, 10 were categorised as arti- cer Service in the south west of Sydney and concluded cles concerned primarily with multicultural health- that ethnic-specific service models are necessary for lin- related issues, 15 as moderately inclusive and 29 as hav- guistic and cultural relevance; Heaney and Moreham ing a minor mention of multicultural health issues. [92] surveyed 109 hospital staff and found they reported Examples of articles concerned primarily concerned under-usage of professional interpreters and inappropri- with multicultural health issues included: an article out- ate usage of family and friends as interpreters; Chan and lining the importance of cultural competence in dealing Quine [93] conducted focus groups in Chinese to deter- with adolescents [68] or in medical practice [69]; an mine the health needs of this community; Han [94] argument for the introduction of RU-486 in Australia explored the factors sustaining usage of herbal medi- [70]; a discussion of the forced detention of non-compli- cines by Koreans in Australia; Renzaho [89] negatively ant TB sufferers [71]; discussions about the usage of reviewed community service delivery to culturally and complementary and alternative medicines and the need linguistically diverse populations and suggested a new to introduce its study into medical schools [72,73]; a model of needs-led ‘cultural consultation’ be implemen- case study of a neonate with high lead levels associated ted; Murray and Skull [88], discussed the barriers to with the mother’s ingestion of herbal remedies [74]; a care faced by refugees, including language, culture, legal, discussion of the legal and ethical implications of medi- employment and policy barriers, and outlined available cally enforced feeding of detained asylum seekers who health and social resources and entitlements; Wen et al. are on hunger strike [75]; concerns about the limited [90] found culturally diverse populations were less likely Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 5 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Figure 2 Australian Health Review literature search method and results. to be visited by child health nurses or volunteers and and welfare data collections and found that Australian more likely to find such visits ‘uncomfortable ’;and Bureau of Statistics standards and classifications relating Strong et al. examined the health status of overseas to ethnicity were quite widely used [100]; Whelan [101] born Australians and found lower reported mortality outlined a process for the rapid appraisal of views of and hospital utilisation [95]. non-English-speaking clients. Six AHR articles related to healthcare workforce Five articles were original research that considered issues. Five of these workforce articles were primarily multicultural health issues. One article [102], rated with based on multicultural health-related issues. Tang et al. a high level of inclusion of multicultural health issues, [96] studied the (negative) attitudes to nursing in sec- examined future directions for Victoria’smaternity ser- ondary students from non-English-speaking background; vices and found ‘immigrant’ women were consistently Mathews et al. [97] differentiated between the role of less satisfied with their care. A moderate level of consid- bilingual staff and interpreters based on the views of a eration of multicultural health issues was evident in an range of bilingual and interpreting staff; Johnson et al. article that examined the use of respite services among [98] surveyed bilingual staff in an area health service carers of non-institutionalised people [103]. Three arti- and found a language ‘mismatch’ between bilingual staff cles were original research articles that took multicul- and the local populations, and that bilingual staff mainly tural health issues into account in a minor way used their language in simple conversations; Mathews et [104-106]. al.[87]qualitativelyevaluated theroleofethnichealth Search Results: Australian and New Zealand Journal of staff in hospitals; and Bayram et al. [86] researched Public Health overseas trained doctors and found that, in comparison There were 1,727 publications in the ANZJPH over this with locally trained doctors, they were younger, worked period.Ofthese,1,168 were articles. The Scopus and more sessions, were less experienced and saw a different Medline searches yielded 175 articles. After exclusions, a range and mix of patients (newer patients, more disad- total of 110 articles were reviewed in full. Twenty-five vantaged and Indigenous patients). The AHR study, reviewed articles contained no consideration of multi- which considered multicultural health issues in a cultural health issues, effectively leaving 85 articles-7.2% moderate way, looked at the changing workforce chal- of the total articles published over the 12-year period. lenges and the changing profile of Australian medical There were 41 original research articles in the area of students [99]. multicultural health in the ANZJPH over the 12 years. Two AHR articles related to multicultural health Of these, 16 (39%), were published in 2001 or more methods: one identified and analysed national health recently. A further 44 research articles contained some Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 6 of 13 http://www.anzhealthpolicy.com/content/7/1/1 inclusion of multicultural health issues; four contained a rates [119]; Hepatitis B status and vaccination coverage major consideration, six a moderate mention and 34 was studied in Vietnamese schoolchildren [125], in Viet- articles contained a minor consideration of multicultural namese intravenous drug users [126], in infants from health issues. ethnic groups with high carrier prevalence [127], and in Of the original research articles, 13 original articles students at intensive English high schools [128]; Davis were concerned with epidemiology or health status et al. [129] found NESB elderly aged care assessment cli- issues. Pell et al. [107] studied demographic and work- ents were under-referred for assessments and were more related changes in ‘Asian’ female sex workers; Hellard et likely to require nursing home placement; Dolman et al. al. [108] found a high prevalence of blood borne viruses [130] highlighted language barriers, cultural insensitivity in 127 ethnic Vietnamese drug users; Steel et al. [109] and service knowledge as access issues for people with found the psychiatric status of asylum seeking families limited English; Davidson et al. [131] reviewed refugee accommodated in remote detention centres was very access to dental services and found several barriers; significantly compromised, and Mares and Jureidini Neale et al. [132] surveyed people recently arrived from [110] found very high levels of mood disturbance and the Horn of Africa and found 50% reported health post-traumatic stress symptoms in children and families access difficulties, mainly related to communication. accommodated in detention centres; Kingsford Smith Two studies outlined major issues associated with and Szuster [111] measured dental health in refugees achieving quality methods in cross-cultural research stu- from the former Yugoslavia and Iraq and found it was dies [5,6]; Mitchell et al. [133] found cervical screening considerably poorer than that of a matched group of rates increased with intensive ethnic media publicity; social security recipients; Rissel et al. [112] surveyed Page et al. [134] found no change in mammography 2,573 secondary students with large ‘Arabic’ and ‘South screening attendance in Italian-born women as a result East Asian contingents’ and found delayed smoking of ethnic media publicity; while Wong and Wang found uptake in these groups; Rissel et al. [113] found 49% of that the participation rates in a Chinese survey were males and 29% of females in the Lebanese community increased by using translated instruments [135]. smoked;Lin andWard[114] studiedthe smoking- Six studies discussed knowledge, attitudes and health- related habits and attitudes of 1,084 ‘ethnic Chinese’; related behaviours. Telephone surveys of Vietnamese Taylor et al. [115] found ‘migrants’ had lower rates of males’ knowledge of sexually transmitted diseases and coronary heart disease probably related to selection, diet blood borne viruses found poor knowledge [136]; high and lifestyle; Burton and Lancaster [116] profiled the levels of Hepatitis B and poor information about Hepati- Pacific Islanders’ obstetric population and found three tis B was found in Lao and Cambodian groups [137]; times the average rate of gestational diabetes, greater Rice and Naksook [138] examined Thai women’sper- hypertension and higher perinatal mortality; Sullivan ceptions about caesarean births; Cheek et al. [139] sur- and Shepherd [117] studied the obstetric profile of Viet- veyed Vietnamese women’s attitudes to cervical namese-born women and found higher gestational dia- screening and found reasonably high participation rates betes, lower pre-eclampsia and lower birth weights; and reliance on GPs and family for information; Plun- Rissel [118] developed an eight-item scale of accultura- kett and Quine [140] found carers with limited English tion for use in cross-cultural studies; Brown et al. [119] were reluctant to institutionalise their elderly relatives in surveyed 198 Filipinas and found good self-perceived nursing homes; and Maneze et al. [141] described the health status; Ireland and Giles [120] found an Italian- pattern of kava use among 73 Tongan men in the born group’s blood pressure increased in comparison to Macarthur area of Sydney. a decline in the Australian-born group in a suburb in Search Results: Summary Melbourne. Table 1 summarises results of the analysis of these three Of the policy-related articles, two were concerned with journals. In total there were 4,146 articles published in the detention of asylum seekers [121,122], and another these journals over the 12-year period. A total of 90, or found poor implementation of ethnic health policy in 2.2% of the total articles, focused primarily on multicul- community mental health centres [123]. tural health issues. A further 62 articles had a major or Service- and screening-related original research find- moderate level of consideration of multicultural health ings included: lower reporting rates of pap test in issues and 107 had a minor mention. In total, 259, or women speaking a language other than English and var- 6.3% of all articles, included some mention of multicul- ied uptake of pap test by region of birth [115]; low cer- tural issues. vical screening rates for Vietnamese women was related Limitations to acculturation and years of residency in Australia This study is limited by the accuracy of the search tools. [124]; translated personalised letters sent to Vietnamese The Medline and Scopus searches in each case yielded women were ineffective in increasing cervical screening different articles. Despite attempts to overcome the Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 7 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Table 1 Summary of Results of the Analysis of Three Journals Total number Number of MC MC articles as a % Number of other articles Number of other of articles in articles of total articles with major or moderate articles with minor journal consideration of MC issues consideration of MC issues MJA 2,227 34 1.53 49 70 AHR 751 15 1.99 3 3 ANZJPH 1,168 41 3.51 10 34 Total 4,146 90 2.17 62 107 shortfalls, relevant articles may not have been retrieved Therewas aslightlylargernumber of originalmulti- through this search strategy, just as some retrieved arti- cultural health articles (n = 41) featured in the ANZJPH cles were clearly not relevant. compared with the MJA, representing 3.4% of the total It is further acknowledged that a significant amount of articles published in the ANZJPH over the 12-year per- Australian multicultural health research has focused on iod. The majority of original ANZJPH articles were pub- mental health. A literature review in the area of mental lished prior to 2001, with only 16 original research health has also demonstrated gaps in research [142]. A articles published since 2001-possibly a reflection of a study such as this requires a level of judgment in respect changing social climate. The range of health issues cov- of the level of consideration of multicultural issues ered in the ANZJPH was somewhat limited, with seven included in a study. It is acknowledged that although concerned with blood borne viruses or sexually trans- the principal researcher checked the categorisation with missible infections, five with cervical cancer and pap another researcher, such judgments can always be tests, three with obstetric profiles, three with smoking debated. prevalence, two with dental health, one with coronary heart disease, one with blood pressure and one with the Discussion health of Asian sex workers. Six articles critically dis- Valuable insights can be gained from comparing the cussed ethical issues, health status or service implica- representations of immigrants in each of these three tions of the policy of detaining asylum seekers and their journals. Almost all the original MJA research articles children in remote detention centres. focused on newly arrived refugees. Almost all focused The 15 original AHR research articles were diverse in on relatively exotic, if not ethnic-specific illnesses. Most subject matter. Five addressed workforce changes, (13 articles) related either to the mental or physical recruitment issues, and bilingual staffing in hospitals. health of newly arrived refugees or asylum seekers, and The other 10 articles addressed a range of issues related five dealt with concerns about vitamin deficiencies in to epidemiology, access, service delivery, and cross-cul- veiled or dark-skinned women and their babies, or in tural research methodologies. Arabic speaking toddlers. The MJA published seminal Apart from two AHR articles that assessed service articles and opinion pieces in these areas particularly access [124,131] it is interesting that few studies in concerning the Australian policy and treatment of asy- these three journals have evaluated service quality or lum seekers. Researchers often focus on the most effectiveness. For example, surprisingly few studies have recently arrived community as they are considered to be evaluated the impact, demand and cost effectiveness of the most different from the mainstream [143]. Yet the healthcare interpreter services. Indeed, there is little representations remain very limited. Of the 2,227 arti- Australian evidence regarding the most common meth- cles published during the 12-year period, only 21 (0.9%) ods of facilitating communication in healthcare with were original research and a total of 34 (1.5%) were con- people who have limited English. Access studies have cerned primarily with multicultural health issues. A focused on community services and aged care services. further 71 MJA original research articles including some Wide-ranging terms were used by researchers in these discussion of multicultural issues, with 11 articles dis- journals to describe ethnicity. Some used various aggre- cussing multicultural health issues as a major compo- gations of ‘countries of birth’ (e.g. North Asian, South nent of the article and 23 as a moderate component. In East Asian, Asian), ‘white’ and ‘non-white’, ‘non-English- others (37 articles), the mention of diversity was inci- speaking’,or ‘ethnic groupings’, one defined ethnicity in dental, or, what Minas et al. [142] described as ‘tacked- a population as related to parental country of birth. This on’, or an after-thought to the main discussion. Of the diversity of terms indicates the continued lack of health- 54 MJA articles categorised as policies, guidelines or care researcher agreement about the appropriate ways of case studies, 10 were primarily concerned with multicul- reporting ethnicity in Australia, although one study tural health issues. noted that government databases tend to follow Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 8 of 13 http://www.anzhealthpolicy.com/content/7/1/1 nationally agreed terminology [100]. Few researchers non-English-speaking countries actually speak very flu- outlined the study methods they used to assess the eth- ent English (e.g. immigrants from Hong Kong, India, nicity-related variables. In articles that included some Holland). Kliewer and Jones [144], in their study of mention of multicultural health issues, few discussed the newly arrived immigrants, found that almost 12% of study’s results related to ethnicity; the majority simply immigrants from NESB countries spoke English as their noted ethnicity as a demographic variable. There were preferred language and another 39% stated they spoke few attempts in these studies to further analyse the English ‘well’ or ‘very well’. Fields that have been incor- effects of socio-economic status, gender, or educational porated into standard healthcare databases, such as ‘lan- status see Figure 3. guage spoken at home’ or ‘preferred language,’ do not Datasets often contain little information on English indicate how well a person speaks English. language proficiency or on the demographic, social, eco- The available research could be described as uneven in nomic and cultural factors that may influence health its coverage of major health status and health risk factor and health service utilisation [100,144]. Much class, eth- issues affecting immigrant communities. There are some nic and geographical variation in health status may be major health status issues that appear to have received masked or homogenised because birthplaces or groups little attention; for example, renal disease, dialysis access, are aggregated (often in inconsistent ways) so as to heart failure, kidney disease, prostate cancer, lung can- achieve statistical meaning. At times, for example, all cer, eye problems, cardiac problems, depression or people born overseas are considered as one group, as chronic diseases. It is interesting that very few original are all people who speak a particular language, irrespec- articles dealt with patient experience, acute care, or the tive of their year of arrival, English language proficiency, ethnic elderly. In terms of health promotion, the empha- age, and region of origin or socio-economic profile sis was limited to screening, general practice access, and [144-147]. Bhopal refers to these epidemiological prac- interventions to promote population-based health tices as ‘inventing ethnic groups’, ‘lumping groups screening. together’, ‘not adjusting for confounding factors’ and Further, little attempt has been made to understand ‘not comparing like with like’ [148]. Coming from a the crucial relationship between poor language profi- non-English-speaking country is frequently used as a ciency, culture and patient safety in the Australian con- surrogate for poor proficiency in English. This aggrega- text. The question of whether there is ethnic disparity tion has an inherent bias as many immigrants from (difference in treatment and care based on ethnicity, Figure 3 Australian and New Zealand Journal of Public Health literature search method and results. Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 9 of 13 http://www.anzhealthpolicy.com/content/7/1/1 race or language ability) in healthcare service provision there are other communities and health issues that are has not been addressed in these major Australian essentially invisible or unrepresented in research. healthcare journals. Studies were mainly descriptive/observational studies Methods or basic epidemiological studies. None were randomised Systematic reviews were undertaken in three major Aus- control trials or longitudinal studies. Some studies were tralian health care journals. These journals arguably a series of cross-sectional surveys. There were no clini- represent the broad spectrum of mainstream healthcare cal trials. A few interventional studies looked at, for research in Australia. The three journals include: the example, theeffect of theethnicmedia on serviceor largest circulation general medical practice and clinical screening access. While there were some studies with research publication in Australia, the Medical Journal of large samples, others had quite small numbers. Australia (MJA), Australia’s largest public health journal Interestingly, many ANZJPH articles studied the The Australian and New Zealand Journal of Public Vietnamese or ‘South East Asian’ populations, with 14 Health (ANZJPH) and Australia’s major health services of the 20 articles which featured specific populations research and management journal, The Australian choosing to study South East Asians. Two other stu- Health Review (AHR). Reviews were undertaken of the dies researched Arabic/Lebanese groups, two studied last twelve 12 years (1996 to August 2008) of journal Italians, two studied Islanders, and one studied each of articles using six standard search terms: ‘non-English- sub-Saharan Africans and Filipinas. Four studies were speaking’, ‘ethnic’, ‘migrant’, ‘immigrant’, ‘refugee’,and concerned with asylum seekers and a further three ‘multicultural’. Each of the categorisations was tailored with refugees. This is an interesting representational to the content of the journal. A single approach across bias even given that Vietnamese is one of the five these three journals was neither possible nor desirable. major languages spoken in Australia. The reasons can Articles were categorised as being primarily concerned only be speculated upon, but it is interesting to recall with multicultural health issues, having some level of the words of Martin [8], who stated that in the 1950s inclusion of multicultural health issues or excluding and 1960s migrant groups were homogenised (as one) multicultural health issues. Within the category of ‘some but that in the 1970s ‘migrant’ equalled Greek and Ita- inclusion’, articles were further categorised a having a lian. The research data from the ANZJPH would seem major, moderate or minor level of consideration of mul- to indicate that in the past decade, ‘migrant’ equals ticultural health issues. A major inclusion required that ‘Vietnamese ’, ‘South-East Asian ’, ‘asylum seeker ’ or a large section or part of the argument of the article ‘refugee’. This observation is also consistent with the related to multicultural health or immigrant health representations of migrants in MJA original studies, issues; a moderate level of inclusion defined multicul- with newly arrived refugees and asylum seekers being tural health or immigrant health issues as one of a the major groups studied. It may be that by the 1990s range of issues within a broader context or set of issues. and this 21st century, the term ‘migrant’ has come to A minor inclusion meant that multicultural health or mean South East Asian, Vietnamese, refugee and asy- immigrant health was included in some minor way in lum seeker. the study, for example, as a demographic descriptor. A zero inclusion means that there was no consideration of Conclusions multicultural or immigrant health issues in the article. The review of these three journals over a 12-year period The principal researcher undertook this categorisation. demonstrates that the quantum, range and quality of the It was checked by a second researcher. research and evidence which is required for equity in Search strategy: Medical Journal of Australia policy, services, interventions and implementation is The MJA review strategy involved searching the six limited. Kagawa-Singer [149] argued that mono-cultural terms through the on-line ejournal. Articles were health services’ research focus has three major limita- excluded if they were concerned with Aboriginal and tions, namely a lack of recognition of different world Torres Strait Islander health, book reviews, repeat arti- views, a lack of understanding of the most appropriate cles, advertisements, tables of content, or archives. Arti- and effective means to cope with illnesses based on cles that did not contain the search words were not those world views, and a lack of ability to hear different included. All other articles were included. A cross-check ways of communicating these perspectives. on this accession list was made via a verifying Medline Whilst the MJA, AHR and ANZJPH research plat- and Scopus search. Articles were categorised as original forms could certainly not be called ‘mono-cultural’,they research based on multicultural health issues or immi- could quite reasonably be called ‘limited’ and ‘uneven’. grant groups, original research that specifically excluded While there is some excellent quality research in respect immigrant groups, original research that included multi- of refugees, asylum seekers and Vietnamese immigrants, cultural health or immigrant health issues to some Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 10 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Competing interests extent, medical workforce articles and clinical guidelines, The authors declare that they have no competing interests. policy, editorials and opinion pieces. 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Just Health: Inequality in Illness, Care and Prevention Melbourne: Churchill LivingstoneWaddell C, Petersen A 1994, 7-25. 144. Kliewer E, Jones R: Immigrant health and the use of medical services: results from the longitudinal survey of immigrants In. Canberra: Research and Statistics Branch - Department of Immigration and Multicultural Affairs 1997. 145. Eagar K, Garrett P, Lin V: Health Planning: Australian Perspective Sydney: Allen & Unwin 2001. 146. Manderson L: Introduction: Does Culture Matter?. The Health of Immigrant Australia: A Social Perspective Sydney: Harcourt Brace JovanovichReid J, Trompf P 1990, xi-xvii. 147. Powles J, Gifford S: How healthy are Australia’s immigrants?. The Health of Immigrant Australia: A Social Perspective Sydney: Harcourt Brace JovanovichReid J, Trompf P 1990, 77-107. 148. Bhopal R: Is research into ethnicity and health racist, unsound, or important science?. Br Med J 1997, 314:1751-1756. 149. Kagawa-Singer M: Improving the validity and generalizability of studies with underserved U.S. populations expanding the research paradigm. Ann Epidemiol 2000, 10(Suppl 1):S92-S103. doi:10.1186/1743-8462-7-1 Cite this article as: Garrett et al.: Representations and coverage of non- English-speaking immigrants and multicultural issues in three major Australian health care publications. Australia and New Zealand Health Policy 2010 7:1. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications

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Springer Journals
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Copyright © 2010 by Garrett et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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10.1186/1743-8462-7-1
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20044938
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Abstract

Background: No recent Australian studies or literature, provide evidence of the extent of coverage of multicultural health issues in Australian healthcare research. A series of systematic literature reviews in three major Australian healthcare journals were undertaken to discover the level, content, coverage and overall quality of research on multicultural health. Australian healthcare journals selected for the study were The Medical Journal of Australia (MJA), The Australian Health Review (AHR), and The Australian and New Zealand Journal of Public Health (ANZPH). Reviews were undertaken of the last twelve (12) years (1996-August 2008) of journal articles using six standard search terms: ‘non-English-speaking’, ‘ethnic’, ‘migrant’, ‘immigrant’, ‘refugee’ and ‘multicultural’. Results: In total there were 4,146 articles published in these journals over the 12-year period. A total of 90 or 2.2% of the total articles were articles primarily based on multicultural issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention. Conclusions: The quantum and range of multicultural health research and evidence required for equity in policy, services, interventions and implementation is limited and uneven. Most of the original multicultural health research articles focused on newly arrived refugees, asylum seekers, Vietnamese or South East Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies has implications for evidence-based health and human services policy. Background culturally diverse social contexts, and, in a healthcare Mainstream healthcare research can be perceived as environment increasingly committed to evidence-based being neglectful of cross-cultural research. It is fre- policy, may ultimately produce poor policy. quently seen as methodologically difficult to do with sig- Representations of immigrants have shifted consider- nificant interpretative problems [1,2]. Resources may be ably in the period since the end of World War Two. inadequate for the translation of study instruments or Thirty years ago cross-cultural health researchers would the employment of bicultural researchers and inter- have studied ‘migrant patients’, or, a little later, ‘patients preters. Concepts do not always have semantic or lin- from non-English-speaking backgrounds’-at that time, a guistic equivalence across languages or cultures [3,4]. definable (constructed) field of study, which assumed Sampling methods, subject recruitment, achieving ade- that the similarities within these groups allowed them to quate sample sizes and representative samples may pose be neatly categorised, labelled and understood as one additional challenges [5,6]. However, it can equally be entity. From the post-World War Two period to the argued that to ignore populations with limited English 1960s, the presence of immigrants was basically ignored. proficiency may result in poor study validity and gener- They were expected to be invisible and assimilate into alisabilty, could be considered discriminatory in the dominant society as quickly and as fully as possible [7]. Research studies indicate that, in the 1960s, doctors * Correspondence: Pam.Garrett@sswahs.nsw.gov.au and psychiatrists developed an interest in exotic migrant Simpson Centre for Health Services Research, University of New South ‘diseases’ or pathologies and the ‘culture-specific’ health Wales, 2-4 Speed St Liverpool, BC1871, Sydney, Australia © 2010 Garrett et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 2 of 13 http://www.anzhealthpolicy.com/content/7/1/1 problems of migrants [8]. In the 1970s, the developing the state indicates continued attention to people who interest in social justice led to a desire to build social have migrated to Australia in the past several decades. capital (including universal health insurance and The changing representations reflect the ongoing pro- migrant participation) to overcome the poverty and duction and re-production of social understandings inequity experienced by, amongst others, migrant groups about immigrants. [9]. Lobby groups advocated for healthcare access and No recent Australian studies or literature provide evi- migrant rights in the 1980s [7,10]. Most recently, multi- dence of the extent of coverage of multicultural health cultural health services have operated as targeted strate- issues in Australian healthcare research. A series of lit- gies to address the specific needs of specific groups of erature reviews in major healthcare journals were under- people with limited English proficiency [11]. In other taken to discover the level, content, coverage and overall words, conceptions (and re-conceptions) of the field of quality of research on multicultural health. immigrant health study are a product of history, are relational, and have associated socially constructed Results meanings. Search Results: Medical Journal of Australia Congruent with these shifts in constructions of immi- In the MJA, over this 12-year period, there were 7,176 grant health problems and issues has been a shift in the publications, of which 2,227 were articles. The Scopus language for representing and describing immigrants. search, using six search terms, yielded 80 articles, after Immediately post-war, the official term for immigrants exclusions, and the Medline search yielded 69 articles, was ‘new Australians’, indicating a sense of differentness, after exclusions. Three hundred and fifty articles were of welcome, but also an expectation of assimilation. This accessed through the eMJA search. A further two arti- changed to ‘ethnic’ or ‘migrant’ in the 1970s and to cles accessed through the other two search strategies ‘non-English speaking background’ (NESB) in the 1980s and not accessed by the eMJA search were added to and 1990s. These terms reflected the cultural pluralism those included in the study [15,16]. After exclusions (N that was current at the time, with a person’scultural = 205), 184 articles were studied in depth. Thirty-one of and linguistic origins and migration status being viewed theseweresubsequentlyexcludedastheycontained no as constants, rather than evolving in dynamic interaction mention of multicultural health-related issues, leaving with the host country. In 1996, the federal government 153 MJA articles in the final analysis. formally replace the term ‘NESB’. The House of Repre- Thirty-four original articles, or 1.5% of the articles sentatives Standing Committee on Community Affairs published in the MJA over the 12 year period, directly Inquiry into Migrant Access and Equity [12] argued that related to multicultural health concerns. Twenty-one being from a non-English-speaking background did not articles were original research articles, 10 more were indicate disadvantage; an increasingly valid observation policy issues, guidelines or case studies and three were as the class and educational background of immigrants related to medical workforce issues. Figure 1 outlines had shifted by that decade. the strategy and results of the search. However, the agreed replacement term, ‘culturally and The 31 articles which were excluded at this final stage linguistically diverse (CALD)’ was taken up by federal are worthy of examination. There were 10 clinical guide- authorities in Australia (but not unilaterally by the pre- lines or workforce articles that did not mention non- dominately Labor state government authorities). It English-speaking populations or groups. A further 21 asserted and highlighted the difference between immi- original research articles in the MJA explicitly excluded grants and mainstream Australians, and emphasised cul- the participation of people with limited English. These ture, rather than language. The new term’s emphasis on articles, which knowingly excluded the participation of being different from the Australian cultural norm people with limited English proficiency, included articles implied a marginalising attribute-a distinction from the concerning: women’s understanding of their breast can- majority, the Australian-born. This representational cer diagnosis [17]; a prevalence study of domestic vio- change was undertaken within a context where there lence [18]; a random sample of young people to was increasing national questioning about the ideology determine their ability to identify depression and psy- of multiculturalism, immigration levels, and contestation chosis [19]; a random sample testing the intentions of over what it meant to be Australian. The changing dis- young people should they experience mental health pro- course on immigrants has frequently served to define blems [20]; a random sample of South Australian house- non-immigrants as legitimate and immigrants as differ- holds to determine the extent of self-reported ent, and therefore marginal, and potentially less legiti- medication [21]; predictors of participation in screening mate: ‘The Other’ [13,14]. Interestingly, CALD has also programs or cancer tests [22,23]; pathways to care for come to convey a sense of being ‘up-to-date’ or current. cancer patients [24]; health status during treatments The naming and re-naming of this population group by [25]; co-morbidity studies [26]; and, studies of post- Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 3 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Figure 1 Medical Journal of Australia literature search method and results. operative or post-treatment complications [27,28]. Gen- intravenous drug use and Human Immunodeficiency erally, these articles simply listed their exclusion in the Virus in Indochinese communities [48]. methods section or in a section on the study’s limita- A further 71 original MJA research articles took some tions. In explanation, one said that lack of funds for account of patients with limited English, ethnic groups translators restricted the study to people who could or multicultural health. These articles were further cate- speak English. Others noted that the questionnaire was gorised as having a high (11 studies), moderate (23 stu- in English only or that the study required consent to be dies) or minor (37 studies) treatment of multicultural signed in English. One study [29] did not provide the health issues within the study. program of outpatient stabilisation of newly diagnosed The 11 original research articles categorised with a Type 1 Diabetes patients to patients without English. high level of consideration of multicultural health Of the 153 included articles, 21 were original research included, for example, a study showing that overseas- studies that specifically focused on immigrant groups. born men were more likely to commit domestic homi- Five articles provided descriptive information on African cide and that NESB women in arranged marriages were or refugee medical and physical health derived from on- particularly at risk [49]; a case study of an immigrant arrival screening or related services [30-34]; three dis- patient negatively affected by herbal medicine usage cussed Vitamin D deficiency in veiled and dark-skinned [50]; a study of the use of complementary medicines women and their babies [35-37]; five were concerned [51]; a study reporting mainstream community concerns with the mental health of refugees [15,38-41]; one with about refugees bringing diseases to Australia [52]; a pre- iron depletion in Arabic-speaking toddlers [42]; one valence study of tuberculosis (TB) in Melbourne sec- examined the hospital utilisation of refugees based on ondary students, which found that being born overseas their source country [43]; one examined the differential was a predictor for contraction of TB [53]; an analysis access rights of Temporary Permit Visa holders, as com- of the differential death and disability risk factors in pared with refugees [44]; one studied the primary care developed and developing countries [54]; a study of the utilisation patterns of 341 asylum seekers in Melbourne efficacy of intramuscular cholecalciferol injection for [45]; one studied the effectiveness of outpatient malarial Vitamin D deficiency [55]; and, a study finding non- treatment with African refugees [46]; one looked at the English-speaking (NES) patients, in comparison with barriers to healthcare access for newly arrived African English-speaking patients, were more likely to consult a refugees [47]; one studied shared antenatal care by bilingual GP, attend a solo metropolitan practitioner women of non-English speaking backgrounds [16]; and and to consult a GP for respiratory, endocrine and one studied the positive relationship between digestive problems [56]. Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 4 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Examples of the 23 original research articles that were rights to healthcare of asylum seekers [76,77]; and an rated as having a moderate consideration of multicul- article detailing the trauma experienced by children and tural health included: a study of young women and risk their families held in detention [78]. taking, which found young women from non-English- Seven MJA articles related to medical workforce speaking backgrounds (NESB) were more likely to be issues, mainly focused on the stresses associated with involved in car accidents [57]; a study of snorkelling being a doctor [79-82]. Birrell et al. [83] discussed the deaths, which found 10 out of 27 were ‘NESB tourists’ lack of national standards and variable standards and [58]; a study of homicides during psychotic episodes, knowledge of overseas trained doctors (OTDs); Arkles which found that 19% (an over-representation) were et al. [84] outlined similar issues associated with health- from a ‘NES background’ [59]; a study predicting deaths care provided by OTDs in remote Aboriginal popula- among young offenders, which found that having a tions; McGrath [85] discussed the importance of drug-related offence was a major predictor and that the integrating OTDs into the medical workforce. The latter risk of drug-related offences was 13 times greater for three articles are considered to be based on multicul- ‘Asian’ young offenders and two times greater for those tural health issues. from other non-English-speaking backgrounds [60]; a Search Results: Australian Health Review study of cosmetic surgery and health status noting that In the AHR over this 12-year period there were a total NESB women were less likely to undergo cosmetic sur- of 866 publications. Of these, 751 were articles. Eighteen gery [61]; a study of the spread of Hepatitis C, finding articles relating to multicultural health issues were iden- that Vietnamese migrants and prisoners were more tified initially from the Medline and Scopus searches- likely to share needles [62]; a study of the help-seeking two of these were excluded as they were New Zealand behaviour of men with erectile dysfunction finding that articles. A verifying manual search through the journal NESB men with this problem were less likely to seek website yielded a further five articles [86-90]. Of these help [63]; a study of gestational diabetes noting a gen- final 21 articles, eight were original research based on eral prevalence of 3.6% ‘north east Asian’ and ‘south multicultural health, six were health workforce articles east Asian’ women having prevalence rates of 13.7% and based on multicultural health issues and two were arti- 12.5% respectively [64]; a study of obesity and over- cles concerned with cross-cultural research methods. weight in an obstetric population noting increasingly Fifteen original articles, or 1.9% of the articles published high body mass index (BMI) associated with ‘minority over the 12-year period, directly related to multicultural ethnic descent’ [65]; a study of Type 2 Diabetes in youth health concerns. One further workforce article had a finding ‘ethnic’ young people were over-represented moderate consideration of multicultural issues and three [66]; and an epidemiological study and discussion of original research articles had a minor inclusion of multi- child health in Australia, which noted the particular vul- cultural health issues. Figure 2 outlines the AHR search nerability of asylum seekers and the problems of institu- strategy and the results of the search. tional racism [67]. The AHR contained eight original research articles Fifty-four MJA articles were clinical guidelines, policy based on multicultural health issues. Tran et al. [91] issues, or case study articles rather than original profiled 829 clients of the Ethnic Obstetric Liaison Offi- research articles. Of these, 10 were categorised as arti- cer Service in the south west of Sydney and concluded cles concerned primarily with multicultural health- that ethnic-specific service models are necessary for lin- related issues, 15 as moderately inclusive and 29 as hav- guistic and cultural relevance; Heaney and Moreham ing a minor mention of multicultural health issues. [92] surveyed 109 hospital staff and found they reported Examples of articles concerned primarily concerned under-usage of professional interpreters and inappropri- with multicultural health issues included: an article out- ate usage of family and friends as interpreters; Chan and lining the importance of cultural competence in dealing Quine [93] conducted focus groups in Chinese to deter- with adolescents [68] or in medical practice [69]; an mine the health needs of this community; Han [94] argument for the introduction of RU-486 in Australia explored the factors sustaining usage of herbal medi- [70]; a discussion of the forced detention of non-compli- cines by Koreans in Australia; Renzaho [89] negatively ant TB sufferers [71]; discussions about the usage of reviewed community service delivery to culturally and complementary and alternative medicines and the need linguistically diverse populations and suggested a new to introduce its study into medical schools [72,73]; a model of needs-led ‘cultural consultation’ be implemen- case study of a neonate with high lead levels associated ted; Murray and Skull [88], discussed the barriers to with the mother’s ingestion of herbal remedies [74]; a care faced by refugees, including language, culture, legal, discussion of the legal and ethical implications of medi- employment and policy barriers, and outlined available cally enforced feeding of detained asylum seekers who health and social resources and entitlements; Wen et al. are on hunger strike [75]; concerns about the limited [90] found culturally diverse populations were less likely Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 5 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Figure 2 Australian Health Review literature search method and results. to be visited by child health nurses or volunteers and and welfare data collections and found that Australian more likely to find such visits ‘uncomfortable ’;and Bureau of Statistics standards and classifications relating Strong et al. examined the health status of overseas to ethnicity were quite widely used [100]; Whelan [101] born Australians and found lower reported mortality outlined a process for the rapid appraisal of views of and hospital utilisation [95]. non-English-speaking clients. Six AHR articles related to healthcare workforce Five articles were original research that considered issues. Five of these workforce articles were primarily multicultural health issues. One article [102], rated with based on multicultural health-related issues. Tang et al. a high level of inclusion of multicultural health issues, [96] studied the (negative) attitudes to nursing in sec- examined future directions for Victoria’smaternity ser- ondary students from non-English-speaking background; vices and found ‘immigrant’ women were consistently Mathews et al. [97] differentiated between the role of less satisfied with their care. A moderate level of consid- bilingual staff and interpreters based on the views of a eration of multicultural health issues was evident in an range of bilingual and interpreting staff; Johnson et al. article that examined the use of respite services among [98] surveyed bilingual staff in an area health service carers of non-institutionalised people [103]. Three arti- and found a language ‘mismatch’ between bilingual staff cles were original research articles that took multicul- and the local populations, and that bilingual staff mainly tural health issues into account in a minor way used their language in simple conversations; Mathews et [104-106]. al.[87]qualitativelyevaluated theroleofethnichealth Search Results: Australian and New Zealand Journal of staff in hospitals; and Bayram et al. [86] researched Public Health overseas trained doctors and found that, in comparison There were 1,727 publications in the ANZJPH over this with locally trained doctors, they were younger, worked period.Ofthese,1,168 were articles. The Scopus and more sessions, were less experienced and saw a different Medline searches yielded 175 articles. After exclusions, a range and mix of patients (newer patients, more disad- total of 110 articles were reviewed in full. Twenty-five vantaged and Indigenous patients). The AHR study, reviewed articles contained no consideration of multi- which considered multicultural health issues in a cultural health issues, effectively leaving 85 articles-7.2% moderate way, looked at the changing workforce chal- of the total articles published over the 12-year period. lenges and the changing profile of Australian medical There were 41 original research articles in the area of students [99]. multicultural health in the ANZJPH over the 12 years. Two AHR articles related to multicultural health Of these, 16 (39%), were published in 2001 or more methods: one identified and analysed national health recently. A further 44 research articles contained some Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 6 of 13 http://www.anzhealthpolicy.com/content/7/1/1 inclusion of multicultural health issues; four contained a rates [119]; Hepatitis B status and vaccination coverage major consideration, six a moderate mention and 34 was studied in Vietnamese schoolchildren [125], in Viet- articles contained a minor consideration of multicultural namese intravenous drug users [126], in infants from health issues. ethnic groups with high carrier prevalence [127], and in Of the original research articles, 13 original articles students at intensive English high schools [128]; Davis were concerned with epidemiology or health status et al. [129] found NESB elderly aged care assessment cli- issues. Pell et al. [107] studied demographic and work- ents were under-referred for assessments and were more related changes in ‘Asian’ female sex workers; Hellard et likely to require nursing home placement; Dolman et al. al. [108] found a high prevalence of blood borne viruses [130] highlighted language barriers, cultural insensitivity in 127 ethnic Vietnamese drug users; Steel et al. [109] and service knowledge as access issues for people with found the psychiatric status of asylum seeking families limited English; Davidson et al. [131] reviewed refugee accommodated in remote detention centres was very access to dental services and found several barriers; significantly compromised, and Mares and Jureidini Neale et al. [132] surveyed people recently arrived from [110] found very high levels of mood disturbance and the Horn of Africa and found 50% reported health post-traumatic stress symptoms in children and families access difficulties, mainly related to communication. accommodated in detention centres; Kingsford Smith Two studies outlined major issues associated with and Szuster [111] measured dental health in refugees achieving quality methods in cross-cultural research stu- from the former Yugoslavia and Iraq and found it was dies [5,6]; Mitchell et al. [133] found cervical screening considerably poorer than that of a matched group of rates increased with intensive ethnic media publicity; social security recipients; Rissel et al. [112] surveyed Page et al. [134] found no change in mammography 2,573 secondary students with large ‘Arabic’ and ‘South screening attendance in Italian-born women as a result East Asian contingents’ and found delayed smoking of ethnic media publicity; while Wong and Wang found uptake in these groups; Rissel et al. [113] found 49% of that the participation rates in a Chinese survey were males and 29% of females in the Lebanese community increased by using translated instruments [135]. smoked;Lin andWard[114] studiedthe smoking- Six studies discussed knowledge, attitudes and health- related habits and attitudes of 1,084 ‘ethnic Chinese’; related behaviours. Telephone surveys of Vietnamese Taylor et al. [115] found ‘migrants’ had lower rates of males’ knowledge of sexually transmitted diseases and coronary heart disease probably related to selection, diet blood borne viruses found poor knowledge [136]; high and lifestyle; Burton and Lancaster [116] profiled the levels of Hepatitis B and poor information about Hepati- Pacific Islanders’ obstetric population and found three tis B was found in Lao and Cambodian groups [137]; times the average rate of gestational diabetes, greater Rice and Naksook [138] examined Thai women’sper- hypertension and higher perinatal mortality; Sullivan ceptions about caesarean births; Cheek et al. [139] sur- and Shepherd [117] studied the obstetric profile of Viet- veyed Vietnamese women’s attitudes to cervical namese-born women and found higher gestational dia- screening and found reasonably high participation rates betes, lower pre-eclampsia and lower birth weights; and reliance on GPs and family for information; Plun- Rissel [118] developed an eight-item scale of accultura- kett and Quine [140] found carers with limited English tion for use in cross-cultural studies; Brown et al. [119] were reluctant to institutionalise their elderly relatives in surveyed 198 Filipinas and found good self-perceived nursing homes; and Maneze et al. [141] described the health status; Ireland and Giles [120] found an Italian- pattern of kava use among 73 Tongan men in the born group’s blood pressure increased in comparison to Macarthur area of Sydney. a decline in the Australian-born group in a suburb in Search Results: Summary Melbourne. Table 1 summarises results of the analysis of these three Of the policy-related articles, two were concerned with journals. In total there were 4,146 articles published in the detention of asylum seekers [121,122], and another these journals over the 12-year period. A total of 90, or found poor implementation of ethnic health policy in 2.2% of the total articles, focused primarily on multicul- community mental health centres [123]. tural health issues. A further 62 articles had a major or Service- and screening-related original research find- moderate level of consideration of multicultural health ings included: lower reporting rates of pap test in issues and 107 had a minor mention. In total, 259, or women speaking a language other than English and var- 6.3% of all articles, included some mention of multicul- ied uptake of pap test by region of birth [115]; low cer- tural issues. vical screening rates for Vietnamese women was related Limitations to acculturation and years of residency in Australia This study is limited by the accuracy of the search tools. [124]; translated personalised letters sent to Vietnamese The Medline and Scopus searches in each case yielded women were ineffective in increasing cervical screening different articles. Despite attempts to overcome the Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 7 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Table 1 Summary of Results of the Analysis of Three Journals Total number Number of MC MC articles as a % Number of other articles Number of other of articles in articles of total articles with major or moderate articles with minor journal consideration of MC issues consideration of MC issues MJA 2,227 34 1.53 49 70 AHR 751 15 1.99 3 3 ANZJPH 1,168 41 3.51 10 34 Total 4,146 90 2.17 62 107 shortfalls, relevant articles may not have been retrieved Therewas aslightlylargernumber of originalmulti- through this search strategy, just as some retrieved arti- cultural health articles (n = 41) featured in the ANZJPH cles were clearly not relevant. compared with the MJA, representing 3.4% of the total It is further acknowledged that a significant amount of articles published in the ANZJPH over the 12-year per- Australian multicultural health research has focused on iod. The majority of original ANZJPH articles were pub- mental health. A literature review in the area of mental lished prior to 2001, with only 16 original research health has also demonstrated gaps in research [142]. A articles published since 2001-possibly a reflection of a study such as this requires a level of judgment in respect changing social climate. The range of health issues cov- of the level of consideration of multicultural issues ered in the ANZJPH was somewhat limited, with seven included in a study. It is acknowledged that although concerned with blood borne viruses or sexually trans- the principal researcher checked the categorisation with missible infections, five with cervical cancer and pap another researcher, such judgments can always be tests, three with obstetric profiles, three with smoking debated. prevalence, two with dental health, one with coronary heart disease, one with blood pressure and one with the Discussion health of Asian sex workers. Six articles critically dis- Valuable insights can be gained from comparing the cussed ethical issues, health status or service implica- representations of immigrants in each of these three tions of the policy of detaining asylum seekers and their journals. Almost all the original MJA research articles children in remote detention centres. focused on newly arrived refugees. Almost all focused The 15 original AHR research articles were diverse in on relatively exotic, if not ethnic-specific illnesses. Most subject matter. Five addressed workforce changes, (13 articles) related either to the mental or physical recruitment issues, and bilingual staffing in hospitals. health of newly arrived refugees or asylum seekers, and The other 10 articles addressed a range of issues related five dealt with concerns about vitamin deficiencies in to epidemiology, access, service delivery, and cross-cul- veiled or dark-skinned women and their babies, or in tural research methodologies. Arabic speaking toddlers. The MJA published seminal Apart from two AHR articles that assessed service articles and opinion pieces in these areas particularly access [124,131] it is interesting that few studies in concerning the Australian policy and treatment of asy- these three journals have evaluated service quality or lum seekers. Researchers often focus on the most effectiveness. For example, surprisingly few studies have recently arrived community as they are considered to be evaluated the impact, demand and cost effectiveness of the most different from the mainstream [143]. Yet the healthcare interpreter services. Indeed, there is little representations remain very limited. Of the 2,227 arti- Australian evidence regarding the most common meth- cles published during the 12-year period, only 21 (0.9%) ods of facilitating communication in healthcare with were original research and a total of 34 (1.5%) were con- people who have limited English. Access studies have cerned primarily with multicultural health issues. A focused on community services and aged care services. further 71 MJA original research articles including some Wide-ranging terms were used by researchers in these discussion of multicultural issues, with 11 articles dis- journals to describe ethnicity. Some used various aggre- cussing multicultural health issues as a major compo- gations of ‘countries of birth’ (e.g. North Asian, South nent of the article and 23 as a moderate component. In East Asian, Asian), ‘white’ and ‘non-white’, ‘non-English- others (37 articles), the mention of diversity was inci- speaking’,or ‘ethnic groupings’, one defined ethnicity in dental, or, what Minas et al. [142] described as ‘tacked- a population as related to parental country of birth. This on’, or an after-thought to the main discussion. Of the diversity of terms indicates the continued lack of health- 54 MJA articles categorised as policies, guidelines or care researcher agreement about the appropriate ways of case studies, 10 were primarily concerned with multicul- reporting ethnicity in Australia, although one study tural health issues. noted that government databases tend to follow Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 8 of 13 http://www.anzhealthpolicy.com/content/7/1/1 nationally agreed terminology [100]. Few researchers non-English-speaking countries actually speak very flu- outlined the study methods they used to assess the eth- ent English (e.g. immigrants from Hong Kong, India, nicity-related variables. In articles that included some Holland). Kliewer and Jones [144], in their study of mention of multicultural health issues, few discussed the newly arrived immigrants, found that almost 12% of study’s results related to ethnicity; the majority simply immigrants from NESB countries spoke English as their noted ethnicity as a demographic variable. There were preferred language and another 39% stated they spoke few attempts in these studies to further analyse the English ‘well’ or ‘very well’. Fields that have been incor- effects of socio-economic status, gender, or educational porated into standard healthcare databases, such as ‘lan- status see Figure 3. guage spoken at home’ or ‘preferred language,’ do not Datasets often contain little information on English indicate how well a person speaks English. language proficiency or on the demographic, social, eco- The available research could be described as uneven in nomic and cultural factors that may influence health its coverage of major health status and health risk factor and health service utilisation [100,144]. Much class, eth- issues affecting immigrant communities. There are some nic and geographical variation in health status may be major health status issues that appear to have received masked or homogenised because birthplaces or groups little attention; for example, renal disease, dialysis access, are aggregated (often in inconsistent ways) so as to heart failure, kidney disease, prostate cancer, lung can- achieve statistical meaning. At times, for example, all cer, eye problems, cardiac problems, depression or people born overseas are considered as one group, as chronic diseases. It is interesting that very few original are all people who speak a particular language, irrespec- articles dealt with patient experience, acute care, or the tive of their year of arrival, English language proficiency, ethnic elderly. In terms of health promotion, the empha- age, and region of origin or socio-economic profile sis was limited to screening, general practice access, and [144-147]. Bhopal refers to these epidemiological prac- interventions to promote population-based health tices as ‘inventing ethnic groups’, ‘lumping groups screening. together’, ‘not adjusting for confounding factors’ and Further, little attempt has been made to understand ‘not comparing like with like’ [148]. Coming from a the crucial relationship between poor language profi- non-English-speaking country is frequently used as a ciency, culture and patient safety in the Australian con- surrogate for poor proficiency in English. This aggrega- text. The question of whether there is ethnic disparity tion has an inherent bias as many immigrants from (difference in treatment and care based on ethnicity, Figure 3 Australian and New Zealand Journal of Public Health literature search method and results. Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 9 of 13 http://www.anzhealthpolicy.com/content/7/1/1 race or language ability) in healthcare service provision there are other communities and health issues that are has not been addressed in these major Australian essentially invisible or unrepresented in research. healthcare journals. Studies were mainly descriptive/observational studies Methods or basic epidemiological studies. None were randomised Systematic reviews were undertaken in three major Aus- control trials or longitudinal studies. Some studies were tralian health care journals. These journals arguably a series of cross-sectional surveys. There were no clini- represent the broad spectrum of mainstream healthcare cal trials. A few interventional studies looked at, for research in Australia. The three journals include: the example, theeffect of theethnicmedia on serviceor largest circulation general medical practice and clinical screening access. While there were some studies with research publication in Australia, the Medical Journal of large samples, others had quite small numbers. Australia (MJA), Australia’s largest public health journal Interestingly, many ANZJPH articles studied the The Australian and New Zealand Journal of Public Vietnamese or ‘South East Asian’ populations, with 14 Health (ANZJPH) and Australia’s major health services of the 20 articles which featured specific populations research and management journal, The Australian choosing to study South East Asians. Two other stu- Health Review (AHR). Reviews were undertaken of the dies researched Arabic/Lebanese groups, two studied last twelve 12 years (1996 to August 2008) of journal Italians, two studied Islanders, and one studied each of articles using six standard search terms: ‘non-English- sub-Saharan Africans and Filipinas. Four studies were speaking’, ‘ethnic’, ‘migrant’, ‘immigrant’, ‘refugee’,and concerned with asylum seekers and a further three ‘multicultural’. Each of the categorisations was tailored with refugees. This is an interesting representational to the content of the journal. A single approach across bias even given that Vietnamese is one of the five these three journals was neither possible nor desirable. major languages spoken in Australia. The reasons can Articles were categorised as being primarily concerned only be speculated upon, but it is interesting to recall with multicultural health issues, having some level of the words of Martin [8], who stated that in the 1950s inclusion of multicultural health issues or excluding and 1960s migrant groups were homogenised (as one) multicultural health issues. Within the category of ‘some but that in the 1970s ‘migrant’ equalled Greek and Ita- inclusion’, articles were further categorised a having a lian. The research data from the ANZJPH would seem major, moderate or minor level of consideration of mul- to indicate that in the past decade, ‘migrant’ equals ticultural health issues. A major inclusion required that ‘Vietnamese ’, ‘South-East Asian ’, ‘asylum seeker ’ or a large section or part of the argument of the article ‘refugee’. This observation is also consistent with the related to multicultural health or immigrant health representations of migrants in MJA original studies, issues; a moderate level of inclusion defined multicul- with newly arrived refugees and asylum seekers being tural health or immigrant health issues as one of a the major groups studied. It may be that by the 1990s range of issues within a broader context or set of issues. and this 21st century, the term ‘migrant’ has come to A minor inclusion meant that multicultural health or mean South East Asian, Vietnamese, refugee and asy- immigrant health was included in some minor way in lum seeker. the study, for example, as a demographic descriptor. A zero inclusion means that there was no consideration of Conclusions multicultural or immigrant health issues in the article. The review of these three journals over a 12-year period The principal researcher undertook this categorisation. demonstrates that the quantum, range and quality of the It was checked by a second researcher. research and evidence which is required for equity in Search strategy: Medical Journal of Australia policy, services, interventions and implementation is The MJA review strategy involved searching the six limited. Kagawa-Singer [149] argued that mono-cultural terms through the on-line ejournal. Articles were health services’ research focus has three major limita- excluded if they were concerned with Aboriginal and tions, namely a lack of recognition of different world Torres Strait Islander health, book reviews, repeat arti- views, a lack of understanding of the most appropriate cles, advertisements, tables of content, or archives. Arti- and effective means to cope with illnesses based on cles that did not contain the search words were not those world views, and a lack of ability to hear different included. All other articles were included. A cross-check ways of communicating these perspectives. on this accession list was made via a verifying Medline Whilst the MJA, AHR and ANZJPH research plat- and Scopus search. Articles were categorised as original forms could certainly not be called ‘mono-cultural’,they research based on multicultural health issues or immi- could quite reasonably be called ‘limited’ and ‘uneven’. grant groups, original research that specifically excluded While there is some excellent quality research in respect immigrant groups, original research that included multi- of refugees, asylum seekers and Vietnamese immigrants, cultural health or immigrant health issues to some Garrett et al. Australia and New Zealand Health Policy 2010, 7:1 Page 10 of 13 http://www.anzhealthpolicy.com/content/7/1/1 Competing interests extent, medical workforce articles and clinical guidelines, The authors declare that they have no competing interests. policy, editorials and opinion pieces. The main search strategy and categorisation system is outlined in Figure Received: 3 February 2009 Accepted: 3 January 2010 Published: 3 January 2010 Search strategy: Australian Health Review References A similar process was undertaken using the same six 1. Harkness J, Vijer Van de F, Mohler P: Cross-Cultural Survey Methods (Wiley keywords from 1996 to August 2008 in the Australian Series in Survey Methodology) New Jersey: Wiley-Interscience 2002. 2. NHMRC: Cultural Competency in Health: a guide for policy, partnerships and Health Review (AHR). AHR does not have an online participation Canberra: National Health and Medical Research Council 2005. search facility, so a search was undertaken using the 3. Bullinger M, Anderson R, Cella D, Aaronson N: Developing and evaluating Scopus database followed by a Medline search. The cross-cultural instruments from minimum requirements to optimal models. Qual Life Res 1993, 2:451-459. results were checked by a manual perusal of the articles. 4. 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Kagawa-Singer M: Improving the validity and generalizability of studies with underserved U.S. populations expanding the research paradigm. Ann Epidemiol 2000, 10(Suppl 1):S92-S103. doi:10.1186/1743-8462-7-1 Cite this article as: Garrett et al.: Representations and coverage of non- English-speaking immigrants and multicultural issues in three major Australian health care publications. Australia and New Zealand Health Policy 2010 7:1. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Australia and New Zealand Health PolicySpringer Journals

Published: Jan 3, 2010

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