Wellbeing programs for culturally and linguistically diverse population in Australia: barriers and improvements

ABSTRACT

Objectives

Despite the emphasis on the wellbeing of culturally and linguistically diverse (CALD) populations in Australia, programs that promote wellbeing are scarce. Wellbeing programs are often not developed empirically and under-utilised. The present qualitative study explored limitations of current wellbeing programs, refinements that are warranted, and barriers encountered when implementing these programs.

Method

Mental and allied health practitioners (N = 16), working with CALD populations in Australia participated in semi-structured online focus groups. Data were transcribed and analysed using thematic analysis.

Results

The generated themes identified limited funding as a major problem. Further weaknesses of existing programs and barriers that prevented CALD populations in engaging with these programs were highlighted. Features of an effective wellbeing program and strategies applied to implement the programs were identified. Theoretical and practical implications for developing and implementing wellbeing interventions for CALD Australians were discussed.

Conclusions

Significant dearth of research in this area and the necessity of further literature to identify the value of wellbeing interventions for CALD populations is emphasised.

Key Points

What is already known about this topic:

1. Past research in Australia has focussed more on the challenges of culturally and linguistically diverse population.

2. Programs that promote the wellbeing of culturally and linguistically diverse populations in Australia are limited and underutilised.

3. Barriers in developing and implementing wellbeing programs should be explored.

What this topic adds:

1. Funding is vital for the development and evaluation of wellbeing programs for culturally and linguistically diverse populations in Australia.

2. Consultations with culturally and linguistically diverse populations would improve the content and implementation of wellbeing programs.

3. Holistic and flexible programs should be rolled out at the community level.

KEYWORDS:

• CALD
• wellbeing programs
• barriers
• improvements

Australia’s culturally and linguistically diverse (CALD) population is growing. The 2021 census revealed that 27.6% of the population was born overseas, 48.2% have a parent born overseas and 22% spoke a language other than English at home (Australian Bureau of Statistics, 2022). Resettling as an ethnic minority can be challenging, and migration-related stressors can impact the wellbeing of CALD populations (Bhugra, 2015). Although there has been some emphasis addressing the acculturation and managing the mental health concerns of CALD population (Blignault et al., 2022), the emphasis on promoting wellbeing has been limited (Khawaja et al., 2021). There is now a growing consensus, that support should be offered at an earlier resettlement phase to promote wellbeing and to avoid CALD from deteriorating into mental health issues. Despite the importance of enhancing wellbeing of CALD, there is a scarcity of information about programs that try to achieve this goal in Australia. Further, it is unclear if these programs are effective or require refinement. In the case of an absence of such programs, it is vital to understand how they can be developed and implemented effectively.

Wellbeing is a complex concept with multiple dimensions (Dooris et al., 2018). It includes good physical and mental health, sound social interpersonal relations with others and good cognitive and problem-solving skills (Diener et al., 2018; Vally & Ahmed, 2020). It is expressed through settling into the new setting, successfully navigating the new environment, feeling safe and enjoying a sense of belonging and safety in the new society (Hashemi et al., 2019). A range of factors, such as acculturation (Hashemi et al., 2020), religion and religious identity (Abu-Rayya et al., 2016), strong social support (Hashemi et al., 2020), being integration-oriented and having higher levels of resilience (Wu et al., 2018), have emerged as some salient determinants of CALD wellbeing. Factors such as acculturative and adjustment stressors, limited knowledge of health systems, limited opportunity to appropriately use occupational skills (Minas et al., 2013), temporary visa status (Momartin et al., 2006), stereotypes and prejudice (Pekerti et al., 2020), unemployment (Hosseini et al., 2017), underutilisation of skills when employed (Reid, 2012), and lack of functional language skills (Maneze et al., 2016), role and intergenerational conflicts (Deans et al., 2016) have appeared as risks. These findings emphasise the necessity of wellbeing programs that focus on increasing determinants of wellbeing and addressing risks to wellbeing, rather than pathologising experiences based on Western, biomedical models (Wohler & Dantas, 2017). Programs that enhance wellbeing, can reduce the burden on health systems by ensuring that such issues are mitigated. Wellbeing programs focus on enhancing an individuals’ knowledge and skills so that they are able to strengthen their protective factors and deter risk factors (Khawaja et al., 2013).

While wellbeing programs are essential, Australian organisations and services are simply not meeting this demand. The programs available are incredibly limited, and those available often lack empirical grounding. Furthermore, programs are often framed as “mental health” programs and focus on specific areas of disability and mental illness, rather than taking a holistic perspective on wellbeing. For example, the Programme of Assistance for Survivors of Torture and Trauma (PASTT; Department of Health and Aged Care, 2021) is a service for humanitarian migrants who have pre-migration experiences of torture and trauma. There has been an attempt to develop wellbeing programs to enhance the CALD populations acculturation to the Australian society and the protective factors. For example, Building Resilience in Transcultural Australians (BRiTA Futures) program, has been shown to support positive acculturation experiences and resilience of minors and adults (Khawaja et al., 2013, 2021). However, recent recommendations from consumers indicate the importance of revising the content to ensure that it reflects aforementioned determinants of wellbeing (Ahangari et al., 2021). Thus, a holistic wellbeing program that is culturally aware and accessible is required (Dooris et al., 2018).

It is important to note that, compared to the Australian-born population, the uptake of health services by CALD populations is at a much lower rate (Khatri & Assefa, 2022; Logan et al., 2017). Multiple barriers, such as not perceiving the professional psychological help as appropriate (Hamid et al., 2009), stigma, limited knowledge of available services (Minas et al., 2013), language barriers (Haralambous et al., 2014), preferring informal modes of help seeking (Ghafournia & Easteal, 2021), transport challenges (Baker et al., 2016), health literacy and difficulty navigating health systems (Javanparast et al., 2020) have been reported. Understanding barriers to accessing services would allow policy makers and organisations to actively mitigate such barriers.

While individual factors may impact service utilisation, the systemic deficiencies in Australian service systems cannot be ignored. The limited funding allocated to CALD wellbeing is a critical barrier. Even though past funding models (National Health and Medical Research Council (Australia) [NHMRC], 2006) endorsed wellbeing programs as vital for CALD populations, funding cuts have impacted service’s abilities to create programs that effectively reflect the factors that promote wellbeing for CALD populations (Pruitt et al., 2017; Ziersch et al., 2020). A lack of appropriate resourcing may inadvertently reinforce CALD stigma associated with help-seeking (Peñuela O’Brien et al., 2022). Limited CALD engagement reduces the likelihood that organisations increase their staff training and resourcing (Posselt et al., 2017), establishing a perpetual cycle.

Health care workers with a limited understanding of cultural safety and sensitivity can negatively impact consumer outcomes and the therapeutic alliance (Dune et al., 2018). Cultural safety is acknowledging and addressing factors that can reduce health equity for culturally diverse consumers, such as bias and prejudices (Curtis et al., 2019). Subsequently, CALD populations have a higher likelihood of receiving poor quality care than the general population, which may perpetuate concerns about being understood and respected (Mental Health in Multicultural Australia [MHiMA], 2014). Poor cultural safety of service providers and inadequate interpretation services were also identified as barriers (Javanparast et al., 2020; Khatri & Assefa, 2022). While policy makers in Australia are aware of factors that promote wellbeing for CALD populations, implementation of such policies is negligible (Minas et al., 2013). These inequities and disparities are essentially invisible due to the limited reporting on the implementation of such policies on a national level (MHiMA, 2014).

Literature suggests various strategies to mitigate such barriers (see Peñuela O’Brien et al., 2022 for a systematic review). Health professionals have identified the following recommendations: establishing therapeutic alliance, understanding and addressing immediate concerns rather than complex mental health issues, practical support, and a phased approach whereby interventions focus on factors that promote wellbeing, with an option for further referral if required (Blignault et al., 2022). Developing partnerships with specialist agencies and CALD communities is essential for continuity of care and enabling efficacious provisions of care (Posselt et al., 2017; Sibson & Stanway, 2022).

While mental health intervention is crucial, wellbeing promotion for CALD populations is neglected. Wellbeing promotion requires a holistic lens, acknowledging social determinants of health (Khatri & Assefa, 2022). Thus, wellbeing interventions can reduce the burden of disease (Arango et al., 2018). Understanding how services can provide wellbeing promotion support that is culturally responsive would result in better health outcomes, greater consumer satisfaction and efficient resource utilisation (MHiMA, 2014). This study utilised a qualitative approach to engage with mental and allied health practitioners, who worked extensively with CALD populations in Australia. It was important to explore their perspective on wellbeing programs for CALD populations used in Australia; barriers implementing the programs for these populations and improvements that are warranted.

Method

Design

A qualitative methodology allowed researchers to explore the unique cultural factors that occur in a given environment (Malagon-Maldonado, 2014). Focus groups enable rich discussion among participants and is more appropriate than one-to-one interviews for research aiming to generate new ideas formed within a social context. Purposive and snowball sampling was used to recruit mental and allied health professionals. This is usual practice in qualitative research that requires the identification and selection of proficient and well-informed participants in a relatively niche area (Etikan et al., 2016).

Procedure

Recruitment

Ethics and health and safety clearances were obtained through the respective university committees. Inclusion criteria were being above the age of 18, having conversational English skills, and being a mental or allied health professional who works with, and/or facilitates wellbeing programs for CALD Australians. Due to the online nature of the focus groups, participants also required access to the internet and Zoom. The authors disseminated information about the study among their professional networks. These contacts were requested to participate in the research and to disseminate the research information further among their contacts. Project flyers were also sent to organisations that offer services to CALD Australians (e.g., NGOs; Queensland Transcultural Mental Health Centre). Social media (e.g., LinkedIn and Facebook) were also utilised. Those who participated in the research were also asked to disseminate the research information to known professional networks.

Participants

Sixteen mental and allied health practitioners (females: 11; males: 5) across two states in Australia participated. Participants’ occupations included clinical psychologists, social workers, and CALD caseworkers. Their age ranged from 21 to 70 years (M = 40), and three participants did not disclose their age. Most (93.8%, n = 15) participants spoke a language other than English. Altogether, 15 languages were spoken with the most common being Arabic, Spanish, French, Urdu, Mandarin, and Cantonese. All participants identified as ethnically diverse (including being mixed-race), the most common being Asian and African ethnicities (56%). Most (n=14) participants had completed a university-level education, while others (n=2) completed other levels of training (e.g., vocational).

Measures

Participants completed a consent form and an online demographic form on Qualtrics. This form captured age, gender, cultural background, languages spoken, and highest level of completed educational qualification.

Prompts

The prompts were developed by the first author in collaboration with the second author. The prompts asked the participants to comment on the wellbeing programs for CALD populations in Australia known to them. Further, the limitations of these programs; possible improvements; what content could be included; delivery methods; strengths; limitations; barriers accessing and implementing these programs were explored.

Focus groups

Four semi-structured focus groups were conducted over Zoom using English language and facilitated by the first author. Each focus group had three to five allied health practitioners and had an average duration of one hour. Participants were provided a brief outline of the study and a rationale for utilising focus groups. They were also encouraged to actively engage with prompts and to provide different perspectives. Focus group discussions were then transcribed verbatim by the first author and a research assistant.

Data analysis

A Thematic analysis (TA; Braun & Clarke, 2021) was utilised to analyse transcripts. TA is a theoretically flexible approach used to generate knowledge about human experiences within a broader sociocultural context. A degree of deductive theory-driven approach was adopted to ensure that the open-coding produced themes that were meaningful to the study goals (Squires, 2023). In line with Braun and Clarke’s (2021) six phases of TA, the first author, who conducted the analysis, read, re-read, and familiarised herself with the transcripts, making notes of initial observations. Using NVivo the data were coded (NVivo 12.0; released in March 2020). Labels which captured the content were assigned. The codes were reviewed to identify patterns and to group different ideas together. Themes were reviewed and merged until higher-order themes, that captured the data well were generated. The themes formed by the authors through a reflexive approach were named in a meaningful manner. These themes later became the subject of the write-up phase.

Reflexivity

The first author is a second-generation CALD Australian, who was aware of the challenges of ethnic minorities. Further, at the time of the study she was completing her Master of Clinical Psychology and engaged in psychological practice with vulnerable clients from all backgrounds. The second author is a CALD first-generation migrant. As a clinical psychologist, she researched and practiced with ethnic minorities. As researchers and insiders, the authors kept reflexive memos and shared observations with each other and interpreted the data considering the experiences of CALD populations as well as the clinicians working with this population. Researchers’ cultural heritage and the acknowledgement of the challenges that CALD consumers and clinicians experience helped participants speak openly.

Quality techniques

Quality assurance strategies were employed to mitigate potential biases. The first author discussed the coding and themes with a colleague, who was not part of the project to cross-check whether her codes captured the participants’ views accurately. Further, the first author had extensive discussions with the second author to collapse codes into meaningful themes.

Findings

The following five major themes and subthemes were identified from the focus group data. As seen by Table 1 participants discussed the role of limited funding in developing and implementing wellbeing programs, weaknesses of the current programs, barriers in engaging with the programs, what effective programs will look like and how they can be implemented successful.

Table 1. Themes.

Limited Funding	Program Weaknesses	Barriers to CALD Engagement	The Ideal Wellbeing Program	Implementing a Successful Program
Tokenism	Limited Understanding of CALD Experiences	Stigma	Acculturation	Facilitator Factors
Sustainability	Assumptions and biases	Language	Parenting	Flexible Delivery
Research	No Follow-Up	Awareness	Flexible Content	Community Outreach
		Practical Barriers	Holistic

Limited funding

All focus groups emphasised the financial constraints placed on program developers and facilitators. Limited funding impacted wellbeing programs in a number of ways. First, it resulted in tokenistic approaches to CALD wellbeing, such as relying on CALD workers instead of adopting a robust method of developing and delivering wellbeing programs. Second, limited funding resulted in programs that lack sustainability and ongoing continuation. Finally, a systematic impact of limited funding in research for CALD wellbeing was identified as impacting the ability to support the efficacy of programs.

Participants indicated that due to the lack of funding dedicated to wellbeing programs for CALD populations, programs became “budget centred” rather than “people centred” (Participant 15). Participants also expressed their frustration at the strict criteria that accompanied funding, resulting in some populations being excluded. As CALD could be defined in varying ways, its narrow definition could restrict attendees. Inconsistencies were also identified between government and non-for-profit organisations claiming that while CALD wellbeing is priority, the necessary funding is not being applied to wellbeing programs: “ … we facing that hypocrisy saying where we, you know, we say we do something for CALD populations, we’re not putting the money” (Participant 15).

A sense of hopelessness emerged amongst participants who discussed wanting to improve services while being constrained by funding. Some participants also felt that this impacted their ability to effectively practice as professionals: “We just want to do our job and we want to do it well and this is what is needed, why are you like sort of tying us up in these restrictions of the funding?” (Participant 6). An alternate perspective proposed by a participant pertained to the challenge of attracting money through a system that is “magnetised for ill health” (Participant 1). This participant explained that because funding is dedicated to reducing sickness, advocating and justifying funding for wellbeing becomes improbable.

Tokenism

The tokenistic nature of how organisations approach CALD wellbeing due to limited funding was identified as a subtheme. Some participants perceived the use of CALD facilitators as a strength which increases CALD engagement and reflects their consumer base. Other participants perceived this as a tokenistic way organisations claim culturally safe practice without providing further training. Participants added that CALD facilitators need cultural competence training, as assuming competence based on ethnicity or CALD status is inappropriate. “In order to achieve multi-cultural competence, which is the requirement these days, we heavily rely on recruiting CALD practitioners” (Participant 15).

Participants expressed concerns that wellbeing programs were superficially adjusted from existing programs targeted at the general population. This results in “tokenistic” (Participant 12) wellbeing programs that are neither relevant to CALD experiences, nor culturally specific:

Let’s just throw in a few little diagrams and colourful pictures, you know, for things to make sense. I think they can also be a lack of understanding for a lot of, like, deep like deeply rooted cultural issues within a community. (Participant 12)

Sustainability

Participants acknowledged that wellbeing programs were unsustainable. They were concerned about a reliance on unpaid volunteers conducting wellbeing programs, inevitably resulting in burnt out professionals due to pressures on time and resources.

I think most of the wellbeing programs that I have known are all volunteer run. So, like I said, everyone starts off passionate and excited and enthusiastic. And it runs well but then it’s just not sustainable, in terms of money like people, you know, run out of, they get burnt out … in terms of feasibility that’s an issue that, that comes to mind for me for these programs. It’s just not funded well. (Participant 8)

Research

While research was identified as pivotal in being able to improve programs and justify more funding, a lack of research funding in the CALD wellbeing area was identified. One participant asked “… how could anyone invest any money into something that’s not been proven to work?” (Participant 1). Limited research in this area suggests limited research funding. Consequently, organisations struggle to advocate for increased funding. The challenge of maintaining accurate and current content without empirical evidence was also discussed (e.g., culturally inaccurate information).

Program weaknesses

Limited understanding of CALD experiences

Most of the discourse concerning weaknesses of current wellbeing programs was categorised as a limited understanding of CALD experiences. Participants discussed a range of complexities that occur in CALD experiences, including intergenerational trauma, identity challenges, and CALD perspectives of wellbeing which are not effectively reflected in wellbeing programs. Programs were described as “barely scratching the surface” (Participant 4). One participant gave an example of how coping could be misunderstood from an Australian perspective: “Some cultures have something called active forgetting and that’s how you deal with trauma, as a community, whereas you’re in Australia we might see that as denial” (Participant 16).

The limited understanding of CALD experiences was attributed to the lack of CALD involvement when developing wellbeing programs. Participants discussed the importance of working from a “grassroots level” (Participant 12) to ensure programs incorporate factors that promote CALD wellbeing.

Assumptions and biases

Establishing programs on assumptions and biases was identified as a weakness. The grouping of all CALD, or all members of an ethnic group, was assuming they “… have the exact same thoughts and feelings because you’re all Lebanese” (Participant 16). One participant stated that this “defeats the purpose of delivering a program to a multicultural community” (Participant 11). Another participant added that this approach was “patronising” and created an “us and them situation” (Participant 12).

No follow-up

Not providing a follow-up was another weakness. Participants supported the notion that by not providing a follow-up, the likelihood that CALD people continue engaging is decreased. Participant 3 stated “A good follow up is important because, obviously, yeah, once we finished the program, you are leaving them with a certain amount of knowledge. But would that be enough?”

Barriers to CALD engagement

Stigma

Stigma associated with mental health and accessing support was determined to be a major barrier for CALD people. CALD people may perceive their engagement as a sign of being “weak” (Participant 5), which “really hinders people to access or to reach out for the support that they actually need, and to accept the support” (Participant 6). Participants frequently mentioned how wellbeing programs’ titles can also be a deterrent to engagement, giving the following examples: “A DBT (Dialectical Behaviour Therapy) group may not be quite suitable for some cultures, because it assumes that they have problems that they need to address using DBT” (Participant 7). Another participant added, “I’ve also made the experience that calling a workshop, “sexual violence” is something very different than “healthy relationships” (Participant 6).

Intergenerational differences in stigma seem to appear, and first-generation Australians may be more resistant. Although newer generations may be more likely to engage, resistance from older generations makes this difficult. One participant suggested that mental health and wellbeing is lower priority for the first generation because “typically, these migrants may come from, you know, backgrounds where they would just have survival on their agenda, you know just making money, having food on the table, having a place to live” (Participant 8). Another participant explained that the older generations may emphasise coping through cultural and spiritual means, which creates conflicts in younger generations: “… this whole idea of ‘well I’m doing everything religiously and culturally right, yet I’m still struggling’. So, it just reinforces the feelings of low self-worth it just reinforces this idea that there’s something wrong with them” (Participant 16).

Language

The use of interpreters, inaccurate translations, and having to speak in a language that is not the mother tongue, was established as a barrier. Participants represented the use of interpreters as being time consuming, occasionally used inappropriately (i.e., using family members or support workers), and making CALD people feel uneasy. Needing to have a certain level of English proficiency to engage in programs was also discussed:

… so they’re intimidated by going somewhere where they are going to have to communicate in their second or third language, and they’re going to be amongst the people who do not speak in their native tongue who have a very different cultural perspective. (Participant 13)

When discussing translations, one participant explained the impact that incorrectly translated content can have, beyond mis-understanding the content:

… it takes away from the useful information and the content that’s actually here … the focus just becomes on, “you don’t know who I am, you don’t know me, you’re trying to pander to me without actually understanding me and my cultural background”. (Participant 11)

Awareness

Participants acknowledged the disconnect between available services and professional networks, exposing the issue of limited dissemination of relevant information/services among professionals. Similarly, for CALD people, “not knowing where to access support” (Participant 5) is a major barrier in their engagement in programs.

Practical barriers

Other barriers that emerged included family responsibilities (i.e., having children to care for), transport, wait lists, and access to reliable internet for online resources. The pressures placed on services to provide wellbeing programs mean lengthy wait lists that are “really discouraging” (Participant 1) for CALD people struggling to access support.

The ideal wellbeing program

Participants’ recommendations for what wellbeing programs for CALD Australians should include have been condensed below. The prevailing pattern of recommendations was that programs needed to reflect the diverse requirements of CALD communities, rather than based on biases and assumptions.

Acculturation

Participants acknowledged that CALD people may struggle with identity when migrating to Australia: “a lot of people struggle with this being bicultural or tricultural, … it’s trying to understand where you belong” (Participant 14). Addressing such issues, while incorporating information regarding understanding systems (e.g., health care system), laws, human rights, racism and reporting culturally incompetent care, were all mentioned by participants. Essentially, supporting CALD people through identity exploration, while developing skills and an understanding of Australian systems to establish independence was strongly indicated.

Parenting

Even though there were no probes about parenting, parenting challenges, or needing parenting support for CALD communities were mentioned in all four focus groups. Participants in all groups represented parenting within a new culture as challenging, both for parents and children: “… a lot of young people are completely feeling a bit lost because their parents don’t have any coping skills” (Participant 5).

Parenting support was discussed in terms of understanding cultural differences in parenting practices, supporting their children through acculturation and mental health challenges, and raising children in an Australian context while also trying to maintain cultural and religious practices.

Flexible content

A subtheme that was strongly reflected was the significance of program flexibility. The statement, or variations of the statement “not one size fits all” was mentioned seven times, and at least once in each focus group. This suggests that participants overwhelmingly agreed that with the uniqueness and complexity that comes with working with CALD people, comes ensuring services are appropriately diverse. One participant reflected: “I think the strength of any program in that area is if it can be as diverse as possible and as open and inclusive as possible” (Participant 6).

Holistic

Participants indicated that Western models of wellbeing are unable to capture the intricacies of CALD experiences, and conceptualisations of wellbeing. Western models were described in the following ways: “The Western type of mental health doesn’t incorporate spiritual health as much into the framework” (Participant 8) and:

It’s very different than I think the Western world, which is very individualized … we really need to put there is a collective approach. And instead of an individualised approach would be really good, because, you know, a client from a CALD background, they don’t see themselves as one, they see themselves as part of their family’s part of the community. (Participant 5)

One participant recommended taking an approach centred around the individual’s understanding of the world:

How do you make sense of the world? Or how do you make sense of this issue that’s in your life? Or how do you make sense of this issue that’s in your community through the lens of your own culture? (Participant 14)

Furthermore, participants made recommendations for the broad spectrum of wellbeing to be explored, including physical, mental, social, and spiritual. One participant recommended exploring wellbeing from a wide range of perspectives “You know, this topic from both theoretical, legal perspective, but as well as from a cultural and religious perspective as well” (Participant 12).

Participants identified that programs that have a broad focus would be more approachable and would increase the likelihood of engagement: “I think in communities where there’s so much stigma around mental health, that can help address that barrier or stigma where, you know, you are talking about a lot more topics than just mental health” (Participant 16).

Implementing a successful program

Facilitator factors

Cultural competence, friendly, non-clinical approach, strengths-based approach, and promoting the sharing of personal perceptions and perspectives were all identified as facilitation recommendations. Participants explained that CALD people may have concerns regarding “exposing” themselves (Participant 6), confidentiality, and judgement, making it pertinent for facilitators to establishing rapport and trust: “That’s one thing that I always do from the get-go is you know, setting that safe space in a judgement free zone and a trigger warning” (Participant 12).

Flexible delivery

A flexible delivery approach was discussed as being instrumental in mitigating barriers identified above. For example, participants discussed offering online, recorded, and self-paced programs to mitigate language barriers. Furthermore, approaches that allow CALD people to share their experiences and hear others’ experiences were explored as ways to normalise and validate their experiences which may alleviate stigma. Using non-clinical spaces (e.g., outdoors), incorporating practical activities, and taking a storytelling approach also emerged as frequent recommendations.

Community outreach

Narratives from participants revealed the importance of effective community outreach, both for disseminating program information and when implementing the program. Participants suggested that “word of mouth” (Participant 6) be prioritised over large marketing campaigns. Another participant recommended training community members in program implementation to establish a sustainable program: “Instead of having the organisations or the services organising for people, then we empower people to be able to share to pass the message on for the rest of the community” (Participant 4).

Discussion

Mental and allied health practitioners, working with CALD populations, provided their perspectives on the status of the wellbeing programs for the CALD populations, the limitations of these programs and how future programs could be developed and implemented more effectively. Lack of funding for developing and researching programs for CALD was identified as a major concern. Generic programs, developed without the consultation of CALD stakeholders, were identified as not addressing the factors that promote the wellbeing of different ethnic groups. A range of barriers that prevented CALD populations from attending the programs were highlighted. Flexible and holistic programs that are delivered as a community outreach initiative were suggested. Findings lead to important considerations both for future research and program development.

Lack of funding, and its direct and indirect effects emerged as salient issues. While government reports and literature emphasise the importance of adequate funding allocation (NHMRC, 2006; Peñuela O’Brien et al., 2022; Ziersch et al., 2020), current findings suggest that this continues to be a frustration and a cause for hopelessness for organisations and professionals. Despite CALD being a priority (Ziersch et al., 2020), professionals questioned the prioritisation of CALD wellbeing in Australian funding bodies. In line with past research (Minas et al., 2013), limited funding allocated to CALD wellbeing research was identified. Findings suggested that the chronic dearth of literature concerning wellbeing programs for CALD Australians makes it difficult to justify funding (Posselt et al., 2017), hence establishing a perpetual cycle of limited funding.

Findings revealed that funding had repercussions on program quality. The approach with which wellbeing programs are developed, advertised and implemented to CALD communities were often perceived as tokenistic and superficial. Practitioners potentially feel incompetent or ill-equipped to address the issues of CALD populations (Peñuela O’Brien et al., 2022). Findings indicated that a lack of CALD involvement during program development fostered programs that were unable to truly capture the complexities of CALD requirements in Australia, including intergenerational trauma, identity challenges and CALD perspectives of wellbeing. Effectively tailoring programs to CALD needs requires developing partnerships with specialist agencies, and community involvement in co-development and co-facilitation of programs (Posselt et al., 2017; Sibson & Stanway, 2022). The potential for a positive outcome increases when practitioners acknowledge and appreciate the consumer’s culture, and places problems in the context of the culture (MHiMA, 2014). However, it seems that collaboration with migrant organisations and communities is often unsuccessful (Ziersch et al., 2020).

The present findings suggested that relying on CALD practitioners was tokenistic. This was consistent with the literature that recommends a bi-cultural workforce to support interpretation and provision of valuable insights into nuanced, sensitive material (Posselt et al., 2017). The present study found that these reasons were used by organisations to substantiate claims of culturally safe practice. Interestingly, although being from a CALD background was not a criterion to participant in the study, 100% of participants identified as being from a diverse background, and 93.8% spoke a language other than English. Despite researchers utilising convenience and snowball sampling, it speaks to the nature of the cohort of professionals who work with CALD populations. While CALD practitioners may have higher levels of cultural competency, these differences diminish after multicultural training (Dune et al., 2018). Furthermore, social and/or clinical experience with CALD people is a stronger predictor of cultural competency and less ethnic/racial/colour-blind attitudes (Dune et al., 2018). Therefore, cultural competency training in organisations requires improvements (Peñuela O’Brien et al., 2022), and organisations’ tendency to rely on CALD practitioners for cultural competency is an ill-informed approach that necessitates reform.

The data analysed indicated that a significant weakness of current programs was that they were based on assumptions and biases as a direct result of aforementioned tokenism and a lack of CALD involvement. Given that practitioners are often unaware of the impact of their Eurocentric norms and values on consumer outcomes and the therapeutic alliance (Dune et al., 2018), involving CALD agencies and communities is once again vital. Rather than being based on preconceived notions of CALD wellbeing determinants, the present findings, in line with Marcus’s et al. (2022) findings, emphasised the importance of recognising heterogeneity of CALD populations. Instead, the sentiment that “not-one-size-fits-all” was strongly reflected in findings, valuing diversity rather than specificity among CALD people.

Barriers to CALD engagement identified in the present study were similar to those identified in previous research. In line with past investigations, stigma, language barriers (Haralambous et al., 2014), and awareness of services (Henderson & Kendall, 2011; Minas et al., 2013) emerged as major issues. In fact, in line with a past investigation (Henderson & Kendall, 2011), unfamiliarity with health services and difficulty accessing appropriate care is present even in long-standing CALD communities, a major concern for the long-term wellbeing of these communities.

The negative impact of receiving culturally incompetent care on help-seeking behaviours was also acknowledged by the professionals. The incorrect use of translators, and the inaccurate translations of important resources were identified as making CALD consumers uneasy. It appeared that despite wide-ranging policies and procedures on cultural competence, services fail to provide culturally safe services which creates cultural dissonance between consumers and service providers (Wohler & Dantas, 2017). In line with past studies, the findings identified a lack of rapport and culturally sensitive services, and cultural misunderstanding on behalf of the provider as impacting provision of care (Komaric et al., 2012).

Generational differences in help-seeking behaviour were also identified, such that first-generation migrants are less likely to engage in wellbeing programs than second generation. Khatri and Assefa (2022) found that more time in Australia led to poorer health outcomes. It is possible that second-generation immigrants become familiarised and influenced by Western models of mental health, increasing the prevalence of mental illness (Liddell et al., 2016). Familiarisation with Western models may also lead to a less-stigmatised outlook of mental health.

Consistent with literature (Maneze et al., 2016), current findings highlighted the importance of the wellbeing programs to focus on reducing acculturative stress and enhancing parenting support. Parenting support that addresses issues like intergenerational conflict, parenting in a new cultural context and trying to maintain cultural and religious practices were endorsed as important areas requiring preventative intervention (Khawaja et al., 2021). The data indicated that endorsing individual family cultural practices while supporting parents align cultural practices within the Australian context increases their coping capacities and equips parents with an understanding of their parenting journey (Deans et al., 2016).

The present findings indicated that health and welfare services for CALD communities are generalist in nature, and prioritise funding opportunities over consumer needs (Renzaho, 2008). Professionals suggested that programs should cater for the diverse and complex requirements of CALD communities, rather than be one-size-fits-all. Consistent with Dooris et al. (2018), a holistic approach, and a move away from strict Western models was also recommended to capture the broad spectrum of wellbeing factors.

Facilitator approaches that are founded in flexibility, rapport building, and trust was discussed as crucial for effective program implementation. It was apparent that practitioners who possess skills and self-awareness (Khawaja & Lathopolous, 2014), and establish trust (Blignault et al., 2022) could contribute to stable therapeutic alliances and high retention rates. Consistent with past investigation (Murray et al., 2022), being flexible with delivery methods and providing storytelling opportunities in a group setting were also identified as key recommendations. It appeared that establishing strong relationships with CALD communities would increase the likelihood that program participants inform their community about available programs.

Implications

Theoretically, the study elaborated on acculturative stress model by highlighting the ongoing stressors that precipitate stress for CALD populations. The principles of engaging effectively with these consumers are reinforced. Importance of the policies and research framework that consults stakeholders at every level is highlighted. The findings endorse the significance of empirically based wellbeing intervention for CALD populations in Australia. Research, that enhances the value of evaluating the effectiveness of these programs to enable organisations to offer these programs confidently to CALD communities is warranted. Subsequently, considering the poor empirically supported services for CALD, it is anticipated that the government would allocate more funds to promote scientific endeavours.

Practically, an increase in funding for programs and research is emphasised. Findings suggest that equitable partnerships with CALD organisations and communities should be established to involve stakeholders in all stages of program development, from conceptualisation to implementation. Further, stronger actions are required to mitigate the barriers to access health care that have been identified in research for decades. Wellbeing programs that explore issues like acculturation and parenting in a flexible and holistic way, incorporating individual conceptualisations of how culture and spirituality inform their perspectives need to be developed. Mental/allied health professionals, need to be trained to execute these programs in a culturally safe and sensitive manner. Cultural safety training that focuses on rapport building and establishing trust should be prioritised amongst mental/allied health professionals in general and specially those who work with CALD populations to strengthen positive outcomes.

Limitations & future directions

The present study is not free from limitations. The participants were limited to a part of the country; therefore, future studies should collect a larger sample of practitioners from all Australian States and Territories. Although the focus groups facilitated discussions among professionals, the group settings may have inhibited them from sharing sensitive information. In-depth individual interviews may be used in future to learn about professional perspectives on the subject matter. It was interesting to explore the practitioner’s perspective, future research should recruit CALD populations to explore their views and to ensure that researchers and program developers are adhering to recommendations for culturally competent practice (MHiMA, 2014; NHMRC, 2006).

Conclusion

To the authors’ knowledge, the study is the first of its kind to engage with mental/allied health practitioners who work with CALD populations. These professionals have, based on their own lived experiences, provided a good understanding of the barriers in the implementation and utilisation of wellbeing programs. Further, the mental/allied health professionals provided useful ideas and suggestions on how future wellbeing programs could be developed and delivered. The information gathered is promising for stakeholders who endeavour to offer accessible and culturally safe and sensitive wellbeing programs for CALD populations.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Acknowledgements

The authors would like to thank participants for their participation and valuable insights.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Transcribed data are available on request.