Background
Australia has witnessed a rapid increase in migration over the past 10 years, with annual migrant numbers doubling as a proportion of the total population [
1]. With the diversity of this growing population Australia faces a number of population health challenges. Close examination of epidemiological data reveals particular burdens of disease in women from Culturally and Linguistically Diverse (CALD) communities now living throughout Australia [
2]. Moreover, there is a consensus among western countries, including Australia, New Zealand, United Kingdom, United States and Canada, that significant racial and ethnic disparities exist with regard to prevalence, mortality, and morbidity, highlighting higher rates of risk factors for a number of chronic diseases in these women [
3,
4]. Of particular concern is the greater risk of hypertension, diabetes, and overweight/obesity, all of which are predominant risk factors to cardiovascular disease (CVD) [
4,
5].
Despite the high risk of these non-communicable diseases, women from CALD groups are less likely to be proactive in accessing health care or undertaking preventative measures to reduce risk of chronic disease [
6,
7] and ensure optimal health outcomes [
8,
9]. Physical activity, which is operationally defined as any bodily movement produced by skeletal muscles that results in energy expenditure [
10], is a particular preventative measure in which women from CALD backgrounds are less likely to undertake then other non-CALD women [
11,
12]. For instance, CALD women born outside of Australia have reported a 20% less participation rate in sport and physical activity in Australia compared to Australian born women (46.3% in CALD women compared to 66.5% in Australian born women) [
12].
For many CALD individuals there are several constraints on activity participation beyond personal motivation. Cultural barriers, socioeconomic factors, psychological trauma relating to migration, perceptions of ill health and injury, and alternate health seeking behaviours are just a few of the constraints that are likely to have a detrimental impact on health in these populations [
13‐
16]. In an attempt to limit these constraints and positively influence the physical activity behaviours of CALD women, it is necessary to carefully consider cultural diversity whilst developing and planning health promotion (e.g., physical activity) resources and programs. The limited nature of research in this area is evident [
2,
17,
18]. Despite the significance of the work outlined above, there are a number of gaps in the literature. Thus, the purpose of this study was to build upon existing, yet limited research, and examine the socio-cultural influences on the physical activity behaviours of CALD women living in Australia by identifing the barriers, constraints and possible enablers to physical activity participation for this population. Such information will support the development of culturally appropriate programs designed to positively influence the physical activity behaviours of women from CALD populations [
14,
19].
Methods
Study Participants
This study was conducted with CALD women living in three Australian cities with the highest proportion of CALD migrants: Sydney, New South Wales; Brisbane, Queensland; and Melbourne, Victoria [
20]. Four distinct CALD groups were chosen as they were identified as being interested in participating, and were accessible to the research team due to prior research linkages the researchers had with organisations that provided services for these groups. These included Bosnian, Arabic speaking (including women from Eygpt, Iraq, Syria, Jordan, Palestine, and Lebanon), Fillipino, and Sudanense adult women (18 years+). A total of 110 women participated in one of 12 focus group sessions, separated by CALD group. Mean age was 46.2 (SD ± 11.6) years, with an age range of 18-87 years. The majority of the women were married and had children. All participants were born outside of Australia and had lived in Australia for an average of 12.4 years. Participant characteristics are detailed in Table
1.
Table 1
Demographic Characteristics of Study Participants
Age of each group (Mean ± SD) | |
Filipino | 55.7 (15.3) |
Sudanese | 26.8 (7.0) |
Bosnian | 63.0 (13.1) |
Arabic Speaking | 39.1 (10.4) |
Cultural group (%) | |
Filipino | 28.2 |
Sudanese | 22.7 |
Bosnian | 22.7 |
Arabic Speaking | 26.4 |
Years living in Australia (Mean ± SD) | |
Filipino | 18.2 (9.1) |
Sudanese | 5.0 (2.4) |
Bosnian | 14.8 (10.2) |
Arabic Speaking | 11.6 (9.8) |
Marital Status (%) | |
Married | 81.0 |
Divorced | 2.0 |
Widowed | 7.0 |
Not married | 10.0 |
Total those with children (%) | 86.0 |
Children per woman (Mean ± SD) | |
Filipino | 3.1 (1.7) |
Sudanese | 1.7 (1.1) |
Bosnian | 2.5 (1.1) |
Arabic Speaking | 3.1 (1.4) |
Study Design and Procedures
The proposed project is exploratory in nature and aims to explore perceptions, attitudes, opinions, and beliefs concerning the physical activity behaviours of CALD women. With this intention, the researchers chose to utilise focus group research as a method of data collection. Focus group research is recognised as an exploratory research method that best draws upon respondents' attitudes, feelings, beliefs, experiences and reactions in a way in which would not be feasible using other methods, for example, one-to-one interviewing [
21]. These attitudes, feelings and beliefs may be partially independent of a group or its social setting, but are more likely to be revealed via the social gathering and the interaction which being in a focus group entails.
With assistance from community partners in each of the three cities, CALD women were recruited to take part in focus group sessions between April and July, 2009. CALD women who were clients, accessed services, or who were somehow associated with each community partner organisation were contacted by phone, email or in person by a community health worker or project officer from each partner organisation. These partnerships were a crucial aspect of the overall project as each partner provided comprehensive knowledge and advice pertaining to the different CALD groups, as well as playing a lead role in recruiting participants. Each of these community partners are not-for-profit organisations funded by different arms of their own state government (e.g. health services, immigration services). These community partners represent the interests of the many CALD groups throughout New South Wales, Queensland, and Victoria, particularly focusing on such matters as health promotion, cultural diversity and health, cultural competence, language services, cross cultural communication, health assessment and consumer participation.
A total of 125 potential participants were contacted and invited to participate in the focus group sessions. Initially, all 125 invited participants agreed to take part in the project, however only 110 participants attended each of their CALD specific focus groups. Participants who did not attend the groups (N = 15) indicated that they had either forgotten about the focus group session or had an unplanned matter that they had to attend to. Researchers from the project team undertook four focus group sessions (one representing each of the four CALD groups) in each of the three cities (total of 12 focus groups). These included Bosnian (N = 25), Arabic speaking (N = 29), Fillipino (N = 31), and (4) Sudanense (N = 25) women. Participation was voluntary, however all participants were given a $40 honorarium to assist with transport and childcare costs for the duration of their focus group session.
The principal researcher (CC) acted as the moderator, guiding the discussion and providing assistance where needed, whilst a second researcher (RT) took notes and was responsible for the audio recording of each session. A translator/interpreter was used during four focus group sessions (one Arabic group and all three Bosnian groups) to accommodate CALD group participants who spoke minimal or no English. Although these sessions did take longer to complete, the researchers felt that these sessions flowed well and were not disrupted by the language barrier. All other sessions were held in English at the request of the group members. Focus groups were held at a central location convenient for participants and ranged from 45-90 minutes in duration. During this time participants were encouraged to share their opinions, perceptions and beliefs regarding the barriers and enablers to women's physical activity, in a semi-structured, open table discussion.
Questions in the focus group schedule were guided by the objectives of the project and based on previous literature concerning the physical activity and health behaviours of women [
7] and CALD populations [
9]. As well, the focus group schedule was informed by questions used in previous studies by members of the research team [
22‐
24]. Questions were open-ended in order to encourage a range of responses, and probes and clarifying questions were used to stimulate further discussion. For example, to uncover some of the barriers and motives to physical activity participation in CALD groups, participants were asked 'Can you tell me some of the reasons why you and other people from your community might
not participate in physical activity?' and 'What are some of the things and/or reasons that would motivate you to regularly participate in physical activity?'.
Data Management and Analysis
Following each of the sessions the data were professionally transcribed verbatim. QSR NVivo qualitative analysis software (QSR International Pty Ltd, Melbourne, Australia) was used to organise and manage the data. Using an inductive approach, data analysis focused on eliciting themes concerning barriers and enablers to women's physical activity participation. Research team members systematically read the transcripts multiple times, highlighted segments of interest and made annotated comments on the transcripts to identify potential themes. Emerging themes were summarised and categorised during the process of reading and rereading. Structural corroboration, where segments of data validated each other, was performed by noting emerging descriptors, issues and concerns in each transcript [
25]. Members of the research team reached consensus concerning emerging themes and categories through a process of ongoing discussion to mutually resolve any discrepancies or concerns with analysis. Final themes and categories were identified by the researchers and are summarised in the results section below.
Ethical approval was obtained from the Central Queensland University's Human Research Ethics Committee. The standard university guidelines of informed consent, voluntary participation, confidentiality, and anonymity were rigorously followed. All participants gave written and verbal informed consent prior to each focus group session.
Discussion
This study revealed a number of common and ethnic-specific themes concerning the physical activity behaviours of Bosnian, Arabic speaking, Filipino and Sudanese women. With regards to common themes, most participants described what physical activity was within a broad context (and in line with a Western interpretation), and were able to distinguish between moderate and vigorous intensity physical activity. This is largely inconsistent with previous research which has indicated that the use of these modifiers (moderate, vigorous) are commonly misunderstood by the mainstream white culture and further complicated when culture and language translations are considered [
26]. A clear understanding of what physical activity is and how much is good for you may be influenced by the increase in public health messages regarding recommended levels and intensities of physical activity.
When discussing physical activity levels at the present time and prior to migration to Australia, the majority of participants indicated that they were much more active in their country of origin due to the more labour-intensive nature of daily life. These responses were consistent with what researchers have labelled the 'healthy immigrant effect'. A 'healthy immigrant effect' exists where migrants are in generally very good health on arrival to a western country, however, this condition changes with increased time since migration, and is associated with acculturation, defined as changes in cultural patterns when groups of individuals from different cultures come into first-hand continuous contact with each other [
27‐
29]. Acculturation is often associated with detrimental behaviours such as the consumption of high fat, calorie dense diets and physical inactivity [
30]. It has been suggested that an educational component should be a major part of any health promotion initiative, paying close attention to cultural differences pertaining to the interpretation, and benefits of, physical activity [
31].
The majority of participants indicated that family commitments, in particular childcare and domestic home duties, such as preparing meals and cleaning the home, prevented them from being physically active. This is a common theme between both CALD women and Australian born women who have indicated that finding time to be active outside of their family duties is a major barrier [
31,
32]. It has been suggested that competing demands may only be constraints for organised activities that require women to attend activity sessions at a specific time and place [
33,
34]. Encouraging women to engage in physical activities that fit into the context of their daily lives may help to overcome this barrier [
31].
Environmental factors such as safety concerns and access to programs and facilities were reported as common barriers to physical activity for CALD women. Structural environmental changes (e.g. improved lighting, well maintained footpaths, access to indoor facilities, etc.) have been reported as a way to overcome safety issues as well as assist with facility accessibility. In addition, offering programs and facilities in the heart of these local neighbourhoods will increase program awareness and allow for these facilities to be easily accessed. This has become a common practice in the United Kingdom in which local health organisations and centres have set up 'health action zones' in deprived communities where many CALD communities reside [
35]. These 'health action zones' provide health care resources and different health promotion initiatives in an area of the community in which the majority of community members can walk to. Similar zones should be considered in specific suburbs of Sydney, Melbourne and Brisbane, and other areas which are heavily populated by CALD communities.
Ill health and injury was both a motivator and barrier to participants' physical activity engagement. Consistent with the Health Belief Model [
36], some participants perceived their ill health to be at a level of severity that required action, while others were fearful of being susceptible to disease due to an unhealthy lifestyle. When the risk of disease, and possibly death, is described as a consequence of physical inactivity and an unhealthy lifestyle, women in particular are motivated to change their lifestyle behaviours when they realise the benefits of doing so [
37]. This is synonymous with the findings of the current study, with a number of older participants making changes to their lifestyle behaviours by attempting to be more physically active and making healthier diet choices.
Ill health and injury also acted as a barrier to physical activity for many participants. Specific to CALD populations, perceptions of ill health and injury associated with being physically inactive may be related to different understandings and/or misunderstandings of physical activity and its' benefits. For instance, previous research has reported that many Arabic speaking groups perceived sweating, increased heart rate, and breathlessness as illness states rather than 'normal' by-products of physical activity [
14]. Similarly, many of the participants in our study also associated physical activity with health concerns such as injury, tiredness and soreness. Although these different understandings may be conflicting with the health and physical activity messages traditionally promoted in Australia, they are not necessarily incorrect or inappropriate. It is essential that health professionals are sensitive to the different understandings and perceptions that some CALD groups may have regarding health and physical activity, as many CALD groups believe that their understanding of physical activity and health is both culturally appropriate and legitimate.
In addition to the common themes outlined above, there were also a number of ethnic specific themes revealed by each of the four groups. For example, Bosnian women highlighted the detrimental effect of the experiences of war, indicating that depression and stress are common symptoms of post-war trauma, and that these psychological states limit their motivation to be active. Post-war trauma and the effect it has on health, has commonly been associated with migrant populations and those entering a new country as a refugee [
38,
39]. In contrast, some women felt that being active promoted their psychological well-being. Cultural competence and sensitivity is essential in these circumstances, however, it is necessary that health professionals establish the link between trauma and health and wellbeing for these populations, and clearly outline the psychological and physical benefits associated with preventive health measures such as physical activity. Additionally, Bosnian women also recognised prayer as a form of physical activity due to the up and down movements and rising and lowering of arms during each visit to temple. It may be useful to also build awareness around the physical benefits that may be associated with this religious practice.
Arabic speaking participants indicated that public modesty was a barrier to engaging in physical activity outside of their home due to their religious beliefs and practices. Many women of Muslim faith interpret scriptures of the Qur'an as prohibiting physical activity participation [
40], as this is seen to conflict with their family responsibilities [
14]. These women feel underpinned by their 'ethic of care' to their children and other family members and believe that taking time out for themselves to engage in physical activities would signify that they were neglecting their role of mother and family caregiver [
41,
42]. Developing programs in an environment that is mother-child friendly, where mothers can participate in activities with their children, would provide mothers with the opportunity to benefit from physical activity while still upholding their 'ethic of care' [
41].
Furthermore, cultural modesty in the form of acceptable dress was also a barrier for these women. Thus, appropriate adjustments may need to be made to activities, activity facilities and activity session times, creating suitable alternatives for these women that will allow them to either participate in their cultural dress or in an environment which is appropriate if they are not in their traditional dress. Recommendations such as holding women-only classes and maintaining closed off sections of the gym or facility for women only should be considered as ways to address these barriers. However, these are only short term solutions. For long term effects, health professionals must work towards empowering these women by placing them at the centre of program development and encouraging them to take lead roles in development and implementation throughout their own communities so they can make changes, develop programs and embark on new initiatives that are meaningful and suitable to them and other members of their CALD group [
18,
43].
Surprisingly, the Filipino women were the only participants that indicated that changes in socioeconomic status upon migration to Australia limited them from being as active as they were when living in the Philippines. They describe how in the Philippines many of them had relatives to help with childminding as well as housekeepers to deal with domestic duties such as cleaning and preparing meals. Now living in Australia, these women have greater financial restrictions and no longer have the luxury of this type of support. However, many of the women indicated that they had close relationships with other Filipino women in their community, thus it may be worthwhile exploring the possibility of shared childminding and alternate participation times amongst the women. It may also be worthwhile to explore alternative modes of physical activity such as occupational physical activity [
44] for these women, given that many of them work fulltime. Research has revealed a numbers of ways in which physical activity can be incorporated into a working day, including lunchtime walks, using the stairs instead of the lifts, and organising physical activity team challenges with other workmates [
42,
45,
46].
Lack of social support and social isolation were specifically reported by the Sudanese women. Commonly revealed as a barrier in many CALD groups [
31], researchers have reiterated the importance of developing a social network both within the same culture, and with those from other cultures [
47,
48]. Furthermore, undertaking group physical activity with others from your social network, or joining a physical activity group with new members, has been reported to positively influence physical activity behaviours, while providing motivational and emotional support and addressing social isolation [
49,
50]. This strategy may be particularly useful in the initial stages of migration and resettlement, where social isolation is most evident [
51].
The Sudanese women also indicated that due to a lack of understanding within Australia of specific Sudanese cultural activities, they were reluctant to engage in such traditional activities. This resonates with previous research suggesting that a lack of self-efficacy can restrict women from being physically active [
33,
52], and highlights the importance in promoting and encouraging activities in which CALD communities have mastered, enjoy undertaking and feel comfortable performing. Adapting new and unique strategies and initiatives is an asset to promoting physical activity amongst CALD populations. Again, this highlights the importance of cultural competence, sensitivity and the acknowledgement of cultural diversity [
18,
43]. Additionally, Sudanese women and health professionals should work together to develop new initiatives which include undertaking physical activity with their children. These activities could incorporate the traditional activities they once undertook with their children in Sudan and new initiatives they have learnt since migrating to Australia. This may also open the door to an integrated mother-child program which would include Sudanese participants as well as women and children from different cultures, including Australian-born participants. This type of program would promote physical activity for mothers and their children as well as provide an outlet for social engagement.
Strengths and Limitations
A major strength of this study is the sample size and diversity, which included women from four different CALD groups. More importantly, our study included three focus groups for each of the four CALD groups (Bosnian, Arabic speaking, Filipino, Sudanese), allowing for a more in-depth examination of the topic or area of study. As a standard protocol for focus group research, it is recommended that three focus groups for each group represented is conducted in order to reach data saturatation and provide a deeper understanding of the issues or topic [
13,
53]. However, it is important to note that the participants in this study are not considered representative of all adults in their CALD group.
Although this study has made a significant contribution to the literature pertaining to physical activity in CALD groups throughout Australia, the inclusion of only four different CALD groups also becomes a limitation as there are a significant number of other CALD groups in Australia. Given that CALD groups vary in many respects (e.g. culture, religion, language, socioeconomic status, education, employment, etc.) future research should extend to other CALD groups. Furthermore, the sample was limited to CALD women living in Sydney, Melbourne, and Brisbane. Although, it has been documented that the capital cities and surrounding areas of these states have the greatest porportion of CALD populations [
20], there are other areas in South Australia, Western Australia and particular rural areas of Australia which are witnessing a rapid growth in CALD populations through international and inter-state migration [
20]. Future research should focus on large representative sampling, throughout all states in Australia to clearly establish a national profile regarding the physical activity behaviours of CALD populations, as well as provide a comparison of similarities and differences across multiple sites and multiple CALD groups. This sampling should include more of the existing groups used in this study (Bosnian, Arabic speaking, Filipino, Sudanese), a variety of other CALD groups, groups including both CALD men and women, and groups including CALD individuals from varying age groups. This sampling could also be extended to CALD groups from other countries, providing camparative data on an international level.
Declaration of Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CMC was a Chief Investigator on the study. She designed the study, collected and analysed data, wrote the first draft of the paper and lead the critical review and revision of the paper. GSK was a Chief Investigator on the study. He contributed to the study design, interpretation of the data, and review of the paper. RT was the study researcher. She assisted with the collection and analysis of data, and contributed to the drafting and critical reviewing of the paper. WKM was also a Chief Investigator on the study. He contributed to the study design, interpretation of data, and review of the paper. All authors have read and approved the final manuscript.