Background
Disparities in health outcomes among migrants are a growing concern in developed countries including Australia, Canada, USA, and New Zealand where most migration from other countries occurs for various reasons - study, employment, safety and better life experiences [
1‐
4]. Lower access to health care is a major challenge in addressing disparities in health outcomes globally [
1,
3,
5,
6]. Australia reported lower utilisation of services and higher risks of chronic diseases among migrant populations [
7‐
10]. A similar trend is reported in Canada [
2,
3], USA [
3], and New Zealand [
4]. What is so far known is that reasons for lower utilisation of services among migrants in Australia is related to their inability to navigate available health services due to a range of factors [
11‐
13].
The Australian population represents diverse cultures, ethnicities, languages, and nationalities, with people coming from over 200 countries through migration and humanitarian programs, and 29.7% of the population is overseas born [
14]. According to the Australian Government, the South Asian population is categorised under the CALD (culturally and linguistically diverse) community category [
1]. In the last 5 years, the South Asian population has increased rapidly in Australia comprising over 14.2% of the total overseas-born population as reported by census [
15]. The South Asia region represents countries under the South Asian Association of Regional Cooperation (SAARC): Afghanistan, Bangladesh, Bhutan, India, the Maldives, Pakistan, Nepal, and Sri Lanka [
16]. While most South Asians come as migrants to seek better life opportunities in Australia, their settlement experiences are impacted by multiple factors such as language differences, cultural backlash, lack of suitable employment, social isolation and experiences of different forms of discrimination [
7,
17,
18].
Health is a socially constructed concept and the way that people view health impacts their decisions around seeking care and use of available health care [
8,
19‐
21]. On one hand, there have been growing concerns around ensuring access to culturally safe health services to meet the needs of diverse population groups [
8,
17,
22,
23]. On the other hand, migrant populations are struggling to navigate health systems to access information and services [
24,
25]. Consequently, increasing access to health care for migrant populations to improve utilisation of care has been a continuing challenge for the health system [
9,
10,
25‐
27].
Despite targeted programs designed to address linguistic, cultural, financial, and social barriers experienced by cross-cultural communities while accessing health care, progress towards enhancing health outcomes has been insignificant [
13,
28]. Evidence suggests that Asian migrants have reported high levels of anxiety and confusion in understanding how health services operate in Australia and this has discouraged access to health care in general [
13,
17]. It is encouraging that there has been ongoing advocacy to take the socio-cultural context of migrant populations into account to enable access to health care [
29]. Given the limited evidence available to understand health practices of South Asian migrants living in Australia [
17,
30], the influence of their socio-cultural environment is critical to determining health and wellbeing outcomes [
7,
17]. Arguments are made for the health care system to play a significant role in improving accessibility to health care and enhancing migrant patients’ experiences of utilising health care so existing health inequalities can be effectively addressed [
19,
31‐
33].
Consideration of a sense of safety among migrant populations has been critical to health care delivery as migrants develop feelings of insecurity and a fear of losing independence, and have privacy and confidentiality concerns while accessing health care in new countries [
20,
34]. Other reported barriers include communication difficulties, the complexity of navigating the health system, the cost of health care, cultural differences, and the different nature of health care [
5,
11,
13,
20,
22,
23]. Consequently, their health care needs are often left unmet [
35‐
38]. Some argue that these experiences of barriers could be effectively addressed by generating positive interactions between health care providers and patients in a culturally safe, socially appropriate, and respectful environment [
8,
36,
38]. In addition, health care models must consider socio-cultural needs to ensure access to migrant populations [
28,
37].
The health care system of Australia includes the national health insurance system Medicare, which is designed to cover the entire population with the intention of protecting individuals from high out-of-pocket costs to access general health care. The health care system also allows a choice for all individuals to obtain private health insurance which gives more flexibility in deciding the type of care or specialists the patient can choose within private and public health care settings. Of the total eligible populations, about 45% has private health insurance to access certain types of hospital care [
39]. The average waiting time for elective procedure in public hospital is from 12 to 18 months where similar procedure can be done within three to 6 months with private health cover [
40].
Given limited evidence available to understand factors that influence access to health care by South Asian migrants [
41‐
46], lower utilisation of health care and relatively higher risks of chronic diseases among these population groups has been a consistent challenge. To gain a deeper understanding of factors influencing access to health care among migrant populations, this paper focuses on the experiences of accessing health care in general among South Asian migrants in Australia.
Discussion
This paper presented the findings of a study conducted in Australia to explore experiences of accessing health care services among migrants from South Asian backgrounds. While these migrants presented themselves as a patient to receive needed care and treatment, they experienced a range of difficulties regarding the response of the public health care system. Commonly experienced barriers included a number of factors: delays in accessing care, the high cost of care, language problems, poor quality of care, and experience of discrimination and lack of understanding of the context of migrant patients by service providers. Although service utilisation experiences of migrant patients are comparatively better in Australia, results of this study highlight gaps that health care services need to pay attention to in order to provide culturally competent care to migrant populations from South Asia.
Although health services in Australia have wider coverage and a comparatively better quality of care, the longer waits to access public services have been an ongoing issue [
53,
54]. The South Asian migrants’ experiences of accessing health care services in Australia involve a complex interplay of factors resulting in mistrust of the quality of health care services that mostly originated at the level of systems. This is consistent with experiences of multiple barriers reported in other studies [
9,
10,
13,
20,
54‐
58]. Participants shared their disappointment in long waiting periods to receive treatment, experiences of poor quality of care, financial burdens to cover the cost of health care services and discriminatory behaviour of health professionals while accessing health services in Australia.
Similar to findings reported in previous studies [
59‐
61], this study confirms negative experiences of using public health services which has influenced decisions around accessing private health services. Even though the experience of using private services was comparatively positive, the cost of care is still a significant burden for these migrants from South Asian countries. However, compared to experiences of seeking health care services in their home countries, participants found health care services in Australia are more systematic, well designed, and suited to meet the care needs of different age groups and populations. As most South Asian migrants come to Australia from socio-economically vulnerable communities; it is not surprising that they develop positive impressions of Australian services and health care systems [
41,
62,
63].
Alongside positive experiences of receiving health care, participants reported experiences of discrimination based on their language and cultural differences that resulted in mistrust of health professionals and the health care system. While previous studies reported similar consequences of discriminatory experiences [
64,
65], this study revealed experiences of cultural differences in communication that raise serious questions about their capacity to be treated equally in health care settings. Other studies have suggested a need to make services responsive, culturally appropriate and respectful to migrant communities who share diverse cultural backgrounds [
3,
55,
66]. Compared to mainstream population, the tendency of avoiding the use of emergency or other health care is common among the migrants and other ethnic minorities [
67]. We noted similar practice of South Asian migrants which was based on their experiences of existing barriers to access health care and the nature of care they were able to receive in Australia.
Drawing on the voices of South Asian migrants settled in the metropolitan region of Melbourne, Australia, provided insights for addressing consistent financial, social, institutional, systemic, and cultural barriers to accessing quality health care services. As participants constantly described the cost of services being problematic to them, they suggested that health services should be made more affordable to everyone. Given that evidence around associations between income and the likelihood of being at risk of chronic diseases are prevalent among the South Asian migrants [
68‐
70], it is important to make health services accessible to these population groups. Consistent with arguments made in other studies [
13,
20,
54,
58,
71,
72], participants in this study strongly highlight the urgency of getting on-time care to manage health conditions and express optimism for minimising waiting times to access care.
Communication plays a critical role in ensuring positive service experiences and quality of care [
11,
20,
23,
34,
58]. This study highlighted those experiences of different treatment and communication in health care settings must be effectively addressed to enable better access to care, so the community feels safe, valued, and respected when utilising available services. Having services culturally safe, appropriate, and respectful to meet the needs of communities contributes to increased service utilisation and helps address existing health inequalities among migrant populations [
65,
73,
74]. Participants offered some solutions to increase service utilisation by investing more resources for service improvement, enabling access to health professionals and interpreters from the same cultural and linguistic backgrounds and creating non-judgemental and respectful service environments. These are critical components of health care [
75] and can be incorporated into a culturally competent model of care where clients, families, and service providers work together to enhance the quality of experiences while receiving or providing care.
Limitations of the study
This study provides significant insights into the experiences of South Asian migrants settling in Australia. However, the data collected in this study is limited as not all countries of South Asia are represented and the sample size is too limited to fully capture diverse perspectives. Further, all participants involved in this study speak a language other than English at home and this study was conducted in English which might have limited expression of the depth of experiences. We are not sure whether research in the first language could have influenced the results of this study. Out study did not differentiate the types or levels of services to explore the experience of barriers and satisfaction to care, so the results are limited to make specific reference to access emergency or primary care. We do understand that use of face-to-face interviews was a culturally preferred method of communication for these participants, but we were not able to do so due to the restrictions caused by the COVID-19 outbreak.
We made every effort to ensure participants felt comfortable sharing their experiences during remote interviews, but we couldn’t rule out that face-to-face interviews might have enhanced the richness of the data. For qualitative evidence, experiences shared by the participants in this study put forward a case for a better health care system which is able to identify, acknowledge, understand and provide appropriate responses to barriers in accessing health care services, but the experiences may be different to the experiences of migrants from other countries and regions who have come to settle in Australia.
Conclusion
Most migrants experience multiple barriers while settling in a new country because of socio-cultural differences and struggle to navigate a new health system. Australia has increased migration from South Asian countries in recent years and these groups of population come with their unique cultural and social system which sometimes can be challenging. Considering the context of South Asian migrants, we explored various social, cultural, institutional, and financial factors that are influential in making decisions about utilisation of services. Consistent experiences of long waiting times, the higher cost of services, and differences in communication by service provides not only limited access to services but also discouraged service use when needed.
Although experiences of receiving services in Australia are better compared to the home country, South Asian migrants shared expectations for timely and affordable services, access to health professionals and interpreters from the same cultural and linguistic backgrounds and culturally appropriate and respectful environments across the public health system in Australia. We recommend implementation of a collaborative and culturally competent model of care which allows the involvement of patients, families, communities, and services providers to enhance positive experiences across all levels of the service delivery system. We argue that incorporating collaborative models of care with diverse perspectives helps to improve utilisation of health care services and address existing disparities in health outcomes among migrant populations.
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