Defining CALD and Australian Demographics
What Does CALD Mean?
The term Culturally and Linguistically Diverse (CALD) was introduced by the Australian Bureau of Statistics (ABS) to describe populations with diverse cultural and linguistic characteristics. It is not a homogenous group. The four primary indicators used by the ABS are:
- Country of Birth
- Main Language Other Than English Spoken at Home
- Proficiency in Spoken English
- Indigenous Status
Australia's Multicultural Landscape
Australia is one of the most multicultural countries in the world.
- In 2021, over 7 million people (27.6%) in Australia were born overseas.
- Nearly a quarter of the population (22.8%) reported speaking a language other than English at home.
- The top 5 languages other than English are Mandarin, Arabic, Vietnamese, Cantonese, and Punjabi.
- Areas with the highest proportion of overseas-born populations are concentrated in major urban centers like Western Sydney and Melbourne.
Cultural Safety and Anti-Racism in Healthcare
From Cultural Competence to Cultural Safety
The approach to multicultural healthcare has evolved from focusing on practitioner skills to focusing on the patient's experience and addressing systemic power imbalances.
- Cultural Competence: An older concept focused on acquiring knowledge and skills about different cultures. It has been criticized for being static and potentially reinforcing stereotypes.
- Cultural Safety: A more contemporary approach that focuses on the power imbalance between the healthcare provider and the patient. It is an environment that is spiritually, socially, and emotionally safe, as defined by the patient. It requires the practitioner to reflect on their own culture, biases, and the power they hold in the clinical encounter.
Implementing Anti-Racism in Healthcare Settings
Cultural safety cannot be achieved without an active anti-racism stance. The Hassen et al. (2021) review outlines key strategies for healthcare organizations:
- Explicit Language: Use the term "anti-racism" instead of more ambiguous terms like "diversity" or "cultural competence" to clearly define the goal.
- Leadership Commitment: Anti-racism initiatives require buy-in, dedicated funding, and resources from leadership.
- Multi-Level Approach: Interventions must target all levels: individual (training), interpersonal (provider-patient relationship), community (partnerships), organizational (policies, hiring), and systemic (advocacy).
- Accountability: Implement transparent accountability and monitoring mechanisms to ensure sustainable change.
Health Disparities and Barriers to Care for CALD Populations
The "Healthy Migrant Effect" and Chronic Disease
Many migrants arrive in Australia healthier than the Australian-born population (the "healthy migrant effect"). However, this advantage can diminish over time as they adopt Western lifestyles and face systemic barriers. CALD populations experience a higher prevalence of certain chronic conditions:
- Diabetes and Heart Disease: Highest in people from Bangladesh, Polynesia, South Asia, and the Middle East.
- Kidney Disease: Highest in people from Polynesian countries like Tonga and Samoa.
Barriers to Accessing Healthcare
CALD patients face a multi-layered system of barriers that limit their ability to access timely and appropriate care. These barriers exist at all levels:
| Level | Examples of Barriers |
|---|---|
| Individual/Family (Micro) | Language barriers, low health literacy, different health beliefs, reliance on family for interpretation, mistrust of the system, trauma history (especially for refugees). |
| Community/Organizational (Meso) | Lack of culturally appropriate services, inadequate use of professional interpreters, lack of bilingual staff, racism and discrimination from healthcare providers. |
| System/Policy (Macro) | Complex healthcare system navigation, financial costs, policies that don't account for cultural needs, lack of culturally diverse representation in healthcare leadership. |
Implications for Paramedic Practice
Challenges in the Pre-hospital Environment
The unique nature of unscheduled care amplifies the challenges for CALD patients.
- Communication: Language barriers are a primary issue. The Sawalha et al. (2023) review found that CALD patients experience significant difficulties in treatment decision-making and receive deficient information about their medicines.
- Emergency Services Utilisation: Studies show complex patterns. Le et al. (2024) found that while overall EMS use was lower for CALD patients, it was higher for those aged 75+. For time-critical conditions like chest pain, CALD patients from Africa, the Middle East, and Asia had the longest pre-hospital delays (Middleton et al., 2020).
- Unconscious Bias: In the high-pressure pre-hospital environment, paramedics may rely on "Type 1" (fast, intuitive) thinking, which is vulnerable to implicit bias and stereotyping, potentially leading to misdiagnosis or delayed treatment.
Strategies for Culturally Safe Paramedic Care
- Use Professional Interpreters: Engaging an interpreter is essential for obtaining informed consent and ensuring accurate communication. Family members, especially minors, should not be used as interpreters due to issues of confidentiality, competence, and emotional burden. Utilize telephone interpreter services (e.g., TIS National).
- Practice Self-Reflection: Actively question your own assumptions and biases. Use reflexive questions: "Am I stereotyping this patient?", "Did I consider causes other than the obvious one?"
- Adopt a Trauma-Informed Approach: Especially for refugee populations, be aware that past trauma can influence the interaction. Explain your actions, ensure consent, and be mindful that the environment (sirens, uniforms) may be triggering.
- Advocate for Your Patient: Be a strong advocate within the healthcare system. Ensure that crucial cultural or linguistic information is clearly communicated during handover to the hospital.
- Recognize Intersectional Risks: Understand that a patient's experience is shaped by multiple overlapping factors (e.g., an elderly refugee woman with limited English and low income). Care must be individualized, not based on a single cultural label.