Background

Each summer Australia experiences periods of very hot temperatures, and extended heatwaves with maximum temperatures exceeding 35°C for several consecutive days are not uncommon. Despite the population being acclimatised, thermal tolerance can be exceeded when heat extremes occur, and the consequent health impacts can range from marginal increases in morbidity to significant increases in mortality [1–4]. It is well established that the elderly, the young and the sick are disproportionately at risk [3]. However, other subgroups are also vulnerable and with warmer temperatures imminent, identifying these groups is important for public health authorities in formulating targeted inventions.

The number of permanent immigrants to Australia has increased over several decades to the extent that more than one quarter of the nation’s population of 23.3 million is overseas-born, and a further one fifth has at least one parent born overseas. Immigrants include those arriving through the Migration Program (including skilled and family stream migrants) and the Humanitarian Program for refugees forced to leave their homeland [5]. Many migrants arrived from South-East Asia in the 1970s and in recent years the proportion of migrants from Asia, as well as other countries, has increased. According to the 2011 national census, almost half of the ‘long-standing migrants’ who arrived before 2007 and more than two thirds of the recently arrived, speak languages other than English at home [6].

The impacts of heat on the health of people in migrant and minority groups are not well documented. Some studies conducted in the United States have shown that heat-related deaths can be high in people of African American descent [7–10], and undocumented immigrants from Mexico entering the United States across borders adjoining the Arizona desert [11, 12]. However, in countries outside of the United States the literature on susceptibility and adaptation to heat in culturally diverse groups is scarce. This may be due to the issue not previously being seen as an area of public health concern or that data have not been readily available for epidemiological studies. Ancestry has not been well recorded in health statistics to date, and people in non-English speaking communities have often been excluded from traditional health research studies [13].

Despite the nation’s diversity in cultures, language and climate experiences, it is unknown if migrants seamlessly adapt to Australia’s hot summers or if certain barriers are encountered which could affect wellbeing during bouts of extreme heat. This is a critical gap in public health knowledge, particularly in countries where migration and cultural diversity is increasing and the climate is warming. The aim of this research was to ascertain using qualitative methods, if barriers affecting adaptation to extreme heat exist within culturally and linguistically diverse (CALD) communities in Australia and if so, to identify vulnerable subgroups.

Methods

The study was based in Adelaide, South Australia, and data were also collected in Melbourne, Victoria; and Sydney, New South Wales (Figure 1). Of the three cities, Adelaide has the lowest population (1.2 million) and the warmest climate; Melbourne has a population of 4.1 million and the coolest climate; and Sydney has the largest population (4.6 million) and a more humid climate [5]. The percentage of residents born overseas in the respective states of South Australia, Victoria and New South Wales is 22%, 26% and 27% respectively [5].

Figure 1
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Map showing study locations of Adelaide, Melbourne and Sydney, Australia.

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Cross-cultural research calls for a degree of flexibility in sampling and recruitment as standard community sampling techniques can be unduly time-consuming and expensive [14]. Careful consideration was therefore given to a sampling strategy that would adequately answer the research question whilst providing information about issues affecting a range of immigrants of diverse cultural and linguistic backgrounds, ages, and length of stay in Australia. Hence, using purposive sampling methods, key informants closely associated with a range of migrant groups were identified through a research reference group and a comprehensive internet search of services and support groups. Stakeholders from three main sectors (state and local government; non-government organisations and service providers; and migrant and refugee health services) were contacted by telephone and/or email and interested persons provided with further information. On occasions the primary contact declined to participate and suggested a secondary contact more experienced in the research topic. An advantage of our sampling strategy was that stakeholders acted as conduits and were able to speak freely about their observations and experiences of barriers and enablers encountered by clients and community members. Snowball sampling also resulted in a convenience sample of members of an Asian community group and a recently arrived refugee family.

Interviews and group interviews/focus groups (with between two and five participants) were conducted in the warm months between December 2011 and April 2012 in a range of venues. In Adelaide, interviews and focus groups were held at the University of Adelaide or on site at the respondents’ organisation. In Melbourne, sessions were held at the respondents’ place of employment, and a family home, whilst in Sydney sessions took place at venues in the multicultural inner west/western suburbs. Informed, written consent was provided by respondents prior to the commencement of the interviews and confidentiality was assured. For one community group information sheets and consent forms were translated and a bi-lingual speaker assisted with the session.

The interview topic guide was informed by a literature review and the research reference group comprising a panel of experts. Questions related to experiences with extreme heat in the communities, factors contributing to vulnerability, adaptive behaviours, and knowledge of heat-health warnings, as detailed previously [15]. Whilst the questions for community members were essentially the same as those for other stakeholders, the wording was modified slightly. Respondents were encouraged to use the questions as a guide only and to expand on points of interest. All except one interview was digitally recorded and subsequently transcribed by either the researcher or an independent service.

Data analysis

Transcripts were imported into the qualitative data analysis software package NVivo 9 (QSR International, Doncaster, Australia). Data for each city were analysed separately using the framework approach. Described by Ritchie and Spencer (1994), framework analysis uses a systematic approach to data management to provide coherence and structure to qualitative data [16, 17]. Passages of text representing repeated themes were identified and assigned headings according to the context and coded to as many relevant categories as possible to reduce the likelihood of missing key points. The data were then synthesised in a chart format using headings identified from the thematic analysis [16]. This approach enhances rigour, transparency and validity of the analytic process [18]. Analysis was both deductive, with categories derived from prior knowledge, and inductive, with categories emerging purely from the data [19].

Ethics approval for the study was received from the University of Adelaide, Monash University and the South Australian Department of Health. The study adheres to the ‘RATS’ qualitative research review guidelines for reporting qualitative studies (http://www.biomedcentral.com/authors/rats) (Additional file 1).

Results

In total there were 36 respondents across the three cities, with the majority being from Adelaide (Table 1). Most were involved in service provision to, and liaison with, clients in CALD communities. Many were migrants themselves (or descendants of immigrants) from Africa, Asia, Europe or the Middle East.

Table 1 Numbers of respondents in each city and affiliations
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Respondents spoke about the barriers and enablers facing some in migrant and refugee communities during periods of extreme heat in Australia, and also commented that some were relatively unaffected. In depth narratives revealed the disparities between the communities regarding abilities to cope with heat and one respondent spoke of the migrant population not being considered by authorities:

“Extreme heat, it happens every year but nobody thinks of the migrants and how it affects them, … OK, you survive like everybody else but not everybody is prepared the same way for it and not everybody has the resources to manage that time.”

Coordinator, Adelaide

Eleven emergent and often inter-linking themes were identified from the narratives: ‘Cultural factors’, ‘Fluid intake’, ‘Health issues’, ‘Heat is different’, ‘Housing’, ‘Language barriers’, ‘Isolation’, ‘Low literacy’, ‘Power costs’, ‘SES’, and ‘Transport’. Displayed in Table 2 are the themes from the Adelaide narratives, some of which were reiterated interstate - i.e. the first six of these eleven themes also emerged from the Melbourne narratives, whilst from Sydney there were five (‘Cultural factors’, ‘Health issues’, ‘Housing’, ‘Language barriers’ and ‘Power costs’). Another theme identified in each city was ‘Who is vulnerable?’

Table 2 Vulnerability factors identified from Adelaide data
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Cultural factors and norms

Although many new arrivals adapt quickly in Australia, some can be unaware of the need for adults and children to dress lightly during the heat to aid thermoregulation. Additionally, some cultural and religious mores at times dictate the wearing of traditional heavy, dark coloured garments not ideally suited to hot weather.

A culture-specific barrier that was raised in Melbourne and Adelaide by stakeholders from Africa was that sometimes people in visible minorities reportedly do not feel comfortable “hanging around” in cooled spaces such as shopping centres because “you stand out when you’re different”. By contrast, a refugee from Bhutan stated that going to shopping centres was a more practical alternative for his community than cooling off at swimming pools, because “95% of Bhutanese they don't know how to swim”.

Cultural differences surrounding preferences for hot food and being unable to drink between dawn and sunset during the Islamic month of fasting (Ramadan) can be problematic during hot weather. Respondents also highlighted that due to previous experience in their home countries, many migrants are wary of officials or people in uniform offering assistance, and that access to culturally appropriate emergency health care can be an issue for some women.

The practice of Asian women using sun umbrellas to preserve skin colour and Muslim women wearing culturally appropriate swimwear were mentioned as examples of cultural adaptation to the hot climate. The strong family connections and social networks of migrant groups can be beneficial during the heat, particularly for older people in CALD communities who are cared for by their families. By contrast, a Sydney respondent mentioned that the cultural norm of elders living with their family may not always reduce vulnerability if there is a disincentive for them to use air conditioning because of the added cost to the household.

Health issues and lack of fluid intake

Some migrants and refugees do not drink enough water for reasons which include a dislike of the taste, a lack of awareness about the need to keep hydrated during hot weather and recollection of poor water quality in refugee camps. However, one respondent stated he drank more water now than when he was in Africa. Another spoke of people who have built up a “resistance” to lack of water because of past experiences, and can “go for hours without water”. Health care providers and others also spoke of people having insufficient fluid intake leading to health issues such as kidney stones, gall stones, headaches and constipation. A manager spoke about refugees preferring soft drinks to water as it is a “sign of affluence” and of the consequent impact on physical and dental health. Another respondent pointed out that promoting water to migrants as the “standard drink” should be encouraged. It was mentioned that for older people, a reluctance to drink water can be related to incontinence issues and that messages about dehydration for the young as well as older people, need to be reinforced:

“But I still think a lot of the key messages in keeping hydrated and what to do when working with young children or caring for young children, some of those messages I don’t think are still reaching the communities.”

Diversity Officer, Melbourne

A physician in Adelaide mentioned that people in new and emerging communities can have a range of co-morbidities, nutritional deficiencies and mental health issues which can affect vulnerability. Also mentioned was the mental anguish that can be experienced during periods of extreme heat by being confined to a hot house. Strong descriptive terms such as “emotionally disturbing” and “tormenting” were used.

Health issues were raised by respondents in Melbourne who spoke about the effect of the dry heat causing people to “feel exhausted and tired” and that chronic health conditions influenced vulnerability. Valuable information about heat and its effect on the health of new arrivals was gained from discussion with a refugee family. When asked if very hot weather affects how people feel, the respondent answered passionately that it was “affecting the total health of the people”. He spoke about headaches, feeling lazy, itchy skin rashes and sunburn. The respondent expanded on the lack of acclimatisation and underlying health problems that could be contributing factors:

“They came from refugee background so they never had proper amount of nutrition food in their camp life and lack of light so they lack vitamin D as we too so they don't have a high resistance capacity of all those things …. This community is facing a high problem … in refugee camp was some kind of terrible lack of nutritious food, lack of good, er water … and lack of medical capacities.”

Community member, Melbourne

Heat is different

Many respondents who were migrants commented that the heat in Adelaide and Melbourne was different to that with which they were familiar. They spoke of the dry heat; that the temperature often does not cool down at night, and that sunburn can be an issue. Moreover, a Sydney community worker said that people in her Asian community were not used to wearing sunscreen as sunburn was rare in their country. A newly arrived community member said he was not aware of the climate in Melbourne before coming to Australia, and compared to Bhutan he found it “extremely hot, extremely hot”. Furthermore, it was mentioned by more than one respondent that Australians stereotypically make assumptions about people from hot countries and their ability to cope with the heat:

“The problem we have as Africans in the heat is that the sun here you can actually feel it burning your skin where [as] … sun [in Africa] does not burn your skin.”… “Most Australians think that, especially Africans … are used to heat… But, as I said before, it is a different type of heat…”

Health care worker, Adelaide

Socioeconomic status, housing and power costs

Narratives revealed that when migrants and refugees arrive they are often unable to gain employment and can face financial disadvantage. Poor educational attainment for some makes this quest more difficult. Low socioeconomic status (SES) can be linked to poor housing, and difficulty in paying utility bills. One respondent also spoke of the sense of “obligation” felt by people in his community to send monetary support to family in their home country, adding to financial stress.

Housing was mentioned by most respondents who said that usually rental accommodation for migrants is very basic with no air conditioning and often no fans. Sometimes occupants can stay in these properties as they age and their vulnerability increases. Compared to Adelaide, there were some differences in Melbourne where a lower proportion of homes have air conditioning. A program coordinator said that people once thought they could cope with the heat but now “because of the changing weather and more hot days, people are installing air-conditioning.” A manager from Sydney said that central air conditioning should be standard in Australian homes as central heating is in Europe. Another respondent spoke of housing issues for two main groups - older people and new arrivals:

“What we have got is - the two different groups who are impacted, the older people are often in old houses that don’t have insulation and … the houses aren’t good for … the heat. The newly-arrived are in rental properties and often at the lower end of the market too and … don’t necessarily insulate their houses for their tenants.”

Program Coordinator, Sydney

Adelaide has hot summers and the vast majority of homes are air conditioned. In each of the interview sessions in Adelaide, the high cost of power was mentioned as a major barrier to air conditioner usage. This issue was raised to a lesser extent in Sydney, where a notable difference was the numerous clubs and gambling venues offering a cooled, welcoming environment. These are often frequented when the weather is hot, leading to financial stress for gamblers who are then unable to pay their power bills. Rising utility costs are a concern for many including older migrants and low income earners in the general population including those in new and emerging communities:

“…This is the community in general … the increasing rising costs of electricity is a huge issue and factor…. People still will make that decision consciously not to put their air-conditioner on because they don’t want the stress and the worry about getting that bill.”

Coordinator, Adelaide

Language barriers and low literacy

Having poor English proficiency can be a barrier during hot weather, and can increase vulnerability and isolation in people unable to access services, receive information or communicate to others. Language barriers can exist not only for new migrants of non-English speaking backgrounds, but also, as reported by respondents, long-standing elderly migrants who may revert to their first language and culture due to age-related neuro-cognitive conditions. Many older migrants who arrived post World War II, and recent humanitarian entrants, have had minimal if any, schooling and cannot read well even in their native language. These low literacy levels can also affect the transfer of information, the uptake of heat-health messages and the ability to read safety signs (e.g. at the beach), as mentioned by one respondent.

A service manager in Sydney explained that older people in new and emerging communities find it particularly difficult to learn English. Similarly, an Adelaide respondent said this can lead to limited verbal communication as younger family members who were born and raised in refugee camps often do not speak the traditional dialects of their elders. Furthermore, a refugee family in Melbourne said that being unable to understand the language was a “real barrier” to being able to access information about extreme heat. Additionally, language barriers can hamper access to health care:

“If I don’t speak English … for example I had someone sick at home - so even if I find a place to help I don’t know how to say it how to describe it, what I need.”

Community Worker, Sydney

Isolation and transport issues

Respondents spoke of strong social and family connections in CALD communities; however, as mentioned above, certain factors can lead to individuals or families becoming linguistically or socially isolated. In Adelaide, accessing cooler places can be a problem for people without transport options, thereby adding to social isolation and vulnerability during extreme heat. Although asylum seekers, humanitarian entrants and others may lack connections in the community, isolation was mainly spoken about in the context of older people.

“And we do have clients that don’t have English and they are living on their own and some cases they are the only ones in the country. We even have clients who don’t have any other relatives, so that really isolates them.”

Service provider, Adelaide

Who is vulnerable?

Respondents mentioned that amongst the vulnerable were people from areas in Africa, Bhutan, Middle East and the cool European and Scandinavian countries. Also mentioned were asylum seekers, mothers with babies (particularly single mothers), young children, people with low SES and low income, the homeless, people with poor English and the isolated in CALD communities. People with a disability and their carers, people with mental health problems and multiple chronic illnesses, and those taking certain medications were also vulnerable. Most often mentioned however, were the newly arrived, low SES migrants and refugees in new and emerging communities and who are not acclimatised to the conditions, and older people in migrant communities, especially those who lack English proficiency, as highlighted by these extracts:

“The older ones are particularly vulnerable because of the language and other cultural issues and … - there is an attitude of: we are going to stick it out and cope with it.”

Program Coordinator, Melbourne

“So I would suggest that the newly-arrived because they don’t understand this environment, … they are at a loss about how to cool themselves.”

Program Coordinator, Sydney

There are some similarities in risk factors for these two groups as shown in Table 3 which summarises some of the points previously mentioned.

Table 3 Key issues contributing to vulnerability in new arrivals and older migrants
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Although some respondents stressed the importance of the issue and concerns for their community members in the heat, others thought that in the context of the complexity of issues facing those in the midst of resettlement, weather is unlikely to rank as a priority:

“It comes last for them to know: oh, okay, the sun is burning me or I have to drink water - who cares if I have to drink water or not if I don’t have money to pay my bill, you know, that comes not being essential in a priority.”

Health care worker, Adelaide

Discussion

This qualitative investigation has given voice to stakeholders and people in cultural and linguistic minorities about the topic of extreme heat in Australia. Whilst the definition of ‘culturally and linguistically diverse’ in Australia is broad, respondents’ narratives related mainly to people or their descendants who have migrated from countries abroad with cultural differences to Australia, and the main spoken language is not English; hence in this instance ‘CALD’ is used as a descriptor in these terms.

This study draws on previous research in Adelaide recognising a need to investigate potential heat-susceptibility in non-Australian born residents [20, 21] given the paucity of current literature on this topic [22]. It also builds on international evidence that points to a disparity in the risk of heat-related illness in people of different ethnic/racial backgrounds [10, 23–26].

Findings have identified a range of multi-factorial issues that may hamper some migrants and refugees in adapting to periods of very high to extreme summer temperatures in Australia. These relate to cultural factors including wearing garments more suited to cool weather, not drinking enough water, and unfamiliarity with certain aspects of Australian culture including the use of sunscreen. Health issues, socioeconomic disadvantage and poor quality rental accommodation for low income migrants, social isolation, language and literacy barriers limiting access to heat health warning messages, and lack of acclimatisation to the ‘different’ heat in south-eastern Australia can also impact on the potential risk of harm during heat extremes.

The vulnerable individuals in CALD communities were often identified as older people, new arrivals (i.e. who settled in Australia within the last 5 years), and people in new and emerging communities. Older people in general can have declining physical and mental health that can increase heat-susceptibility. However, they generally do not consider themselves to be at risk [27] and are reluctant to using cooling systems [21]. Older people in new and emerging communities may be doubly at risk, particularly if they lack English proficiency skills which can add to isolation and limit access to harm minimisation information. This is mirrored by other studies reporting that ethnic minority language groups can be vulnerable to extreme heat because of exclusion from access to English-based reports and heat information [28, 29]. As a consequence there can be a lower uptake of adaptive behaviour messages [23]. Language barriers not only apply to the recently arrived but also the ageing post-war European migrants who can become nostalgic later in life and revert to their primary culture and language, as described by Schmid and Keijzer [30].

Stakeholders mentioned a range of physical and psychological conditions affecting humanitarian entrants and older migrants. In a Sydney study of access to health care for recently arrived refugee families, it was found that few owned a house or car, nearly all were unemployed, and most did not have functional English language skills [31]. There was also the disadvantages of low literacy skills, financial handicap, language barriers, lack of transport, not knowing where to seek help, and poor health knowledge [31]. These findings parallel the narratives of respondents in this study and highlight the barriers for resettled refugees that can hinder acculturation. Not being physiologically and behaviourally acclimatised to the local climatic conditions can influence risk [25, 32] and can be a factor in heat-related deaths in Australia [33]. Immigrants of different skin colours and pre-migration climatic experiences commented on the different type of heat in Australia. However, this was not the case in Sydney, where humidity is higher during the summer months [34]. Migration–related factors can influence tolerance and adaptation to extreme heat and it is understandable that newly arrived migrants may suffer in the uniquely dry heat of south-eastern Australia.

Turning on home air conditioners, and using air conditioned cars to drive to cooler places as practiced by most Australian-born families [35] are options unavailable to the financially disadvantaged. This lack of ability to attain thermal comfort during extreme heat has the potential to increase the risk of adverse heat health outcomes. Conversely, using cooling devices is highly protective [36, 37], however usage is expensive and we found the high cost of power to be a common barrier mentioned in narratives from Adelaide and Sydney. Adelaide has the third highest household electricity costs in the world behind Denmark and Germany [38], reportedly as a result of the high power demand caused by air conditioner usage during hot weather [39]. Smarter technologies and improvements to housing design are needed to reduce the health impacts of high temperatures [32] and lower the need for home air conditioning. Publicly cooled spaces can be frequented by people not wishing to incur high energy bills at home. Disturbingly however, there was evidence that for some people in new and emerging communities the risk of being marginalised in public can influence adaptive behaviour and was a deterrent to people retreating to shopping centres. This is supported by another study which claims that in a predominantly Caucasian society, “visibility” due to different skin colour, attire or accent, can render refugees and others vulnerable to “street discrimination” [40].

Notwithstanding these issues migrants, by necessity, can be resilient and have a high adaptive capacity, and certain cultural norms and life experiences can be beneficial to the resettlement process. Enablers to heat adaptation include strong family structure and social networks that exist within collectivist communities. High social capital and having elders live with the family reduces the likelihood of isolation which is known to be linked to societal vulnerability and a risk factor for heat-related mortality [23, 41].

Simple harm minimisation behaviours can mitigate the health threat posed by extreme heat, but these are not necessarily intuitive, particularly to those who have not long resided in Australia. Multilingual heat-health advisories could be broadcast via a range of ethnic media outlets and community networks during heatwaves to increase awareness about the health risks of heat exposure including dehydration, and inform about behaviours to minimise the risk of harm in the heat [22]. Furthermore, a better understanding and knowledge of effective health promotion measures within collectivist societies, and the influence of cultural practices and sensitivities on health outcomes, will better inform population health programs and services [42].

This study has several limitations. Sample sizes were relatively small and there were few interviews at the community level. However, this scoping study has laid the foundations for a further study currently being undertaken involving community members. The migrant population of Australia is vastly heterogeneous and findings are not intended to be generalisable beyond the scope of the study. Findings may reflect problems that exist in only a minority of migrants and refugees if recruitment inadvertently resulted in a biased sample. Indeed, among immigrants arriving as part of the skilled migration program employment rates can be low and English proficiency high [43] and it would therefore be less likely that heat risks in this group would differ to that of the equivalent Australian-born population. Nevertheless, this study has given voice to those who have expressed genuine concerns about the potential impact of extreme heat on the disadvantaged with cultural and linguistic vulnerabilities, and an unmet need for access to appropriate information about adaptive behaviours. Further qualitative and quantitative research is required to investigate potential disparities in the impacts of extreme heat on minority groups in Australia.

Conclusions

Stakeholders within and working with CALD communities have observed sociocultural barriers that can hinder effective adaptation of migrants to extreme heat in Australia. Low income, recently arrived non-English speaking migrants, as well as isolated and older migrants who lack access to a cooled environment are of particular concern. With migration increasing, first generation migrants becoming part of the ageing population, and climate change bringing more frequent and intense periods of extreme heat, policymakers need to be mindful of the need for culturally and linguistically competent strategies for disseminating risk messages and heatwave warnings.

Authors’ information

Alana Hansen is the Submitting author.