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Review

Definitions of Culturally and Linguistically Diverse (CALD): A Literature Review of Epidemiological Research in Australia

by
Thi Thu Le Pham
1,*,
Janneke Berecki-Gisolf
1,
Angela Clapperton
1,2,
Kerry S. O’Brien
3,
Sara Liu
1 and
Katharine Gibson
4
1
Monash University Accident Research Centre, Monash University, 3800 Clayton, Australia
2
Centre for Mental Health, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 3010 Melbourne, Australia
3
School of Social Sciences, Monash University, 3000 Melbourne, Australia
4
Department of Health & Human Services, 3000 Melbourne, Australia
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2021, 18(2), 737; https://doi.org/10.3390/ijerph18020737
Submission received: 17 November 2020 / Revised: 10 January 2021 / Accepted: 11 January 2021 / Published: 16 January 2021
Browse Figure
Versions Notes

Abstract

:
Objective: To identify how Culturally and Linguistically Diverse (CALD) communities are defined in epidemiological research in Australia and provide a definition of CALD status that aids the consistency and interpretability of epidemiological studies. Methods: Peer-reviewed literature from January 2015 to May 2020 was searched via four databases (Ovid Medline combined with PubMed, Embase, Emcare, and CINAHL) to identify quantitative studies of CALD people in Australia. Results: A total of 108 studies met the criteria for inclusion in the review. Country of birth was the most commonly used CALD definition (n = 33, 30.6%), with combinations of two or more components also frequently used (n = 31, 28.7%). No studies used all the components suggested as core to defining CALD status. including country of birth, languages other than English spoken at home, English proficiency, and indigenous status. Conclusions: There was considerable inconsistency in how CALD status was defined. The review suggests that CALD status would best be defined as people born in non-English speaking countries, and/or who do not speak English at home. Additionally, indigenous peoples should be considered separately. This recommended definition will support the better identification of potential health disparity and needs in CALD and indigenous communities.

1. Background

Australia is a multicultural society experiencing rapid immigration from diverse countries, and, accordingly, the cultural and linguistic diversity of Australia has increased. The 2016 census showed that more than 28% of the Australian population was born overseas [1]. Recent figures from the Australian Bureau of Statistics (ABS) revealed that over 300 separate ethnic backgrounds were identified in the 2016 census, with over 300 separately identified languages spoken in Australian homes [2]. In 2016, one-fifth of Australians spoke a language other than English at home [2].
Indigenous peoples were the first Australians and the original inhabitants of the land, who also contributed an important part of the cultural and linguistic diversity of Australia. While different terms have been used to refer to indigenous peoples, such as Aboriginal and Torres Strait Islander peoples, indigenous Australians/peoples, Australia’s indigenous peoples, first people/nations/Australians, and traditional owners, we have decided to use the term “Indigenous peoples/individuals” throughout this study. This term is used by the United Nations in the “United Nations Declaration on the Rights of Indigenous peoples” [3]. In 2016, an estimated 798,365 indigenous peoples were living in Australia, representing 3.3% of the total Australian population [4]. More than 250 indigenous Australian languages, including 800 dialectal varieties, were spoken. Among indigenous peoples, 11% (46,700 people) spoke an indigenous Australian language as their main language at home [5]. These statistics highlight the fact that Australia has over seven million people (of 25 million) who may be defined as being from Culturally and Linguistically Diverse (CALD) backgrounds, including migrants or individuals of indigenous descent.
Due to the large number of Australians belonging to CALD communities, research into cultural diversity has been attracting significant attention from researchers and policy-makers in Australia. These groups of people have been reported to experience health disparities [6,7,8,9] and unique conditions such as language barriers, prejudice, discrimination, and racism. An inquiry from the Australian government in 2013 found that new migrants with lower levels of English proficiency and indigenous peoples were statistically more likely to be overrepresented in social-economic disadvantaged groups [10] due to relatively high rates of unemployment and limited access to available services [11]. Importantly, taking cultural differences and accessibility into account when developing interventions can help enable resources to be accessible, inclusive, and responsive to the needs of all people who require assistance. In contrast, poor identification and communication with CALD populations might lead to ineffective resource allocation and interventions. Therefore, research into cultural and linguistical diversity is recommended in seeking to address health and social inequities [12,13].
In order to conduct research about people from multicultural communities, defining the CALD status of study participants is the first important step. While the term CALD is commonly used in Australia, the acronym CALD might be replaced by other terms, such as ethnicity (widely used in England); BAME (Black and Asia Minor Ethnicity); BAEM (Black and Asia Ethnic Minority); minority ethnic groups; race; and specific names of cultural backgrounds such as African, Asian, and Hispanic in an international context. The term “Cultural and Linguistic Diversity”, introduced by the ABS in 1999, is a broad concept drawing attention to both the linguistic and cultural characteristics of multicultural populations living in Australia [14]. To measure the CALD status of individuals in data collection, the ABS (1999) recommended a standard set of cultural and language diversity measures to be used to provide the basis of comparability of information [14]. The set includes four primary indicators: “Country of Birth”, “Main Language Other than English Spoken at Home” (herein referred to as “language spoken at home”), “Proficiency in Spoken English”, and “Indigenous Status”. This is the minimum core set that needs to be collected to determine an individual’s CALD status [14]. They also suggest a range of further optional variables that can be added to meet particular information needs and to get more insight into a person’s diversity characteristics. These include “Ancestry”, “Country of Birth of Father”, “Country of Birth of Mother”, “First Language Spoken”, “Languages Spoken at Home”, “Main Language Spoken at Home”, “Religious Affiliation”, and “Year of Arrival in Australia” [14].
Published by the ABS in 2019, the core set is recommended in all administrative and service provision settings where information on CALD is required. However, it is acceptable to omit variables which may not be appropriate or useful [14]; for example, indigenous status can be omitted when researching migrant issues only. This approach can prove to be problematic and can result in various definitions of CALD being used interchangeably in epidemiological studies. As a consequence, there is variation in the reported prevalence of health outcomes and other factors identified in CALD communities. The inconsistency in the definitions of the CALD status of study participants can undermine the comparability and generalisability of research findings [15], consequently, limiting the quality and applicability of such studies.
Therefore, it is necessary to provide a working definition of CALD in order to increase the consistency of defining CALD status in future epidemiological research. The literature review firstly aims to identify the most commonly used definitions of CALD in current quantitative research in Australia. Additionally, we outline and discuss the advantages and disadvantages of the various CALD definitions in research settings, then provide a practical CALD definition for future research, contributing to improving the quality of CALD-related studies in terms of comparability and generalisability.

2. Methods

2.1. Data Sources

Systematic searches of published research were carried out to capture studies of CALD people in Australia. The search was performed in the databases including Ovid Medline and PubMed combined, Embase, Emcare, and CINAHL (the Cumulative Index of Nursing and Allied Health Literature) in May 2020. These databases were selected because their scopes are biomedicine and health, broadly defined to encompass those areas of the life sciences and behavioural sciences needed by health professionals and others engaged in basic research and clinical care, public health, health policy development, or related educational activities.

2.2. Key Terms and Search Strategies

  • 1: CALD OR (cultural* and linguistic* divers*) OR cultural* divers* OR multicultural OR multi-cultural: to capture all possible research articles relating to CALD people.
  • 2: Australia* OR Victoria* OR New South Wales OR Northern Territory OR Tasmania* OR Queensland: to capture studies conducted in Australia.
  • 3: (1) and (2): to capture studies of CALD communities in Australia.

2.3. Inclusion Criteria

Studies were included if they used a quantitative research method and mentioned how the CALD or multicultural status of study participants was defined. We based this on the ABS’s suggestion about the components of CALD status, including country of birth, ancestry, religious affiliation, year of arrival in Australia, proficiency in spoken English, and main language other than English spoken at home [14]. As a result, the inclusion criteria were broadened to include refugees, immigrants, and indigenous status and indigenous peoples if they were captured by the search and met other eligibility criteria. Under the concept of the definitions of CALD status of the study participants, we only included articles about indigenous peoples that explicitly mentioned (1) the aspect of cultural diversity and multicultural background of participants and (2) how to identify their indigenous status within the manuscripts (any other terms referring to indigenous peoples accepted).
We limited the results to studies conducted in Australia only. Studies in multiple countries were not considered because of the differences in setting, and because CALD is a term not commonly used outside of Australian literature. We included only peer-reviewed articles in the English language and with full text available (records of conference abstracts were excluded). We decided to limit the searches to articles published in 2015 or later because we are empirically confident that the research results were saturated within the 108 articles included (please refer to Section 3 for more detail). Specifically, we found similar definitions of CALD repeatedly, and going back further did not add any types of studies that were not already captured and therefore did not provide further insights into CALD studies/terminology.

2.4. Data Selection Process

Only peer-reviewed quantitative studies indicating the definition of CALD status of study participants were included in the present review.
Literature searches were conducted (Figure 1) with four selected databases. In the first step, we deleted duplicate article results. Titles and abstracts were then screened in accordance with the inclusion and exclusion criteria. Finally, full-text articles were critically examined to find relevant studies for data analysis.

2.5. Data Extraction and Analysis

Information regarding the definitions of CALD status, research topics, research locations, study design, data sources, and potential pros and cons of each CALD definition were gathered into an excel template. The data were then coded and analysed to determine the number of articles and percentages within each defined category based on CALD definitions and by the sources of data used. The limitations and strengths of the CALD definitions were extracted from the selected studies. These were then discussed in the context of CALD definitions more generally (Australian and international; not limited to studies included in the review) to compare the pros and cons of each definition and to suggest the most applicable definition of CALD status for research purposes.

3. Results

The systematic literature searches revealed 1440 eligible papers (Figure 1), of which 737 duplicates were identified and deleted. Titles and abstracts were then examined in accordance with the inclusion and exclusion criteria. After this screening, we excluded 488 articles because they were not quantitative studies (according to the research methods mentioned in abstracts) or failed to recruit or include CALD people as participants. We then reviewed the full-text versions of the remaining 215 publications to further evaluate them for eligibility: 19 articles were excluded because they were conference abstracts (first/corresponding authors were contacted). After evaluating the remaining 196 full-text articles, 37 articles were excluded because they did not report a definition of CALD status, 19 studies were excluded due to multiple-country study sites, and 32 because they were not quantitative studies. These studies did not mention all relevant information regarding research methods in the abstracts, but we found them to be non-quantitative research after full-text reading. The screening process resulted in 108 articles meeting the inclusion requirements and being included in the review.
The 108 selected epidemiological studies covered a variety of topics such as aged care, antenatal care, asthma, and autism (Table 1). The majority of the studies examined CALD communities in New South Wales (n = 41), followed by Victoria (n = 29), Queensland (n = 13), Western Australia (n = 4), South Australia (n = 3), and Northern Territory (n = 1). Another 15 studies examined CALD groups in the whole of Australia or without mentioning the specific locations of CALD participants, whilst two other studies looked at three specific Australian states—namely, New South Wales/Victoria/Western Australia and Victoria/New South Wales/Queensland.
Regarding the data sources and study designs of the selected studies, approximately half of them used available data (n =52.5%), including administrative hospital databases, household surveys, and data collected in other studies. The remainder collected data via face-to-face interviews, self-reported surveys, or phone calls (n = 56.5%). There was considerable variability in how the study designs were described in these articles: some categorised themselves as descriptive, quantitative, experimental, observational, or mixed qualitative and quantitative studies; others mentioned the exact terminology of their research methods. Specifically, the most common (self-reported) study designs/types were cross-sectional studies (n = 54), followed by 17 retrospective studies and 5 longitudinal studies (Table 1).
Among 108 articles, 88 papers explicitly mentioned CALD definitions in the methodology (81.5%), whilst the remaining articles did not explicitly state how CALD status was defined, but this information could be inferred from the manuscripts.

3.1. Definitions of CALD

Table 1 presents how CALD status was defined in each article, demonstrating that CALD definitions were inconsistently used in the selected 108 quantitative studies. The various definitions of CALD from these studies were categorised into six main groups, as shown in Table 2.
Although country of birth (COB), language spoken at home (LSAH), English proficiency, and indigenous status make up the minimum core set to measure CALD status suggested by The Australian Bureau of Statistics [14], Table 2 shows that no articles used all four, with English proficiency not reported by any of the studies included in this review. COB, LSAH, and indigenous status were each commonly used as a stand-alone definition of CALD, in which COB was the most frequently used definition (used in 33 articles: 30.6%), LSAH was used in 21 articles (19.4%), and indigenous status was used in 3 articles (2.8%). The following are the detailed measurements of these three definitions:
“Country of birth” was used in 33 articles. There were two methods to define CALD status of participants by COB. First, if the respondents reported a COB other than Australia, they were defined as CALD participants, whilst non-CALD participants were those who were born in Australia. This type of definition was used in 16 articles. Second, if the respondents reported non-English speaking countries as COB, they were defined as CALD participants, in contrast to those born in English-speaking countries, who were defined as non-CALD participants. Further, some articles used a particular COB, such as “China” or “Spanish speaking countries”, as the definition (see Table 1).
“Language spoken at home”: in 21 studies, the participants were asked about the language they used in daily conversation at home. If it was English, they were categorised as being in non-CALD groups, whereas non-English speakers were categorised as being in CALD groups.
“Indigenous status”: only three articles that used indigenous status as a measure of CALD were captured by the current literature review’s search strategies. There could be other articles that used similar methods to define CALD but that did not meet the search criteria (i.e., explicitly mentioning cultural diversity and multicultural), and hence failed to be captured by the present literature review. In these articles, indigenous status was self-reported by answering whether the participants were born to indigenous mothers or not (in 1/3 studies). Additionally, they were categorised as CALD if they responded “Yes” to the question regarding indigenous status (1/3 studies) or Māori and Pacifica Islander background (1/3) (see Table 1).
In addition to the use of the variables in the minimum core set to define CALD status, “ethnicity”, “cultural”, or “CALD background” were also used as CALD definitions in 13.9% of the selected articles (n = 15). Overall, approximately 30% of the articles clearly stated how they measured ethnicity/cultural background, whilst the rest had no information (Table 1). Among the studies that provided inadequate information on the measurement of ethnicity (cultural background/CALD), some authors possibly used an ethnicity (cultural background/CALD) variable readily available from administrative or secondary datasets, failing to mention how it was collected. CALD backgrounds were also self-reported by participants reflecting how they perceived their CALD/ethnicity status; again, instruction on how people self-evaluated CALD background was missing in the manuscripts. Although some authors stated how ethnicity (or cultural background) was measured, no consistent measurement of ethnicity was found. For example, in one study, ethnicity was defined through self-reported nationality, in which people were classified as CALD if they self-identified as having a nationality or mix of nationalities other than Australian. In contrast, in another study, the participants’ ethnicity was based on their own culture, as well as their language and beliefs, rather than strictly on nationality or country of birth. Further, participants were recruited from specific community groups with Chinese and Vietnamese backgrounds in other studies. To summarise, there was variation in defining ethnicity, with some studies inadequately reporting their definition. This further contributed to CALD status being measured differently across studies.
Furthermore, “migrant” and “refugee” statuses were used in five articles (4.6%) based on people’s self-report of having migrated from another country, or were identified by visa types.
Definitions using combinations of more than one component to categorize CALD or non-CALD status were the second most common method of defining CALD status (31 articles: 28.7%), following the definition by COB only. This measure used two or more indicators of CALD status; for example, when COB and LSAH were combined, participants with CALD status were those born in non-English speaking countries and/or those who spoke a language other than English at home. More examples of these definitions such as interpreter required or duration of time staying in Australia are provided in Table 1.

3.2. CALD Definitions in Different Data Sources

Although various sources of data were used in the 108 selected articles, COB, LSAH, and the combinations of two or more CALD variables were widely used to define the CALD status of participants. Table 3 presents definitions of CALD per two main data sources: administrative data or other secondary data analysis and self-collected data. Researchers who used administrative or other types of available databases such as national surveys, hospital records, or routine clinical services data were more likely to select combined definitions (36.5%) and COB (34.6%). On the other hand, LSAH (23.2%), ethnicity group (16.1%), migrants and refugees, or indigenous peoples were more common in survey data collected by telephone, face-to-face interviews, or online surveys.

4. Discussion

To our knowledge, this is the first literature review to systematically explore how researchers have defined CALD communities in quantitative studies in Australia. The review showed that various definitions of CALD have been inconsistently used in the 108 selected articles, and none of the selected articles used the full minimum core set that is recommended by the ABS [14] to define CALD status.

4.1. Pros and Cons of Definitions

Researchers use various definitions to determine the CALD status of their study participants; this is likely due to the flexible guidelines for defining CALD by its components suggested by the ABS [14]. Each definition has its advantages and disadvantages, which can determine suitability depending on data availability and difficulties in data collection. The inconsistency in using a variety of CALD definitions might limit the generalisability of study results and make them difficult to compare. Therefore, this review critically analysed the strengths and limitations (of each definition) which were pointed out by published literature (not limited to articles included in the review) from Australia and other countries to broadly understand how CALD participants were identified, then to provide an evidence-based suggestion for how future research could define CALD status to collect data related to CALD communities.

4.2. Country of Birth

One third of the selected articles used COB to define CALD status; this was the most widely used definition (n = 33, 30.6%). This is consistent with the CALD definition in the chapter of CALD population health under “Australia’s Health 2018” reported by the Australian Institute of Health and Welfare (AIHW) [123]. AIHW stated that defining the CALD population by COB was used in the report as it was the most common data element among AIHW health data collections [123]. Additionally, this definition was commonly used as a proxy measure for CALD, particularly in clinical settings, as it indicates individuals’ geographical place of origin and is consistently presented over time.
While some argue for the benefits of using country of birth due to the ease of data collection and consistency in presenting [124], others have identified limitations to this definitional approach. First, there appears to be variation in reporting and recording these data [125,126]. Tran et al. (2012) found that 19% of overseas-born people in New South Wales Admitted Patient Data Collection incorrectly reported their COB [125]. The authors mentioned that COB was mainly recorded inaccurately as “Australia” or “Inadequately described”, and that it was recorded with greater accuracy in principal referral hospitals, public hospitals, and hospitals in metropolitan areas. Longer duration of stays in Australia deceased the accuracy of COB recorded, and the accuracy increased with age at immigration and varied according to COB [125]. Another study about the accuracy of information provided by pregnant women to survey questions on cultural backgrounds and country of birth supported this notion, as the COB variable was not a reliable proxy measure of cultural background [121]. Second, defining participants who were not born in Australia as CALD means that the CALD group included both people with English-speaking and non-English-speaking backgrounds. This may affect the results, as no linguistic aspects of CALD are considered. As a result, CALD status defined by having a non-English speaking country of birth is likely a better option. Third, CALD defined based on country of birth only might not capture people who were born in Australia but whose families were originally migrants. The reverse may also be true for people who were born overseas but arrived in Australia when they were very young and grew up in Australia. These people could be very different from those who arrive later in their childhood or as an adult, despite all being born overseas. Last, when this definition is applied to indigenous peoples who were born in Australia, they would be categorised as part of the non-CALD population. However, the cultural and linguistic aspects and needs of indigenous peoples are significantly different from those of Anglo-Australians. Thus, it can be concluded that relying on COB only might lead to some misclassifications of CALD because of the failure to capture linguistic and ethnic aspects. Therefore, where possible COB should be combined with other information to define CALD status.

4.3. Language Spoken at Home

In the 108 selected articles, 21 articles used LSAH as the definition of CALD. Such studies are likely to explore language barriers, which is one of the most important challenges for CALD people. A limitation of defining CALD by LSAH is that it might be affected by acculturation [58]. Specifically, children of immigrants (from CALD backgrounds) living in Australia for many years might report English as LSAH [52]; therefore, they would be misclassified as the non-CALD group. Further, CALD backgrounds of English-speaking people such as Singaporeans or Indians might also be miscategorized as the non-CALD group by the current definition [52]. Finally, this definition is likely to under-represent the full CALD population and may represent a relatively more culturally isolated subgroup [51]. People who are not English native speakers have a relatively higher level of need for assistance than other subgroups [111]. Thus, using LSAH other than English as the only indicator of CALD is an imperfect definition as only the potential language barrier is considered [50]. This leads to a limited generalisability of the findings to other regions or other cultural groups [62]. Therefore, it is recommended that LSAH should not be the only variable to define CALD status.

4.4. Indigenous Status

Defining this group under the CALD concept is challenging for CALD research because indigenous peoples are mostly born in Australia and many of them speak an indigenous language (other than English). In the studies captured in this review, the CALD definition was mostly based on COB, so that indigenous peoples were commonly included in non-CALD communities. However, it becomes difficult if researchers use both COB and LSAH to identify CALD status of indigenous Australian-born peoples who do not speak English at home. This results in a conflict because if the definitions of CALD status are based on COB of participants, this group would be included in the non-CALD group; in contrast, if the LSAH were used, the indigenous peoples would then be categorised in the CALD group (due to speaking an indigenous language at home). Therefore, two approaches can be used here. First, researchers could exclude indigenous peoples from CALD studies, explaining that indigenous peoples are not representative of either CALD or non-CALD groups in their research framework [72,105]; and indigenous research could be conducted in targeted studies instead of being included in more general CALD studies. Second, indigenous peoples could be included in CALD research but categorised in a separate group. This latter approach is a suitable method as the experiences and needs of such first nation people are seen as significantly different from the two other groups—i.e., CALD and non-CALD. For example, Stephane et al. (2015) categorised research participants into three groups, including English-speaking, CALD, and indigenous background [118,119], in their studies of young offenders. Similarly, the ABS (2014) discussed the three most common components of CALD (country of birth, language spoken at home, and English proficiency) together, but separately referred to indigenous people [127].
It is important to note when indigenous peoples are categorised as a separate group, the population size needs to be taken into consideration because the population is much smaller than that of CALD and non-CALD groups in Australia. To support this, Adam (2017) revealed that gaining enough numbers of people for statistical analysis in indigenous status research is often a challenge [70]. Thus, indigenous peoples should reasonably be considered as a separate entity with attention to the challenge of sample size for recruitment and also analysis.

4.5. English Proficiency

None of the studies included in this review used English proficiency as an indicator for CALD status. Possibly, this is because information regarding the level of English proficiency is not readily available in most administrative datasets. Additionally, it is normally self-assessed (and therefore subjective), which might lead to limitations of data accuracy. Further studies regarding the availability and quality of data about “Proficiency in Spoken English” among people from non-English speaking backgrounds are recommended.

4.6. Ethnicity and Cultural Background

Cultural background and ethnicity are reported as ambiguous definitions of CALD as it is self-evaluated and changeable, without explicit criteria. Internationally, the use of the term “ethnicity” in data collection and the subsequent interpretation of people’s cultural diversity is widely debated [121]. In England, an audit of the accuracy of coding in English National Health Services hospital records found that 39–43% of ethnicity data for ethnic minorities was incorrect [128]. A systematic review of self-harm among minority ethnic groups in the United Kingdom found that: while some studies failed to clearly mention how “ethnicity” was defined, it was variously defined in other studies (based on participants’ names, or countries of birth of participants) [15]. In Australia, the ABS, which is responsible for population census data collection, defines ethnicity as a multi-dimensional concept that may include cultural traditions and customs, shared history, geography, language, religion, and/or identification with a minority group [129]. Ethnicity, cultural identity, or cultural background are complex, dynamic, and multi-layered concepts referring to an individual’s sense of identity, which can change over time and across generations [130,131]. This information is not readily available in administrative data [22], and if available it might be collected for different purposes which can lead to potential bias and misunderstanding. Therefore, cultural background and ethnicity should only be considered to define CALD status if they are captured and presented with clear definitions alongside appropriate and well-described data collection strategies.

4.7. Definitions Using More than One Component of CALD

There is no single characteristic that should merely be used to define the CALD status of study participants as CALD is a broad concept drawing attention on both cultural and linguistic characteristics of people. For example, if only asking a person’s country of birth, there is a risk that differences within communities such as language barriers are masked; in contrast, if only asking about the main language spoken at home, cultural differences might not be captured. Researching CALD communities requires researchers to touch on multiple relevant aspects of CALD. Consistent with the ABS (1999), this review found that COB, LSAH, and indigenous status are three of the most important aspects of CALD in Australia [14]. Research methods capturing all three key aspects including linguistic, cultural, and ethnic factors are optimal for identifying any barriers or disadvantages that CALD people may experience. Therefore, we suggest that if feasible, the definition of CALD should involve more than one suitable component of CALD.

4.8. Other Definitions of CALD

Other less common CALD definitions such as interpreter required or duration of time staying in Australia were used when language barriers or acculturation aspects of CALD were the study focus. However, they were less common than COB/LSAH/Indigenous status. The literature review revealed that longer duration of stay in Australia [132] and sufficient English proficiency [133] are significant factors affecting how migrants generally acculturate and adapt to the Australian culture and demands. It is self-evaluated, and therefore, people’s self-evaluation of CALD status changes over time depending on how they feel about their degree of acculturation and adaptation to the host culture. The topic of acculturation is not the prime focus of the current research because interpreter required or length of stay in Australia were less commonly chosen to define CALD status of study participants in the selected articles; however, they could be used as additional components to define CALD when necessary.

4.9. Comparison with Research in Other Countries

Not all countries used the term CALD; for example, other terms such as “BAEM (Black and Asia Ethnic Minority)”, “ethnicity”, and “minority ethnic groups” are more common to classify cultural backgrounds of people in other countries such as in England, America, and Canada. However, this review was specifically focussed on cultural and linguistic diversity and not specifically on ethnicity, which tends to be the focus of other studies (the United Kingdom and the United States). Therefore, the study findings cannot be directly compared with research from countries where there is more of a focus on ethnicity (some comparisons were made while discussing “ethnicity”). Additionally, to our knowledge to date, research to evaluate how multicultural backgrounds of study participants were classified in other countries is relatively scarce. No literature review on definitions of CALD status (or other terms) of study participants has been published elsewhere, which leads to limited comparison to similar research in other countries. Further research in this area is recommended.

5. Limitations of This Study

This review aimed to investigate the definitions of CALD in quantitative research of CALD communities to recommend a suitable definition of CALD for future studies. This review has limitations that need to be acknowledged. First, the review focused on health research only; this might not reflect the overall definition of CALD in other social fields. Second, the systematic searches were limited to papers indexed in four selected databases, and written in English, not including grey literature. Last, comparisons with other international studies were limited not only because of the specific focus of this review (on cultural and linguistic diversity) but also the availability of similar research in other countries, which was discussed in detail in the previous section.

6. Recommendations

The flexible and adaptable application of CALD definitions potentially leads to limitations in terms of research generality and comparison. To contribute to the improvement of future research of CALD groups, a clear-cut definition of CALD status for research purposes is recommended.
Ideally, researchers should capture as many CALD components as possible to avoid the limitations of a single definition. Covering multiple aspects of CALD status leads to a broader representation of CALD communities. However, in practice, the decision of researchers on how to define CALD status is usually limited by data availability and resources to conduct surveys. Researchers using administrative data only have access to variables in the data set they are using, whereas researchers collecting their data have different options. Researchers using administrative data should consider data linkage options to obtain the most complete set of CALD variables possible. Conversely, researchers collecting their own data through survey should at least collect data regarding three components of CALD, including COB, LSAH, and indigenous status (plus any additional ones relevant to the study), as recommended by the ABS [14]. Therefore, three components of CALD should be used as the minimum core indicators of CALD while using any sources of data, and if possible other variables such as English proficiency, ethnicity, and length of stay in Australia should also be obtained.

6.1. Definition of CALD Status

In order to define the CALD status of research participants, we suggest a definition of CALD communities based on three main components including COB, LSAH, indigenous status:
  • ALD group: people who were born in non-English speaking countries and/or English is not the main language spoken at home. English-speaking countries as suggested by the ABS, 2013 include Australia, the United Kingdom (England, Scotland, Wales, Northern Ireland), the Republic of Ireland, New Zealand, Canada, the United States of America, and South Africa) [134].
  • Indigenous group: people who are of indigenous status descent, or self-identified as with indigenous status, or accepted by indigenous communities [3,135]. However, in practice, in the general Australian population, the number of Indigenous peoples are significantly smaller than the CALD and non-CALD communities, which may potentially affect the statistical power of studies. More importantly, when using indigenous identification to define a culturally and linguistically diverse group, researchers should undertake ethical research practices and indigenous data sovereignty consistent with the UNDRIP [3].
  • Non-CALD group: people who are neither in CALD nor from Indigenous groups.
This suggestion is to define CALD status of participants in data collection for research purpose only. It is not intended to determine whether a person has CALD status or not.
In the scenario where one or two variables are unavailable and there is no option to obtain them (through data linkage or otherwise), the recommended definition could still be considered as the best applicable measurement of CALD study participants by omitting the unavailable variables from the suggested definition. The flexible applications of the definition may create inconsistency in identifying CALD status and should, therefore, be well-described and acknowledged as limitations of the research.

6.2. Key Take-Home Messages

  • Existing definitions of CALD status for data collection were inconsistently applied in current epidemiological studies, limiting the interpretability and comparability of such research.
  • The use of single components of CALD status in defining CALD communities is insufficient to reflect both cultural and language aspects of CALD communities.
  • A clear-cut definition and standardised terminology to define CALD status (for research purposes only) will improve the quality of future research in the area; this paper gives recommendations for such a definition.

7. Conclusions

In this review of 108 studies, we have confirmed the inconsistency in defining CALD status as well as the lack of a consistent definition and terminology for Australian epidemiological studies. Each of the specific definitions has advantages and disadvantages which might lead to limitations in the comparability and generalisability of such studies. This highlights the need for a consistent and practical general definition of CALD status for research purposes. After reviewing current published studies using various CALD definitions and critically analysing the pros and cons of each, we propose an evidence-based definition, which is that CALD study participants should be defined in research as those who were born in non-English-speaking countries and/or their main language spoken at home is not English. It is not suggested to determine whether a person “is CALD” or not because there is no explicit criterion to define CALD members. Indigenous peoples should be categorised in a separate group. The application of a clear-cut definition with standardized terminology of CALD status for study participants in data collection (only) will improve the quality and consistency of future research findings.

Author Contributions

T.T.L.P. and J.B.-G. led the study and T.T.L.P. conducted the primary literature review with assistance in screening from J.B.-G., A.C., K.S.O., S.L., K.G. T.T.L.P. led the drafting of the manuscript with contributions from all authors on the manuscript. All the authors contributed to the interpretation of the results. All authors have read and agreed to the published version of the manuscript.

Funding

This paper is part of a PhD thesis which is supported by the Injury Prevention Graduate Research Industry Partnership Program under the collaboration between Monash University Accident Research Centre and the Victorian Department of Health and Human Services.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data sharing not applicable.

Conflicts of Interest

The authors declare they have no competing interests.

Abbreviations

AIHWAustralian Institute of Health and Welfare
BAEMBlack and Asia Ethnic Minority
BAMEBlack and Asia Minor Ethnicity
CALDCultural and Linguistic Diversity, Culturally and Linguistically Diverse
COBCountry of Birth
LSAHLanguage spoken at home
NESCNon-English-speaking countries
NSWNew South Wales
UNDRIPUnited Nations Declaration on the Rights of Indigenous Peoples

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Ijerph 18 00737 g001 550
Figure 1. Summary of search and review process.
Figure 1. Summary of search and review process.
Ijerph 18 00737 g001
Table
Table 1. Definitions of CALD in the selected studies.
Table 1. Definitions of CALD in the selected studies.
StudyResearch TopicRegionsCALD DefinitionStudy DesignsData SourcesSample Size
Definitions of CALD by COB
Sanchez, 2020 [13]Migrant healthQueenslandBorn in Spanish-speaking Latin American countriesCross-sectional studyElectronic medical records382
Ponsford, 2020 [16]Brain injuryVictoriaBorn outside of Australia, New Zealand, the United Kingdom, and the United StatesLongitudinal studyHead injury outcome study database206
Heilat, 2019 [17]Breast cancerNew South Wales (NSW)Born in Arabic speaking countriesRetrospective audit Prospectively maintained institutional database2086
Counted, 2019 [18]Quality of lifeNSWBorn in AfricaCross-sectionalSurvey261
Green, 2018 [19]Palliative careNSWBorn in non-English speaking countries (NESC)Retrospective audit Medical record audit data100
Wechkunanukul (2016) [20]Chest painSouth AustraliaBorn in NESCCross-sectionalHospital administrative data8225
Ghosh, 2017 [21]Mental health Western Australia Born in NESCPopulation-based retrospective cohort studyLinked data using Western Australia Data Linkage System665,523
Basic, 2017 [22]Age careNSWBorn in NESCCross-sectionalReferral source, medical diagnoses2180
Khawaja, 2017 [23]Mental healthQueenslandBorn in NESCCross-sectionalSurvey221
Law, 2015 [24]Physical activityVictoriaBorn in NESCMixed methodSurvey402
Lin, 2016 [25]AgingVictoriaBorn in NESCCross-sectionalSurvey by questionnaire122
Casey, 2015 [26]Occupational safetyAustraliaBorn in NESCCross-sectionalSelf-evaluation questionnaire562
Mazza, 2018 [27]CancerVictoria, NSW, QueenslandBorn in NESCObservational cohort study using a mixed-method approachSurvey60
Trinh, 2017 [28]Caesarean sectionNSWBorn overseasObservational studyAdministrative hospital data48,711
Tilley, 2015 [29]HIV/AIDSAustraliaBorn overseasObservational clinical cohort study Australian HIV Observational Database3894
Ogbo, 2019 [30]DepressionNSWBorn overseasRetrospective studyLinked retrospective maternal and child health data 20,560
Ogbo, 2019 [31]BreastfeedingNSWBorn overseasRetrospective studyLinked retrospective maternal and child health data 25,407
Berry, 2018 [32]NeuropsychologyAustraliaBorn overseasCross-sectionalNormative data obtained from Chinese Australian Neuropsychological Normative Study 145
Wallace, 2018 [33]NeuropsychologyAustraliaBorn overseasCross-sectionalNormative data obtained from Chinese Australians Neuropsychological Normative Study 145
Dahlen, 2018 [34]Violence and perinatal outcomesNSWBorn overseasRetrospective population-based data studyWestern Sydney Local Health District Obstetric database33,542
Maneze, (2016) [35]Survey responsesNSWBorn overseasCross-sectionalOnline Survey552
Harrison, 2016 [36]Sexual healthNSWBorn overseasPilot studySurvey262
Glew, 2015 [37] Nursing studentsNSWBorn overseasProspective studySurvey2669
Poon, 2015 [38]Psychosis VictoriaBorn overseasLongitudinal studySurvey52
Tirlea, 2016 [39]Improve self-esteemVictoriaBorn overseasCluster randomized control trialsSurvey122
Kisely and Xiao, 2018 [40]Mental healthWestern AustraliaBorn outside of Australia, New Zealand or the British IslesCase-controlAdministrative health data5916
Tervonen, 2017 [41]CancerNSWBorn in NESCCohort studyPopulation-based NSW Cancer Registry651,245
Thai, 2017 [42]CancerVictoriaBorn in NESCRetrospective analysisSurvey143
Bhaskar, 2019 [43]StrokeNSWBorn overseasRetrospective study designAdministrative datasets3537
MacLachlan, 2018 [44]Hepatitis bAustraliaBorn overseasCross-sectional studyLinkage data of Census and seroprevalence data237,894
Xiao, 2020 [45]Aged careSouth AustraliaBorn overseasPre-and post-evaluation designSurvey113
Strugnell, 2015 [46]Physical activityVictoriaParticipants or parents were born in NESC Cross-sectional studySurvey, self-reported286
Gibbs, 2015 [47]Dental healthVictoriaBorn overseasExploratory trialSurvey692
Definitions of CALD by LSAH
Kilkenny, 2018 [48]StrokeAustraliaInterpreter required/language barrier -as LSAH other than EnglishObservational StudyAustralian stroke Clinical Registry1461
Bent, 2015 [49]AutismAustraliaLSAH other than EnglishCross-sectional studyAvailable database 15,074
Scott, 2019 [50]ObesityVictoriaLSAH other than EnglishCross-sectional studyData of children participating in Healthy Together Victoria and Childhood Obesity Study2407
Guo, 2019 [51]Discharge against medical advice NSWLSAH other than EnglishCross-sectional studyHospital records 192,948
Hardy, 2018 [52]ObesityNSWLSAH other than EnglishCross-sectional studyPopulation health Survey26,449
Beauchamp, 2020 [53]Breast cancer screeningVictoriaLSAH other than EnglishRandomised controlled trialsSurveyed by Breast Screen Victoria1032
Cullerto, 2016 [54]CancerQueenslandLSAH other than EnglishPilot program/intervention studyCollected via quantitative interviewer-administered questionnaire146
Emerson, 2019 [55]RehabilitationNSWLSAH other than EnglishLongitudinal studyInterview102
Okely, 2017 [56]Physical activityNSWLSAH other than EnglishCluster non-randomized trialSurvey420
Soon, 2018 [57]CancerNSWLSAH other than EnglishCross-sectionalSurvey168
Zhang, 2018 [58]Cardiac rehabilitationNSWLSAH other than EnglishDescriptive, case-matched comparative studySurvey90
Martin, 2016 [59]EducationNSW, Victoria, and Western AustraliaLSAH other than EnglishCross-sectional studySurvey450
Abu-Arab, 2015 [60]Challenges to supervise cald nursing studentsVictoriaLSAH other than EnglishCross-sectional studySurvey19
Barnett, 2015 [61]Physical activityVictoriaLSAH other than EnglishCross-sectional studySurvey261
O’Hara, 2018 [62]CancerVictoriaLSAH other than EnglishCross-sectional studySurvey317
Freyne, 2018 [63]Ehealth allied healthVictoriaLSAH other than EnglishCross-sectional studySurvey45
Arjunan, 2019 [64]Body indexNSWLSAH other than EnglishCross-sectional studySurvey 272
Lim, 2019 [65]CancerNSWLSAH other than English Cross-sectional studyPaper-based questionnaire68
Foster, 2018 [66]Sex industryNSWLSAH is Chinese and ThaiCross-sectional studySelf-completed questionnaire from previous survey435
Cranney, 2018 [67]Chronic diseaseNSWLSAH is Mandarin or CantoneseMixed methodsSurvey (self-administered structured questionnaire)253
Wood, 2015 [68]AsthmaNSWLSAH other than EnglishCross-sectional nested studySurvey144
Definitions of CALD by indigenous status
Mihrshahi, 2017 [69]Eating and physical activityQueenslandIndigenous statusQuantitative uncontrolled pre-post designSurvey375
Adams, 2017 [70]DiabetesVictoriaIndigenous statusMixed-methods study design Survey129
Davison, 2018 [71]StressNorth TerritoryIndigenous peopleCross-sectional studyData from the Life Course Program576
Definitions of CALD by ethnicity/cultural background or CALD status
Dudley, 2015 [72]Physical activityNSWAsian or Middle-Eastern cultural backgrounds, indigenous people excludedProspective cohort studySchool enrolment records658
Wickramasinghe, 2019 [73]Paediatric careNSWCultural backgroundRetrospective auditHospital records279
Eh, 2016 [74]DiabetesNSWCultural background (Chinese background)Cross-sectional studySelf-completed questionnaire139
Masri, 2019 [75]Chronic diseaseNSWEthnicityCross-sectional studyData collected through the 45 and Up Study 41,940
Lennox, 2017 [76] Oral language proficiency QueenslandEthnicityBroader longitudinal studyStudents’ assessment data, Australian Early Development Census104
Lau, 2016 [77]Simulation training VictoriaEthnicityPilot study used mixed methodsSurvey45
Gallegos, 2020 [78]Chronic diseaseQueenslandEthnicitypragmatic evaluation Face-to-face data collection700
Burns, 2018 [79]Iodine deficiencyNSWEthnicityCross-sectional studySurvey97
Gallegos, 2019 [80]Cardiometabolic riskQueenslandEthnicity Cross-sectional studySurvey693
Bloomer, 2019 [81]End-of-life careVictoriaEthnicity and religionRetrospective studyMedical record audit 132
Gallegos, 2019 [82]Physical activityQueenslandEthnicity, time in AustraliaCross-sectionalRoutinely collected clinical information700
Khawaja and Ramirez, 2019 [83]AcculturationAustraliaSelf-defined CALD statusNon-experimentalSurvey229
Wantanabe, 2017 [84]Age careNSWSelf-determined ethnicity.Mixed methodsSurveyed by postal questionnaire82
Hum and Carr, 2018 [85]GamblingVictoriaSelf-reported cultural backgroundCross-sectionalSurvey628
Singh, 2019 [86]Chronic diseaseVictoriaSelf-reported Indian ethnicityCross-sectionalPaper Survey 138
Definitions of CALD by migrant/refugee
Correa-Velez, 2015 [87]Wellbeing of refugeeAustraliaMigrantMixed method, longitudinal analysisSurvey120
Ploot, 2018 [88]PsychologicalAustraliaMigrant Cross-sectional studyOnline Survey1334
Satyen, 2018 [89]Family violenceAustraliaMigrant Cross-sectional studySurvey (self-administered)130
Khawaja, 2018 [90]AcculturationQueenslandMigrant and refugeeCross-sectional studyA part of a larger study 237
Specker, 2018 [91]Post-traumatic stress disorderAustraliaRefugee or asylum-seeker backgroundCross-sectional studyOnline questionnaire246
Definitions of CALD by combining two or more components
Waller, 2020 [92]Organ donorsNSWBorn overseas/non-English speakingCohort studyLinkage data using available databases2977
Eapen, 2017 [93]Child developmentNSWBorn overseas/non-English speakingLongitudinal birth cohort studyRoutinely clinical data collection 1763
Rowe, 2017 [94]Injecting drug useNSWBorn outside Australia/non-English speaking, self-defined cultural backgroundCross-sectionalSurvey560
Basu, 2019 [95]Mental healthVictoriaBorn overseas/parents were born overseas/from a non-English-speaking or Aboriginal backgroundRetrospective studySurvey101
Cyril, 2017 [96]ObesityVictoriaBorn overseas, spoke a language other than English at homeCross-sectional studySurvey39
Krishnaswamy, 2018 [97]Antenatal vaccinationVictoriaBorn overseas, first language was not EnglishCross-sectional studySurvey537
Martin, 2019 [98]Cultural identificationAustraliaCOB and cultural backgrounds/ethnicityQuantitative studiesSurvey133
Gemert, 2016 [99]Hepatitis b testVictoriaCOB and ethnicity, indigenous peoplesNon-randomised, pre-post pilot studyClinic electronic health records33,297
Rowe, 2020 [100]Drug, alcohol; tobaccoAustraliaCOB and/or languageCross-sectional studyThe 2013 National Drug Strategy Household Survey22,696
Moss, 2019 [101]Mental illnessQueenslandBorn in non-English speaking countries, interpreter required; Cross-sectional studythe Transitions of Care and the Patient Integrated Mental Health Application976
Mozooni, 2020 [102]Stillbirth Western AustraliaBorn overseas/ethnicity (indigenous births excluded)Retrospective cohort studyLinked administrative health data260,997
Nicholson, 2016 [103]Early home learningVictoriaBorn overseas/LSAH other than EnglishCluster randomised controlled trialSurvey1200
Jessup, 2017 [104]Health literacyVictoriaBorn in NESC, LSAH other than EnglishCross-sectional studySelf-reported written Survey384
Mander and Miller, 2016 [105]Maternity careQueenslandBorn in NESC, LSAH other than EnglishCross-sectional studyAvailable data from Having a baby in Queensland Survey4704
Brady, 2018 [106]Chronic diseaseNSWBorn in NESC, LSAH, interpreter required, self-identified ethnoculturalPilot randomised controlled trial.Survey48
Blay, 2018 [107] Interpreter utilisationNSWBorn in NESC, LSAH other than EnglishRetrospective analysisHealth administrative data19,627
Ghayour-Minaie, 2019 [108]Substance useVictoriaBorn overseas/LSAH is not EnglishCross-sectional studyObtained as part of the large-scale “Resilient Families Research Initiative” 2080
Attrill, 2017 [109]Speech–language pathologySouth AustraliaBorn overseas/LSAH is not EnglishCross-sectional studySurvey854
Kisely, 2020 [110]Community treatment ordersQueenslandBorn outside of Australia, NZ, UK, Ireland, and North America, or preferred language is not English/indigenous Cases and controls Linked administrative health data7432
Zhou, 2016 [111]DisabilityAustraliaBorn overseas/LSAH is not EnglishCross-sectional studyTwo ABS collections of data 312,539
Ogbo, 2016 [112]BreastfeedingNSWCOB, LSAH, ethnic, dress, traditions, foodRetrospective clinical auditRoutinely collected perinatal data17,564
Ogbo, 2018 [113]Antennal depressionNSWCOB, LSAH, ethnic, dress, traditions, foodRetrospective clinical auditRoutinely collected perinatal data17,564
Hwang, 2018 [114]CancerNSWCOB, LSAH, interpreter requiredRetrospective studyClinical Cancer Registry1215
James-McAlphine, 2020 [115]Nutrition and birth outcomesQueenslandEthnicity and/or COB or indigenous AustralianCross-sectional studySelf-reported Survey431
Kwan, 2019 [116]Depression in dialysis patientsNSWLSAH and aboriginal backgroundCross-sectional studySurvey110
Kippin, 2018 [117]Young offenderWestern AustraliaLSAH/indigenous statusCross-sectional studySelf-reported Survey98
Shepherd, 2018 [118]Young offenderVictoriaSelf-identified (1) CALD = non-Australian cultural background/ (2) indigenous status/ (3) English speaking backgroundCross-sectional studyFace to face interview212
Shepherd, 2015 [119]Re-offendingVictoriaSelf-identified (1) CALD = non-Australian cultural background/ (2) indigenous status/ (3) English-speaking backgroundCross-sectional studyFace to face interview207
Chan, 2018 [120]Hiv/aidsNSWSelf-reported overseas born/LSAH is not English, length of stay if born overseas/indigenous statusRetrospective, non-consecutive auditPatientregistration data264
Porter, 2016 [121]Cultural group of pregnant womenNSWTwo different definitions, including self-reported COB and CALD/ethnicity, were comparedCross-sectional studySurvey762
Petrov, 2017 [122]Nursing homeVictoriaBorn in NESC and/or have a preferred language other than EnglishCross-sectional studyAIHW National Aged Care Data Clearinghouse44,925
Table
Table 2. CALD definitions used in the selected studies.
Table 2. CALD definitions used in the selected studies.
Definitions of CALDn%
Country of birth (COB)3330.6
Language spoken at home (LSAH) 2119.4
Indigenous status 32.8
Ethnicity/cultural/self-defined CALD background 1513.9
Migrants and refugees 54.6
Combination of two or more definitions3128.7
The minimum core set of CALD definition *00.0
Total108100.0
* The combination of four variables in the minimum core set (COB, LSAH, indigenous status, and English proficiency) to measure the CALD status of study participants in data collection.
Table
Table 3. CALD definitions by data sources.
Table 3. CALD definitions by data sources.
Definitions of CALDAdministrative/Available DataSelf-Collected Data
n%n%
Country of Birth (COB)1834.61526.8
Language spoken at home (LSAH) other than English815.41323.2
Indigenous status11.923.6
Ethnicity/cultural/CALD background 611.5916.1
Migrants and refugees 00.058.9
Combination of two above or more1936.51221.4
Total52100.056100.0
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Pham, T.T.L.; Berecki-Gisolf, J.; Clapperton, A.; O’Brien, K.S.; Liu, S.; Gibson, K. Definitions of Culturally and Linguistically Diverse (CALD): A Literature Review of Epidemiological Research in Australia. Int. J. Environ. Res. Public Health 2021, 18, 737. https://doi.org/10.3390/ijerph18020737

AMA Style

Pham TTL, Berecki-Gisolf J, Clapperton A, O’Brien KS, Liu S, Gibson K. Definitions of Culturally and Linguistically Diverse (CALD): A Literature Review of Epidemiological Research in Australia. International Journal of Environmental Research and Public Health. 2021; 18(2):737. https://doi.org/10.3390/ijerph18020737

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Pham, Thi Thu Le, Janneke Berecki-Gisolf, Angela Clapperton, Kerry S. O’Brien, Sara Liu, and Katharine Gibson. 2021. "Definitions of Culturally and Linguistically Diverse (CALD): A Literature Review of Epidemiological Research in Australia" International Journal of Environmental Research and Public Health 18, no. 2: 737. https://doi.org/10.3390/ijerph18020737

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