A scoping review of barriers to accessing aged care services for older adults from culturally and linguistically diverse communities in Australia

Abstract

The ageing population of the culturally and linguistically diverse (CALD) population is increasing in Australia. This is because the number of early migrants in Australia is ageing, coupled with increasing family reunification. This scoping review aimed to describe the nature and extent of research on the barriers to aged care services for CALD older adults in Australia using Penchansky and Thomas’s Access to Care Framework of five A's dimensions: availability, accessibility, accommodation, affordability, and acceptability. Arksey and O’Malley’s five-step scoping review framework was adopted to search 6 databases from inception till August 2024. Title/abstract and full-text screening were conducted using predefined inclusion and exclusion criteria, with supplementary search of references from included articles to identify additional articles. Findings show that while all the five A's of access to care services were barriers for CALD older adults, accommodation and acceptability of services were the major areas of concern due to the lack of cultural sensitivity of such services in Australia. An additional barrier captured and termed as Awareness was noted in some of the included studies, highlighting the need to expand the five A's to 6 A’s. Researchers, practitioners, and policymakers on ageing could leverage these findings to improve cultural practice sensitivities when supporting these populations.

Background

Culturally and Linguistically Diverse [CALD] people, defined as persons born overseas, have a parent born overseas and speak a variety of languages, are increasing in Australia [10]. Australian Bureau of Statistics [ABS] [5] reported that CALD constitutes about 49% of the Australian population; this is expected to increase because of ongoing immigration trends and Australia's commitment to multiculturalism [6]. Older adults, defined as individuals aged 65 years and older constitute 37% of the entire CALD population [12]. This percentage is expected to increase as immigration policies facilitate parents and grandparents migrating to Australia  [61] bringing to the fore emerging health and social care needs of older adults from CALD communities [13]. This warrants the need to explore the access and barriers to formal aged care services for CALD older adults in Australia. Aged care services, sometimes referred to as care services, is a formal arrangement that encompasses a variety of support services for older people including home support, respite home, and residential facility services, and are provided at a subsidized rate for citizens and permanent residents by the Australian Government [21, 68].

Older migrant adults, referred to as the CALD people in Australia, require greater access to formal care services due to their susceptibility to poor health conditions [37, 87]. The demand for formal aged care services, such as residential aged care facilities, home support care, and respite care, is on the rise in many Western countries, including Australia. This heightened demand can be attributed to the increasingly busy schedules of family and friend carers [54, 58, 62]. These individuals often find themselves balancing their professional responsibilities, careers, and other familial duties, ultimately constrained in their capacity to provide comprehensive care to their older relatives [47]. Consequently, over the past decade, an increase in the availability and utilization of formal aged-care services has been observed in these nations [77].

The ageing CALD population in Australia has unique care needs and experiences, arising from their cultural beliefs and values, which differ from other English-speaking and Anglo-Saxon cultures. A 2021 Royal Commission Australian report acknowledged that accessing care services for CALD older adults presents numerous challenges which are ingrained in social and cultural differences, and non-culturally sensitive care provision [67]. These social and cultural differences are rooted firmly in the concepts of reciprocity and filial obligation, where older parents expect their children to support and care for them under one roof [44,45,46]. Reports have also shown that formal aged care services are not culturally accepted among most collectivist CALD communities due to the lack of a culturally sensitive care system and structure [12, 67].

Different health and social care professional bodies in Australia have emphasized the invaluable need for a culturally responsive practice that caters to the needs of all individuals [4, 43], in alignment with the National standard of inclusivity and equity [8, 14, 21, 75]. The Royal Commission into Aged Care recommends a fundamental shift in Australian aged care to make services more culturally sensitive and accessible for all, particularly for the CALD community [67]. Other literature has also established the importance of access to care services for the general older adult’s health and wellbeing [15], particularly for those from CALD backgrounds [29].

Access to equitable health and social care (aged care) services is a fundamental human right [86]. Access has been conceptualized as unrestricted navigation of service use [55, 64]. Many factors, including the lack of awareness of available services, and language and cultural barriers can negatively affect access to formal care services among CALD older adults [70]. Penchansky & Thomas’s [64] five A's Access to Care framework: accessibility, affordability, availability, accommodation, and acceptance, provides a comprehensive model for understanding and evaluating access to health and social care services. According to Penchansky and Thomas, the definitions of the 5 A’s are as follows: Accessibility- defined as a set of specific dimensions that reflect the fit between care recipients (CALD older adults) and care providers’ (carers) characteristics and expectations [70]. Geographically, it also reflects the ease with which clients can physically access the provider's location,affordability refers to the cost of services compared to the client's capacity and willingness to pay; availability refers to the demand and supply of services; accommodation refers to the degree to which the service agency’s operations are structured to cater to the client's needs and preferences; and acceptance measures how clients perceive the service they seek or receive, either objectively or subjectively. Scholars argue that for a service to be truly accessible, all five A's need to be considered simultaneously [60, 64]. For example, providing culturally appropriate care for a citizen who is unable to travel to the location to receive it is not considered an efficient and effective way of providing social care. For a service to be truly accessible, aspects such as accommodation, acceptance, affordability, availability, and geographical access need to be adequately addressed. Although this framework is important and has been widely used, studies utilising this framework to investigate the access to care services in Western countries, including Australia especially among minoritised older adults are limited.

Research on access to care for culturally and linguistically diverse (CALD) families in Australia has primarily focused on children [71,72,73] and the middle-aged population [65]. However, there is a notable gap in understanding the experiences of older CALD individuals in accessing aged care services. The ageing process introduces additional barriers, including age-related health conditions, mobility issues, and differing cultural perceptions of ageing and care needs. Therefore, it is imperative to conduct a review specifically addressing the barriers experienced by CALD older adults, in accessing aged care services. A scoping review utilizing the Penchasky and Thomas’s five A's Care Framework is recommended to gain a comprehensive understanding of the barriers faced by CALD older adults when accessing aged care services. This approach will help identify frequently reported barriers and could guide future systematic reviews to inform policy and practice [3].

This scoping review therefore aims to answer the following research questions: (1) What are the gaps in the existing literature on caregiving for older adults from the CALD communities in Australia? (2) What are the barriers faced by CALD older adults in accessing aged care services in Australia? Identifying gaps will contribute to finding what support is needed and where the risk of inaccessibility is exacerbated for CALD older adults. The findings from this review will potentially help achieve objective 2 of the National Ageing and Aged Care Strategy for People from CALD Backgrounds: “Achieve a level of knowledge, systems capacity, and confidence for older people from CALD backgrounds, their families, and carers to exercise informed choice in aged care” and objective 5: “Enhance the CALD sector’s capacity to provide ageing and aged care services” [11]. These will potentially improve the access and quality of services for CALD older Australians and the findings will potentially inform policymakers and researchers on key focus areas limiting equitable access to aged care services.

Methods

Arksey and O'Malley's [3] scoping review framework was utilized for this review due to its methodological rigor and transparency. The methodological processes developed by Arksey and O'Malley are: 1) identifying the research question(s); 2) identifying relevant studies; 3) study selection- based on inclusion and exclusion criteria; 4) charting the data, and 5) collating and summarizing findings and reporting the result.

Stage 1 – identifying the research question

The research questions guiding the scope of the review are: (1) What are the gaps in the existing literature on caregiving for older adults from the CALD communities in Australia? and (2) What are the barriers faced by CALD older adults in accessing aged care services in Australia?

Stage 2 – identifying relevant studies

This study identified peer-reviewed empirical studies (qualitative & quantitative) and grey literature including reports, a submission, and a thesis for the analysis. In consultation with a social sciences librarian in our university, search terms and strategies were developed and conducted in six databases: CINAHL, Web of Science, PsycINFO, PUBMED, Embase, and Family and Society Worldwide. This consultation with our university librarian who is a search expert, ensured that the search strategy and databases searched align with the objective and scope of the study [3]. The librarian offered training and expert advice for the scoping review search. Articles from fields relevant to this review including social work, psychology, nursing, and psychiatry were covered in these databases. The search strategy identified peer-reviewed articles without year limitation (from inception till August 2024). The following search key concepts and associated synonyms were applied in the database search: caregiving, older adults, culturally and linguistically diverse, and Australia (see Table 1 for key terms and MeSH terms). The symbol * was used in all database searches, allowing the inclusion of varied word endings. For grey literature, relevant organisational websites in Australia including the Australian Institute of Health and Welfare, Home Affairs, Carers Australia, National Ageing Research Institute (NARI), Aged Care Royal Commission Australia, Council on the Ageing (COTA) Victoria, Centre of Excellence in Population Ageing Research (CEPAR), and University of New South Wales Ageing Futures Institutes were also searched to ensure comprehensive coverage.

Table 1 Key terms and MeSH terms

Stage 3 – study selection

Citations from the databases were exported into Rayyan QCRI [63]. After the removal of duplicates, screening was conducted in two stages. Firstly, the first author conducted title and abstract screening of the identified articles and discrepancies were checked with the second and third authors. Secondly, the full text of the screened articles was assessed by the first author for eligibility, using the inclusion and exclusion criteria in Table 2. Discrepancies were again checked with the second and third authors against the inclusion/exclusion criteria. Finally, the first author conducted a hand search of references and citation chaining of the included articles to identify relevant research articles that may have been missed. The second and third authors independently verified the included articles for relevance to the aims of the review and the two research questions. Disagreements on including any articles were discussed and resolved during research meetings.

Table 2 Inclusion and exclusion criteria

Stage 4—charting the data

The authors conducted a pilot test using 3 articles from those included. Data from the included articles were extracted by the first author using a standardized data extraction Ms Excel sheet used in a previous review study [51]. The second and third authors independently reviewed and confirmed the extraction. Study characteristics such as year of publication, study methodology, location, population, and ethnicity of CALD groups were extracted to answer research question 1. In addition, study findings or discussions on barriers to accessing aged care services were extracted to answer research question 2.

Stage 5—collating and summarizing findings and reporting the result

For the analysis of the extracted data, the researchers adopted an apriori "best-fit" framework synthesising- Penchasky and Thomas’s [64] framework for access to care services. This approach allowed the researchers to map findings across the five A's of access to care: availability, accessibility, affordability, accommodation, and acceptability [64]. The authors chose this framework to map the existing literature due to its alignment with the specific objective of the study, and the research questions. Specifically, the Penchansky and Thomas’s [64] framework offers a comprehensive view of access. For instance, the Penchansky and Colleagues framework examines access from a structural (availability, accessibility, and accommodation), sociocultural (acceptability), and financial (affordability) dimension. The authors read and re-read the included articles before mapping them across the framework, noting articles that did not apply. Some issues which were not covered by Penchansky and Thomas’s access framework emerged and were mapped to a new possible dimension—awareness. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used as reporting guidelines for this scoping review [81]. Since this review was a scoping review, the use of a critical appraisal tool and ethics approval was not recommended [3].

Result

The database search retrieved 5,168 articles, and 593 duplicates were removed, resulting in 4,575 articles for title and abstract screening. 4,472 were excluded leaving 103 articles which were sought, retrieved, and assessed for full-text screening. After the full-text screening, 95 articles were excluded for various reasons (see inclusion and exclusion criteria in Table 2) and eight articles were included from the database search. For the hand search of references and citation chaining, 33 records were identified and assessed for eligibility. 14 articles were included in the final analysis using other search methods. A total of 22 articles (8 from databases and 14 from other search methods) were included in this review (see Fig. 1 for a flow chart diagram of the study selection process).

Fig. 1

PRISMA Flowchart of study selection process. From: Haddaway et al. [33]. Visit app at: https://estech.shinyapps.io/prisma_flowdiagram/

Description of included studies

The 22 articles included are presented in Table 3. Of these included articles, 17 were focussed on states or regions (location) such as Sydney (n = 5, 22.7%), Melbourne (n = 4, 18.2%), South Australia/Adelaide (n = 4, 18.2%), Perth (n = 3, 13.6%) and Queensland (n = 1, 4.5%). One (n = 4.5%) was focused on a combination of states (Melbourne, Sydney, and Perth). The remaining articles (n = 4, 18.1%) focused on general Australia [7, 9, 11, 67]. Study methodology/type included qualitative studies (n = 12, 54.6%), quantitative studies (n = 3,13.6%), and others are reports (n = 6, 27.3%) and a submission (n = 1, 4.5%). All the included articles focussed on either CALD older adults (n = 10, 45.5%), their carers (n = 8, 36.4%), or both (n = 4, 18.2%) [24, 59, 67, 88].

Table 3 Overview of included studies

Most (n = 16, 73.0%) articles were focused on CALD populations from a wide range of backgrounds or country groups in a single study. Others focused on specific CALD populations [1, 16, 24, 25, 39] and a binary of CALD population [69]. Six articles specifically recruited carers of older adults living with dementia [16, 17, 24, 69, 76, 89]. Five studies recruited participants from Residential Aged care facilities (Institutions) [16, 59, 88, 90, 91]. Eight studies recruited participants from the community [1, 18, 24, 25, 39, 49, 76, 89]. One study recruited individuals from both institutions and communities [69]. For others, one recruited from the community and online, while (n = 6) did not report participant recruitment. See Table 4 for a summary of the included studies’ characteristics.

Table 4 Summary of included study characteristics

Mapping the identified barriers across Penchasky and Thomas’s framework

The researchers mapped the existing articles across Penchasky and Thomas’s [64] five A's framework to ascertain the domains of barriers to accessing aged care services among CALD people in Australia. Studies were mapped to availability (n = 2), accessibility (n = 7), affordability (n = 6), accommodation (n = 19), and acceptance barriers (n = 20). Although not part of the five A's framework, emerging issues revealed a theme of awareness which was incorporated into the mapping process (awareness n = 16). See Table 5 for mapping and Fig. 2 for chart representation of findings domain.

Table 5 Mapping the barriers to accessing care services for CALD older adults in Australia

Fig. 2

Bar chart representation of the frequency of barriers

Availability (n = 2)

Two articles captured the availability barrier. Adebayo et al.'s [1] qualitative study on oral care for African CALD older adults in residential care homes highlighted the absence of structures, including human and material resources, low staffing, poor staff development, and poor funding as barriers to adequate oral/ dental care for institutionalized older adults. Similarly, the Royal Commission [67] report shows that respite aged care services are often short in supply, especially in rural and regional areas.

Accessibility (n = 7)

Seven articles reported physical access, longer waiting periods, and distance to locate services as barriers, especially for persons living in rural localities or with a disability [18, 25, 31, 67, 90]. Of the seven articles, two highlighted that persons with a disability have limited access to the uptake of services, mainly due to physical (distance), structural (service delivery barriers), and mobility restrictions/barriers [18, 31]. One governmental report [11] shows that older adults residing in rural areas have difficulty accessing aged care services because they live far away from the service areas, highlighting severe accessibility issues due to the distance to services and the remoteness of the area. Another governmental report shows that older people who wished to be enrolled in aged care homes were kept on a waiting list for a long time, and this constitutes a significant barrier to accessing aged care services on time [67]. Studies with specific cultural backgrounds such as Chinese [39] and Greek Italians [25] further identified transportation as a major barrier to accessing aged care services [25, 39]. Lastly, a study on diverse cultural groups added that the long distance to nursing homes or care facilities discourages them from accessing aged care services [90].

Affordability (n = 6)

Six articles identified affordability barriers. Two studies on Chinese and Italian populations identified a ‘high cost of services’ that is not affordable nor adequately subsidized by the government [16, 39]. The remaining three reports of diverse groups highlighted poor financial status leading to the inability to make out-of-pocket payments for direct care services [18, 30, 31]. Notably, Cardona et al. [18] highlighted that CALD population who migrated at old age have no pension funds to pay for or access subsidised aged care services. Lastly, a governmental report captures that financing residential aged care accommodation is costly in Australia, and this poses a huge cost burden on older adults and their families [67].

Accommodation (n = 19)

Nineteen articles of specific and general CALD populations identified accommodation barriers [7, 16,17,18, 27, 30, 31, 39, 59, 76, 89, 9, 11, 24, 25, 49, 67, 69, 88, 91]. These studies rated the level of satisfaction in care homes and formal service use as ‘unsatisfactory’ for different reasons categorised inductively in four pillars of accommodation: (a) communication-related reasons including language, and/or lack of interpreter services (n = 16); (b) culture-related reasons including culturally inappropriate services and ethno-specific needs (n = 7); (c) carers-related reasons including negative attitude (n = 4); and (d) agencies-related reasons such as mode of operation including quality of care, regulations and compliance (n = 4).

Communication, language, and/or lack of interpreter services: The majority of the articles (n = 16) identified communication, language, and/or lack of interpreter services [7, 9, 11, 16, 24, 25, 27, 30, 31, 39, 59, 69, 76, 88, 89, 91]. These articles show that CALD adults do not access aged care services due to differences in language and a lack of carers’ understanding of older adults’ needs (physical, social, and emotional) due to language barrier.

Culturally inappropriate services and ethno-specific needs: Seven articles identified other culturally inappropriate services in care homes concerning food, music, entertainment, and festivals [24, 30, 76, 69, 88, 91]. The articles highlighted that older adults were familiar with their homes and would only consider formal care such as aged care facilities if they were created to have the same features as their homes and communities. These features include providing culture-specific food, culture-specific music, and culture-specific festivals in care homes and general aged care arrangements. These however were reported to be lacking in care homes and aged care arrangements and limited the accessibility and utilisation of aged care arrangements including relocation to long-term care placement. While their request for culture-specific food was considered in some aged care homes in Australia, it often did not meet CALD older peoples’ expectations [88].

Carers’ negative attitude: Four articles describe the negative attitudes of formal carers (professional paid carers such as aged care staff) towards giving care to older adults [7, 31, 59]. These negative attitudes include the absence of honesty and tolerance and the presence of neglect and discrimination or racism among carers to CALD older adults. For instance, the Australian government reports stated that paternalistic attitudes, racism, and cultural stereotyping by aged care service providers as barriers to the utilisation of services among CALD families [7, 31].

Agency-related reasons: Four studies describe ‘the agency’s poor mode of operation’ including quality of care, regulations, and compliance [39, 59, 76], as barriers. This agency-related accommodation barrier hinders the access to and use of aged care services in Australia.

Acceptability (n = 20)

Twenty articles identified acceptability issues [1, 7, 9, 11, 16,17,18, 24, 25, 27, 30, 31, 39, 49, 59, 67, 76, 89, 90, 91]. These articles were categorised into (a) Cultural values and beliefs (n = 19), (b) Older adults’ attitudes (n = 6), and (c) Health beliefs (n = 4).

Cultural values and beliefs: Nineteen articles describe that cultural beliefs of family care, filial piety, and care reciprocity are major acceptability issues influencing whether CALD older adults will accept, access, or reject aged care services. Some of the reports concluded that older adults are reluctant to use aged care placements or services due to familial loyalty, cultural expectations, community pressures, and the resultant shame and stigma [17, 31, 59].

Older adults’ attitudes: Among the articles that describe acceptability issues, six (n = 6) describe older adults’ attitudes [1, 7, 18, 39, 89, 90]. These articles highlighted the negative attitudes of older adults towards using care homes or formal aged care services as being barriers to their acceptance and access to services. Some of the reports also pointed out attitudinal barriers of older adults such as feeling awkward about asking for or receiving help, outright refusal of care provided by formal carers, and feeling of self-sufficiency (confidence in caring for self) [1, 39].

Health beliefs: Four articles identify 'health beliefs' influencing the acceptability and access to aged care services [7, 76]. These studies showed that CALD families weighed their perceived health needs and their severity, to make decisions about the use of aged care services or placement.

An article indicated that there are more care placement admissions among the advanced aged, those living with disability, and those in their last year of life [11]. Overall, these factors discussed above negatively influence CALD families' decision to accept aged care services as they perceive their older adults may not need formal care.

Unanticipated finding

Awareness (n = 16)

Sixteen articles mentioned a lack of awareness of services and programs by CALD older adults and family carers. This factor limits care service utilisation among the population in Australia [11, 16, 18, 24, 25, 27, 31, 30, 39, 49, 59, 67, 76, 89, 90, 91]. They also highlighted that CALD family carers are unfamiliar with the concept of formal services, and they lack information about services and available financial support [59, 76]. Summarizing findings from the 16 articles, one of the reports quoted: "The lack of awareness of available support services can lead to under-utilisation by older people from CALD background" [30]. Finally, a study specifically identified a need for improved information about related services to mitigate awareness barriers to aged care services [90].

Discussion

This review mapped the existing literature on the barriers to accessing aged care services for CALD population, using the Penchasky and Thomas’s [64] five A's model of access to care framework: availability, accessibility, affordability, accommodation, and acceptance. From the analysis of the included literature, it is evident that the available studies largely concentrated on some selected regions, leaving a gap in the representation of other states and regions such as Queensland and remote areas. Results also show limitations arising from the nature of study methodology in the literature reviewed, as the majority are qualitative studies and organisational reports. These findings show the need for more quantitative studies for statistical validation. It also points to the need for caution in generalising the findings among a larger population group and region in Australia. The results also show that the majority of the studies and reports focused on a combination of diverse ethnic groups within CALD communities, however specific CALD groups were less frequently investigated in a single study. Future studies should focus on specific individual CALD community to provide a tailored understanding of their specific needs and interventions. Only a small number of studies addressed carers of older adults with dementia. Due to the increasing prevalence of dementia among older adults, this calls for more caregiving and aged care research focusing on older adults with dementia to explore their unique needs and care challenges. While the review aimed to map the literature across the five A's of access by Penchansky and Thomas’s [64] framework, a new dimension, ‘awareness' emerged, providing additional ‘A' to the existing framework, thus modifying it into a 6 ‘A’ framework discussed in the next paragraph. This finding of an expanded 6A of access is supported by Saurman [70] who advocated for an additional A (awareness) to Penchasky and Thomas Access framework.

Availability of services is crucial in the discussion of aged care access. Findings from this review show that aged care services are mostly available for CALD older adults in Australia. Previous literature in Australia among the general older adult population including, a review [83] and a retrospective cohort study [42] also positively reported the availability of aged care services. From the findings, only two articles reported unavailability and barriers to services [1, 67]. Although findings show that general aged care services are available, there are barriers to accessing specific types of aged care services (oral care provision) for older adults in residential aged care facilities. The difference in these findings could be because Adebayo’s study focused on the availability of a specific aged care service, (oral health care) rather than the general aged care services. Also, the Royal Commission could have reported an availability barrier due to the specificity of the findings being in the rural and remote areas.

The findings of this review show that physical access (structures), long distance to services, and disability-related issues act as barriers to accessing aged care services for some CALD older adults. Previous studies in Australia have reported distance and disability as common factors limiting access to services for the general population and, particularly for older adults [23, 41, 83]. For instance, Temple et al. [78] found that older adults living with a disability in Australia had a threefold decrease in the odds of accessing care services, indicating a prevailing barrier. CALD older adults may be more susceptible to this barrier given their intersectionality of migration, cultural and socioeconomic status. For instance, a census-based study in Australia pointed out that the CALD population is less likely to reside in urban locations due to their socioeconomic status [84], plausibly van Gaans and Dent [83] concluded that such distance to services areas and the time spent travelling could adversely affect CALD older adults’ access to services. Other studies globally and in Australia have also reported distance barrier to care services for older adults in the general healthcare system [23, 28, 32]. This finding underscores the importance of addressing geographical (distance) and structural accessibility to improve access to aged care services in Australia. Illustratively, programs should be implemented to ensure aged care services are not more than a 3-km radius apart [26]. There should also be a specific focus on metropolitan areas with high numbers of CALD population, and rural areas where CALD older adults often reside, and where there are higher rates of hospitalization, injury, and deaths [6]. Further, intensifying telehealth use, particularly for CALD older adults with a disability can help remove barriers to accessing aged care services. Telehealth can promote ongoing monitoring, support, and adjustment of care plans by the care manager and the older adults who are not able to attend physical consultations with the aged care manager [53, 80]. Such regular check-ins can help manage and facilitate emergency response to support needs.

Affordability, the relationship between the cost of services and the client’s ability to pay, is essential to service use. Although the Australian government continues to fund and subsidise aged care services, there continue to be affordability issues among CALD older adults, as this present review found that CALD older adults are unable to pay the out-of-pocket cost associated with accessing care services. This finding is consistent with the finding of a scoping review that the out-of-pocket costs of services was not covered by universal health coverage in Canada [82]. This may hinder access to adequate or special care, such as emergency care services and counselling services among immigrants [82]. Furthermore, previous evidence showed that younger and older Australians [92] and older adults in the United States skipped or postponed their health and care service needs due to out-of-pocket payments [48]. While only a few articles in this review reporting affordability barriers, it remains critical for policy and programs to leverage findings on the cost of services, and the client’s ability and willingness to pay, in policy decision-making. This will alongside other measures improve access to aged care services for CALD older adults who may be faced with socio-economic barriers and or their unwillingness to pay the cost of services. With the projected increased budget by the Australian government to allow for more access to services for the older adult population in the future [20], there is a possibility that the affordability issues among CALD could receive more attention and be addressed more adequately.

Accommodation , described as a means of service delivery to suit the client’s needs and satisfaction, is one of the requirements for accrediting aged care agencies in Australia [2]. Findings from this review show that accommodation is a more frequent barrier to accessing aged care services for CALD older adults in Australia. ‘Accommodation’ was marked with cultural differences, values, and expectations of care needs that are depicted in communication, language, interpreter services, food, music, entertainment, festivals, negative attitudes of carers, and poor social support. Although most of these articles focus on aged care institutional placements, the result may reflect the general situation across the spectrum of formal aged care including home support care. Therefore, it is plausible that addressing some of these barriers, such as facilitating access to language interpreting services and providing formal carers with education on understanding the cultural nuances surrounding care provision for older adults from culturally and linguistically diverse backgrounds, could enhance access and utilization. Among these factors, this review shows that communication, language, and the absence of specific interpreting services are the most frequent accommodation barriers impacting access to services for CALD older adults. Findings of previous studies show that limited English proficiency was the biggest barrier faced by CALD older adults in accessing aged care services [34, 35].

The result also shows the lack of satisfaction with care services, given the cultural inappropriateness of services to meet ethno-specific needs. Language and communication among culture-specific accommodation issues are specific to the CALD population [69, 76, 88, 91]. CALD older adults in Australia have reported a lack of satisfaction with care services, consistent with studies in England [19, 52, 56, 57, 83]. According to Hughes [40], this lack of satisfaction of care by CALD older adults in Australia could be partly because of the heterogeneity of the CALD community making it difficult to design an appropriate culture-specific model to accommodate all cultures. Notwithstanding, scholars continued to call for a framework that will be culturally sensitive to accommodate people of diverse cultures as this will improve access for older people [69, 91], 67]. Policy and programs should focus on the priority areas of the CALD cultural values such as respect, family inclusion, language and communication to food, music, and cultural festivals, and a sense of home away from home [36].

Across health and social care research, acceptability has been increasingly acknowledged as a crucial element for developing and accessing care interventions [74]. However, findings from this review show that acceptability is a major issue in accessing care services among CALD older adults in Australia. Acceptability, with roots in cultural differences and the attitudes of older adults towards care, could adversely affect care utilisation and access for CALD older adults. Findings from this review show that personal attitudes including feeling awkward about asking for or receiving help, outright refusal of care from formal carers, and the feeling of self-sufficiency, have adversely affected care acceptance. Some of these attitudes stem from the feeling of worthlessness being cared for by formal carers. Acceptability is influenced by the health beliefs of CALD older adults which is not surprising as it aligns with the Health Belief Model [66]. Health Belief Model hypothesised that CALD older adults would accept care based on perceived or ascertained health risks and benefits including deteriorating health or the inability to provide/receive the required help at home [11, 39]. In line with the health belief model, we recommend educational programs and community outreach initiatives aimed at educating the CALD community and older adults specifically on the potential benefits of accessing and utilising formal aged care services, as well as the risks involved in declining such services.

Awareness emerged as an additional A in the five A's of Penchasky and Thomas [64]. Saurman [70] has suggested the addition of awareness as a component of barriers to access framework and defined awareness as knowing about service existence and acting to access the service. Our findings support this assertion of 6A, highlighting the contribution of awareness in care access among CALD communities in Australia. Several reviews have reported the importance of awareness of health and social services as an eye opener for immigrants to access mental health services in the USA [22] and Canada [79], immigrant women in Canada to access maternity care services [38] or health care services [50, 82], or undocumented migrants to access health care services in Europe [85]. Findings of this study therefore reiterate the need for awareness to be considered in investigating and implementing policies and interventions aimed at improving access to aged care services for CALD older adults in Australia.

Strengths and limitations

Although this review is the first to map the literature on barriers to accessing aged care and services in Australia using the Penchasky and Thomas’s [64] five A's framework, there are limitations to report. Despite efforts to include a comprehensive range of databases and grey literature, there is a possibility of missing some relevant articles not indexed in the databases or identified through the search terms. Although the lack of application of critical appraisal tools aligns with the scoping review methodology, it means studies of varying methodological quality could have been included, affecting the robustness of the findings. Although only one author conducted the initial screening, multiple steps were taken by the authors to ensure rigor and reliability, including the final inclusion of the articles, data piloting, and cross-verification. These possible limitations notwithstanding, the review provides viable information for Australian stakeholders of older adult care and would potentially inform future research, policy, and practice considerations in Australia.

Conclusion

This review set out to describe the barriers to accessing aged care services for older adults from CALD community in Australia. Findings show substantial barriers in all five A's of access to care service domain in the Penchansky and Thomas’s [64] Access framework. The review also reiterates the need for awareness to be considered in investigating and implementing policies and interventions aimed at improving access to aged care services for CALD older adults. The six A’s access to care framework might be a better approach to addressing Australia’s aged care services for older CALD people. Future studies should focus on exploring specific differences in care needs among specific CALD communities, especially those populations that have received less attention in Australian research.