Views and Experiences of Drug and Alcohol Services by Individuals From Migrant,Non-English-Speaking Backgrounds and of Their Service Providers in South Western Sydney,Australia

Abstract

People from migrant, non-English-speaking backgrounds face a variety of challenges when settling in Australia. Although evidence suggests that alcohol and other drug (AOD) use among this group is lower than among the general population, individuals from these communities are at increased risk of mental health issues and racial discrimination, which are known risk factors for increased use of alcohol and other drugs. This study aimed to address current gaps in the literature by using a qualitative methodology to explore the lived experiences of AOD clients who are from migrant, non-English-speaking backgrounds in terms of access to and utilization of AOD services. Eighteen AOD service users and ten service providers (i.e., health clinicians) were interviewed for the study. In this article, we present stories that, collectively, represent the group of AOD service users and their experiences of AOD services as individuals from “culturally and linguistically diverse” backgrounds. We complement those stories with the views provided by health professionals who work providing AOD services. We present these stories organized into three main themes: intersectionality of vulnerabilities, risky environments, and institutional stigma. The stories are interweaved with our theoretical analysis of the material collected through the interviews using a structural vulnerability lens. We conclude that using “culture” as a marker to determine the quality and provision of services or to somehow specialize delivery can be problematic if there is little acknowledgement of the forces that are at play to homogenize health and healthcare provision.

Introduction

Australia is one of the most culturally and linguistically diverse countries in the world, with close to one third (30.7%) of the population born overseas (Australian Bureau of Statistics, 2024) and nearly half with at least one parent born overseas (Australian Bureau of Statistics, 2022). In the South Western Sydney region of New South Wales (NSW), more than half (52.7%) of the population are overseas-born and the majority of households (68.5%) speak a language other than English at home (Australian Bureau of Statistics, 2016). In recent decades, the pattern of migration to Australia has changed significantly, shifting from European countries to Asian countries (Australian Bureau of Statistics, 2023). While such an increment in the migrant population brings opportunities for economic and social development, it also poses several challenges, including a range of health and behavioral issues. While migrants to Australia seem to have relatively better physical health than those born overseas when they first arrive in the country (Anikeeva et al., 2010), research suggests that this situation changes overtime given the social and economic challenges faced by migrants, particularly those from non-English-speaking backgrounds (Jatrana et al., 2018; Khatri & Assefa, 2022). However, evidence relating to the prevalence of alcohol and other drug (AOD) use among people from culturally and linguistically diverse backgrounds is very limited, and the few studies conducted so far report conflicting results (Donato-Hunt et al., 2012; Mwanri & Mude, 2021; Rowe et al., 2020). This is unsurprising given the concept of “culturally and linguistically diverse” (or as it is commonly known in Australia: CALD) encompasses a multitude of “cultures” and intersectionalities that are not (and should not be) easily compartmentalized into one category (Maturi & Munro, 2023). Nonetheless, it is useful to review and explore some of the common experiences of those who come from migrant backgrounds, particularly from non-White Western cultures, and their experiences of services to support AOD management and recovery.

The most recent National Drug Strategy Household Survey in Australia found that people from non-English-speaking backgrounds are much less likely to drink alcohol at risky levels and that people with diverse backgrounds are much less likely to have ever used illicit drugs (Australian Institute of Health and Welfare, 2024). In contrast, a survey conducted in Sydney, Australia, that involved 2212 individuals reported higher rates of daily smoking among Vietnamese and Italian men, and men and women from Pacific and Arabic-speaking communities (Donato-Hunt et al., 2012). Similarly, a study conducted among Vietnamese migrants living in Melbourne reported several risky health behaviors, such as illicit drug use, harmful use of alcohol, and injecting drug use (Horyniak et al., 2014).

There are many potential contributing factors to harmful and hazardous behaviors among migrants and refugees, and these include experiencing low socio-economic conditions, low levels of health literacy, inadequate support to community and cultural adjustment, and limited access and utilization of culturally and context-specific health services (Horyniak et al., 2014, 2016; McCann et al., 2016; Reid et al., 2002). However, limited evidence and understanding of the behaviors and factors related to the utilization of support services available make it more difficult to provide appropriate services for people from migrant, non-English-speaking backgrounds (De Crespigny et al., 2015). Furthermore, there is also a lack of guidelines or training on providing culturally appropriate substance use services (Rowe et al., 2020). Culturally safe and respectful practice requires having knowledge of how culture, values, attitudes, assumptions, and beliefs influence care providers’ interactions with service users, their families, and communities, and how these interactions impact service users (Curtis et al., 2019).

Although some evidence suggests that AOD use among people from migrant, non-English-speaking backgrounds is lower than among the general population (Australian Institute of Health and Welfare, 2024; Donato-Hunt et al., 2012; Rowe et al., 2020), individuals from these communities are at increased risk of mental health issues and racial discrimination, which are known risk factors for increased use of alcohol and other drugs (Ferdinand et al., 2015; Mwanri & Mude, 2021). A population-based study conducted among migrants and refugees living in Sweden reported that these groups face higher levels of health and psychiatric disorders, including post-traumatic stress disorder (PTSD) and psychotic disorders, compared to the local population (Harris et al., 2019). Indeed, systematic reviews conducted among migrant populations living in industrialized countries have reported higher levels of mental health problems (e.g., stress, depression, and anxiety) and poor health and well-being among migrants (Bas-Sarmiento et al., 2017; Mucci et al., 2019). Furthermore, the majority of people from such backgrounds face various challenges when trying to access AOD services, such as stigma and discrimination, language, and other cultural barriers (Douglass et al., 2023; Henderson & Kendall, 2011; Khatri & Assefa, 2022). Overall, migrants from non-English-speaking backgrounds commonly experience systematic isolation from community and government support, further entrenching systems of discrimination and exclusion.

A systematic review by Agramunt and Tait (2019) found insufficient evidence of the effectiveness of AOD interventions for individuals from CALD backgrounds in Australia and indicated that culturally appropriate and context-specific interventions are needed to address AOD use among these populations. Another systematic review reported that the programs that involved migrants and refugees were effective in terms of delivery and community participation; however, such programs did not provide conclusive evidence in terms of the effectiveness of drug-related health promotion programs being implemented for migrants and refugees (O’Mara et al., 2020). Previous Australian-based studies have identified the need for developing and implementing specific targeted interventions while working with ethnic minorities (Horyniak et al., 2014; Jaworski et al., 2016). For example, Horyniak et al. (2014) suggested the need for implementing community-led programs to increase awareness and reduce stigma around AOD use. Another study suggested considering certain factors while working with people from multicultural backgrounds, including psycho-education programs, bi-cultural and bilingual treatments, considering clients’ cultural identity, cultural sensitivity, understanding social and cultural roles, using cultural resources, and developing a culturally appropriate support system (Rowe, 2014). In addition, a study conducted among AOD care providers in Melbourne identified that the care providers experienced challenges building relationships with young people from migrant and ethnic minority backgrounds (Douglass et al., 2021). The AOD care providers also reported lack of funding and time constraints while providing AOD care and building trust with the AOD clients. This study recommended ensuring long-term funding for AOD services along with developing approaches to building strong relationships with AOD clients from migrant and ethnic minority backgrounds.

Most of the studies conducted in the past used quantitative surveys and reported the factors associated with AOD consumption in people from migrant, non-English-speaking backgrounds. As the recent National Drug Strategy Household Survey suggested in its recommendations, further research is still needed to thoroughly comprehend AOD use within this population, particularly how communities access and utilize AOD treatment services (Australian Institute of Health and Welfare, 2024). Therefore, this study aims to address current gaps in the literature by using a qualitative methodology to explore the lived experiences of AOD clients who are from migrant, non-English-speaking backgrounds in terms of access to and utilization of AOD services. While we are critical of the term “CALD” to identify individuals who are from migrant, non-English-speaking backgrounds in Australia, we have used the term in the remaining sections of this article given its currency in health services in the context of this study and the ease of reading facilitated by its abbreviated nature.

Methodology

An exploratory qualitative study design with clients of AOD services and AOD care providers was used for this study. Based on the assumption that knowledge can be articulated through words, in-depth semi-structure interviews were conducted to explore how participants “experience and understand their world” (Brinkmann & Kvale, 2018, p. 9). Through asking questions, the researcher was able to gather detailed information about clients’ experiences in order to construct knowledge about their reality. Care providers’ perceptions of clients’ experiences were used to gain further understanding of the complexities of the context in which service provision is situated.

Context

In Australia, AOD services are generally accessible through government-funded public services, non-government organizations, and private providers. Public AOD services, funded by state and federal governments, offer free or low-cost treatment, including counselling, rehabilitation programs, withdrawal management, and harm reduction. Patients rarely need to pay in full; however, they may face out-of-pocket costs if they opt for private treatment or additional services not fully covered by Medicare. ¹ Private AOD services are typically more costly, and private health insurance may cover part of the expense, depending on the level of coverage. Due to demand, public AOD services often have waitlists, with wait times varying based on location and service type. While some urban areas have shorter waits, patients in rural or remote regions may face longer delays, which can impact timely access to care. In addition, waiting lists are triaged. For example, pregnant homeless women using AOD get priority. For others, waiting lists can take anything from 1 week to 6 months.

The study site was the Drug Health Services (DHS) at a metropolitan Local Health District (LHD) in New South Wales, Australia. The services provided by DHS include, among others, opioid treatment programs, harm reduction programs, counselling, specialist medical consultation, withdrawal management programs, and assertive community services. Data from the first quarter of 2024 at one of the service centers in this LHD show that 24.4% of the total clients are from CALD backgrounds. The study’s Drug Health Service only has its own inpatient beds (15) at one site. They are involved with other in-patients through the Hospital Consultation Liaison (HCL) services, but these patients are admitted under other teams. All other DHS services are outpatient/community.

Sampling and Recruitment

Purposive sampling was used to recruit clients and care providers from DHS. A snowball sampling was also used in order to identify other clients. Posters and snowballing cards advertising the study were distributed through DHS located at different suburbs of the LHD. The snowballing cards provided basic details about the study, including eligibility criteria, a $50 gift voucher offer for all participants, and the lead researcher’s contact information. The lead researcher, who also conducted the interviews, attended key facilities to address any questions from potential participants. However, she was not involved in their care and had no prior relationship with any participant. All recruitment material was available in English language only.

For care providers, an email invitation along with a participant information sheet was sent through a generic executive mailbox to all the DHS staff. Interested participants were asked to contact the study investigators for further information and to arrange an interview if they met the inclusion criteria.

Recruitment was conducted until the researchers were satisfied that information power had been reached (Malterud et al., 2016). As this study focuses on investigating the experiences of a specific demographic employing in-depth analyses of narratives from a limited group of participants, the informational power of data gathered from a relatively small sample size was anticipated to be significant (Malterud et al., 2016). Moreover, the depth of the interview dialogue was expected to be substantial, given the interviewers’ extensive experience in addressing sensitive topics with study participants as well as her own lived experiences (Malterud et al., 2016). The determination of the sample size in qualitative health research remains a debated issue, and it is crucial to consider the intrinsic characteristics of the study in question (Vasileiou et al., 2018); therefore, recruitment was based on the ongoing iterative assessment of the informational power of the collected data throughout the research process.

Participants’ Characteristics

This study included clients who were receiving AOD services at the time of the study or who received AOD services in the previous 12 months and who were from a CALD background. Those with concurrent health issues that diminish their capacity to understand the aims and procedures of the study and provide consent were excluded. An interpreter was utilized for participants with limited English (n = 4).

Eighteen AOD service users were interviewed in person, only one of them being a woman. Ages ranged from 38 to 65 years, and cultural backgrounds included Vietnamese, Sri Lankan, Lebanese, Afghan, Polish, Philippine, El Salvadorian, Chilean, Indian, East Timorese, and Laotian. All but three participants were born overseas, but all identified as coming from a CALD background. In most cases, both parents came from a non-English-speaking country, and a language other than English was spoken at home. Several came to Australia as refugees, with one participant staying 7 years in immigration detention before being able to join Australian society. Six participants came to Australia already as adults while the remaining came in as a child (6) or adolescent (3).

Ten interviews were conducted with health professionals, including social workers, visiting and career medical officers, registered nurses, clinical nurse consultants, staff specialists, advanced trainees in addiction medicine, and drug and alcohol clinicians. All interviews with health professionals were conducted virtually, using an online conferencing platform.

Data Collection and Analysis

A participant information sheet was provided to all the clients and care providers. Informed written consent was obtained from all clients. The audio files from the qualitative interviews were professionally transcribed. Interviews with AOD service users ranged from 27 to 133 minutes, with the majority lasting approximately 1 hour. Interviews with AOD service providers lasted between 12 and 55 minutes, with the majority lasting approximately half hour. All participants were given a pseudonym to ensure de-identification and the protection of their privacy. This strategy was maintained throughout the data collection and analysis process and within the present manuscript.

The process of qualitative data analysis was iterative, inductive, and data led, but informed by theory, particularly theory related to the risk environment (Rhodes, 2002) and structural vulnerabilities (Rhodes et al., 2012) and AOD use. Qualitative data were analyzed using narrative analysis. Narrative inquiry is a vast field of research and methodological practice and offers a range of approaches and techniques for analysis of complex qualitative data (Andrews et al., 2013). For the purposes of this project, and in line with a “worldmaking” approach to research and knowledge production (Herman, 2013), an experiential approach to narrative analysis was adopted (Patterson, 2002). This involved describing the interviews thematically, in the first instance, followed by the formulation and testing of theories that provide significance and a sort of predictive understanding to the stories (i.e., interviews). The iterative process of moving between stories and theory, known as the “hermeneutic circle,” facilitates the generalizability of their meanings, enabling an interpretive procedure that combines both top-down and bottom-up approaches (Squire, 2013). NVivo R14© software was used to assist with notetaking, organization, and analysis of qualitative data.

The experiential approach to narrative analysis also implies a personal engagement of the researcher with the “researched” and the world they share. Thus, this research act is founded on a relentless reflection about one’s involvement in the research project. Our way of “being” in this world and our experiences of the world we share with our participants inevitably shape our thinking and formulations and, consequently, shape the way we share our findings. Here, it is important to note that this does not mean an uncritical and biased account of realities we look into from the outside, but a painstakingly process of critical reflection to ensure the narratives created and shared are critically founded in robust theory. It is important, nonetheless, to acknowledge the lens through which the researchers come to the “researched” or our positionality in this project (Lumsden, 2019).

While only a brief summary of the key points relating to our positionality, the following acknowledgement seeks to provide the reader with some understanding of the worlds we share and, inevitably, the lenses through which this study was conducted. AR, KF, PP and LR are all immigrants who speak English as a second language and use a language other than English at home, therefore classifying as CALD residents in Australia. Our lived experience of being migrants in Australia provides us a nuanced understanding of the systems and structures that perpetuate exclusion and differentiation in this country. JL is Australian born but grew up with an Italian mother and Australian father and was exposed to the “broken English” challenges of a migrant from an early age, sometimes helping her mother communicate in English. GW is a White male, who is at least third generation Australian born.

Several team members also have lived experiences of alcohol and drug use, some of them extensive and traumatic. AR’s lived experience comes from a father, two brothers, and an ex-husband with a dependence on alcohol; one of the brothers losing his life too early due to alcohol use. While this lived experience brought some challenges related to re-living some traumatic past experiences during interviews, it also allowed a great deal of connection and rapport with study participants, and a greater and more nuanced understanding of their own lived experiences of AOD use. Similarly, LR has lived experiences of AOD use through brothers who experienced a dependence on alcohol, two of them also losing their lives at an early age due to alcohol use. LR is currently providing support and care to two brothers-in-law with a dependence on alcohol and a nephew with a dependence on drugs. Such experiences supported him in building rapport with the AOD care providers he interviewed and in obtaining a better understanding of access, delivery, and use of AOD services. JL has had lived experience of AOD use through a past marriage, living with a person with a dependence on alcohol and cannabis use. PP’s lived experience comes from a father who died of liver disease due to alcohol consumption and a cousin who PP witnessed suffer stigma and taboo while seeking care for dependence on alcohol and drug use in Nepal. The family also accessed traditional/spiritual care leaders for support. These experiences inspired PP to conceptualize this study to better understand the barriers in accessing AOD treatment in Australia.

In addition to the above, AR, KF, PP and LR have extensive experience in conducting qualitative and quantitative research with individuals from migrant, non-English-speaking backgrounds in Australia and other countries, and in complex social environments. JL and GW both have extensive professional experience in AOD services, serving the multicultural community of the LHD for over 10 and 30 years, respectively, JL as a nurse and GW as a medical practitioner.

Theoretical Framework

As briefly mentioned before, our data analysis was informed by theory, particularly theory related to the risk environment (Rhodes, 2002) and structural vulnerabilities (Rhodes et al., 2012) of AOD use. The concept of structural vulnerability was developed to enhance our comprehension of how established institutions and systems actively marginalize certain social groups, thereby increasing their susceptibility to engage in health-harming behaviors (Quesada et al., 2011). It posits that an individual’s risk of experiencing adverse health outcomes, such as drug and alcohol use, is intricately related to their position within the broader social and economic hierarchies of their local context (Friedman et al., 2021), constraining individual agency (Rhodes et al., 2012). This vulnerability persists due to the interplay between everyday norms and practices with the suppressive impact of government policies that continue to prioritize individual solutions to health issues. Structural vulnerability as a theoretical framework enables the examination of socio-structural factors as forces that underlie the challenges in cultivating and utilizing external resilience (Friedman et al., 2021).

The notion of a “risk environment” is inherently related to the concept of structural vulnerability. As described by Rhodes et al. (2012), a risk environment framework views “environments as capacitating individuals to act according to particular kinds of habitus, wherein socially acquired practices and habits are reproduced iteratively… through everyday practices that… incorporate processes of governmentality and the positive effects of power” (p. 224). The risk environment encompasses both micro- and macro-environments, suggesting that the two work interactively to produce and maintain vulnerabilities. The social norms, rules, and values of the micro-environment function simultaneously alongside social, political, and economic structures of the macro-environment, institutionalizing discriminatory norms (Mbwambo et al., 2018). A consideration of the risk environment shifts the focus from the individual to the socio-political structures that form individual choice and agency (Rhodes, 2002). In the case of migrant communities, their sociocultural position creates particular kinds of habitus that produce micro-environments of exclusion and discrimination that contribute to the establishment of risk environments (Quesada et al., 2011).

In relation to drug and alcohol use, the influence of structural vulnerabilities and the risk environment is clear. As stated by Rhodes et al. (2012), “the risks of drug use… are virtually meaningless outside their sociocultural as well as political economic contexts” (p. 208). For example, in a study conducted by Tomko et al. (2022), substance use was often expressed as a distraction from traumatic experiences or the realities of a harsh environment, often one where social support and other external resources were either unavailable or perceived to be so. Some factors contributing to this risk environment include the criminalization of drugs, colonial practices and policies, gender, and violence, among others (Bardwell et al., 2021).

In the current study, we use the concepts of risk environments and structural vulnerability to better understand the experiences of AOD service use by individuals from non-English-speaking backgrounds. In order to do this, we need to first understand their position within these risk environments to then try to explain how these shape their experiences of the services.

Ethics Approval

Ethics approval was obtained prior to commencement of the study through the relevant Human Research Ethics Committee (approval number 2021/ETH11717). All participants provided written informed consent to participate in the study.

Stories from AOD Services Clients

In this section, we present stories that, collectively, represent the group of AOD service users and their experiences of AOD services as individuals from CALD backgrounds. We complement those stories with the views provided by health professionals who work providing AOD services whenever pertinent. We present these stories organized into three main themes: intersectionality of vulnerabilities, risky environments, and institutional stigma. The stories are interweaved with our theoretical analysis of the material collected through the interviews using a structural vulnerability lens.

Intersectionality of Vulnerabilities

In the case of our participants, it was clear that the structural vulnerabilities experienced by them were compounded by a set of intersectionalities that made AOD service use and “recovery” ² difficult. A recurrent experience of participants in this study was their engagement with the criminal justice system given the illegal nature of drug use in Australia. As several participants noted, once one enters the criminal justice system because of their AOD use (or other reasons), they are stuck in a system of disadvantage that is hard to break from:

Yeah, I get out of jail, spend 6 weeks trying to do the right thing and then I muck up and I’m cut off the doll [social security]. And it’s just easier for me to go back to selling drugs and do that lifestyle. It’s what I knew. (Oliver, AOD services client)

I lost my house [..] before I had gotten out of jail. So, I went to the rehab and I had to find a friend that I could rent a house with. So, I’m going halves with a friend in a house at the moment. [just with the doll money]. It’s not easy. Yeah, like I said, housing is a big thing. I’ve tried on and off but when you go to jail you get taken off the lease and you got to start again. I’ve been trying for years. (Nam, AOD services client)

The issue here, from a structural vulnerability point of view, is that the system is not designed to support those who are at their most vulnerable position, experiencing intersecting vulnerabilities, and the structure of our systems further creates disadvantage as a consequence. While they might be trying to access the AOD services that can “medically” support their recovery, their position within a system that places them as marginalized and vulnerable hinders their ability to achieve their goals.

Another issue raised by health professionals relating to these intersecting vulnerabilities and how they impact on the experience of AOD services by those in need relates to migrants’ access to the public health system. For instance, as one health professional explained, migrants who are not yet recipients of government support, like Medicare services, face significant challenges in accessing services:

Essentially, at the public service, we cater towards people who are Medicare eligible. There is a cost for patients who aren’t on Medicare. (Robert, AOD service provider)

Members of the CALD community in Australia have different levels of access to social security systems like Medicare, with those in temporary visa regimes or with expired visas being particularly vulnerable to lack of access.

On rehab, one patient had an issue with the prescribed medication, who were on Centrelink and were homeless, without a job. There was a barrier there, they get in the whole Medicare situation, whether or not they are on it, whether or not they’re on a permanent visa, that becomes an issue in those cases. Sometimes they’re refugees, so their funding is through the Department of Immigration […] Not always, though, as some people fall in through the cracks, as they might have overstayed, for example. (Robert, AOD service provider)

However, even for those who are covered by Medicare and other social security services, their economic insecurity often impacts their ability to access services:

I can think of a patient I saw today. She’d probably be residing with family but because the family members are from another country and they’ve come over, as in the grandparents, then she’s unable to reside [with them]. So, she’s in unstable housing, she’s accessing resources which aren’t as safe and therefore she’s more at risk. (Robert, AOD service provider)

Again, while the services may be available, several of those who need the services face significant challenges to accessing it, making any attempts at recovery further complicated. In these cases, whether the services being offered are adequate, appropriate, culturally safe, or any other classification, a significant number of migrants from non-English backgrounds will not be able to access it in the first place due to these structural barriers that position them at the margins and accentuates vulnerability.

In addition, individuals who are in the margins of society also have more limited access to knowledge that could empower and allow for structural vulnerabilities to be overcome. In the case of our participants, this was seen frequently through the reporting of lack of knowledge among their family members and community about how to deal with health issues generally, but particularly mental health problems and the associated drug use:

But I think another thing is families don’t know how to support as well, don’t know where to, don’t know how to deal, uhm, know what to do? Like, for example, my mother or my father or other person, their parents or their family don’t know how to help them, because they don’t know how to do it, you know? Uhm. They don’t know about people that, they don’t know about people on drugs, how come they’re on drugs, they don’t know much about mental health, so that’s another problem as well altogether. (Anuson, AOD service client)

While some may attribute lack of family engagement or negative attitudes of family members to drug and alcohol use to stigma based on “culture,” ultimately their position in society reinforces this stigma due to lack of access to knowledge that can empower them and their family members to be better equipped to deal with AOD use. Again, this affects their ability to access the appropriate medical support and, when they do, there is distrust that the system will actually support them. As one health professional indicated: “They’re so used to seeing, I think, us as part of the problem rather than part of the solution that trust between the health professional and the patient might take quite a bit of time to develop” (Joanne, AOD service provider).

However, when the trust is established, AOD service users feel extremely thankful for the support they receive. As one participant indicated:

It was great, it was great, beautiful like, the photo of paradise these people show us. I swear, from the bottom of my heart [...] they show what kind of you deserve. And the forgiveness, too much, people, too much. [...] I can’t even explain. Really, I’m so happy. (Farhad, AOD service user)

It seems like they cannot believe that they are being helped by a system that constantly discriminates and marginalizes them. They then become thankful for being given a chance and being treated with respect.

Another key aspect that highlights how the intersectionality of vulnerabilities helps shape the experiences (or non-experiences) of CALD AOD service users is discrimination. Clearly, culture and language are strong aspects of one’s identity. However, for those who come to Australia as a migrant from a non-English background, these aspects of identity determine much of their life’s experiences, particularly when it comes to heightened and intersecting vulnerabilities. Recurring experiences of discrimination often lead to poor mental health, less sense of belonging, lower levels of trust, reduced sense of control, and less hope, all of which are well known risk factors for drug use. Participants described experiencing exclusion and discrimination for speaking languages other than English. This exclusion/discrimination shaped people’s use of alcohol and other drugs. This was particularly common among those who arrived as teenagers and were exposed to bullying at school, as the two quotes below emphasize:

Just being fearful all the time, scared, nervous, and just, just hide. Always hiding all the time, you don’t want to, ‘cause you don’t know how to deal with it, for example, jig school, just to run away from all that uhm, you know, how can I say it, uhm, all that problem that I had at school. Not able to, you know, put my hand up, not able to talk to the teacher, couldn’t, didn’t know how to talk at all, like, communicate. […] so that’s when I started to hang around with people from the streets. (Anuson, AOD service client)

Everything was really difficult [at school], I couldn’t um, it was always really hard, always nervous, almost, like um, cause I couldn’t keep up and I wasn’t, didn’t have the confidence, wasn’t confident. And, you know, how to ask the teacher how to, and probably, felt, let me say embarrassed, or felt you know, you don’t want people to see that I’m, can’t do what they do, you know what I mean? (Hoang, AOD service client)

Hoang ended up leaving school in Year 7, a few months after starting high school, because he “couldn’t do all that” and said he was “just hiding, not facing it,” becoming “a lost child.”

In summary, people from CALD communities who use AOD are made disadvantaged in their access to services due to several intersecting vulnerabilities. In the examples provided in this section, we can see that lower levels of education, English as a second language, low income, lack of social security rights, criminal history, and discrimination all intersect to hinder access to AOD services that can support them.

Risky Environments

Our participants’ lived experiences emphasized the centrality of risk environments as part of vulnerabilities:

I’ll say that life at home for me wasn’t the best, so I, I was hanging with some real bad people, but I felt real comfortable with. And that led to me experimenting drugs and using drugs, you know. (Fernando, AOD service client)

Yeah, see now I don’t do much, and I don’t go out much. I don’t have real friends, I don’t have friends at all, because uhm, where I pretty much go when I grew up, where I hang around, I didn’t really meet, uhm, the, the nice people, I suppose. Nice and proper people. Just all like, trouble people… (Anuson, AOD service client)

For our participants, “trouble” was always around the corner and affected their behavior and drug use. If they were on a pattern of recovery, they were “forced” to cut ties with everything they knew—old friends, familiar places—in order to stay away from experiences that would take them back into their “troubled” past. If they could not do that, then they would commonly return to the same pattern of drug use, as Oliver explains:

I don’t use when I go to jail. You know, the drugs are there, I just choose not to do it when I’m in jail.

Why do you think that is?

I don’t know. […] When I get out I normally do it within 24 hours. I suppose it’s because it’s all I’ve known for so long. (Oliver, AOD service client)

The majority of our participants had been involved with the criminal justice system, with most of them spending several years in jail, with high rates of recidivism. Most of the offences were directly related to their AOD use but the system fails to acknowledge the social determinants of their offences, and rather than dealing with the risky environments and the associated vulnerabilities experienced by these offenders, it punishes them with imprisonment again.

The risky environments of our participants were not only the streets but in their own houses. Frequently coming from dysfunctional family relationships, where trauma, discrimination, hardship, and vulnerability are constantly present and unaddressed due to the same patterns of societal marginalization, our participants are frequently surrounded by spaces that hinder their search for help and recovery. When they reach out, the system provides them with “solutions” that do not go far enough in addressing the root causes of the issue, beyond medical support. While the medical support is important and valued by participants, the model is insufficient to support them fully, taking into account the complexities of their environments. Several of the participants, for instance, indicated they never received psychological support, despite the service being available. Tuan (AOD service user) talked about being “on and off” in the methadone program for 10 years and indicated that he frequently relapses because the support that they are providing is not enough: “it’s enough physically” only. For those who have had access to psychological support, this is often insufficient to address their issues. When Anuson spoke about accessing help, he highlighted the insufficient understanding of counsellors of the complexities of his condition:

It’s not, it’s not very open, open-minded, not really like, let you grow, kind of think. It’s like, maybe trying to put too much uhm, you know, like, for example, it was like a “go and do this, go and do that,” but don’t really know what I’m capable of or what I’m good at, what I’m not good at, first, you know what I mean? (Anuson, AOD service user)

It is important to note again here that most participants expressed an appreciation for the services they receive, from the methadone program to the rehabilitation facility. However, without the system addressing the risky environments in which these individuals are situated, accessing the services is the least of their hurdles to recovery. As Oliver (AOD service user) explained:

It’s just too hard. It’s like you’re just left with it. You get out of jail, apply for housing. 7 years. What are you meant to do for 7 years? No way someone with an addiction can last for 7 years without turning back to addiction when it’s all just too much. No rehab will fix that.

Institutionalized Stigma

Structural vulnerability is further constructed through the institutionalized stigma within the healthcare system. Some of the health professionals interviewed used language like: “too many addicts and not enough services” or “interconnection with the community and building trust is also other important to these CALD people” (our emphasis). While such language was not the norm among the health professionals interviewed, their presence points to larger structures/norms of discrimination.

In addition, health professionals repeatedly used “culture” as the reason why CALD populations refrain from using services:

I think a lot of the times for the young people it’s the barriers […] like family pressures or the particular understanding that their family has around drug and alcohol, which I think can create some barriers for them in terms of following up with treatment just because they’re coming from two different sort of lenses, especially for young people who are maybe more kind of assimilated than some of their family members or trying to kind of fit in and belong in kind of more Western spaces. (Emily, AOD service provider)

This points to the homogenizing use of “culture,” acting as a signifier of basically any difference. The use of such language further entrenches exclusionary power structures where the white Australian “manages” other “cultures.” That is, the white Australian is still central in the narratives of these health professionals, and any other culture treated within this setting is treated as “other” to the white norm.

Interestingly, the statements from health professionals around family support and stigma contrasted with the narratives of participants, who frequently praised their families, usually mothers, for their unwavering support:

What actually helped, was me knowing that she [mother] would sell her jewellery not to see me sick. That, that said enough. I just said nah, fuck that man, I’m not gonna make my mum do that shit. Cause she was selling her jewellery to help me, behind my brothers’ back. (Jose, AOD service client)

This, however, does not negate the experience of many participants who indicated lack of health literacy among family members, which created barriers for them to provide support to their loved ones:

I put myself in my mum’s position, the first time I went up to her and told her I had a heroin problem and I need help. And when I told her about the detox etc. I put myself in her position and think, alright. It would have been good to have services where she could’ve gone and seek more information. Services to help her, fill her in on the problems that I have, drug problems, everything that comes with it. Behaviour, the withdrawals. And things that she could do to help me. (Fernando, AOD service client)

It is important to note that institutionalized stigma is not only related to culture but also to drug use more broadly, which leads us back to the intersection of vulnerabilities. While this experience is not unique to CALD individuals who use AOD, it compounds with other forms of discrimination and stigma that they already experience. And as one of our participants highlighted, there can be life-or-death consequences of such institutionalized stigma:

I’ve had mates, I’ve even had it happen to myself, start ringing up a drug, methadone doctor, to get on methadone cause I’m sick of using drugs, done using drugs. Someone will make an appointment that’s a week later, you know what I mean? […] You can’t see him on the same day, can’t see him on the next couple of days. All that time that, you know, it’s a week. Gotta wait a week, wait a week. And I just think you could be dead in that time, or in jail, or both, you know. (Fernando, AOD service client)

This attests to the pervasive discrimination and stigma embedded within institutions such as healthcare, whereby patients are treated “in a psychological, social, cultural and class vacuum” (Quesada et al., 2011, p. 344), neglecting a consideration of structural vulnerabilities. As stated by Farrugia et al. (2021), “‘addiction’ has long been associated with moral decay and seen as a threat to the ideal of the rational, choosing subject” (p. 95); a notion which manifests itself clearly as institutionalized stigma and discrimination.

These institutionalized discriminatory practices are not, however, left unchallenged. Most health professionals interviewed demonstrated a great deal of understanding of the limitations imposed by the healthcare system on their ability to support AOD users and were fighting for reform:

So, as I said it is not well structured and because historically the opioid treatment program has overwhelmed every other aspect of addiction medicine, and some people even equate drug health services just with the methadone buprenorphine treatment. So that’s a cultural shift that is happening, has happened, and needs to continue to happen to reach the full form of drug and alcohol services. (Robert, AOD service provider)

We should be able to provide similar services on an outpatient basis … Currently that does not happen in a formalized way, and it’s something that some doctors will do that. But one of the challenges that we have is having something with a bit more structure around that is the model of care where is developed, I think it should be multidisciplinary. But currently the multidisciplinary aspect of drug health services only extends to the opioid treatment program. (Matthew, AOD service provider)

The matter then becomes one of breaking cycles of vulnerabilities; but if one’s identity is perpetually marked by stigma and shame that are endorsed by our systems, then the breaking of these cycles becomes almost impossible for the individual who has been disempowered, who blames themselves rather than the structural systems in place that constrain their individual agency:

I just couldn’t quite understand why my life, why you fuck me so bad, in the past like that, why do I went, kept turning back to it, why, what drove me? What was it? What, what did it do to me? (Jose, AOD service client)

We argue, using a structural vulnerability lens, that our systems have allowed such disempowerment to happen, despite the efforts of individuals, such as health professionals or the users themselves, to break the vulnerability cycle.

Lessons Learned

It is undeniably challenging to make sense of “stories” that are told by agents navigating, and situated within, very different cultural environments. Although all “CALD,” our participants’ cultural spaces are too complex and varied to create a coherent story that makes sense across these culturally diverse experiences. In order to deal with these challenges, our analysis used an experience-centered and socioculturally oriented approach to their narratives (Squire, 2013), but one that attempted to look at the “small stories” (Phoenix, 2013), allowing for a more nuanced understanding of the narratives in the context of different sociocultural norms. We sought to explore the lived experiences of AOD clients who are from migrant, non-English-speaking backgrounds in terms of access to and utilization of AOD services. Through our qualitative narrative inquiry, we found that the experience of services is shaped by, and probably less important than, the experience of AOD use in a society that not only discriminates non-White citizens but also those who use drugs. Participants in our study were entangled in a mesh of intersections that pushed them further into a vulnerable position that almost denies them the opportunity for recovery. While health professionals are well intended and good at medically treating their patients, the system does not offer comprehensive care that addresses the social determinants of drug use among those from CALD backgrounds.

What we found is that “culture” and language, as guiding terms in the concept of “culturally and linguistically diverse,” become less prominent and deterministic of AOD users’ experience of health services. Instead, they compound to create vulnerabilities that intersect and, therefore, are more entangled and wicked to address. In spite of this, participants demonstrated incredible resilience in the face of almost immovable structural barriers to their well-being. As Tippens (2017) suggest, “resilience is vulnerability’s paradigmatic parallel” (p. 1092) and allows agency to individuals who are consistently stripped of their sovereignty by structural systems that oppress rather than empower those who are most vulnerable in our society.

The concept of the risk environment also proved helpful in our analysis, particularly given the recurrent experience of our participants with the criminal justice system. A common institutional factor within the risk environment includes law enforcement. As found by Rhodes et al. (2012), “everyday policing practises, and especially extrajudicial practices, generated a pervasive sense among drug injectors of being at risk, in turn reinforcing a sense of stigma, powerlessness and, importantly, a fatalistic acceptance of harm and suffering” (p. 212). A study conducted by Friedman et al. (2021) found that 42% of drug-injecting participants faced physical violence from police, 62% experienced verbal abuse, 9% experienced sexual violence, and 39% had their new/unused syringes confiscated. This structural violence establishes a pervasive fear of police among people who use drugs, leading to the engagement in high-risk behavior such as rushing injection, neglecting needle hygiene, and injecting in unsanitary locations in order to evade detection (Rhodes et al., 2012). Thus, encounters with the police are a key structural determinant of health for people who use drugs (Friedman et al., 2021), and an all-too-common experience among our participants.

Institutionalized stigma was also a key aspect of the experiences of our participants. Stigma surrounding people who use alcohol and other drugs discredits and denies them legitimacy, functioning as a barrier to seeking and receiving help (Farrugia et al., 2021). Farrugia et al. (2019) examined the accessibility of healthcare for people who use drugs in Western Sydney, finding that hospitals and general practices “were not necessarily considered welcoming environments, making them less accessible to clients of […] drug health services” (p. 5). From our results, this is not surprising.

In addition, despite what the narratives of some health professionals in our study indicate, evidence suggests that the stigma associated with alcohol and drug use is not a particular characteristic of CALD and non-Western cultures but a common experience across cultures (Douglass et al., 2023). Nonetheless, the view that “culture” in CALD communities is the main explanation for negative behaviors still persists (Maturi & Munro, 2023) and affects the experience of AOD service users and their ability and willingness to seek support. As expressed by Farrugia et al. (2021), this reflects the power of routinized experiences of stigma, which over time “accrete to shape understandings and experiences of care” (p. 104), constructing perceptions of healthcare among people who use drugs as an uncomfortable and alienating experience. One participant in Farrugia et al.’s (2019) study stated, “I find private doctors, I find them to be judgemental” (p. 16). An additional participant further emphasized this institutionalized stigma, stating that “not enough GPs are willing to treat patients with alcohol and other drug problems” (Farrugia et al., 2019, p. 17). While most of our participants expressed gratitude for the services they received, institutionalized stigma was still prevalent in their experiences.

The lived experiences of our participants remind us that when considering the shortcomings of current approaches to drug and alcohol support, it is vital that both health practitioners and the systems they work within consider structural vulnerabilities in order to become more responsive to groups that are constantly marginalized, including those coming from migrant, non-English-speaking backgrounds. Brookfield et al. (2023) suggested the need for considering four important elements within what they called an extended recovery model to address the harmful use of drugs. These include (i) considering drug use as a multidimensional health issue; (ii) engaging family and social network in the efforts of addressing drug use; (iii) that treatment services should consider divergent priorities of people using drugs; and (iv) that the changes and growth people experience should be recognized. Some of the key aspects of our participants’ experiences arose from an intersectionality of vulnerabilities that would benefit from such an approach and included factors such as discrimination and stigma, language barriers (for them and their loved ones), financial constraints, unstable employment and housing, limited social networks, and the consequent cycle of recidivism. Previous studies have emphasized the need for cultural competence and sensitivity when dealing with migrant, non-English-speaking clients in the health system (Flynn et al., 2020; Olaussen & Renzaho, 2016; Young & Guo, 2020). These studies include recommendations around the importance of understanding and respecting diverse cultural norms, beliefs, and practices; the importance of ongoing education of the health workforce to become more culturally competent; the need for culturally appropriate resources, including translated materials, educational tools, and support groups tailored to specific cultural groups; and incorporating cultural factors into treatment plans. While we concur with such recommendations, we echo the view of scholars who remind us that we all have culture; it is not something that only those from non-White, non-English-speaking backgrounds have (Maturi & Munro, 2023; Sue, 2006). Therefore, using “culture” as a marker to determine the quality and provision of services or to somehow specialize delivery can be problematic if there is little acknowledgement of the forces that are at play to homogenize health and healthcare provision. While we use culture in this way, we are reinforcing the dominant experiences and norms, and therefore further discriminating against anything that deviates from the established norm. We also run the risk of associating AOD use and behavior with “culture” in a way that is not helpful to those who need support.

For these reasons, it is important to approach healthcare in a more intersectional way in order to take into account the syndemics of factors and their interactions in constructing vulnerability. Structural vulnerability can thus work to counteract the essentialization and individualization of health present within a range of contemporary institutions. That is, through a structural vulnerability lens, we can challenge established norms that put the blame and responsibility on individuals for their health and well-being, and that rigidly define health as something to be fully achieved if certain criteria are met, ignoring its subjectivities and the societal demands on our minds and bodies.

Limitations

This study has some limitations that need to be acknowledged. First, recruitment materials were provided only in English, which may have excluded potential participants with limited English proficiency. In addition, although interpreters were used in some cases, cultural and linguistic nuances in participants’ responses may have been missed, potentially affecting the richness of the data collected. Second, the study used purposive and snowball sampling, which, while helpful for reaching hard-to-reach populations, can lead to a sample that may not fully represent the broader client and provider populations of AOD services. Furthermore, only one female client was interviewed, limiting insights into potential gender-specific experiences and needs within AOD services.

Implications for Research, Practice, and Policy

This study has important implications in terms of future research, policy development and revision, and improving services delivery to address the problems associated with use of alcohol and other drugs among CALD populations living in Australia and similar high-income countries. The findings are expected to guide designing and conducting future research that focuses on integrated and intersectional approaches that move beyond viewing culture and language as isolated factors; instead recognizing how structural vulnerabilities such as stigma, discrimination, economic instability, and housing insecurity intersect for AOD users from non-English-speaking backgrounds. In practice, addressing these structural vulnerabilities requires building capacity of healthcare providers not only in cultural competence but also in understanding structural inequality, equipping them to provide personalized and holistic care. This would include involving family, community organizations, and social networks into AOD care and offering multilingual, patient-centered services that cater for the diverse priorities of diverse populations.

Policies relevant to AOD services and care should focus on systemic reforms that address root causes of health inequities including socio-economic and cultural vulnerabilities. Key policy reforms should include expanding access to multidisciplinary integrated care models, redesigning AOD services to reduce institutional stigma and create supportive environments that prioritize resilience and empowerment. Further, effective implementation and sustainability of AOD services depends on collaborative efforts between governments, policymakers, industry partners, and health systems to create supportive and relevant AOD policies and programs, and ensure continued adaptation and adequate funding for cost-effective interventions, with rigorous supervision, monitoring, and evaluation.