Barriers and enablers to accessing child health resources and services: Findings from qualitative interviews with Arabic and Mongolian immigrant mothers in Australia

Abstract

Background:

Over the past two decades, there has been an increase of immigrants in Australia. Despite this, the availability of culturally responsive resources and services that cater to their needs remains insufficient.

Objective:

The aim of this study was to explore the resources used and trusted by Mongolian- and Arabic-speaking migrant mothers in Australia for child health information and examine how they navigate and overcome challenges they encounter accessing this information.

Design:

Semi-structured telephone interview

Methods:

A theory informed semi-structured 60-min telephone interview was conducted in Arabic and Mongolian with 20 Arabic- and 20 Mongolian-speaking migrant mothers of children younger than 2 years or currently pregnant and living in Australia. Data were analysed thematically using the framework method.

Results:

The reliance on digital platforms such as google emerged as a common trend among both groups of mothers when seeking child health information. Notably, there were differences in resources selection, with Mongolian mothers showing a preference for Australian-based websites, while Arabic-speaking mothers tended to opt for culturally familiar resources. There were various barriers that hindered their access to health services and resources, including language barriers, cost, and limited knowledge or familiarity with their existence. Negative encounters with healthcare professionals contributed to a perception among many mothers that they were unhelpful. Both groups of mothers employed a cross-checking approach across multiple websites to verify trustworthiness of information. Acculturation was shown only among the Mongolian-speaking mothers who adapted their cultural practices in line with their country of residence.

Conclusion:

The findings of this study highlight the importance of addressing the needs of migrant mothers in accessing child health information. Health professionals, government agencies, and researchers have an opportunity to provide culturally responsive support by fostering a culturally inclusive approach to developing and promoting equitable access to services and resources, ultimately enhancing the wellbeing of migrant families.

Plain language summary

Barriers and enablers to accessing child health resources and services: Findings from qualitative interviews with Arabic and Mongolian immigrant mothers in Australia

Mothers may experience barriers accessing resources and services related to child health behaviours after migration to Australia. Studies have found that parents actively seek health information and have a significant impact on their child’s health behaviours, which can have long-term effects. Various factors influence parental decision-making regarding child health, including the socio-cultural environment, life experiences, and access to services and resources.

This study reveals that both Arabic- and Mongolian-speaking migrant mothers heavily depend on online sources for accessing health information, primarily due to various barriers they face when accessing in person services, such as language constraints, financial limitations, and challenges in accessing healthcare services. This article also provides recommendations for future research and initiatives to be considered addressing the challenges faced by migrant mothers in accessing healthcare resources and services.

Keywords

barriers to accessing services and resources culturally and linguistically diverse health services infant health migrants maternal and child health resources for child health

Introduction

Parents and caregivers have a considerable influence on their children’s health behaviours including dietary intake, sleep, and active play.^1,2 The first 2000 days of life is a crucial time for the healthy development of children’s cognitive, emotional, social, and physical health that can persist throughout life.^3,4 Parental capacity to make informed decisions regarding their children’s early exposure to health behaviours has a significant impact on various health and developmental conditions, including childhood obesity.⁵

Many factors influence parental decision-making around child health including socio-cultural environment, life experiences, and access to services, and resources.^6,7 Several studies have shown a positive correlation between the educational attainment of parents and their ability to make informed health decisions regarding their children.^7,8 A 2022 systematic review exploring parental health literacy on the health outcomes of children found that poor parental health literacy negatively impacted children’s health outcomes due to several factors including delay in health-seeking behaviours.⁹ This could indicate that parents have varying levels of access to accurate and reliable information sources. Parents encounter challenges in assessing the credibility and trustworthiness of resources and often resort to using unreliable sources to facilitate health-related decisions for their children, likely due to the ease of accessibility.^10,11

The use of unreliable sources of information is particularly common for parents from a cultural and linguistically diverse (CALD) background as they contend with additional obstacles such as social disadvantage, stigma, and language barriers.^12,13 In many countries, the needs of CALD communities often are not considered in resource development or service delivery.^14,15 In a 2022 systematic evaluation of 66 infant health websites globally, it was found that the majority of the websites had a high readability level and lacked multilingual options or culturally relevant content.¹⁶ Other studies have shown the impact of immigration on parental health decision-making, and the struggles encountered in navigating between two cultures and reconciling different health practices.^17,18 Mothers’ cultural values and customs (e.g. food habits) can present challenges when adapting to new health behaviours in a foreign country.¹⁹

In 2020, the number of international migrants was estimated to be 281 million globally, with a considerable proportion having relocated to countries such as Australia.²⁰ Australia is one of the most multicultural countries in the world, with around 30% of the population born overseas and one-fifth speaking a language other than English at home.^21,22 Despite the growing influx of immigrants to Australia, access to resources and services that are culturally compatible and sensitive to their needs remains inadequate.^23,24

Although some efforts have been made to understand the barriers migrant parents face when accessing health services and resources,^12–16 there is a lack of consolidated information about how migrant parents navigate these challenges and what resources they rely upon. This study aimed to gain further understanding of the barriers and enablers to accessing child health resources and services among migrant mothers in Australia.

Methods

Context

This study was conducted in Australia at Sydney Local Health District (SLHD) between June 2022 and October 2022. SLHD is a prominent healthcare district that encompasses various neighbourhoods and suburbs in Sydney, attracting residents from different cultural backgrounds and ethnicities. It has a large proportion of residents born overseas and a wide range of languages spoken.

This study contributed to a formative research study for a broader project aiming to build an interactive web-based platform in English, Arabic, and Mongolian languages to support parents of young children with information related to child health behaviours.²⁵

Study design

A qualitative approach was used to gain a deeper understanding into the resources used and barriers or facilitators faced by CALD parents searching for information related to child health behaviours. Data were collected through telephone interviews in order to achieve personal in-depth insights and to enhance access to participants who were geographically dispersed, of varying literacy proficiencies and who needed flexibility in scheduling.^26,27

Study participants

Twenty Arabic- and 20 Mongolian-speaking parents were invited to participate in an audio-recorded 60-min telephone interview. Eligibility included speaking Arabic or Mongolian as a first language, being newly migrated to Australia (up to 10 years), and currently pregnant or having a child younger than 2 years. Participants who did not speak Arabic or Mongolian as a first language, resided in Australia for more than 10 years, and were not pregnant or had a child younger than 2 years at the time of the interview were excluded from the study.

The research team pragmatically chose these two language groups to explore the subject in question. The Arabic-speaking community is one of the largest established communities and is the third most commonly spoken language in Australia.²⁸ The Mongolian community is an emerging community within Australia and support was required for these two communities within the district.²⁹

Participants were recruited through in-language promotional material that was advertised on social media platforms, in antenatal clinics at Hospitals in SLHD, and through face-to-face recruitment facilitated by multilingual cultural support workers at various community organization centres and events. Participants were offered a AUD$20 grocery voucher to compensate their time.

Telephone interviews

The Arabic telephone interviews were facilitated by the first author (D.J.) who speaks Arabic and English. The Mongolian telephone interviews were facilitated by a Mongolian-speaking cultural support worker. Facilitators were trained to conduct the qualitative telephone interviews by an experienced qualitative researcher (S.T.).

The telephone interviews followed a semi-structured guide (Supplementary Appendix 1 available online). The guide was mapped to the Capability, Opportunity, Motivation, Behaviour (COM-B) model of the Behaviour Change Wheel, which provides a basis for understanding behaviour prior to intervention design.^30,31 Open-ended questions focussed on exploring parents’ capability of searching and accessing credible information sources, physical opportunities to use the Internet for health information and barriers they may face, cultural practices and motivation behind engagement with selection of resources and web-features. The guide was translated and then refined based on pilot testing with two Arabic- and two Mongolian-speaking mothers.

Audio files were directly translated and transcribed in English by an Arabic- or Mongolian-speaking bilingual cultural support worker. All transcripts were checked for accuracy and preservation of linguistic meanings by D.J. and a Mongolian-speaking translator, respectively.

Data analysis

Thematic analysis using the framework method was conducted. Framework method outlines a series of iterative steps that researchers must pass in order to conduct a thematic analysis.³² This provides a clear, replicable, and well-defined systematic methodology while maintaining the ‘flexibility’, which can be adapted for different epistemological positions.³² A combination of inductive and deductive processes was chosen to code the data. Using an inductive approach to initially code and identify themes in the data allowing for a richer description of the data overall without trying to fit it into pre-defined codes.^32,33 This was followed by using the COM-B model deductively to help further explain specific themes. The analysis process was as follows:

Discussion and reflective activity;

Set up an initial code manual by first researcher (D.J.);

Second researcher codes using the code manual;

Both researchers discuss the code manual and amend accordingly;

Recode using the updated code manual;

Researchers discuss their experience and reach consensus.

In the first stage, a reflective activity was conducted by D.J. and S.T. with the aim of identifying any potential research bias before analysis.³⁴ This involved individually documenting any pre-existing experiences, assumptions, and beliefs that could influence our perspectives on the research topic, followed by collaborative discussions to ensure awareness and mitigate potential biases. Subsequently, three interviews were coded inductively by D.J. to develop an initial coding manual. This coding manual served as a foundation for the second reviewer to review and assess the codes developed. New codes were continually developed until data saturation was achieved and a comprehensive coding manual was set based on a substantial number of interviews. A second researcher (S.T.) used the developed coding manual to code an additional two interviews. The codes were then discussed and amended accordingly. Through an iterative process, we ensured that the categories were mutually exclusive and exhaustive by merging and revising redundant codes. Once framework consensus was reached, all data were coded using the framework via NVivo (1.7). The first author (D.J.) led the analysis with input from all authors.

Results

Table 1 presents the sociodemographic characteristics of the 20 Arabic- and 20 Mongolian-speaking mothers who participated in the telephone interviews. All the Mongolian-speaking women were born in Mongolia while the Arabic-speaking women were born in Lebanon, Syria, Palestine, Iraq, Egypt, or Jordan. All Mongolian-speaking mothers were highly educated (University degree or higher), while the majority of Arabic-speaking mothers had completed high school, technical and further education (TAFE), or held a diploma. There was a higher proportion of newly arrived mothers (< 4 years in Australia) among the Arabic-speaking participants compared to the Mongolian-speaking participants. All participants indicated that they had access to the Internet.

Table 1.

Socio-demographic characteristics of Arabic- (n = 20) and Mongolian (n = 20)-speaking mothers.

Characteristics	Arabic-speaking mothers	Mongolian-speaking mothers
Country of birth	Lebanon (5) Syria (5) Palestine (5) Iraq (3) Egypt (1) Jordan (1)	Mongolia (20)
Time living in Australia (years)
1	4	1
2	2	0
3	3	5
4 or more	11	14
Number of children
Pregnant	2	1
1 child	4	10
2 children	7	6
3 children	1	3
4 or more children	6	0
Education
Up to HSC/TAFE/Diploma	14	0
University degree or higher	6	20

HSC: Higher School Certificate; TAFE: technical and further education.

Findings from the qualitive data were illustrated as three key themes: (1) Parental health information-seeking behaviour (2) Cultural influences on parental practices in the early years of child’s life and (3) Migrant parents’ experiences accessing support related to infant health behaviours in a foreign country. Each theme comprised several sub-themes that encapsulated components of the main theme (see Figure 1).

Figure 1.

Themes.

Theme 1: parental health information-seeking behaviour

The first theme pertains to the information resources used by migrant parents to acquire knowledge related to their child’s health behaviours, including assessing the reliability of information, their motives for selecting resources, and their needs for parental health information (Supplementary Appendix 2 available online).

Parental information sources for infant health

Responses from migrant mothers revealed three main sources used for information related to their child’s health behaviours: digital platforms, health professionals, and experienced mothers.

Digital platforms

Apps and websites for pregnancy and child health-related information, TikTok, YouTube, Instagram, and Facebook parent groups were the main digital platforms cited. Almost all mothers mentioned using Google as their primary source for searching information and accessing websites and videos in language and less frequently in English. The reasons for using Google varied among mothers and were often centred around conducting independent research to prepare themselves before a doctor’s visit or in order to seek additional information after the visit ‘generally before going to see a General Practitioner (GP), I usually do some research and reading about the issue. So, I understand more clearly what the GP is talking about’ (Mongolian-speaking mother, 7 years in Australia).

Mothers also mentioned using Google when they had general enquiries about their baby’s health or needed urgent information and were unable to access health professionals ‘Google at night for example, when there are issues, I cannot wait till the morning, I look up a little bit before I have the chance to go to the doctor’ (Arabic-speaking mother, 10 years in Australia).

Mongolian-speaking mothers predominantly used Facebook parent groups as a source of information, a trend that was less frequently mentioned by the Arabic-speaking mothers. Facebook groups served as an interactive platform for Mongolian-speaking mothers where they reported to actively participate by asking questions and seeking advice

‘I usually get information from Facebook groups. For example, there is a group named “Идъе” [means “let’s eat”] and Mongolian mothers share their information about how they have started solid feeding and how they feed their babies. This group has more than 35,000 members, so it’s quite a big group.’ (Mongolian-speaking mother, 4 years in Australia)

Arabic-speaking mothers were more conservative in participating in forums that could potentially reveal their identity, hence, they preferred to read posts without actively engaging ‘I like to read but not to interact. It’s my nature. I cannot interact with people I have never met’ (Arabic-speaking mother, 2 years in Australia). Furthermore, watching YouTube videos in their native language was a more common information-seeking behaviour among Arabic-speaking mothers, with many referring to universal videos created by Arabic-speaking doctors for health-related information.

In terms of website features that were engaging, both groups of mothers expressed a preference for clear, short, summarized information. However, Mongolian-speaking mothers specifically mentioned a preference for reading information and using books or listening to books through podcasts, which was not mentioned in the Arabic-speaking group

‘My English is not good, especially understanding books, I can only understand general ideas. I subscribed and I listen to podcasts [about health and self-development] as soon as something new is posted. In other words, I like to listen to books.’ (Mongolian-speaking mother, 5 years in Australia)

Conversely, the Arabic-speaking mothers preferred obtaining information through visual formats such as short videos and images.

‘I like videos because sometimes a person will be in a hurry and can’t be bothered reading. Sometimes I put it on and hang the washing, cook, clean and listen. That way I can finish my chores and also benefit from the information.’ (Arabic-speaking mother, 4 years in Australia)

Health professionals

Health professionals, such as GPs, Child and Family Health nurses, nutritionists and dietitians were often sought after for guidance on child health behaviours by both groups. However, both Arabic- and Mongolian-speaking mothers encountered barriers when accessing healthcare in Australia compared to their home countries. These barriers included the intricacies of navigating the different health system in Australia, which posed a challenge for some mothers, leading them to seek guidance from doctors in their home country as a coping mechanism

‘The GP service here is totally different from Lebanon. The system is totally different. In Lebanon, when I need to see a doctor, I can contact the paediatrician by phone for a consultation or advice in case of high fever or other health issue at night or throughout the weekend. Even the pharmacists in Lebanon don’t need a script, I could get a medication or antibiotics on the spot and solve the problem. It is complicated here. I have to make an appointment with the GP then I have to see the GP who might refer me to a Paediatrician if he couldn’t solve the issue or should the matter be taken further.’ (Arabic-speaking mother, 1 year in Australia)

Doctors in Australia were perceived as ‘unhelpful’ in comparison to doctors in their home country. This perception often arose when mothers observed doctors searching for information on Google, eroding their trust in the doctor’s expertise and giving rise to doubts about the accuracy of the medical information provided, which could potentially have led to concerns about the quality of care received. ‘To be frank, I don’t find the doctors here like the ones in our country. You go to the doctor for example to tell her something, she searches it on Google or on their program to give me the answer’ (Arabic-speaking mother, 5 years in Australia). Mothers also expressed their sense of unease resulting from the perception that doctors are time poor and rushed which affects their ability to fully engage in conversations and obtain information they need during interactions.

‘The GP’s time is limited and very rushed and (the GP) doesn’t explain the progress. And the big hospitals are the same, they just quickly check us with less explanation, and it makes me nervous by being rushed. In that circumstance, I forget what I was going to ask.’ (Mongolian-speaking mother, 6 years in Australia)

An Arabic-speaking interviewee stated that it was considered impolite to pose too many questions to healthcare professionals and hence she would often resort to other sources for information to compensate for the perceived limitations in obtaining comprehensive information during consultations ‘You know we get embarrassed asking too many questions. Instead, I spend an hour or two on the Internet to understand the information and get convinced’ (Arabic-speaking mother, 4 years in Australia).

Experienced mothers

Experienced family members and friends with children were identified as an important source of information for both groups of mothers, particularly when raising their first child. However, mothers also noted that as they gained personal experience in child rearing, they relied less on seeking advice from others, indicating transitional confidence in their own parenting skills over time

‘I used to ask my mother or mother-in-law sometimes. But that was in the past when I had my first baby. I had no experience. Now with my third child I didn’t need to. I am experienced now because it is my third baby.’ (Arabic-speaking mother, 7 years in Australia)

Assessing trustworthiness of online information

The Internet was perceived as beneficial and a valuable platform for mothers to access a wealth of information. However, some concerns were expressed about the trustworthiness of online information. Mothers in both groups mentioned employing various strategies to assess the reliability and trustworthiness of information they found online. Mothers typically adopted a multi-step approach, which involved cross-checking the information across multiple websites. If the information was found to be consistent, it was considered trustworthy. However, if discrepancies arose, mothers in both groups often sought validation from family members or consulted their GPs ‘I check several websites. If the information is contradictory, I ask my family or look at something else. But if the information matches, this is it’ (Arabic-speaking mother, 1 year in Australia). Nonetheless, the previously mentioned challenges associated with accessing GPs, led mothers to resort to alternative methods.

‘If the situation is more complicated, then I go to see my GP. But seeing a GP here is not easy, sometimes the available appointment is a week away. Now everything is developed, and all the information is out there, so taking that much time waiting for someone is a bit tricky. Sometimes I just consult with my mother.’ (Mongolian-speaking mother, 3 years in Australia)

Mongolian-speaking mothers usually selected and trusted resources that were Australian based, including official government or hospital websites ‘Generally, I prefer to use Australian websites when I do the search’ (Mongolian-speaking mother, 5 years in Australia). In contrast, Arabic-speaking mothers tended to select resources that they could culturally relate to, such as websites for Arabic-speaking doctors ‘I follow an Egyptian doctor on YouTube. I follow his information which I trust’ (Arabic-speaking mother, 10 years in Australia). Some mothers would choose resources that would provide reassurance and validation for their parenting practices and would often feel relieved when the information they found aligned with their current approach ‘. . . For example, let’s say I am just looking for information on how many hours a baby should sleep and if I find the information that matches with how I am doing, I am satisfied and relieved’ (Mongolian-speaking mother, 6 years in Australia).

Topics most commonly searched for by parents

Mothers typically sought information related to various child health practices such as nutrition, sleep, and play or when they encountered health concerns and wanted quick answers. Notably, mothers tended to search for information that was relevant to their child’s current age or developmental milestone, rather than for future milestones.

‘For food, I used to search for information around what age a child can eat certain food. Now since my child is 16 months, I don’t search for it much. When she/he was 6 months old starting solid food, I usually googled what to feed and what I can’t feed.’ (Mongolian-speaking mother, 3 years in Australia)

A common topic of concern that mothers in both groups frequently searched for was information related to physical, cognitive, and verbal developmental delays, indicating the importance of this issue among mothers of young children.

‘Also concerning my son, since he is turning 2, I read that there are words he should be using. His vocabulary is limited in general. He keeps using the same words. I’m trying to search for the cause of the problem when it comes to his speech. How to correct the situation? Is it me? Is it our family environment?’ (Arabic-speaking mother, 1 year in Australia)

Theme 2: cultural influences on parental practices in early years of child’s life

The second theme discusses cultural customs embraced by mothers regarding child health behaviours, their recognition of generational variations, and the factors influencing their decisions to either adopt or abstain from these practices. Furthermore, it sheds light on the concept of acculturation and mothers’ willingness to modify their cultural traditions in alignment with their host country’s norms.

Mothers in both groups mentioned various traditional practices they implemented related to child health behaviours. Among Mongolian-speaking mothers, common practices included strict confinement periods (mothers avoiding showers for 40 days, using cotton balls in ears, dressing in warm clothes, avoid touching frozen meat and cold water), feeding babies rice water to coat their gut and mothers consuming flour-based foods to increase milk supply. They also pointed out the cultural differences in the first solid foods introduced to children. In Australia, a wide variety of vegetables exist that are not available in Mongolia

‘I have learnt that Australians start with vegetables and starting with vegetables is the right way instead of starting with our Mongolian ways such as rice soup or meat soup. And I have learnt there are many different varieties of vegetables, some of them I never knew existed.’ (Mongolian-speaking mother, 4 years in Australia)

Arabic-speaking mothers practised less strict confinement, addressed baby’s tummy aches by offering herbal drinks such as cumin, aniseed, or distilled orange blossom; gave sugar water to prevent jaundice; and wrapped and rocked the baby vigorously to induce drowsiness.

Despite the adoption of these cultural practices among many mothers, a significant portion of them were aware of the generational differences and refrained from implementing these practices. These mothers believed that modern medicine has advanced and would seek doctors’ advice before incorporating cultural practices related to child health.

‘The way she raised her (child’s grandmother) children is way outdated. Nowadays science has advanced knowledge. She tells me to give him aniseed. We always raised our kids giving them aniseed and no one was harmed. I didn’t give it to my son. I told her I gave it to him just to get her to rest.’ (Arabic-speaking mother, 4 years in Australia)

Conversely, a few mothers greatly valued the experience and advice of their elders and trusted their advice regardless of what the health professionals said.

‘Yes of course. The experience is important. As soon as mum arrives, she predicts why the baby was crying, whether a tummy ache or hungry or what is bothering him. No matter what you are told or how much you read on the internet, experience is more essential. I have 100% more trust in mum’s experience.’ (Arabic-speaking mother, 1 year in Australia)

Mongolian-speaking mothers were found to acculturate and adapt their cultural practices based on their country of residence, adhering to Australian practices while in Australia and reverting to their traditional practices in Mongolia. This behaviour was attributed to their belief that the environment and geographical differences impact health in distinct ways and would adjust accordingly. Such behaviour was not identified among the Arabic-speaking group.

‘For my first born, I was here so I followed Australian practice. But for my second child, I was in Mongolia, and I followed Mongolian confinement period because I thought maybe the difference of geography affects our health in a different way ‘If you drink the water of the land, then follow of the custom of the land [Mongolian proverb].’ (Mongolian-speaking mother, 4 years in Australia)

Theme 3: migrant parent experiences accessing support related to infant health behaviours in a foreign country

Theme 3 encapsulates the journey of migrant mothers as they navigate the complexities of accessing health information in Australia. It delves into the impediments encountered when seeking healthcare services and the challenges associated with raising their children in a foreign land.

Barriers to accessing health services and resources

Migrant mothers experienced barriers to accessing health information and voiced concerns regarding Internet usage, noting that the available health information was often too generic and vague. One Arabic-speaking interviewee expressed a desire for an Australian-based website that was in language and specifically tailored to their needs ‘There are no websites for us in Australia. The majority you get from Arab countries. I wish to have a website for us here’ (Arabic-speaking mother, 10 years in Australia). Mongolian-speaking mothers reported difficulties finding accessible health websites in their native language and would often resort to using Google translate ‘Mongolian websites are very tricky and hard to find what I am looking for and hard to navigate. So, I search it in English and use Google translate to understand’ (Mongolian-speaking mother, 3 years in Australia). Language barriers were a significant obstacle, making it challenging for mothers to articulate the questions for their queries ‘sometimes I don’t know the right word or expression to search and or sometimes I can’t find what I am looking for’ (Mongolian-speaking mother, 5 years in Australia). This often left them feeling frustrated and hopeless ‘“If you have languages, you have legs” means if you have learnt languages, you can go wherever you want to go and succeed. I feel like I am blind’ (Mongolian-speaking mother, 3 years in Australia).

Language barriers were also an obstacle for mothers accessing healthcare services in Australia. Some mothers mentioned refraining from asking for help or discussing their concerns with health professionals due to their limited English proficiency and lack of confidence ‘During my pregnancy, if the doctor asked me any questions related to health concerns, I tried to avoid further questions and always used to say everything was good even though there were some concerns’ (Mongolian-speaking mother, 4 years in Australia).

While some Mongolian-speaking mothers were aware of existing interpreter services, they reported negative experiences such as difficulties navigating through the booking system and no-show interpreters on the day ‘there were not enough interpreters even though I always used to book an interpreter when I went to see a doctor, but there were times when the interpreter would not show up and or the waiting period was long’ (Mongolian-speaking mother, 4 years in Australia). Arabic-speaking mothers, on the contrary, heavily relied on their husbands to translate information ‘My husband attends my appointments and translates for us’ (Arabic-speaking mother, 1 year in Australia).

Due to lack of knowledge and understanding of the available services, mothers encountered challenges in navigating the differing healthcare systems between Australia and their country of origin. For instance, mothers were unfamiliar with Child and Family Health and lactation consultant services since these services were not available in their country ‘some services provided here are not in Mongolia such as Child and Family Health Centre etc as it’s a bit different’ (Mongolian-speaking mother, 5 years in Australia). In addition, mothers reported difficulties with the referral process as they were accustomed to directly seeing specialists in their home country, while in Australia they had to be referred by a GP.

Fear of costs as a barrier to accessing services was specifically mentioned among Mongolian-speaking mothers. They often avoided seeking professional help due to uncertainty of the charges, as in Mongolia they would be required to pay upfront for any service they wanted to access.

‘It’s hard for us to guess the cost of the service and what to expect for a bill. Some people couldn’t go because they were afraid how much money they might have to pay after the service. Even if they went to the doctor, they were afraid how much they would be charged for that. So, I wish they would give information about the price. They don’t write it on their own website. In Mongolia, we pay instantly even before the service, but here we get the service first and pay later and that’s tricky and surprising if the bill is huge.’ (Mongolian-speaking mother, 4 years in Australia)

Lack of social supports to help manage parenting challenges

Both groups encountered challenges with raising children in a foreign country without the support of family and friends and found that people in Australia tended to be occupied, which left them feeling isolated ‘Being a new mother without the support of someone experienced like my mum is hard. She might give me advice over the phone that I can’t apply. It’s different from being next to her’ (Arabic-speaking mother, 1 year in Australia). This predicament contributed to considerable mental strain on the Mongolian-speaking mothers, who said to have frequently observed elevated levels of postpartum depression within their community. This was concerning given the difficulties they face in accessing appropriate healthcare services ‘Yes, Mongolian mothers in Australia are very vulnerable as they are far from their parents and loved ones and doing everything on their own in a foreign country . . . I have noticed that our Mongolian mothers get depressed a lot’. (Mongolian-speaking mother, 3 years in Australia).

Discussion

This study explored the barriers and enablers experienced by migrant mothers who speak Arabic and Mongolian in accessing child health information in Australia. The main findings revealed that there were variations in the selection and trust of resources between mothers in these cultural groups. Although there were differences for individuals, there were also several shared challenges that migrant mothers encountered in their interactions with health professionals and accessing health services in Australia.

Challenges accessing resources and health services

Both groups of mothers heavily relied on the Internet for information related to child health behaviours. This was a salient theme in a recent study investigating infant feeding supports among Arabic- and Chinese-speaking migrant mothers’ living in Australia.³⁵ One reason for this may be the adverse encounters mothers have experienced with health professionals. The presence of language barriers and perceptions that GPs are time constrained may have contributed to migrant mothers viewing GPs as unhelpful and culturally incompetent when seeking health information. This may have also contributed to their reliance on other sources such as the Internet for health information. Similarly, a study conducted in Melbourne, examining the access of migrants to maternal and child health services, revealed that migrants encountered considerable obstacles when accessing health services in Australia and would resort frequently to alternative sources for health information.³⁶ While Arabic- and Mongolian-speaking migrant mothers heavily depend on the Internet for information, their behaviour is not distinctly different from that of the global population, as such reliance on the Internet is now a commonplace. Due to technological advancements, there is an ongoing rise in Internet accessibility.³⁷ A growing number of Internet users, accounting for approximately 4.5% of all searches, now seek health-related information through various web-based resources.^38,39

Previous studies have highlighted the barriers migrants face in accessing health services and their low use of such services.^24,40 However, a gap remains in the availability of a strategic, on-arrival service to assist migrants in navigating and overcoming these barriers. A service should be provided to inform migrants of ways to access available services and link them with culturally competent health professionals. Furthermore, improved interpreter services are vital for increasing access to health services. Although Arabic-speaking mothers relied on family members to translate information during consultations with GPs, they are not qualified interpreters. Using non-qualified interpreters in healthcare poses a significant risk as it can lead to miscommunication, misunderstanding, and compromised patient safety, potentially resulting in inaccurate information.⁴¹ In addition, Mongolian-speaking mothers would often hesitate to discuss their concerns or queries with health professionals due to the language barriers they experienced and the struggles they faced with obtaining an interpreter. Therefore, providing onsite interpreting services or employing an effortless booking system is key to improving accessibility among migrant parents.^23,42,43

Another significant barrier to accessing healthcare services that emerged, especially among Mongolian mothers was the fear of incurring costs. A previous study found that parents from CALD backgrounds who give birth in Australia are less likely to use health services due to many factors including cost.⁴⁴ Although private health insurance is available in Australia, the out-of-pocket costs for treatments and services can be substantial.⁴⁵ Although publicly funded services are available in Australia, accessing them may be challenging due to longer waiting lists and limited options for choosing health professionals. The unfamiliarity with a new system and challenges adapting to a new way of life can exacerbate these barriers to healthcare access. This aligns with findings from a Canadian study, which revealed that immigrants faced difficulty accessing care due to economic and geographical barriers.⁴⁶ This emphasizes the need for a more transparent healthcare system that clearly outlines available services and associated costs, reducing the financial barriers that hinder access to care.

Mode of delivery of information

Mongolian mothers exhibited a high level of engagement with Facebook as a source of information, whereas Arabic-speaking mothers demonstrated a reluctance to participate in online forums. This may be due to the influence of different cultural norms, values, and privacy concerns between cultural groups that can potentially impact social media adoption and usage.⁴⁷ Another reason for this difference is that the Mongolian community in Australia is relatively smaller compared to the culturally diverse Arabic-speaking community, which encompasses individuals from various countries. As a result, Mongolian-speaking mothers may face challenges in connecting with their community face-to-face, leading them to rely more on online sources for support and information. This corresponds with a study which found that minority communities who do not speak English are more inclined to seek information and assistance through social media platforms.⁴⁸

A notable trend observed was that most Arabic-speaking mothers obtained information through visual aids such as videos and images, whereas Mongolian mothers preferred written textual information. This difference may have been influenced by the disparity in education levels between the two groups, with all Mongolian-speaking mothers having completed a university degree or higher, while the majority of Arabic-speaking mothers had only completed high school or obtained a diploma. This aligns with previous research demonstrating that video-based health education is particularly effective for improving knowledge and addressing low literacy levels among CALD communities.^49,50 A study conducted with Korean immigrants to America also found that mothers were much more likely to use books and booklets as their health information source if they had completed a high level of education.⁵¹ This highlights the additional challenges faced by migrant mothers with lower levels of education in reading and comprehending written information, which may reduce the accessibility of such resources for them. Hence, it is crucial to offer health information in various formats to cater to the diverse educational backgrounds of migrants.

Assessing trustworthiness of information

In both groups, parents reported using cross-checking techniques to assess trustworthiness of online information by checking the information across multiple websites to ensure consistency. This finding aligns with a survey conducted among Canadian parents investigating Internet usage for child healthcare information, revealing that more than half the participants cross-checked the accuracy of information with a doctor or family and friends.⁵² However, in our study, mothers tended to cross-check information with individuals and healthcare professionals as a secondary, rather than a primary, step. This may be due to the difficulties migrant parents encounter when accessing health professionals as mentioned above and the limited social networks and family members available in their new environment after migration.

Generational differences and acculturation

Mongolian mothers exhibited a pattern of acculturation, adapting to Australian practices while residing in Australia but reverting to their traditional practices in Mongolia. Acculturation is a nuanced and flexible approach where it recognizes the importance of maintaining one’s cultural identity while embracing elements of the new culture, allowing individuals to selectively adopt practices that align with their preferences and needs.⁵³ The degree of acculturation of Mongolian-speaking mothers may be attributed to the notion that they believe the environment influences health outcome and adjusting their practices to the country and environment of residence to optimize their health and wellbeing. In contrast, Arabic-speaking mothers did not demonstrate the same acculturation pattern. This is likely related to the influence of moderating variables that may impact the extent of acculturation such as challenges in establishing social networks, cultural preservation, education levels, and the belief that the cultural practice will yield optimal health outcomes.^54,55

Many mothers acknowledged the advances in medicine and the generational differences in child health practices between the times when their own parents were caring for young children and current health recommendations. Interestingly, various studies have previously highlighted the heavy reliance of migrant parents on advice from family members regarding child health behaviours.^35,56 This difference may be due to rapid advances in technology and increasing digital literacy among individuals.¹⁰ This digital literacy enables them to access a vast range of online information, and then read and compare advice to ultimately make informed health decisions based on their level of conviction.

COM-B model

This semi-structured telephone interview was mapped to the COM-B model. This model emphasizes the importance of external elements, including physical and social opportunities, in facilitating the occurrence of behaviour.^30,31 The results indicated that almost all mothers relied on the Internet for health information, highlighting the importance of ‘physical opportunity’ in adopting behaviours. Language barriers experienced during interactions with healthcare professionals hindered the mothers’ ‘psychological capability’ to articulate their questions effectively and engage fully in discussions, leading to feelings of helplessness. This is supported by research conducted in Australia, which identified that language or communication barriers hindered the patient’s ability to communicate their healthcare needs effectively resulting in unmet healthcare needs.⁵⁷

Mongolian mothers predominantly used social media parent groups to connect with individuals from their own culture and access health information, exemplifying the significance of ‘social opportunity’ in their decision-making process. However, Arabic-speaking mothers, while also valuing social connections, preferred more conservative approaches, relying more on people they already knew for information. This may be influenced by the presence of a larger Arabic-speaking community in Australia, which provides them with a wider network of familiar individuals to socialize with.²⁸ Visual-based health education was perceived by Arabic-speaking mothers as an effective means to improve their uptake of information, thus influencing their automatic motivation to engage with the resource. This is in line with findings from multiple studies that have reported the positive impact of information presented in visual formats on parental knowledge, satisfaction, and health outcomes.^58,59

Participants demonstrated a strong sense of ‘reflective motivation’ by acknowledging the advances in medicine and recognizing generational differences in practices. They were selective in their approach, focusing only on practices they were convinced would benefit their child’s health, a common mindset and practice among parents.⁷ These findings underscore the multifaceted nature of motivation and the complex interplay between cultural factors, information preferences, and belief systems in shaping mothers’ health-related behaviours.

Strengths and limitations

This study has several limitations. First, most participants resided in New South Wales (NSW), which may limit the generalizability of the findings to Arabic and Mongolian mothers in other jurisdictions. A broader recruitment approach may have captured a wider range of educational backgrounds and provided more diverse insights and perspectives. Furthermore, while the interviews were conducted in their respective language, the analysis was done in English. Although efforts were made to ensure the integrity and credibility of analysis, there remains a possibility of nuances and cultural subtleties being lost during translation.

A strength of this study is that interview data coding was validated by a senior qualitative researcher, enhancing the overall rigour of the study. In addition, the interviewers shared the same cultural background as the participants, allowing for a deeper understanding and connection during the interviews. The use of interviewers who spoke the same language as the participants eliminated the need for an interpreter, saving time and potentially enhancing the quality of the interviews. Furthermore, the recruitment of a diverse group of Arabic-speaking participants from multiple countries added to the richness and inclusivity of the findings, considering the cultural diversity within the Arabic-speaking community.

Implications for policy, practice, and research

Parents who have migrated from CALD countries often encounter unique challenges when accessing resources and health services. To address these barriers, it is essential for health professionals to be culturally competent and allocate sufficient time to engage with CALD families.⁶⁰ Taking proactive measures to understand and address their questions and concerns can greatly improve quality of care and support provided. Also, establishing effective communication channels and culturally responsive resources can help prevent misinformation from unreliable sources. The provision of credible, culturally tailored resources is crucial in ensuring that migrant parents receive trustworthy information for their healthcare needs.

Implementing on-arrival services specifically designed to assist migrants in navigating the healthcare system can greatly enhance their access to available services. Such services should prioritize transparency in costs, ensuring that migrants are well-informed about the financial aspects of healthcare and the resources available to them.⁶¹

Language barriers can be a major challenge for migrant parents during health consultations. To overcome this, policies should be implemented to streamline access to interpreters, which can contribute to more effective and efficient communication between healthcare providers and migrant parents.

Future initiatives aimed at developing resources or services for this target group should involve them as co-design researchers to enhance the relevance and effectiveness of these resources and services. This will empower them by providing a sense of ownership and will ensure that all developed materials are culturally responsive and align with their specific needs.

Conclusion

This study sheds light on the diverse range of barriers and enablers that immigrant mothers encounter when accessing child health resources and services. Language barriers, financial constraints, and difficulties accessing services were identified as significant challenges. This study also revealed notable difference in the modes of content delivery preferred by Arabic and Mongolian mothers, which should be considered in the development of future resources and services. Health professionals, government agencies and researchers should work on addressing some of the key recommendations to promote health equity and enhance the overall well-being of the CALD population.

Supplemental Material

sj-docx-1-whe-10.1177_17455057241242674 – Supplemental material for Barriers and enablers to accessing child health resources and services: Findings from qualitative interviews with Arabic and Mongolian immigrant mothers in Australia

Supplemental material, sj-docx-1-whe-10.1177_17455057241242674 for Barriers and enablers to accessing child health resources and services: Findings from qualitative interviews with Arabic and Mongolian immigrant mothers in Australia by Danielle Jawad, Li Ming Wen, Chris Rissel, Louise Baur, Seema Mihrshahi and Sarah Taki in Women's Health

Footnotes

Acknowledgements

The authors would like to thank the participants for sharing their experiences with us and the cultural support workers from Diversity Hub at Sydney Local Health District. We also like to thank the project team and partners from Tripoli and Mena Association and Sydney Local Health District. This work is a component of PhD studies of D.J. at the University of Sydney.

Declarations

ORCID iDs

Danielle Jawad

Li Ming Wen

Supplemental material

Supplemental material for this article is available online.

References

Scaglioni

De Cosmi

Ciappolino

, et al. Factors influencing children’s eating behaviours. Nutrients 2018; 10(6): 706.

Morgan

Schoonees

Sriram

, et al. Caregiver involvement in interventions for improving children’s dietary intake and physical activity behaviors. Cochrane Database Syst Rev 2020; 1(1): CD012547.

Mihrshahi

Gow

Baur

. Contemporary approaches to the prevention and management of paediatric obesity: an Australian focus. Med J Aust 2018; 209(6): 267–274.

Health and Social Policy. The first 2000 days framework. NSW Ministry of Health, 2019, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2019_008.pdf

World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization, 2009.

Nicholson

McDonnell

De Brun

, et al. Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare – systematic review. BMC Health Serv Res 2020; 20(1): 663.

Breiner

Ford

Gadsden

(eds). Parenting matters: supporting parents of children ages 0-8. Washington, DC: National Academies Press, 2016.

Hamzallari

Rosinski

Petrenko

, et al. Mothers’ emotion regulation and negative affect in infants: the role of self-efficacy and knowledge of parenting practices. Children (Basel) 2022; 10(1): 85.

Zaidman

Scott

Hahn

, et al. Impact of parental health literacy on the health outcomes of children with chronic disease globally: a systematic review. J Paediatr Child Health 2023; 59(1): 12–31.

10.

Kubb

Foran

. Online health information seeking by parents for their children: systematic review and agenda for further research. J Med Internet Res 2020; 22(8): e19985.

11.

Yardi

Caldwell

Barnes

, et al. Determining parents’ patterns of behaviour when searching for online information on their child’s health. J Paediatr Child Health 2018; 54(11): 1246–1254.

12.

Willey

Gibson-Helm

Finch

, et al. Implementing innovative evidence-based perinatal mental health screening for women of refugee background. Women Birth 2020; 33(3): e245–e255.

13.

Vergani

Mansouri

Weng

, et al. The effectiveness of ethno-specific and mainstream health services: an evidence gap map. BMC Health Serv Res 2022; 22(1): 879.

14.

Renzaho

AMN

Green

Smith

, et al. Exploring factors influencing childhood obesity prevention among migrant communities in Victoria, Australia: a qualitative study. J Immigr Minor Health 2018; 20(4): 865–883.

15.

Fauk

Ziersch

Gesesew

, et al. Migrants and service providers’ perspectives of barriers to accessing mental health services in South Australia: a case of African migrants with a refugee background in South Australia. Int J Environ Res Public Health 2021; 18(17): 8906.

16.

Jawad

Cheng

Wen

, et al. Interactivity, quality, and content of websites promoting health behaviors during infancy: 6-year update of the systematic assessment. J Med Internet Res 2022; 24(10): e38641.

17.

Bhugra

Becker

. Migration, cultural bereavement and cultural identity. World Psychiatry 2005; 4(1): 18–24.

18.

Afonso

Barros

Albert

. The sense of belonging in the context of migration: development and trajectories regarding Portuguese migrants in Luxembourg. Integr Psychol Behav Sci 2023; 57(2): 518–546.

19.

Zulfiqar

Strazdins

Banwell

. How to fit in? Acculturation and risk of overweight and obesity. Experiences of Australian immigrant mothers from South Asia and their 8- to 11-year-old children. SAGE Open 2021; 11(3), https://doi.org/10.1177/21582440211031798

20.

McAuliffe

Triandafyllidou

. World migration report 2022. Geneva: International Organization for Migration (IOM), 2021.

21.

Australian Bureau of Statistics (ABS). Migration, Australia. Canberra, ACT, Australia: ABS, 2019.

22.

Australian Bureau of Statistics (ABS). Cultural diversity: census. Canberra, ACT, Australia: ABS, 2021.

23.

Anandakumar

Preston

, et al. A model explaining refugee experiences of the Australian healthcare system: a systematic review of refugee perceptions. BMC Int Health Hum Rights 2019; 19(1): 22.

24.

Khatri

Assefa

. Access to health services among culturally and linguistically diverse populations in the Australian universal health care system: issues and challenges. BMC Public Health 2022; 22(1): 880.

25.

Wen

Baur

Simpson

, et al. Effectiveness of home based early intervention on children’s BMI at age 2: randomised controlled trial. BMJ 2012; 344: e3732.

26.

Cachia

Millward

. The telephone medium and semi-structured interviews: a complementary fit. Qualitat Res Organ Manage 2011; 6: 265–277.

27.

Musselwhite

Cuff

McGregor

, et al. The telephone interview is an effective method of data collection in clinical nursing research: a discussion paper. Int J Nurs Stud 2007; 44(6): 1064–1070.

28.

Australian Bureau of Statistics (ABS). Language used at home (LANP). Canberra, ACT, Australia: ABS, 2021.

29.

Department of Foreign Affairs and Trade. Mongolia country brief, 2021, https://www.dfat.gov.au/geo/mongolia/mongolia-country-brief

30.

Susan Michie

Gainforth

. The behaviour change wheel – a guide to designing interventions. Great Britain: Silverback Publishing, 2014.;

31.

Michie

van Stralen

West

. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011; 6: 42.

32.

Gale

Heath

Cameron

, et al. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013; 13: 117.

33.

Smith

Firth

. Qualitative data analysis: the framework approach. Nurse Res 2011; 18(2): 52–62.

34.

Lester

Cho

Lochmiller

. Learning to do qualitative data analysis: a starting point. Hum Resour Develop Rev 2020; 19(1): 94–106.

35.

Marshall

Taki

Love

, et al. Navigating infant feeding supports after migration: perspectives of Arabic and Chinese mothers and health professionals in Australia. Women Birth 2021; 34(4): e346–e356.

36.

Riggs

Davis

Gibbs

, et al. Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers. BMC Health Serv Res 2012; 12: 117.

37.

Poushter

. Internet access growing worldwide but remains higher in advanced economies. Pew Research Center, 22 February 2016, https://www.pewresearch.org/global/2016/02/22/internet-access-growing-worldwide-but-remains-higher-in-advanced-economies/#:~:text=and%20the%20UK.-,Daily%20internet%20use%20is%20fairly%20common%20globally,at%20least%20once%20a%20day.

38.

Eysenbach

Kohler

. What is the prevalence of health-related searches on the World Wide Web? Qualitative and quantitative analysis of search engine queries on the internet. AMIA Annu Symp Proc 2003; 2003: 225–229.

39.

Cheng

Dunn

. Health literacy and the internet: a study on the readability of Australian online health information. Aust N Z J Public Health 2015; 39(4): 309–314.

40.

Guo

Liu

Chong

, et al. Health service utilisation and unmet healthcare needs of Australian children from immigrant families: a population-based cohort study. Health Soc Care Community 2020; 28(6): 2331–2342.

41.

White

Plompen

Tao

, et al. What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting. BMC Public Health 2019; 19(1): 1096.

42.

Blay

Seremetkoska

Morris

, et al. Interpreter provision and hospital-associated outcomes within the limited English proficiency population: analysis of administrative data. J Gen Intern Med 2019; 34(6): 820–822.

43.

McBride

Block

Russo

. An integrated healthcare service for asylum seekers and refugees in the South-Eastern Region of Melbourne: Monash Health Refugee Health and Wellbeing. Aust J Prim Health 2017; 23(4): 323–328.

44.

Chen

Hillman

. Health services utilisation disparities between English speaking and non-English speaking background Australian infants. BMC Public Health 2010; 10: 182.

45.

Department of Health Aged and Care (ed.). Out of pocket costs. Australian Government, 2021, https://www.health.gov.au/topics/private-health-insurance/what-private-health-insurance-covers/out-of-pocket-costs

46.

Asanin

Wilson

. ‘I spent nine years looking for a doctor’: exploring access to health care among immigrants in Mississauga, Ontario, Canada. Soc Sci Med 2008; 66(6): 1271–1283.

47.

Chai

. Does cultural difference matter on social media? An examination of the ethical culture and information privacy concerns. Sustainability 2020; 12(19): 8286.

48.

Wen

Jawad

, et al. Ethnicity matters in perceived impacts and information sources of COVID-19 among mothers with young children in Australia: a cross-sectional study. BMJ Open 2021; 11(11): e050557.

49.

O’Mara

. Social media, digital video and health promotion in a culturally and linguistically diverse Australia. Health Promot Int 2013; 28(3): 466–476.

50.

Mead

Tindall

Charlton

. Evaluation of a nutrition education resource for refugees and newly arrived migrants to Australia. Health Promot J Austr 2023; 34: 536–543.

51.

Lee

. A comparative study on the health information needs, seeking and source preferences among mothers of young healthy children: American mothers compared to recent immigrant Korean mothers. Inform Res 2018; 23(4), https://files.eric.ed.gov/fulltext/EJ1200063.pdf

52.

Pehora

Gajaria

Stoute

, et al. Are parents getting it right? A survey of parents’ internet use for children’s health care information. Interact J Med Res 2015; 4(2): e12.

53.

Berry

. Acculturation: living successfully in two cultures. Int J Intercul Rel 2005; 29(6): 697–712.

54.

Renzaho

Dhingra

Georgeou

. Youth as contested sites of culture: the intergenerational acculturation gap amongst new migrant communities-Parental and young adult perspectives. PLoS ONE 2017; 12(2): e0170700.

55.

Fox

Thayer

Wadhwa

. Acculturation and health: the moderating role of socio-cultural context. Am Anthropol 2017; 119(3): 405–421.

56.

Rehayem

Taki

Brown

, et al. Infant feeding beliefs and practices of Arabic mothers in Australia. Women Birth 2020; 33(4): e391–e399.

57.

Komaric

Bedford

van Driel

. Two sides of the coin: patient and provider perceptions of health care delivery to patients from culturally and linguistically diverse backgrounds. BMC Health Serv Res 2012; 12: 322.

58.

Singh

Patil

, et al. Evaluation of the effectiveness of video-based intervention on the knowledge of infant oral health among new mothers. Int J Clin Pediatr Dent 2022; 15(3): 280–286.

59.

Wayan Romantika

Lusmilasari

Prabandari

, et al. Application of video-based health education in improving mother’s knowledge and attitudes about behavioral problems among preschool children. Enfermería Clínica 2020; 30: 172–176.

60.

Australian Government National Health and Medical Research Council. Cultural Competency in health: a guide for policy, partnerships and participation. Australian Government National Health and Medical Research Council, 2005, https://www.mhahs.org.au/images/cald/CulturalCompetencyInHealth.pdf

61.

Abood

Green

Polonsky

, et al. The importance of information acquisition to settlement services literacy for humanitarian migrants in Australia. PLoS ONE 2023; 18(1): e0280041.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB