Searching for choice and control: Western Australian service provider experiences of health, housing and migration

Abstract

This research aimed to inform approaches to increase access to secure housing and improve mental health outcomes for migrants from culturally and linguistically diverse backgrounds (hereafter migrants) who are generally invisible in health and social policy and service provision in Western Australia. We used semi-structured, in-depth interviews (n = 11) and interpretative phenomenological analysis to explore service provider experiences and perspectives of issues impacting service provision and the needs of migrants in this context. Five superordinate themes reveal complex experiences for both service providers and the migrants with whom they work. Findings reflect tensions between contemporary notions of choice and control and a social service system that is difficult to navigate, reflects systemic racism and appears to rely heavily on the non-government sector. Insights have important and practical implications for health promotion policy, practice and research. Recommendations include improvements to housing access, provision, funding and policies; addressing service barriers via staff training and more accessible community resources; and co-design and community outreach approaches.

BACKGROUND

The intersections among migration, housing and health present complex public health challenges (Kaur et al., 2021). There is extensive annual immigration into Australia. Approximately 395 000 migrants arrived in 2021–22 (Australian Bureau of Statistics, 2022a), and over a third of the Western Australian population was born overseas (Australian Bureau of Statistics, 2022b). In this research, migrants from culturally and linguistically diverse (CaLD) backgrounds (hereafter migrants) are categorized as those born in non-English-speaking countries and/or their primary language spoken at home is not English (Pham et al., 2021). Research suggests that migrants experience a duality of place (Fathi, 2021) and compounding social determinants of health across the migration journey. For example, settlement processes, loss of connection with country of origin, and stress associated with seeking asylum can increase the risk of homelessness, housing stress, social exclusion and discrimination, associated with a range of physical and mental health challenges (Kaleveld, Atkins et al., 2019; Wali et al., 2018).

When a person does not have suitable accommodation alternatives, they are considered homeless if their current living arrangement: is in an inadequate dwelling; or has no tenure, or if their initial tenure is short and not extendable; or does not allow them to have control of, and access to space for social relations (Australian Bureau of Statistics, 2012). In 2016, 15% of people experiencing homelessness in Australia were born overseas and had been in Australia for less than 5 years (Australian Bureau of Statistics, 2018). Recent census data indicate that just under half of those experiencing homelessness were born overseas (46%, n = ~56 000) (Australian Bureau of Statistics, 2023). Previous research has shown that in Western Australia (WA), almost 13% of people accessing homelessness support were born overseas (Government of Western Australia, 2019). However, in WA, while government strategies exist to address the intersection between housing and mental health (Mental Health Commission, 2020), they do not adequately recognize migrant needs.

The literature further demonstrates that migrants experience a range of service and policy barriers to secure housing. For example, Huynh and Neyland (2020) highlight the pervasive ‘whiteness’ of Australian refugee settlement policy and border control approaches, that is, ‘a perceived need to exert strict and often violent control over the movement of people of colour in and around Australia’ (p. 111). Government policies and processes concerning visas, immigration and social service access can be discriminatory and unsuitable (Shabbar, 2012; Wali et al., 2018). Communication and language barriers, negative experiences with government agencies (Wali et al., 2018), lack of cultural competence within government services, and lack of responsiveness due to a “one-size-fits-all” approach hinder accessibility and positive outcomes (Commonwealth of Australia, 2012). Lack of access to welfare support is also a driver of migrant homelessness (Kaleveld, Atkins et al., 2019). Attracting and maintaining staff (Katz and Sawrikar, 2008), access to interpreters (Ethnic Communities’ Council of Victoria, 2012) and lack of resources (Government of Western Australia, 2010) are also barriers.

Community-based services provide vital supports that complement housing provision for migrants (Mental Health Commission, 2020; Pleace and Quilgars, 2013; Wali et al., 2018). Housing, mental health and social service providers (hereafter service providers), including government and non-government organizations (NGOs) are essential in shaping the experiences of migrants accessing culturally responsive services (Smith et al., 2020; Wali et al., 2018). Service providers’ perspectives are crucial to understanding and improving migrant services (Pruitt et al., 2017). As Vergani et al. contend, ‘service provision is a key platform for enacting core citizenship rights’ (2022). However, these perspectives on homelessness, housing and mental health services are underexplored (Posselt et al., 2017). Furthermore, there is a paucity of public health interventions for migrants globally (Crawford et al., 2022).

This research is part of a project to inform service provision and policy approaches to housing and health for WA migrants vulnerable to or experiencing homelessness. Our work is informed by the Framework for Migration and Health adapted by the Odyssey Migration and Public Health Research Hub (Crawford and Vujcich, 2021) demonstrating the relationship between health and migration (Davies et al., 2009). It positions migration and health in its socioecological context, useful in identifying micro-, meso- and macro-level influences that act as facilitators or barriers to positive migrant health outcomes. Application of the socioecological model, foundational to a health promotion approach, is critical for multilevel interventions addressing individual, interpersonal, institutional and societal factors (Gray et al., 2021). The project had multiple components to explore this, including interviews with migrants from CaLD backgrounds, a scoping review (Crawford et al., 2022) and cluster analysis (Blackford et al., 2023). This article reports on qualitative research findings with WA service providers exploring two broad research questions: (i) What are the experiences of service providers working with people from CaLD backgrounds in the social services sector? and (ii) How do service providers make sense of and understand the needs of people from CaLD backgrounds in this work?

METHODS

Methodology

While service providers play a critical role in shaping and guiding the experiences of people from CaLD backgrounds in the social and human services space (Smith et al., 2020; Wali et al., 2018), there is a paucity of evidence offering sufficient insights into the nuance of this experience, or into effective service and policy approaches in the Australian setting (Smith et al., 2020). As such, the study used interpretative phenomenological analysis (IPA) to facilitate deep investigation into the nature of the work of service providers supporting people from CaLD backgrounds, and rich understandings of the dynamics and experiences of these providers working in the social and human services sectors (Larkin et al., 2006; Smith, 1996). IPA is grounded in the Heideggerian viewpoint of hermeneutics, focusing on experiential meaning and the critical role of ‘personal awareness’ and interpretation in understanding and exploring experiences (Reiners, 2012) and the critical role of the researchers in interpreting and making sense of these descriptions (Larkin et al., 2006; Smith, 1996). In this way, IPA is understood to constitute a double hermeneutic approach, in which phenomena or experiences as described and interpreted by the participant are, in turn, interpreted and given meaning by the researchers (Pietkiewicz and Smith, 2014).

Consistent with the Heideggerian perspective and IPA, considering temporal and spatial aspects of participant experience was essential. This meant understanding and interpretation were situated in the context of the subjective worlds in which they emerge (Davidsen, 2013; Tuohy et al., 2013). For example, the space that individuals occupy and where their experiences take place can impact the quality of this experience, and experiences necessarily occur at a point in time (Tuohy et al., 2013), in ‘a temporal context between past, present, and future’ (Davidsen, 2013). These considerations became especially relevant when considering the discussions of homelessness, housing and the experiences of people from CaLD backgrounds that emerged during the research. Careful consideration was also taken to assess the alignment of IPA with the research team’s ontological and epistemological standpoints. Consistent with work by Cuthbertson et al. (2020), this research was guided ontologically by critical realism, with an interpretivist epistemological viewpoint, recognizing not only the ‘socially and societally embedded’ nature of reality as it exists in individual’s minds but also the nature of knowledge as being socially constructed and generated through personal experience and interpretations (Cuthbertson et al., 2020).

Research team, reflexivity and ethical oversight

The research team comprised five WA-based women. Interviews were conducted by a medical doctor undertaking postgraduate studies with experience in public health and mental health. Other researchers were university-based academics and practitioners with experience in health promotion, public health and working with migrants and the housing and homelessness sector. The team established processes to ensure rigour: applying COREQ (Tong et al., 2007), reflexive practice, field notes and peer validation (Larkin and Thompson, 2012; Palaganas et al., 2017). The [Anon] Human Research Ethics Committee (HRE2020-0533) granted ethical approval for the study. Participants provided written informed consent before participation.

Sampling and recruitment

Using purposive sampling we recruited participants from metropolitan organizations providing migrants services for housing and homelessness, mental health or other social services (the sector) in 2021 based on recommendations from the Research Steering Group and research team. The capacity to comment on the domains of inquiry was stipulated as the inclusion criteria. Organizations were invited to participate by email and were provided with a participant information statement and consent form. The sample (n = 11) was mostly women (n = 8). More than half self-identified from a CaLD background (n = 6) and worked predominantly with migrants (n = 6). Participants had worked in the sector for between 3 and 30 years, and most worked in housing and homelessness (n = 7).

Data collection

The study conducted semi-structured, in-depth interviews (50–94 min) via telephone or videoconferencing. A scoping review exploring public health interventions to address migrant housing and mental health needs (Crawford et al., 2022) informed inquiry domains. Findings from a cluster analysis (Blackford et al., 2023) undertaken as part of the broader project to identify profiles of migrants at risk of homelessness informed vignettes included in the interview guide. This component encouraged participants to explore their experiences and understandings of migrant journeys through the service system (Crosier and Handford, 2012; Kelly et al., 2016). Interviews were audio-recorded with participant permission and transcribed.

Data explication

For data management, we uploaded transcripts to Nvivo 12 (Version 12.6.1.970). Transcripts were de-identified and reviewed for familiarization with the data before commencing the IPA process (Pietkiewicz and Smith, 2014; Smith and Osborne, 2007). IPA involved entering the ‘hermeneutic circle’ (Pietkiewicz and Smith, 2014). This involved a cycle of naïve reading, structural analysis and interpretation of the whole data set (Lindseth and Norberg, 2004). Initially, we considered transcripts individually to explore unique participant characteristics before connecting themes and pattern meaning across participant narratives. This process facilitated immersion in individual accounts, supporting in-depth interpretation and connection to the data (Larkin and Thompson, 2012; Smith and Osborne, 2007).

Individual transcripts were re-read, making initial observations, then read a third time, with annotations and broad initial concepts structured into specific emergent themes (Pietkiewicz and Smith, 2014), such as ‘lack of self-agency’, ‘reluctance to engage’ and ‘resilience’. Weight was given to temporal and spatial aspects of narratives (Davidsen, 2013), particularly about participant descriptions of migrant journeys into, through and out of services and systems (often encompassing a return into the system). Emergent themes were examined for relationships and then pooled to create superordinate and subordinate themes. Multiple researchers reviewed themes across the data, consolidating common narratives and core concepts (Smith and Osborne, 2007). This stage commenced the construction of a theoretical narrative, establishing themes reflecting both content, as well as meaning ascribed to content by participants (Larkin and Thompson, 2012). Increasing abstraction occurred as themes were finalized.

RESULTS

Findings are presented with illustrative participant quotes and sources. Each of the superordinate themes contains subordinate themes illustrated in Table 1.

Common threads and recurring issues

Participants identified common experiences in their interactions with migrants, including multiple intersecting factors related to housing, language and trauma.

Multiple vulnerabilities and compounding intersections

Participants described issues experienced by migrant clients, such as housing, employment, income, language skills, mental health, alcohol and other drugs, trauma, obligation to family, shame and stigma and discrimination and racism. Narratives suggested these issues acted as service provision barriers. In describing a ‘typical’ profile of someone attending their service, a common thread was that ‘chaos happens’ for migrants who experience multiple vulnerabilities:

Say single parents, typically female, around four children, roughly, four or five, low income, Centrelink dependent (Centrelink provides social security payments and services to Australians), low to medium English. Sometimes requiring an interpreter, sometimes not. Not working. Not well supported by the community or locally. (Housing)

In describing the journeys and experiences of migrants, participants used terms such as ‘intersectionalities’, ‘exacerbated’ and ‘layered’ to capture aspects of marginalization, often described as negatively shaping the experiences of migrants. For example, reluctance to engage with government-provided services was identified as preventing migrants from accessing support. Reasons included fear of authority, such as police, or distrust of government agencies, based on previous experiences.

Housing as priority, place and security

Participants agreed housing was a priority for migrants, framed as more than accommodation, creating a space of security, refuge and belonging. Across and within narratives, participants were clear that ‘people deserve to have a roof over their head’. Housing was also described as the foundation from which other services could be accessed and delivered and central to engagement with recovery (related to trauma, homelessness, alcohol and other drug use or mental health). Several participants specifically identified Housing First (an approach quickly connecting people experiencing homelessness with long-term housing without preconditions) as valuable because of its philosophy on reducing barriers to housing and focus on wraparound services.

Participants also described housing as precarious. Difficulties experienced by migrants were noted in obtaining secure accommodation, including a lack of employment and income, insufficient social support and the impact of the COVID-19 pandemic:

Housing stress comes because of how high the cost of housing has gone and how scarce the housing supply is. If you don’t have a stable income or any income, you won’t be competitive to get a rental. And then they get … threats from their landlords … and they get taken advantage of in substandard housing conditions, or be charged extremely high cost, or … we’ve had clients facing, like direct discrimination. (Welfare)

Participants highlighted systemic barriers such as housing prices and lack of public housing stock, as well as the inability of accommodation providers and the broader public housing sector to provide for the specific needs of migrant families regarding housing size and location.

The limitations of language

Language and communication were considered key barriers to service access and provision for migrants, including lack of language-appropriate, accessible resources, poor English proficiency and first-language illiteracy. Some participants identified a lack of access to technology and the internet for clients with low literacy, noting it as necessary for contemporary and accessible communication. While participants reported value in the role of interpreters, they cited multiple issues, including availability, quality and lack of confidentiality. Government-provided social services and systems were reportedly difficult to navigate:

They say, “get them to call us or come in”, but they don’t provide an interpreter. They’re supposed to provide an interpreting service, but it’s never offered to them [migrants]. It’s not beneficial for them to go in or to call; they’re not going to get any understanding because they don’t understand English very well. (Housing)

Trauma permeates experience

Participants identified multifaceted trauma as pervasive in the lives of migrants. Trauma resulted from significant life events (for example, interpersonal violence), described by one participant as ‘big T trauma’. However, ‘little t trauma’, was also reported reflecting more personal experiences such as discrimination:

… I think for some people, it’s past trauma of either intergenerational trauma or trauma within their country of origin. But additionally, you’ve got the family domestic violence trauma that may follow them here, or additional struggles once they’re here, and particularly for those … who are migrating, and trying to learn a new language, find supports, find communities. (Homelessness)

Trauma was both a driver of and barrier to service access; ‘trauma-informed’ approaches were reportedly integral. Approaches described included gaining an in-depth understanding of individual circumstances, reducing the need for clients to re-tell their stories, adapting practices and expectations to align with the ability of the client to engage with them, ensuring consistency of support and providing ‘choice and control’ in support provision.

The dissonance of ‘CaLD’ identity

Participant narratives revealed how the use of ‘CaLD’ was problematized in service delivery. While participants recognized the value of this terminology, they reported being more likely to apply ‘person-centred’ approaches than ways of working that reflected an understanding of unique or ‘CaLD-specific’ sociocultural considerations. Narratives also highlighted tensions regarding mainstream versus tailored migrant services.

The vexed nature of ‘CaLD’

Participants generally associated ‘CaLD’ with ‘non-Western’, ‘non-white’ culture and being from a non-English speaking background. However, participants also described ‘CaLD’ as entailing extensive diversity and a broad range of needs. Accordingly, some contested the notion that ‘CaLD’ could capture the unique needs of migrants:

Working with CaLD, …it’s not a homogenous group, right. There’s different cultures that you’re working with. (Mental health)

Significantly, participants raised concerns that individuals ‘labelled’ by service providers as people from CaLD backgrounds may not identify themselves as ‘CaLD’ and, therefore, may not be aware of or seek the support they were entitled to.

Tailoring or mainstreaming

While participants questioned the utility of ‘CaLD’ terminology, they also indicated that services specific to migrant needs were necessary. They described specific considerations (such as language) that were better catered for by ‘CaLD-specific’ services, suggesting migrants may also be more comfortable accessing these specific services:

Considering some of those other barriers we talked about, I think services that cater particularly to CaLD groups are going to be more sensitive to those issues. They’ll provide interpreters, I think people would [come], knowing that there’s someone who speaks Arabic, or is from a Muslim background, who works there. (Mental health)

Participants reported a lack of local ‘CaLD-specific’ services as a barrier. However, they also noted a need for upskilling and resource provision to enhance the capacity of mainstream services to address this gap. For example, participants described the value of feedback from migrants and their lived experience guiding policy and service provision. Narratives also illuminated various levels of understanding, ability or desire by migrants to engage in feedback processes across the spectrum of participation.

Individualized approaches

Participants referenced the importance of general or universal approaches using ‘person-centred care’, ‘trauma-informed practice’ and ‘strengths-based approaches’. In many instances, narratives suggested that using these approaches negated any requirement for ‘CaLD-specific’ considerations, as they capture needs more precisely and comprehensively:

What we focus on, is person-centred program[s]. When we do the recovery … I give suggestion[s], I give recommendation[s], but at end of the day it is a client who chooses where to go or what to do. Because it is about [the] client or client[s] family. (Mental health)

Fighting to be seen

Participants consistently noted that Australian services, systems and policy approaches made migrants ineligible and invisible, with implications for their sense of belonging and NGO sector service provision.

Eligibility and invisibility

Participants observed that migrants often had to ‘fight’ for eligibility—for services, their needs and societal acceptance. They consistently cited a lack of Centrelink eligibility and restrictions due to visa status. Participants described scenarios of service ineligibility leading to invisibility, both in the social services sector and community:

Another one that I constantly come up against is eligibility. Everywhere. It is like people seeking asylum are unknown or forgotten. People aren’t concerned about them. But there are barriers everywhere and for some of the most basic stuff. For example, for a welfare safety net, like financially, Medicare (Australia’s universal health insurance scheme). Access to health. Things like public transport, access to education at an affordable cost. The list goes on and on. (Welfare)

Participants were conscious of the deep sense of loss accompanying migrant invisibility. Loss of identity, dignity and hope for the future were associated with experiences of ineligibility. For example, narratives reflected a failure to recognize migrant skills and qualifications in Australia or discriminatory and racist Australian policy approaches. Similarly, migrants experienced a limbo effect awaiting the outcome of visa, residency or citizenship applications. This lack of identity ostensibly propelled migrants into a liminal space, unable to meaningfully establish belonging or a sense of home in Australia.

Creating visibility in social services

Participants described the role of NGO service providers in ‘making the unseen seen’. Actions included advocacy, guidance on visas and citizenship and helping migrants to understand and engage with social service systems:

People are invisible to that system [social services], like if you’re sleeping rough, you’re not visible to the housing system because you haven’t done the housing application. You don’t have your ID [identification], and, so you’re not seen as an unmet need. So, the job of workers is to make people visible to those systems. So that system can go, “Oh, shit, we need to be doing something here”. And I think that’s that whole piece of work in the CaLD thing about making the stuff visible. So it can be seen. (Housing)

Participants identified active outreach as necessary. Narratives suggested that the lived experience of migrants was such that it separated and removed them from service engagement opportunities. Consequently, participants suggested a greater need for service providers to move into spaces that hold migrants, including communities and areas that they live in, ensuring that migrant needs were top of mind.

Complexity and confusion

Overwhelmingly, participants characterized their work with migrants as complex and confusing, reporting difficulty traversing systems and processes.

Finding a way through

Social services were seen as complicated. Effective navigation was challenging, requiring significant time and effort by consumers and service providers. Participants raised concerns that clients were unaware of how systems worked and their rights in those systems:

Well, I mean they don’t know it [service] exists, usually. And then, if they know it exists, they don’t know how to access it. And if they try to access it, they come up and find they’re not eligible. So it’s barrier after barrier after barrier. I can see why people don’t persist. (Welfare)

Participants suggested this meant migrants might not know what to ask for or be unable to exercise their rights in complicated and overwhelming situations. Consequently, the service provider as navigator emerged as an essential role to ‘really walk alongside’ migrants in their journey through the system by building rapport with and advocating for migrants, assisting with language barriers and administrative requirements and ensuring that migrants understood the processes they were engaging with.

The illusion of choice

Participants employed approaches privileging individual choice and control but often observed that migrants lacked choice in service access or did not understand options. Accordingly, narratives suggested that while in theory, migrants may be eligible for particular supports, access was much more complicated:

A lot of our client group don’t have many choices, don’t have many options, as far as where they’re going to live, how they’re going to live, what their environment is going to look like. It’s very limited because of their situation, be it financial, or just a basic understanding of what’s available to them… (Housing)

The illusory nature of choice and control significantly hindered migrants’ ability to establish a sense of self-agency, empowerment and participation. Notably, these scenarios illustrated dissonance in participant experiences, where they recognized the lack of choice available to migrants while emphasizing a government policy perspective that centres on client choice in service provision, making clients ultimately ‘responsible’ for their journeys.

The dichotomy of government and non-government supports

While participants commonly highlighted the issue of navigation in a complex and confusing social service system, narratives also pointed to the nature and impact of the social service system more generally and the interplay between government and non-government facets of this system.

Government failure

Participants identified the negative impact of government social support systems on migrants. They identified issues related to application processes, inclusion criteria and accessibility concerning Centrelink and Medicare, visas, immigration, detention and citizenship. Participants reported that processes were punitive, narrow, time-intensive, inflexible, insufficient and failing to cater to the needs of migrants:

If a person has mental health issues, homelessness, legal issues…two hours per fortnight is not really sufficient to work with that person with the intention [of] getting these people to a better position even in two years. (Mental health)

Several participants noted federal policy changes while working in the sector, such as reduced availability and increasingly strict eligibility criteria for receiving social support, had negatively impacted the security and welfare of migrants in Australia. Similarly, participants suggested that treatment by government services such as detention centres was damaging, cruel and traumatizing, with the aim ‘… to make your life so difficult, you’re not going to want to stay [in Australia]’. However, most participants also identified the government as a critical funder of their service; consequently, many NGO services were at the government’s behest in one way or another, creating ethical and practical implications for their work.

The non-government safety net

Participant narratives suggested an overriding frustration towards a perceived government system failure in supporting secure housing for migrants. Participants cited a lack of relationships and referral pathways between the government and NGO sectors, hampering effective service delivery. NGO work was identified as compensatory, supporting migrants where the government system had essentially abandoned them:

Some, with visa stuff, visa issues, some of them have come as refugees, and somehow something within the system, they come into Australia, they’ve got visas to stay, but they don’t have anyone to support them to get things together. And they end up on the streets. So, then we try and support them, get the ID [identification] cards, and or get them set up into the Australian community and then get those supports. (Homelessness)

Participants frequently stated that they exceeded their role requirements to support migrant clients, as did their organizations, noting that personal values and staff dedication drove NGO service delivery. A significant amount of work was reported as uncaptured and underfunded. Due to the stories and journeys encountered, service delivery was reportedly confronting. Work conditions, lack of debriefing or supervision and burnout exacerbated these experiences. However, participants reported a sense of ‘responsibility’ to provide migrants with support where they perceived government services had failed to do so, suggesting, ‘a lot of the time … it falls back on us’.

DISCUSSION

This research explored the lived experience of individuals providing services to migrants in WA vulnerable to or experiencing homelessness. Findings support literature reporting on the drivers of homelessness primarily being macro-level factors such as housing market characteristics rather than micro-level factors such as individual characteristics and behaviour (Bramley and Fitzpatrick, 2018). Participants presented migrant experiences as complex, reflecting ‘super-diversity’, described by Wessendorf (2014) as ‘the multiplication of social categories’ (p. 2). This complexity was accompanied by an acknowledgement of the experience of compounding intersectionalities, such as housing insecurity, language, and trauma, reflected in other research (Kaleveld, Flatau et al., 2019; Taylor and Lamaro Haintz, 2018). Participants framed housing for migrants as more than physical shelter, both as a sense of ‘home’, as described by Van Manen (1990), a place ‘where we can be what we are’, and a basis for service access—critical to enhancing a sense of belonging post-migration (Couch, 2017).

While narratives highlighted many issues consistent with non-migrant experiences, participants also suggested migrants experienced significant housing barriers due to broader structural factors (Kaur et al., 2021). Service providers and the migrants they worked with were forced into uncomfortable places in terms of policies and service provision. Narratives reflected pathways into and through services related to housing, mental health and other social determinants that were complicated and confusing and reflected broader tensions between mainstream or tailored (‘ethno-specific’) service delivery. Similar to other research, findings highlight the vital role of NGOs in the social services landscape (Butcher and Dalton, 2014; Edgar, 2008); however, point to perceived and actual power imbalances between government and NGOs. Overarching themes emerged regarding applying person-centred approaches and varying degrees of ‘choice and control’ for service providers and migrant clients. Despite a strong moral imperative, these dominant narratives reflect a broader uncomfortable neoliberal policy position towards social welfare of rationalization and responsibility, highlighted in the literature (O’Keeffe and David, 2022; van den Akker, 2019).

While this study is specific to the WA context, housing insecurity and its relationship with migration and health are complex public health problems of global significance. For example, the International Organization of Migration estimates more than 280 million international migrants worldwide (UN Migration, 2022). Across the globe, migrant health remains underserved (World Health Organization, 2023). Migrant homelessness is a symptom of a range of economic and structural factors along with punitive migration and other social policies evident across many high-income jurisdictions. Consequently, our research findings may be transferable to countries with similar policy environments to Australia’s, specifically capitalist democracies grappling with neoliberal reforms in social welfare policy. Informed by the Framework for Migration and Health (Crawford and Vujcich, 2021), we expand on recommendations to address these issues below, many of which we suggest are applicable beyond WA.

Socio-economic, cultural and environmental conditions

Environmental, economic, social, legal and health system factors influence migrant health immediately after arrival and longer term (Crawford and Vujcich, 2021). Consistent with the literature, service providers noted housing barriers, including options suitable for large families, affordability, employment opportunities and discrimination in the private rental market (Flatau et al., 2015; Kaleveld, Flatau et al., 2019; Smith et al., 2020). Findings point to the importance of strategies to address the structural determinants of health inequities, service access and more responsive housing and accommodation options, considering the pre-, during- and post-migration experiences of migrants (Wickramage et al., 2018). Recommendations to address these issues focus on migrant housing first approaches and NGO resourcing.

Migrant housing first approaches

Applying socio-ecological models and approaches would be beneficial (Taylor and Lamaro Haintz, 2018), as previously recommended regarding housing and homelessness policy (Flatau and Geelhoed, 2016; Kaleveld et al., 2018). While participants in our research made limited suggestions regarding policy approaches to address migrant homelessness, the public health potential of Housing First, implemented extensively internationally, was discussed (Aubry et al., 2019; Pleace and Quilgars, 2013). However, it is unclear whether Housing First approaches for migrant populations are effective due to limited evidence (Crawford et al., 2022), an area for further exploration. Other research supports more culturally responsive housing options for migrants utilizing Housing First approaches across crisis, public, community and private rental spaces (Aubry et al., 2019).

Resourcing and support for NGOs

While narratives spoke to the care and commitment of service providers towards their migrant clients, they also reflected a broader policy approach where addressing complex health and social issues has been broadly shifted to NGOs from governments. The literature reports power imbalances and difficulties in governments and NGOs engaging meaningfully (Butcher and Dalton, 2014), with governments having a history of limiting the scope of work and advocacy of NGOs (Edgar, 2008). The NGO sector has also documented challenges related to staff turnover, high workloads and funding (Pruitt et al., 2017). The importance of effective collaboration concerning migrant policy is recognized, with NGOs identified as key providers of services related to housing, employment and settlement assistance (Office of Multicultural Interests, 2014). Adequate funding that captures the real work of NGOs with migrants is fundamental (Pruitt et al., 2017) and requires collaboration to determine the quantum of funding to support migrant housing needs adequately. The impact of broad determinants and intersections requires government agencies to work more closely with NGOs, including those working outside housing, for example, in migrant resettlement and inclusion. Staged targets for investment should be established, with the development of funding and commissioning plans that will progress these targets.

Living and working conditions

Access to amenities, employment, occupational safety and recognition of qualifications are important factors influencing migrant health upon arrival and longer term (Crawford and Vujcich, 2021). Our research highlighted issues of eligibility, visibility and choice for migrants. Recommendations to address these factors focus on migration policies and processes.

Migration policies and processes

Participants reported problematic and often traumatic migrant experiences with housing and social services. Lack of social security access (e.g. Centrelink), limitations or precarity associated with visa status and lack of housing options were key concerns supported by the literature (Kaleveld, Atkins et al., 2019; Pruitt et al., 2017; Wali et al., 2018). The literature suggests that rather than encourage belonging, available housing and other social services may function as a deterrent for migration and reduce feelings of security, reflecting a punitive and discriminatory system that fails to provide for fundamental rights and needs (Meer et al., 2021). Experiences of ineligibility and invisibility spoke to the notion of ‘Type 1 denizens’, as described by Turner (2016) as ‘a group of people permanently resident in a foreign country, but only enjoying limited partial rights of citizenship’ (p. 679). This partial citizenship translates to ‘limited rights to welfare’, and the eligibility of Type 1 denizens to stay in a country is ‘conditional on good behaviour’ (p. 682), epitomizing ‘second-class status’ (p. 684) and reflecting the descriptions given by participants in the current research such as ‘sub-class’ and ‘unwelcome’. Federal policy change is needed to streamline processes to ensure recognition of overseas qualifications. Other research (Abdelkerim and Grace, 2012; Udah et al., 2019) supports this recommendation. Greater recognition of qualifications would help address post-migration factors, including unemployment and access to income, which are barriers to housing access and drivers of homelessness (Kaleveld, Atkins et al., 2019).

Society and community

Social support services, community connections, integration, discrimination and cultural norms play a role in migrant health at the societal and community level (Crawford and Vujcich, 2021). Participant narratives identified a lack of services catering to migrant needs and tensions between mainstream and tailored services. Whilst mainstream service delivery may appear ‘fair’ on the surface, the literature suggests it requires sufficient resourcing and political will (Donaghy, 2004) and that a ‘one-size-fits-all’ approach is insufficient (Pruitt et al., 2017). Recommendations to address these issues focus on culturally responsive services, community capacity building and co-design.

Culturally responsive systems and services

Our findings suggest that even when mainstream services are present, migrants may experience a range of barriers to their use. We would argue that such equality of services and policy does little to reduce health and social disparities, which require broader equity-focused approaches. Radermacher et al. (2009) conclude that mainstream and migrant-specific services and partnership approaches are needed to enhance service provision, focusing on consumer feedback. Similarly, Kaleveld et al. (2019) identified the need for mainstream housing and homelessness services to be equipped to support migrants, supported by migrant-specific services. The lack of migrant-specific services requires attention.

Participants identified that the vexed nature of common service and policy terms related to migration (e.g. CaLD) may pose unintended consequences for migrants who do not identify with such terminology, creating additional barriers to service access. Consistent terminology is an important consideration (Blackford et al., 2023; Federation of Ethnic Communities Councils of Australia, 2020). Participants tended to favour person-centred, individualized approaches to service provision rather than employing ‘CaLD-specific’ ways of working, such as approaches recognizing the collectivist cultures of many migrants (e.g. whole of family approaches). Similar findings are present in the broader literature. For example, Tsantefski et al. (2018) found that while staff working in the context of family and domestic violence recognized migrants as a minority group and acknowledged CaLD-specific experiences, in practice, they treated ‘all clients uniformly’ (p. 206). Harrison et al. (2019) identified a tendency in health care to prioritise person-centred, individualized approaches when working with migrants.

Arnold et al. (2020) highlight salient concerns regarding non-critical approaches to person-centeredness, reflected in this research. They raise legitimate concerns regarding its application within a broader neoliberal policy landscape, which may constrain individual autonomy in favour of more market-driven approaches. While participants cited choice and control as critical, they also suggested migrants had little awareness of choices and little control over circumstances. In turn, situations were imposed on service providers where they also experienced little choice or control, particularly within environments perceived to be resource constrained. The literature suggests that such architecture may only work in contexts where the complexity of decisions is deemed manageable (Botti and Iyengar, 2006). We contend that such application of ‘choice and control’ and person-centred discourse is, as McWade (2016) argues, ‘neoliberal state making that is discriminatory and unjust, in that it is “designed to fail” some (notably ethnic minorities and/or people living in poverty) more than others’ (p. 64). This approach abrogates government welfare responsibility and creates a system of personal responsibility, where choices are constrained within prevailing (often discriminatory) social norms (McWade, 2016). Failure to ‘choose’ correctly contributes to migrant experiences of systemic discrimination.

Capacity building

Kaleveld et al. (2019) have documented the importance of strengths-based, culturally responsive approaches to working with migrants in the context of homelessness, a recommendation echoed in this research. Participants highlighted the need for relevant cultural awareness and competency training for service providers, acknowledged in the literature (Ghafournia and Easteal, 2021; Laverack, 2018; Tsantefski et al., 2018). Participants identified explicit experiences of migrant trauma, documented in the broader literature (Abdelkerim and Grace, 2012; Bowden et al., 2020) as a driver of migrant homelessness (Kaleveld, Atkins et al., 2019). Front-line workers including those working within government require education and training in trauma-informed approaches (Office of Multicultural Interests, 2020) and NGOs.

Participation and co-design

Findings identified the importance of participatory approaches in policy, service design and delivery. Co-design is high on the spectrum of participation (Mental Health Commission, 2018), consistent with health promotion goals for community empowerment (Laverack and Keshavarz Mohammadi, 2011). Co-design has a range of reported benefits, including increasing service utility and impact, using all available expertise and increasing service user agency (WA Council of Social Service, 2020), and has been used in housing and homelessness responses (Mullins et al., 2021), and with migrants (O’Brien et al., 2021). Meaningful involvement of those with lived experience of migration and housing insecurity can improve the development and implementation of health and social service policy and delivery; however, there is limited evaluation evidence to support this claim. Examining the use of peer and social influence strategies to leverage existing social networks, capital, trust and shared experience (Laverack, 2018) may be instructive. Potential models may include greater use of bi-cultural workers (cohealth, 2020) or community navigator models (Ethnic Communities’ Council of Victoria & Federation of Ethnic Communities’ Councils of Australia, 2020; Henderson and Kendall, 2011). Navigators have been used to assist individuals and groups to overcome barriers to accessing health and social services through advocacy, community mobilization and support to navigate resources, systems and services (Thomas et al., 2016). The use of navigators has demonstrated utility with migrants (Henderson and Kendall, 2011), which may be useful in the context of stigma, cultural barriers, and systemic service barriers. O’Brien et al. (2021) have highlighted methodological considerations associated with co-design with migrants including ‘the need to consider explanatory models of mental health, community and co-design to optimally engage CALD communities in collaborative research’ (p. 15). Accordingly, there is value in determining the utility of these models, based on methodologically robust co-design principles for migrants in the context of housing and homelessness.

Individual and lifestyle

Factors at the individual level influencing migrant health upon arrival and longer-term include demographic factors, behaviours, relationships, socio-economic status, education and health literacy (Crawford and Vujcich, 2021). Our findings inform recommendations focusing specifically on building health literacy.

Health literacy

This research reinforces the need to address language barriers for migrants. Whilst we suggest a more comprehensive range of communication options, we also urge consideration of more nuanced approaches. Nutbeam (2000) outlined three broad categories of health literacy—functional, interactive and critical. The Australian Quality and Safety Commission (2014) further suggests responses for both individuals (e.g. skills, knowledge and capacity) and organizations (e.g. infrastructure, policies and relationships). We agree with these considerations, and support calls for more critical health literacy perspectives. As Sykes et al. (2013) have argued, this means ‘acting individually or collectively to improve health through the political system or membership of social movements …with its focus on community capacity to act on social and economic determinants of health’ (p. 2). In our research, language barriers and a lack of access to appropriate support, such as interpreters, hindered service provision, particularly in government settings. These are unresolved, recurring issues for migrants in social services (Abdelkerim and Grace, 2012; Pruitt et al., 2017; Wali et al., 2018) and central to public health approaches to housing and other service access (Kaleveld, Atkins et al., 2019; Taylor and Lamaro Haintz, 2018). Governments at all levels must work to improve migrant access to interpreters, particularly in housing and homelessness and in government settings (Kaleveld, Atkins et al., 2019). We also suggest that resources about services in various languages and accessible formats, including online and via other media such as radio (Kaleveld, Atkins et al., 2019), are necessary but insufficient. Australia is developing a national health literacy strategy (Department of Health and Aged Care, 2022), providing opportunities for more expansive approaches to health literacy with a focus on the critical domain.

Strengths and limitations

We consulted a range of service providers, including those who identified as migrants. The use of IPA facilitated in-depth understanding and the opportunity for the research team to meaningfully incorporate their knowledge into interpreting research findings. Quote usage in data explication offered rich descriptions of participant accounts and enhanced research credibility (Noble and Smith, 2015). Social desirability bias may have influenced participant accounts (Bergen and Labonté, 2019). The participants were all NGO service providers. Consequently, there was a limited exploration of the lived experience of decision-makers on policy approaches and their implications, an opportunity for future research. We did not explore differences and similarities with non-migrant populations; this may be worth further consideration. Findings may not be transferable to other national or international contexts, including regional or rural service provision, as all study participants were based in metropolitan Perth, WA.

CONCLUSION

This research aimed to address real-world public health concerns in WA regarding housing access and mental health outcomes for migrants. Findings illustrate the broad and complex needs of migrants and the role that service providers, government and people with lived experience play in addressing these. In the context of increasing population mobility and migration, we require further attention to the factors influencing housing and health for migrants. Accordingly, we offer specific areas for action and call for appropriate co-design processes that create genuine roles for and engagement with migrants to guide appropriately targeted and tailored service improvements and policy reform.

AUTHOR CONTRIBUTIONS

Contributions to the article were as follows: study conception and design: G.C., K.B., R.L.; data collection: E.C.; analysis and interpretation: E.C., G.C., K.B., R.L., K.M.; manuscript preparation: E.C., G.C., K.B. All authors reviewed and approved the final version of the manuscript.

ACKNOWLEDGEMENTS

The authors thank the research participants for their time and contributions.

FUNDING

Healthway (Exploratory Grant #33617) funded this research.

REFERENCES