Australia is one of the most diverse countries in the world; some 280 countries of origin are represented. Moreover, 28% of its population were born in another country. Traditionally immigrants have settled in large metropolitan areas in Australia, but through government initiatives and planned immigration policies, this trend has been changing.
The Australian Government initiated changes in the national immigration policy in 1996 to encourage new immigrants to settle in regional and rural Australia by offering additional points to those immigrants who possess skills in demand and who are willing to settle in regional areas under the state-specific migration mechanism. Although this has led to an increase in immigrant population settlement in regional areas1, not all immigrants in the regions are employed or have jobs that are commensurate with their educational qualifications and skills2. This trend is especially true for secondary immigrants who are either spouses or adult children of primary applicants. A report on skilled migrant women in regional Australia3 cites Australian Bureau of Statistics (ABS) 2009 and 2010 data that suggest that secondary applicants (likely to be women, in most cases) are either 'unemployed or inappropriately employed' (p. 11), and thus unable to use their knowledge and skills. The same study also reported the availability of jobs in the child care and aged care sectors, resulting in migrant women undertaking education in these sectors to help them prepare for new job prospects.
Moreover, there is evidence in literature that Australia is facing a potential crisis in aged care staffing, particularly aged care nurses4-8. The demand for aged care workers is predicted to exceed the supply in coming decades5. Hugo8 reports that three times the current number of workers will be needed to meet demand in the next 25 years. Factors that will impact on the requirements of the workforce include the ageing population of Australia8; increased average length of stay in residential facilities leading to a greater requirement for service provision9; a growing number of women joining the workforce, thus reducing the number of people able to provide informal care5; and a concentration of older-age workers which can potentially lead to skill shortages as they retire7. Aged and Community Services Australia (ACSA)10 reports that aged care providers have regularly experienced difficulties filling vacancies. According to Martin and King11, there was increasing difficulty filling vacant positions for registered aged care nurses from 2003 to 2007, with nearly 40% of vacancies taking more than a month to fill. In a recent media release, the Australian Nursing Federation12 commented that there is an immediate requirement for 20 000 nurses in aged care.
ACSA10 suggests that rural and regional areas are facing this crisis more than their urban counterparts as most Australians prefer to live in cities. The larger study on the aged care workforce in Australia conducted by King et al. reports two-thirds of direct care workers in metropolitan cities, whereas one quarter are in inner regional areas and slightly over 1% of the total workforce in very remote locations. Although 'the proportion of direct care workers located in South Australia is higher than the state's share of total population' this reflects the difference in age composition of the state's population, which is 7.7%13 (p. 51). This highlights a larger ageing population in South Australia as compared to other states; Western Australia, for example, has 5.4% ageing population13.
The aged care workforce shortage is further accentuated because of the low status given to aged care. Gray and Heinsch5, Bellino14, and Palmer and Eveline15 report that aged care work has been paid poorly and is considered to be a low-status, unskilled position. The low wage and low status have led to these jobs acquiring a stigma; the work is seen as undesirable by the 'local' populations8,16 (p. 203) and therefore increasingly filled by immigrants11,17-19. It has been reported that 'locals' (non-immigrants) avoid these jobs16. Harris has been cited as stating that there is an 'unwritten social contract' in the developed countries that spares locals from ... accept[ing] the bottom jobs'16 (p. 216). Furthermore, for some immigrants, language barriers, cultural background and educational level can impede finding positions of high status, making aged care work, along with taxi driving and cleaning jobs, the predominant options16. It has also been noted that the qualifications of immigrants may not be recognised in Australia16. Thus, immigrants have filled positions beneath their education levels in order to generate income.
The National Institute of Labour Studies (NILS) study of the residential aged care workforce records that 24.4% were immigrant workers (overseas-born)20. The number of overseas-born workers in the Australian residential aged care sector rose from 25% reported in 2003 to 33% in 200711. There has been a 1% increase in the overseas-born population working in aged care since 2007, to 34% in 201213. According to Martin and King11, more than 90% of the workforce in aged care is female. This percentage was unchanged in the 2012 aged care workforce census13. Howe18 compared overseas-born female workers in the Australian long-term aged care sector with the total overseas-born female workforce, based on NILS data of 2008 and ABS; this showed a higher representation of overseas-born female workers (more than 25%) in aged care compared with the total overseas-born female workforce (20%).
Although recruitment and development of the immigrant workforce is indicated as one of the strategies to overcome shortages in the aged care workforce10, concerns have also been raised about immigrant workers' vulnerable status, as well as possible discrimination and barriers to employing them. An Australian study of nurses in the state of New South Wales reports that their experiences were isolating, negative and unsatisfying21. When managers were asked about their experiences with workers whose primary language was not English, over two-thirds reported document completion and client communication as issues to address11. Clients' difficulty in understanding workers' accents is exacerbated by hearing difficulties and dementias associated with older age11. Besides these, the experiences of immigrant workers in Australia are affected by their physical locations. While approximately 23% of all residential aged care employees worked in regional Australia4,20, the proportion of immigrant workers is much lower in regional and rural areas as the majority of immigrants choose to live in metropolitan cities22,23. Moreover, a search of the literature revealed little about the aged care immigrant workforce in regional areas, possibly due to the small size of the population in regional areas. Hence, further research on immigrant workers employed in aged care in regional and rural areas is warranted, considering their valuable contribution to the Australian aged care workforce. It is important to understand their employment experiences, identify areas of concern, and have policies and procedures in place if necessary to ensure continued improvement in practice and community service.
This article addresses the gap in research noted above and provides an understanding of the experiences of immigrant workers in aged care in regional South Australia. In this study, the word 'experience' refers to the encounter or exposure to an employment setting, while an immigrant worker is defined as an overseas-born worker from both English- and non-English-speaking backgrounds. A non-immigrant worker refers to an Australian-born worker. The research question is, 'What is the lived experience of immigrant workers in the aged care industry in a regional setting in South Australia?' The objectives of the study are to determine the needs of immigrant workers in aged care, identify the barriers and challenges encountered while working in aged care, provide strategies and/or interventions that might assist in improving work satisfaction and increase retention in aged care.
An interpretative phenomenological approach to research was used in this study to answer the research question and meet the study objectives. In this approach, a description of a particular life event or experience is achieved24 by gaining access to the beliefs, practices and self-disclosed needs, barriers and challenges of immigrant workers providing service in aged care facilities. While working may be a daily occurrence, it is a major life event for others who come from a totally different culture. This research approach also sheds light on how the aged care workforce may be assisted in providing a satisfactory work experience for immigrant workers in regional locations. This study is part of a larger study that includes co-workers and managers in aged care; however, the present article reports only the immigrant workers' experiences in aged care.
Setting and study sample
The study was conducted in three community-based residential aged care facilities attached to a public hospital in a regional city of South Australia. These aged care homes are run by a not-for-profit organisation which is subsidised through government funding. These facilities were selected for the purpose of the study because they operated under one incorporated body and management.
The sample consisted of seven participants who immigrated to Australia as adults and worked in the aged care industry. Purposive sampling was used; the participants who were invited to join the study were individuals who shared common characteristics such as being an immigrant over 18 years of age, employed in aged care in regional South Australia and willing to join the focus group. The director of nursing and chief executive officers of the local hospital and nursing homes were asked to distribute the researchers' introductory letter to their staff. The letter explained the purpose of the study, potential outcomes, expected benefits of the research and the focus group procedure. The would-be participants directly informed the researcher(s) of their willingness to participate. All those who indicated willingness to participate were included in the study. There was no actual or potential coercion exerted on the participants to influence the recruitment process. Participants all signed consent forms.
A protocol for the research was submitted to and granted by the University of South Australia's Human Research Ethics Committee, according to the National Health and Medical Research Council guidelines. Permission to undertake the study was granted. Permission was also sought from the various regional aged care facilities where the research was undertaken.
Data were collected during a two-hour focus group discussion involving seven immigrant workers and facilitated by the two authors. Only one focus group was conducted due to the limited number of prospective research participants in the area. The authors believe, however, that valid data may be obtained from a small number of participants in accordance with qualitative research principles25.
The authors acted as moderators for the group, posing questions and encouraging discussion and full participation of all participants26. A focus group, which ideally consists of four to six individuals, was preferred over interviews because it allows participants to bounce ideas off each other in order to reflect thoughts, attitudes, feelings and experiences at greater depth. Focus groups are also time saving and economical. The pattern of conversation in focus group meetings is naturalistic, where people from a homogeneous background (such as all immigrants, females), having worked in aged care, could have natural exchange and sharing of ideas about work. This research method has been used in many social science research projects because of its many advantages27.
The discussion began by clarifying the participants' current position and responsibilities in their organisations. Pre-determined questions were used to prompt and guide the discussion (Appendix 1). The participants' responses during the focus group meeting were audiotaped and transcribed verbatim. It had been made clear that the discussion would be recorded.
Thematic analysis was used to analyse the focus group data. Recurring ideas reflecting the essential issues from the participants' description and understanding of their work experiences were identified from the transcript. These ideas/issues were further examined for revelatory phrases, grouped together and coded to identify the recurring themes. The 'descriptive counts' of codes were then used to report the qualitative nature of data and provide an overview of the phenomenon of the work experience of immigrants26. Data were anonymised; pseudonyms were used to cite excerpts from the text.
In addition, the analysis of data was undertaken through triangulation by both researchers separately examining the data28. This established credibility, accuracy of representation and trustworthiness of the researchers, which meets Sandelowski's29 criteria for credibility, auditability and objectivity in qualitative research.
Description of participants and their career plans
The demographic characteristics of participants are summarised in Table 1.
The participants had mixed experiences with employment in aged care. Two major themes emerged from the data: satisfaction and dissatisfaction. Three participants expressed satisfaction, while two conveyed general dissatisfaction. The remaining two participants experienced both satisfaction and dissatisfaction. Table 2 summarises the reasons the participants deemed work to be satisfactory or unsatisfactory.
The following quotations depict participants' satisfaction:
A very good experience ... The residents appreciate us, the clients in the community appreciate us. Feedback is good. Clients still ask about me indicating a positive experience with me. (Lourdes, personal carer)
I'm doing well personally. The clients like me. They want me to be their permanent carer, but that's not possible. (Mona, personal carer)
Overall, a good experience. It's probably because we are good workers, hardworking, but we get racist experiences also ... (Christine, personal carer)
When queried about the benefits they derive from working in the aged care sector, the participants volunteered a number of benefits such as the 'experience', 'flexible hours', 'self-satisfaction' that comes from caring and interacting with others, and 'the money'. The participants perceived that it was easy to find work in this industry and that aged care workers were in 'demand'. Having satisfaction with caring, ability to develop social networks and the contribution of work to their financial support had an impact on the lives of workers.
Dissatisfaction came from time constraints, workload, staffing, peer relations and the nature of the job itself. The reasons for dissatisfaction were categorised into three subthemes: nature of the job, staff relationships, and supervision and organisation.
The demands of the job and the health profile of clients contributed to the general dissatisfaction of the participating immigrant aged care staff. The difficult nature of the job for them included dealing with the frail and aged, individuals with dementia, individuals with chronic illnesses, emotional and psychological problems and life-limiting conditions. Some clients suffered from progressive losses of human faculties such as cognition and reasoning, although 'they can still feel' one participant clarified; and some 'deteriorated fast' from stable to comatose state, a disturbing experience for staff.
The relationships between staff were a crucial factor in determining job satisfaction. The majority of the participants cited the importance of staff attitudes at work. One participant highlighted the support provided by co-immigrant workers, explaining that 'immigrants help immigrants', presumably because they share common hardships and empathise with each other. However, others told a different story, one that reflected difficulties in maintaining harmonious work relationships because of alleged discrimination and racism, manifested in the ways non-immigrant staff talked and related to immigrant workers. There were complaints of 'backbiting and politics', 'nonchalant attitude', 'swearing amongst staff and clients', 'bossiness' and 'selfishness'. According to one participant, some non-immigrant staff members were not supportive of immigrant staff educating themselves to become registered nurses.
Participants expressed the view that they were under a lot of pressure brought about by a 'heavy workload', 'constraints in time', 'staff shortage' and 'absenteeism of others'. They complained about the lack of support in workplace and work politics. Comments included:
There is direct and indirect discrimination. We work as casual employees. Some people, however, are given preferences in shifts. We [immigrant workers] get lousy shifts. (Wilma, home support worker)
They [management] give us difficult tasks, for example, spring cleaning, but other Australian workers were not given those difficult tasks or shifts. (Nadine, personal carer)
Table 1: Participant characteristics
Table 2: Reasons the participants deemed work to be satisfactory or unsatisfactory
Challenges, barriers, needs and suggested strategies
The responses to queries relating to specific needs while employed, barriers/challenges faced, and the strategies that will assist while working in the aged care sector are summarised in Table 3.
Limitations in resources and support from the organisation: Participant feelings of pressure to do the job well or stress from making mistakes at work, or being called at short notice and getting shifts that they did not prefer, relate to management problems at the organisational level. The following excerpts conveyed these sentiments:
While I was credentialed for medications, I am hesitant to undertake medication administration because there are so many interruptions [for example, questions from other worker or requests for assistance] and I can make mistakes. (Lourdes, personal carer)
We are always short of enrolled nurses. There is too much work and there is hardly time for documentation. Also, I can't read the care plan 30 minutes before shift to help me prepare because of constraints of time. (Terry, personal carer)
I think there is a need for more structure in calling shifts. Staff calls you with short notice to work. We have a limited pool of workers to substitute staff who are sick or on leave. (Maria, allied health worker)
Participants identified the need for 'more training in the areas of nursing':
We miss out on staff development opportunities in nursing for various reasons. We need more training; for example, how do you care for patients refusing to shower? (Mona, personal carer)
Participants also considered the need for workplace supervision and mentorship:
It would be good to have a supervisor, one who would oversee the team and take interest in each worker's performance. It would be good to have a mentor ... (Nadine, personal carer)
Increased pay was another area that warranted management attention. One of the participants alluded to this feeling:
We are paid very less, but we work the hardest. Admittedly, by comparison with other workers, aged care workers are underpaid. (Mona, personal carer)
Family concerns, health and financial pressures were burdens mentioned requiring some form of organisational support and counselling.
There are challenges too in the home front. The pressures go to the family. I have difficulties with my study, with work, study and caring for a difficult client. I recently had a car accident, I felt dizzy and stressed ... I probably need some counselling! (Wilma, home support worker)
Cultural influence on work practices: The participants alluded to cultural differences that caused differences of opinion about how care should be performed when working in aged care. The manner in which the participants carried out their roles and responsibilities was influenced by their cultural background. They explained:
We get emotionally involved with clients, but some workers are so mechanical. ... Asians are different in their approach to clients. (Mona, personal carer)
There is a huge cultural difference. We need to give clients what they want, like a simple request for toasted bread. For other nurses, individual preferences are not important, but they are. We need to be sensitive about how clients want to be cared for. (Nadine, personal carer)
This participant (Nadine) also explained the need for '... assistance to make us understand cultural differences.'
Language as a barrier: Difficulty with the English language was another barrier for these participants, which led to confusion and misunderstanding with co-workers and clients. The immigrant workers, in trying to be understood, spoke slowly and deliberately. They did not understand their co-workers who spoke fast. In trying to be understood, staff would emphasise instructions and be misconstrued as 'bossing' people around. One participant articulated the problem clearly:
Language is such a barrier for us. They [other staff members] cannot understand us. Some just refuse to understand you. One said, 'I understand your sign language'. (Christine, personal carer)
Suggested strategies: Specific strategies that might support immigrant workers were identified by the focus group participants. These strategies could be categorised into three themes: intrapersonal, interpersonal and transpersonal. Providing staff development opportunities in nursing, and professional training in the areas of language, communication and culture, would be considered intrapersonal strategies; interpersonal strategies might include peer support, improved communication amongst staff, increased staff awareness of cultural beliefs/practices; providing structured handover of care, mentoring and emphasising team work, salary review and better shift allocations are transpersonal strategies that the organisation's management and policy makers could undertake to meet the needs of these immigrant workers. The excerpts below demonstrate participants' opinions about how they might be assisted to gain a satisfactory employment experience in aged care:
It would be good to have a mentor ... someone who would clarify the goal and put structure, one who would review the approach with you. Monitoring or keeping watch in what you are doing at least for the first few months. (Nadine, personal carer)
Team work must be emphasised. While we use our own initiative in carrying out our duties, working with others is very important. (Lourdes, personal carer)
Good handovers will help you know about the client. (Wilma, home support worker, citing the case of a woman who fell because the carer put on the wrong shoes, highlighting the problem of not communicating during handover)
Management must invest in training staff on effective communication, language. (Terry, personal carer)
All employees must have some cultural awareness and sensitivity training in order to work amicably with each other. (Christine, personal carer)
... and a way by which we might air our grievances, voice our concerns, that should be profitable ... (Wilma, home support worker)
Table 3: Summary of challenges, barriers, needs and suggested strategies
The discussion addresses the research question and the objectives set out in the study. The employment experiences of immigrant workers in the aged care workforce were both satisfactory and unsatisfactory.
The fact that their clients valued their work was a source of satisfaction to the immigrant workers, who considered themselves hardworking and good workers. These specific qualities were recognised by their clients. Studies conducted by Martin30, King et al13., and King, Wei and Howe31 affirm that satisfaction derived from direct caring for clients has a substantial effect on workers' job satisfaction. Similarly, Khatutsky, Wiener and Anderson have asserted that 'immigrants seek jobs as Certified Nursing Assistants (CNAs) because of their desire to help others'19 (p. 281). Another source of satisfaction was easy job availability in aged care, because of the increasing demand for caring work amongst the ageing population. This was clearly highlighted in this study by immigrant workers who also identified certain benefits of doing aged care work, including 'job availability' in the aged care sector, and also 'flexible working hours' and 'pay [having a source of income]'. These advantages point out that there are jobs available in the sector that may entice immigrant workers who may otherwise struggle to find jobs in the Australian labour market16. However, it also indicates that immigrants are over-represented in jobs that are undesirable because of their language barriers, race/ethnicity and non-recognition of educational qualifications that may impede finding positions of higher status17; thus it raises questions about labour market fairness.
Despite satisfaction with their work, immigrant workers raised concerns about how work was organised for them in an institutional setting. The findings also indicate that workers felt lack of support in their roles and uncared for in their personal lives. For example, the participants who were trying to educate themselves felt unsupported when they felt that they should have been valued and encouraged. Workers in this study also reported staff shortages, eg in enrolled nurses, as one of the reasons for work overload and inadequate supervision. This study's findings corroborate what has been stated by Gray and Heinsch about Australian Nursing Federation reports of 2006 and 2009, that there is a shortage of registered and enrolled nurses in aged care who could support and supervise workers, and that there is a 'lot of pressure on [personal] carers to do more than they are qualified for'5 (p. 104). It is important to note, however, that such reasons for dissatisfaction are not exclusive for immigrant workers; they are reported by the aged care workforce in general13.
The immigrant workers felt discriminated against, due to racism manifested in the way staff spoke to and related with them. Having shifts nobody else wanted to do, and being allocated heavy workloads and difficult tasks, were reported as discriminatory practices. These findings reflect what Khatutsky, Wiener and Anderson found in their study where immigrant workers expressed having working conditions dissimilar to those of non-immigrant workers19. These differences are referred to as 'prejudice' based on cultural background and ethnicity. Such practices may indirectly be affecting workers' self-esteem and promoting workplace dissatisfaction. Moreover, no infrastructure was in place for dealing with workers' complaints, or at least they were not aware, as this study revealed.
A review of 2008 NILS data on retention and intention to stay in the aged care workforce concluded that 'employment conditions and organisational and structural factors have a strong bearing on stability'32 (p. 87). Martin also concurs with the need for management in the industry to create workplace experiences that enhance job satisfaction for workers30.
Besides working conditions, low pay was a key issue for immigrant workers. While employment in aged care provides the opportunity to have a source of income, the participants believed that pay was not commensurate with the work performed. Personal carers' low pay is widely acknowledged in the literature30,33,34 and competitive wages need to be addressed at the national government level.
Concerns were raised about cultural differences in practice, and language was seen as a barrier to effective communication. Other studies concur, reporting differences in practice due to culture and ethnicity. Omeri and Atkins21 (p. 497) cite an earlier study by Davitz et al. which, while acknowledging cultural differences, underlines that it is the 'bedside approach' of immigrant workers, intimate and personal, that has earned their clients' respect and appreciation. However, others warn of the real possibility of exploitation due to language and cultural differences35,36.
Language as a barrier and challenge has been recognised in literature19,37,38. Akin to the experiences of the study participants, difficulties in language may lead to miscommunication, which could result in misunderstanding, anxiety, stress and fear of job loss37. On the other hand, although immigrant workers faced challenges because of their English language disadvantage, it is likely that their co-workers and managers are equally challenged by shortcomings in intelligible communication. Similar concerns are raised in studies emphasising client communication and immigrant workers' accents as areas for improvement10,11. This study's findings show that variations in the cultural way of caring for the elderly may require training and mentoring of workers from different cultural backgrounds.
Given the issues identified by the participants, the training and support, mentorship and supervision suggested by them have merit. These suggestions align with what other studies have recommended, such as provision of certificate level training; 'opportunities for skill development'32 (p. 88); benefits of staff supervision, coaching and mentoring39; and 'onsite English classes and cultural sensitivity training for both native born and immigrant staff'19 (p. 283). A recent analysis of work satisfaction and intention to leave amongst the aged care workforce31 points out that work-related reforms, including support from employers and other workers, training opportunities and stress reduction mechanisms, are helpful in maximising workers' satisfaction.
Based on the findings of this study, the authors suggest three recommendations that may help immigrant workers specially in having satisfying work place experiences and enhance retention in aged care.
First, courses in language and culture must be expanded and provided early, even before immigrants start working in aged care. Ongoing education sessions are also warranted. In-service training on language and culture must be provided for non-immigrant aged care workers to give them a working understanding of the norms, behaviours and ideas of different people. Strategies to narrow the cultural gap could include group dynamics sessions exploring co-workers' beliefs and value orientations which give meaning and worth to their existence, dictate customs and traditions, and influence end-of-life decisions and practices40,41.
Second, mentoring of new immigrant workers should be planned by the aged care facility managers and executive officers. As mentioned earlier, mentorship was suggested by the participants. It refers to a relationship between a mentor, who has experience and contextual knowledge of a situation, and a mentee, who is about to embark on the same or similar experiences or situations42. The learning process that transpires involves the new learner becoming socialised and acculturated into the workplace culture. These 'performance partnerships'43 (p. 68) have resulted in impressive alterations in the manner in which beginners are educated and taught the skills of work environments.
Third, as aged care work involves multidisciplinary workers, teamwork is necessary. Aged care facilities should focus on supporting effective teams by acknowledging the effort of all workers, clarifying goals, emphasising mutual trust, support and open communication. This valuable and effective skill must be developed as early as possible and regularly reinforced44. Application of the teamwork concept may help alleviate problems regarding inequitable shifts, job allocation and opportunities to pursue further education and training.
Implications of the study
This study has implications for clinical practice and the future educational preparation of aged care workers. This study has illuminated the need to increase cultural awareness and sensitivity in the aged care workplace with the realisation that, in spite of the 'cultural awareness aura' in the health sector, it is still largely 'monocultural' in practice21 (p. 497). Immigrant workers continue to feel marginalised and undermined in their professional roles; hence, concrete strategies and strong infrastructure must be put in place in clinical practice to help their situations and acknowledge their contributions. The future educational preparation of aged care workers must include, along with gratification brought about by caring, awareness of the difficult nature of the job - that is, working with frail, elderly people with chronic and life-limiting conditions - as well as language and culture awareness.
Limitations of the study
While the findings of the study raise key issues about the extent of satisfaction and dissatisfaction of immigrant workers in the aged care sector in a regional area, and suggest strategies that are applicable in enhancing the employment experiences of immigrant workers, the study is limited in its scope. The conclusions cannot be generalised for the aged care sector as a whole, because it is based on a small sample of workers who volunteered to participate in the study from a single regional city. Thus, a different group of participants may provide a different set of experiences. Nevertheless, the study illustrates current work experiences and challenges confronted by this group of workers employed in regional aged care facilities. The future direction for this research, to have generalisability, would be further focus groups and in-depth interviews with a larger sample and wider coverage of aged care facilities in regional South Australia.
This small-scale research provided evidence of both satisfactory and unsatisfactory experiences of immigrant workers in aged care. Given that regional areas have high demand for aged care workers and immigrants are increasingly occupying positions as direct care workers in aged care, this study suggests that aged care facility managers and executive officers can enhance immigrant workers' positive work experience by making some workplace reforms. This research, validating findings from previous studies, reiterates the need for such reforms to sustain the immigrant aged care workforce in regional areas.
The authors wish to thank Ms Sarah Liston, a health science student, for undertaking the preliminary review of literature as part of her research vacation scholarship, and Dr Olga Gostin and Ms Bronwyn Ellis for editing the manuscript.
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Appendix 1: Focus group questions