Physical activity amongst culturally and linguistically diverse communities in Australia: a scoping review

ABSTRACT Background: Australia’s overseas-born population continues to grow. This population is disproportionately affected by chronic, non-communicable diseases. Physical activity is the cornerstone of all chronic disease management. Engaging people from culturally and linguistically diverse (CALD) backgrounds in physical activity is an important public health objective. The purpose of this scoping review was to examine the factors that shape physical activity participation among people from CALD backgrounds in Australia. Methods: This scoping review followed Arksey and O’Malley’s framework. Medline, Embase and CINAHL were searched with key words relating to ‘physical activity’, ‘CALD’ and ‘Australia’ in July 2021 and again in February 2022 for qualitative studies published in English since 2000. Exclusion criteria were: participants < 18 years old, studies specifically focusing on populations with health issues, pregnant or postpartum states. Methodological quality of included studies was evaluated using the Critical Appraisal Skills Programme with the purpose of informing future research. Data extracted from each study were analysed thematically and results were interpreted using Acculturation theory. Results: Of the 1130 studies, 17 met the inclusion criteria. Findings from each study were captured in three themes: Perceptions of physical activity; Acceptability and Appropriateness; and Access. Following migration, a decrease in physical activity, especially leisure-time activity, was reported. Common factors influencing physical activity engagement included perceptions of physical activity and wellbeing; language, financial and environmental barriers; as well as social, cultural, and religious considerations. Conclusion: This review identified several factors which may interact and contribute to the decline in self-reported physical activity upon migration. Findings from this review may be used to inform future health promotion initiatives targeting people from CALD backgrounds. Future research may benefit from devising a shared definition of physical activity and studying different CALD communities over time.


Introduction
Internationally, there has been steady growth in the number of migrants over the last two decades.Notwithstanding the disruptions imposed by COVID-19, in 2020, there were 281 million people living outside their country of origin, encompassing 3.6 percent of the world's population (United Nations Department of Economic and Social Affairs 2021).In Australia, approximately one third of the population is born overseas with most migrants from England, India and China (Australian Bureau of Statistics 2021).The term 'culturally and linguistically diverse' (CALD) is used in this paper to refer to people living in Australia who were born overseas or are descendants of those who were born overseas and differ in language and/or culture to the wider population (Parliament of Victoria 2021).This encompasses migrants as well as refugees and asylum seekers who face additional hurdles beyond the struggles and consequences of migration.
The growing diversity of the Australian population imposes several population health challenges.Some researchers have proposed that individuals from CALD communities are disproportionately affected by chronic diseases especially hypertension, diabetes, and obesity, all of which contribute to a higher burden of cardiovascular disease (Davidson et al. 2003;Johnson and Fulp 2002;Torpy, Lynm, and Glass 2003).In 2001, approximately 35% of people who reported having diabetes were born overseas in spite of making up only 28% of the Australian population (Holdenson et al. 2003).Despite a higher prevalence and burden of non-communicable diseases, individuals from CALD communities appear less likely to engage in preventative measures like physical activity compared to people from non-CALD backgrounds in Australia (Marquez and McAuley 2006;Henderson, Kendall, and See 2011).In particular those with limited English proficiency report significantly lower rates of participation in physical activity compared to their Australian counterparts (participation rate of 36.9% vs 66.0% respectively) (Australian Bureau of Statistics 2006).
Physical activity is the cornerstone of all chronic disease management (Das and Horton 2016).It is associated with numerous benefits including reductions in metabolic syndrome, promotion of musculoskeletal health, mental wellbeing as well as fostering social cohesion (Lewis et al. 2019;Penedo and Dahn 2005).Accepted scientific definition of physical activity is a body movement produced by skeletal muscles that results in the expenditure of energy (Caspersen, Powell, and Christenson 1985).Guidelines recommend adults participate in 150-300 min of moderate intensity physical activity each week to obtain health benefits (Bull et al. 2020).Increasing participation in physical activity to both prevent and manage chronic disease among people from CALD backgrounds is an important public health objective (Briggs et al. 2019).
To positively influence physical activity behaviours with corresponding improvements in health, it is critical to understand the factors that influence participation in physical activity among people from CALD backgrounds.This can then inform the design and implementation of culturally appropriate interventions that meet communities' needs and preferences.Previous reviews have investigated correlates of physical activity behaviour amongst adults from CALD communities in Western countries with individual health, past exercise behaviour, neighbourhood characteristics and access to transport been reported as predictors of physical activity engagement after migration (Caperchoine, Mummery, and Joyner 2009;O'Driscoll et al. 2014).However, health behaviour is heavily influenced by context (Bandura 2004), and understanding the factors that shape physical activity participation within a given context is necessary to inform local and national policy.In the past decade, a number of qualitative studies has investigated the experience of physical activity among CALD populations living in Australia.In this scoping review, we synthesise findings from these studies to identify factors shaping physical activity participation in the Australian context.

Methodological framework
This scoping review was guided by an established framework described by Arksey and O'Malley (Arksey and O'Malley 2005).Themes were constructed to present a narrative account of the existing literature however no attempt was made to weight evidence.Acculturation theory was used to guide interpretation of results and assist in contextualisation of findings in the discussion section.This theory describes the process of adaptation that may occur due to continuous contact with culturally dissimilar people, groups and social influences.The acculturation experience is highly specific, influenced by factors including the country of origin, the social composition of the communities in which they settle, fluency in the language of the host country amongst others (Gibson 2001).

Search strategy and selection criteria
Electronic databases Medline, Embase and CINAHL were searched in July 2021 and again in February 2022 using key words relating to 'physical activity', 'CALD' and 'Australia'.Boolean operator 'AND' was used to combine concepts with 'OR' used for key words under each concept (see example search Table 1).Title, abstract and full text screening based on the eligibility criteria (see Table 2) was conducted independently by pairs of authors (QW and PO or LH) on COVIDENCE systematic review software (Covidence systematic review software).Any discrepancies were resolved through discussion with another author (SB).

Data extraction and analysis
Data extracted from each study comprised: participant characteristics (age, sex, cultural and linguistic background where available), study characteristics (setting, sample size, method of data collection) and findings relevant to physical activity participation amongst people from CALD backgrounds in Australia.Relevant findings extracted related to perceptions about physical activity participation (including themes headings, descriptive sentences, and participant quotes).Inductive codes were generated by the first author (QW) through line by line reading of extracted findings.Codes were then grouped into categories describing the factors that shape physical activity participation through discussion between four authors (QW, SB, RWK, MD).Where appropriate, factors specific to certain CALD communities were identified.Finally, categories were consolidated into themes describing overarching factors influencing physical activity participation.Emerging themes were re-checked against original sources to ensure they remained grounded in participant experiences as interpreted by the authors of each study.Consensus on final themes was achieved through group discussion in which themes were considered in the context of existing literature on physical activity participation in the wider population, health behaviour theory and acculturation theory.The multidisciplinary authorship team comprised of clinician-researchers with backgrounds in orthopaedic nursing and physiotherapy; a medical student, social scientist and applied linguist with expertise in health communication.

Methodological rigour
While not a necessary step in the Arskey and O'Malley framework, a quality assessment was conducted in order to inform future qualitative studies in the field, rather than to determine how robust individual study findings were.In addition, it has been suggested that inclusion of a quality assessment such as the CASP (Critical Appraisal Skills Programme (2022)) may  improve the uptake and relevance of scoping review findings, hence its inclusion here (Levac, Colquhoun, and O'Brien 2010).Using the CASP, each study was evaluated by pairs of authors (QW and PO or LH) who independently scored 'yes', 'no' or 'unclear' for each of the ten criteria on the checklist.Discrepancies between reviewers were resolved by discussion with another author (SB) until consensus was reached.

Results
The primary search was conducted in July 2021 and updated in February 2022.The search retrieved 1130 articles, with 680 titles remaining after removal of duplicates.
From 680 titles and abstracts, 59 full text articles were screened.Seventeen met the eligibility criteria and were included in the final dataset (see Figure 1).The 17 studies included 595 participants from CALD communities, 442 (74%) were women.Thirty-three additional participants were stakeholders interacting with CALD communities.Twenty-seven CALD communities were represented including Afghanistan, Arab-Australians (majority from Lebanon), Arabic speaking people (countries not specified), Bosnia, Burkina Faso, Burundi, China, Cook Islands (Pukapuka people), Democratic Republic of the Congo, Ethiopia, Eritrea, Hong Kong, India, Iran, Iraq, Liberia, Middle East (majority from Lebanon), Myanmar, Philippines, Somalia, South Sudan, Sri Lanka, Sub Saharan Africa (countries not specified), Sudan, Syria, Togo and Vietnam (see Table 3).
Only one of the 17 included studies satisfied all 10 quality domains on the CASP.Domain one ('Was there a clear statement of the aims of the research?')and domain two ('Is a qualitative methodology appropriate?')were met in all 17 studies.Most studies failed to address domain six ('Has the relationship between the researchers and participants been adequately considered?') with only six studies providing appropriate detail (See Table 4).
Findings from each study were captured in three themes: Perceptions of physical activity; Acceptability and Appropriateness; and Accessibility.These themes are described narratively below, supported by quotes (Q) extracted from included studies (see Table 5).

Theme 1. Perceptions of physical activity
Misconceptions about what constitutes physical activity and the consequences of being physically active appeared to play a role in influencing physical activity behaviour among participants in the included studies.Physical activity was often defined in a broad context, with definitions ranging from incidental activities to structured physical actions including sport (Caperchione et al. 2011;Caperchoine, Mummery, and Joyner 2009;El Masri, Kolt, and George 2021;Fernandes et al. 2021).Studies including individuals who identified as Arab-Australian, Bosnian, Filipino and Sudanese found that participants were unaware or unclear of the distinction between physical activity and exercise (Caperchione et al. 2011) and appeared to be unfamiliar with recommended guidelines for physical activity (El Masri, Kolt, and George 2021).(Q1-4) Many participants were cognizant of the benefits of physical activity on physical health (Koo 2011;El Masri, Kolt, and George 2021).(Q6) However for some, excessive physical activity was a cause for health concern (Caperchione et al. 2011) and the physiological responses to exercise acted as a deterrent (El Masri, Kolt, and George 2021).In a study of African migrants from Somalia, Ethiopia and Sudan, some participants reported restricting physical activity because weight gain was culturally endorsed within the community (Renzaho, McCabe, and Swinburn 2012).(Q6-7) There were also inconsistent views on the impact of physical activity on mental, emotional and cognitive health among participants who self-identified as Chinese as well as first generation migrants from Afghanistan, India and Sri Lanka (You et al. 2021;Willcox-Pidgeon et al. 2021).While some participants understood the mental health benefits of being physically active, participants who were asylum seekers, refugees (Hartley, Fleay, and Tye 2017) or migrants born in regions affected by unrest, such as Afghanistan, Iran, Syria, Myanmar, Democratic Republic of Congo, Ethiopia, Liberia, South Sudan, Togo, Burkina Faso and Burundi (Reis et al. 2020) poor mental health and associated amotivation was reported as a barrier to physical activity participation.(Q8-11) Misconceptions about the importance of physical activity in preventative health meant some participants only engaged in physical activity once they were already experiencing symptoms of illhealth to prevent further deterioration in well-being (El Masri, Kolt, and George 2021; You et al. 2021;Caperchione et al. 2011;Koo 2011;Addo et al. 2019).(Q12-15) For others, advancing age and existing health conditions limited the type and intensity of physical activity they felt able to engage in (Koo 2011;Caperchione et al. 2011;El Masri, Kolt, and George 2021;Addo et al. 2019).(Q16-17) Q3 'I like to push myself physically to the limit where my body starts to shut down and almost get exhausted, that to me is exercise, rather than just going for a nice, gentle walk'.(Fernandes et al. 2021) Q4 'Physical activity means the overall development of a person … mentally as well as physically'.(Fernandes et al. 2021) Q5 'I will encourage her not to lose weight more than this, and I will not bring instruments or equipment for exercise into the house.So I will ban exercise instruments in the house'.
(Renzaho, McCabe, and Swinburn 2012) Q6 'Like I said, being physically active can deter a lot of health issues and just maintaining a good body weight and so helps with the growth as well and things like that.So, I think it's very important.Yes'.(Hayba, Shi, and Allman-Farinelli 2021) Q7 'When we were in Somalia we never had consciousness of the link between heavy weight and diseases.And now we have this awareness all the time.Teenagers know they are at risk of obesity.They know their risk because of being in school.This brings arguments, and trying to tell the father or the mother the right way, but he or she does not want to know'.(Renzaho, McCabe, and (You et al. 2021) Q18 'So, the difference here is when you come to physical activities, […] there we do because we do what we are supposed to do and at the same time we are physical active.Here, you are not so active, you need to have your own plan to do physical activities intentionally'.(Reis et al. 2020) Q19 'What I find interesting is that in Africa, you are not aware that you're exercising but you're exercising.We were exercising unconsciously.Because there's a lot of walking.I wasn't driving back then, so there was a lot of walking … here (in Australia) … I am always driving, … ' (Addo et al. 2019) Q20 'We were more active in (country of origin) then here, it was part of our day.In (country of origin) we don't have a school bus so we walk on our legs, we walk to collect kerosene to use to cook or to go shopping'.(Caperchoine, Mummery, and Joyner 2009) Q21 'I used to be a sports' girl, every kind of sports, tennis, netball, swimming, everything … When I came to Australia, I got lazy, I don't play sports anymore'.(Addo et al. 2019) Q22 ' … I don't exercise as much as I used to in Ghana.I used to do a lot of exercise back in Ghana, but I'm not able to do that much exercise here'.(Addo et  not so open-minded.The people were very conservative.If I wore a swimsuit, my father-in-law would scold me and say, "you are so bad"'.(Koo 2011) Q28 'But I don't feel comfortable around men, to do any exercise'.(El Masri, Kolt, and George 2021) Q29 'If we would like to go to the gym then we have to mention the person there, there is no men to go inside.That's a bit of problem for us.You have to trust the people there, because it's our religion.It's very hard'.(Caperchione et al. 2011) Q30 'If I have a company, I will have the motivation to play it (Tai Chi)'.(You et al. 2021) Q31 ' … like the encouragement, like if you have friends who have similar, similar hobbies or similar activities, like two or three want to go walking, it will be a habit on a certain day, a certain time, but sometimes if you are alone, you'll skip it today'.(El Masri, Kolt, and George 2021) Q32 'One of the reasons why I joined the walking group was because I was going to be in a group.When (name) and (name) mentioned this group I jumped at the chance because I know I can lose a bit of weight and get the right nutrition values as well as everything.Now that I have joined the walking group I've met heaps of other women, we've got a friendship now.That's all I wanted, was to find friends as well as go on a walk and feel safe'.(Caperchoine, Mummery, and Joyner 2009) Q33 'Yes, we need someone to push us harder because sometimes we are doing it but we laugh and we're not really pushing hard, we need someone to make us huff and puff'.(Caperchoine, Mummery, and  Q39 'The problem is we don't want to swim mixedboys and girls mixed.We don't know of any other places where it's close to our houses and has women only so that's the problem'.(Willcox-Pidgeon et al. 2021) Q40 'They don't know English, so they don't know there's this thing (exercise class) so that they can join'.(You et al. 2021) Q41 'It will be much better for them to communicate; a lot complain about the interpreter.So, if they can use their own language, [this] will make them feel comfortable to tell [the coaches] their issues'.(O'Callaghan et al. 2021) Q42 'I am very introverted.I don't know English.I don't know how to communicate with other people.I'm afraid of saying something wrong.I enjoy staying at home and doing indoor activities'.(Koo 2011) Q43 'Like jogging, it was a normal way of life as you don't have money to afford transport (in Nigeria) … When I came here (Australia), when I try to go to the gym and I was asked to pay $700 to register to start "gyming", I said, "this was a free thing that I was getting back home.Now, why should I be paying for it?"'(Addo et al. 2019) Q44 'I wanted to go [to the gym] but the income support that I'm receiving, it's not really enough … if I [had enough money] I definitely would go because days are very hard to pass so that would be a very good hobby to go and just pass the day.' (Hartley, Fleay, and Tye 2017) Q45 'If it (Tai Chi) needs to pay, many people will not learn.Older people do not have money.'(You et al. 2021) Q46 'Sometimes I think its money, can't afford.Like I was enjoying when my kids were there and I was joining in with my kids but when I asked about the money they said $15 per lesson, it's good but with four kids I don't think I can afford to have $15 to pay for myself every week … ' (Willcox-Pidgeon et al. 2021) Q47 'I always set aside the time for me to walk in the morning but then one time I was walking, there was somebody who stopped his car near me and followed me.I didn't go walking any more after that.' (Caperchione et al. 2011) Q48 ' … I've had some unpleasant experiences.I used to go for walks.On two occasions and two different paths, while walking by the street, people threw things (e.g.eggs) at me.' (Addo et al. 2019) Q49 'Around the suburb and the house, it is not safe.The park is far, because here there are people who inject drugs and they throw syringe, and if you step on it then you are finished.
I am worried about that.' (Renzaho, McCabe, and Swinburn 2012) Q50 'We have great walking tracks around the area but they are very secluded so safety is an issue.I prefer to go in groups because my husband won't agree to me walking on my own.' (Caperchoine, Mummery, and Joyner 2009) Q51 ' … I really think that somehow transportation needs to be met.Transport has always been an issue in our community and I think it's probably a problem overall, no matter which community.' (Caperchoine, Mummery, and  There was a consistent decline in self-reported physical activity levels upon migration in all five articles that explored this change (Addo et al. 2019;El Masri, Kolt, and George 2021;Caperchione et al. 2011;Reis et al. 2020;Oliver et al. 2007), four of which focussed on migrants from developing countries (Addo et al. 2019;El Masri, Kolt, and George 2021;Caperchione et al. 2011;Reis et al. 2020).On close examination, participants in these studies were mainly referring to incidental physical activities.For many, such as participants from the Cook Islands (the Pukapuka people) the lifestyle in their native country was inherently more physically active particularly in the context of work (Oliver et al. 2007;Reis et al. 2020) and housekeeping (Caperchione et al. 2011).Participants cited convenient access to labour saving devices such as cars, elevators and laundry machines upon migration as a reason why incidental physical activity was reduced (Addo et al. 2019;Reis et al. 2020;Caperchione et al. 2011;El Masri, Kolt, and George 2021;Oliver et al. 2007).This was particularly the case for participants of lower socioeconomic status who reported greater reductions in physical activity upon migration (Caperchione et al. 2011).Most of the physical activity undertaken by migrants in Australia was reportedly transport related (Caperchione et al. 2011) or traditional activities (Oliver et al. 2007;Koo 2011;Caperchoine, Mummery, and Joyner 2009).In a study exploring leisure-time physical activity among humanitarian migrants in regional Australia, participants who engaged in physical activity prior to migration tended to remain more physically active than those who never engaged at all (Reis et al. 2020).While leisure-time physical activities that migrants previously engaged in were often reportedly discontinued after arrival in Australia (Reis et al. 2020), walking was a popular exercise for its simplicity and convenience, especially among those experiencing low self-esteem and poor body image (Caperchoine, Mummery, and Joyner 2009;Koo 2011;Oliver et al. 2007;You et al. 2021).(Q18-22)

Theme 2. Acceptability and appropriateness
Cultural and religious factors appeared to play a role in defining what was acceptable and appropriate physical activity behaviour.Among participants from Arabic (El Masri, Kolt, and George 2021) and Bosnian-speaking backgrounds (Caperchione, Kolt, and Mummery 2013), physical activity was seen as a religious obligation.Among women, gender roles established and reinforced through culture were a commonly reported barrier to physical activity.The cultural norm for many CALD communities in the included studies was for women to take up the bulk of domestic duties regardless of employment status leaving them limited time and energy to engage in physical activity (Caperchione et al. 2011;Caperchoine, Mummery, and Joyner 2009;El Masri, Kolt, and George 2021).(Q23-26) Poor body image and low self-esteem among female Arab-Australian participants appeared to be exacerbated by the lack of appropriate environment and type of activities available (El Masri, Kolt, and George 2021).Certain settings such as beaches and activities where revealing clothes were the norm could be deemed inappropriate for women from conservative cultures like Chinese (Koo 2011) and Muslim Arab-Australians (El Masri, Kolt, and George 2021) and first generation migrants from Afghanistan, India and Sri Lanka (Willcox-Pidgeon et al. 2021).(Q27) Female Arab migrants suggested that gender exclusive settings were required for public modesty (Caperchione et al. 2011;El Masri, Kolt, and George 2021).(Q28-29) The desire to avoid imposing on others (e.g. to family members and friends) within the Chinese culture served as a barrier to physical activity participation (You et al. 2021), especially to those conducted at community centres (Koo 2011).
Many participants in the included studies reported high levels of social isolation (Reis et al. 2020;Hartley, Fleay, and Tye 2017;El Masri, Kolt, and George 2021;Caperchione et al. 2011;Pink, Mahoney, and Saunders 2020) and acknowledged a positive correlation between physical activity behaviours and social supports (Koo 2011;Caperchione et al. 2011;El Masri, Kolt, and George 2021;Hartley, Fleay, and Tye 2017;Reis et al. 2020;You et al. 2021;Willcox-Pidgeon et al. 2021).Participants in a study of Chinese adults attributed the mental health benefits of being physically active to the social aspect of participation rather than the physical activity itself (You et al. 2021).A strong preference for group activities (Addo et al. 2019;Cerin et al. 2019;El Masri, Kolt, and (Caperchione et al. 2011;Reis et al. 2020;El Masri, Kolt, and George 2021).(Q35) Some parents from Middle Eastern backgrounds engaged in physical activity to stimulate greater participation by their children (Hayba, Shi, and Allman-Farinelli 2021;Willcox-Pidgeon et al. 2021).In one study, participants from sub-Saharan Africa suggested that social media messages promoting physical activity were an enabler for greater participation (Addo et al. 2019).

Theme 3. Accessibility
Participants in the included studies experienced reduced access to existing services and initiatives that were intended to support physical activity participation.The participants suggested these were often limited in frequency (El Masri, Kolt, and George 2021;Cerin et al. 2019), of short duration (Willcox-Pidgeon et al. 2021) and were not tailored to the needs and preferences of CALD communities (Caperchione, Kolt, and Mummery 2013;El Masri, Kolt, and George 2021).Language barriers, financial considerations and environmental factors influenced uptake of such programs.(Q36-39) Language barriers were reported in several studies (Caperchione, Kolt, and Mummery 2013;Caperchione et al. 2011;Cerin et al. 2019;El Masri, Kolt, and George 2021;Hartley, Fleay, and Tye 2017;Reis et al. 2020;Willcox-Pidgeon et al. 2021).Due to limited English proficiency, individuals including those who identified as first generation Chinese frequently reported being unaware of existing services and how to access them (Reis et al. 2020;Cerin et al. 2019) or they were deterred from ongoing participation in initiatives conducted in English (Caperchione, Kolt, and Mummery 2013;Caperchione et al. 2011).In one study, asylum seekers from Afghanistan, Sri Lanka and Iran who had arrived to Australia by boat noted that government policy denied them access to adequate English classes (Hartley, Fleay, and Tye 2017).In a study of Chinese migrants, interpreters alone were perceived as insufficient to engage people from CALD backgrounds and participants perceived a greater hesitancy among stakeholders to recommend programs to those with limited English language proficiency (O'Callaghan et al. 2021).Instead, bicultural/bilingual programs were viewed favourably and seen as critical for the success and effectiveness of programs (O'Callaghan et al. 2021). (Q40-42) Financial barriers were reported in several studies (Addo et al. 2019;Caperchione, Kolt, and Mummery 2013;Caperchoine, Mummery, and Joyner 2009;Cerin et al. 2019;El Masri, Kolt, and George 2021;Reis et al. 2020;Smith, Thomas, and Batras 2016;Pink, Mahoney, and Saunders 2020) especially among asylum seekers who did not yet have the right to work in Australia (Hartley, Fleay, and Tye 2017).Financial resources tended to be dedicated to daily necessities with little left for health promotion measures such as physical activity (Caperchione, Kolt, and Mummery 2013;Hartley, Fleay, and Tye 2017).Indeed, for some participants, physical activity was viewed as a 'luxury' rather than 'necessity' (Caperchione et al. 2011;Willcox-Pidgeon et al. 2021).Costs of registration and membership fees associated with structured physical activity programs were identified as barriers to participation by participants who were first generation migrants from Sub-Saharan Africa (Addo et al. 2019).Some participants prioritised financing the participation of their children in organised physical activity, in particular swimming, as water confidence was considered an important life skill (Willcox-Pidgeon et al. 2021). (Q43-46) Environmental factors were also recognised as major determinants of physical activity participation.Many participants resided in low-middle socioeconomic areas (Hayba, Shi, and Allman-Farinelli 2021) with higher than average crime rates and expressed safety concerns regarding engagement in traditional (Caperchione et al. 2011) and outdoor physical activities (Addo et al. 2019;Caperchoine, Mummery, and Joyner 2009;Oliver et al. 2007;Renzaho, McCabe, and Swinburn 2012;You et al. 2021).Participants in studies that included refugee migrants from Myanmar, Afghanistan, Eritrea as well as Arab Australians reflected that safety concerns were exacerbated by the contested nature of refugee settlement in Australia and stereotypical media portrayals which contributed to racist behaviour among some members of the mainstream Australian society (El Masri, Kolt, and George 2021;Pink, Mahoney, and Saunders 2020).(Q47-50) However, locally available physical activity destinations were regarded as key enablers to greater engagement in physical activity (Cerin et al. 2019;El Masri, Kolt, and George 2021), particularly among newly arrived migrants who often did not have access to private vehicles and found public transport intimidating (Caperchoine, Mummery, and Joyner 2009), inadequate (Cerin et al. 2019;Caperchione, Kolt, and Mummery 2013;Koo 2011;Pink, Mahoney, and Saunders 2020) and/or unaffordable (Hartley, Fleay, and Tye 2017).(Q51-52) Climate and weather conditions were reported by some members of CALD community to discourage outdoor physical activity (Addo et al. 2019;Caperchoine, Mummery, and Joyner 2009;You et al. 2021) and associated with amotivation.(Q53-54)

Discussion
This synthesis of qualitative findings related to physical activity participation among CALD populations in Australia identified three overarching themes that shaped physical activity behaviour: 1. Perceptions of physical activity; 2. Access to services and initiatives; 3. Acceptability and Appropriateness.These findings can be compared to that of the broader Australian population and considered through a lens of acculturation theory (Gibson 2001), leading to recommendations for future policy and programs to support physical activity in Australian CALD communities (see Figure 2).
The consistent decline in self-reported physical activity upon migration in all five articles exploring this change is consistent with what previous researchers have labelled the 'healthy immigrant effect'.This effect is whereby migrants arrive in a Western country in good health, but experience a decline in health as a result of continuous contact with culturally dissimilar people, groups and social influences; known as acculturation (Gibson 2001).While acculturation has been associated with behaviours such as sedentarism and consumption of high caloric, processed diets (Hosper, Klazinga, andStronks 2007a, 2007b), greater assimilation into the host culture has been linked to higher levels of physical activity (O'Driscoll et al. 2014), especially in the non-occupational domain (Hosper, Klazinga, and Stronks 2007;Gerber, Barker, and Pühse 2012).Indeed, participants in included studies often expressed a need to balance the decrease in incidental activities due to the more sedentary lifestyle of Australia with increases in intentional formalised physical activity such as sport and exercise.Host language proficiency is linked to greater assimilation (Dassanayake et al. 2011).Among Australian migrants, English language skills are correlated with important health benefits for women and increased physical activity in men (Guven and Islam 2015), highlighting the need to provide language adapted interventions for CALD communities.Some of the included studies focused on asylum seekers who had been in migrant detention centres (Reis et al. 2020;Renzaho, McCabe, and Swinburn 2012;Hartley, Fleay, and Tye 2017;Pink, Mahoney, and Saunders 2020), While none explored time and experiences in detention centres and their impact on physical activity behaviour, previous literature has identified that past trauma including exposure to extreme violence, human rights abuses, persecution (Shawyer et al. 2017), prolonged time in detention (Newman, Proctor, and Dudley 2013) and ongoing uncertainty for the future may all contribute to the prevalence of mental health concerns among refugee communities.People with severe mental illness have been found to have significantly lower levels of physical activity compared to controls (Nyboe and Lund 2013).Experiences of racism further shaped physical activity behaviour for some participants in the included studies.Racism can be defined as a system of oppression which 'creates hierarchies between social groups based on perceived differences relating to origin and cultural background' and is expressed and shaped by policies, practices and media (Ben et al. 2022, page 2).Research in Australia has identified a link between exposure to racism and poorer health, including higher body mass index, depression and sleep disturbance (Priest et al. 2017;Sharif et al. 2021).Initiatives at an individual, social and political level to build a more inclusive Australia are fundamental to improving the health of CALD communities.
Beyond factors relating to migration, CALD communities also face general barriers to greater engagement with physical activity.Misconceptions about what physical activity is, how much is necessary and why, have been noted among the wider Australian population with suggestions that many Australians are 'in the dark' about physical activity (Hawke et al. 2022;Fredriksson et al. 2018).While most studies to date have focussed on individual behavioural change approaches, calls have been made for greater focus on public health and policy interventions to increase physical activity in the general population (Ding et al. 2020).Public health messaging tailored to the linguistic and literacy needs of diverse Australian communities is needed to improve knowledge about physical activity among people from CALD backgrounds.While the majority of participants in the studies included in this scoping review recognised the benefits of being physically active, two studies examining the perspectives of service providers (Smith, Thomas, and Batras 2016;Caperchione, Kolt, and Mummery 2013), perceived a lack of understanding about preventative health existed in most CALD communities.This discrepancy between service providers and CALD communities underscores the importance of building a culturally diverse work force and of cultural awareness training so that service providers understand the broader factors contributing to physical activity participation among people from CALD backgrounds.
Indeed, consistent with health behaviour theory (Bandura 2004), our findings suggest that knowledge alone is unlikely to be sufficient to increase physical activity participation in CALD communities.Strategies are required to address financial, environmental, and social barriers and improve access to cultural safe environments in which people are able to participate in physical activity.In this review, service providers and CALD communities recognised limited availability of targeted physical activity programs (Caperchione, Kolt, and Mummery 2013;Cerin et al. 2019;El Masri, Kolt, and George 2021).While resource strain is a suggested cause for this (Caperchione, Kolt, and Mummery 2013), there was a lack of discussion in the included studies on the sources of funding and what that entailed (Caperchione, Kolt, and Mummery 2013;Smith, Thomas, and Batras 2016).A variety of strategies have been trialled in practice to address financial constraints to physical activity including free-ofcharge activities and subsidised fees but with little evidence of a financially sustainable model (Smith, Thomas, and Batras 2016).These challenges suggest the need to trial alternative, innovative approaches with involvement of non-traditional sectors.Proximity to parks, walking tracks, shops and recreational centres have been proposed as strategies to address environmental barriers to physical activity engagement (Barnett et al. 2017;Van Cauwenberg et al. 2018).Improvements in public transport networks have demonstrated the potential to improve physical activity participation (Brown et al. 2019), although limitations with the existing system were reported as barriers to greater participation with formal physical activity programs by participants in included studies (Cerin et al. 2019;Caperchione, Kolt, and Mummery 2013;Koo 2011;Pink, Mahoney, and Saunders 2020;Caperchoine, Mummery, and Joyner 2009;Hartley, Fleay, and Tye 2017).Assistance with transport through provision of private vehicles, community buses (Smith, Thomas, and Batras 2016), orientation sessions where a facilitator guides individuals on how to reach destinations may also be trialled.Collaborative partnerships with external organisations offering services to CALD communities may be crucial for program sustainability through sharing of equipment, facilities and staff.Cross-promotion of initiatives between partners may also facilitate greater awareness and engagement with programs.Empowering members of CALD communities to be involved in the design and implementation of initiatives would further strengthen community trust.In particular, as noted elsewhere (Caperchione et al. 2011), placing women at the centre of program development may help address barriers such as cultural modesty, acceptable dress and childcare when participating in physical activities.
Integrating findings from our scoping review with an international systematic review of cultural adaptations to interventions seeking to improve physical activity participation, (El Masri, Kolt, and George 2022) we suggest that future culturally appropriate interventions in the Australian context should incorporate community consultation, language adjustments, use of bilingual/bicultural personnel and culturally relevant material or content to optimise reach, adoption and effectiveness.Future interventions should also be theoretically-informed and embedded within implementation frameworks to facilitate scale-up, adaptation to diverse groups and sustainability over time.

Design considerations and future research
This scoping review focused on qualitative studies to enable in-depth insight into the factors that shape and define physical activity behaviours among people from CALD backgrounds living in Australia.We included studies that explored the perspective of both people from CALD backgrounds and service providers to enable insight into individual, community, service and policy level factors.A key limitation of this study is the secondary analysis of primary data.The definition of physical activity was often not established in the included studies.Individuals from different backgrounds may have conceptualised physical activity in different ways which may have influenced their responses.Future research would benefit from establishing a shared definition of physical activity.To facilitate our interpretations, we adopted the accepted scientific definition of physical activity (Caspersen, Powell, and Christenson 1985), also adopted by some of the included studies.The majority of included studies were cross-sectional in nature and relied on recall of change in physical activity on migration.Future prospective studies are needed to understand how perceptions and behaviours related to physical activity change over time.Social desirability biases may have influenced participants' responses in the included studies, with only 6/17 studies reporting on the nature of the relationship between the study participants and researchers.Future qualitative studies involving people from CALD backgrounds are encouraged to provide evidence of reflexivity so that readers can assess the credibility of interpretations.
Most of the included studies were based in New South Wales and Victoria, the two states in Australia with the greatest proportion of CALD populations (Australian Bureau of Statistics 2021).Future research should include individuals from diverse regions in Australia to inform national guidelines regarding physical activity amongst individuals of CALD backgrounds.The main CALD communities studied in this review include African, Arabic speaking, Filipino and Chinese migrants among others as well as refugees and asylum seekers.Future research should extend to other CALD communities across Australia.While we identified overarching themes that were common across the communities included in this review, it is important to acknowledge the diversity that exists among CALD communities in Australia.Within the major themes identified, where possible, we described findings relevant to specific groups.

Conclusion
This scoping review of qualitative studies investigated the factors that shape physical activity participation among CALD communities in Australia.Physical activity for CALD communities encompassed a wide range of events from incidental activities to structured exercises.Several factors appeared to contribute to the decline in selfreported physical activity levels upon migration including perceptions of health and physical activity; social, cultural and religious differences relating to acceptability of physical activity participation; and language, financial and environmental barriers to accessibility of physical activity.The effects of these correlates were not uniform across all groups or even necessarily within the same CALD community.Consultation with CALD communities should be the forefront of future initiatives targeting community perceptions, acceptability and access to improve physical activity participation.
2020) Q12 'Exercise is not my priority because I don't think I'm obese or I'm fat'.(Addo et al. 2019) Q13 'No, personally I think that nothing motivated me expect when I found out like I'm low on vitamin D. Now I'm really motivated to do some exercise'.(El Masri, Kolt, and George 2021) Q14 'I had a stroke 10 years ago and half of my body could not move.So I started to do exercise, Tai Chi'.(You et al. 2021) Q15 'If I have any health problems, it is irreversible.Just like a pot and a wok.You cannot use them forever.You will discard them in the rubbish bin one day'.(Koo 2011) Q16 'I have problems in my cervix, so I feel restricted to the kind of exercise I can handle … I used to love to swim but I started to get cramps so now I panic when I am swimming'.(Caperchione et al. 2011) Q17 'I used to ride bike.No matter how far away the destination was, I would ride there.Now I do not have the courage, I am worried I would fall over'.
George 2021; Caperchione et al. 2011) led by a leader/program coordinator (Caperchoine, Mummery, and Joyner 2009; Willcox-Pidgeon et al. 2021) with face to face delivery (El Masri, Kolt, and George 2021; O'Callaghan et al. 2021) was reported amongst individuals of diverse CALD background.(Q30-34) Social supports, especially from family, were seen as important facilitators of participation in physical activity; the absence of family support in Australia made it difficult, particularly for parents

Figure 2 .
Figure 2. Recommendations to increase physical activity participation for people from culturally and linguistically diverse backgrounds in Australia.

Table 1 .
Search strategy in MEDLINE.

Table 2 .
Inclusion and exclusion criteria.

Table 3 .
Characteristics of included studies. .
. .Reactive approach to health .Importance of social support .Limited by physical health Accessibility . ...Financial barriers .Transport barriers ..Physical activity seen as a privilege that they could not afford . . ...Financial barriers.

Table 5 .
(El Masri, Kolt, and George 2021)every day, I would not say it is sport or exercise, I feel we have to make special exercises for our bodies'.(Caperchioneetal.2011) Q2 ' … it's um, actually jogging, that's what I feel, it's like um not walking, [rather] doing hard exercise which we need and we don't, we don't do it'.(ElMasri, Kolt, and George 2021) .Varied definitions.Complex relationships with health.
(Willcox-Pidgeon et al. 2021re active, exercising more is good for our bodies, want to continue going more regularly, weight loss, very good for mental health'.(Willcox-Pidgeonetal.2021)Q9'Iknow for myself, if I don't exercise, I'm grumpy all the time.I'm eating anything.I'm making excuses not to exercise or, you know, and just feeling bad all day.Like, physically and mentally because you're not doing any movement, there's no movement.There's no, there's nothing there, like … And you notice the change in the anger now that he's actually more calmer that he's go to the gym.He's you know, the weights he does or whatever he does.He's releasing his tension in that.So, which is better.Like, you see a complete mood changes as well so yeah'.(Hayba,Shi,andAllman-Farinelli2021)Q10 'Even if you're awake you don't get out of the bed because there's nothing else to do.Even if [we want to be] physically active, mentally it doesn't allow us to do or participate in activities'.(Hartley,Fleay,andTye 2017) Q11 'I don't have a good head to do any activity.Before I was a soccer player in my country.But when I have become refugee, a refugee life!I don't wish this life to anybody.
[…] You lost everything.Every day no good life for refugee […] I am in Australia.I thank God to provide such an opportunity to me and my family.But there is no job to do.We also have language barrier […] This is a very big problem for me.I don't have anything to think, doing any activities like sports'.(Reiset al. (Caperchione et al. 2011ly do nothing at home.Women do the cooking and the cleaning, even if they work.If they want to do something they don't have the chance'.(Caperchioneetal.2011)Q24 ' … You come from a certain class or a certain caste, where women are expected to do traditional roles.So, a mother is just a mother, and her role is defined.She has got to cook she has got to look after the family.She's not somebody who is encouraged to take up any hobbies'.(Fernandesetal.2021) Q25 'We don't have [a] life mate, just get kids, clean, cook, look after [the] husband … ' (El Masri, Kolt, and George 2021) Q26 'Because in my culture, women have different rules and boys have different laws.We are not equal.We're all living in Australia but we are not equal.[…] In my culture, if boys do anything that come from any other culture, it's ok.But if girls do, […] it becomes a very big issue.So I feel like in my culture we are not equal, we are not in equal right'.(Reis et al. 2020) Q27 'When I was your age, we were Joyner 2009) Q34 'Doing it with other people is really good because you're always learning new stuff.But doing it by your own sometime you don't feel motivated, you feel lazy.But if you have someone with you, he will push you.I always want someone to come with me'.(Reis et al. 2020) Q35 'In Australia, we don't have any help at all.In our country, we have our relatives, like brother or sister or nephews or nieces to look after the kids while we can have time a little bit to ourselves to relax.But in here you tend to do everything and as they said, it's more kind of a stressful way financially and physically.' (Caperchione et al. 2011) Q36 'I feel because there are fewer people in Australia (compared with China), so they have fewer exercise facilities.I hope they can provide more facilities'.(You et al. 2021) Q37 'We don't have enough people that can facilitate these types of things.There's not that many people here that have the level of skill that can run things like this'.(Caperchoine, Mummery, and Joyner 2009) Q38 ' … for us, as, like as mothers in that age, I don't [think] there is a lot of things available for us … '. (El Masri, Kolt, and George 2021) Joyner 2009) Q52 'I don't have any means of transportation, any vehicle to travel far distances, even if I catch the public transportation so I need to pay much more money for that … if I catch the bus from here to my house, it's $1.25 and if I want to go to the city by bus, it's $7 or something … ' (Hartley, Fleay, and Tye 2017) Q53 ' … in Africa, it was always warm.So just walking … back and forth and doing things, you just sweat, you're burning things, … (in Australia) winter comes, too cold … ,you postpone it (planned exercise) to the next day, you postpone it (to) the other day.It's just kind of start getting harder, as you get colder, it gets harder … ' (Addo et al. 2019) Q54 'I guess the weather it prevents you from going out … like going out today when it's cold and wet.You just keep yourself warm at home, so of course you won't exercise when you're home.' (You et al. 2021)