Language and cultural differences are often significant barriers for people from culturally and linguistically diverse (CALD) communities accessing health care services and managing health care needs.
Dr Cheefoong Chong and Dr Liam Walsh present the case of a young Palestinian mother and her baby boy living in New Zealand. This heart-warming case demonstrates the capacity of specialist services to support the wellbeing and integration of people in CALD communities.
In Kirikiriroa (Hamilton), a favourite pastime is to walk along the Waikato River. The river is one of the largest in Aotearoa New Zealand and is a life-giving sustenance, drawing many new migrants to the area over centuries. Like the stories of the people who live on its shoreline, the river flows endlessly, its particles jostling and mixing, eventually joining, becoming indistinguishable, in time.
Kirikiriroa in Te Ika a Maui (North Island) is New Zealand’s largest inland city, known for its richness of stunning natural landscapes and thriving economy. One of the most diverse cities in New Zealand, up to 15% of Hamilton’s population come from CALD backgrounds, particularly from Asia.1
CALD is a term commonly used in Australia, describing those who are not from Indigenous or mainstream (English speaking) cultural backgrounds.2 In our increasingly multicultural world, CALD – along with cultural and community diversity – are all concepts that are frequently spoken about.
The Case of Joseph
Joseph* is a Palestinian boy, whose family arrived in New Zealand as refugees. He was initially referred as a newborn in 2023 with bilateral congenital cataracts secondary to Lowe syndrome. Joseph faced a multitude of systemic issues on top of his eye conditions, including gastroenteric, skeletal, renal, and cognitive impairment, for which he saw multiple paediatric specialists.
For his cataracts, it was decided the best approach was to remove both cataracts simultaneously in mid-2023, under general anaesthetic. A bilateral lensectomy was conducted via a pars plana approach, with posterior capsulectomy and anterior vitrectomy. Fundus examination was unremarkable. Post-operatively day one, Joseph had a round pupil and a formed anterior chamber (visual acuities were unable to be recorded due to age and co-operation).
A plan was made for Joseph to use 32.00D soft contact lenses, which would correct for an aphakic eye and provide a clear near point (with an overcorrection of +3.00D).
Unfortunately, Joseph’s mother Wendy* faced significant barriers to fulfilling Joseph’s need for care. Medically, she had also suffered from bilateral cataracts as a child, along with nystagmus. Her cataracts had been removed and intraocular lenses inserted, but with persisting poor vision, she had experienced subsequent learning/processing difficulties.
Wendy had moved with her husband to New Zealand as a refugee, fleeing from the Palestinian and Israeli conflicts.
On arrival in New Zealand, the only person Wendy knew was her Auntie, who lived in the small town of Huntly, just north of Hamilton. She relied on her husband to communicate in English and provide for the family. However, soon after immigrating, she separated from her husband, reporting him for physical abuse. Wendy moved with her son to a women’s refuge. Her Auntie no longer talked to Wendy after the separation.
Alone in the women’s refuge, Wendy faced difficulties communicating with others, speaking mainly Arabic, with limited English. She struggled to keep up with the tasks of cooking, cleaning, and providing adequate care for Joseph. Getting food and other supplies from the store was also challenging. Wendy felt embarrassed to ask for help, and uncomfortable asking strangers, particularly men, for assistance. Language barriers made direct communication with community services – and even leaving the house – difficult. Medical barriers, such as the cognition to adequately process complex tasks, compromised her ability to care for herself and Joseph.
Medical barriers, such as the cognition to adequately process complex tasks, compromised her ability to care for herself and Joseph
Turning Point
Through Health NZ, Waikato Hospital provides diverse interpretation services, which are available over the phone and in person.3
This service was made available to Wendy from her first appointment, with an Arabic interpreter who had a thorough knowledge of Arabic medical terminology, helping to improve her understanding of Joseph’s condition and the planned management approach.
Additionally, with the help of the interpreter, Wendy attended several education sessions at the Waikids day stay unit, a service that integrates all child and youth health services provided by the Waikato District Health Board. Here she learnt how to care for Joseph during his visual rehabilitation, and manage the insertion, removal, and hygiene of his contact lenses. During the sessions, educators observed Wendy to ensure she was able to perform all the required steps.
In follow-up appointments, however, Joseph was found to have developed nystagmus, indicating bilateral poor visual development in infancy. Soon after, it was established that Joseph’s mother was seldom administering the contact lenses and was not putting them back in when they fell out. Concerns arose about her ability to process and retain more complex instructions.
To find a way forward, the ophthalmology team reached a compromise with Joseph’s mother, whereby it was agreed that Joseph would wear aphakic glasses.
Finding Care
Social workers with an understanding of Palestinian culture helped access a children’s disability allowance for Joseph and a disability allowance for Wendy. This funding allowed for a package of care including accommodation and transport. Carers were organised to assist with five hours of care per week and an additional 15 days per year (for unexpected needs). A cognitive assessment was also arranged for Joseph’s mother, given the cognitive association with her genetic condition and concern regarding her ability to retain instructions.
Local Palestinian networks and Muslim support services were also engaged to help Joseph and Wendy throughout this time; promoting socialisation, material, cultural, and financial support, along with spiritual time.
Several months later, Joseph and his mother were met by Waikato Hospital’s multidisciplinary team. Joseph’s mother reported slow but good progress in all areas of development to the paediatricians. More specifically to ophthalmology, she reported Joseph “was occasionally annoyed by the glasses” but that she persisted with them as she recognised the importance.
The road to Joseph’s visual rehabilitation continues to be difficult with frequent reviews, prescription updates, and reinforcement of the need for consistent use of his glasses.
Discussion
CALD patients and their families often have complex needs, requiring comprehensive and multi-disciplinary solutions. Complex family and interpersonal dynamics are often driven by an interplay of cultural, religious, and social differences.
A patient-centred approach is essential, controlling for clinician biases and using respectful, effective communication.
Access to an interpreter, along with experienced social workers with similar cultural backgrounds, is essential to understand the unique needs of the patient and their family.
Additionally, effective communication is important to establish how family and friends, and the wider CALD communities, can be of assistance in the CALD patient’s journey. Often there are separate religious and community groups who can offer support in addition to what is available in the healthcare system. Some family dynamics, such as domestic abuse or family role changes, such as Wendy stepping into a new role as provider and caregiver, will often require additional support, understanding, and healing.
Investigating whether the family or other carers have unmet health needs is also very important, as many CALD individuals have never had formal medical reviews due to the complexities of immigrating and previous health system standards.
Education through language-appropriate resources and nurse specialists (with a translator) aids not only patient understanding but is also an opportunity for health professionals to gauge that understanding.
When there are concerns around a carer’s abilities to meet the needs of a child, then agreements with the families should be reached on what is achievable for them alone, or what can be achieved with support. In New Zealand, exploring the options of applying for certain governmental allowances empowers families to provide more comprehensive at-home care, decreases financial burden, assists with attending appointments, and builds cross-cultural relationships with the health sector.
Successful CALD family support services should seek to improve the feelings of belonging and integration with the local community, respecting family autonomy and dignity, while also making sure that their Tamariki (children) receive the best care.
*Names changed for anonymity.
Dr Cheefoong Chong serves as a consultant comprehensive and paediatric ophthalmologist at three major teaching hospitals in New Zealand and is the Co-Chair of the New Zealand Eye Health National Clinical Network Childhood Expert Workstream. Dr Chong is dedicated to advancing ophthalmic care and education through his commitment with the New Zealand National Retinoblastoma Service and as the Co-director of Training for the RANZCO Education Committee in New Zealand.
Dr Liam Walsh received his Bachelor of Medicine and Surgery from Auckland University. He then completed post graduate diplomas in paediatrics (Auckland University) and ophthalmology (University of Otago), winning the Adam Locket prize for the top mark in anatomy. He now works as an advanced trainee in the Ophthalmology Department of Waikato Hospital. Dr Walsh is passionate about providing equitable ophthalmic care to Indigenous and underprivileged people.
References
- 2018 Census External Data Quality Panel. Final report of the 2018 Census External Data Quality Panel. 2020.Available at stats.govt.nz/reports/final-report-of-the-2018-census-external-data-quality-panel [accessed Nov 2024].
- Henderson S, Kendall E. ‘Community navigators’: making a difference by promoting health in culturally and linguistically diverse (CALD) communities in Logan, Queensland. Aust J Prim Health. 2011;17(4):347-54. doi: 10.1071/PY11053.
- Gray B, Hilder J, Stubbe M. How to use interpreters in general practice: the development of a New Zealand toolkit. J Prim Health Care. 2012 Mar 1;4(1):52-61, A1-8. PMID: 22377550.
