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Improving cultural competence

Improving cultural competence

What is cultural competence?

Cultural competence requires an awareness of cultural diversity and the ability to function effectively, and respectfully, when working with and treating people of different cultural backgrounds.  At Waitemata DHB, cultural competence means our staff have the attitudes, skills and knowledge needed to achieve this. 

Value: Everyone MattersA culturally competent staff member will acknowledge that:

  • New Zealand has a culturally diverse population
  • a staff member’s culture and belief systems influence his or her interactions with patients and accepts this may impact on the staff member’s-client relationship
  • a positive client outcome is achieved when a staff member and client have mutual respect and understanding[1]
  1. Statement on Cultural Competence. NZ Medical Council, 2006.


What are we trying to achieve?

Background – population profile

Auckland is the most ethnically diverse region in New Zealand with over 200 ethnic communities settled in the area.  A quarter of the region’s population is from Asian, Middle Eastern, Latin American and African backgrounds and 40% of the Auckland population are overseas born.

International and New Zealand health studies demonstrate that the culturally and linguistically diverse (CALD)[2] groups have disparities in health status compared to national groups even when adjusted for income and health conditions. New Zealand studies[3, 4] show that health practitioners’ poor understanding of cultural difference between themselves and their patients is an important factor in poor patient outcomes, and also the under-utilisation of health and disability services.

Our health workforce is diverse and the health populations served are diverse, resulting in increased cross-cultural interactions between CALD patients and clinicians.

  1. CALD in this article refers to migrants and refugees from Asian, Middle Eastern, Latin American and African backgrounds.
  2. Asian Health Needs Assessment, Mehta, S. (2012)  [Download document (3.2Mb)]
  3. Health Needs Assessment – Middle Eastern, Latin American and African People living in the Auckland region, Perumal, L. (2010)  [Download document (2.7Mb)]

Providing culturally competent care

Cultural competence of healthcare providers is essential to the health sector’s ability to provide culturally responsive services to improve access, equity, and quality of care to the CALD population. Providers with low cultural competency can lead to miscommunication; misdiagnosis; non-compliance of treatment, care and follow-up; and disengagement by CALD patients/clients.

The primary and secondary health workforce in the Auckland region is currently not well prepared with cultural awareness, knowledge and skills to meet the needs of the growing and increasingly diverse CALD population.

What have we done?

CALDIn 2007 the CALD Cultural Competency Project was initiated by our Asian Health Support Service (AHSS) to:

  • develop face-to-face and e-Learning CALD Cultural Competency Training Programmes
  • produce a range of CALD Cross-Cultural Resources
  • develop a CALD Resources website and a Learning Management System
  • develop a CALD Online Forum to support CALD learners
  • publish a range of cross-cultural resources; multi-language health information; information on Asian, Migrant and Refugee services and publications online

1. CALD Cultural Competency Training Programme

The overall goal of the CALD cultural competency training programme is to improve the cultural awareness, sensitivity, knowledge and skills of health practitioners working with CALD patients and their families.

The aims of the training programme are to:

  • increase the health workforce’s level of confidence to work with CALD patients and their families
  • enhance the cross-cultural interactions in the long term
  • increase CALD patients’ satisfaction with the services delivered
  • reduce miscommunication, misdiagnosis, non-compliance of treatment and follow up, and disengagement

Since 2007 our AHSS has been working with clinicians, migrant and refugee cultural experts, and researchers to produce a series of face-to-face cultural competency courses (CALD 1-5).  In 2009 we contracted the Goodfellow Unit from the University of Auckland to convert CALD 1-4 courses into an e-Learning format.  During the 2012-13 period, we completed the 9th course of the CALD programme.

The full list of CALD face-to-face courses are:

  • CALD 1 - Culture and Cultural Competency [pre-requisite]
  • CALD 2 - Working with migrant (Asian) patients
  • CALD 3 - Working with refugee patients
  • CALD 4 - Working with Interpreters
  • CALD 5 - Working with Asian mental health clients
  • CALD 6 - Working with Refugee mental health clients [no longer available as replaced by CALD 9]
  • CALD 7 - Working with Religious Diversity
  • CALD 8 - Working with CALD families – Disability Awareness
  • CALD 9 - Working in mental health context with CALD clients

All of the CALD courses above are CME/CNE and MOPS[5] accredited and are available in both face-to-face and e-Learning formats, except for CALD 5 which is only offered in face-to-face format.

  1. Continuous Medical Education (CME), Continuous Nursing Education (CNE) and Maintenance of Professional Standards (MOPS) accreditation means CALD courses are recognised for the purpose of health practitioners’ professional re-certification.

CALD Face-to-face Training Courses
CALD Face-to-face Training Courses

Who is eligible to access these courses?

The courses are available to staff working in Waitemata DHB, Auckland DHB, Counties Manukau DHB, as well as Primary Health Organisations, Primary Care and NGO organisations funded by any of these three DHBs and/or the Ministry of Health (MOH).

Go to CALD Resources website for more details - www.caldresources.org.nz.

2. CALD Cross-Cultural Resources

Becoming culturally competent is an ongoing process. It requires the learner to further expand and explore or research additional cultural knowledge and develop approaches based on cultural considerations.  Therefore, in addition to the CALD courses, our Asian Health Support Service has produced and published a range of academically researched online toolkits and HTML supplementary resources for CALD learners to further increase cultural awareness, knowledge and skills as part of the cultural competency developmental process.

The resources provide additional cross-cultural communication tips and guidelines, research material to increase cultural specific knowledge about working with Asian and Middle Eastern, Latin American and African People (MELAA) groups.  Most of the resources include case studies/scenarios.

The cross-cultural resources include:

  • Toolkit for Staff Working in a CALD Health Environment
  • Cross-Cultural Resource for Health Practitioners working with CALD clients
  • Ayurvedic Medicine
  • Working with CALD Families – Disability Awareness
  • Working with Religious Diversity
  • Working with Asian mental health clients
  • Working with MELAA mental health clients
  • CALD Family Violence Resource (to be published in Oct 2013)
  • CALD Older People Resource (to be published in April 2014)

Waitemata DHB CALD toolkit
Waitemata DHB toolkit for staff working in a CALD health environment

CALD Cross-Cultural Resource
Cross-Cultural Resource for Health Practitioners working with CALD clients

Go to CALD Resources website for more details - www.caldresources.org.nz.

3. CALD Resources Website – Learning Management System

The CALD Resources website - www.caldresources.org.nz was developed to serve three functions.

A. Learning Management System

The website is a dynamic web-based learning management system (LMS) where health professionals can:

  • enrol for CALD e-Learning and face-to-face courses
  • access the e-Learning courses to do self-paced learning from anywhere

The Northern Regional Alliance Ltd has contracted our Asian Health Support Service to provide this LMS system to manage online course enrolment; to track course uptake, completion, evaluation results; and to host all the online learning objects for CALD to enable easy access by learners.

CALD website is a Learning Management System (LMS)
CALD Resources website is a Learning Management System (LMS) - www.caldresources.org.nz

B. CALD Online Forum

CALD Online ForumAn online forum is available on the website for CALD learners (members) to:

  • post questions to trainers regarding CALD courses
  • share CALD knowledge and experience with other members
  • post questions to the CALD forum about available resources
  • access ‘Frequently Asked Questions’ about CALD training and resources

C. CALD Resources Online

To support health professionals with cross-cultural interactions with their CALD clients/patients or for research purposes, we have published a range of cross-cultural resources, health information in multiple languages as well as information on how to access Asian, migrant and refugee services and publications.

Go to the CALD Resources website to access the available resources - www.caldresources.org.nz.

Resources and information on CALD website
Resources, information and publications available on CALD Resources website - www.caldresources.org.nz

Did we make a difference?

In order to see if the project tools and resources have made a difference we have carried out the following:

  1. Tracked the demand of all the CALD courses.
  2. Evaluated the satisfaction ratings from participants on content, delivery, overall learning experience, sharing their learning and applying learning in their job.
  3. Evaluated the impact of CALD 1 Culture and Cultural Competency on participants in terms of longer term behavioural changes in practice and increase in cultural competency scores.
  4. Tracked the “Did Not Attend (DNA) Rate” of Asian outpatient appointments and interpreter-assisted non-English speaking CALD patient appointments.

A. Tracking demand of CALD Courses

The following table shows the cumulative CALD course enrolments by module, by e-Learning or face-to-face from May 2010-Aug 2013 across the Auckland region.

CALD 1-9 course enrolments (May 2010-Aug 2013)
CALD 1-9 course enrolments for e-Learning and Face-to-Face from May 2010-Aug 2013

The following graph shows the increasing CALD 1 uptake across the Auckland region – cumulative enrolments from May 2010-Aug 2013 (NB: CALD 1 is a pre-requisite of all CALD courses).

CALD 1 cumulative enrolments (May 2010-Aug 2013)
CALD 1 cumulative enrolments from May 2010-Aug 2013

The above results tell us that:

  • there is high demand for the CALD courses – the CALD courses have achieved more than 7789 enrolments over a 39 month period (average of 200 per month).
  • flexible learning options are making it possible to meet the needs of learners – some prefer face-to-face while e-Learning can reach out to learners who have no access to face-to-face courses
  • e-Learning is a more sustainable way of delivering training as it is not dependent on trainers and courses are always available to learners

B. Evaluating satisfaction ratings from courses

i) Participants’ satisfaction ratings (quantitative) for all the CALD courses (1-9)

These are measured using a tool called “Your Immediate Impression of the Learning Experience” in terms of:

  • relevance of the content
  • usefulness of the activities and delivery modes to support learning
  • likelihood of the participant sharing their learning with colleagues in the workplace
  • intention to apply the learning in their job in the next two weeks

Northern Regional Alliance Ltd has set a target of ≥70% satisfaction ratings across the range of quantitative indicators for CALD e-Learning and face-to-face courses.

Overall all the courses have scored above 70% from participants’ perception about the value of the different areas.

ii) Participants’ qualitative feedback about all the CALD courses (1-9)

Participants’ qualitative comments are also gathered using the same tool as above. The qualitative findings support the quantitative findings. The participants’ experience of the face-to-face and e-Learning courses was overwhelmingly positive. They reported high levels of satisfaction with the content, delivery and quality of the resources and there is a lot of positive feedback about the courses.

Examples of some feedback on the courses during the 2012-2013 period:

Although I come from a different culture myself, and have lived in different countries through my life, I still needed help with some of the skills required to work with clients, as demonstrated here. This course spelt it out for me! – CALD 1: Culture and cultural competency (e-Learning)

I found this module very powerful and emotionally challenging at times. It was really worth it – CALD 3: Working with refugee patients (e-Learning)

I was able to apply the skills in your course and the results were amazing, clients were calm and their response was with interest. Thank you for this helpful course – CALD 9: Working in a mental health context with CALD clients (e-Learning) 

C. Evaluating the impact of CALD in terms of longer term behavioural changes

The Auckland Uniservices Ltd, University of Auckland, was commissioned to conduct an independent evaluation of the CALD 1 Culture and Cultural Competency Course.  The evaluation included a questionnaire that incorporated the Cultural Competency Assessment Instrument (CCAI) for Health Care Providers[6] and participant interviews.

A summary of the evaluation findings:

  • There was significant impact on participants' cultural competence including:
    • participants reported increased knowledge of cultural differences including values, health beliefs, religious beliefs, gestures and customs, and better skills when interacting and communicating with CALD patients
    • the course heightened the participants’ awareness of their own culture and how their own cultural beliefs impacted on how they viewed other cultures different from their own
  • Participants' experience of CALD Module 1 was overwhelmingly positive. They reported high levels of satisfaction with the content, programme delivery and quality of resources.
  • Overall, CALD 1 achieved the aims of delivering a high quality, well designed, interactive, engaging, educational and self-reflective programme, with good quality video scenarios, offering mixed learning options that enhanced learning.
  1. Psychometric evaluation of the cultural competence assessment instrument among health providers.  Dorenbos et al, 2005.


D. Tracking “Did Not Attend” (DNA) rates

“Did Not Attend” or DNA refers to non-attendance of patients at health service appointments. We have been tracking DNA rates of Asian outpatient appointments and interpreter-assisted non-English speaking patient appointments to see if CALD training contributes to improving client engagement and access for CALD patients/clients and helps to reduce DNA rates.

The graphs show a reducing trend of DNA rates from Feb 2009-Aug 2013. Over the last 12 months Waitemata DHB has achieved a:

  • 7.33% DNA rate for Asian outpatient appointments
  • 1.52% DNA rate for Non-English speaking CALD patient appointments

Asian outpatient DNA rate

 Non-English speaking patient appointments DNA rate

Impact of CALD Training on reduction of DNA rates

One of the aims of CALD training is to improve health professionals’ cultural awareness, sensitivity, knowledge and skills to improve cross-cultural interactions and to reduce CALD patients disengaging with the services/ service providers.

Although currently there is no specific link between the CALD trained health professionals and CALD patient DNA incidents, the improving DNA trend could be attributed to our increasing number of the CALD-trained health professionals.

Positive reduction of DNA is a tangible return on Investment.


  • CALD Cultural Competency Training Courses are innovative, well designed, effective, in demand and easily accessible.
  • Staff have access to quality and accredited courses with flexible learning options.
  • Results showed sufficient evidence that the CALD Cultural Competence Training is making a difference in the following areas:
    • increasing health workforce’s level of confidence to work with CALD patients and their families
    • enhancing cross-cultural interactions between health professionals and CALD patients/clients in the long term
    • reducing DNA rates
  • CALD Training Programme and Online Resources are the “first of its kind” in New Zealand that enable primary and secondary health practitioners working in the Auckland region to increase their cultural competence.

Where to from here?

  • Online HTML CALD Family Violence Resource for health practitioners – Working with Asian, Middle Eastern and African clients – complete and rollout by October 2013.
  • Online HTML CALD Older People Resource for health providers – Working with Asian, Middle Eastern and African older people – complete and rollout by April 2014.
  • Continue to promote CALD courses and resources (CALD News, Catalogue).
  • CALD Consumer Survey – We are currently only getting feedback from learners and health practitioners. There is a need to get feedback from CALD consumers to assess whether the CALD courses have made a difference in order to:
    • inform continuous improvement
    • determine cultural appropriateness of services delivered
    • determine cultural competence of staff
  • Provide CALD follow-up training sessions to review case studies with CALD learners as part of continuous learning.
  • Promote the Waitemata DHB Best Practice Principles: CALD Cultural Competency Standards and Framework across the organisation.


Waitemata DHB Best Practice Principles for CALD
Waitemata DHB Best Practice Principles: CALD Cultural Competency Standards and Framework