Challenges of multicultural healthcare practice in type 2 diabetes care: a qualitative study of Australian healthcare professionals

Abstract

Objectives

This study explores the challenges experienced by Australian healthcare professionals (HCPs) in delivering type 2 diabetes care to people of culturally and linguistically diverse (CALD) backgrounds. We examined how sociocultural, linguistic and health systems factors influence their clinical practice.

Design

A qualitative study employing semi-structured interviews was conducted from April to October 2024. Data were analysed using Braun and Clarke’s reflexive thematic analysis to identify patterns and themes in HCPs’ experiences, guided by a constructivist perspective.

Settings

The study was conducted in metropolitan Melbourne, Australia, across primary and tertiary healthcare settings.

Participants

A purposive sample of 11 Australian HCPs from diverse disciplines, including general practice, pharmacy, nursing, endocrinology, dietetics and podiatry, participated. All had provided type 2 diabetes care to people of CALD backgrounds within the previous 12 months. Participants included both male and female professionals, many from ethnically diverse backgrounds.

Results

Three overarching themes were identified, reflecting HCPs’ perceived challenges to providing culturally responsive type 2 diabetes care to people of CALD backgrounds. These themes illustrated the multilevel challenges encountered by HCPs at the patient, organisational and provider levels, namely: (1) healthcare provision across diverse health literacy and cultural contexts, (2) navigating system gaps in multicultural clinical practice and (3) workforce preparedness gaps in culturally responsive care.

Conclusions

HCPs remain committed to providing culturally responsive type 2 diabetes care but continue to face constraints, including limited cross-cultural training and exposure, inadequate interpreter access, time pressures and insufficient culturally adapted resources. Effective care in multicultural settings requires recognising patients’ culturally shaped beliefs about health and illness and embedding cultural humility, reflexivity and competence within professional practice, essential steps towards advancing equitable type 2 diabetes care across Australia’s diverse communities.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A qualitative exploratory design informed by a constructivist perspective was used, enabling in-depth examination of how HCPs understand and navigate multicultural type 2 diabetes care challenges.

• A purposive, multidisciplinary sample of HCPs was recruited, with sample adequacy guided by the richness and relevance of data needed to address the study aims.

• Methodological rigour was supported through researcher reflexivity, peer debriefing, transcript review and iterative team discussions, enhancing consistency and credibility across the analytic process.

• All interviews were conducted by a single clinician-researcher, ensuring procedural consistency but carrying a risk of interviewer-related bias despite reflexive strategies.

• The study captured only HCPs’ perspectives and was conducted solely in metropolitan settings, which may limit transferability and restrict triangulation across other stakeholder groups.

Introduction

Australia is one of the most culturally diverse countries, with 32% of its population born overseas, a significant increase from 23% in 2000.¹ Despite a universal healthcare system,² disparities in type 2 diabetes prevalence and management persist among people of culturally and linguistically diverse (CALD) backgrounds. Although there is no single definition,³ the Australian Bureau of Statistics identifies CALD populations using indicators such as country of birth, main language spoken at home, English proficiency and ancestry.⁴ People of CALD backgrounds represent the wide range of cultural, ethnic and linguistic identities that make up Australia’s population, whose languages, beliefs and experiences shape their health perceptions, needs and interaction.^{5 6} Notably, the proportion of overseas-born individuals living with type 2 diabetes is higher (7%) than among Australian-born individuals (5%).⁷ These disparities are influenced by sociocultural, linguistic and system barriers that hinder access to healthcare services, affect patient engagement and complicate chronic disease management.⁸ While much research has examined people of CALD backgrounds’ experiences, less is known about how healthcare professionals (HCPs) perceive and navigate the complexities of cross-cultural type 2 diabetes care.^{9 10} This gap may limit the development of effective practitioner support systems and may hinder broader health equity initiatives.

Type 2 diabetes care is shaped not only by biomedical indicators but also by psychosocial and cultural contexts.⁸ Reflecting this, the 2016 National Diabetes Strategy recognised people of CALD backgrounds as a priority for targeted interventions.¹¹ The National Strategic Framework for Chronic Conditions reinforces the need to tailor services for people of CALD backgrounds and to coordinate efforts across the health system to address inequities.¹² Complementing these policies, the National Safety and Quality Health Service Standards calls for improved health literacy, better service access and cultural competence training for healthcare workers.¹³

HCPs play a crucial role in supporting people to prevent and manage type 2 diabetes. However, providing culturally responsive type 2 diabetes care in a multicultural context presents unique, evolving and under-explored challenges. These include not only interpersonal and communication barriers but also structural constraints embedded within healthcare institutions.^{14 15}

For HCPs, providing care to people of CALD backgrounds involves navigating challenges including language mismatch, differing cultural beliefs, time constraints, limited culturally appropriate resources and insufficient organisational support for cultural competence training,^{14 16 17} many of which were reported in Australian type 2 diabetes studies nearly a decade ago.^{9 18} Cultural and linguistic diversity of individuals significantly influences how people understand, access and engage with health services.¹⁵ Thus, effective chronic disease management, especially type 2 diabetes, requires addressing patient’s social contexts and adapting care to cultural and structural differences.^{14 15}

Our study seeks to update understanding of the challenges experienced by Australian HCPs in providing type 2 diabetes care to people of CALD backgrounds, in the context of an increasingly diverse Australian population. Using a reflexive thematic analysis (RTA)¹⁹ approach, it explores how HCPs understand and describe the challenges they face based on their personal experiences and knowledge in caring for people of CALD backgrounds living with type 2 diabetes.

Methods

Study Design

This study adopted a qualitative exploratory design informed by a constructivist perspective, recognising that HCPs’ experiences are shaped by both structural conditions (eg, time pressures, communication barriers) and their own interpretive frameworks. Semi-structured interviews were used to enable flexible yet structured exploration of participants’ perspectives, allowing in-depth examination of lived experiences and contextual meanings within multicultural clinical practice.19,21

Participant Recruitment

A purposive sampling strategy, supplemented by snowball recruitment, was employed to identify and recruit Australian-registered or recognised HCPs with direct experience providing type 2 diabetes care to people of CALD backgrounds within the previous twelve months. Sampling sought diversity in discipline, years of experience and practice setting, reflecting the range of HCPs involved in the ongoing, multidisciplinary provision of diabetes care. Participant number adequacy was guided by Malterud et al’s information power model suggesting that a smaller sample is sufficient when the data are rich and closely aligned with the study aim.²² Recruitment continued until the interviews yielded no new or conceptually distinct insights. This approach supported both depth and diversity of perspectives while remaining consistent with the study’s constructivist and exploratory design.

Recruitment across metropolitan Melbourne, Australia, was conducted through the researchers’ professional networks, including the Australian Diabetes Educators Association, LinkedIn, professional Facebook groups and HCPs known to the research team, via direct email, in-person invitation and social media posts. The lead author (DG) managed all invitations via email and follow-up communication.

Patient and Public Involvement

People living with type 2 diabetes and the public were not involved in the design, planning or conduct of this study.

Data Collection

All interviews were conducted by the first author (DG), a registered pharmacist and credentialled diabetes educator with prior experience conducting one-on-one qualitative interviews in health services research. DG’s professional background supported rapport-building and contextual understanding of type 2 diabetes care practice. Interviews were conducted between April and October 2024, either face-to-face in private consultation rooms, online via secure Microsoft Teams²³ video calls or by telephone, according to each participant’s preference and availability. Written informed consent was obtained prior to participation, and verbal consent, including permission for audio-recording, was confirmed at the start of each interview. Each session lasted approximately 30–60 min.

To ensure methodological rigour and reflexivity, DG discussed the first four interviews with co-researchers experienced in qualitative methods, focusing on interview flow, depth of probing and researcher positionality. One interview recording was also reviewed by co-author CL, who provided targeted feedback on interviewing style and alignment with the study’s constructivist framework. These reflective and supervisory processes strengthened the quality, consistency and interpretive depth of data collection.

Interview audio files were transcribed using Microsoft Teams²³ Microsoft Word²⁴ and subsequently corrected by the first author to produce a verbatim transcript that retained participants’ wording, pauses and false starts where relevant to meaning. Identifying information was removed during transcription, and pseudonyms were applied to ensure anonymity. Two transcripts were reviewed by three team members (CL, TT and VC). De-identified data were stored on secure, password-protected university servers in line with institutional ethics and data management protocols. Participants received an AUD30 voucher as appreciation and could request a summary of findings. They were advised they could withdraw at any time during the interview without consequence, and any data would be removed if withdrawal occurred within two weeks of interview completion.

An interview guide, developed based on review of relevant literature,^{10 17} was refined following pilot testing with two HCPs to ensure clarity and contextual relevance (online supplemental appendix A).

Data Analysis

Data analysis was undertaken following the six phases of RTA (online supplemental appendix B), which seeks to identify patterns of meaning while acknowledging the active role of the researchers in theme development.¹⁹ An inductive, semantic approach guided the analysis. The first author (DG) familiarised herself with the dataset through repeated reading and initial note-taking. Initial coding of four interviews was conducted iteratively, followed by a thorough discussion to review codes, thoughts and interpretations among the research team (DG, CL, VC, TT, IS). The remaining seven interviews were coded by DG, supported by Microsoft Word²⁴ and Miro²⁵ board for organisation and visual mapping. Provisional themes, subthemes, higher level codes and codes were developed and refined through several collaborative discussions among the research team (DG, CL, VC, TT, IS, KK and BdC) to integrate additional insights (online supplemental appendix C and D). Theme names were developed to capture each theme’s central organising concept and interpretive story, with labels refined through team discussion.

Reflexivity was maintained throughout the analytic process. Regular debriefing sessions allowed the team to critically reflect on how cultural assumptions, both within participant narratives and researcher interpretation, may shape meaning-making. This reflexive process ensured that findings were presented as contextually informed and relational, acknowledging diversity within groups and avoiding generalising or stereotypical interpretations.

DG maintained a reflexive journal documenting analytic decisions, reflections and potential biases. A detailed electronic trail of the analysis was maintained to ensure transparency. Researchers’ positionalities as healthcare practitioners and members of diverse cultural backgrounds were acknowledged and reflected on throughout the process, with the team engaging in reflexive dialogue to examine how cultural backgrounds and clinical roles informed interpretations, consistent with RTA principles. Final themes were agreed on after iterative review, team reflection and consensus (online supplemental appendix D). The study adhered to the Reflexive Thematic Analysis Reporting Guidelines (RTARG)²⁶ when reporting the study findings (online supplemental appendix E).

Results

A total of 19 HCPs expressed interest in participating in the study, with recruitment facilitated primarily through the researchers’ professional networks. Of these, 11 were interviewed. The remaining individuals either did not respond to several attempts to confirm availability or had a practice focus that fell outside the scope of the study. The final sample included HCPs from various disciplines, including general practitioners, endocrinologists, nurses, pharmacists, dietitians and a podiatrist (table 1). Most participants were recruited through targeted invitations or network-based postings, reflecting the central role of professional networks in facilitating recruitment.

Table 1. Demographic characteristics of participants.

Participants	n=11
Profession/ Occupation		Practice Description*		Years of providing diabetes care median=12 years (range 3-40 years)		Sex
• Pharmacist • Dietician • Nurse • General Practitioner • Endocrinologist • Podiatrist • Credentialled Diabetes Educator (CDE)	2 2 2 2 2 1 2†	• Primary healthcare - private practice • Primary healthcare - community health • Tertiary healthcare - outpatient	7 2 2	• 1-10 years • 11-20 years • >20 years	5 3 3	• Female • Male	9 2
Ethnic background provided by HCP‡ Filipino, Malaysian, Fijian-Indian, Vietnamese, Macedonian, Greek, Pakistani

^*Primary healthcare - private practice: General practitioners, pharmacists, and dietitians providing ongoing diabetes management, medication review, and lifestyle counselling in privately operated clinics; Primary healthcare - community health: Multidisciplinary care delivered within publicly funded community health centres, focusing on education, prevention, and chronic disease management; Tertiary healthcare - outpatient: Specialist diabetes care provided in hospital-based outpatient clinics, including endocrinology consultations and allied health support for complex cases and advanced management.

^†One nurse and one dietician also held dual roles as CDE.

^‡Personal demographic information such as ethnicity or country of birth was not systematically collected, as the study focused on healthcare professionals’ clinical experiences and perspectives on diabetes care. However, some participants voluntarily shared aspects of their cultural background when these were relevant to their reflections on practice.

This study identified three overarching themes that illustrate HCPs’ perceived barriers to providing culturally responsive type 2 diabetes care to people of CALD backgrounds. These themes include (1) healthcare provision across diverse health literacy and cultural contexts, (2) navigating system gaps in multicultural clinical practice and (3) workforce preparedness gaps in culturally responsive care, reflecting the multilevel challenges encountered at the patient, organisational and provider levels (figure 1).

Figure 1. Themes and subthemes of healthcare professionals’ challenges in providing type 2 diabetes care to people of CALD backgrounds. CALD, culturally and linguistically diverse; HCP, healthcare professional;

Theme 1: Healthcare provisions across diverse health literacy and cultural contexts

HCPs described difficulties in delivering effective and responsive type 2 diabetes care within the context of diverse health literacy levels and cultural backgrounds. These challenges were compounded by patients’ unique cultural contexts and migration-related experiences.

Managing health literacy diversity among people of CALD backgrounds

HCPs noted that patients’ health literacy was shaped by more than just formal education. It was also influenced by cultural beliefs, previous healthcare experiences and knowledge shared within their communities.

HCPs described patient distrust in Western medications including negative beliefs associated with commencing insulin.

One of the challenges has always been that there [is] sometimes a distrust and hesitancy with modern medicine and especially around insulin, there’s a lot of misinformation. There’s a lot of fixed beliefs that stop people from going on to insulin… it comes from experiences that they've had… this often happens in the subcontinental group. I've noticed that they've had relatives who have been on insulin, and they seem to associate insulin [with] death and so they don't want to go [into] insulin. And it’s really hard to sort of work through [this misconception]. -HCP9

Patient engagement in type 2 diabetes care was further limited by patient’s conceptualisation of healthcare as predominantly acute care, rather than chronic disease management.

When you live in your own country, you go to the doctor not for chronic disease. You go to the doctor because you have an acute condition… You don't just go to the GP for preventative health on your own. It’s a very different mindset… They only access [is] when they have an acute problem, they don't access [healthcare] for long term maintenance problems. -HCP9

Inconsistencies between type 2 diabetes education received from overseas healthcare providers and current Australian guidelines often created confusion for patients, resulting in non-adherence to treatments prescribed.

The biggest issue I've experienced is… the differences in [diabetes] education that’s been provided… [it’s] what’s been taught… previously and what’s been advocated for that patient… when they come and see us here, we're feeding them different information… and they aren't very reciprocated or they don't adhere to it because they’ve been told to do this or they've been told not to worry about it -HCP10

Migration-related factors further compounded health literacy challenges. Limited formal education was a significant barrier to healthcare access, particularly among older adults of CALD backgrounds.

I think the key thing… the language barrier, the education. Because a lot of them, the [older] generation specifically, a lot of them, some of them only went to grade four, grade five, they worked in the village… A lot of them didn't finish school… they're not stupid or anything, but their education level also stops them because they don't know what care they can get or they accept [e.g.] OK, the doctor told me this and that’s it. Like they wouldn't even know that there’s someone to help them with their feet, like a podiatrist or physio… not just from [the] dietetics. -HCP2

HCPs also observed that many patients struggled to navigate the Australian healthcare system due to unfamiliarity or a lack of prior structured healthcare experiences. Low health literacy and numeracy were especially prevalent among refugee populations, creating further difficulties in understanding and managing chronic conditions. They often rely on the other family members to interpret information and to help them navigate through the health system and manage their chronic conditions.

We have a very high refugee population as well, who do have low health literacy. And so I think, that is a separate issue, but unfortunately… There [seems to be] a high preponderance of that in our CALD groups where there is low health literacy, low literacy, [and] low numeracy. -HCP9

Navigating dynamic patient social and cultural contexts

Beyond health literacy, HCPs described the complex and evolving social and cultural realities that shaped patient care. They emphasised the importance of recognising how family roles, household structures and cultural expectations influenced patients’ health behaviours and engagement.

In practice, HCPs often encountered family dynamics that limited patients’ autonomy, particularly among women from some cultural backgrounds who relied on other family members for health-related decisions. When working with multigenerational or extended families, HCPs described how care routines were shaped by traditional norms around caregiving responsibilities, gender roles and decision-making hierarchies.

Some of the women do find it quite difficult to actually have a voice. Sometimes their husbands do take over in those sort of circumstances. We do find that the husbands are making the decisions for the women rather than the women making their own decisions. -HCP9

Her family were hiding it from her thinking that the knowledge would actually harm her and make her sort of emotionally give up. -HCP8

In many cases, roles were assigned based on traditional expectations of who was permitted or expected to undertake specific health-related tasks.

Who looks after whom? In a family, that can sometimes be a huge one to navigate, especially if you've got some older people in the family. Who is looking after that person in the family and what will they do for that person? And all of those things comes down to culture as well. So some people will say, no, no, my son won't do that. I won't let them do that, but my daughter in law can do that. She can inject. -HCP9

HCPs also needed to adjust their approaches based on the multiplicity and fluidity of migrant identities. They observed that adaptation to the Australian healthcare system varied widely with newly arrived patients often requiring more time to adjust.

The more newly arrived, you know refugees and usually from Southeast Asia, they clearly need a little bit of time to acclimatise to the healthcare system. -HCP8

In contrast, younger or longer-settled patients tended to have different patterns of engagement.

If they're a bit younger, they might have sort of acclimatised to the Australian culture quite a bit. Especially if they have been in Australia for a long time… Their dietary choices may not be the traditional Chinese kind of diet… they’ve gotten used to the lifestyle here. -HCP6

Cultural norms around interpersonal interaction influenced how HCPs build rapport.

You can't come across as, like, very straightforward. They can take offence from that and then that will form a barrier between your relationship as well… -HCP1

Some patients expected a more relational and informal communication style. In response, HCPs had to share small aspects of their personal lives to meet cultural expectations.

It’s almost always our CALD population that are asking those [personal] questions and it’s just a way of connecting, you know, and knowing us as a person because… they want to know and trust you. -HCP5

HCPs also encountered patient preferences regarding provider characteristics, such as gender, language or cultural background.

They tend to gravitate [to] older looking pharmacist… towards your more European looking male… they're not used to women being in that position. -HCP1

HCPs noted that patients might avoid disclosing information due to pride or fear of judgement.

I think they felt that… they might be yelled at, that maybe even their care might be changed. I think they just felt that people wouldn't understand why they were doing it [fasting]… I think they really just felt that they wouldn't be supported at all by healthcare professionals. -HCP3

Health expectations and learning styles also varied culturally. Some patients preferred prescriptive, structured advice and became frustrated when this was not provided.

I do find that some of my clientele, especially the Chinese, [tends] to have very stringent kind of expectation, really high strict expectation of themselves. The CALD clients tend to be very eager to have set rules… they get a bit deflated when I explain to them that like, it’s not going to work long term… -HCP6

Others displayed a passive approach to care, deferring care decisions entirely to HCPs.

You go through the consult and you [ask] say any questions? And they'll be like, nope, you just tell me what to do… whereas someone born here, who knows how to advocate for themselves will also ask questions to either seek more information or even just to clarify things, whereas I find they won't. -HCP2

Theme 2: Navigating system gaps in multicultural clinical practice

HCPs reported that structural limitations within the healthcare system constrained their ability to deliver equitable and culturally responsive type 2 diabetes care in multicultural settings.

Structural gaps in supporting multilingual communications

HCPs highlighted that language barriers went beyond translation issues; they affected the quality of clinical interactions and therapeutic relationships. Language mismatch undermined patient engagement and understanding.

I do think that it is harder to connect to a patient when you cannot speak [the] same language… more on getting them to engage, ensuring that we can understand each other well enough and they know what the next steps are to do. -HCP11

Others highlighted how even basic communication about type 2 diabetes was compromised due to language barriers.

Especially the migrants or the refugees, they're trying to grasp the English language. They don't have the full workings of the language shift and then you give all this information in English. They wouldn't understand it… Most of them they don't speak English… They can't speak conversational English, especially the first generation, second generation migrants or your elderly population. -HCP1

Access to qualified interpreters remained inconsistent. Several HCPs reported situations where no interpreter was available.

[I] tried two other phone translation services and they had no interpreters around… in the end [when] I gave the recommendations and [the patient] said, ‘I'm just going to go to my Korean speaking GP this week. -HCP11

These limitations often led patients to rely on family members, which was not viewed favourably by HCPs within the clinical context.

You definitely need to be using an appropriate interpreter. I think that you shouldn't use family members because things don't get interpreted correctly. -HCP9

The integration of interpreter services into telehealth further exacerbated communication barriers, with HCPs highlighting the logistical difficulties of coordinating remote interpreters.

Handling telehealth technology and needing to navigate the fact that the interpreter needs to be on telehealth, it all needs to be quite coordinated. That is a feat on its own. -HCP11

Resource gaps

HCPs identified critical gaps in the availability, cultural relevance and promotion of resources for people of CALD backgrounds, which constrained their ability to deliver culturally responsive type 2 diabetes care.

HCPs emphasised that many educational and support materials were developed without meaningful input from communities of CALD backgrounds, resulting in content that was culturally mismatched or ineffective in practice.

With a lot of government funded [programmes], they'll put all this money into training and all things look good on paper, but… a lot of the people that designed them have never come from CALD backgrounds… they're all well-meaning, well-intentioned… it creates more work. -HCP2

HCPs noted a deficit in multilingual resources, particularly digital tools, to support type 2 diabetes education and self-management.

There’s a huge deficit in terms of online or apps or electronic type of information available in other languages… We use what we can, but I think there’s a real deficit. There’s not [enough] information in other languages… technology is all English… we struggle with that. -HCP3

Others reported that existing materials often relied on mainstream Anglo-European diets or language structures, limiting their relevance.

The resources that we have in Australia are mostly geared towards European diet… It’s hard to find references… I just try to find something in their language which is hard. -HCP1

In addition to gaps in availability, HCPs highlighted a lack of awareness and promotion of culturally tailored resources that do exist.

I don’t think it’s being told. I don’t think it’s being promoted… most clinicians don’t realise that there are [resources available in] other languages. But there’s also an English version using the same graphics. -HCP3

Time constraints during standard clinical consultations limited the opportunity to explore and address cultural factors in depth, undermining efforts at person-centred care.

There’s a limitation to how much you can find out about culturally and linguistically diverse patients… a more culturally diverse patient requires a bit more time in terms of lifestyle advice, lifestyle counselling as well. -HCP11

Theme 3: Workforce preparedness gaps in culturally responsive care

HCPs identified gaps in their own training, experiential exposure and healthcare system support for developing culturally responsive skills and knowledge.

Education and training limitations in culturally responsive care

HCPs consistently acknowledged the limited formal preparation in understanding and adapting to the cultural diversity of patients, particularly in the context of dietary counselling. A key concern was the knowledge gap regarding culturally specific food practices.

What I find is the way we think is more of the Western [medicine] and then we train [in] Western [lifestyles], like even with the food, the diet.- HCP1

This gap was evident in the challenges of recommending appropriate nutrition advice without familiarity with traditional meals or food items of people of CALD backgrounds.

Trying to advise them on dietary plans, what food to have, it is personally more challenging for myself. Sometimes they may tell me the food types that they take and I wouldn't really know or have been exposed to the kinds of food that they normally eat day to day. -HCP11

Others reflected on the difficulties of interpreting food types in clinical terms.

A challenge for me is understanding the differences in their food groups and what’s got carbs, what’s not a carbohydrate based?…I don't know exactly what that is, is it a carbohydrate?… Just the actual distinction of diet, macronutrients, micronutrients and understanding of how that interacts with their blood glucose levels, is also been something that I've found quite hard for certain groups as well. -HCP9

HCPs described their efforts to adapt recommendations based on trial and error, particularly due to limited formal training in culturally influenced food practices.

We found out [after a guided food tour] that they weren't using very much oil because they were buying big tins of ghee [which they understood was not oil]… so it was trial and error. A lot of trial and error. -HCP3

In this instance, HCPs explained that this insight only emerged after practical exposure to the cultural group’s food practices.

I think because it’s just a lack of opportunity, I haven't had a lot of exposure to say Sudanese people… I think it’s just the lack of opportunity, lack of experience. -HCP3

These gaps were amplified by limited experiential exposure to diverse cultures which was driven by the HCPs’ cultural curiosity.

If you're working in [suburbs] with the Vietnamese community, apart from pho [or rice-noodle soup], try other things, outside that comfort zone, be familiar with what else they have… Not everyone is comfortable to step out in that way and try the food. And when you don't, as a dietician, I feel like that that you could be missing a bit there. -HCP6

Balancing cultural generalisations and individual patient needs

While cultural understanding was acknowledged as essential, HCPs expressed concerns about inadvertently stereotyping patients based on broad assumptions. Some described the risk of omitting key health assessments due to presumed behaviours.

You do find some healthcare professionals that don't ask about alcohol and say ‘Oh well, they're Muslim, they wouldn't be drinking alcohol.’ But it’s surprising what you [could] find. So sometimes there’s assumptions made that someone isn't drinking alcohol because maybe they're Muslim, and that’s often not the situation at all. -HCP3

Others reflected on the importance of individualised care, even when patients shared a cultural or linguistic background.

This demographic of people, everyone is so different. Even if you're part of the same culture… no two people will have the same engagement… you're always adjusting. -HCP5

HCPs articulated the nuanced use of cultural cues to guide, rather than dictate, clinical care.

I wouldn't deny like there’s a bit of that bias from my end, but it’s to guide me to (sic). I feel like to practise a bit better as a health practitioner. -HCP6

HCPs highlighted that even when language was not a barrier, cultural dissonance could remain.

Just because you speak English and read English doesn't necessarily mean that culturally, that information is relevant… I think that’s something that’s being missed… Although it’s in English and you understand everything that’s there, it still might not meet your needs because it’s not culturally relevant. -HCP3

Together, these findings highlight the multilevel and intersecting challenges HCPs face in providing culturally responsive type 2 diabetes care, shaped by patient diversity, systems constraints and workforce preparedness.

Our analysis reflected a motivated workforce wanting to provide culturally responsive care, however, constrained by structural and educational gaps, limited opportunities for cross-cultural engagement and the complexities of balancing cultural awareness with personalised, non-stereotypical approaches.

Discussion

This study underscores the ongoing tension between clinical responsibilities and the provision of culturally responsive care, particularly in the context of chronic disease management such as type 2 diabetes. Three interrelated themes illustrate this tension: (1) healthcare provision across diverse health literacy and cultural contexts, (2) navigating system gaps in multicultural clinical practice and (3) workforce preparedness gaps in culturally responsive care. Collectively, these themes illustrate how HCPs in this study navigate complex cultural, organisational and structural challenges within a system that aspires to equity but remains constrained by time, resources and training.

HCPs describe working across a spectrum of health literacy shaped by patient’s migration experiences, cultural beliefs and social contexts. Engaging people of CALD backgrounds, particularly refugees, in chronic disease self-management is challenging; many have differing understandings of type 2 diabetes, reluctance or distrust towards medication and are unfamiliar with preventative care pathways.^{16 27} Differing conceptualisations of health and illness are often shaped by cultural, familial and spiritual values, which in turn influence self-care practices and healthcare-seeking behaviours, consistent with previous research.1416 27,29

Health professional training remains grounded largely in Western biomedical framework,²¹ which, while essential for clinical accuracy, provides limited preparation for cross-cultural encounters. When cultural content is included, it is often generic, offering little practical guidance.^{5 15 16 30} In the absence of formal instruction, cultural competence is often developed through professional experience, usually involving trial and error.^{10 21 30 31} Participants emphasise that cultural identities and acculturation processes evolve over time, meaning that static cultural knowledge is inadequate.632,34 Models emphasising cultural humility and reflexive practice encourage HCPs to examine their own assumptions, actively understand patients’ lived experiences and adapt care approaches accordingly.^{31 34 35} This approach aligns with broader calls for cultural competence and safety within health professional education as dynamic, context-sensitive rather than fixed knowledge sets.^{6 35 36}

Structural limitations, particularly language barriers, further constrain the delivery of culturally responsive care.^{18 21 36 37} Access to interpreters remains inconsistent, particularly for less common languages and in telehealth settings. Previous studies have shown that staff and patients are often unaware of entitlements to interpreter services, often resulting in communication breakdown and reduced quality of consultation.^{14 38} These challenges mirror earlier findings from Australian and international research, which identify interpreted access and communication fidelity as persistent determinants of healthcare inequity.^{10 15 39}

Participants also note that health education resources and technologies remain poorly adapted for cultural relevance. Digital health tools and printed materials are frequently limited to literal language translation without deeper cultural adaptation, overlooking key aspects such as health beliefs, family dynamics and dietary traditions.³⁸ Consistent with Diabetes Australia’s 2024 State of the Nation report, the study reinforces the need for co-designed, community-informed resources that reflect both linguistic and cultural diversity.^{40 41}

Time constraints are a recurring challenge that intensifies these issues.^{15 16 18} The fee-for-service model governing much of Australian primary care restricts consultation duration, which HCPs perceived as leaving insufficient time for relationship-building and dialogue required to address cultural and linguistic complexity.^{2 12} This structural tension between efficiency and engagement is particularly pronounced in chronic disease care, where trust and shared understanding are critical for sustained self-management.^{18 39 42} Based on these practice insights, more flexible funding arrangements or consultation categories that recognise cultural and communication complexity may support more equitable engagement.

Cultural diversity also characterises the healthcare workforce itself. Several HCPs self-identifed as having CALD backgrounds, reflecting Australia’s multicultural professional landscape. Nationally, approximately one-third of medical practitioners are trained overseas, positioning Australia among the highest of Organisation for Economic Co-operation and Development countries for internationally educated clinicians.⁴³ A diverse workforce may enhance health system responsiveness through linguistic capacity, cross-cultural empathy and broader understandings of health and illness.^{16 36 44} However, it also introduces organisational challenges that require structural support, such as mentorship, inclusive workforce policies and anti-discrimination safeguards, to ensure that diversity translates into improved patient care rather than additional burden.⁴⁴ Recognising cultural diversity as a system-wide characteristic, encompassing both health providers and patients, moves beyond an ‘us vs them’ framing and aligns with calls for cultural humility, reflexivity and competency as cornerstones of modern health practice.^{13 34 35}

Despite multiple national frameworks supporting multicultural healthcare,11,13 HCPs in this study continue to encounter challenges reminiscent of those reported over a decade ago.^{9 18 33} Their capacity to provide culturally responsive care appears constrained not by lack of motivation but by systemic factors, including fragmented care coordination, inadequate funding models and insufficient institutional support.^{14 15 27} These observations suggest a persistent disconnect between policy intent and operational implementation, highlighting potential leverage points for system reform. Our findings generate practice-informed hypotheses regarding how cultural responsiveness might be more effectively embedded at a structural level, through funding models, workflow design, interpreter integration and education systems, rather than leaving responsibility solely with individual HCPs.^{10 36}

The study’s strength lies in its diverse sample of HCPs across professional disciplines and care settings, offering multi-level perspectives into systems challenges in multicultural type 2 diabetes care. However, several limitations shape the interpretative boundaries of the analysis. The study reflects experiences from a metropolitan cohort, and findings may not readily transfer to non-metropolitan settings where healthcare access and resources differ. Recruitment through purposive sampling through professional networks may also mean that participants with a greater interest or confidence in cross-cultural care were more likely to take part, potentially narrowing the range of perspective captured. The use of multiple interview modes (in-person, virtual and telephone) enhanced accessibility for time-constrained HCPs but may influence rapport and depth of discussion; virtual formats limit observation of non-verbal cues while face-to-face interviews support richer interpersonal engagement. Across all formats, the interviewer’s clinical background and familiarity with type 2 diabetes care appear to contribute to a constructive interview climate.

As with all qualitative research, the analytical insights are context-bound and shaped by researcher reflexivity. Although reflexive discussions and peer debriefing strengthen analytic rigour, the insights represent practice-informed interpretations rather than generalisable conclusions. Moreover, the study captures only HCP perspectives; the absence of patient, administrative and policy perspectives constrains understanding of how these challenges are experienced across stakeholder groups. Future research may benefit from a multi-stakeholder and multi-setting approach to triangulate and extend these findings.

Conclusion

This study sought to update understanding of how Australian HCPs’ experience the challenges of providing type 2 diabetes care to people of CALD backgrounds. The analysis highlights the ongoing tensions HCPs navigate between clinical responsibilities and the cultural and structural complexities of multicultural care, constrained by limited formal training, inconsistent interpreter access, time pressures and gaps in culturally adapted resources. Culturally responsive care was often developed informally, placing responsibility largely at the individual level. The study suggests that effective communication, relational engagement and understanding the person’s culturally shaped beliefs about health, illness and self-management are central to effective type 2 diabetes care in diverse contexts. Embedding cultural humility, reflexivity and competency within professional education and organisational systems may help strengthen HCP confidence and capacity. Future efforts that improve access to interpreters, co-design culturally relevant resources and allow adequate or flexible time for person-centred engagement may help address these challenges.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.