Culture and Communication

Original Editor - Marissa Fourie Top Contributors - Mandy Roscher
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Challenge of Cultural Diversity in Medical Practice

Worldwide, cultural and ethnical diversity is on the rise due to an increase in factors such as extensive global human migration and the influx of refugees into foreign countries[1]. Wide intercultural and ethnical variety also exists within populations of single nations [2]. Medical professionals often need to attend to patients from different cultures, backgrounds, and languages. Unfortunately, ethnic minorities still experience inferior service in health care industries worldwide. Issues such as barriers in access to healthcare, inequalities, lower quality of healthcare and poorer health outcomes have been reported [3][4][5]

Several causative factors can play a role in poor delivery of multicultural medical service, including language barriers, differences in health literacy, socioeconomic stressors, scarcity of resources in healthcare facilities, a different understanding of illness and treatment, negative attitudes among both patient and clinician/caregivers as well as a difference in culture and tradition.[3] For optimal medical outcomes, it is integral for clinicians to remain mindful of their patients’ values, beliefs and behaviours regarding healthcare and to respond accordingly [6].

The Role of Culture in Health

Culture can be defined as an homogenous set of values, norms or attitudes (often deeply rooted), shared by a specific group of people [2]. Every culture comprises distinct visible aspects (for example, language, clothing, music, food) and non-visible aspects (such as communication styles, beliefs, values, ethics and handling of emotions).  The non-visible aspects of culture will determine how people perceive health and illness, and how they will respond thereto[6]. Culture can thus influence health in many ways. This includes communication and presentation of symptoms, coping styles, willingness to seek medical care [4], bias/preference towards management strategies[6] as well as trust and compliance to health care professionals[7].

A need exists for effective and high-quality healthcare with acknowledgement and respect for patients’ cultural orientations[4]. Successful implementation hereof will contribute to patient adherence to current care as well as preventative medicine. Culturally inclusive healthcare models need to be patient-centred and promote sensitivity and humility of patient culture among clinicians [8].  Clinicians should thus be willing to comply with core values, behaviours or attitudes that may be of cultural importance to their patients. These can include factors such as religion, age, sexual orientation, the role of family, occupation and education[7]. The role of (often culturally-rooted) medical belief systems should also not be underestimated in the potential success of medical management. Patients’ beliefs on health influence the perception and interpretation of disease to the individual and may determine whether medical help will be sought [6]

Health belief systems are generally grouped into three categories: supernatural, holistic and scientific. 

Supernatural Belief Systems

The supernatural belief system acknowledges the influence of a higher being or force to which the patient is subjected. For example, an ill patient may see himself as a victim of punishment rendered by a supernatural force, such as God or ancestral spirits. Patients may visit traditional healers who are believed to possess the ability to intervene with the supernatural forces. 

Holistic Belief Systems

The holistic belief system presents a person as a combination of interdependent parts, namely a body, mind, emotion and spirit. If one of these aspects is not functioning optimally, the entire being is affected.  The holistic belief system therefore, strives towards the maximum well-being of mind, body and soul throughout all areas of life.

Scientific Belief Systems

The scientific belief system depends on objective, valid and reliable measures in diagnosis and treatment, with scientific reasoning and a biomedical approach to illness and health. This system provides the foundation for the training of most medical professionals. Typically, the scientific belief leaves little space for the coexistence of holistic and supernatural beliefs in the treatment of disease, especially if they pose any opposition to practice of the more scientific method[6].

Health care professionals’ respect and knowledge of different health belief systems enables optimal communication [3] and reduces the incidence of false diagnosis or ineffective treatment[6]. Unfortunately, many scientifically-trained health care providers have a limited knowledge on cross-cultural health beliefs[6] [1]. Literature suggests a need for medical schools to invest more in the teaching of adequate multicultural skills[6][1], as well as the importance of post-graduate training in cultural sensitivity[6].  Instead of dismissing patient beliefs which are in objection to your scientific view, it is sometimes necessary to explore these beliefs within a specific context in order to better understand your patient’s reasoning. 

Intercultural Medical Communication

From the previous section, it is clear that the meeting between a clinician and patient from different cultural backgrounds can potentially be a meeting of two very different ideas and contexts of care and medical service [6]. The culturally determined context, values, beliefs and practices will strongly influence patient expectations, preferences and behaviours[3].

Intercultural communication poses a number of challenges.  

Low Language Ability 

Low language ability leads to much disparity, where patients are unable to properly express themselves, verbalise their needs and complaints and may also find it hard to follow the speech of the clinician or caregiver. Proper shared goal-setting and decision-making is often compromised in this way.  

Non-Verbal Communication Cues 

Non-verbal communication cues are often different amongst different cultures which can lead to mass misinterpretation of non-verbal messages.  

Cultural Sensitivity of Communication 

Cultural sensitivity of communication refers to how the interpretation and deeper nuances of verbal messages can differ according to cultural contexts, even if both parties in the conversation speak the same language.  For example, the well-intended use of humour in conversation may be deemed as inappropriate in the cultural context of the receiver.  

Social Dimension of Communication 

The social dimension of communication describes the concept of humanity in care. Often, especially in the presence of low language ability, caregivers will keep communication down to a minimum and only focus on the clinical contents thereof. Patients experience this as inattentive and lacking in social support. Conversely, where clinicians actively try to incorporate the social aspect of a person into communication, patients feel more supported and cared for.  

Structural Conditions of Cimmunication 

structural conditions of communication refer to barriers such as the unavailability of an interpreter, the issue of confidentiality when using a third party interpreter, or a lack of time to repeat poorly understood concepts or make sense of an attempted conversation [3]

Principles of Cross-cultural Communication

Rust and colleagues (2006) devised the CRASH Course in Cultural Competency to address much of the communication issues that clinicians may experience in culturally diverse patient contact sessions. The implementation of these steps will help clinicians to incorporate the patient’s culture into shared medical decision making. CRASH is a mnemonic of five components of culturally sensitive healthcare namely to consider Culture, show Respect, Assess/Affirm differences, show Sensitivity and Self-awareness, and do it all with Humility [7]. These components are discussed in more detail in Table 1.

C In the consideration of culture, the clinician acknowledges that cultural diversity comes along with different perceptions, values and experience of health care and patient-clinician interaction. 
R Showing respect does not merely imply being polite or tolerating differences, but actually understanding what respect entails in the context of each patient. Don’t shy away from asking the patient if you do not know. Dialogue may include phrases like the following: “It is important for me to respect you. Is there anything specific that I should avoid that could be seen as disrespectful?” Possible sensitive topics, especially relating to previous oppression or minority status, should be handled with extreme caution.  
A Assess refers to establishing the “within-group differences” in your patient’s culture, and where he/she fits. Possible questions may be: “What is your family background?” or “Does your culture have any possible effect on your healthcare?”. 
To affirm means to embrace cultural differences rather than to discard them. There are certain culturally-driven habits that are easily perceived in a negative light because they do not correlate with the clinician’s idea of correct. For example, a patient being five minutes late can be perceived as disrespectful, where the intention was not meant as such at all (in certain cultures, being somewhat late is totally acceptable).  Rather try to see the positive intention, than perceive a negative effect.
S Being culturally sensitive will empower you to know what behaviour or expressions can cause offence or negatively impact the trust relationship between clinician and patient. We should also be careful not to stereotype an individual patient according to typical conduct or habits of the cultural group he/she identifies with.
Self-awareness is established by reflecting on our own cultural norms, values and potential issues that may lead to miscommunication with others. 
H Humility refers to the acceptance that we, as clinicians, will never be fully “culturally competent” and that we need to always be willing to learn and continually change our own perceptions and biases. We should never be too confident to apologise after a cultural miscommunication or mishap, and should always be open to learn from others’ first-hand accounts of their experience.

Table 1: CRASH Course in Cultural Competency (adapted from Rust et al., 2006)[7]

Practical Pointers for Culturally Diverse Communication

The following pointers provide some guidance on cross-cultural communication:

  • Empathy is vital. Patients will often only visit a health care provider after their own attempts to recovery, and will thus already be anxious and exhausted [3]. Engage in warm, supporting conversations and communicate the attempt to understand the patient’s point of view. Put aside scientific beliefs and values for a second and refrain from trying to influence your patients in a scientific direction if science is not their belief system. Remain cautious not to transmit any judgemental communication that the patient may read as disapproving (verbal or non-verbal), but rather reinforce patients’ attempts and positive behaviours to better health[6].
  • Be more formal initially when addressing your patient. Use last names (Mr/Mrs XYZ) rather than first names until the patient indicates that a more informal address is preferred. It is easier to relax your formality a little, than to need to step it up[6][7].
  • Consider marital and gender-based conduct in different cultures. To some, it is not acceptable to be treated by a clinician of the opposite sex, or for a spouse to stay behind in the waiting room while his/her significant other receives treatment [7]. Be proactive and enquire on preferences beforehand rather than making assumptions (for example: “Would you prefer your husband to come along?” or “Hello Mr Smith, you are welcome to come along”.)
  • Create an environment where patients can be open and honest, especially with regards to their current management of their condition. They may be hesitant to disclose that they have attempted traditional medicine, for example, although this may be important information for the clinician. Open the discussion with easy questions, gaining more insight into your patient’s day to day activities (for example, let them elaborate on their jobs, sports or families). Then, prompt the patient to share the reason for visit in his/her own words [6].
  • Be aware of potential differences in health beliefs. Your patient might not necessarily share your scientific belief on health, illness and the body. Be respectful, try do determine how they view their illness and attempt to adapt to your patients’ perspective to better understand their reality. Remain polite and caring[6].
  • Still on health beliefs, keep in mind the effect of supernatural beliefs. If the patient’s reality is that her illness is due to a curse, she is not going to take full responsibility for the management thereof. Attempt to gain insight from the patient’s perspective with questions such as “Are there any other stressors that may play a role in your illness? What do you think are the reasons for the disease? In your opinion, what kind of treatment do you think is necessary?” [6].
  • Trust comes before relationship. If cultural differences restrict the flow of a spontaneous good relationship, do not be deterred. Focus on building a base of mutual respect and trust, on which a more open relationship will follow [7].
  • Refrain from using your own (or local) culture-specific language, slang or hand signals [7]. These can either be interpreted in a completely wrong way by someone of another culture, or if patients do not understand it, they may feel isolated. All in all, this raises the risk for improper communication
  • Be cautious with touch. As physiotherapists, touching our patients is the most natural thing to do. This is not necessarily acceptable behaviour in all cultures [7]. Before treatment, verify whether touch is okay (it is good practice to include this on your informed consent form). Even if the patient consents, communicate to him/her before moving into their personal space, or making bodily contact. 
  • Build good relationships with patient family members, especially in the case of hospitalisation. In many cultures, family members play an important role in the care-taking and support of the patient [7]. They can assist with discrepancies in communication, sometimes help with language interpretation and also play an active part in shared decision making [3].
  • Always negotiate the need for your recommended treatment instead of forcing it on the patient in less critical cases. Explain to your patient the importance of the suggested management plan and make sure that they understand, instead of simply insisting on compliance[6].
  • Try to predict and determine how your patient will react to a bad prognosis and communicate accordingly. Patient personality is often a major component of the way in which bad news is dealt with, but cultural behaviour can also play a prominent role[6].
  • Ensure that as little as possible information is lost in the communication process. After the medical interview, make sure that your patient understands by asking them to restate the recommended treatment regime, or by comprehensively writing down any specific instructions they need to comply to (rehabilitation or medication use, for example). At the end of the interview, the patient must be given a chance to ask questions and clarify any uncertainties [6]

The product of good intercultural communication is a trusting and meaningful relationship. Such a relationship between clinician and patient is earmarked by both parties’ ability to cross the two cultural contexts of care. Clinicians who contribute to an effective intercultural care process exhibits a combination of competence, knowledge, seeing the patient as a human being, being sociable and kind, and accepting the role of providing family support [3]. Once the patient leaves your room, you should have deserved their trust and they should not be hesitant to return for a follow-up or contact you with any related questions.

Further reading: Some practical examples of cross-cultural communication gone wrong

Below are some examples of well-known people and brands who have overstepped the cultural boundaries. All of these were genuinely very well-intended, but unfortunately not well thought through. Much humiliation could have been spared with better cultural sensitivity. Reflect on these incidents, and try to identify what mistakes were made in terms of communication, and how it could have been better managed.  

1.     Cricket commentary going south:

2.     Just do… research before launching products.

3.     V for Victory… or not??

4.     When in Rome (or Punjab)

5.     Wrong place, wrong time.

6.     Hands where I can see them!

7.     Cinderella in context.

8.     Niqab necessary or needless?

References

  1. 1.0 1.1 1.2 Bernaciak, E., Farbicka, P., Jaworska-Czerwińska, A., Nartowicz, M., Juraszek, K.M.,Problems of multiculturalism in the polish health care system. J. Educ. Health Sport. 2018. 8, 285–302.
  2. 2.0 2.1 Desmet, K., Ortuño Ortín, I., Wacziarg, R.,Culture, ethnicity, and diversity. 2017.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Degrie, L., Gastmans, C., Mahieu, L., Dierckx de Casterlé, B., Denier, Y.,How do ethnic minority patients experience the intercultural care encounter in hospitals? A systematic review of qualitative research. BMC Med. Ethics 2017. 18.
  4. 4.0 4.1 4.2 Holden, K., McGregor, B., Thandi, P., Fresh, E., Sheats, K., Belton, A., Mattox, G., Satcher, D.,Toward Culturally Centered Integrative Care for Addressing Mental Health Disparities among Ethnic Minorities. Psychol. Serv. 2014. 11, 357–368.
  5. Kmietowicz, Z., Ladher, N., Rao, M., Salway, S., Abbasi, K., Adebowale, V.,Ethnic minority staff and patients: a health service failure. BMJ 2019. 365.
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 Bakić-Mirić, N.M., Butt, S., Kennedy, C., Bakić, N.M., Gaipov, D.E., Lončar-Vujnović, M., Davis, B.,Communicating with patients from different cultures: Intercultural medical interview. Srp. Arh. Celok. Lek. 2018. 146, 97–101.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 Rust, G., Kondwani, K., Martinez, R., Dansie, R., Wong, W., Fry-Johnson, Y., Woody, R., Daniels, E., Herbert-Carter, J., Aponte, L., Strothers, H.,A crash-course in cultural competence. Ethn. Dis. 2006. 16, S3-29.
  8. Tucker, C.M., Herman, K.C., Ferdinand, L.A., Bailey, T.R., Lopez, M.T., Beato, C., Adams, D., Cooper, L.L.,Providing Patient-Centered Culturally Sensitive Health Care: A Formative Model. Couns. Psychol. 2007. 35, 679–705.