International medical ventures, from providing humanitarian crisis relief missions to delivering conference lectures, all entail interactions at least between persons of two different societal cultures, and often multiple persons from multiple different societies with different primary languages. Even in health care providers’ home settings, mis-communications and mis-understandings occur; problems that have only a greater chance of occurring when there are more differences among the persons involved in an interaction. Failure to understand, appreciate and respond to cultural characteristics increases the risk of misdiagnosis from compromised historical and physical examination data gathering, non-compliance or misunderstanding regarding care instructions and patient dissatisfaction that may lead to future avoidance of care in the “Western” biomedical system when necessary. Being apprised of this risk and being attentive to a number of principles can decrease the likelihood of unintended consequences of well intentioned acts or speech.
Relevant medical literature discussions of issues in communication between health care workers and patients have evolved from analyses of differences in the perception of illness through evaluations of the sources of differences in care received by various minority groups to recommendations and licensing requirements for training in cross-cultural healthcare delivery.
Many of the concepts applied to training United States health care workers skills for optimizing delivery of cross-cultural health care are equally applicable to international health care delivery. Several of these core concepts of intercultural health care communication are listed here with brief descriptions and a few key references.
Explanatory Model of Disease –The patient’s, or health care worker’s, view of the cause, severity, and prognosis of an illness, the expected treatment, and how the illness affects his or her life and position in his or her society. Explanatory models of illness are based on cultural background and social factors, such as socioeconomic status and education.These may be quite different between patient and health care worker.
Health Care Provider/Patient Negotiation – For various reasons, including differences in the explanatory models of illness, patients and health care workers may have different ideas on how to progress in the process of trying to restore the patient to “healthiness.”Through understanding the concept of explanatory models, health care workers can more effectively follow the core principles of negotiation to reach the best plan for helping a patient; relationship building, agenda setting, assessment, problem clariﬁcation, management, and closure. The initial aspect of negotiation is to come to a shared terminology between the health care worker and the patient to describe the illness being experienced.The second phase of negotiation involves developing an effective and acceptable management plan.
Culture – Culture being an implicit construct, has been subject to varying deﬁnitions based on sets of criteria, frequently including beliefs, values, customs, language, behaviors and other factors shared by a group of people.Though such groups are often thought of as delineated by national, ethnic or racial identities, the construct applies equally well to professional and social groups potentially composed of various national, racial and ethnic members. For example, in this model, physicians belong to a culture and to sub-cultures based on medical specialty in addition to the various other cultural determinants that deﬁne them individually. Effectively, every person can also be seen as culturally unique based on their unique life experiences.
The movement to develop formal training of health care workers and institutions in cross cultural health care delivery formalized following an Institute of Medicine Report indicating that the incidence of less than ideal medical care was much greater when there were cultural and linguistic differences between the health care workers and patients. In response, various credentialing agencies and organizations in the United States have adopted curricula and requirements for physician training in cross-cultural health care delivery.
In summary, for all patients, the experience of illness is culturally deﬁned by numerous factors including beliefs, perceptions and coping skills, as well as the socioeconomic positioning of the patient. By supplementing medical knowledge with an understanding of culture-speciﬁc beliefs and values, particularly those related to health, life and death, health care providers can better understand and more appropriately inﬂuence patients’ decision-making processes.
Several models have been proposed for effectively communicating with patients across cultural differences.The following Cross-Cultural Review of Systems, based on questions developed by Kleinman, et al covers some of the major points in information gathering – exploring the patient’s explanatory model.
A Cross-Cultural “Review Of Systems”
Step One:Identify relevant Core Cross-Cultural Issues
Styles of Communication: How does the patient interact with the health care worker?
- Eye contact, physical contact, and personal space
- Deferential vs. confrontational
- Stoicism vs. expression of symptoms
- Relating “bad news”—patient preferences
Mistrust and Prejudice: Does the patient appear to trust the health care system?
- Explore patient perception of and/or previous experiences with the health care system
- Explore how perceptions and experiences have inﬂuenced patient behavior (e.g., compliance with medical recommendations)
- Keep in perspective “what’s at stake” for patient; showing respect and address the patient’s concerns
Autonomy,Authority, and Family Dynamics: How does the patient make decisions?
- Establish the role of the individual and signiﬁcant others in decision making/support
- Identify the role of any authority ﬁgure within family or social group
- Identify role of community leaders or spiritual leaders in important decisions
Role of Physician and Biomedicine:What does the patient expect of us?What is our role?
- Ideas, Concerns, and Expectations (ICE) for the physician and biomedicine
- Perspectives about the physician
- Views on biomedicine/other health and healing practices
Traditions, Customs, and Spirituality: How do these factors inﬂuence the patient?
- Issues regarding medical procedures (e.g., drawing blood, blood transfusion, vaccination)
- Rituals pertinent to the medical encounter
- Culture-speciﬁc therapies (including culturally speciﬁc diet/preferences)
Sexual and gender issues: How central are these issues to the patient’s life?
- Gender concordance/discordance—Attitudes towards physical exam, gender of physician
- Embarrassment in discussion of sexual issues
- Differences in sexual orientation and identity
Step Two: Explore the Meaning of the Illness
Incorporating elements of the “explanatory model,” probing into the patient’s understanding of their ailment, improves insight into behaviors and can help minimize misunderstanding and conﬁlct between healthcare providers and patients.
- What do you think has caused your problem?
- What do you call it?
- Why do you think it started when it did?
- How does it affect your life?
- How severe is it?
- What worries you the most?
- What kind of treatment do you think would work?
- What kind of treatment do you think you should receive? (Expectations?)
Step Three: Determine the Social Context
The “social context” is of equal important and warrants exploration, given how intertwined social factors are with cultural factors.The following areas should be considered.
General social environment
- Can you afford the medication?
- Are you ever short of food or clothing?
- Will you be able to follow up as recommended?
Change in environment
- Have you recently left your home setting?Why? How long ago?
- How long have you been living in this area where we are meeting?
- What was your previous experience with health care?
Social stressors and support network
- Do you have friends or relatives that you can call on for help? Do they live close to you?
Literacy and language
- Do you have trouble reading your medication bottles or appointment slips?
- What language do you speak at home?
- Do you ever feel that you have difficulty communicating everything you want to say to the doctor or staff?
The questions and principles presented above may seem quite familiar to many readers. Communicating in multi-cultural situations is little different from applying good communication skills in any setting.
- Cross,T., Basron, B., Dennis, k., & Isaacs, M., (1989). Towards a Culturally Competent System of Care,Volume I.Washington, DC: Georgetown University Child Development Center, CASSPTechnicalAssistance Center
- U.S. Department of Health and Human Services Ofﬁce of Minority Health. Assuring Cultural Competence in HealthCare:Recommendations for National Standards and Outcomes-Focused ResearchAgenda. Washington, DC: U.S. Government Printing Ofﬁce; 2000.
- KleinmanA, Eisenberg L, Good B. Culture,illness andcare:clinicallessons from anthropologicandcrossculturalresearch.Annals of Internal Medicine. 1978 Feb; 88(2):251-8
- Joint Commission. The Joint Commission to develop hospital standards for culturally competent patient-centerd care.Common wealth grant to support initiative. Joint Commission Perspective. 2009 March; 29(3):7
- Pasick RJ, D’Onofrio CN, Otero-Sabogal R. Similarities anddifferencesacross cultures:questions to informathirdgenerationfor healthpromotionresearch. Health Education Quarterly.1994;23(suppl):S142–61
- Hunt LM. Healthresearch:what’s culturegot to do withit. Lancet.2005;366:617–8.
- Martin DR. Challenges and opportunities in the care of international patients: clinical and health service issues for academic medical centers.Academic medicine. 2006 Feb; 81(2):189-92.