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The patient’s culture and effective communication

The patient’s culture and effective communication
Authors:
Joseph R Betancourt, MD, MPH
Alexander R Green, MD, MPH
J Emilio Carrillo, MD, MPH
Section Editor:
Mark D Aronson, MD
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Dec 2022. | This topic last updated: Nov 29, 2021.

INTRODUCTION — Every patient is unique, and has their own culture, shaped by many factors such as race, ethnicity, geography, education, income, religion, sexual orientation, and gender identity or expression [1]. The impact of these cultural and social determinants, language barriers, and medical literacy on clinical care is increasingly important in the delivery of quality health care [2-8]. Each patient's unique culture influences their perspectives, values, beliefs, and behaviors regarding health and wellbeing. These factors give rise to variation in recognition of symptoms, thresholds for seeking care, comprehension of or agreement with management strategies, expectations of care (including preferences for or against diagnostic and therapeutic procedures), and acceptance of preventive measures and medications.

This topic will identify the key issues faced when caring for all patients, not just patients from specific backgrounds, and will provide a framework for an effective clinical encounter. These recommendations are based on a combination of expert opinion and, when possible, evidence from related literature such as the field of clinician-patient communication. Other issues related to the patient-provider relationship are discussed separately. (See "A patient-centered view of the clinician-patient relationship".)

TERMINOLOGY

Culture — Culture is a system of beliefs, values, rules, and customs shared by a group, used to interpret experiences and direct patterns of behavior. Culture plays a large role in shaping each individual's health-related values, beliefs, and behaviors, and it clearly impacts clinical care. Culture is often influenced by race, ethnicity, and religion, but it is a separate concept; there is likely substantial variation in beliefs and practices among persons within any given racial, ethnic, or religious group.

When a clinician interacts with a patient, three cultures are juxtaposed: the patient's, the clinician's, and the culture of medicine. All three cultures influence the outcome of the encounter. To understand patients, it is first necessary to recognize our own cultural beliefs, values, and behaviors as well as personal life experiences that have influenced the way we think about health care and make clinical decisions. In addition, the culture of medicine has its own particular beliefs, values, and customs (eg, the idea of patient autonomy and the value placed on scientific evidence). Finally, the patient's social and cultural background affect the quality of mutual understanding and communication that occurs in the clinical encounter.

The core values necessary for providing effective patient care are values fundamental to the practice of medicine: empathy, curiosity, and respect [1].

Cross-cultural care and communication — Cross-cultural care is in essence the care of every patient and is not limited to encounters where the patient and clinician have different sociocultural characteristics. Rather, it focuses on the ability to communicate effectively and provide quality health care to all patients. However, caring for patients with diverse sociocultural determinants can be challenging for clinicians, and disparities in health care may stem in part from a lack of skill in this regard.

There is no empirical literature comparing the effectiveness of different models of cross-cultural care and communication. There is excellent empirical evidence showing that efforts to educate health care clinicians in cross-cultural care improve knowledge, as well as good evidence that they improve attitudes and skills [9-12].

WHY IT MATTERS — Several issues have put the field of cross-cultural care and communication in the spotlight: an increasingly diverse population, recognition of the need for effective communication to achieve quality health care, evidence of the disparity in health care provided to patients from underrepresented racial and ethnic backgrounds, and new accreditation standards and quality measures.

Importance of communication — Sociocultural differences between patients and providers influence communication and clinical decision-making. Evidence clearly links clinician-patient communication to patient satisfaction, adherence, and health outcomes [13-16]. However, lower-quality care may result when clinicians fail to recognize and understand sociocultural differences between their patients and themselves [17].

Effective clinician-patient communication is directly linked to improved patient satisfaction, adherence, and, subsequently, health outcomes including patient safety [14,18]. Physicians' communication has been shown to be significantly associated with overall patient satisfaction. One study including 3123 patients found a significant positive relationship between overall ratings of attendings' communication behaviors and overall satisfaction [19].

Relationship to health disparities — Clinicians increasingly see patients from a variety of sociocultural backgrounds, some of whom may hold beliefs and values that differ from their own [20]. For example, the 2010 United States Census reported that there were 39.9 million foreign-born residents living in the United States and about 55.4 million residents (19.7 percent of the total population) who speak a language other than English at home. In some states, such as California, the figure is as high as 42.6 percent of the population. More recently, immigrants and their United States-born children number approximately 85.7 million people, or 26 percent of the United States population according to the 2020 Current Population Survey (CPS) [21].

Two reports from the Institute of Medicine highlighted the importance of patient-centered care and effective cross-cultural communication as a means of improving quality, achieving equity, and eliminating the significant racial/ethnic disparities in health care that persist today [22,23]. Multiple factors contribute to racial disparity in health care, including barriers to effective clinician-patient interactions (eg, language and literacy issues and different cultural beliefs), systems barriers (eg, lack of interpreter services or ethnically diverse clinicians), and clinician biases [24]. It is unlikely any single intervention to improve treatment adherence or screening rates, for example, will address the variety of issues across different populations [25].

Accreditation standards and quality measures — The Joint Commission, which accredits health care organizations, and the National Quality Forum, which endorses health care measures, have developed standards and measures in the area of cultural competence [26-28]. The US Department of Health and Human Services has also released national standards for Culturally and Linguistically Appropriate Services (CLAS) that provide organizations with a framework to providing these services in health care, summarized here.

Accreditation groups for undergraduate and graduate medical education in the United States require training in cultural competency and racial/ethnic disparities, and a curriculum guide has been developed for trainees and practitioners in primary care [29].

The Joint Commission has introduced cultural competency guidelines and standards, which include training of clinical staff practicing in the hospital environment [30].

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) will impact hospital Medicare reimbursements by measuring clinician-patient communication as a major determinant of satisfaction scores [31]. The development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence Item Set promotes efforts to study the impact of cultural competency on patient satisfaction [32].

SKILLS FOR CROSS-CULTURAL CARE — Cross-cultural care is based on universal principles of patient-centered care. In the past, many thought that cross-cultural care simply entailed addressing language barriers in the clinical encounter and learning the norms of specific cultures [33]. While the former remains a key component of cross-cultural care, the latter is more problematic. Previous efforts in cross-cultural education have aimed to teach about attitudes, values, beliefs, and behaviors of certain cultural groups (eg, the key practice "do's and don'ts" in caring for patients from a specific group) [34].

Learning about a particular local community or cultural group can be helpful in certain situations. Following the principles of community-oriented care, it is important to explore the beliefs, values, and customs, as well as the historical experiences, of the cultural groups most frequently seen in a given medical practice. This may be especially important for new immigrant groups, who may reside in the same neighborhood and share the immigration experience.

This approach, however, can lead to stereotyping and oversimplification of culture without respect for its complexity. Balancing knowledge of an individual and knowledge about groups is one of the tightropes of cross-cultural health care. As an example, Hispanic persons may have some commonalities (eg, the Spanish language) but represent many subgroups from different countries, ethnicities, and cultures. Diversity also exists within subgroups, based on factors such as social status, acculturation, age, local environment, and individuality.

Components of cross-cultural care include effective use of interpreters, familiarity with differences in disease epidemiology, and comfort level in working with patients who are culturally different than oneself. Additionally, cross-cultural care goes beyond learning about patients based on their racial, ethnic, or cultural background to focusing on the skills required to follow the principles of patient-centered care [1].

Patient-centeredness encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient. Cross-cultural care aims to take this a step further to include skills that are especially useful in cross-cultural interactions but remain vital to all clinical encounters.

THE PATIENT-BASED APPROACH — The patient-based approach is derived from research in cross-cultural care and communication, medical anthropology, and sociology, as well as medical interviewing [1]. This framework allows the clinician to learn from the individual patient the social and cultural factors that influence their health values, beliefs, and behaviors and offers strategies to negotiate for the best health outcome possible.

The patient-based approach to cross-cultural care and communication entails four components: assessing core cross-cultural issues, exploring the meaning of the illness, determining the social context, and engaging in negotiation. Time constraints will likely make it difficult to address in detail all of these components in a single visit; clinicians should tailor their exploration to aspects pertinent to the specific patient. In some cases, it might be preferable to involve community resource specialists or social workers when it is felt likely that the patient might be lost to follow-up or have difficulty completing recommended tests or referrals.

Assess core cross-cultural issues — Misunderstandings between patients and health care clinicians often reflect inherent differences in cultural values and expectations. These misunderstandings can lead to outcomes ranging from mild discomfort to a major lack of trust that disintegrates the therapeutic relationship.

The vast number of cultural and ethnic groups that may be encountered in a clinical practice make it impractical, if not impossible, to learn specific aspects of each that could influence the medical encounter. Fortunately, certain core cross-cultural issues tend to recur across cultures. As an example, one study found a lower level of patient autonomy and an emphasis on the role of the family in medical decision-making among both Korean and Hispanic patients compared with Black Americans and White Americans [35].

Rather than attempt to learn an encyclopedia of culture-specific issues, a more practical approach is to recognize a set of common problems that occur in cross-cultural medical encounters.

Five core cross-cultural issues that should be taken into account are:

Styles of communication

Mistrust and prejudice

Decision-making and family dynamics

Traditions, customs, and spirituality

Sexual and gender issues

Once a potential core issue is recognized, it can be explored further by inquiring about the patient's own belief or preference rather than making assumptions based on the patient's ethnicity, religion, or other characteristics.

Styles of communication — Differences in styles of communication between patient and clinician, which can lead to discomfort and miscommunication, include both verbal and nonverbal communication: eye contact, touch, and personal space. Direct eye contact may be avoided in some cultures, while in others it is a sign of respect. Providers should be aware of their own tendencies and should be sensitive to the preferences of their patients.

Another key aspect of communication is level of assertiveness, which may range from deferent to aggressive. It should not be assumed that a quiet patient agrees with the plan outlined by the provider. A deferent patient may simply be hesitant to voice a conflicting view, making it crucial to ask for the patient's input and encourage verbalization of any disagreement. While this may still be difficult for some patients, it can be helpful to use a normalizing statement to show your openness to their perspectives. For example, "A lot of people get worried about the idea of starting a new medication. What concerns do you have about this?"

Communication issues become particularly complex when preferences around relating "bad news" to a patient need to be considered. Providers may incorrectly assume that patients should be informed of results and diagnoses, just as providers themselves may wish such news delivered. Personal and/or cultural preferences for a direct or indirect approach vary and should be elicited from patients, ideally before ordering an important test. This technique is often used in HIV pretest counseling, and an abbreviated version can be adapted for other tests such as a colonoscopy or computed tomography scan.

Techniques for adapting to different communication styles and customs are as follows:

Get a sense for the patient's general communication style and adapt your style of communicating to fit best with theirs.

Try to draw out indirect or reserved patients by making them feel comfortable and asking open-ended questions. Do not assume that lack of resistance means agreement with your plan or recommendations.

Determine how the patient prefers to receive information about results of testing.

"I am going to check the report of your sonogram tomorrow and would like to let you know the results. Some of my patients want to be told directly, no matter what the test shows, even over the phone. While I don't suspect that there will be anything serious, I would like to know how you prefer to hear the results."

Get a sense for whether the patient is more stoic or expressive of pain and symptoms. Avoid judging patients based on your own cultural perspective.

Pay attention to cultural differences in personal space, eye contact, body language. Try to be flexible and not to be misled by misinterpretation of communication cues.

Trust — Trust is a crucial element in the therapeutic alliance between patient and health care provider. It correlates directly with adherence to clinician recommendations and patient satisfaction [36,37]. Mistrust of the health care system also affects patient's use of services and results in inconsistent care, doctor shopping, self-medicating, and an increased demand for referrals and diagnostic tests by patients [38].

A national telephone survey in 2000 found significant mistrust for the health care system among members of underrepresented racial and ethnic populations: of the individuals surveyed (n = 3884), 35 percent of Black Americans and 36 percent of Hispanic Americans (compared with 15 percent of White Americans) felt they had been treated unfairly in the health care system, and 65 percent of Black Americans and 58 percent of Hispanic Americans (compared with 22 percent of White Americans) were afraid of being treated unfairly in the future based on their race and ethnicity [39].

Black Americans in particular may be mistrustful of providers based on a history of discrimination, segregation, and medical experimentation [40]. The exploitation by the United States Public Health Service during the Tuskegee study left a legacy that persists today [41,42]. Further, systemic racism has negatively impacted many patients directly, and through its impact on social determinants of health, contributing to health care disparities [43,44].

The provider should be aware of cues that may indicate some degree of mistrust. Patients may express concerns about whether a particular test is necessary, or they may mention a bad experience in the past. These should lead to direct efforts at reassurance and trust-building. Suggestions for building trust with patients, especially across cultures, include:

Discuss mistrust openly. If the patient seems open to it, discuss why they might feel mistrustful of doctors or medical care. Reassure them of your intentions to help.

"You've mentioned that you don't really like coming to doctors. Was there anything in particular that led you to feel that way? (Any bad experiences or concerns?)"

Explore the patient's perspective. Ask what's important for them.

"What are your thoughts about having this operation?"

"What were you hoping that I could do for you today?"

Provide focused reassurance. After determining the patient's perspective and concerns, focus reassurance on those concerns.

"You've told me that the pain is what you're really worried about, so I'm going to make absolutely sure that you'll have enough pain medication after the operation."

Build a partnership. Many mistrustful patients respond well to being given options and some control over their health care decisions.

Communicate clearly. Listen carefully, avoid medical jargon, and check in regularly for feedback from the patient.

Family dynamics — Clinicians in the United States may take for granted that patients wish to make decisions about their own medical care, based on information and guidance provided by their health care providers. Autonomy is not the norm in all cultures, however, and family members or others may be very involved in the decision-making process. The family may look to a specific authority figure, determined by sex/gender, position in the family, or level of acculturation, as the decision-maker.

Some families may even wish to exclude the patient from decisions, to avoid what they perceive as undue stress for the patient. A common issue occurs when a family asks the health care team to withhold a terminal diagnosis from a patient. In this situation, the family as a unit is trying to do what they feel is best for the individual patient. However, this conflicts with our own medical ethics which place great value on patient autonomy and the "right to know." A negotiation might lead to accord in these situations, if the patient themself agrees to allow their family to make medical decisions on their behalf.

Techniques for understanding cultural differences in decision-making and family dynamics include:

Introduce yourself respectfully to the patient and others in the room and determine their relation to the patient, keeping in mind that in some cultures it is appropriate to speak only to certain individuals.

Find out if the patient prefers autonomy or would want the family, or someone else in particular, to be involved in medical decision-making.

"How much do you want your family/loved ones to be involved in making decisions regarding your health care (such as tests or medications)?"

Find out if there is an authority figure in the family or other social network, community, or religious group to consult and involve in important decisions.

"Is there anyone in particular whom we should talk to about your health care besides you, someone who makes decisions in your family, social network, or community?"

Consider allowing a patient to waive their right to know (legal documents can be signed in this case) when the family or other decision-maker wants to withhold information.

When a dominant family member or other decision-maker is not allowing direct communication with the patient, explain the situation tactfully. If this fails, try ways to obtain information directly from the patient without offending the relative. However, if there is any concern for domestic abuse, laws protecting the patient should supersede issues of cultural sensitivity.

"I appreciate what you're saying, Mr./Ms. ------, your input is very important. From a medical standpoint, though, it's also very important for me to hear a description of the problem from the patient themself, so I can make a more accurate diagnosis."

Realize that in many cultures it is typical (and important) for family members (as many as 5 or 10) to stay with the patient in the hospital at all times. If this leads to difficulty for the staff, it should be negotiated openly.

Traditions, customs, and spirituality — Many of the myriad traditions and customs that help to shape a person's cultural environment have a significant relation to health and illness, including issues relating to dietary practices, folk remedies, and certain religious customs. It is not possible to describe even a fraction of these medically relevant traditions and customs. It is important to have an awareness of their importance, as well as openness and skills to explore them further with individual patients.

Many of these health-based traditions and customs are directly related to the patient's worldview, religion, or spiritual beliefs. Illness and death are among the most powerful and mysterious phenomena in our existence, and people often seek meaning in these experiences through spirituality. Clinicians may undervalue the importance of addressing spiritual concerns with patients in the primary care setting [45]. Patient expressions of spirituality should be discussed when appropriate and relevant to the clinical interaction.

Questions for clinicians about customs, religion, and spirituality include:

"Can you tell me anything about your customs that might affect your health care? What about your diet?"

"How important is religion (or spirituality) in your life?"

"Some patients have spiritual or religious beliefs that prevent them from having certain tests or treatments, such as blood transfusions. Do you have any specific concerns?"

"How important are these beliefs to you, and do they influence how you care for yourself or the type of care you might receive?"

Further discussion of spirituality in palliative care, including information on tools to assess spirituality, is provided elsewhere. (See "Overview of spirituality in palliative care".)

Sexual and gender issues — In many parts of the world, gender roles tend to be strictly defined and enforced. For example, the male role may be commonly seen as that of protector and spokesperson for the family. Cultural differences in attitudes towards sexuality and gender roles can be "hot-button" issues and should be negotiated with tact and respect to maintain the therapeutic relationship.

Difficult situations may arise due to the patient and provider being of different (or the same) sex or gender: discomfort with genital, breast, or rectal examinations, or shame, or other difficulties in discussing sexual issues. Health care providers should keep sexual and gender issues in mind when dealing with patients of all cultures, and they should pay particular attention to cues and body language. Addressing these with tact and sensitivity will help promote trusting relationships with patients.

Misgendering (making incorrect assumptions about a patient’s gender) can cause difficulties in trust and communication [46,47].

Techniques for understanding sexual and gender issues include:

Be aware of the different ways that patients and families/loved ones view gender roles and try to accommodate them when feasible.

"Unfortunately, we have no female obstetricians in clinic today, but if you are willing to reschedule your appointment, I can make sure that your wife will see a female doctor next week."

Avoid adopting a judgmental attitude toward patients, as this is unlikely to change behaviors and values but is likely to compromise the clinician-patient relationship and the ability to provide good health care.

Ask patients/family/loved ones what is acceptable to them, rather than making assumptions based on limited information (name, clothing, etc).

"I perform breast examinations on all of my female patients to look for signs of breast cancer or other problems. Is this okay with you?"

Be particularly sensitive to patients' views on discussing sexual issues openly. State that you will be asking about some personal issues and explain why, especially in interactions where you are unfamiliar with the patient's cultural background.

"I generally ask all patients about some very personal matters at this point, which are important for doctors to know about. Are you comfortable talking about these things with me?"

Recognize that patients' views and language regarding sexuality and sexual orientation may differ. Information on sexual orientation and behavior should be obtained using open-ended questions and gender-neutral terms. Ask patients about the sex/gender of their sexual partners rather than whether they identify as gay, bisexual, etc. (See "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care" and "Primary care of gay men and men who have sex with men", section on 'Obtaining a history'.)

Be open to and learn and use appropriate terminology for patients' gender identity. Ask new patients what pronouns they use and avoid making assumptions about gender.

Explore the meaning of illness

The explanatory model — Patients seeking care for a medical issue come with certain beliefs about the cause of their symptoms, concerns about their illness, and expectations about potential treatment. Their overall conceptualization of their illness has been called the patient's explanatory model [2].

The explanatory model represents the "meaning of the illness" for the patient, or how they understand and explain their condition. Patients' explanatory models can range broadly, from the mundane to the exotic, and may be more complex than what is initially apparent. Understanding these models is useful for all patient encounters, but particularly so for patients whose perspectives on health and illness may differ significantly from the Western model of biomedicine.

Common sense and lay health beliefs are the most typical type of explanatory model. Limited education, low health literacy, lack of information, or mistrust of medicine may lead people to develop their own ideas about the causes, consequences, and appropriate treatment of their illness. Sometimes beliefs are simply misunderstandings about medical information, such as the idea that diabetes can be controlled by avoiding sugar.

There is individual variation in how tightly people adhere to their beliefs. Some will be happy to learn "the truth" from a clinician. Others will ignore whatever they are told if it doesn't take into account their own particular perspective and respect their common sense.

Belief systems — Patients are often initially hesitant to reveal their beliefs and fears. Respectful questioning and reassurance may overcome this resistance. Focusing on what others may believe, or on hypothetical situations, may help relieve the patient's discomfort [48].

The following questions can be adapted for use in various contexts besides illness [2]. As an example, they may be used to explore the meaning of a particular procedure or treatment for a patient, such as a breast biopsy or chemotherapy.

"What do you think may have caused the problem?" – This question gets at the patient's beliefs about the cause of the illness, the most fundamental and important aspect of the explanatory model. Clinicians have developed their own personal styles and phrasing, modified to suit the particular situation, to address this question.

"What do you call the problem?" – This question may be especially useful when you suspect the patient believes a particular folk illness to be causing the symptoms. Another way to phrase this would be, "Do you have a name for this sickness (in your language)?"

"Why do you think it started when it did?" – This can help link the illness to certain events in the patient's life that may be important elements of the explanatory model. A related question is, "What was going on in your life at the time that this illness started?"

"What do you know about the illness and how it works?" – This gets at the patient's deeper understanding of the illness and how it affects them. Patients may not be able to answer this, just as patients who believe that viruses cause colds most often would not be able to describe how this works.

"How severe is the illness? How worried are you about it?" – Patients may be very worried about an illness while the clinician is not, when symptoms do not suggest a concerning disease. The opposite may also be true, when the patient feels the illness to be minor and does not fully believe the clinician's diagnosis. This is important to discuss as openly as possible.

"What kind of treatment do you think you should receive? What are the most important results you hope to get from this treatment?" – Part of the patient's understanding of their illness has to do with their beliefs about its treatment. Traditional and alternative healers and remedies play a large role in many patients' perspective on health and illness. They may also have opinions on Western medical therapy as well, which should be taken into consideration.

"What are the chief problems the sickness has caused?" – This is a good way to discuss the effect that the illness has had on the patient's life and daily routine. Understanding this allows better insight into the patient's unique illness experience. Other ways to phrase this include, "How has this illness affected your life?" or "What has changed in your life since this illness started?"

"What do you fear most about the sickness?" – This is a crucial question; it allows the clinician to tailor their explanation of the illness and its treatment to the patient's concerns. This can also be extremely helpful to understand a patient's perspective on a particular medication or procedure.

Complementary and alternative therapies — The use of traditional remedies, healing practices, or other forms of alternative therapy is widespread both in patients in the United States mainstream as well as those from other cultures. The Institute of Medicine report on complementary and alternative medicine (CAM) found that over a third of Americans rely on unconventional practices either in conjunction with medications or in place of them [49]. Use in the pediatric population is also high [50]. (See "Overview of herbal medicine and dietary supplements" and "Complementary and alternative therapies for cancer" and "Complementary and alternative therapies for rheumatic disorders".)

"Integrative medicine" is a term to describe integration of CAM therapies into mainstream medical practice based upon evidence of safety and effectiveness within the context of relationship-based care [51]. Techniques to understand the patients use of CAM include:

Ask patients in a nonjudgmental, open-minded way about nonmedical, alternative practices (can be asked after "medications" in the medical history). This also provides an opportunity to find out more about symptoms and problems the patient is having.

"A lot of my patients use other forms of treatment, like home remedies, herbs, or acupuncture, that can be helpful. Besides the medications that you mentioned, have you used any other types of therapy?"

Check to see whether alternative therapies are safe and look for any interactions with medications.

Negotiate the use of alternative therapies along with standard medicine when safe and important to the patient, and discuss reasons to discontinue any dangerous ones.

Determine the social context — The manifestations of a person's illness are inextricably linked to the individual's social environment [52]. This social context is not limited to socioeconomic status but encompasses migration history, social networks, literacy, and other factors. There is a vast literature defining the relationship of these social factors to health status and elucidating the effects of social class barriers between patient and doctor [53]. Models have been developed to explore the social determinants of health with patients, irrespective of cultural factors [54].

Three specific aspects of the patient's social context have particular relevance to the cross-cultural clinical encounter: change in environment (such as migration); literacy and language; and life control, social stressors, and supports [55].

Environment change — Environment change refers to any migration, whether from a different country, town, or even neighborhood, that requires adaptation to new physical and social surroundings. Adaptation to a new way of life often poses an enormous stress on the individual.

The reasons for the migration, ranging from fleeing political persecution or torture to attending a university, may be crucial in understanding past and present stresses. A change in economic and professional status (eg, from physician to laboratory technician) may also be relevant. Mental illness and psychosomatization are potential consequences of this stress and should be recognized and managed with awareness of the social context.

There may be difficulty negotiating the unfamiliar medical system, especially for patients accustomed to a very different health system. Understanding the patient's unique migration experience can help the health care provider build rapport and trust, allay certain concerns (such as fear of deportation), acknowledge sources of distress which may be causing psychological or psychosomatic problems, and focus on interventions which facilitate the patient's transition.

Questions regarding environment change include:

"Where are you from originally? When did you come and why did you decide to come?"

"How have you found life here compared with life in your country (city, town)?"

"What was medical care like there compared with here?"

It should be made very clear to the patient that all information of this type will be kept completely confidential and will in never be used outside of the purposes of clinical care.

Language and literacy — According to the 2010 United States Census, 55.4 million United States residents speak languages other than English at home. This represents 19.7 percent of the total population (up from 18 percent in 2000), and in some states, such as California, the figure is as high as 42.6 percent. Nearly half of these individuals have difficulty speaking and understanding English.

Language barriers affect quality of care in several ways. Studies have found that Spanish-speaking patients discharged from the emergency department are less likely than English-speaking patients to understand their diagnosis, medication plans, special instructions, and plans for follow-up care; less likely to be satisfied with their care or willing to return if they had a problem; more likely to report problems with their care; and less satisfied with the patient-clinician relationship [56,57]. Hispanic patients who spoke Spanish at home, compared with those who spoke English at home, were less likely to receive recommended health services in a representative household survey of health care utilization in the United States [58].

Patients with limited English proficiency are more likely to suffer from adverse events, and these adverse events tend to have greater clinical consequences [59]. Communication problems are the most frequent cause of serious adverse events as recorded by the Joint Commission [60]. Effective communication is compromised by language barriers, cultural differences, and low health literacy, all of which are particularly important issues for patients who are members of racial/ethnic underrepresented groups [61].

In the United States, interpreter services are required by law to be available at clinical sites receiving federal funds [62,63]. However, they are often unavailable, informal interpreters such as family members (especially children) or other nonprofessionals are often inaccurate and unreliable, and clinicians are rarely trained in how best to work with interpreters [64-66]. Assessing a patient's language proficiency is essential for delivering care to immigrant populations. Four factors should be considered in determining need for an interpreter: the clinical situation, the degree of language gap, available resources, and patient preferences [66]. When an interpreter is needed and a professional interpreter is not readily available, options include telephone interpretation systems, or a family member or friend who has been briefed on the expectations of interpretation. Children should not be used as interpreters except in emergency situations where there are no alternatives.

The following are some basic tips for working with interpreter services:

Consider a short pre-meeting to orient the interpreter to the interaction

Introduce the interpreter to patient

Position the patient, interpreter, and yourself in triangle so everyone each can see each other's face

Address and make eye contact with the patient, not the interpreter

Ask one question or express one idea at a time and keep phrases short

Encourage the interpreter to clarify terms with you and confirm understanding and agreement with the patient

Empower team members (including the interpreter) to speak up when they notice a communication problem

It is your responsibility to ensure that the medical interpreter and patient understand what is being communicated: avoid medical jargon, idiomatic expressions, and acronyms

Consider debriefing with the interpreter afterwards, if the encounter was difficult

More detailed guidelines can be found here.

More than 30 percent of the United States population is functionally illiterate and innumerate, and approximately 45 percent have low health literacy [67]. Health literacy is the degree to which an individual can understand medical terms about symptoms and illness, follow directions for procedures and therapies, and ask pertinent questions. Immigrant patients may be illiterate in both English and their native language.

Clinicians need to identify patients with language and literacy barriers and refer them to appropriate resources. Questions to be asked regarding language and need for interpretative services are:

"How well do you speak English: Not at all, not well, well, or very well?"

If the patient responds "not at all" or "not well," an interpreter is appropriate; if the response is "very well," interpretation is generally not necessary; if the response is "well," a second question should be asked:

"In what language do you prefer to receive your medical care?"

A study of 300 patients in a California clinic found that these two sequential questions had a sensitivity of 99 percent and specificity of 92 percent in identifying patients who would prefer to discuss their medical concerns in Spanish [68].

Questions that may be asked to evaluate literacy include:

"How confident are you filling out medical forms?"

"Do you have trouble reading your medication bottles, instructions, or other patient information?"

"Do you have trouble with reading in general?"

Life control, stress, and support — A patient's lack of control over their environment can clearly impact their health-seeking behavior and symptom threshold. Some patients will present at the earliest stages of their disease, while others will tolerate a great deal of symptomatic distress before presenting for care. While part of this variation may be cultural or characterological, there is undeniably a socioeconomic component related to being able to take time from work or other responsibilities or being able to pay medical fees. Awareness helps the health care provider develop a plan that may include accessing available financial supports and social services.

Social stressors and supports, and, more broadly speaking, the social determinants of health [69], may have strong impact on a patient's illness experience. A socially isolated patient may manifest more symptomatology related to a given illness than a patient with a broader set of social supports.

Questions helpful to gain understanding of issues related to life control, social stressors, and supports include:

"What is causing the most stress in your life? How do you deal with this (ie, family, friends, activities, religion)?"

"Do you ever feel that you're not able to afford food, medications, or other medical expenses?"

"Do you feel that you have the ability to affect your own health (or particular medical condition) or is it out of your control?"

Engage in negotiation — Much of the emphasis of cross-cultural communication has to do with exploring patients' perspectives. Even when sociocultural backgrounds are similar, substantial differences may exist in expectations, agendas, and values between patients and clinicians. There is no simple answer to the problems that arise when patient views differ and conflict with our own. The process of cross-cultural negotiation can be helpful in acknowledging different explanatory models or agendas and developing management strategies.

Negotiation is not about trying to convince patients who are refusing medical treatment that they should accept what we say. It requires getting beyond the notion that whatever we think as medical professionals is right for everyone. It is about teaching people what we know in a way that they can understand and that also values their system of beliefs [70,71].

The following steps are helpful in the negotiation process:

Step 1: Explore the patient's perspective – Ask open-ended questions about the patient's understanding and concerns about the illness and its treatment.

Step 2: Explain your perspective – Provide the patient with an explanation in terms that are understandable and familiar, sharing what you hope will be beneficial for them if they follow your recommendations.

Step 3: Acknowledge the difference in opinion – Do this in a way that is nonjudgmental and accepting of difference.

Step 4: Create common ground – This may mean offering a compromise or asking the patient what they are willing to do. This often requires some back and forth discussion in an environment where the patient feels they can be open.

Step 5: Settle on a mutually acceptable plan – Once a plan is developed, check in with the patient again to make sure that it is acceptable. Look for any sign of hesitation on the part of the patient and discuss this openly. Ensure that the patient understands and has retained the plan that has been negotiated and articulated by the provider in language that is plain, simple, and understandable to the patient.

If conflict remains after initial negotiation, it may be helpful, if the patient is willing, to involve other individuals who the patient trusts. When a mutually agreeable plan or understanding cannot be reached with a competent adult patient, it is important to document the negotiation process in the medical record and acknowledge that the patient has the ultimate decision in their health care.

Assess for understanding — A simple yet effective way to assess whether the patient has captured the explanations and instructions derived from the clinical encounter is to use the "teach-back" technique [72]. At the end of the visit, ask the patient to explain back what they are going to do. Ask the patient to "tell me in your own words." Not all patients will respond well to this approach, so it may be helpful to explain the reason for asking ("I'd like to make sure I was able to explain things well"). This technique may expose cognitive, cultural, language, or health literacy barriers [73] that have impeded communication or retention.

SUMMARY AND RECOMMENDATIONS

Importance – Sociocultural differences between patient and provider influence communication and clinical decision-making. Lower-quality care may result when clinicians fail to recognize and understand sociocultural differences between their patients and themselves. (See 'Introduction' above.)

Relevance – Cross-cultural care is in essence the care of every patient and is not limited to encounters where the patient and clinician have different sociocultural characteristics. Rather, it focuses on the ability to communicate effectively and provide quality health care to all patients. (See 'Cross-cultural care and communication' above.)

Patient-based approach – The patient-based approach to providing quality cross-cultural care entails four basic components: (See 'The patient-based approach' above.)

Assessing core cross-cultural issues – Core issues that should be explored, when relevant to care, are: styles of communication, trust, decision-making and family/loved one dynamics, traditions and spirituality, and sexual and gender issues. (See 'Assess core cross-cultural issues' above.)

Exploring the patient's understanding of illness – The explanatory model represents how the patient understands their illness: its cause, meaning, and consequence. Understanding a patient's explanatory model allows the clinician to adapt communication and treatment recommendations to the patient's concerns and perspectives. (See 'Explore the meaning of illness' above.)

Social context – The manifestations of a person's illness are linked to the individual's social environment. Three specific aspects of the patient's social context have particular relevance to the cross-cultural clinical encounter: change in environment (such as migration); literacy and language; and life control, social stressors, and supports. (See 'Determine the social context' above.)

Negotiate a mutually acceptable approach to treatment – Even when sociocultural backgrounds are similar, substantial differences may exist in expectations, agendas, and values between patients and clinicians. The process of cross-cultural negotiation can be helpful in acknowledging different explanatory models or agendas and developing management strategies. (See 'Engage in negotiation' above.)

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Topic 2753 Version 31.0

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