Good communication is essential to ensure optimum health care for people from different cultural backgrounds. Culture is something that we all have, so whilst some cultural beliefs and practices may seem strange to a white indigenous British person, then the opposite is likely to be true to a person from a different culture. Harris (1999) asserts that a culture is the socially learned ways of living found in human societies, and that it embraces all aspects of social life, including both thought and behaviour.
Leinger (1991) described culture as ‘the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned or certain ways (Burnard and Gill 2008). Culture is learned rather than innate and dynamic and constantly changing. The UK is becoming an increasingly diverse multicultural society and the different migration patterns throughout recent centuries have added to the dynamic nature of the British culture and society.
It is estimated that there are at least 3 million people living in the UK where English is not their first language and the challenges that this poses for the NHS and other caring agencies are immense.
At the heart of these challenges is the fostering of good communications where people from all cultural backgrounds can understand and respect each other. The first part of this essay outlines some cultural variations regarding communication. In the second part of this essay the implications that these cultural variations have for health and social care practice are investigated.
Some of the different cultural variations that are detailed relate to national backgrounds, age, social class and gender.
Cultural variations and communication It is a normal human condition to interpret actions, facial expressions, choice of words and other forms of communication according to a person’s cultural conditioning and past experience. As language is the primary vehicle of culture, perhaps the most obvious indicator of a person’s culture is the way they speak. Statistics from the 2011 Census shows that there are more than one hundred spoken languages in London, alone (Bentham, M 2013).
There are also major differences in accents, dialect and usage of words throughout the general population of the United Kingdom. Furthermore, language is central to any subculture so different age groups, gender, different occupations and people with different lifestyles and preferences will develop their own cultures and languages. A good example of this is the recent use of the words ‘sick’ (meaning great or awesome) and ‘dope’ (meaning good, great or cool) by teenagers and young people.
These words have a complete opposite meaning to people from an older generation. As well as cultural variations in the spoken word there are major variations in the body language of different cultures. Being bear hugged by a Russian person or being rebuked for smiling too much at somebody from Korea highlights the cultural blunders and confusions inherent in today’s global village. In Bulgaria, for instance, they shake their head for yes and nod for no, and in Korea touching your nose is very rude, and in France the V-sign is used for smoking.
Other pitfalls include colours and symbols, for example in India the colour of mourning is white whilst in Saudi Arabia it is insulting to cross an ankle over a knee and display the sole of the shoe while talking to another person. Other taboos include Japanese people viewing it as rude to use too much eye contact, whilst in Saudi Arabia eye contact between a man and a woman would be frowned upon and seen by many as the woman being sexually promiscuous.
And whilst people from Mediterranean countries are very animated when expressing themselves this may be misinterpreted to someone from a more reserved culture as being aggressive. It is important, therefore, in multicultural Britain that health and social care workers learn and embrace cultural variations in communication, as it is the responsibility of all healthcare professionals to provide equitable care for patients irrespective of their cultural background or communication abilities. Implications for Practice All health and social care workers need to be aware of cultural variations in communication.
These include the care assistant who recognises the symbolic importance of the bindi and assists the Hindu service user to apply the red dot, to the midwife who refrains from installing praise on a new born Vietnamese baby because she (or he) understands the significance of Vietnamese taboos and superstitions. Furthermore, the surgeon who realises that the Asian child with a swastika painted on his head is displaying it for good look rather than for Nazi sympathiser reasons and this would hopefully prevent a reoccurrence where a surgeon refused to operate on a patient because they had a swastika tattoo (Day, M 2010).
Other examples of understanding cultural variations in healthcare include the pharmacist underestimating the risks of dispensing medicines to non-literate people who statistically are in additional danger of being hospitalised through not being able to understand labels and written instructions. People from non-literate and lower social class groups are also less likely to be as autonomous in healthcare interactions as their white middle-class counterparts. One doctor in primary care reported how low literacy meant that patients were unable to articulate problems accurately and more time was required for explanation.
These cultural barriers encourage healthcare workers, such as doctors, to make decisions for patients and service users believing that they are culturally limited in their ability to make big decisions. Equally, many older people may refrain from asking for clarification about matters for fear of being labelled confused or demented (Likupe, G 2014). Johnson et al (2004) reported that physicians in the US were more dominant and engaged in less patient-centred communication with African-American patients compared with white patients.
As a result, African-American patients demonstrated reduced adherence to treatment regimens and less satisfaction with care compared with the white patients in the study (Likupe, G 2014) and again cultural variations influenced the communication and in turn outcomes for these patients. These examples highlight how cultural variations and misunderstandings can result in the manifestation of stereotypical views which in turn leads to discrimination. Another study showed that African-American women received different treatment from white women and that stereotyping influenced this treatment.
These women were often stereotyped as being aggressive and this affected their interactions with healthcare professionals. Sometimes they felt that their conversations were being misinterpreted. One woman in the study described how a doctor was scared of her because she used her hands often when speaking and the doctor thought she was going to hit him (Likupe, G 2014). Cultural variations will also affect the way that health and social care workers and service users greet each other.
The friendly, firm handshake common to the indigenous British population may appear rude to somebody from Arabic Middle-Eastern cultures. And in China, not only are weak handshakes preferred, but the custom is to hold on for an extended time after the initial shake. With no knowledge of this the indigenous healthcare worker may believe that the patient is very nervous. On the other hand receiving an extra firm hand shake from somebody with a South African culture, will not mean that they are being aggressive as in South Africa, the stronger the handshake, the better.
Some cultures prohibit physical contact between men and women, so an handshake greeting would not be an option as it may cause offence. In such circumstances a nod of the head may be the appropriate way to greet a service user, and understanding these nuances are vital for building up relationships of respect and trust with the client and their family. There are also other cultural taboos that the healthcare worker will benefit from knowing. For example, not to shake hands over the doorstep when leaving the home of a Russian service-user, as they believe that this may cause an argument.
Russian culture also has a different approach to proximity. Proxemics reveals that people handle space differently, depending on the type of culture they come from. If personal space is violated, people from individualistic cultures may react actively while people from collectivist cultures may adopt a passive stance. It is crucial for healthcare workers to understand more about how physical space is dealt with in different cultures in order to increase their comprehension and expression.
Axtell (1997 p40) places cultures into the following categories. High contact” are touching cultures (for example, Middle East, Latin American, Greece,…), “moderate contact” are middle ground (for example, France, China, Ireland,…) and “low contact” do not touch (for example, Japan, US, England,…). Healthcare workers need to be sensitive to these differences since a body gesture can appear personal or intimate depending on the culture of the person. Perceptions of health and well-being, illness and disease are culturally defined and healthcare workers need to be aware of how this may translate to the way a service user understands and articulates pain.
Some commentators have pointed out that some cultures have a more stoic attitude towards pain whilst others are more expressive with their reaction to pain. Expressive patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, whilst stoic patients often come from Northern European and Asian backgrounds. However, whilst providing meaning to the way an individual responds to illness and other conditions, healthcare workers should not stereotype and always be vigilante when looking out for signs of ill health.
Following on, some people may believe that their illness is caused by God, due to a sin (morality failure), and even karma. For instance, an Indian patient may believe that their illness or condition is due to events in a past life. Whilst acknowledging these beliefs it is equally important that the service user is given the best care in order to produce the best outcomes as possible. It may be that a family member who is helping to perpetuate such beliefs is spoken to sensitively. Safeguarding may also become a concern if a dominant member of the family insists on always being present when healthcare workers are there.
For example in matriarchal cultures the head female will expect all communication to first go through her, and in patriarchal cultures it will be the head male. Consequently, a teenage girl from a patriarchal family may be unwilling to speak in front of her father about the real reasons that she wants to visit a healthcare professional. The professional, such as a GP or district nurse needs to be aware of this, especially if the father or mother is always present during healthcare appointments (especially when they are adults).
It could be, for example, related to sexual health and early intervention may prevent the dangers of a patient contracting a sexually transmitted infection or having an unwanted pregnancy. Such dilemmas of who to respect can be difficult for the healthcare worker. Being a core value of health and social care interactions, the concept of respect has much cultural meaning. For example, respect may mean different things to people from different cultures, and it is these cultural differences that need to be taken into account when providing care.
For example, in most African cultures, older people prefer not to be addressed by their first names and may like to be referred to as uncle, aunt or mama, depending on the relationship and difference in age between those they are communicating with. In Asian cultures older people may prefer to be addressed by their titles, such as doctor, Mr or Mrs (Likupe, G 2014). Due to negative stereotypes of older people it has also be shown that many younger people depersonalise older people in a process known as ‘over-accommodation’ where they use ‘elderspeak’.
This involves communication being overly polite and warm, with a slowed speaking rate, increased volume of speech and use of exaggerated intonation and simple language. This for many older people is seen as condescending and patronising, to the older person and can result in lowering their self-esteem. Therefore, healthcare workers need to be aware that this may happen when talking to older people and be active in refraining from using elderspeak and pointing out to colleagues if they see them over accommodating.
This is particularly important as elderspeak has been shown to increase aggressiveness and decrease receptiveness to care interventions. A good guide for health and social care organisations would be for them to provide staff with information about different cultural groups. For example, how in some cultures, old age is associated with wisdom, and often used to indicate status and power, and younger people are expected to respect older people.
Another factor which has major implications to the way cultural variations may affect communication is the increasing reliance of overseas workers in British healthcare who bring with them a diverse range of cultures. For example, in 2005 Internationally Recruited Nurses (IRNs) accounted for more than 60% of the nursing workforce in some healthcare organisations (Nursing Standard). Whilst the majority of these healthcare workers provide an excellent service there has been criticism that due to language barriers some are unable to engage in ‘small-talk’ with service users.
These informal chats between nurse and patient are arguably very important to the patient’s experience and road to recovery. Conclusion It is important for health and social care workers to become familiar with cultural practices and behaviours because unfamiliarity could lead to misinterpretation and misunderstanding, with service users not receiving the desired care, thereby affecting safety and outcomes. The refusal of a Jewish surgeon to operate on a patient with a Nazi tattoo highlights the difficulties of cultural variations in communication and health and social care contexts (Day, M 2010).
This also illustrates the power of non-verbal communication and how signs, symbols and the use of body language can influence the way a person interprets another person’s actions and intentions. In Multi-cultural Britain it is important that health and social care providers and educators make sure that the healthcare workforce are aware of cultural variations in health and social care in order to deliver the best care possible and achieve the best outcomes.