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Increase Awareness of Cultural Diversity

We recognize that every patient encounter is unique. Every patient is different in age, sex, ethnicity, religion or sexual preference and will bring to the medical encounter their unique perspectives and experiences. This factor will always impact communication, compliance and health care outcomes.

The suggestions presented here are intended to help build sensitivity to differences and styles, minimize patient-provider and patient-office staff miscommunication, and foster an environment that is non-threatening and comfortable to the patient.

Tips for successful encounters with diverse patients

To enhance patient/provider communication and to avoid being unintentionally insulting or patronizing, be aware of the following:

Styles of Speech

People vary greatly in length of time between comment and response, the speed of their speech, and their willingness to interrupt.

  • Tolerate gaps between questions and answers; impatience can be seen as a sign of disrespect.
  • Listen to the volume and speed of the patient's speech as well as the content. Modify your own speech to more closely match that of the patient to make them more comfortable.
  • Rapid exchanges, and even interruptions, are a part of some conversational styles. Don't be offended if no offense is intended when a patient interrupts you.
  • Stay aware of your own pattern of interruptions, especially if the patient is older than you.

Eye Contact

The way people interpret various types of eye contact is tied to cultural background and life experience.

  • Most Euro-Americans expect to look people directly in the eyes and interpret failure to do so as a sign of dishonesty or disrespect.
  • For many other cultures direct gazing is considered rude or disrespectful. Never force a patient to make eye contact with you.
  • If a patient seems uncomfortable with direct gazes, try sitting next to them instead of across from them.

Body Language

Sociologists say that 80% of communication is non-verbal. The meaning of body language varies greatly by culture, class, gender, and age.

  • Follow the patient's lead on physical distance and touching. If the patient moves closer to you or touches you, you may do the same. However, stay sensitive to those who do not feel comfortable, and ask permission to touch them.
  • Gestures can mean very different things to different people. Be very conservative in your own use of gestures and body language. Ask patients about unknown gestures or reactions.
  • Do not interpret a patient's feelings or level of pain just from facial expressions. The way that pain or fear is expressed is closely tied to a person's cultural and personal background.

Gently Guide Patient Conversation

English predisposes us to a direct communication style. However, other languages and cultures differ.

  • Initial greetings can set the tone for the visit. Many older people from traditional societies expect to be addressed more formally, no matter how long they have known their physician. If the patient's preference is not clear, ask how they would like to be addressed.
  • Patients from other language or cultural backgrounds may be less likely to ask questions and more likely to answer questions through narrative than with direct responses. Facilitate patient-centered communication by asking open-ended questions whenever possible.
  • Avoid questions that can be answered with "yes" or "no." Research indicates that when patients, regardless of cultural background, are asked, "Do you understand," many will answer, "yes" even when they really do not understand. This tends to be more common in teens and older patients.
  • Steer the patient back to the topic by asking a question that clearly demonstrates that you are listening. Some patients can tell you more about their health through story telling than by answering direct questions.

Tips for identifying and addressing health literacy issues

Health literacy is the ability of a person to obtain, interpret, and understand basic health information and services. This includes the ability to understand written instructions on prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms, and the ability to negotiate complex health care systems.

Health literacy is not the same as the ability to read, and is not necessarily related to years of education. A person who functions adequately at home or work may have marginal or inadequate literacy in a health care environment. Low health literacy can prevent people from understanding basic health care services. This section provides tips to identify barriers to health literacy, and address low health literacy issues.

Barriers to Health Literacy

  • The ability to read and comprehend health information is impacted by a range of factors including age, socioeconomic background, education and culture.
    Example: All seniors may not have had the same educational opportunities afforded to them.
  • A patient's culture and life experience may have an effect on their health literacy.
    Example: A patient's background culture may stress oral, not written, communication styles.
  • An accent, or a lack of an accent, can be misread as an indicator of a person's ability to read English.
    Example: A patient who has learned to speak English with very little accent may not be able to read instructions on a prescription bottle.
  • Different family dynamics can play a role in how a patient receives and processes information.
  • In some cultures it is inappropriate for people to discuss certain body parts or functions, leaving some with a very poor vocabulary for discussing health issues.
  • In adults, reading skills in a second language may take 6–12 years to develop.

Possible Signs of Low Health Literacy

  • Your patients' may frequently say:
    • I forgot my glasses.
    • My eyes are tired.
    • I'll take this home for my family to read.
    • What does this say? I don't understand this.
  • Your patients' behavior may include:
    • Not getting their prescriptions filled, or not taking their medications as prescribed.
    • Consistently arriving late to appointments.
    • Returning forms without completing them.
    • Requiring several calls between appointments to clarify instructions.

Tips for Dealing with Low Health Literacy

  • Use simple words and avoid jargon.
  • Never use acronyms.
  • Avoid technical language (if possible).
  • Repeat important information; a patient's logic may be different from yours.
  • Ask patients to repeat back to you important information.
  • Ask open-ended questions.
  • Use medically trained interpreters familiar with cultural nuances.
  • Give information in small chunks.
  • Articulate words.
  • "Read" written instructions out loud.
  • Speak slowly; don't shout.
  • Use body language to support what you are saying.
  • Draw pictures, use posters, models or physical demonstrations.
  • Use video and audio media as an alternative to written communications.

Gender roles in health care

  • Gender roles vary and change as a person ages (e.g. women may have much more freedom to openly discuss sexual issues as they age).
  • A patient may not be permitted to visit providers of the opposite sex unaccompanied (i.e. a woman's husband or mother-in-law will accompany her to an appointment with a male provider).
  • Some cultures prohibit the use of sexual terms in front of someone of the opposite sex or an older person.
  • Several family members may accompany an older patient to a medical appointment as a sign of respect and family support.
  • Before entering the exam room, tell the patient and their companion exactly what the examination will include and what needs to be discussed.
  • Offer the option of calling the companion(s) back into the exam room immediately following the physical exam.
  • As you invite the companion or guardian to leave the exam room, have a health professional of the same gender as the patient standing by and re-assure the companion or guardian that the person will be in the room at all times.
  • Use same sex non-family members as interpreters.

Interview guide for clinical staff with diversity awareness

The following sets of questions are meant to help you determine whether a job candidate will be sensitive to the cultural and linguistic needs of your patient population. By integrating some or all of these questions into your interview process, you will be more likely to hire staff who will help you create an office/clinic atmosphere of openness, affirmation, and trust between patients and staff.

Remember that bias and discrimination can be obvious and flagrant or small and subtle. Hiring practices should reflect this understanding.

Interview Questions

Q. What experience do you have in working with people of diverse backgrounds, cultures and ethnicities? The experiences can be in or out of a health care environment.

  • The interviewee should demonstrate understanding and willingness to serve diverse communities. Any experience, whether professional or volunteer, is valuable.

Q: Please share any particular challenges or successes you have experienced in working with people from diverse backgrounds.

  • You will want to get a sense that the interviewee has an appreciation for working with people from diverse backgrounds and understands the accompanying complexities and needs in an office setting.

Q. In the health care field we come across patients of different ages, language preference, sexual orientation, religions, cultures, genders, immigration status, etc., all with different needs. What skills from your past customer service or community/healthcare work do you think are relevant to this job?

  • This question should allow a better understanding of the interviewee's approach to customer service across the spectrum of diversity, their previous experience, and if their skills are transferable to the position in question. Look for examples that demonstrate an understanding of varying needs. Answers should demonstrate listening and clear communication skills.

Q. What would you do to make all patients feel respected? For example, some Medicaid or Medicare recipients may be concerned about receiving substandard care because they lack private insurance.

  • The answer should demonstrate an understanding of the behaviors that facilitate respect and the type of prejudices and bias that can result in substandard service and care.

Cultural background: information on special topics

This section provides information on how to become familiar with diverse cultural backgrounds. Information include basic understanding of (1) the use of alternative or herbal medications, (2) weight perception, (3) infant health traditions, (4) substance abuse, (5) physical abuse, (5) communication tips to the Elderly.

Use of Alternative or Herbal Medications

  • People who have lived in poverty, or who come from places where medical treatment is difficult to get, will often come to the doctor only after trying many traditional or home treatments. Usually patients are very willing to share what has been used if asked in an accepting, non- judgmental way. This information is important for the accuracy of the clinical assessment.
  • Many of these treatments are effective for treating the symptoms of illnesses. However, some patients may not be aware of the difference between treating symptoms and treating the disease.
  • Some treatments and "medicines" that are considered "folk" medicine or "herbal" medications in the United States are part of standard medical care in other countries. Asking about the use of medicines that are "hard to find" or that are purchased "at special stores" may get you a more accurate understanding of what people are using than asking about "alternative," "traditional," "folk," or "herbal" medicine.

Pregnancy and Breastfeeding

  • Preferred and acceptable ages for a first pregnancy vary from culture to culture. Latinos are more accepting of teen pregnancy; in fact it is quite common in many of the countries of origin. Russians tend to prefer to have children when they are older. It is important to understand the cultural context of any particular pregnancy. Determine the level of social support for the pregnant women, which may not be a function of age.
  • Acceptance of pregnancy outside of marriage also varies from culture to culture and from family to family. In many Asian cultures there is often a profound stigma associated with pregnancy outside of marriage. However, it is important to avoid making assumptions about how welcome any pregnancy may be.
  • Some Vietnamese and Latino women believe that colostrum is not good for a baby. An explanation from the doctor about why the milk changes can be the best tool to counter any negative traditional beliefs.
  • The belief that breastfeeding works as a form of birth control is very strongly held by many new immigrants. It is important to explain to them that breastfeeding does not work as well for birth control if the mother gets plenty of good food, as they are more able to do here than in other parts of the world.

Weight

  • In many poor countries, and among people who come from these countries, "chubby" children are viewed as healthy children because historically they have been better able to survive childhood diseases. Remind parents that sanitary conditions and medical treatment here protect children better than extra weight.
  • In many of the countries that immigrants come from, weight is seen as a sign of wealth and prosperity. It has the same cultural value as extreme thinness has in our culture – treat it as a cultural as well as a medical issue for better success.

Infant Health

  • It is very important to avoid making too many positive comments about a baby's general health. Among traditional Hmong, saying a baby is "pretty" or "cute" may be seen as a threat because of fears that spirits will be attracted to the child and take it away.
  • Some traditional Latinos will avoid praise to avoid attracting the "evil eye."
  • Some Vietnamese consider profuse praise as mockery.
  • It is often better to focus on the quality of the mother's care – "the baby looks like you take good care of him."
  • Talking about a new baby is an excellent time to introduce the idea that preventive medicine should be a regular part of the new child's experience. Well-baby visits may be an entirely new concept to some new mothers from other countries. Protective immunizations are often the most accepted form of preventive medicine. It may be helpful to explain well-baby visits and check-ups as a kind of extension of the immunization process.

Substance Abuse

  • When asking question regarding issues of substance (or physical) abuse, concerns about family honor and privacy may come into play. For example, in Vietnamese and Chinese cultures, family loyalty, hierarchy, and filial piety are of the utmost importance and may therefore have a direct effect on how a patient responds to questioning, especially if family members are in the same room. Separating family members, even if there is some resistance to the idea, may be the only way to accurately assess some of these problems.
  • Gender roles are often expressed in the use or avoidance of many substances, especially alcohol and cigarettes. When discussing and treating these issues, the social component of the abuse needs to be considered in the context of the patient's culture.

Physical Abuse

  • Ideas about acceptable forms of discipline vary from culture to culture. In particular, various forms of corporal punishment are accepted in many places. Emphasis must be placed on what is acceptable here, and what may cause physical harm.
  • Women may have been raised with different standards of personal control and autonomy than we expect in the United States. They may be accepting physical abuse not because of feelings of low self-esteem, but because it is socially accepted among their peers, or because they have nobody they can go to with their concerns. It is important to treat these cases as social rather than psychological problems.
  • Immigrants learn quickly that abuse is reported and will lead to intervention by police and social workers. Even victims may not trust doctors, social workers, or police. It may take time and repeated visits to win the trust of patients. Remind patients that they do not have to answer questions (silence may tell you more than misleading answers). Using depersonalized conversational methods will increase success in reaching reluctant patients.
  • Families may have members with conflicting values and rules for acceptable behavior that may result in conflicting reports about suspected physical abuse. This does not necessarily mean that anyone is being deceptive, just seeing things differently. This may cause special difficulties for teens who may have adopted new cultural values common to Western society, but must live in families that have different standards and behaviors.
  • Behavioral indicators of abuse are different in different cultures. Many people are not very emotionally and physically expressive of physical and mental pain. Learn about the cultural norms of your patient populations to avoid overlooking or misinterpreting unknown signs of trauma.
  • Do not confuse physical evidence of traditional treatments with physical abuse. Acceptable traditional treatments, such as coin rubbing or cupping, may leave marks on the skin, which look like physical abuse. Always consider this possibility if you know the family uses traditional home remedies.
  • Alcohol is considered part of the meal in many societies, and should be discussed together with eating and other dietary issues.

Communicating with the Elderly

  • Always address older patients using formal terms of address unless you are directly told that you may use personal names. Also remind staff that they should do the same.
  • Stay aware of how the physical setting may be affecting the patient. Background noise, glaring or reflecting light, and small print forms are examples of things that may interfere with communication. The patients may not say anything, or even be aware that something physical is interfering with their understanding.
  • Stay aware that many people believe that giving a patient a terminal prognosis is unlucky or will bring death sooner and families may not want the patient to know exactly what is expected to happen. If the family has strong beliefs along these lines, the patient probably shares them. Follow ethical and legal requirements, but stay cognizant of the patient's cultural perspective. Offer the opportunity to learn the truth, at whatever level of detail desired by the patient.
  • It is important to explain the specific needs for having an advance directive before talking about the treatment choices and instructions. This will help alleviate concerns that an advance directive is for the benefit of the medical staff rather than the patient.
  • Elderly, low-literacy patients may be very skilled at disguising their lack of reading skills and may feel stigmatized by their inability to read. If you suspect this is the case you should not draw attention to this issue but seek out other methods of communication.