Cross-cultural communication: Tools for working with families and children

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CONTEXT

Canada has a long-standing history of immigration and ethnic diversity [1]. In addition to a diverse range of Indigenous populations, there are more than 200 distinct ethnic origins represented in Canada and more than 50,000 newcomer children and youth arrive every year [2]–[4]. Culture—which may include language, values, beliefs and behaviours in any community—can also shape interactions between families and health care providers.

Physicians need to be aware of the personal values they bring to the patient–provider relationship as well as how a patient’s culture may be impacting their health or management of an illness [5]. Ineffective cross-cultural communication can affect patient outcomes adversely through misdiagnosis, repeated hospital admissions or lower treatment adherence [5]. By applying the LEARN model to three patient vignettes, this practice point provides a practical framework for patient interactions [6].

WHAT IS CULTURAL COMPETENCE?

Cultural competence includes providing effective health care across diverse cultures by working collaboratively and communicating effectively [5]. Physicians who are aware of their own and their patients’ cultural backgrounds, along with the values that are often implicit in current medical models, are better able to achieve mutual understanding within the patient encounter and to focus on culturally appropriate health care interventions [5]–[7].

THE LEARN MODEL FOR CROSS-CULTURAL COMMUNICATION

The LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model is a framework for cross-cultural communication that helps build mutual understanding and enhance patient care [6].

Listen: Assess each patient’s understanding of their health condition, its causes and potential treatments. Elicit expectations for the encounter, and bring an attitude of curiosity and humility to promote trust and understanding.

Explain: Convey your own perceptions of the health condition, keeping in mind that patients may understand health or illness differently, based on culture or ethnic background.

Acknowledge: Be respectful when discussing the differences between their views and your own. Point out areas of agreement as well as difference, and try to determine whether disparate belief systems may lead to a therapeutic dilemma.

Recommend: Develop and propose a treatment plan to the patient and their family.

Negotiate: Reach an agreement on the treatment plan in partnership with the patient and family, incorporating culturally relevant approaches that fit with the patient’s perceptions of health and healing.

APPLYING THE LEARN MODEL IN CROSS-CULTURAL SITUATIONS

The role of silence and shared meanings

You are a paediatrician working in an outpatient clinic in an urban centre. Myna is a 10-year-old Inuit girl from a northern Inuit community. You are seeing her for symptoms of depression and oppositional behaviour. You ask Myna’s mother about these behaviours and find that she is not sharing much information. You ask Myna, “How things are going at home?” Your question is greeted by silence. Her mother looks away.

Knowing how to interpret and respond to silences is a skill that requires understanding of the role of silence in an interaction [8]. Silence may stem from discomfort with a question, uncertainty about its meaning or apprehension about the reasons for the question. Also, in Inuit and other cultures, facial expressions may be used to respond to questions. It is essential that the health care provider not jump in to fill a silence [9]. Paying attention to nonverbal cues can help to bridge perceived power differentials that sometimes hinder development of the provider–patient relationship [5]. Establishing trust and mutual understanding is key to empowering families and optimizing patient care [10].

Some common challenges can arise when negotiating health care plans with caregivers, including: parental absence from hospital, limited opportunities for dialogue, and the involvement of community members apart from the patient’s family in medical decision-making. Some cultures encourage broader decision-making authority beyond the nuclear family in medical decision-making. In collectivist cultures, it may be important to involve members of the community when devising the treatment plan.

Back to our case…

Applying the LEARN model, you start by assessing Myna’s family’s expectations for this visit. Inquire about the family’s background, their concerns, and their understanding of the purpose of the visit. Explain why specific questions are being asked and how the answers help. This approach may alleviate family stress and concern. Based on information obtained in the history, recommend further evaluation and/or treatment, involving family and other community members through a culturally appropriate negotiation.

NONVERBAL COMMUNICATION AND AVOIDING GENERALIZATION

You are volunteering with a medical organization overseas, in India. You see a 9-month-old boy, Ayaan, who has severe iron deficiency anemia and is being breastfed, with no solid food intake. You advise his mother on the importance of iron supplements and of transitioning to iron-rich solid foods. As you counsel, she lowers her gaze and shakes her head. You assume that Ayaan’s mother is worried about the side effects of a foreign medication and begin to reassure her. She responds that she will try to follow your directions, but still averts her gaze.

Communication styles differ greatly among cultures. Traditionally, Western cultures use direct (low-context) forms of communication, which do not rely heavily on background, nonverbal cues or context to convey meaning [11]. Many cultures rely on indirect (high-context) forms of communication, in which meanings are conveyed but not explicit, using body language, tone of voice and other cues [12]. For such interactions, diplomacy and tact are highly valued, and perceived differences in status can interfere easily with frank communication. Being aware of such diverse forms of communication can facilitate shared understanding.

While culture may be an important influence on communication styles and health care beliefs, broad diversity can also exist within cultural groups. It is essential to try to understand each individual patient’s beliefs and to avoid cultural generalizations. In some situations, issues arise from personal values or familial or environmental factors [12].

Back to our case…

Realizing that something is wrong, you begin to apply the LEARN model. You ask the mother whether she has concerns about the anemia or iron supplements. You also reassure her that it is okay for her to express concern or disagree. She divulges that her concern lies with your recommendations for solid food, rather than iron supplements. She explains that her son has no teeth yet and she is worried about him choking. You acknowledge her concern and explain the reason for transitioning to solid foods, including Ayaan’s need to learn to mouth first foods safely. You discuss some common family foods eaten in her home and agree on introducing a few iron-rich soft mashed foods and cereals that she is comfortable trying, along with an iron supplement.

WORKING WITH INTERPRETERS

You are seeing Waseem, a 2-year-old boy who has recently arrived as a refugee from Iraq. His parents speak mainly Arabic. Waseem’s eldest brother, Fariz, a 13-year-old, agrees to translate for you. Using the LEARN model, you start by asking open-ended questions about the family’s migration history and their prior and current living conditions. Fariz tells you most of the story without asking his parents questions. When you ask about challenges with acculturation, Fariz replies that the family is “doing fine.” You later learn that Waseem says only a few words and is not yet walking. You wonder how you might gain a clearer understanding of the issues contributing to Waseem’s developmental delay.

Providing care in a language that a family does not speak well is a known risk factor for negative effects on health outcomes [13]. Cultural interpreters are trained to help newcomer families navigate medical conversations. They can provide clear, precise translations that include nuances in meaning and nonverbal cues, while being careful not to ‘lead’ the conversation.

Using a family member or friend (particularly a child) to translate, should be avoided. They are more likely to edit or reinterpret information to avoid conflict or protect family members [14]. The patient and family may also be less forthcoming if community members are present to translate. It is recommended practice to use a cultural interpreter or language service by telephone.

Translation applications, such as ‘Google Translate’ can help with simple questions but are unreliable aids for history-taking. They cannot communicate the nuances of language or culture that are essential for effective medical care. See Box 1 for useful tips on working with interpreters, and the CPS Caring for Kids New to Canada website (www.kidsnewtocanada.ca) for more information on this topic [14].

Box 1. Tips for working with interpreters Familiarize yourself with professional interpreter services in your area. Speak with the interpreter before each appointment to clarify expectations, such as whether to directly translate all communication among family members during the visit. Use the interpreter to arrange the next appointment and confirm transportation arrangements. Arrange for triangular seating, so everyone present can see nonverbal cues. Introduce everyone who is present. Ask who is the most appropriate person to address your questions to. Look at family members as you speak, and try to speak directly with them. Debrief with interpreter afterward to ensure communications were fully translated.

Providing written materials to newcomer families whose command of English or French may be limited can be confusing. Whenever possible, use materials that are translated into the languages spoken by your patient population [15]. Asking families how they prefer to receive information can also mitigate concerns around literacy.

Appropriate cultural interpretation takes extra time, as does exploring sensitive issues, such as acculturation or a family’s understanding of health and illness. Booking longer visits and repeat visits with the same health care provider—as well as (ideally) the same interpreter—can help with developing a mutual understanding of health issues and mutually acceptable management plans.

PRACTICE POINTS TO REMEMBER

• Try to identify influential cultural differences in yourself and your patients. Be self-aware of biases and values that you may be bringing to medical encounters.
• Use a trained interpreter rather than a family member to translate, when needed.
• Build awareness of differences in communication style (e.g., verbal and nonverbal) that may influence care.
• Consider the role of silences in each patient encounter. They may represent discomfort with a topic or uncertainty about a question being asked. Paying attention to nonverbal cues can help determine whether a differential power relationship is hindering communication.
• Building trust and understanding helps empower families and optimize patient care.
• Booking longer and repeat visits with the same interpreter can forge trust and understanding around child and youth health issues and management plans.
• Devise a tailored treatment plan that involves the patient’s immediate family, extended family or other community members, as appropriate.
• Recognize that a ‘high-context’ communication style may be a family’s cultural norm and stay attuned to tone, body language and other nonverbal cues.
• Recognize that diversity exists within ethnic and cultural groups as much as between groups, and avoid generalizing or stereotyping cross-cultural encounters.
• Assess the literacy levels of patients or families and adjust the use of written materials accordingly.

Acknowledgements

This practice point was reviewed by the Community Paediatrics, Fetus and Newborn, and First Nations, Inuit and Métis Health Committees of the Canadian Paediatric Society.

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CPS GLOBAL CHILD AND YOUTH HEALTH SECTION EXECUTIVE

Members: Dominic Allain MD (President), Tobey Audcent MD (past member), Robert Bortolussi MD (past President), Mahli Brindamour MD (President-Elect), Andrea Evans MD (Member at Large), Tehseen Ladha MD (past Member at Large), Jennifer Turnbull MD (Secretary-Treasurer), Ashley Vandermorris MD (Member at Large)

Liaisons: Sara Citron MD, Alyson Holland MD (CPS Residents Section)

Principal authors: Tehseen Ladha MD, Mohammad Zubairi MD, Andrea Hunter MD, Tobey Audcent MD, Julie Johnstone MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.