December 16, 2012

Cross-cultural Communication: Know Your Audience

by Mamta Karani, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center
In 2008, I had the life-changing opportunity to volunteer at a medical mission camp in Bidada, Kutchh, India. The Kutchhi people lived in a rural, desert area and travelled over 100 kilometers to get medical care at the Bidada Sarvodaya Trust Hospital. Health care practitioners and volunteers flew in from all over the world to provide care for these patients. For some volunteers, this was their fifth trip. For others, like me, this was our first.

During our trip, we had multiple opportunities to educate and provide medical services to the Kutchhi people, a population with a different language and culture than ours. This experience sparked my interest in teaching because I was assigned to teach these patients about how to properly use the medicines that we were dispensing. Patients would quietly wait in line while I read a piece of paper and filled medications in a little plastic bag. I learned how to say “take it once a day” in Kutchhi and give other simple instructions on the proper administration of the medications. However when patients were prescribed over five medications to take on a daily basis, I really had to reassess my methods to make sure they understood what I was saying.  In an attempt to help patients remember, I learned how to write the directions.  After I’d given written instructions, I would ask the patient to teach me regarding the proper administration. However, when checking the patient’s understanding of the regimen, I'd often get a blank stare. I had explained the directions and wrote them out, why hadn’t the patient understood?  I learned the language, collaborated with the local people, and provide both verbal and written instructions.  What went wrong?
When addressing cultural differences and learning how best to effectively communicate, knowledge is key and understanding the audience is vital.1  As in any teaching plan, we need to:
  • prepare by performing strong background research
  • actively teach, learn to adapt, keep an open mind, and be patient
  • evaluate and make changes when necessary
To effectively address cultural differences, what research is required? First, self-knowledge and self-awareness are needed.  Before we can try to understand someone else’s culture, we have to be aware of our own. Next we should learn about our patients through observation and collaborating with a local team member. Some questions to consider in your research include:
What is the preferred style of the communication for the audience? Are the communication preferences similar or different from our own? In the United States we tend to be low-context communicators — meaning we speak directly. In some cultures, people prefer high-context communication which involves speaking in conceptual terms to get a point across. In general, high-context communicators find nonverbal messages and gestures equally if not more important than what’s verbally stated.  Building a good relationship contributes to the effectiveness of communication over time; and indirect routes and creative thinking are important. In the Navajo culture, for example, if I told a patient that his/her poor blood sugar control might one day lead to a limb amputation if he/she doesn’t take the prescribed medications, the patient may feel insulted and disrespected.  Rather, if I created a story of how a person with high blood sugar required an amputation after not receiving treatment, the patient would be more motivated to learn and intuit the importance of adherence with treatment.
Does the audience believe in individualism or in communitarianism? Do members feel like they each are entitled to make their own decisions or are decisions driven by society and/or family.  Understanding this concept is vital to gaining the respect and trust from the individual and community.
What is the audience’s baseline knowledge?  Are they well educated regarding health issues?  Have they ever attended school?  What is their level of literacy? Can they read? Learning the answers to these questions up front is really important to making certain the audience can understand our take home messages.  As I learned, this was one step I neglected to research.

After having the baseline research, how can we overcome language and cultural barriers? Intercultural trainer, Kate Berardo, states we should:2
  1. Speak slowly and clearly.  Even if the patient speaks some English, its hard to digest complex instructions.   If using a translator, simplify your statements and questions — discuss one issue at a time.
  2. Ask for clarification. If someone asks questions, assess if you have answered the question and do not make assumptions.
  3. Frequently check for understanding. Engage the learner by asking open-ended questions to see if your message is coming across as intended.
  4. Avoid idioms. Idiomatic phrases and slang terms that are well understood in one culture, may not translate or make sense to someone in another culture.  Avoid them. Provide examples of things they might be familiar instead. For example, when educating someone about diet, talk about foods that are commonly eaten in that culture. Teaching vegetarians to increase their protein intake by eating meat would be insensitive. Rather teaching vegetarians to increase their protein source by consuming more legumes and beans would be more effective.
  5. Be careful of medical jargon. Use simple terms.  Although as practitioners we may be comfortable talking about hypertension, diabetes, condoms, etc, using these terms may confuse or even insult some patients. Consider using simple terms like high blood pressure, high blood sugar, and safe sex practices to get your message across.
  6. Be patient and attentive. They are trying to understand us as much as we are them.
In my case, I could have prepared better by asking the organizers more information about the patients and their literacy levels.  Fortunately, I checked for understanding and asked the patient to teach me about the medications.  In doing so, I realized that many patients were not able to read.  I was able to make changes in how I communicated to get the point across.  I drew a sun and a moon and explained that the sun meant morning and the moon meant evening.  It was like a light bulb turning on and the patient’s eyes gleamed with happiness. When asked again, the patient was able to explain how to appropriately take the medications.  I now realized the importance of doing an analysis and truly understanding your audience before delivering instruction. Without preparation before and evaluation after, we can’t overcome cultural barriers and educate patients.  But, the same is true for any teaching assignment.
1.   Cross-cultural communication strategies.  International Online Training Program on Intractable Conflict.   Conflict Research Consortium, University of Colorado.  Accessed on: December 15, 2012
2.  Berardo K.  10 Strategies for Overcoming Language Barriers.  The Culturosity Group, LLC.  Accessed on:  December 15, 2012
3.  LeBaron M.  Communication Tools for Understanding Cultural Differences.  Beyond Intractability.  Accessed on:  December 15, 2012
4.  HubPages.  Identifying and Overcomign Communcation Barriers.  Accessed on:  December 15, 2012

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