Australia is a culturally diverse nation. The 2016 census showed that almost 1 in 3 (29%) Australians, and ACT residents (28%), were born overseas [i]. Of the over 6 million Australians born overseas, nearly 1 in 5 (18%) of them were newly arrived in Australia, having arrived in the last four years [ii]. There are over 300 languages spoken in Australian homes, and more than 1 in 5 (21%) Australians speak a language other than English at home [i] . In 2016, nearly half (49%) of Australians had either been born overseas or one or both of their parents had been born overseas [i] .
This diversity makes clear communication in health care challenging, but vital. The way people understand, communicate and make decisions about health and wellbeing varies across cultural backgrounds. This can make clear communication challenging for consumers, health services and practitioners.
When health professionals and services are culturally responsive, they improve health outcomes, reduce health disparities and can assist marginalised communities to change health related values, beliefs and behaviours[iii] .
Culture and Health
We often take for granted the way we communicate with one another. However, the way we communicate is shaped by our culture. We tend to be unaware of our own biases, unconscious stereotypes and cultural assumptions.
Culture is a system of beliefs, values, rules and customs that is shared by a group and is used to interpret experiences and direct patterns of behaviour[iv].
Culture is fundamental in shaping an individual’s health-related values, beliefs, and behaviours.
Individuals can practice culture and conform to dominant cultural values and norms to different levels. It is important to explore with individual consumers and carers their beliefs, values, understandings about health and disease processes, expectations about health care and willingness to participate in shared decision making. This will influence the choices they make about healthcare.
Religion, culture, and ethnic customs can influence how patients:
- understand health concepts,
- identify symptoms,
- decide when to seek care,
- take care of their health, and
- make decisions related to their health.
Culturally responsive care
Understanding how individual health beliefs and cultural practices influence the way consumers receive medical information and advice can help ensure it is understood and acted on. Asking about religion, culture, and ethnic customs can engage patients and support effective communication, so that consumers and carers can participate in shared decision making.
Successful cross-cultural communication involves:
- Being aware of the influences that sociocultural factors have on patients, clinicians, and the clinical relationship
- Taking responsibility for understanding the cultural aspects of health and illness that affect patients
- Making clinical settings welcoming and accessible to patients of different cultures
- Recognising personal biases, which may be unconscious, against people of different cultures
- Demonstrating respect and tolerance for cultural differences
- Accepting responsibility to combat racism, classism, ageism, sexism, homophobia, and other kinds of biases and discrimination that occur in health care settings.
Sources of Miscommunication in Cross Cultural Communication
1) Assumption of similarities: This refers to our tendency to think that the way we behave and act is the universally accepted way to behave. We rarely consider the different cultural norms that could be guiding the behaviour or response of other people.
2) Language Contexts: Even speaking the same language can sometimes lead to misunderstanding as some words have different meanings in various contexts, countries or cultures. This is particularly an issue when common words have different meanings in different contexts. It can be challenging for someone for whom English is their second (or third, or fourth) language to understand the specific application of words in different contexts.
3) Nonverbal Misinterpretation: The way we dress, our body language, eye contact and gestures are also parts of communication where the meaning can vary between cultures. A simple gesture like nodding the head means “yes” in some cultures and “no” in others. Making eye contact can show respect in one culture, and disrespect in another.
4) Generalisations and Stereotypes:
A generalisation is a broad statement about something a group has in common. Stereotypes are qualities assigned to groups of people related to their race, nationality and sexual orientation. When you stereotype someone you assume that because they are from a certain background they must have certain qualities.
Cultural generalisations involve recognising that members of the same group often have similar cultural norms and characteristics. They are a hypothesis, or theory, about what we expect to encounter when we interact with a consumer from a certain culture. Generalisations are a necessary part of culturally responsive communication because they help us to anticipate and make sense of the information and interactions we experience in intercultural situations.
Cultural generalisations offer a starting point to establish culturally responsive communication while we find out more about individuals from other cultures. An example of a cultural generalisation would be “People from Country X tend to have an indirect style of communication.”
Generalisations become stereotypes when all members of a group are categorised as having the same characteristics. Stereotypes can be linked to any type of cultural group, such as nationality, religion, gender, race, or age. Stereotypes tend to be more negative than generalisations. They tend to be inflexible and resistant to new information. They can lead to prejudice and intentional or unintentional discrimination. Cultural stereotypes do not allow for individual difference and interfere with efforts to understand others.
In all cultural interactions, culturally responsive communication requires you to recognise that generalisations do not apply to everyone within a cultural group – and that the onus is on the health professional to ask questions and explore the cultural norms that may apply.
Reports and Guidelines
Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health, Australian Health Ministers’ Advisory Council, Council of Australian Governments Health Council.
Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds – Competency Standards Framework For Clinicians
January 2019, Migrant and Refugee Women’s Health Partnership.
Cultural competency in the delivery of health services for indigenous groups – Issues Paper, 2015, Australian Institute for Health and Welfare, Closing the Gap Clearinghouse.
Australian Commission on Safety and Quality in Health Care: Information on Improving Cultural Competency.
NSW Agency for Clinical Innovation: Information for clinicians on Culturally Responsive Practice
Australian Indigenous Health Info: This website provides information on how to appropriately engage with Aboriginal and Torres Strait Islander people and communities. The Culture Ways section provides information on the holistic nature of the Aboriginal and Torres Strait Islander concept of health, and covers a number of key concepts like traditional healing and medicine, Men’s Business and Women’s Business. The Working with Community section focuses on how non-Indigenous people can respectfully work with Aboriginal and Torres Strait Islander people and communities, and looks at various cross-cultural issues, cultural learning and respect, ethics, and best-practice.
Centre for Culture, Ethnicity & Health is a Victorian community organisation that aims to improve the health and well being of people from refugee and migrant backgrounds. They offer cultural responsiveness training and have a number of resources for health providers.
EthnoMed: An American website that aims to make information about culture, language, health, illness and community resources directly accessible to health care providers who see patients from different ethnic groups. EthnoMed was designed to be used in clinics by care providers in the few minutes before seeing a patient in clinic. For instance, before seeing a Cambodian patient with asthma, a provider might access the website to learn how the concept of asthma is translated and about common cultural and interpretive issues in the Cambodian community that might complicate asthma management.
Health Translations is an initiative of the Victorian Government. They provide health professionals and community members with reliable, accurate, and up to date health and wellbeing information in over 100 languages. The website provides a link to multilingual resources published by government departments, peak health bodies, hospitals, and community health and welfare organisations.
Migrant & Refugee Health Partnership is a multisectoral partnership that brings together health professionals and the community to address systemic barriers to health access for migrant and refugee communities. Their goal is to improve the health and wellbeing of migrant and refugee communities by consolidating cross-sector knowledge and expertise, fostering good policy and supporting culturally competent practice.
[i] Australian Bureau of Statistics 3412.0 Migration, Australia 2018-19. https://www.abs.gov.au/ausstats/[email protected]/Latestproducts/3412.0Main%20Features42018-19?opendocument&tabname=Summary&prodno=3412.0&issue=2018-19&num=&view=
[ii] https://www.abs.gov.au/ausstats/[email protected]/lookup/Media%20Release3
[iii] El-Amouri S, O’Neill S. Supporting cross-cultural communication and culturally competent care in the linguistically and culturally diverse hospital settings of UAE. Contemp Nurse. 2011;39(2):240–55. https://doi.org/10.5172/ conu.2011.240. 7.
Brown O, Ham-Baloyi WT, Rooyen DV, et al. Culturally competent patientprovider communication in the management of cancer: an integrative literature review. Glob Health Action. 2016;9(1):33208. https://doi.org/10. 3402/gha.v9.33208.
[iv] Betancourt JR, Green AR, Carrillo JE. Cross-cultural care and communication. 2018 https://www.uptodate.com/ contents/cross-cultural-care-and-communication