Successful communication between healthcare providers and their patients from different cultural backgrounds depends on developing awareness of the normative cultural values of patients and how these differ from the cultural values of most western medical professionals. When cultural differences are poorly understood, a variety of adverse clinical outcomes may result: reduced participation in preventive screenings, delayed immunizations, inaccurate histories, use of harmful remedies, non-compliance, and decreased satisfaction with care.
In this newsletter article we will take a look at Asian cultures. We are intentionally taking a very general approach here, keeping in mind that there are three general ethnicities within the “Asian” community: (1) Pacific Islanders, mostly Hawaiians, Samoans, and Guamanians; (2) Southeast Asians, largely comprised of Indochinese from Vietnam, Thailand, Cambodia, Laos, and Burmese and Philippinos; and (3) East Asians, including Chinese, Japanese, and Korean (Trueba, Cheng, & Ima 1993). Each of these communities differs in socio-cultural traits, as do the subgroups within each. That said, people belonging to “Asian” cultures are accustomed to distinct communication norms that are significantly different from those of native born Americans and other immigrants. To better understand how we will use culture-based generalizations to learn about Asian cultures in this article, please review our newsletter contrasting culture-based generalizations and stereotypes.
Collectivist Cultures With Strong Family Values
Keep in mind that we are purposefully generalizing about cultural values here, and that individuals may deviate from these cultural norms for many reasons. The degree to which US cultural values have been adopted has a dramatic impact on whether these values and any associated behaviors apply to a given individual.
Asians tend to be highly group-oriented people who place a strong emphasis on family connection as the major source of identity and protection against the hardships of life. The family model is an extended one including immediate family and relatives, and loyalty to the family is expected. Thus, independent behavior that may disrupt the harmony of the family is highly discouraged. One must never bring dishonor or disgrace to one’s self or the family. In the traditional Asian family, parents define the law and the children are expected to abide by their requests and demands; filial piety or respect for one’s parents and elders is critically important. In the most traditional of families this manifests in rules of conduct such as: only speak when spoken to, speak only if one has something important to say. Self-control is expected and individuals should demonstrate inner stamina and strength to tolerate crisis. In healthcare settings, Asians may be unwilling to acknowledge strong emotion, grief, or pain due to their family and cultural values. Western medical professionals often find the stoic demeanors of Asian people difficult to interpret.
Asian People are High-Context Communicators
An intentional lack of directness in conversation is favored by people from many Asian cultures because preserving harmony between people is often more important than getting at the exact “truth”. Asian cultures are typically high context cultures in which gesture, body language, eye contact, pitch, intonation, word stress, and the use of silence are as important as the actual words being spoken in conversation. Asians are typically polite in social encounters whereas Americans, being very low context communicators, are comfortable with very direct questions and answers and often seem abrupt to people from high context cultures. This is important to keep in mind when communicating with Asian people, especially those who are relatively new to the United States. Asian people may be “tuned” to the moods of the others during conversation, and culturally they expect others to be similarly sensitive. Asians patients may expect doctors to sort out their concerns, confusion, and hesitance within the context of polite conversation, while western doctors mistake head-nodding, smiles, and verbal assent as clear indication of understanding and agreement when the opposite is in fact true. Particularly enigmatic to Americans is the Asian tendency to smile when confused or embarrassed. Smiling does not necessarily indicate pleasure or humor in all cultures. When dealing with Asian children in particular, it is important to make careful observations and ask clarifying questions.
Asian Cultures and Concepts of Time.
Some Asian cultures have a more relaxed attitude towards time than is typical of Americans. This is in part due to a polychronic time framework which means that different social interactions can occur at the same time. This is very different form the Western monochronic time which demands a linear scheduling of events one at a time. Some Asian parents may arrive late for appointments without offering an apology because they are simply not aware of the linear scheduling of doctors’ time. Similarly, some Asians, such as the Hmong, don’t believe in pushing hard to get things done and being hasty as a result. Rather, they believe that events run their own course. Concepts of time can vary greatly between Asian cultures. The Japanese tend to be highly punctual. The Vietnamese use what translates roughly as “rubber time” – if you expect people to come to an appointment or meeting at 8:00 am, you should invite them for 7:30 am. In any case, attitudes towards time vary a great deal person to person, and cultural differences with regards to time serve only as a touch point of consideration when dealing with patients/families.
Asian Cultures and the Acceptance of Uncertainty
Because human beings display a variety of cultural attitudes about controlling external forces, attitudes about time, destiny and fate can vary dramatically different between people. In US American culture, we struggle with simply accepting things as they are which creates high levels of stress and anxiety in our lives. Our inner urge to be busy is directly related to our need to control life’s uncertainty and feelings of powerlessness toward external forces. We focus on the individual as the locus of control in decision making and put little faith in fate or karma. Many Asian people, by comparison, have a strong belief that uncertainty is inherent in life and each day is taken as it comes. This mindset manifests in health beliefs and behaviors in significant ways. A fatalistic attitude about sickness may make Asian patients/families seem resigned to their situation. Talking in terms of beating a disease will not resonate with those who embrace an attitude of acceptance. US healthcare professionals will benefit from keeping this cultural difference in mind when dealing with Asian patients/families. Acceptance of what life brings does not indicate an unwillingness to cooperate with doctors and treatment, but rather a belief that fighting illness is a negative approach to healing.
Some Suggestions for Providers
Checking for understanding when communicating with Asian patients/families is critical. It is all too easy to misinterpret a common gesture as agreement or understanding when the patient is actually confused or even resistant to a diagnosis/treatment. Avoiding the use of yes/no questions is very important. (Click here for Tip#3 in previous newsletter article) Keep in mind that for cultural reasons Asian patients/families will often be reluctant to complain or ask for clarification. Also, Asian families may value group consensus on healthcare matters much more so than American families do. Naturally, this can delay important medical decisions because extended family consultation can be time consuming. However, building trust with Asian families often depends on showing awareness of how important reaching consensus is among people from many non-American cultures.
The following suggestions for healthcare professionals may help avoid a communication breakdown with Asian patients and families: (Matsuda. 1989)
- Establish the professional’s role and assume authority.
- Check for understanding
- Be patient, and consider periods of silence opportunities for reflection on what has been said.
- Provide clear and full information, such as what is expected from each participant in the discussion.
- Be attentive to nonverbal cues.
- Address immediate needs and give concrete advice.
- Reach consensus by compromising.
The information provided here about Asian cultures is meant to assist clinicians by providing a general framework. No hard and fast rules about interacting with Asian patients/families are being offered because they would lead to stereotyping.
A cross-cultural mindset requires understanding one’s own health beliefs and behaviors first and then applying that baseline of understanding as a means of making effective comparisons across cultures. Clinicians can learn more about specific cultures by using published references, consulting colleagues from other ethnic groups, and speaking to interpreters and community members. Learning to ask patients questions in a culturally sensitive way is also a crucial tool for gaining knowledge.
Finally, individuals subscribe to group norms to varying degrees. Factors such as socio-economics, education, degree of acculturation and English proficiency have an enormous impact on an individual’s health beliefs and behaviors. So does religion. All these factors challenge one’s ability to understand and treat patients in cross-cultural settings, but meeting those challenges can be vital in reducing health disparities for Asian people in the U.S.