plan that incorporates their concerns and perspectives. Using the explanatory model requires a culturally appropriate communication style and active listening skills.
Listening and Attending
Active listening is a primary tool through which anthropologists learn about the perspec- tives of other cultures; it involves attention to the speakers and an effort to place what they say in the broader context of their life. To be an effective listener, one has to refrain from judgment, using cultural relativism to understand communications in the context—
personal, social, and cultural—of the communicator. In provider-client relations, active listening can occur only with the acquisition of the patient’s perspective. Cultural compe- tence requires active listening: an effort to grasp the meaning of the range of messages and feelings communicated by others. Physical attending uses the body to enhance receptivity to communications and to show others that one is focusing attention on them. This requires a knowledge of social interaction rules of the culture, including appropriate social distance and personal space, touching, culturally appropriate eye contact, and other social dynamics.
See Self-Assessment 3.4. Group Exercise at the end of this chapter, which illustrates the consequences of different styles of relating.
Behavioral and Social Relations
Intercultural effectiveness requires adopting a variety of social interaction rules that involve behavioral and nonverbal communication forms such as gestures, gaze, and pos- tures; emotional communication rules and patterns; space and touch rules (proxemics and kinesics); and patterns of social reasoning. The list shown in the sidebar (“Interpersonal Differences in Social Interaction Rules”) illustrates some of these differences. These dif- ferences are key to acquiring cultural competence because this competence requires developing appropriate social relationships. These culturally shaped dynamics of interac- tion are important in getting patients to agree to implement their treatment plans. The changes in perspective necessary for incorporating cultural competence into physicians’
clinical behaviors are inhibited by the biomedical belief that the profession naturally selects for people with interpersonal sensitivity. This is manifested in the belief that cul- tural sensitivity is represented in concepts such as bedside manner, good will, and com- passion (Press, 1982). The traditional white upper-middle-class cultural background of physicians contributes to their lack of awareness of how their characteristics differ from the populations they serve. Their perceptions from their upper-middle-class views of family life, social behavior, norms, and worldviews are distant from the realities of most Americans; this produces problems in doctor-patient consultation that are worsened by the relational and communication styles of the biomedical culture. This is changing with the fairly recent large infl ux of women, ethnic minorities, and foreign-born people into the rolls of physicians in America.
Cultural Communication Style
Appropriate communication with others involves stylistic and nonverbal cultural norms regarding social and informational priorities and aspects of interaction involving posture, spacing, gestures, physical and eye contact, interpersonal space, tone of voice, and timing.
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Health care providers need a heightened awareness of how their culturally and profession- ally based relational patterns affect patients’ perceptions and, consequently, health care. For instance, a direct communication style is offensive in cultures where social pleasantries and indirect reference to embarrassing situations are preferred. For many cultures, a lack of a personal relationship may impede effective clinical consultation. Biomedical interpersonal relations styles exemplify the European American impersonal task orientation.
Major cultural differences in communication priorities regarding how messages are delivered contrast technical approaches with relational approaches. Technical styles empha- size information and speaking directly, openly, and honestly. Relational styles are concerned with harmony and respect, avoiding offense to dignity and reputation or disturbing others’
harmony. In relational cultures, communication serves the need to maintain appropriate human relationships. Verbal communication is frequently suppressed and emphasis placed on maintaining socially appropriate moods, emotions, and relations. Communication takes place through nonverbal mediums (such as gesture and facial expressions) that carry the bulk of information. European American preferences for direct, verbally explicit messages may lead them to miss signifi cant communication.
This biomedical focus on information relevant for diagnoses, a “doctor-centered” rather than “patient-centered” approach, contributes to patients’ dissatisfaction. The biomedical doctor-centered interactional style is authoritarian, dictatorial, self-protective, and largely unskilled in counseling and communication techniques and is intended to control the inter- action with the patient. Implementation of most treatment depends on cooperative relations between provider and client. More effective communication can be achieved by adapting
SIDEBAR 3.1.
Interpersonal Differences in Social Interaction RulesLanguage dialects and jargon Contextual communication Paralinguistic cues Metalinguistic messages Communication style Relational styles Greetings and formalities Formality of relations
Family roles Gender roles
Expressions of respect Personal relations Presentation of self (“face”) Self-disclosure Emotional communication Proxemics (space) Kinesics (touch) Facial expressions
Eye contact Gestures and signs
Body posture Time orientation
Learning styles Authority relations
Decision-making processes Persuasion or argument styles Negotiation approaches Confl ict management Power distance Work values and attitudes
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different styles; providers can reduce their image as uncaring, insensitive, and arrogant by adopting client-sensitive styles of communication and using nonverbal mediums to assure and encourage patients. Most cultures’ rules of communication and social behavior affect medical communication because questioning authority fi gures is considered inappropriate.
Consequently, providers need to encourage clients to ask questions (Press, 1982).