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Navigating the United States healthcare system can be a daunting task for native English speakers, but it can become a true barrier to medical care for Asian Americans with limited English proficiency.  According to the U.S. Census Bureau, 5.6% percent of the U.S. population identifies as Asian or Asian American, with the three largest ethnic groups being Chinese, Indian, and Filipino. There is a common misconception that Asian Americans are more acculturated to the American lifestyle than other ethnic minorities. This assumption may cause healthcare professionals to overlook the cultural barriers some Asian Americans may face in accessing health care.

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Successful communication hinges on an awareness of how the values of patients from other cultural backgrounds differ from those traditionally held in Western culture. However, the term Asian American encompasses a diversity of cultures. Asian Americans come from over 50 countries, speak over 100 different languages, and belong to diverse ethnic groups, each with their own cultural values and healthcare needs. With this in mind, the following points are meant to illuminate those core Western beliefs which interfere with effective communication with patients from Asian cultures. In general, the structure of the American medical profession assumes that individuals and their needs have priority over the needs of the group, that the literal meanings of words are more important than the context in which they are spoken, and that the uncertainties of life can be overcome with the right tools and the right attitude. Questioning these assumptions is a first step in meaningful cross-cultural communication.

A diagnosis impacts the whole family, not just the individual

Many Asian Americans place a strong emphasis on family ties and interpersonal relationships. The family becomes a source of identity and guidance during times of crisis, and individuals are often expected to demonstrate self-control during difficult situations. Individualistic, disruptive behavior is discouraged. Thus, some Asian Americans may not be willing to express negative emotions of grief or sadness within a healthcare setting, in order to preserve harmony, but this does not mean these feelings are absent. In addition, reluctance to seek care can originate in a desire not to negatively impact the family. Finally, patients may need to consult with family members before deciding on a course of treatment. Healthcare providers should understand that Asian American families value group consensus when making important medical decisions. When creating outreach materials, keep the following in mind:

  • In a patient information brochure, instead of addressing only the patient, as in, for example, “You will decide on a course of treatment,” recognize the role of the family: “Your family will help you decide on a course of treatment.”
  • Imagery of interactions between patients and health care providers should also reflect the importance of family support. For example, an elderly woman would not be pictured alone, but in the company of family members.
  • Benefits of treatment should be described not in individualistic terms alone, but also in terms of improvement to the patient’s family life.

Spoken or written words are not the only means of communication

In the literature on cultural differences, Asians are generally considered “high-context” communicators, because meaning is not explicit but rather implicit. Body language, tone of voice, eye contact, and gestures can convey as much as spoken or written words. In cross-cultural communication with “low context” communicators, many behavioral cues can be misinterpreted. For example, in health care encounters as well as business encounters, respect is demonstrated differently.  Those of us raised in a Western family recognize the importance of eye contact – looking someone directly in the eye and speaking frankly is considered a sign of respect. This is not the case in many “high-context” cultures, for whom looking directly into the eyes of a person of higher status is considered disrespectful. Lack of eye contact does not mean someone is not paying attention. In addition, smiling and nodding does not always indicate understanding. In many settings, it is considered disrespectful to question instructions given by a person of status, such as a doctor. To say one does not understand implies that the instructions were poorly explained, and to articulate such a challenge would cause a doctor to lose face. Nobody, in any culture, wishes to insult the person they are asking for help!

  • Outreach materials may need to provide more context via images and descriptions. Working with cultural consultants before preparing source materials will be a helpful means for ensuring appropriate context.
  • Intake questionnaires and interviews should not rely heavily on yes/no questions.
  • In clinical settings, instead of asking, “Do you understand?” and accepting a “yes” at face value, one should ask more open-ended “how” questions and listen closely to the answers. This may take more time, but it will lead to better outcomes in terms of compliance with treatment recommendations.

Life is uncertain

Many Asian cultural groups feel that uncertainty is an inherent part of life, especially in the face of suffering over which one has very little control. This belief can directly impact attitudes about sickness and receiving long-term medical treatment. To a Western mind, which prefers vigorous action in response to any challenge, this attitude can look like a fatalistic unwillingness to receive care and cooperate with doctors. This is not the case. This attitude reflects a different understanding of how to conceptualize illness, not that illness cannot or should not be treated. Americans are accustomed to talking about “fighting” or “battling” serious long-term diseases such as cancer or depression. This is not a belief that is universally held, especially in that it presumes the disease is a force that is not really a part of the person.

  • Acknowledge that the patient’s goal is to improve health and well-being overall, not just to focus on a single ailment and “beat” it. To this end, do not minimize or dismiss the value of holistic or traditional treatments.
  • Especially in cultures that value harmony, the idea of “fighting a battle” may be more alarming than motivating. The overall tone of outreach materials should be assessed through pre-translation cultural consulting.

In a study conducted by the Asian American Health Initiative, many Asian Americans believed that their medical providers did not understand their cultural values. As a result, they were less likely to have confidence in the care provided, which lead to delayed diagnoses and worse outcomes. Pre-translation cultural assessment, transcreation of outreach material, and cross-cultural training for front line staff can help healthcare providers communicate more effectively within the context of a target culture’s beliefs surrounding illness, healing, and healthcare services.

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