Conceptual framework for communicating health and illness across cultures.

The formal study of intercultural communication is generally associated with the publication of Edward Hall’s “The Silent Language” in 1959, where the author showed how culture is critical to understanding intercultural communication. After millennia of research, intercultural communication challenges today are global and by that it is meant that intercultural communication is present in every segment of life and in every profession. Correspondingly, the significance of health communication is very important because if people are to interculturally interact with other people, it is important to understand how socio-cultural factors shape the well-being of others. Owing to that, effective health care delivery relies on clear and effective communication which is an essential element in every form of medicine and health care between all of the individuals who are involved: patients, physicians, and other health care professionals. If, in any way, communication between health care providers and patients is not clear, the entire medical treatment process can be problematic and clear communication may be hindered when the participants come from diverse cultural backgrounds. Thus, it is exactly the health care provider who is responsible for communicating effectively with people from diverse cultural backgrounds meaning that a fundamental understanding of the relationships among health care providers, culture and communication is a prerequisite for everyone involved in the health care professions. Furthermore, culturally competent communication appropriates sophisticated and contextually suitable communication behaviors designed to foster maximum physician sensitivity to cultural differences in patients and concomitantly serve as bedrock of the physician-communication competence in interacting with patients. Diverse health care belief systems


Introduction
The formal study of intercultural communication is generally associated with the publication of Edward Hall's "The Silent Language" in 1959, where the author showed how culture is critical to understanding intercultural communication.After millennia of research, intercultural communication challenges today are global and by that it is meant that intercultural communication is present in every segment of life and in every profession.Correspondingly, the significance of health communication is very important because if people are to interculturally interact with other people, it is important to understand how socio-cultural factors shape the well-being of others.Owing to that, effective health care delivery relies on clear and effective communication which is an essential element in every form of medicine and health care between all of the individuals who are involved: patients, physicians, and other health care professionals.If, in any way, communication between health care providers and patients is not clear, the entire medical treatment process can be problematic and clear communication may be hindered when the participants come from diverse cultural backgrounds.Thus, it is exactly the health care provider who is responsible for communicating effectively with people from diverse cultural backgrounds meaning that a fundamental understanding of the relationships among health care providers, culture and communication is a prerequisite for everyone involved in the health care professions.Furthermore, culturally competent communication appropriates sophisticated and contextually suitable communication behaviors designed to foster maximum physician sensitivity to cultural differences in patients and concomitantly serve as bedrock of the physician-communication competence in interacting with patients.

Diverse health care belief systems
Cultures all over the world have beliefs about illness and health that derive from the way they perceive the world.Generally speaking, people are taught well what to value or devalue, appreciate or denigrate, love or hate with regard to the healing process [1][2][3][4] .Therefore, culture and ethnicity create unique patterns of beliefs and perceptions about health and illness.In turn, these patterns influence how illness is recognized, to what it is attributed, how it is interpreted and how and when health services are sought [1][2][3][4] .To this end, health care providers should not approach health care from a single cultural perspective and must learn to treat patients from other cultures in a culturally competent manner because cultural barriers can greatly influence the healing process 5 .Granting all this, health belief systems are divided into three major categories: occult, holistic and scientific traditions, each with its own corresponding system of related beliefs 1,2 .
The occult health care tradition comes from a belief system in which the world is perceived as an arena where supernatural forces predominate.Followers of this tradition hold strong beliefs about the existence of sorcery, magic and evil spirits.In this tradition, the fate of the world and all of those in it depends upon God, gods or other supernatural forces of good or evil.Here, illness is attributed to spiritual forces and results from the possession of the body by evil spirits or from casting evil spells.The ill person is considered a victim of punishment rendered by the occult being or power.In the supernatural tradition, treatment involves achieving a positive association with spirits, deities and the like where treatment is carried out by healer-practitioners recognized by their communities as shamans (Siberian word for spirit healer) who have supernatural powers and strength to ward off the evil spirits or entities that possess and torture the body and soul of the ill person 1-4 .This tradition is characteristic of some parts of Southeast Asia, Vietnamese, the Caribbean and some Latino countries.Also some of the oldest and most widespread superstitions regarding the cause of illness is the evil eye, which is the belief that someone can inflict harm by gazing or staring at another person.Belief in the power of the evil eye still exists in many parts of the world as well such as Southern Europe, the Middle East and North America.

Bakić
The holistic tradition is based on the principle that a whole is made up of interdependent, interacting parts.In the same view, an individual is a whole made up of interdependent parts which are known as physical, mental, emotional and spiritual.Therefore, if one part is not functioning at its best, it affects all of the other parts of that person because all parts are in constant interaction with everything in the surrounding environment 1,2 .
Interestingly enough, holistic health is an approach to life as well.The goal is to achieve maximum well-being, where everything is functioning in the best way possiblethe mind, the body and the soul.With holistic approach to health, people accept responsibility for their own level of well-being and everyday choices are used to take change of one's own health.This approach is embraced by Asian people (Filipinos, Koreans, Japanese and Southeast Asians), Africans, Haitians and Jamaicans [1][2][3][4] .
Holistic treatment of illness is found in some Chinese and Japanese medical practices as well.It includes ingesting thousand-year-old eggs, strict rules of food combinations or a Japanese tradition of drinking turtle blood which is considered a youth and health elixir.Traditional cures also include acupuncture (applying needles to the body to cure diseases or relieve pain), moxibustion (therapy based on the value of heat), herbal remedies, such as ginseng as well as exercising programs such as tai chi (an internal Chinese martial art practiced for both its defense training and its health benefits).
The scientific tradition focuses on the objective diagnosis and scientific explanation of disease.It is an evidencebased approach to illness and other bodily disorders and relies on procedures such as laboratory tests to verify the presence and diagnosis of disease.Since it is based on rational thinking it very often ignores psychosocial aspects of illness such as cultural norms, coping abilities and life events that may interact with physical problems.
The scientific tradition understands health in terms of physical and chemical processes and most doctors in the world are trained in this tradition.This health care system rejects the metaphysical and usually ignores holistic approaches to medicine as well.Such a strong and shared belief in the scientific health care approach is inclined to become in some cases the Western biomedical ethnocentrism 1, 2 which can be a serious barrier to effective health care communication and oftentimes results in an undermining response to a patient's use of or interest in alternative supernatural or holistic health practices.For the firm supporters of scientific tradition, these practices are perceived to lie outside accepted medical practices and will be tolerated only if they do not interfere with the widely accepted treatment plan of scientific tradition.Consequently, treatments in this approach seek to destroy or remove the causative agent of disease or illness and seek to return the body to its normal state.The treatments include: surgery, medications and other therapeutic interventions such as antibiotics, nutritional supplements, vitamins and minerals.
As seen from the above, diverse cultural beliefs regarding the causes and treatments of illness have led to a variety of methods to deal with the prevention of illness.Many cultures incorporate a combination of supernatural, holistic and scientific approaches to prevent illness.For example, in the United States and other highly technological cultures such as Germany or Japan, good health is based on regular annual physical examinations, immunizations at specified times, exercise and good nutrition.Additionally, many people also follow preventive health regimens such as anti-stress massage and meditation, yoga, ingestion of probiotic bacteria, a variety of natural herbs to prevent and/or reduce memory loss, promote energy and seek preventive treatment from chiropractors, chiropodists, acupuncturists and colonic irrigationists.In contrast, many Muslims rely on the Koran to protect them from illness.Latino and Asian cultures, on the other hand, believe that illness may be prevented by maintaining a "hot-cold" balance.Many members of Mexican and Puerto Rican cultures believe that health may be the result of good luck or reward from God for good behavior.The Chinese prepare amulets (especially jade charms) to ward off evil spirits and to protect their health [1][2][3][4] .An eloquent Serbian adage "good thoughts are half of health" implies that the act of thinking good thoughts wards off illness.
So far, the point of this discussion indicates that what patient believes can strongly affect the treatment process.But even so, each health care provider should bear in mind that health care delivery anywhere in the world can be impeded by cultural diversity, lack of knowledge about diversity and an inability to communicate effectively that altogether lead to false diagnosis.Conjointly, in order to achieve an objective of optimal health care for all people, health care providers and institutions must be culturally competent.

Intercultural health care competence
As indicated before, intercultural competence is generally defined as the knowledge, motivation and skills to interact effectively and appropriately with members of different cultures [1][2][3][4][6][7][8][9][10][11] . Overtl, five attributes of intercultural competence that are a must in health care are: 1) cultural awareness, 2) cultural knowledge, 3) cultural understanding, 4) cultural sensitivity, and 5) cultural skill 1-3, 5, 7-11 .Still and all, when applied in health care settings such as a physician's office, clinic or hospital, intercultural competence must include tailor-made attributes of the intercultural healthcare competence (Table 1).In other words, healthcare providers must take a proactive attitude and develop sensitivity to the role culture plays in health care.It is essential, therefore, that health care providers not only learn about other cultures but their own beliefs respectively, only to realize how they affect their ability to look at, understand and appreciate other belief systems 2,3,5,6 .The more health care professionals know about someone's health care beliefs or practices, the better their care and treatment plans can take into account a patient's worldview that in most cases might be completely different from their own.Owing to that, health care in a multicultural environment can enhance medical providers' ability to communicate with patients from other cultures.At the same time, it must focus on the cultural beliefs and lifestyles of diverse groups and apply this knowledge to achieve culturally appropriate patient care.Still and all, in multicultural health care situations, health care providers must respect and, in more difficult cases, even explore patient's beliefs within the context of the patient's religion and culture rather than dismiss traditional practices (occult or holistic medical traditions and belief systems) that affect patients' acceptance of, and compliance with, treatment protocols 1, 2 .Moreover, beliefs of both provider and patient are influenced by social and cultural factors which are a huge challenge, and if not handled correctly, will adversely affect the clinical interaction [3][4][5] .Thus, when working in a multicultural environment, the first step is to understand the beliefs of the patient and his/her family, towards treatment goals.The next step is to identify a treatment plan that is acceptable to the patient, the family and the health care team 1,2,12 . Concern abut the family is important because in many cultures health care decisions are not made solely by the patient but by the family as a team (Greece and Latin American countries).Furthermore, the delivery of satisfying health care to culturally diverse patients requires that their beliefs concerning the causes of illness, how illness should be treated and how it can be prevented in the future must be acknowledged and the best way to address cultural differences is through an open and balanced intercultural communication 1,2 .

Health care communication strategies
A communication strategy is a model or guide a health care provider can follow to help create effective messages for specific purposes 1 .To this end, health care communication strategies offer advice and/or suggestions about gaining insight into a patient's background, health care beliefs and help overcome barriers to effective communication between caregivers and patients.Conversely, there are eight barriers to effective communication in the health care setting: 1) lack of knowledge about the patient's background and beliefs, 2) patient fear and distrust of caregivers, 3) racism, 4) bias and ethnocentrism on the part of both caregivers and recipients, 5) mutual stereotyping, 6) ritualistic behavior, 7) differences in perceptions and expectations, and 8) language differ-ences 1,2,4,6 .Furthermore, the role of medical English can in many instances affect health care communication.Albeit it is obvious that language differences can complicate medical interactions, the use of medical jargon can also complicate health care instructions.For example, the use of words like "rhinitis" rather than hay fever, "anosmia" instead of loss of smell and "dementia" rather than memory loss can be rather confusing not only to native speakers of English, but to speakers of many other languages.
As a rule of thumb, conducting medical interviews is a primary technique used by physicians and other caregivers to elicit information about the patient necessary to make a diagnosis, determine what tests might be necessary and to ultimately treat an illness 2-4, 13, 14 .Nevertheless, every health care provider should bear in mind that when communicating with patients from different cultures during an intercultural medical interview, the care provider should ask the patient a series of questions that will elicit the information necessary to provide effective treatment.There are no strict rules to how to conduct the intercultural medical interview with the patient and the interview does not require a particular style but it actually encourages the individual physician to develop his/her own approach.What is important, however, is that, at the end of the interview, it is necessary to establish that both the doctor and the patient understand what occurred and what the plan for treatment is going to be.The easiest way to do this is to summarize the encounter for the patient and to get their agreement of the doctor's summary 3,[12][13][14] .
The doctor also has to make sure that all of the patient's questions and concerns have been addressed.On the part of the patient it is important that intercultural rapport has been established because the patient needs to be able to depend on the fact that the doctor will be there in the future for them should they need him/her.Therefore, the doctor should discuss with the patient the next steps in his/her care, userfriendly and patient-centered compliance instructions, determine follow-up for a specific reason or at the very least reassure the patient that they are welcome to come back to see him/her again [12][13][14][15] .To this end, ten general strategies have been singled out for every health care provider to follow during the intercultural medical interview that will help in overcoming possible intercultural barriers 1-5, 12, 14, 15 .
1. Do not treat the patient in the same manner in which you, as a health care provider, would want to be treated because each culture has a set of rules for polite, caring behavior that will, in the end of the day, determine the patient's concept of a satisfactory rapport.
2. Begin an interaction by being more formal with patients who were born in another culture because in many international cultures, there is a greater social distance between

Table 1 Attributes of Intercultural Healthcare Competence 1
A culturally diverse staff that reflects the cultures served Health care providers or interpreters who speak patients` language(s) Training for health care providers about the culture and language of the people they serve Signage and instructional literature in the patients` language(s) that is consistent with their cultural norms Culturally specific health care settings Bakić-Mirić MN, et al.Vojnosanit Pregl 2012; 69(3): 260-264.caregiver and patient.This means that it is best to address the patient by his/her last name and maintain this formal relationship until the patient signals a different approach is appropriate: "Good afternoon Ms X.My name is Dr Y, specialist in hematology." 3. Allow patients to be open and honest because in most cases the patients are reluctant to tell caregivers that they are visiting a folk healer or are taking alternative medication concurrently with prescription drugs.A doctor should start with more relaxing questions.This will enable to create common ground: "Tell me Ms X, what is your present occupation?…How long have you been working there?…What exactly are your duties?"Once the doctor has established rapport with the patient together with the necessary introduction he/she can ask the patient to explain why they are there and let the patient tell their story in their own words: "Ms X, could you please tell me what sort of problems have you been experiencing?"4. Do not disregard the possible effects of beliefs in the supernatural on the patient's health because if patients believe that their illness was caused by bewitchment, the evil eye or God's punishment they will not take responsibility for their cure.The following questions should suffice: "What do you call the illness?What do you has caused the illness?Why do you believe the illness started when it did?How severe is the illness?What kind of treatment do you think is necessary?What are the most important results you hope to receive from this treatment?What are the main problems the illness has caused you?What do you fear most about the illness?Are you visiting a shaman or a holistic healer alongside?" 5. Inquire indirectly about the patient's belief in or use of nontraditional remedies and consequently ask the patient does he/she do too: "What treatments, if any, are you receiving and are you using folk medicines?What obstacles/factors would prevent you from being able to comply with the proposed treatment plan?"This may lead to negotiation with the patient to arrive at a mutually acceptable course of action.
6. Never try to force change or demand compliance from patients because a caregiver should be prepared to negotiate with the patient about the instructions he/she must follow on less critical health issues: "Ms.X, I believe that somewhere down that road we will have to take a turn, which means that you should start with antibiotics instead of the holistic medication you have been taking in order to make sure that the bacteria causing your illness is completely destroyed.This is the only way to avoid further deterioration of your health condition." 7. Always employ empathy in constructing messages because in most cases patients visit healthcare providers at a very vulnerable time in their lives when a patient has exhausted all attempts to care for him/herself at home.This is the point when a caregiver must show vulnerability, offer compassion and determine patients' views and beliefs in order to accurately decode verbal messages: "I am really worried about this lump.It is completely natural for you to have concern, and if you let me, I would like to ask you some questions so as to figure out what is going on."When the patient does reveal such information, the doctor should take a moment to explore what they have revealed i.e: "You mentioned you feel overwhelmed.Can you tell me more about that?You seem quite nervous.Can you tell me why you might be a bit anxious?"More importantly, as the patient's health care provider, the doctor must put aside his/her own beliefs and values and refrain from projecting them onto the patient.The medical problem or issue is not about you, but about the patient and his/her belief system and the doctor needs to understand it from their perspective.Avoid judgmental language or nonverbal behaviors that the patient may interpret as disapproving (for instance making faces, frowning, nodding as a sign of disapproving).Encouragement is another key trait that also strengthens the intercultural patient-doctor rapport.The doctor should reinforce the patient's positive behaviors by offering them praise for the steps he/she has taken up to that point e.g: -It sounds like cutting back on smoking has been difficult for you, but I am glad to hear you have not given up trying.Have you tried nicotine patches?
8. Be careful in relating bad news.This means, that a health care provider must determine how much are patients able to deal with when their diagnosis is concerned and not abide by an American trait that the patient needs to know everything: "I feel a lump under your arm pit.What we need to do, in order to be sure that it is harmless, is run some tests and wait for the lab results.After they come out, we will determine the diagnosis and set up the appropriate type of treatment.Meanwhile, you can go home and continue with your daily activities." 9. Follow the patient's lead in communication style which means that if a health care provider is unaware of the patient's cultural rules in communication, he/she should observe how the patient communicates and follow suit.Thus, there are five verbal and nonverbal techniques that will help every health care provider to follow the patient's lead 1,4,5,16 : If the patient does not look you in the eyes when speaking, do not look the patient in the eyes but direct your gaze to whatever the patient is looking; Speak in the same manner as the patient which means if he/she speaks slowly and softly, speak the same way; Mirror the patient's handshake and apply the same pressure, rather than firmly squeezing his/her hand; If a patient allows a family member answer questions, refer to the family member and permit him/her to answer the questions; Observe the patient's physical comfort zone for interpersonal communication meaning that if the patient moves closer to you while engaged in conversation, do not back away and move out of his/her comfort zone.
10. Use the LEARN model (Table 2) as a comprehensive guide to interactions with patients coming from a different culture.
As a point of note, a health care provider should keep in mind that the above mentioned key points in an intercultural medical interwiew are by no means definitive, but should prove effective in the majority of communication situations in any culture.

Conclusion
Living in a multicultural world not only opens a new world of opportunities but also brings myriad of challenges for all individuals.The cultural challenges especially, can be of significance for the individuals working in the health care setting as they often collect sensitive personal and private information about patients.In most cases, such information is subjected to culture specific behavior and rules of disclosure.Overtly, living in a multicultural world requires different sets of skills for a health care professional in order to competently and effectively maneuver intercultural interactions with patients.Accordingly, intercultural communication competence plays a significant role in preparing the health care professional to be an effective communicator in intercultural interactions.Pertaining to this, communicating health and illness across cultures is not an easy task.Until a health care provider actually overcomes cultural, and oftentimes, language barriers, the treatment and cure of the patient may be seriously hampered.Simply stated, an understanding of different cultural health belief systems, communication styles and individual beliefs will assist health care providers in becoming more attuned to the culturally based health expectations held by people whose cultural background is different from their own.Nevertheless, it is noteworthy to observe that people in all cultures go about their daily lives enacting health practices and values that are deeply rooted in their cultural experiences.Knowing how to approach a person from a different culture will enhance a health care provider with understanding of what happens to cultural knowledge when it crosses intercultural boarders.After all, effective communication between doctors and patients coming from different cultures is a central clinical objective and one of the first steps in building a successful intercultural rapport.Finally, building a successful intercultural rapport largely depends upon the effectiveness of communication between patients and doctors, the validity of the patient expectations and the ability of the doctor to fulfill them.