Cross-Cultural Communication, Competence

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Almost all American public health professionals work with people from a variety of cultural backgrounds and communication styles. Developing and refining one's skills for communicating effectively with people different from one's self is a process that requires trust, awareness, sensitivity, respect, and honesty. The public health professional may be very proficient when working with one culture (i.e., "cross cultural"), yet inadvertently insult another. Competence is not a state but a constantly evolving process of adaptation and refinement.

The lack of cultural and geographic relevance in public health materials and programs may result in communities erroneously feeling that they are not susceptible to the health problem discussed. Various cultural communities are likely to have worldviews completely different from one's ownincluding the causes, spread, and treatment of diseases.

Many cultural communication styles incorporate stories and analogies rather than using the linear style of scientists. When responding to a survey or intake, the client may respond by telling a story about his aunt. The public health professional can actively listen to the story, then fill in the appropriate items on the instrument and collect additional information as needed.

In contemporary speech patterns, one person may be talking and another could begin responding prior to the first speaker's completion of the last sentence. Several cultural groups include a lengthy pause between speakers to allow a polite and respectful period of time for the person to finish speaking prior to the listener responding. The public health professional needs to adopt a similar pause when speaking with members of those cultures.

The public health professional is usually taught to look the client directly in the eye to develop trust. However, such direct eye contact is interpreted by some to be intrusive and offensive. Standing or sitting close to the client without realizing that he or she has entered the client's personal space can also result in making the client feel uncomfortable and uneasy.

Selected health information or screening may violate one's personal feelings of modesty. Many health tests require partial nudity and violate one's personal modesty, resulting in a refusal to participate in screening programs. One adaptation is to allow the patient to wear some clothing during the test to respect personal modesty.

Public health professionals need to develop and retain a sense of trust with the client and the community. To instill trust requires that the professional be honest, provide quality programs or services, and remain in the community for years. Trust includes respecting the client's privacy and confidentiality in all matters and requires consistency and time to develop.

Some words used in the public health fields have totally different connotations in communities. For example, when informing an individual about biopsy results, the test is said to be "positive" (for cancer cells). But the patient being told that the test results are "positive" may interpret this as meaning that there was no cancer.

Public health messages need to be prepared and delivered in an understandable manner to the intended population. Literacy refers to the ability to use reading and writing to get information. It does not imply "limited intelligence." Reading level refers to the average reading skill expected at each year of school in the U.S. public school system. Limited literacy is an inhibiting factor in accessing health information such as patient education materials, informed consent, materials describing insurance or health care plan options, discharge documents, and directions for self-care or medication.

Many professional prepared materials are written at grade fourteen reading level. The word choice and sentence structure need to be modified in informational materials, the informed consent process, directions, and so on. Health information prepared for the general public needs to be at the seventh grade reading level or lower, using a large (e.g., 14-point), plain (e.g., arial) font, with a lot of white (empty) space on the page.

English as a second language (ESL) describes people for whom other language(s) were learned prior to English. It does not imply that the individual has low literacy skills or is of limited intelligence. When public health messages are translated, it is imperative that the messages be "backtranslated" into English. By doing this, slight variations of word choice are frequently identified. For example, there are multiple versions of Spanish, and the translation must be made by someone in the community so that the appropriate dialect is used. Health care facilities should employ trained translators instead of relying on personal acquaintances or staff on hand.

Linda Burhansstipanov

(see also: Acculturation; American Indians and Alaska Natives; Anthropology in Public Health; Assimilation; Biculturalism; Communication for Health; Community Health; Cultural Anthropology; Cultural Appropriateness; Customs; Ethnicity and Health; Social Assessment in Health Promotion Planning; Values in Health Education )


Burhansstipanov, L. (1999). "Developing Culturally Competent Community-Based Interventions." In Cancer Research Interventions among the Medically Underserved, ed. D. Weiner. Westport, CN: Greenwood.

Rudd, R. E.; Colton, T.; and Schacht, R. (2000). An Overview of Medical and Public Health Literature Addressing Literacy Issues: An Annotated Bibliography. Cambridge, MA: The National Center for the Study of Adult Learning and Literacy.