Your exploration of intercultural communication can help you realize the dramatic influence of culture on patient communication.
by Toni S. Adams, RDH, BA
There is nothing more personal than one's name, especially in certain cultures. The Hmong (pronounced "mong") people believe that each person has three souls. The first soul enters a child at conception, the second enters at first breath, but the third soul must be called by a special naming ceremony on the third day after birth. If a child receives the wrong name, the third soul will not enter the child, causing him or her to be sick or even to die. The ceremony will be repeated until a proper name is found.
Imagine what a cultural faux pas it would be to call a person by the wrong name when that name has such deep significance. Many of us are unfamiliar with the use and pronunciation of foreign names. Even more, we are unfamiliar with the sources of those names — the world's various cultures.
What is culture? Here I refer not to a medium in which to grow microorganisms or an appreciation of art or opera, but to a composite of the learned beliefs, values, attitudes, and behaviors that are characteristic of groups of people. Today, more than 25 percent of the residents of my home state of California, and more than 11 percent of the nation's residents, were born outside the United States. My husband taught in a school district in San Jose, Calif., in which more than 20 languages were spoken. Forty-five percent of the residents of Santa Clara County, where I reside, speak a language other than English at home.
Erich Fromm wrote, 'Cultural factors influence the individual behind his back, without his knowledge.'
These are not unique situations. California may be among the more diverse areas of the United States, but most parts of our country have diversified in the past 10 to 20 years. Every day we encounter people of innumerable nationalities, ethnicities, religions, and creeds — people from many cultures. We can better serve the diverse people we treat — and enrich ourselves — by learning some basics of intercultural communication.
Field of study
I acquired an interest in intercultural communication while earning a bachelor's degree in communication studies. As the daughter of an Air Force career officer, I traveled extensively and lived in two foreign countries by age 12. As a stewardess for an international airline, I traveled even more. As a dental hygienist for 26 years, I worked with and for people from numerous places.
Consequently, I didn't think I needed a class in intercultural communication — but my advisor insisted, so I took the class. I am thankful that I did; what I learned was so interesting and helpful that I wish I had known it all these years. I was inspired to take more classes on the topic, read extensively, and work as a research assistant on an intercultural study.
I want to share some information from this huge and fascinating field. I hope to enhance the knowledge and insights you have gained from your training and from your work as dental hygienists. This type of information is so important in the medical field. At least one medical malpractice insurer offers discounts of up to 2 percent for physicians who have undergone cultural sensitivity training. I will explore the concepts of world view, individualism and collectivism, high and low context, and ethnocentrism, and apply them to dentistry.
There are several points to keep in mind while reading this article. First, culture is learned. It is not genetic; it is not mere human nature. Each individual becomes a blend of human nature, innate personality, learned culture, and personal experience.
Second, culture is so ingrained and omnipresent that often we are not aware of it. Erich Fromm, the noted social philosopher and psychoanalyst, wrote, "Cultural factors influence the individual behind his back, without his knowledge." Geert Hofstede, a preeminent intercultural expert, called culture the "software of the mind." It is how we are "programmed" from birth; we think and behave instinctively because of our training. It is only when we are confronted with people who think and behave differently that we realize other ways exist.
Third, the beliefs, values, attitudes, and behaviors that are inculcated into us as we grow up are difficult to change. In most situations, people will behave as they were raised to behave.
Fourth, learning about other cultures can help us understand our own. We can bring our own "programming" into conscious awareness by studying other cultures. Edward T. Hall, a pioneering intercultural researcher, wrote, "The ultimate reason for (studying other cultures) is to learn more about how one's own system works."
Fifth, I am writing from the viewpoint of one who grew up in the culture of the United States. Thus, even though I strive to be objective, some of my own programming may slip through.
Finally, remember that besides the diversity within each culture, the variables of age, class, gender and context also must be considered. So, even though I will refer to certain ethnicities and nationalities as representative of different cultural styles, every individual is unique. Picture each category as existing on a continuum, rather than as a distinct entity.
The dental culture
We might think of the field of dentistry as a culture, with its own rules and norms of behavior and even its own language. We learn about this culture as we "grow up" through education and training. We even change our names by adding "RDH" and other designations to mark milestones in our "coming of age" in this culture.
To further the metaphor, we can see each dental office as a co-culture of the larger dental field, and each individual professional applies his or her diverse training and experience to create unique ways of practicing. Most of us have experienced a sort of "culture shock" when moving to a new job; that is when the diversity within the field is most apparent. Initially, we may feel that the norms in the new place are "wrong," and we are uncomfortable until we adjust and adapt to the new environment. As we become acclimated to the new place, we might contribute new views and ideas to the practice while simultaneously acquiring other views and ideas from it. This is analogous to a person adjusting to a new culture. Just as we can adapt our practice to different offices, we can adjust to various cultural perspectives.
• World view — Who we are depends greatly upon our personal world view, which refers to one's basic assumptions about the nature of reality and human behavior. People from different cultures view the world with different sets of beliefs, values, and attitudes. In health care there are two fundamentally different views of the causes of illness — the biomedical model and the traditional or folk model. Of course, these models are not mutually exclusive but are usually combined in varying ways.
An extension of this Eastern belief is a sort of fatalism, an acceptance that whatever comes is unavoidable and should simply be endured.
In the biomedical model, more predominant in Western cultures, nature is seen as something we can control — even conquer. We seed clouds when we need rain; we dam up rivers to create reservoirs; we complain that, even though we have put a man on the moon, we still have no cure for the common cold. We feel that remedies for everything — including dental diseases — are certainly just waiting to be found.
Eastern and native cultures ascribe to more traditional or folk healing methods. Practitioners believe that maintaining harmony with nature is necessary to achieve spiritual, mental, and physical health and that an interruption in this harmony causes illness. An extension of this Eastern belief is a sort of fatalism, an acceptance that whatever comes is unavoidable and should simply be endured. These two views can conflict in the dental office.
Those with a traditional orientation see no reason to prevent illness, including dental decay and periodontal disease. They feel it is their fate to suffer these maladies. Some people with this view even will refuse pain medication because they believe that pain is a necessary part of life that one must undergo.
Proverbs illustrate a belief that each person's fate is predestined:
• Mexican — "He who is born to suffer will start from the cradle," and "If God is going to give you something, it will come easy."
• Filipino — "Leave it to God."
• African Maasai — "A zebra does not despise its stripes."
• Asian — "One does not make the wind blow, but is blown by it."
Furthermore, in such cultures, it is more important to maintain harmony than to be straightforward. So a patient who appears to agree to floss every day or see a specialist when there is no intent to comply may be attempting to avoid disagreement or to show respect, or to save face, rather than being purposely deceptive. "Yes" may mean "I hear you," rather than "I agree."
In Japan, it is extremely rude to say "no" directly. The Chinese languages have no single word for "yes" or "no," although there are myriad, indirect ways to convey positive or negative meaning. When caring for people with a more traditional world view, it can be more productive to ask open-ended questions. Say, "Tell me what is difficult for you," or "How can I make this more clear?" rather than asking yes/no questions. Knowledge of this perspective can help us understand why some individuals appear more resistant to our preventive education efforts than others.
• Hofstede's individualism and collectivism — Some cultures encourage people to be unique and independent while others expect conformity and interdependence. Hofstede outlined these characteristics:
"Individualism pertains to societies in which the ties between individuals are loose: everyone is expected to look after himself or herself and his or her immediate family. Collectivism ... pertains to societies in which people from birth onwards are integrated into strong, cohesive in-groups, which throughout people's lifetime continue to protect them in exchange for unquestioning loyalty."
Based on his research, Hofstede rated 50 countries on an individualism-collectivism scale. (The words collectivist and collectivism are meant in a social rather than a political sense.) The United States was found to be the most individualistic country, followed by the non-Latin European nations. Central American countries were rated the most collectivistic, followed closely by many nations in Asia and the Middle East. The majority of the world's cultures are at the collectivist end of the continuum.
We can be wrong when we assume that someone will frankly tell us how he or she is feeling.
People in individualistic cultures place greater value on independence, privacy, and competition, and are more "I" centered. One of the United States' most treasured national documents is the Declaration of Independence! "Family" usually means nuclear family — parents and offspring. Those in collectivistic cultures, on the other hand, place more importance on cooperation, loyalty to and harmony within a group, and are more "we" centered. "Family" means extended family and includes grandparents, aunts, uncles, cousins, and so forth.
The concept of "face," as found in collectivist cultures, exemplifies the difference between the two categories. In individualistic cultures such as the United States, the term "to save face" means that an individual wants to be spared personal embarrassment. In collectivist cultures the meaning goes further — members want to save face for their in-groups, and even for the other person in an encounter. So a collectivistic person who agrees to do what a practitioner says, even when s/he doesn't plan to comply or doesn't understand what is being asked, may be saving face for an extended family, not for him or herself as an individual.
Collectivistic people can be embarrassed to be singled out for praise as individuals; they are more comfortable with praise for their in-groups. A friend from a collectivist culture explained it well. She said she would be uncomfortable if someone told her that she has pretty eyes; but she would be pleased to hear that all the women in her family have pretty eyes. In dentistry, this can be applied to motivating people to practice prevention. You might say, "Your family can be proud of you," rather than, "You can be proud of yourself." Focus the praise on the group rather than the individual.
Another example has to do with names. In many Asian cultures, the family name comes first, to represent the preeminence of the family over the individual. Also, group consensus is imperative for collectivistic people before proceeding with treatment or making other decisions. Individualists can find it difficult to understand collectivists' interdependent qualities. When the concepts of individualism and collectivism are understood, many differences can fall into place.
• Hall's high and low context — Hall organizes cultures by the amount of information implied by the setting or context regardless of the specific words that are spoken. Meaning is transferred more explicitly in low context cultures such as in North America and Northern Europe. We are more verbally precise and expect others to "tell it like it is," "say what you mean," and "give the facts, just the facts." Meaning is created more implicitly in high context cultures, such as those in Asia, Latin America and the Middle East, which depend in great part upon nonverbal messages such as tone of voice, inflection, eye contact, body language, and innumerable other subtle cues.
Some areas and co-cultures in the United States, such as the South and some rural areas, are relatively high context. My husband grew up in a large rural family. In the 1940s, when pregnancy was not discussed, one knew a woman was pregnant when she wore a coat in the summertime. This is exactly the kind of implicit communication that occurs in high-context cultures. Insiders understand immediately; outsiders either miss the message or just think the behavior is odd.
Low-context people can have high context relationships with those whom they know well, such as in marriages and work situations when people communicate in ways that outsiders do not understand. My husband and I can share meaning by merely touching an arm or raising an eyebrow.
In the dental culture, we have our own norms and rules, language, and non-verbal communication. People from outside our culture do not understand nonverbal messages passed among us. We learn to not react to a disturbing sight in a patient's mouth so as not to alarm the person; but we can share knowing looks with co-workers. A look from a receptionist can speak volumes: "Your next patient is waiting," or "When will you finish so I can go home?"
Patients from high-context cultures might assume we can sense their meaning without their having to make explicit statements. They may expect us to "know" that they need something or that they are in pain without saying so. Thus, we can be wrong when we assume that someone will frankly tell us how he or she is feeling. I re-emphasize that these categories are not absolute and that individual members of different cultures participate in these practices to varying degrees.
• Ethnocentrism — Ethnocentrism is a tendency to give priority and value to the ideas and customs of one's own group and to view and judge other groups from that perspective. It is the window through which we see the rest of the world and it is not new. Aeschylus wrote around 400 BC, "Everyone's quick to blame the alien." My grandmother revealed her own ethnocentricity when she often said, "Everyone's crazy but me and thee — and I'm not too sure about thee!" This concept explains why people tend to think of their own norms, rules and practices as right, true, and good, as opposed to others' ways as wrong, false, and bad.
People in each part of the world consider themselves to be at the center.
Hofstede tells about purchasing flat maps of the world in three different places. The first, bought on mainland USA, was the map we who grew up here saw as children in school; Europe and Africa are in the middle. Here we can see why we call our part of the world "the West" and Asia the "Far East."
The second map was bought in Hawaii; the Pacific Ocean is in the middle, Asia, Africa, and Europe are on the left, and the Americas are on the right. Here, East is West and West is East!
The third map was purchased in New Zealand. It was similar to the second map, except upside down, with the Southern hemisphere on top and the Northern hemisphere on the bottom. People in each part of the world consider themselves to be at the center.
The perception of difference depends upon one's point of view. Ethnocentricity is a two-way street — when someone seems different to you, it is likely you also seem different to him or her. All individuals and groups are ethnocentric to some degree, which helps cultures survive. However, bear in mind that our own ethnocentrism can interfere with our being open and understanding to others' ways and with providing culturally sensitive care.
• Sights and sounds — Dental practitioners can learn from the concept of ethnocentrism why people from different cultures are unsure, even suspicious, of the way we practice dentistry. Our ways are new to them and different from what they have known. Imagine finding yourself in a dental office in a foreign country where you may not understand the national language, let alone the dental language. The sights and sounds and smells can be frightening even to those who grew up here. Just as we consider our practices to be right, true and good, newcomers to our culture may find them wrong, false, and bad. One patient from another country could not understand why he needed a hygiene appointment every three months. He felt that if I cleaned his teeth "well enough" a yearly visit should be sufficient because that was his experience in his native country.
By now you might be wondering how you are ever going to keep all of these concepts straight, let alone understand who ascribes to what view! Don't worry. The point is not to memorize a bunch of facts about different cultures. The main objective here is to point out a few general, overall concepts. I believe that a fundamental understanding of world view, individualism and collectivism, high and low context, and ethnocentrism can help bring organization to what appears to be chaotic.
Furthermore, remember that all of us, especially in our cosmopolitan country, are the products of multiple cultures that we combine in an infinite variety of ways. If we become familiar with some underlying principles, we can better understand others and ourselves and learn from the diverse people we treat. Hall wrote, "One of the most effective ways to learn about oneself is by taking seriously the cultures of others."
Finally, I believe that there is a universal language of care. Everyone understands and appreciates kindness, patience, concern, integrity, respect, appropriate humor, a gentle but confident touch, a caring manner, a reassuring gesture and a warm smile. Then, when we use a wrong name or commit other cultural faux pas, as we inevitably will do, we will be more easily forgiven. The way we are with people speaks volumes, traverses cultures, and goes a long way toward building bridges among us.
Toni S. Adams RDH, BA, lives in San Jose, Calif. She earned an associate's degree in dental hygiene from Foothill College in California in 1973 and practiced for 26 years. She earned a bachelor's in communication studies from San Jose State University and will be working on a master's in health communication. She can be contacted at firstname.lastname@example.org.