- cancer
an illness that results from abnormal cell division in the body.
- immigrants
people from countries other than Australia who have moved to Australia.
- minority groups
groups of people from countries other than Australia who have immigrated to Australia.
- interpreters
people who speak English and at least one other language. They are called in to attend doctor–patient consultations to translate technical and medical concepts for the patient.
Introduction
Migration is increasing worldwide, with the number of people who do not speak the primary language of the country in which they live similarly increasing. For example, the 2013 census showed that 27.7% of Australians were born overseas, compared to 23.6% born overseas 10 years earlier in 2003 (Australian Bureau of Statistics, n.d.). Of those born overseas, 11.5% speak English poorly or not at all (Australian Bureau of Statistics, n.d.). Furthermore, Indigenous groups may also differ in language and cultural background from the population that now represents the majority.
Health care is challenging in a multicultural context, and this is particularly true of cancer care, due to the stigma and nihilism associated with this word and the high emotionality of many consultations. Thus it serves as a good exemplar of relevant issues, and will be the focus for this chapter.
Minority groups diagnosed with cancer have poorer cancer outcomes than mainstream groups, with lower screening and survival rates and higher rates of reported side effects (Chu, Miller & Springfield, 2007). A recent meta-analysis revealed significantly higher distress and depression in minority versus mainstream cancer patients. This finding is not wholly accounted for by differences in socio-economic status (Luckett et al., 2011). The finding was reinforced in a large registry-based study of migrants versus Anglo-Australian-born cancer survivors (Butow et al., 2013).
While many factors may contribute to such disparities, including poor health literacy, unfamiliarity with healthcare processes and differing beliefs and attitudes about illness, death and treatment, poor outcomes may also be due to language and communication barriers (Johnstone & Kanitsaki, 2007).
Language and communication barriers
Doctor–patient communication is a critical aspect of cancer care. Doctor–patient communication influences patient understanding and satisfaction with care, the quality of informed consent, adherence to agreed treatment regimens, psychological adjustment and coping in patients and families, and health professional burnout (Ong et al., 1995). In the cancer setting there are many issues which require careful and sensitive communication, including conveying bad news and discussing prognosis. Other such issues include facilitating informed decision-making, given the increasingly complex array of treatment options available. Then there are issues such as gaining patients’ consent to participate in clinical trials, discussing expensive drugs, and advance care planning (see Chapter 7).
While communication can be challenging at any time, it is likely to be more so when health professionals and patients do not speak the same language or share a cultural heritage. Given the increasing rate of migration highlighted above, it is now an everyday experience for health professionals to treat immigrant patients and communicate with immigrant families.
Communication challenges between cultures can arise because of language difficulties (both verbal and non-verbal, as well as written), and can give rise to different illness explanations and role expectations. For example, in a study involving focus groups with 73 cancer patients and 18 caregivers who had migrated to Australia and spoke Chinese, Greek or Arabic:
participants, especially those less acculturated, described feeling alone and misunderstood, failing to comprehend medical instructions, being unable to communicate questions and concerns and experiencing a lack of consistency in interpreters and interpretation. (Butow et al., 2007)
In another large study including over 250 immigrant cancer patients, it was found that the presence of an interpreter did not always compensate for language difficulties (Butow et al., 2013). Indeed, analysis of translated cancer consultations has shown that interpretation is often inexact, particularly of questions and answers about prognosis (Butow, Goldstein et al., 2011).
Patients have culturally determined beliefs about the causes of diseases, the way the body is structured and functions, and the efficacy of different complementary and alternative therapies (Tchen et al., 2003). Religious and spiritual beliefs and practices affect how patients respond to bad news, to offers of medical treatments such as transfusions, and to end-of-life family conferences.
Thus there is ample opportunity for miscommunication and confusion between health professionals and patients from different backgrounds. Patients from some cultural groups expect to be told what to do by health professionals, and they lose confidence in the expertise of their doctor if a shared decision-making approach is taken (Huang et al., 1999). Asian and Indigenous cultures often have a collectivist approach to health decision-making, and expect the family, or a trusted and respected elder in the community, to make decisions on the patient’s behalf (Surbone et al., 2013), and the Western emphasis on the primacy of the doctor–patient relationship is at odds with this approach. These cultures may also believe it is better for patients to be spared knowledge of a cancer diagnosis, or a poor prognosis, to avoid them ‘giving up’ and losing hope. This, too, can be at odds with Western ethical standards of full disclosure and informed consent (Tan et al., 1993).
Cultures also differ in their expectations of non-verbal and emotional expression between health professionals and patients. In some cultures, an informal, warm and compassionate approach is expected of health professionals, and a more formal approach may be interpreted as cold and uncaring (Moore & Butow, 2005). On the other hand, a cultural tradition of silence and deference towards health professionals may lead some patients to be quiet and passive in consultations; this can be misinterpreted as reflecting misunderstanding or confusion (Janz et al., 2009).
Compounding all this, a patient’s personal or historical experiences of discrimination, violence or institutionalised racism may reduce their trust in health professionals and institutions (Tan et al., 1993). For example, the ongoing impact of colonisation and subsequent socio-cultural and political isolation on Aboriginal Australians and their culture is felt throughout the health system (Treloar et al., 2014). Some Aboriginal people may delay seeing a doctor or choose not to take up active treatment for cancer because it would entail entering a hospital system where they are made to feel like second-class citizens (see Chapter 17). Thus, sensitivity to cultural issues; a flexible, enquiring, negotiative approach; and a particular effort to ensure that language and cultural barriers are overcome are often required.
Below is an excerpt from an audio-recorded and translated consultation between a medical oncologist and an elderly Chinese woman, newly diagnosed with metastatic, incurable disease (Butow, Bell et al., 2011). Her husband was interpreting for her. She had just asked the oncologist how bad the cancer was.
[Excerpt 1:]
DOCTOR: [To the husband] I think it is better that she knows. Especially when she is asking the question, for her to know and to be very honest with her. She then knows that she can trust me to be honest and I will answer her questions.
HUSBAND: Hmm, yeh, yeh.
DOCTOR: [Went on explaining that the disease – a stage 3A lung cancer – had spread throughout the body and was no longer curable]
HUSBAND: [To the patient, his wife] She said it should be in its initial stage.
Below is an excerpt, again between a medical oncologist and a patient, newly diagnosed with metastatic, incurable cancer (Butow et al., 2013). The interpreter was a professional interpreter, present in the room.
[Excerpt 2:]
PATIENT: Ask the doctor if these are curable.
INTERPRETER: [To doctor] So the question is … how many in his situation, how many patients that his problem can be cured?
DOCTOR : If you mean by cure that you will be completely cured that is very very unlikely.
INTERPRETER: If you mean to be cured completely, the possibility is not very high …
DOCTOR : But you have a reasonably good chance to respond to the chemotherapy and therefore I should be able to control this cancer for … you know, for months and months.
In focus groups with interpreters who had experience in cancer consultations, one interpreter said the following:
[Excerpt 3:] I mean, to the patients [it] is … critical because in our culture it is really cruel to tell the patient that he is or she is diagnosed with cancer … maybe it can cause him to be depressed or maybe diminish his ability or willingness to survive. So we … can find some code word, like instead of saying you have cancer, we can use the word tumour … and we’re going to … treat you for that tumour, but knowing that a tumour will be treated the same way as cancer would be treated. So we can get around that and use code words just to, you know, just to make it easier … just to alleviate the situation and make it acceptable, more acceptable.
(Butow et al., 2010)
The extract below comes from another oncology consultation at which several family members were present. The exchange was a side-exchange in English to the professional interpreter.
[Excerpt 4:]
FAMILY: The doctor shouldn’t let her know in fact … it just scare her!
Can you please don’t interpret this to her? Actually, she doesn’t need to know. You can ask the questions for us, but you don’t need to interpret to her. She doesn’t need to know.
She now always says that she has pains … she has no mood to eat … we bring her out, go to yum cha with her … before the doctor has told her that, she was very vital. She could even argue with me but she becomes very frustrated after knowing that. That’s why we really don’t want to let her know.
Analysis and reflection
In excerpt 1, the doctor tells the patient’s husband beforehand that she intends to tell the patient the truth, with the rationale that truth and honesty would build trust between her and the patient. This is an approach that is often recommended in texts about cross-cultural communication (Butow & Baile, 2012). Doing this makes communication transparent, and respects patient autonomy. The husband in this case appears to agree with this approach, but a clear negotiation does not take place to ensure there is agreement. In fact, it turns out the husband does not agree, and goes on to falsify the interpretation, to ensure that his wife is not told the bad news. The doctor is not aware that her intended communication has not reached the patient.
- cross-cultural communication
communication that takes place between people from different cultures.
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