ReviewFactors influencing intercultural doctor–patient communication: A realist review
Introduction
Due to increasing worldwide migration since the 1960, healthcare in the modern Western world is confronted with the consequences of a multi-ethnic society [1]. One of the main areas where these consequences are apparent is in the interaction between doctors and patients. As research on communication in healthcare has shown, there is ample evidence that communication affects numerous outcomes, such as patient satisfaction and adherence, and, consequently, health outcomes [2], [3]. One of the challenging areas of healthcare communication is communication with culturally diverse patients [4]. Intercultural doctor–patient contacts are potential sources of misunderstanding and low quality communication, which may reduce the quality of care [5].
Causes for misunderstanding and difficulties in intercultural communication (ICC) are sought in differences in perspectives, values and beliefs about illness between doctors and patients with different ethnic backgrounds [6], [7], [8], [9]. Illness is culturally determined in the sense that how we perceive, experience and cope with disease is based upon our explanations of illness [7]. Hence, difficulties in intercultural doctor–patient communication could be explained by differences in culture rather than by a supposed inferiority of specific cultures [8]. Another possible influence on the quality of patient communication is that many doctors feel incompetent to communicate and relate to patients from different ethnic backgrounds due to a lack of adequate skills, language barriers or knowledge of communication with these patients [10], [11]. For example, doctors behave less effectively when interacting with ethnic minority patients compared to ethnic majority patients [5], [12]. Also, ethnic minority patients themselves are less verbally expressive and seem to be less assertive during the medical encounter than ethnic majority patients [12].
In recent years, medical education has paid more attention to ICC, or to cultural competence on a broader scale (see Table 1 for terminology). Although the necessity of training in ICC has been increasingly recognized [13], many countries with a multi-ethnic patient population have not structurally implemented training in this area in their medical curricula [14], [15], even though there is a flourishing debate about appropriate training of health professionals to respond to ethnic diversity [16], [17]. Next to the difficulties of implementing ICC in medical curricula, assessment of ICC remains challenging [18], and there is a risk that ICC and cultural competence training reinforce stereotyping [19]. The challenge, therefore, is to achieve a balance between theory and practice. Developing an appreciation of theoretical concepts of ICC is desirable for ‘generic learning’. However, such learning would fail without emphasizing its relevance to practice [16].
The field of ICC in healthcare has been studied extensively. For example, Schouten et al. performed a systematic review in this field to gain more insight into the effects of ethnic background on the medical communication process [12]. Although their research was substantial, it was limited by including observational studies only. The authors concluded that there are differences in the communication with ethnic minority patients compared to ethnic majority patients, and they advised to focus further research on explanatory factors to advance knowledge about the origins of and solutions for problems in ICC [12].
Several studies recommended an exploratory review to reveal what factors influence the outcome of ICC [20], but as far as we know, such a review is still lacking. A systematic description of the influencing factors in ICC may inform the development and implementation of training and education for doctors, which could provide opportunities to facilitate communication of better quality [1], [21]. Also, such research could give insight into the link between patient-centered communication and ICC, which was mentioned in several papers [13], [17].
The present paper provides an overview of the literature on the perceptions and experiences of doctors and patients related to communication in an intercultural setting. Although ICC can include many contexts, we focused on the largest and perhaps most challenging group of intercultural encounters, i.e. those between doctors of the ethnic majority and their patients of the ethnic minority (see Table 1 for the used definition of ICC). Our research was guided by the following questions: Which factors influence the communication process between doctors and patients of different ethnic backgrounds? How do these factors influence the communication?
To apply the intended exploratory focus, we performed a realist synthesis, which could help us to gain insight into the complexity of communication between doctors and patients [22]. We tried to formulate a framework for medical education, which could be used for the development of ICC training for doctors. Our main focus was not on the misunderstandings, but on the broader concept of intercultural communication.
Section snippets
Methods
We conducted a systematic review of the literature using the realist synthesis method guided by the RAMESES guideline, a realist review guideline [22]. A realist review is a strategy for synthesizing research that has an explanatory rather than a judgmental focus. It can include qualitative as well as quantitative studies, which enables us to focus on the content, i.e. meaningful and useful results, of the articles. The adjective realist refers to the philosophy of science called Realism, which
Characteristics
For this realist review we considered 51,179 articles, 145 of which met the final inclusion criteria. The included articles were written in English, French, German, Italian and Norwegian. All but 5 articles [31], [32], [33], [34], [35] were from western countries. The 5 remaining articles were from Israel [31] and South Africa [32], [33], [34], [35]. The selection process and subsequent categorization are summarized in Fig. 1. Appendix B presents the characteristics of the included articles and
Discussion
The aim of this review was to summarize the current knowledge on the factors that influence ICC and to explore the mechanisms through which these factors influence ICC. The use of a realist synthesis provided the opportunity to include a broad range of papers and to explore the context, mechanisms and outcomes in each of the included articles. From a total of 145 included articles, we derived four communication challenges (contextual factors) and several objectives and communication skills
Funding/support
None.
Ethical approval
Not applicable.
Conflict of interest statement
The authors report no conflict of interest, no financial competing interests and no non-financial competing interests. The authors alone are responsible for the content and writing of the paper.
Acknowledgments
We are grateful to the persons who helped with the inclusion of articles, Anneli Mellblom, Alessandro Bottacini, Karsten van Loon, Noera Kieviet, Sanne Schinkel en Lex Paternotte. Special thanks are conveyed to Cibele Alvim, intercultural communication specialist, who helped with all the work of selecting the full-text. We are thankful to Hans Ket and Chantal de Haan, information specialists of the Sint Lucas Andreas hospital, who helped with the database searches. Also, Marianne Kerssens,
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