Patient Education and Counseling 58 (2005) 288–295

www.elsevier.com/locate/pateducou

The impact of an intervention in intercultural communication on

doctor–patient interaction in The Netherlands
Barbara C. Schouten a,*, Ludwien Meeuwesen a, Hans A.M. Harmsen b
a
Interdisciplinary Social Science Department, Utrecht University, P.O. Box 80.140, 3508 TC Utrecht, The Netherlands
b
Department of Health Policy and Management, Erasmus MC, University Medical Centre Rotterdam, The Netherlands

Received 24 February 2005; received in revised form 11 May 2005; accepted 4 June 2005

Abstract

Objective: Findings of scarcely available studies indicate that there are substantial gaps in intercultural doctor–patient communication. In
order to improve intercultural communication in medical practice in The Netherlands, an educational intervention was developed. The aim of
the present study was to examine the effects of this intervention on doctor–patient communication.
Methods: Participants (general practitioners: n = 38; patients: n = 124) were assigned at random to an intervention or a control group. GPs in
the intervention group received 2.5 days training on intercultural communication. Patients in the intervention group were exposed to a
videotaped instruction in the waiting room, right before the consultation. Data were collected through videotapes of visits of ethnic minority
patients to their GP and home interviews with the patients after their medical visit. Communication behaviour was assessed using the Roter
interaction analysis system (RIAS). Interview length was assessed as well.
Results: The length of the medical encounter increased significantly after having received the intervention. Total number of GP utterances
increased significantly too. When comparing relative frequencies on affective and instrumental verbal behaviour of both patients and doctors,
no significant changes could be detected.
Conclusion: It is concluded that there seems to be some change in doctor–patient interaction, but RIAS may not be suitable to detect subtle
changes in the medical communication process. It is recommended to use other analysis methods to assess cultural differences in medical
communication.
Practice implications: Knowledge about possible antecedents of gaps in intercultural medical communication should be increased in order to
be able to design effective interventions for intercultural doctor–patient communication.
# 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Doctor–patient communication; Intervention study; Intercultural communication

1. Introduction in many Western countries. For example, in The Netherlands

Patients’ ethnic and cultural background is an often
overlooked but nonetheless important variable within
doctor–patient communication studies. This topic has been
seldom investigated in such studies [1], despite the well-
recognized fact that one’s culture has a profound effect on
the way people communicate [2–6]. Incorporating patients’
cultural and ethnic background as a factor impacting on
doctor–patient communication is becoming increasingly
important though, because of the growing cultural diversity
* Corresponding author. Tel.: +31 30 2537786; fax: +31 30 2534733.
E-mail address: b.c.schouten@fss.uu.nl (B.C. Schouten).
more than 18% of the population is from other ethnic origin
nowadays (Statistics Netherlands, 2004). Findings of
scarcely available studies indicate that there are indeed
variations and gaps in the communication process between
patients and doctors, due to ethnic and cultural background
variables [7–11]. For example, in two recent Dutch studies
on communication differences between medical consulta-
tions with ethnic minority patients and with native-born
patients [7,11], it was found that consultations with migrant
patients are shorter, that there is less social talk and mutual
involvement, and that doctors spend more time trying to
build a relationship with them compared to Dutch patients.
Moreover, the doctor–patient interaction in intercultural

0738-3991/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2005.06.005
 B.C. Schouten et al. / Patient Education and Counseling 58 (2005) 288–295
consultations is rated as less friendly and warm than the
doctor–patient interaction in intra-cultural consultations.
These communication gaps between doctors and patients
can give rise to a wide range of health-related problems,
having detrimental effects on the quality of care ethnic
minority patients receive. Indeed, several studies have
shown that there is more misunderstanding, less compliance
and less satisfaction in intercultural medical consultations
compared to intra-cultural medical consultations [12–15].
Difficulties in intercultural communication are for the
greater part caused by language barriers and differences in
cultural values regarding communication and health [16–
22]. Differences in communication behaviour across
cultures often are explained in terms of diverging cultural
values, such as individualism–collectivism (i.e. the extent to
which personal goals or group norms prevail within a
culture), high-context versus low-context cultures (the
extent to which cultures pay attention to situational cues
within conversations) and independent self-construals
versus interdependent self-construals (the extent to which
the self is seen as independent from groups) [3,4,23,24].
Research shows that variations on these dimensions
influence various aspects of individuals’ communication
behaviour, such as the directness of the communication, the
use of silence in communicative acts, openness in
conversations and so on [3,4,6,25]. It is obvious that this
communicative diversity across cultures can easily lead to
communication problems and misunderstandings between
members of different cultures. Within health care, different
views on health and illness across cultures further
complicate matters. According to Kleinman [26], discre-
pancies between patients’ and doctors’ perceptions about the
patient’s illness, which he labels ‘explanatory models’,
create gaps in doctor–patient communication which in turn
lead to misunderstanding and lack of agreement about
diagnosis and treatment. For effective communication to
take place, doctor and patient should exchange each other’s
views on the patient’s illness during the consultation,
thereby uncovering and solving discrepancies in each other’s
explanatory models [27].
In sum, due to linguistic and cultural barriers, differences
between doctors’ and patients’ cultural and/or ethnic
background may easily result in communication gaps
between the two. As a consequence of these gaps,
compliance, satisfaction and mutual understanding are
likely to be poorer in intercultural medical consultations
compared to intra-cultural medical consultations. In order to
improve intercultural communication in medical practice in
The Netherlands, an educational intervention was developed
by Harmsen [12]. The content of the intervention was based
on Pinto’s theory about intercultural communication
difficulties [28], which states that these problems can be
traced back to a lack of knowledge about cultural differences
in communication behaviour and a lack of skills to bridge
the gap between these cultural differences. The first and
main part of the intervention was directed towards general
289
practitioners, the second part towards patients belonging to
different ethnic groups, who were visiting their general
practitioner. Former research found that this educational
intervention significantly increased the mutual understand-
ing between GPs and non-Western patients [29]. As it is
likely that this finding can at least partly be attributed to
improved doctor–patient communication, the aim of the
present study was to examine the combined effects of this
two-part intervention on patients’ and GPs’ communicative
behaviour. Based on previous literature on gaps in doctor–
patient communication within intercultural consultations, it
was hypothesised that if participants have more knowledge
about cultural differences, this will be reflected in an
increase in both affective communicative behaviour (e.g.
more social talk, more expressions of agreement) of GPs and
migrant patients as well as longer consultation length.
2. Method
2.1. Study design and samples
A total of 170 general practitioners in Rotterdam, The
Netherlands, with at least 25% patients from a non-Western
country of origin were approached by mail and by one repeat
request by telephone to participate in the study. Of the GPs,
38 agreed to participate, 29 male and 9 female. Participants
were assigned at random to an intervention (n = 19) or a
control group (n = 19). The intervention group received an
educational intervention on intercultural communication
given over a 2.5-day period (see below). Measurements of
GPs’ communicative behaviour took place at baseline, and
within 1 and 6 months after the intervention. A randomised
controlled trial study design was thus used to evaluate the
effects of doctors’ exposure to an educational intervention
on intercultural communication in general practice. Com-
munication data were collected by means of videotapes of
migrant patient visits (n = 124) to assess doctors’ commu-
nication skills. 28% of consultations took place at baseline,
38% of consultations took place at 1 month after doctors’
intervention and 34% of consultations took place at 6
months after doctors’ intervention.
Patients were included in the study if they belonged to an
ethnic minority group (mostly of Turkish, Moroccan and
Surinamese origin) and were older than 17. When these
criteria were met, patients visiting one of the 38 GPs for a
consultation in February, May and November 2000 were
asked to participate. Patients were approached in the waiting
room by a research assistant, who explained the procedure
and general aim of the study. When patients agreed to
participate, they signed consent forms indicating their
willingness to participate and their understanding of the
procedures and purpose of the study. Approximately half of
these patients (n = 65) received an intervention on inter-
cultural doctor–patient communication (see below); these
were all patients of GPs in the intervention group. The other
290 B.C. Schouten et al. / Patient Education and Counseling 58 (2005) 288–295
patients (n = 59) did not receive an intervention; these were
patients of GPs in the control group. Comparisons between
these two patient groups were made to evaluate the effects of
the intervention on patients’ communicative behaviour.
2.2. Description of intervention
As mentioned, the educational intervention contained a
combined offering of a main part to the GPs and a small part
to the patients. The GPs in the intervention group received a
2.5-day training on intercultural communication. The
training was based on Pinto’s ‘three step method’ [28]. In
the first step, GPs reflected on their own culturally based
norms, views and communication style; next, GPs’
sensitivity and knowledge about differences in these norms,
views and communication styles between members of
different cultures were enhanced; finally, GPs were trained
in skills to solve possible gaps in intercultural communica-
tion. Two weeks later, GPs were given the opportunity to
discuss problems experienced in their practice concerning
this issue during the last training session.
Additionally, the patients in the intervention group
were exposed to a 12 min communication instruction on
videotape in the waiting room, immediately before the
consultation. The instruction was given in their preferred
language (Moroccan-Arabic, Moroccan-Berber, Turkish and
Dutch). The main message was to illustrate to patients the
advantages of direct communication and to instruct them to
freely express any misunderstandings and disagreements.
This was done by showing them two examples of a
consultation, one with indirect communication leading to
misunderstandings between patient and doctor, and one with
direct communication leading to mutual understanding.
2.3. Data collection and description of study variables
Data for this study were derived from videotaped
observations and home interviews with the patients, carried
out 3–8 days after their visit to the GP. For purposes of the
present study, the following independent variables were
included:
1. Patients’ ethnic background. To assess ethnic back-
ground, the patients were categorised into an ethnic
minority group in accordance with their own and their
parents’ country of birth [30]. Most of the migrants were
from Turkey, Morocco, Surinam and the Antilles.
2. Patients’ orientation. Patients were further divided into a
Western and a non-Western group, based on their own
and their parents’ country of birth. Patients of west-
European, American, Canadian and Australian back-
ground were considered Western, patients from other
countries were considered non-Western.
3. Patients’ language proficiency. Language proficiency
was assessed by means of three methods: patients’ self-
reports, interviewer’s assessment and GPs’ assessment
(good, moderate, poor). Because of the high correlations
between these three measures, patients’ self-reports are
reported and used in further analyses.
4. Patients’ religiosity. This was assessed by asking patients
if they are religious, and if so, whether they are actively
practicing their religion. The answers led to a classifica-
tion into three groups: (a) religious, actively practicing;
(b) religious, not actively practicing, (c) not religious.
5. Patients’ sociodemographics, including age, gender and
educational level.
The dependent variables in this study were interview
length, number of utterances, and instrumental and
affective verbal behaviour of both GPs and patients. Verbal
behaviour of both was based on videotapes of doctor–
patient consultations, and was measured using Roter’s
interaction analysis system (RIAS; [31]), an extensively
used instrument in the field of patient-provider commu-
nication. The instrument’s unit of analysis is the utterance,
that is, the smallest meaningful string of words. The RIAS
consists of several mutually exclusive and exhaustive code
categories representing independent communication ele-
ments, some focusing on affective communicative beha-
viour, some focusing on instrumental communicative
behaviour. All verbal (affective and instrumental) beha-
viour of GPs and patients is thus merged into a number of
mutually exclusive categories. In this study, we made use
of the following seven affective categories: social beha-
viour, agreement, paraphrasing, showing concern, reassur-
ance, reflection, and disagreement. To assess the
instrumental, task-focused verbal behaviour, the following
nine categories were used: giving directions, asking for
clarification, asking questions about medical/therapeutical
issues, asking questions about lifestyle issues and feelings,
counselling on medical/therapeutical issues, counselling
on lifestyle issues and feelings, and other. The consulta-
tions were rated by two trained observers using a
computerised rating method, CAMERA [32]. Interrater
reliability was assessed by means of interclass correlations
for each category and is given in three categories: good
(ICC > 0.60), doubtful (0.40 < ICC < 0.60), and poor
(ICC < 0.40).
2.4. Data analysis
Data were first processed by means of descriptive
analyses (frequencies, means, etc.). To investigate whether
there were differences in patient characteristics between the
intervention and control groups, t-and x2-tests were
performed. t-Tests were carried out to test for differences
in patients’ communication behaviour between the control
group and the intervention group, and MANOVA’s were
performed to look for possible interaction effects between
the intervention and patient characteristics. To test whether
the communicative behaviour of doctors in the intervention
group improved over time in contrast with the commu-
 B.C. Schouten et al. / Patient Education and Counseling 58 (2005) 288–295 291

nicative behaviour of doctors in the control group, ANOVA’s Table 2

with measurement time as repeated measure were performed Number of GPs’ and patients’ utterances in control and intervention groups
for each of the communication variables. Control group Intervention group p
(n = 59) (n = 65)
GP utterances 82.2 (S.D.: 28.4) 109.2 (S.D.: 59.3) .001
Patient utterances 70.8 (S.D.: 32.3) 74.6 (S.D.: 47.3) .607
3. Results

3.1. Patient sample

Patient characteristics are described in Table 1, separately
for the intervention and control groups. There are
significantly more male patients in the intervention group
compared with the control group. With regard to the
remaining patient characteristics, no significant differences
emerged between the control group and the intervention
group. Most migrant patients were Turkish or Surinamese,
or belonged to the ‘other ethnicity’ category (e.g. Cape-
Verdian, Eastern European migrants, etc.).
3.2. Consultation characteristics
3.2.1. Interview length
Mean duration of the medical interview was 8.8 min
(S.D.: 4.8). The interviews in the intervention condition
were significantly longer than the interviews in the control
condition (both at 1 month after the intervention and at 6
months after the intervention) (mean consultation length of
intervention group: 9.8 min, S.D.: 5.6; mean consultation
length of control group: 7.6 min, S.D.: 3.3; p = .01). Table 2
shows the number of utterances of both GPs and patients
in the control and intervention conditions. The total number
of utterances of GPs and patients were higher in the
intervention condition compared with the control condition.
With regard to GP utterances, the difference reached
significance (t( 3.2); p = .001).
3.2.2. Patients’ communicative behaviour
Table 3 shows the percentages of utterances for each
category made by patients for both the control group and the
intervention group. Patients’ utterances mostly concerned
giving information about their medical condition and
therapeutic regimen (39%), followed by showing agreement
(26%). There was also some information giving about
lifestyle and psychosocial issues (11%) and social behaviour
(7%). With regard to patients’ verbal behaviour no
significant differences were found between the intervention
group and the control group on the relative frequencies of the
various RIAS categories.

Table 1
Patient sample
Control group (n = 59) Intervention group (n = 65) Total (n = 124)
Mean age 39.0 (S.D.: 11.9) 40.7 (S.D.: 13.3) 39.9 (S.D.: 12.6)
Sex* (%)
Male 30.5 49.2 40.3
Female 69.5 50.8 59.7
Education (%)
Lower 40.4 41.0 40.7
Medium 25.0 31.1 28.3
Higher 34.6 27.9 31.0
Ethnicity (%)
Surinamese/Antillean 28.8 21.6 25.0
Turkish 23.7 36.9 30.6
Moroccan 6.8 9.2 8.1
Other 40.7 32.3 36.3
Orientation (%)
Western 22.0 13.8 17.7
Non-Western 78.0 86.2 82.3
Proficiency in Dutch (%)
Good 47.5 40.6 43.9
Average 27.1 34.4 30.9
Poor 25.4 25.0 25.2
Religion (%)
Yes, practicing 62.1 67.7 65.0
Yes, not practicing 20.7 23.1 22.0
No religion 17.2 9.2 13.0
*
Significant difference between intervention group and control group on this variable ( p < .05).
292 B.C. Schouten et al. / Patient Education and Counseling 58 (2005) 288–295

Table 3
Patients’ communicative behaviour in control and intervention groups
Behaviour category Control group Intervention group p Total (n = 124) ICC
(n = 59) % (S.D.) (n = 65) % (S.D.) % (S.D.)
Affective behaviour
Social behaviour 7 (5) 6(5) ns 7 (5) G
Agreement 25 (11) 27 (11) ns 26 (11) D
Paraphrase 2 (3) 2 (3) ns 2 (3) G
Showing concern 1 (3) 2 (3) ns 1 (3) G
Reassurance 0 (1) 0 (1) ns 0 (1) D
Disagreement 0(1) 0(1) ns 0 (1) P
Reflect feelings 0 (1) 0 (1) ns 0 (1) G
Total 35 (12) 37 (12) ns 36 (12)

Instrumental behaviour
Giving directions 1 (1) 1 (1) ns 1(1) D
Asking clarification 1 (2) 1 (2) ns 1(1) G
Asking questions
Medical/therapeutical 4 (4) 4 (4) ns 4 (4) G
Lifestyle/psychosocial 1 (4) 0(1) ns 1 (3) P
Giving information
Medical/therapeutical 40 (15) 38 (13) ns 39 (14) G
Lifestyle/psychosocial 12 (13) 11 (11) ns 11 (12) D
Counsels
Medical/therapeutical 0 (0) 0 (0) ns 0 (0) P
Lifestyle/psychosocial 0 (0) 0 (0) ns 0 (0) D
Other utterances 6 (6) 8 (8) 0.08 7 (7) G
Total 65 (12) 63 (12) ns 64 (12)
ICC: intraclass correlation; G: ICC > 0.60; D: 0.40 < ICC < 0.60; P: ICC < 0.40.

Although no main effects of the intervention were found,
a number of significant interaction effects emerged between
some patient characteristics (i.e. educational level and
cultural orientation) and having received the intervention or
not. With regard to education, the intervention had a
significant positive effect on the percentage of utterances in
the ‘other’ category of RIAS for patients with medium and
higher educational levels, but not for patients with lower
educational level (F = 4.4; p = .01). Furthermore, while no
main effect of intervention on giving information on
medical/therapeutical issues emerged, we found an inter-
action effect between the intervention and having Western/
non-Western orientation. Patients in the intervention group
gave significantly more medical/therapeutical information
compared to patients in the control group when they were
Western-oriented, but not when they were non-Western
oriented (F(4.7); p = .03).
3.2.3. Doctors’ communicative behaviour
Table 4 summarises the percentages of utterances for
each category made by doctors for both the control group
and the intervention group at the three different measure-
ment times. Doctors’ utterances mostly concerned giving
medical/therapeutical information, followed by showing
agreement. There was also some paraphrasing, giving
directions and asking questions about medical/therapeutical
issues. To test whether the intervention improved doctors’
communicative behaviour a series of ANOVA’s with
repeated measures were carried out, with each of the
communication measures as dependent variable.1 No
significant effects of the intervention over time on doctors’
communicative behaviour were found.
4. Discussion and conclusion
4.1. Impact of the educational intervention on doctor–
patient interaction
In this article we assessed the effects of an educational
intervention aimed at improving doctors’ and patients’
communicative behaviour during intercultural medical
encounters. Results show that total interview length
increased after the intervention by more than 2 min,
suggesting that changes in the communication process did
take place. Also, a significant increase emerged in doctors’
utterances but not in patients’ utterances. Hence, the
increase in interview length seems to be attributable to
doctors talking significantly more to their patients, but less
so the other way around. Whether the increased talking time
by GPs can be interpreted as a favourable outcome is hard to
tell, because no differences could be detected before and
after the intervention on the relative frequencies of the
1
ANOVA’s with repeated measures could not based on all consultations,
because as this analysis technique is a within-subject design, it requires data
on all measurement times. As this was not always the case, the lower
number of consultations (n = 88) is due to missing data.
 B.C. Schouten et al. / Patient Education and Counseling 58 (2005) 288–295 293

Table 4
Doctors’ verbal behaviour in control and intervention groups
Baseline One month after intervention Six months after intervention ICC
Control Intervention Control Intervention Control Intervention
(N = 15) (N = 12) (N = 13) (N = 15) (N = 16) (N = 17)
% S.D. % S.D. % S.D. % S.D. % S.D. % S.D.
Social behaviour 7 2 7 4 8 3 6 3 7 3 6 6 G
Agreement 18 6 20 9 18 7 19 6 17 4 23 9 G
Paraphrase 10 4 9 5 9 5 11 3 8 4 9 4 G
Reflect feelings 1 1 1 1 1 1 1 1 2 2 1 1 P
Showing concern 1 1 1 1 0 1 0 1 0 1 0 1 G
Reassurance 3 2 3 3 1 1 2 2 2 1 2 1 G
Disagreement 0 0 0 1 0 0 0 0 0 1 0 0 P
Total 40 5 41 9 37 8 39 5 36 6 41 10

Giving directions 10 6 8 4 8 4 9 4 8 3 9 5 G
Asking clarification 4 3 3 2 4 3 3 2 4 3 3 2 D
Asking questions medical/therapeutical 9 3 7 3 8 4 9 3 10 4 8 5 G
Asking questions lifestyle/psychosocial 3 3 4 2 3 2 4 2 3 2 3 2 G
Giving information medical/therapeutical 24 9 23 8 23 10 22 7 24 8 22 11 D
Giving information lifestyle/psychosocial 1 2 1 2 4 5 1 1 3 2 2 3 P
Counsels medical/therapeutical 4 3 5 3 5 2 6 3 5 3 4 2 G
Counsels lifestyle/psychosocial 0 1 2 3 1 1 1 1 1 2 1 1 G
Other utterances 5 4 6 5 7 6 6 5 6 5 6 4 G
Total 60 5 59 9 63 8 61 5 64 6 59 10
ICC: intraclass correlation; G: ICC > 0.60; D: 0.40 < ICC < 0.60; P: ICC < 0.40.

various RIAS categories. That is, all categories of talk were
increased by the same amount, leaving us an unknown in
terms of which factors this increased encounter length can be
ascribed to. Still, when combining the fact that there was
better mutual understanding in the intervention group
compared to the control group [29] with the fact that
previous research has shown that intercultural consultations
are shorter than intra-cultural consultations, we are inclined
to conclude that this increased encounter length is probably
for the better.
Additionally, no main effects of the intervention on
affective and instrumental verbal behaviour (as assessed by
RIAS) of patients could be detected. However, two
significant interaction effects did emerge, suggesting that
the intervention might only have had an effect on specific
subgroups of migrant patients. It was found that for both
higher educated migrant patients and Western-oriented
migrant patients, the intervention has led to increased
percentages in the ‘other’ category of RIAS and in giving
medical/therapeutical information, respectively. So, as far as
RIAS results emerged, it suggests that only Western-
oriented and/or higher educated patients seem to have
benefited from the intervention. These results point to the
possibility that the mere exposure to videotapes in possibly
noisy and crowded waiting rooms may not be enough of an
intervention to reach all migrant patients, and that only
higher educated, Western migrants profited from these
videotaped instructions. It would therefore be worthwhile to
educate these harder-to-reach migrant groups through more
extensive interventions, such as the one carried out by Roter
[33], in which patients were extensively trained and guided
before their medical visit to become more assertive with
their physician.
4.2. Study limitations and prescription for future
research
An important limitation of this study is that especially in
the GP group, the sample size was low, which may have led
to power problems of the statistical tests. For instance, as can
be seen from Table 3, there are some communication
measures that improved over time in the GPs’ intervention
group, such as showing agreement and asking for clarifica-
tion; these might have been statistically significant with a
larger sample size. However, in this kind of research it is
very hard to find enough participants, which makes a
replication study with a larger, more representative sample
unlikely to achieve. Nonetheless, in order to enhance the
generalisability of the results, this study should be replicated
with other samples and intervention techniques, such as the
one described above.
A second limitation of this study is the way the
observational data were analysed, that is, with frequency
countings of behavioural units. Although it is beyond dispute
that scoring techniques such as the RIAS have their own merit,
as they provide us with information about the relational
aspects of interactions, they fail to present us with details on
the dynamics and specific content of doctor–patient interac-
tion. With regard to this study, it is plausible to assume that the
intervention did have an effect on doctors’ and patients’
294 B.C. Schouten et al. / Patient Education and Counseling 58 (2005) 288–295
communicative behaviour, as both interview length and GPs’
utterances significantly increased. The RIAS however may
not be suitable to detect more subtle changes in commu-
nication patterns. Therefore, we are currently investigating
the same data with other observational techniques (i.e.
sequence analysis and discourse analysis), to see to which
changes in communicative behaviour this increased encoun-
ter length can be attributed to. These techniques also enable us
to research the exact content of the ‘other’ category of RIAS,
as this is one of the few categories that increased slightly for
all patients, substantially so in the case of higher educated
migrant patients.
Finally, it should be noted that the intraclass correlations
of a notable number of RIAS categories were low, indicating
that various verbal aspects of doctor–patient communication
were scored unreliable. More empirical research is thus
needed on assessing doctor–patient communication reliably
within an intercultural context, preferably by making use of
observers belonging to the same ethnic groups as the patients
under study.
4.3. Practice implications
To overcome cultural barriers to communication in health
care a number of strategies have been proposed which aim to
increase the cultural competency and sensitivity of health care
practitioners and the health care system. For example, Brach
and Fraser [34] identified nine major cultural competence
techniques, including the use of interpreter services,
increasing the number of minority staff, training health care
practitioners and coordination with other parties involved
such as traditional healers and family members. A technique
to improve intercultural/interethnic doctor–patient commu-
nication that has received considerable attention are educa-
tional interventions aimed at increasing doctors’ (and
sometimes patients’) cultural competence [34–37]. Such
interventions are designed to improve or alter physician’s
attitudes, knowledge and skills in the context of intercultural
communication. The idea behind such interventions is that
difficulties in communicating with migrant patients arise out
of a lack of knowledge about the influence of culture on health
and a deficiency in communicative skills to reach some kind
of mutual understanding with these patients. Enhancing these
skills and knowledge will help achieve a more adequate
negotiating process in which explanatory models can be
exchanged and mutually desirable goals reached. Up to now,
the empirical evidence for the effectiveness of such
interventions is weak. In a review of the empirical literature
on the effectiveness of five different types of interventions to
enhance cultural competence in health care systems,
Anderson et al. [38] concluded that empirical evidence is
insufficient to determine the effectiveness of such interven-
tions, and that more research is needed to arrive at valid
conclusions.
We would like to add that it is necessary to gain more
knowledge about the underlying (cultural) mechanisms of
intercultural communication difficulties in general practice.
That is, more knowledge is needed about which aspects of
patients’ and doctors’ beliefs, values, knowledge systems
and behaviour play a role in these communication gaps, and
why. For example, doctors in this study were trained to
become more aware of the existence of cultural differences
in health views and in strategies to solve gaps in views and
communication styles. While there is no doubt about the
value of such an approach (physicians who are culturally
sensitive report being more capable of adequate intercultural
communication and are less anxious during such encounters
[39]), it is questionable that this will suffice in overcoming
all communication gaps between people with different
cultural or ethnic background. For instance, it is also
possible that communication problems are not primarily the
result of lack of knowledge about cultural differences but of
linguistic barriers or time management problems during the
consultation. Consequently, research aimed at clarifying
which aspects of the intercultural medical communication
process should be the target of behavioural change, would
greatly enhance our possibilities to design effective
interventions to improve intercultural doctor–patient com-
munication.
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