Module 7: Communication and Health Education

There are many components to fostering successful communication between the medical provider and the patient, whether the medical provider and patient are from the same culture and community, or from differing locations.  It is important to comprehend language in spoken, written, and nonverbal forms, in addition to having the ability to generate one's own speech and expressions.  Emotions are a critical aspect of communication, and learning to read the subtleties of facial expressions and gestures is critical.  The medical provider should observe subtle habits of the culture such as whether or not eye contact is permitted, as well as the acceptable hand gestures that are used to signal the commands such as “come here” or “stop.”  In any cultural setting, the key to effective interactions is to adopt the methods and manners of the local community.(1)

Language of course can serve as a huge barrier if the physician cannot communicate on a basic level with his or her patient.  Additionally, culturally specific differences exist in one’s ability to examine, introspect, and articulate.  “The ability to translate the emotional infrastructure to the verbal superstructure is essential in the medical settings”, as the patient and doctor must have a common understanding, and the patient must trust the doctor. It can be frightening for an ill patient to be unable to convey their physical pain or unable to explain any anxieties about diagnosis or treatment.  Ineffective and confusing language exchanges can damage the alliance between patient and physician, and can limit the amount of questions the patient asks the doctor.  It is important to remember that understanding the words of a language does not inevitably translate to understanding the “modes of thought” of that specific culture.  Views on pain tolerance and pain threshold, as well as how pain is expressed, are of particular importance to a physician to ensure they are not hurting their patient.(2)

If a physician is not competent in the patient's language, they should try their best to learn key terms. Also, an on-site language coach is vital to correct “pronunciation, inflection, and idiom.”  It is helpful to be able to convey as many medical phrases as possible because those are the ones most relevant to patient care.  Translators and a plethora of textbooks also assist in providing the best possible language foundation.(3)

In order to effectively communicate with a patient, it is important to appreciate social factors that guide health behaviors.  Cultures vary in their definitions of what is acceptable, and it is imperative that these differences are acknowledged and understood by medical intervention programs so that patients will not be confused or offended.  In addition to differences in language (a discrepancy that is easy to audibly detect), it is important to be sensitive towards differing religious attitudes (sometimes revealed through dietary choices that must be adhered to during hospital stays), and approaches towards dealing with pain.  In a study comparing cancer patients across cultures, it was observed that “members of one culture will maintain stoic self-control, but members of another culture will wail and moan with the same pain stimulus.  A third cultural group first complained about terrible suffering, but then endured it grimly.”(4)

Those involved with healthcare delivery must understand each patient's “family function, sex roles, language, disclosure of information, pain, attitudes towards illness and health practices, immigration, religion, autonomy/dependency, death, and bereavement.”(5)  In order to foster a secure and personal connection with a patient, it is critical that the physician know how the patient views family.  For example, many societies have a comprehensive inclusion of grandparents, cousins, aunts, and uncles – these differences are an example of how different patients expect different levels of involvement from their family members, and the medical provider must be sensitive to a variety of personal needs expressed by each patient.(6)

Case Study: Health Education

The following case study reveals how health education campaigns can be ineffective if there is not an interactive communication between the people implementing the programs and the members of the community.  Before a strong stance on HIV was adopted by governmental leadership in Thailand in the early 1990s, HIV/AIDS severely threatened national health infrastructure and general stability of the country. (7)  In an attempt to contribute to the national goals of HIV-transmission reduction, the Peace Corps made efforts to provide condom demonstrations for local villagers.  However, these sessions were not ultimately successful: “In the old days volunteers used bananas in the demonstration but switched to wooden replicas when they discovered that some participants went home and actually put condoms on bananas thinking it had some sort of power to keep them safe.”(8)

HIV/AIDS education and prevention is a large part of the work that Peace Corps volunteers carry out in health sectors of Africa, the Caribbean, Eastern Europe, and Central Asia.(9)  While encouraging condom use is “a critical element in a comprehensive, effective, and sustainable approach to HIV prevention and treatment,” the way in which the educational material is communicated to its target audience must be adapted to local cultural circumstances.(10)  A document published by the United Nations Population Fund, UNAIDS, and the World Health Organization states that: “Condoms must be readily available universally, either free or at low cost, and promoted in ways that overcome social and personal obstacles to their use,” in addition to the reality that, “HIV prevention education and condom promotion must overcome the challenges of complex gender and cultural factors.”(11)

Recognition and respect for such cultural factors and social obstacles can be achieved through “cultural competence.”  Achieving this competence “implies having the capacity to function effectively as an individual and an organization within the context of cultural beliefs, behaviors, and needs presented by consumers and their communities.”(12)  This includes involving the community in pinpointing issues and generating solutions, collaborating with other local agencies to determine best practices, and evaluating receptivity to and outcomes of community-based endeavors.  In addition to a closer examination of the culturally acceptable methods of knowledge dissemination, a “cultural broker” – a liaison between outsiders and insiders who understands the “health values, beliefs, and practices within their cultural group of community” – might have been helpful in the Peace Corps volunteers’ situation.

A case study from the Asaro Valley of the Eastern Highlands Province of Papua New Guinea provides a counterexample of how community health education about sexually transmitted diseases can be effectively achieved.  In their preliminary investigation, researchers found that the national prevalence of STDs is high (25% of men and women have Chlamydia, and 45% of women suffer from trichomal vaginitis), yet knowledge about STD transmission is low.  Before they started their health education workshops, researchers sought the guidance of a professional health educator from the country’s Division of Health.  The native specialist shared the teaching techniques that she believed would be ideal for the Papua New Guineans.  These included lectures, visual aids, group discussions, one-on-one health education, interviews, and demonstrations.  In order to determine which methods were most well-received, these techniques were then tested and evaluated in various community settings.

Teaching aids included “cardboard models and puppets, line drawings of basic reproductive anatomy and drawings of people engaging in various activities or showing signs of symptoms of disease.”  Initially, educators utilized both bananas and wooden penis models for condom demonstrations.  However, when villagers voiced discontent about the explicit nature of the materials, researchers responded by developing a system in which village representatives would preview the materials before they were used in the workshops.(13)  This action showed the villagers that the researchers were flexible in their methods, accommodating to cultural beliefs about sexuality, and sensitive to participants’ discomfort.  “Enthusiastic support from the leaders” also helped boost the researchers’ credibility.(14)   Researchers found that the majority of women had never seen nor used a condom.  Hence, it was “important to demonstrate their use, and also to get the participants to handle them and, if possible, practice putting them on the models.”  Contrary to the changes that were necessary in the Peace Corps condom demonstration protocol, “bananas worked better than wooden penis models, because the women were less embarrassed about handling them.”(15)

The overarching lesson from all of these experiences is simple: it takes cultural competence, intensive assessment of community values, adjustment to cultural preferences, and space for open dialogue and feedback to implement an efficacious health education or medical intervention program.

Footnotes

(1) Downing, Diana.  Tropical Nursing, Chapter 11 in Surgery and Healing in the Developing World ed. By Glenn W. Geelhoed.  Georgetown, Texas, Landes Bioscience, pages 87 –­­ ­­91.  Accessed on 29 June 2010.

(2) Ibid.

(3) Downing, Diana.  Tropical Nursing, Chapter 11 in Surgery and Healing in the Developing World ed. By Glenn W. Geelhoed.  Georgetown, Texas, Landes Bioscience, pages 87 –­­ ­­91.  Accessed on 29 June 2010.

(4) Trill, M. & Holland, J.  “Cross Cultural Differences in the Care of Patients with Cancer.”  General Hospital Psychiatry, 15, 21-30 (1993).  Accessed on 30 June 2010.

(5) Ibid.

(6) Trill, M. & Holland, J.  “Cross Cultural Differences in the Care of Patients with Cancer.”  General Hospital Psychiatry, 15, 21-30 (1993).  Accessed on 30 June 2010.

(7) “HIV & AIDS in Thailand.” AVERT.org. Accessed on 26 May 2010.

(8) Schimmelpfennig, S. “Mosquito nets, condoms and recycling.” Good Intentions Are Not Enough: An honest conversation about the impact of aid. Posted on 22 September 2009. Accessed on 26 May 2010.

(9) “HIV/AIDS.” Peace Corps. Accessed on 27 May 2010.

(10) “Position Statement on Condoms and HIV Prevention.” UNAIDS, WHO, UNFPA. July 2004, page 1. Accessed on 26 May 2010.

(11) Ibid, pages 1-2.

(12) “Cultural Competence.” National Prevention Information Network. Accessed on 26 May 2010.

(13) Horton, K., Lupiwa, S., Passey, M., and Suve, N. “Knowledge about sexually transmitted diseases in rural and periurban communities of the Asaro Valley of Eastern Highlands Province: the health education component of an STD study.” Papua New Guinea Medical Journal. 39.3 (September 1996): 244. Accessed on 27 May 2010.

(14) Ibid, page 245.

(15) Ibid, page 245.