When cultures meet in general practice: intercultural differences between GPs and parents of child patients

Abstract

Although health care professionals in The Netherlands are increasingly confronted with diverse immigrant groups, medical counselling and treatment of these groups has not been the subject of extensive research yet. From other studies it is well known that intercultural differences can have serious consequences for health care, e.g. in terms of risk of incorrect diagnoses or non-compliance. Eighty-seven autochthonous Dutch and immigrant (mainly from Turkey and Surinam) parents of child patients and their general practitioners (GPs) were recruited to investigate the influence of cultural differences on mutual understanding and patient compliance. Analyses of questionnaires and home interviews revealed that there is a relation between the cultural background of the patient and effectiveness of communication. Communication in consultations between GPs and persons from ethnic minorities is less effective than in consultations with Dutch persons: there is more misunderstanding, and also more non-compliance. In general, mutual understanding between GP and patient proves to be a strong predictor for patient compliance. These findings hold especially true for patients living in two worlds, i.e. a mixture of traditional and western cultures. The results are discussed in terms of methodological issues and practical implications for the health care providers.

Introduction

Due to worldwide migration, health care professionals are increasingly confronted with people from various ethnic backgrounds. In The Netherlands, about 15% of the population are immigrants, the largest group being from Moroccan and Turkish origin. Although there are indications to believe that counselling and treatment of non-Dutch patients is not as effective as in the case of autochthonous Dutch patients [1], this has not yet been the subject of serious research. Elsewhere, this intercultural phenomenon in health care has been studied in relation to consequences for medical care [2], [3], [4] and describes, for example, inappropriate use of health services (particularly out-of-hours use), the risk of incorrect diagnoses, and non-compliance with the advised treatment [5]. Effective communication between physician and patient is crucial to obtain optimal quality of care [6], [7]. In the case of consultations involving children, who are dependent on both parents and general practitioner (GP) for good medical care, both parties have a responsibility to achieve effective communication. Reasons for not effective communication are numerous, however, for interethnic communication the main reasons include cultural differences, linguistic (in)competence, and educational level [2], [3], [8], [9], [10], [11].

Cultural differences (as explanations for the failing health care of certain groups of immigrants) stress the discontinuity between group-oriented norms and values, social coherence in immigrant home cultures, and the emphasis on individualism and autonomy in the dominant culture of the health care [12]. At the same time, cultural values and practices are not regarded as static and unchangeable. On the contrary, they are regarded as dynamic processes which are reinvented in the course of the migration history and in interaction with the recipient country [13]. In this process, the caregivers as well as the caretakers accommodate, and new forms of interaction will be invented. This so-called acculturation process refers to the reciprocal interaction between one or more minority cultures and the dominant culture, and requires mutual adjustments in intercultural contacts [14]. However, the relation between acculturation and health processes is rather complex [15]. To get elucidate these processes of acculturation in the context of patient–GP relations, the concept of clinical reality is relevant.

One of the prerequisites for effective intercultural communication is that patient and physician agree on the health problem of the patient and understand, acknowledge and respect each other’s explanatory models for the health problem [8]. Kleinman et al. [16] illustrated the influence of culture on a person’s perspective of health and illness and called it ‘clinical reality’. Personal experience, family attitudes and group beliefs shape patients’ health beliefs; physicians’ beliefs are formed by the biomedical model, learned in medical training. The authors showed how ‘clinical reality’ influences mutual understanding between GP and patient [16]. The fact that physicians and patients hold discrepant models of health and illness and the fact that this may influence the manner in which health problems are presented, affect the outcome of a clinical visit; for example, patient non-compliance with advised therapy [17]. The only way to become acquainted with each other’s ‘clinical reality’ is by exchanging explanatory models. So cultural differences, expressed in the patient’s and physician’s beliefs about health and illness, should be considered in patient–doctor communication [16], [18], [19], [20].

The aim of the present study is to investigate: the relative influence of the parental ethnic background, the GP’s perception of parental cultural orientation, the (parental) educational level and the parental proficiency in the Dutch language on: mutual understanding between physician and parent regarding the health problem and patient compliance.

The investigated relations are schematically given in Fig. 1.