Patient Education and Counseling 64 (2006) 21–34

www.elsevier.com/locate/pateducou

Review

Cultural differences in medical communication: A review of

the literature
Barbara C. Schouten *, Ludwien Meeuwesen
Interdisciplinary Social Science Department, Research Institute for Psychology and Health, Utrecht University,
Utrecht, The Netherlands

Received 22 June 2005; received in revised form 9 November 2005; accepted 19 November 2005

Abstract

Objective: Culture and ethnicity have often been cited as barriers in establishing an effective and satisfying doctor–patient relationship. The
aim of this paper is to gain more insight in intercultural medical communication difficulties by reviewing observational studies on intercultural
doctor–patient communication. In addition, a research model for studying this topic in future research is proposed.
Methods: A literature review using online databases (Pubmed, Psychlit) was performed.
Results: Findings reveal major differences in doctor–patient communication as a consequence of patients’ ethnic backgrounds. Doctors
behave less affectively when interacting with ethnic minority patients compared to White patients. Ethnic minority patients themselves are
also less verbally expressive; they seem to be less assertive and affective during the medical encounter than White patients.
Conclusion: Most reviewed studies did not relate communication behaviour to possible antecedent culture-related variables, nor did they
assess the effect of cultural variations in doctor–patient communication on outcomes, leaving us in the dark about reasons for and
consequences of differences in intercultural medical communication. Five key predictors of culture-related communication problems are
identified in the literature: (1) cultural differences in explanatory models of health and illness; (2) differences in cultural values; (3) cultural
differences in patients’ preferences for doctor–patient relationships; (4) racism/perceptual biases; (5) linguistic barriers. It is concluded that by
incorporating these variables into a research model future research on this topic can be enhanced, both from a theoretical and a methodological
perspective.
Practice implications: Using a cultural sensitive approach in medical communication is recommended.
# 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Intercultural communication; Doctor–patient communication; Medical communication; Ethnicity; Review

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.1. Study design and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2. Research questions and findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.1. Doctors’ communicative behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.2. Patients’ communicative behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2.3. Culture’s influence on doctor–patient communication: antecedents and outcomes . . . . . . . . . . . . . . . . . . . . . 27
4. Discussion and conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

* Corresponding author at: Interdisciplinary Social Science Department, Utrecht University, P.O. Box 80140, 3508 TC, Utrecht, The Netherlands.
Tel.: +31 30 2537786; fax: +31 30 2534733.
E-mail address: b.c.schouten@fss.uu.nl (B.C. Schouten).

0738-3991/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2005.11.014
22 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34

4.1. Proposal of research model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

4.1.1. Cognitive processes: Kleinman’s explanatory model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.2. Cultural values: individualism–collectivism and self-construals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.1.3. Motivational processes: patient preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.1.4. Perceptions: racism/bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.1.5. Language: linguistic barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.2. Study limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.4. Practice implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

1. Introduction have shown that there are considerable disparities in access

A recent issue in the study of doctor–patient interaction is
the relation between patients’ ethnic background and
medical communication, and the fundamental question this
raises to what extent belonging to an ethnic/cultural group
influences the communication process between patients and
health care practitioners. To pose this question is of vital
importance, because in today’s multicultural society health
care practitioners are increasingly confronted with patients
from different cultural and ethnic backgrounds. For instance,
in The Netherlands more than 18% of the population is from
other ethnic origin nowadays [1]. Encounters with these
patients are likely to differ from meetings between doctors
and patients sharing the same cultural or ethnic background,
because people from different cultures hold different beliefs
about health, illness and communication [2,3]. These
divergent beliefs, as well as linguistic barriers that often
exist between members of different cultures, confront health
care practitioners with the difficult task to deliver good
quality care to a wide diversity of patients, each bringing his
own unique background to the medical encounter.
Culture1 and ethnicity have often been cited as barriers in
establishing an effective and satisfying doctor–patient
relationship [4–6]. For example, results of a number of
survey studies indicate that there is more misunderstanding,
less compliance and less satisfaction in intercultural medical
consultations compared to intra-cultural medical consulta-
tions,2 even after adjusting for socio-economic variables
such as education and income [7–10]. Moreover, health care
providers find consultations with ethnic minority patients
often emotionally demanding and patients’ reasons for
visiting unclear [11,12]. Furthermore, numerous studies
1
Culture has been defined in many ways. It is beyond the scope of this
article to go into this topic in much detail. Important to note here is that we
assume that culture guides communicative behaviour. Furthermore,
although much empirical work seems to equate culture with ethnicity,
we do not equate these two concepts. On the contrary, one of the main
points of this article is that future research should cease to equate culture
with ethnicity, as within one ethnic group various cultures may exist, and
ethnicity is but one element of culture.
2
In the current article, intercultural medical consultations are defined as
consultations between health care practitioners and patients having different
ethnic and/or cultural backgrounds, intra-cultural medical consultations as
consultations between health care practitioners and patients sharing the
same ethnic and/or cultural background.
to care as well as in health outcomes as a consequence of
patients’ ethnic background. For example, ethnic minority
patients are less likely to be recommended for certain
treatments than White patients [13,14]. Although these
disparities in health (care) are probably partly related to
socio-economic variables such as income, gaps in doctor–
patient communication are likely to play a crucial role as
well, since it is well known that this factor is positively
associated with various health-related outcomes [15].
Hence, possible gaps in intercultural medical communica-
tion seem to place ethnic minority patients at an increased
risk of receiving inferior care.
The overall aim of the present study is to gain more
insight into the effects of patients’ and doctors’ cultural/
ethnic backgrounds on the medical communication process.
Main research question is whether there are any differences
in doctors’ and patients’ communicative behaviour between
intercultural and intra-cultural consultations, and if so,
which differences. A second question concerns how these
differences may be explained and what consequences they
have for patient outcomes, such as patient satisfaction,
compliance and understanding. Because our focus in this
review is on communicative behaviour, we will investigate
the first research question by reviewing observational studies
on intercultural medical communication as this method
yields the most reliable data with regard to assessing
behaviour. However, with respect to the second research
question, the broader literature on intercultural health
communication (including other research methods as
surveys, focus groups and so on) will be included as this
may add relevant findings to the results of our observational
review. Combined with our review results, in the second part
of this article these findings will be used to design a research
model that can be used in future research on this topic.
2. Methods
We performed a literature review using online databases
(Pubmed, Psychlit), and searched for further eligible literature
through references in scientific papers and books. The
following key words were used, in different combinations:
doctor–patient communication, physician–patient commu-
nication, culture, ethnicity, race, diversity, non-English
 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
speaking, intercultural communication, cross-cultural com-
munication, medicine, language barriers, medical consu-
ltation, medical communication and medical interview.
Publications were included if they met the following criteria:
1. The study was directed at the verbal and/or non-verbal
communication between doctors and patients, with
patients and doctors having dissimilar cultural/ethnic
backgrounds.
2. The study involved either audio or video recordings of
the consultation or direct scoring of doctor–patient
communication during consultations.
3. The study was published in English from 1974 to 2004.
The literature search produced 14 articles meeting the
inclusion criteria. These articles examined the impact of
patients’ culture/ethnicity on doctor–patient communication
and formed the basis of the current review study. The studies
were evaluated in terms of their methods, research questions
and findings, and whether variations in doctor–patient
communication were related to antecedent factors and
outcome measures.
3. Results
3.1. Study design and methods
Table 1 contains an overview of the study design and
methods used; 12 studies were quantitative and two
studies qualitative in nature. Most studies were carried out
in the United States during the last decade within the
setting of a family practice or general practice. Parti-
cipating physicians were mostly residents in their second
or third year of medical training (in the US) or general
practitioners.
Patients’ age and sex was reported in the quantitative
studies and mostly their educational level too, whereas
patients’ language proficiency was only reported twice
[19,25]. The reason of visit, patients’ perceived health, the
extent to which doctor and patient knew each other and
patients’ religious background were infrequently mentioned.
Age and sex of the physician were reported in most
quantitative studies.
The studies most frequently involved a comparison of
doctor–patient communication between visits of patients
belonging to one of the major ethnic minority groups, White
physicians on the one hand, and visits of White patients to
White doctors on the other. In the American studies ethnic
minority patients were African, Americans and Hispanics; in
the Dutch studies they were mainly of Surinamese,
Antillean, Turkish or Moroccan background, and in the
Australian study they were Aboriginals.
Except for the study by Cooper et al. [28], none of the
studies explicitly reported matching patients’ and physi-
cians’ ethnicity. The sample size of the qualitative studies
23
ranged from five to nine, and for the quantitative studies
from 51 to 458. With regard to the observational strategy,
eight studies were based on audiotapes, four on videotapes,
and two study directly assessed doctor–patient communica-
tion. Four studies applied the Roter Interaction Analysis
System (RIAS) [30] to code the verbal behaviour of
participants. This category system distinguishes between
instrumental utterances, such as information-giving and
question-asking, and affective utterances, such as showing
empathy and giving reassurance. Henbest and Stewart’s
patient-centeredness measure was used in the study by
Rivadeneyra et al. [20]. This system assesses the extent to
which a physician responds to patients’ offers, that is, ‘any
topic or question introduced by the patient during the
medical encounter that was not a direct answer to a
physician’s question’ [20]. The other six quantitative studies
made use of self-developed analysis systems; all of these
were category systems coding (frequencies of) various
aspects of participants’ verbal behaviour. Just one study
assessed non-verbal behaviour [17]. Erzinger [18] made use
of conversation-analytical micro-analysis, Cass et al. [22]
did not mention their observational instrument.
Nine of the quantitative studies mentioned inter-rater
reliabilities, which in general were satisfactory (except for
one study). Finally, about half of the studies mentioned
sampling method and response rates.
3.2. Research questions and findings
The aim of all the studies was to assess the effect of
patients’ ethnic background on the medical communication
process (Table 2). To realise this objective, most studies
compared the communication process between White
doctors and White patients with the communication
process between White doctors and ethnic minority
patients. Both doctors’ and patients’ communicative
behaviour was investigated, and in most cases encounter
length was assessed too. We will first discuss findings
related to doctors’ communicative behaviour, then turn to
findings on patients’ communicative behaviour. Finally, we
will present results on possible factors related to
differences in and consequences of (gaps in) intercultural
communication.
3.2.1. Doctors’ communicative behaviour
In general, all studies found significant differences in
doctors’ behaviour when comparing consultations with
White patients and ethnic minority patients. These
differences concerned doctors’ affective and instrumental
verbal behaviour as well as consultation length. Most
studies found that physicians showed less affective
behaviour when communicating with ethnic minority
patients [16,17,23,24,28,29], but other results indicated no
differences or, on the contrary, found that doctors were
more affective towards ethnic minorities [25]. Three studies
[16,17,28] showed significantly decreased empathy with
 24
Table 1
Overview of studies on intercultural doctor–patient communication: setting, sample and method
Study Country Practice Patient sample a Doctor sample Observational strategy Observational instrument Inter-rater reliability
Shapiro and Saltzer [16] USA Resident clinic 39 WA, 15 LES-Hispanics, 10 WA family practice Audiotapes Self-developed Range: 0.50–0.61
quantitative 7 ES-Hispanics (n = 61) resident physicians interaction analysis (correlation)
(n = 10) instrument
Hooper et al. [17] USA Outpatient clinic of 67 WA, 74 Hispanics 15 WA resident Direct ratings of Self-developed 94% agreement
quantitative teaching hospital (n = 150) physicians (n = 15) interaction interaction
through one-way analysis instrument
mirror
NR b

B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34

Erzinger [18] USA Family practice 9 Hispanics (n = 9) Not reported Audiotapes, Conversation
qualitative residency at transcripts analysis
public hospital
Seijo et al. [19] USA Internal medicine clinic 51 Hispanics (n = 51) 5 WA internal Direct ratings of Self-developed NR
quantitative medicine physicians, interaction interaction
4 Latin American analysis instrument
physicians
Rivadeneyra et al. [20] USA Primary care clinic 15 WA, 19 LES-Latinos, 3 WA, 4 Asian, Videotapes Henbest & Stewart’s 0.96 (correlation)
quantitative affiliated 4 ES-Latinos (n = 38) 1 Middle Eastern Patient-Centeredness
with university primary care (resident) Measure
physicians (n = 8)
Sleath et al. [21] USA Family practices and 153 WA, 254 Hispanics 19 WA, 6 Hispanic, Audiotapes, Self-developed Range: 0.80–0.93
quantitative general internal (n = 407) 2 Asian family transcripts interaction (Cronbach’s alpha)
medicine clinics practice analysis instrument
at university or general internal
medicine resident
physicians (n = 27)
Cass et al. [22] Australia Satellite dialysis unit 5 Aboriginal (n = 5) 5 White Australian Videotapes NR NR
qualitative physicians (n = 5)
van Wieringen The Netherlands General practices 48 Ethnic minority 7 Dutch, 1 Aruban Videotapes Roter interaction NR
et al. [23] (mostly Surinamese/ general practitioners analysis system
quantitative Turkish/Moroccan), (n = 8)
38 Dutch (n = 87)
Sleath and Rubin [24] USA Family practices and 141 WA, 242 Hispanic 19 WA, 6 Hispanic, Audiotapes, Self-developed Range: 0.61–0.87
quantitative general internal (n = 383) 2 Asian family transcripts interaction (correlation)
medicine clinics at practice or general analysis instrument
university internal medicine
resident physicians
(n = 27)
Harmsen [25] Netherlands Family practices 34 Ethnic minority 7 Dutch general Videotapes Roter Interaction Range: 0.55–0.79
quantitative (mostly Surinamese/ practitioners (n = 7) Analysis System (correlation)
Turkish/Moroccan),
32 Dutch (n = 66); children
 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34 25

average doctor: 0.90,

average doctor: 0.88,

average patient: 0.86

average patient: 0.79

ethnic minority patients compared to White patients.

Range: 0.45–1.00

Range: 0.06–1.00
Range: 0.70-0.98

Harmsen [25] found that doctors expressed more empathy

(correlation);

(correlation);
(correlation)

with ethnic minority patients during pediatric consulta-

tions, and Sleath et al. [21] could not detect significant
differences in physicians’ expressions of empathy when
NR

comparing Hispanic with White American patients. Other

affective behavioural variables assessed in the studies were
the extent of rapport-building [16], physicians’ respon-
analysis instrument

analysis instrument

siveness towards patients’ offers [20], physicians’ expres-

Roter interaction

Roter interaction
analysis system

analysis system
Self-developed

Self-developed

siveness of positiveness [21], and affective verbal

interaction

interaction

behaviour as categorised by RIAS, such as physicians’

social talk and partnership-building [23,28,29]. All studies
reported significantly lower scores on these variables in
consultations with ethnic minority patients compared to
White patients: there was less social talk and rapport-
building, doctors were rated as less friendly and concerned,
and patients’ comments were ignored by their doctors
Audiotapes,

Audiotapes,

Audiotapes

Audiotapes
transcripts

transcripts

more often.
With regard to instrumental verbal behaviour, physi-
cians were rated higher on giving medical explanations
[16] and on interviewing skills (using open-ended
30 WA, 21 AA, 9 Asian/

questions and allowing patients to ask questions) when

care physicians (n = 31)
13 WA, 18 AA primary
2 Asian family practice

1 other primary care

communicating with Anglo-American patients compared

19 WA, 6 Hispanic,

19 WA, 6 Hispanic
physicians (n = 27)

physicians (n = 61)
resident physicians
practice or general
or general internal

Indian Americans,
medicine resident

internal medicine

to Hispanic patients [17]. Sleath et al. [26] found that

doctors communicated more about antidepressants use
with White patients than with Hispanics. At the same
(n = 25)
family

time, they asked more questions about anxiety in

WA: White American; LES: limited English-speaking; ES: English-speaking; AA: African-American.

consultations with Hispanics than with White patients

[24]. Four studies reported no significant differences with
regard to doctors’ instrumental verbal behaviour
177 WA, 226 Hispanics

[20,23,25,28].
43 WA, 44 Hispanics

110 WA, 142 AA

202 WA, 256 AA

Results on consultation length were inconsistent. Johnson

et al. [29] and Hooper et al. [17] did not find any difference
in consultation length between visits of Anglo-American
(n = 403)

(n = 252)

(n = 458)
(n = 98)

and Spanish-American patients, while Harmsen [25]

reported that consultations with ethnic minority patients
were on average 3 min longer than consultations with White
patients. In contrast, Cooper et al. [28] found that race-
Primary care practices
Family practices and

Family practices and

concordant visits were significantly longer than race-

Family practices
medicine clinics

medicine clinics
general internal

general internal

discordant visits (about 2 min), and also had lower speech

health centres
at university

at university

and federal

speed.
Erzinger [18] identified various ‘communicative tasks’
for both doctors and patients, which should be completed
for a medical encounter to be successful. Communication
styles were either described as supportive or conflictual,
depending on whether participants assisted each other in
completing the communicative tasks. Both communica-
USA

USA

USA

USA

tion styles occurred in these medical encounters,

suggesting that some consultations with ethnic minority
patients were going smoothly while others were not. Cass
NR: not reported.

et al. [22] found that a shared understanding between

Johnson et al. [29]

doctors and Aboriginal patients was rarely achieved.

Cooper et al. [28]
Sleath et al. [26]

Sleath et al. [27]

Patients had few opportunities to initiate a topic; the

quantitative

quantitative

quantitative

quantitative

doctor determined the conversational direction and often

patients acted politely, which health care practitioners
b
a

were seldom aware of.

26 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
Table 2
Overview of predictors, research questions and findings in intercultural studies
Study Research questions
Shapiro and Comparison of relationship-building and quality
Saltzer [16] of doctors’ explanations between Hispanic and
non-Hispanic patients
Effect of doctor–patient communication on
patient understanding and compliance
Hooper et al. Effect of patient characteristics on physicians’
[17] information conveyance, interviewing skills,
empathy, nonverbal attention, courtesy and
consultation length
Erzinger [18] Exploration of communication problems of
Spanish-speaking patients in the USA
Seijo et al. [19] Comparison of doctor–patient communication
(i.e. patients’ question-asking and doctors’
information-giving) between language-concordant
and language discordant visits
Differences in patient recall between language-
concordant and language discordant visits
Rivadeneyra Comparison of frequency of physicians’
et al. [20] responses to patients’ ‘offers’ between
English-speaking and Spanish-speaking patients
Sleath Comparison of physicians’ expression of
et al. [21] empathy and positiveness between Hispanic
and White patients
Cass Exploration of the extent of miscommunication
et al. [22] between Australian doctors and
Aboriginal patients
van Wieringen Effect of communication and patient beliefs on
et al. [23] understanding and compliance of White and
ethnic minority patients
Sleath and Effect of patients’ ethnicity on physician–patient
Rubin [24] communication about depression and anxiety
Harmsen [25] Comparing doctor–patient communication
between ethnic minority and White patients
Effect of education and language proficiency
on doctor–patient communication
Differences in consultation length and
prescription behaviour
Main findings
Less rapport-building and empathy with Hispanics than with
non-Hispanics, even in the case of English-speaking Hispanics
Relationship between language and ethnicity & patient understanding
No differences between ethnic groups on compliance
Better interviewing skills and more empathy with Anglo-American
than with Spanish-American patients
No other differences observed
Four patient tasks: describing concerns, clarifying doctor’s information,
obtaining an adequate explanation and developing a personal relationship
Four doctor tasks: exploring symptoms, interpreting data, explaining and
advising, understanding patient’s personal situation
Overall success of medical encounter is determined by how doctor and
patient assist each other in completing the communicative tasks
Two dominant communication styles occurred: supportive and conflictual
No difference between language-concordant and language-discordant
consultations on amount of doctors’ information-giving behaviour
More patient question-asking in language-concordant than in
language-discordant consultations
More patient recall in language-concordant than in language-
discordant consultations
English-speaking patients received more responses than
Spanish-speaking patients
No difference in frequency of physicians’ responses between
English-speaking Latino patients and White English-speaking patients
No differences in expression of empathy between
Hispanic and White patients
More expression of positiveness to White patients than to Hispanic patients
Shared understanding between doctors and patients is rarely achieved;
serious miscommunication regarding diagnosis,
treatment and prevention
Less mutual understanding in consultations with ethnic minority patients
than in consultations with White patients
Differences in patient beliefs between ethnic minority
patients and White patients
Consultations with ethnic minority patients show less social talk,
less doctors’ concern and less doctors’ friendliness than
consultations with White patients
No relation between communication and mutual understanding/compliance
No effect of patients’ ethnicity on physician–patient
communication about depression
Physicians were more likely to ask Hispanic patients questions
about anxiety than White patients
More empathy with ethnic minority than with White patients
Ethnic minority patients expressed less interest and concern than
White patients
Education and language proficiency unrelated to communication differences
Consultation length is longer with ethnic minority patients
 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
Table 2 (Continued )
Study Research questions
Sleath Effect of patients’ ethnicity on physician–patient
et al. [26] communication about antidepressants and
antidepressant adherence
Sleath Effect of patients’ ethnicity on patients’
et al. [27] expression of complaints about and problems
of adherence to antidepressant
medication and physicians’ reactions to these
complaints and problems
Cooper Comparison of patient-physician communication
et al. [28] in race-concordant and race-discordant visits
Effect of communication behaviours on
patient ratings of satisfaction and
participatory decision-making
Johnson Comparison of doctor–patient communication
et al. [29] between ethnic minority patients
and White patients
3.2.2. Patients’ communicative behaviour
A majority of the quantitative studies investigated
differences in patients’ verbal behaviour as a function of
ethnic background. Findings of these studies indicated that
ethnic minority patients express less affective and instru-
mental verbal behaviour than White patients and that they
seem to be less assertive. For instance, in the Dutch studies it
was found that ethnic minority patients expressed less
concern as well as less friendliness and social talk [23,25].
These findings are supported by the results of the American
studies, which also yielded evidence of less expression of
verbal behaviour by ethnic minority patients [29]. Sleath
et al. [26,27] found that White Americans were almost twice
more likely to complain and to state information about their
antidepressants than Hispanics. In another study, signifi-
cantly higher ratings of positive patient affect (i.e.
friendliness, interest, responsiveness and engagement) were
found in race-concordant as opposed to race-discordant
visits [28]. Rivadeneyra et al. [20] found that Spanish-
speaking patients mentioned fewer symptoms, feelings,
27
Main findings
Consultation length is unrelated to communication differences
More physician–patient communication about antidepressants
with White patients than with Hispanic patients
Hispanic patients were less adherent to their therapy
than White patients
Only one communication variable (patient question-asking)
related to antidepressant adherence
White patients were more likely to complain
about their medication than Hispanic patients
No differences in reported adherence problems between
the two patient groups
Physicians reacted similarly to Hispanic and to White patients
Race-concordant visits were longer and had slower
speech speed than race-discordant visits
Higher ratings of positive patient affect in race-concordant than
in race-discordant visits
Patients in race-concordant visits rated their physician
as more participatory than patients in race-discordant visits
Patients in race-concordant visits were more satisfied than patients
in race-discordant visits
Race concordance has an independent effect on patients’
judgments about the visit regardless of doctor–patient communication
No difference in duration or speech speed of medical visits between
African-American and White patients
More physicians’ verbal dominance with African-American patients
than with White patients
Physicians are less patient-centred with African-American patients
than with White patients
Less positive affect in medical visits with African-American
patients than with White patients
expectations and thoughts than English-speaking patients. It
should be noted however that no differences emerged
between Latino and non-Latino English-speaking patients,
indicating that differences might be attributable to language
rather than to ethnicity. More evidence for the role of
language on patients’ communicative behaviour comes from
a study by Seijo et al. [19], in which significant differences
were found on the amount of patients’ question-asking
between language-concordant and language-discordant
consultations. Patients who communicated in their own
language with their physician (i.e. Spanish) asked more
questions than Hispanic patients who had to speak English.
3.2.3. Culture’s influence on doctor–patient
communication: antecedents and outcomes
The variable most often studied (seven times) as a
culture-related explanatory factor of gaps in intercultural
medical communication has to do with linguistic factors.
Most studies did not find any relation between linguistic
factors and variations in communication though. Results of
28 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
the study by Rivadeneyra et al. and Seijo et al. [19,20] show
that language may have had an impact on physicians’
communicative behaviour. Also, Cass et al. [22] suggest that
employing differing modes of discourse leads to inter-
cultural communication problems. Other predictor variables
were seldom incorporated in the studies, although Cass et al.
[22] suggest that differences in beliefs about health and
illness as well as differences in cultural values between
members of different ethnic groups are associated with gaps
in doctor–patient communication. As far as educational
level is concerned, results are mixed. Harmsen [25] could
not establish a significant relation between education and
communication, whereas Sleath et al. [24,26,27] found that
higher educated ethnic minority patients did communicate
more about depression issues and also received more
positive responses from their doctors than lower educated
ethnic minority patients.
Three studies assessed the impact of intercultural doctor–
patient communication on a number of health-related
outcomes, such as patient understanding, compliance and
satisfaction [23,26,28]. All in all, no relationship could be
demonstrated between the communication process and these
outcome variables. Difficulties in communicating with
ethnic minority patients did not result in worse compliance,
satisfaction and understanding as compared to commu-
nicating with White patients. What was found is that ethnic
minority patients were less satisfied with GPs’ commu-
nicative behaviour and were less compliant, and that less
mutual understanding was achieved between ethnic minority
patients and their GPs [16,23,26,28]. Harmsen [25] found
that ethnic minority patients were prescribed medication
more often than White patients, irrespective of differences in
communication. It therefore seems that patients’ ethnicity
has an independent and negative effect on outcomes,
regardless of the communication process as measured by the
observational instruments used in these studies.
4. Discussion and conclusion
In reviewing the literature on intercultural medical
communication we only found a handful of observational
studies addressing this topic, yielding partly inconsistent
results. To some extent, these contradictory findings may
have emerged as a consequence of the wide variety of
research questions and designs used in the studies. This
makes it hard to reach definite conclusions about the cultural
variability of doctor–patient communication. Besides, none
of the studies under review explained on what definition the
categorization of ethnic minority patients was based. It
would be worthwhile in future research to clearly state how
the various patients are categorised into different ethnic
groups, and to take into consideration the considerable
variation that may exist between and within ethnic minority
groups. For instance, in the Dutch studies Turkish and
Moroccan patients are regarded as one (Muslim) group,
despite the fact that there are considerable differences
between the two groups on a number of factors relevant for
the topic of doctor–patient communication, such as their
average educational level (Turkish people in The Nether-
lands are higher educated and more literate than Moroccan
people in The Netherlands). In short, clarification of
categorization criteria and the reporting of results per ethnic
minority group would greatly enhance the possibility to
compare across studies and to reach more definite
conclusions, which may well differ between the various
ethnic minority groups.
Taking into account the above, it seems safe to conclude
that findings do suggest considerable differences and
difficulties in communication between doctors and patients
from different cultural and ethnic backgrounds. There is
evidence suggesting that doctors behave less affectively
when interacting with ethnic minority patients. More or less
the same can be said of doctors’ instrumental verbal
behaviour, although these results were less pronounced.
Ethnic minority patients themselves were also less verbally
expressive and seem to be less assertive and affective during
the medical encounter than White patients. These findings
are mostly in concordance with results of another review
study on the topic of culture and the doctor–patient
relationship, which also indicated less affective and assertive
behaviour in medical consultations with minority patients
[31].
Although the current review clearly shows that there is
considerable variation in doctor–patient communication as a
consequence of patients’ ethnic background, explanations
for and consequences of these communication differences
were only seldom incorporated in the studies. For instance,
why White doctors and ethnic minority patients express less
affective verbal behaviour towards each other is hard to tell
because most of the studies did not relate communication
behaviour to possible predictor variables, except for
patients’ ethnic background. The only other variable
researched in the studies under review concerns linguistic
barriers, and in general no relationship could be established
between this variable and variations in doctor–patient
communication [16,25]. None of the intercultural medical
communication studies has incorporated any other predictor
variables, leaving us in the dark about possible explanatory
mechanisms beyond culture and ethnicity for gaps in
intercultural doctor–patient communication.
With regard to the consequences of gaps in intercultural
medical communication, studies could not demonstrate a
relationship with difficulties in doctor–patient communica-
tion. Findings clearly showed that ethnic minority patients
suffer worse health-related outcomes, such as satisfaction
and compliance, than White patients, but patients’ ethnicity
seemed to have an independent effect. This could be due to
the fact that other culture-related variables not assessed in
these studies influence patient satisfaction, understanding
and compliance. For instance, in two studies by Brown and
Segal [32,33] it was found that African-Americans were
 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
more present-oriented than Whites in the daily management
of their hypertension, which is possibly related to higher
non-compliance rates and greater use of home remedies.
However, as it is well established that good doctor–patient
communication is associated with improved health out-
comes [15], it is difficult to assume that no relationship
exists between intercultural problems in medical commu-
nication and patient outcomes. This points to the necessity to
make use of other observational instruments than the ones
most frequently employed at present (i.e. RIAS, other self-
developed frequency systems) to assess doctor–patient
communication. Specifically, almost all studies under
review have made use solely of frequency systems that
focus on the relational aspects of communication (instru-
mental versus affective), thereby neglecting other, more
content-related, aspects of communication. Frequency
countings of behaviour however do not shed light on the
dynamics of the communication process, thereby running
the risk of leaving essential aspects of difficulties in
intercultural medical communication undetected. In addi-
tion to the traditional quantitative measures of communica-
tion behaviour more qualitative methods of observational
analyses should be employed, as we want to gain more
insight into gaps in intercultural medical communication.
From a methodological perspective, it is not only
necessary to use more diverse observational means and
analysis systems (e.g. none of the studies systematically
investigated cultural differences in non-verbal behaviour)
when investigating the doctor–patient communication
process, other research designs should also be employed.
For instance, except for the study by Cooper et al. [28], none
of the studies matched patients and doctors on their ethnic
background. Hence, most studies only compared White
doctor-ethnic minority patient dyads with White doctor–
White patient dyads. However, Cooper et al. [28] found that
race-concordant pairs of physicians and patients had higher
ratings of positive affect than race-discordant pairs,
suggesting that it is perhaps not patients’ ethnic background
per se, but differences in ethnic and cultural background that
lead to difficulties in the medical communication process.
Perhaps resemblance in communication styles among
members of the same ethnic groups enhances verbal
expressions, while differences may get in the way of a
smooth flow of conversation. To test for this possibility,
future research should also incorporate other dyads, such as
ethnic minority patient and ethnic minority doctor dyads,
which up to now have been absent from research on this
topic.
Finally, a closely related methodological issue is the need
to make use of coders who are of the same ethnic
background as the patients whose behaviour they score.
Although none of the studies stated the ethnic background of
the people who scored patients’ and doctors’ communicative
behaviour, it is likely that predominantly White people were
used. This may lead to bias in several ways. First, as it is
nearly impossible in this kind of research to code blindly, the
29
fact that one knows that one scores behaviour of ethnic
minorities may in itself lead to bias, because the label ‘ethnic
minority’ is associated with other connotations than the label
‘White’ or ‘native-born’. Second, the risk of interpreting the
communicative behaviour of someone from another ethnic
group incorrectly may be higher than interpreting the
communicative behaviour of someone belonging to one’s
own group, because of lack of knowledge about cultural
differences in communication styles [34]. Consequently,
future research should not only incorporate other doctor–
patient dyads but also add ethnic minority coders. Thus, to
be able to disentangle possible ethnic effects on doctor–
patient communication, the most effective research design
would be a two (White versus non-White doctor) by two
(White versus non-White patient) by two (White versus non-
White coder) design.
4.1. Proposal of research model
This review clearly shows that there is a profound lack
of knowledge about a wide range of issues related to the
complex research field of intercultural medical commu-
nication. There are hardly any empirical studies in which
doctor–patient communication has been assessed directly,
and most of the study findings are hard to compare
because of differences in definitions, aims and research
designs. Moreover, the majority of the studies did not
relate communication difficulties to outcome measures,
nor did they measure possible explanatory mechanisms for
these communication problems. This has resulted in an
atheoretical, purely descriptive research field, without a
coordinating principle in which the different research
parts can be brought together. Without such a guiding
principle we can hardly expect to find effective solutions
for the communication problems encountered within
intercultural medical visits. It is thus first and foremost
necessary to design a model on which future research in
this area can be based. For this reason we have examined
the broader literature on intercultural (medical) commu-
nication and identified five variables likely to play a
significant role in explaining culture’s influence on
medical communication. We will discuss these factors
in more detail now and propose a research model that can
be used to advance the research field of intercultural
medical communication.
4.1.1. Cognitive processes: Kleinman’s explanatory
model
To understand how patients’ cultural background may
influence doctor–patient communication, Kleinman has
proposed the idea of the Explanatory Model (EM) [3,35].
EM is defined as ‘the notions about an episode of sickness
and its treatment that are employed by all those engaged in
the clinical process’. Both patients and doctors hold EMs as
they offer explanations of episodes of sickness and
appropriate treatments. According to Kleinman, there will
30 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
often be discrepancies between patients’ and doctors’ EMs,
resulting in gaps in doctor–patient communication. These
discrepancies result from patients’ EMs being heavily
influenced by personality and cultural factors, while doctors’
EMs are mostly based on a more narrow biomedical
perspective. With regard to the question of how to
empirically study culture’s influence on patients’ EMs,
the model proposed by Angel and Thoits [36] is particularly
promising. It describes how culture impacts on certain
cognitive structures that mediate people’s interpretation of
physical and emotional states, such as the likelihood of
certain states being labelled as symptoms, the evaluation of
these symptoms and so on, and is a worthwhile starting point
for more extensive research on this topic. Maclachlan [37]
offers another relevant method; he designed a technique for
assessing the interplay of culture and health in such a way
that it acknowledges the influence of culture on health by
embracing the pluralism of conceptual perspectives.
4.1.2. Cultural values: individualism–collectivism and
self-construals
One of the dimensions most often used in explaining
variations in communication between cultures is the
individualism–collectivism construct [38,39]. In short,
people belonging to predominantly individualistic cultures
see the self as independent of groups, whereas in
collectivistic cultures the self is seen as part of the group.
Personal goals are more important in individualistic
cultures, while goals and norms of the group prevail in
more collectivistic-oriented societies. The distinction
between individualistic and collectivistic cultures provides
a useful framework for understanding cultural variations in
communication, and there is indeed much research showing
that rules for communication and conversation as well as
actual communication behaviour differ between these two
types of cultures. For example, Asians, who are collecti-
vistically oriented, are less assertive and less direct in their
conversations than Americans, who are individualistically
oriented [40,41]. Moreover, collectivists pay more attention
to the situation and to paralinguistic cues, whereas
individualists pay more attention to the exact content of
the message but tend to neglect the paralinguistic cues
[39,42]. Hall [43] explained this variation in communication
style by differentiating between low- and high-context
communication. The kind of communication style people
use and find most appropriate also differs between
individuals within a single country who belong to different
ethnic groups [44].
Within medicine, Young and Klingle [45] hypothesised
that cultural norms influence patients’ assertiveness, their
perceived ability to perform certain responses (self-efficacy)
and their conviction that the recommended response is
effective (response-efficacy), which together influence the
amount of patient participation. Although there were no
cultural differences between response- and self-efficacy,
they were indeed related to patient participation (assertive-
ness was not), so the hypothesised explanatory mechanisms
for culture’s influence on patient participation were not
substantiated. In a study by Kim et al. [46], cultural
differences in willingness to be assertive and beliefs about
participation did emerge. They found that Asians had fewer
positive beliefs about patient participation than Western
participants and were less willing to be assertive. Perhaps the
perceived appropriateness of assertiveness rather than the
perceived ability to be assertive or the perceived effective-
ness of assertiveness mediates the influence of patients’
cultural background on patient participation, as is also
suggested by Young and Klingle [45].
While it is clear that the individualism–collectivism
construct provides a useful framework for understanding
cultural differences in communication behaviour, it does not
clarify the underlying psychological processes to which
these differences may be attributable. Besides, it does not
take into consideration the heterogeneity in behaviour and
underlying values within single cultures [47]. One of the
factors that have been identified as possible mediator of the
influence of cultural individualism–collectivism on com-
munication behaviour is the individuals’ self-construal, in
terms of independent versus interdependent [48]. The
independent construal of the self ‘. . .requires construing
oneself as an individual whose behaviour is organized and
made meaningful primarily by reference to one’s own
internal repertoire of thoughts, feelings, and action, rather
than by reference to the thoughts, feelings, and actions of
others’ [48, p. 226]. The interdependent construal of the self
‘. . .entails seeing oneself as part of an encompassing social
relationship and recognizing that one’s behaviour is
determined, contingent on, and, to a large extent organized
by what the actor perceives to be the thoughts, feelings, and
actions of others in the relationship’ [48, p.227]. It is
assumed that in collectivistic cultures individuals tend to
rely more on their interdependent self, whereas people in
individualistic cultures rely mainly on their independent
self. It has been shown however that these two self-
construals coexist in individuals, and that it is partly the
situation that determines which of the two self-construals is
activated [49]. Gudykunst et al. [50] demonstrated that self-
construals are better predictors of and explain more variance
in communication style than the individualism–collectivism
construct.
4.1.3. Motivational processes: patient preferences
An indisputable shift in the doctor–patient relationship
has been noticeable in the last couple of decades. Because of
several societal and technological changes during that time
period in the Western world [51], the traditional paterna-
listic way of treating patients is no longer considered
acceptable; instead, a model of mutual participation in
which patient education, patient involvement and shared
decision-making are the new conventions and patient
autonomy the new ethos is advocated [52,53]. One of the
key dimensions underlying this paradigm shift is the
 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
concept of patient-centeredness, that is, the ideal of an
egalitarian doctor–patient relationship in which doctors and
patients share responsibility for the interaction and its
outcomes [54,55].
One of the main assumption underlying ideas about
shared decision-making and mutual participation is that
patients prefer to be involved in their own care. This
assumption may not be valid for every patient and in every
situation though. It has been shown that depending on one’s
personality (e.g. locus of control, assertiveness), beliefs
about the extent to which powerful others such as doctors
should be responsible for making decisions about patients’
health differ [56]. Patients’ ethnic background is also related
to differences in preferences for different types of doctor–
patient relationships. For instance, Korean-Americans and
Mexican-Americans have less need for information dis-
closure and participation in decision-making than White
American patients [57]. Furthermore, patients from different
European countries attach different importance to various
communication aspects, such as the amount of biomedical
and psychosocial communication they consider important
[58]. Although it is likely that some elements of patient
preferences are universal, such as the need to be heard and
understood, other aspects are likely to be culture-bound. For
instance, for Chilean patients being touched by their doctor
is an important attribute, while British patients do not
mention this as a valuable quality [59]. This finding may
reflect a culture-specific translation of a universal need to
feel understood.
4.1.4. Perceptions: racism/bias
Another barrier to adequate doctor–patient communica-
tion in interethnic encounters is the issue of racism and
perceptual bias [60,61]. For instance, American physicians
perceive their Black patients as being less intelligent, more
likely to perform high-risk behaviours and more likely to be
non-compliant than White patients. They also have less
affiliate feelings towards Black patients compared to White
patients [62]. When ethnic minority patients are asked about
racist experiences, they are more likely to perceive racism,
report mistrust and, in general, perceive more unfairness in
getting the treatment they need than Whites [63,64].
Apart from the study by van Ryn and Burke [62], whether
the racist experiences ethnic minority patients perceive
correspond with how they are actually treated by physicians
and the health care system in general has not been
empirically studied yet. However, their perceptions are
likely to have a negative impact on the quality of care and
should therefore be topic of research in the field of
intercultural doctor–patient communication [63,65].
4.1.5. Language: linguistic barriers
One obvious hindrance to intercultural communication is
the often-encountered lack of language understanding
between doctors and patients belonging to different
ethnic/cultural groups (see for an extensive review of the
31
literature on this topic [66]). In reviewing a number of US
studies on language barriers among Latino and Asian
patients, Ramirez [4] found that linguistic barriers can lead
to a number of negative consequences, such as an increased
chance of non-compliance, feelings of fear and despair, and
problems in achieving rapport. Moreover, the inability of
patients to understand and speak the language of their
physician may be an important obstacle in seeking care. His
findings are supported by results of some European studies,
which show that poor language proficiency is negatively
related to patients’ perceptions of the quality of doctor–
patient communication as well as to compliance [24,67].
Although it is beyond doubt that poor language
proficiency will hinder adequate doctor–patient commu-
nication, the extent to which these linguistic barriers are the
predominant factor in determining the quality of commu-
nication and care is not that clear-cut [68]. There is some
empirical evidence indicating that other barriers play a more
prominent role in intercultural communication problems.
For example, informing ethnic minority patients in their own
language does not improve compliance rates with preventive
screening activities [69]. Besides, patients’ satisfaction with
communication in health care is only partly related to their
ability to speak the same language as the physician. Morales
et al. [70] found that Latinos who spoke English were still
less satisfied than White patients with doctor–patient
communication, and Elsass et al. [71] found that, in spite
of language difficulties and insufficient communication
between 50 Greenlandic patients and their Danish therapists,
patients were satisfied with received care. Patient satisfac-
tion was related to perceptions of emotional factors such as
doctors’ kindness and smiling faces, and not to linguistic
problems.
The way the five aspects described above are related to
intercultural doctor–patient communication is summarised
in Fig. 1.
4.2. Study limitations
Due to the nature of our research questions, our review of
the literature has some limitations. While we define
intercultural health communication broadly, we limited our
review to observational studies, because our primary aim was
to research communicative behaviour. As observational
methods yield the most reliable assessment of behaviour
numerous studies on the topic of intercultural health
communication were excluded, based on their methods.
Thus, studies based on self-reports, surveys, in-depth inter-
views and the like were not included in our review. However,
we did make use of the broader literature on intercultural
health communication in the second part of this article. In
doing so, our aim was not to give an exhaustive account of all
available studies, but to identify key predictors of difficulties
in intercultural health communication, because our aim was to
be able to design a research model that may be used in future
research on this topic. This approach did not make it feasible
32 B.C. Schouten, L. Meeuwesen / Patient Education and Counseling 64 (2006) 21–34
Fig. 1. Research model.
to discuss each variable in detail. Detailed reviews on
language variables do exist [e.g. 4, 66] but with regard to the
other variables, much needed review studies still have to be
carried out.
4.3. Conclusion
As is clear from our review study, the above-identified
variables were not investigated at all in the studies under
review, except for linguistic barriers. To be able to pin down
the explanatory mechanisms beyond gaps in intercultural
doctor–patient communication, future studies should start to
incorporate these variables into their research designs and
begin to integrate available knowledge and theories in the field
of cross-cultural communication with those in the field of
doctor–patient communication. Hopefully this will be a first
step towards advancing our knowledge about the origins and
solutions of gaps in intercultural medical communication.
In sum, the main conclusion of this review is that the
extent of gaps in intercultural medical communication, its
origins and the relationship between cultural variations in
medical communication and health outcomes are still near-
unexplored topics for research. Far more empirical research
on the topic is needed, research that not only takes into
account other observational strategies and communication
variables such as doctors’ and patients’ non-verbal
behaviour, but also tries to explain communication problems
by incorporating theory-based variables such as the ones
outlined in our research model. Closely related is the need to
reach some consensus about what we mean by concepts as
race, culture and ethnicity, why and how we think these
concepts will influence medical communication, and how
we should measure these relationships. Furthermore, a
clearer sense of which problems are culture-specific and
which are related to possible confounders of culture (i.e.
social class, inequality in power, etc.) is needed as well [72].
In other words, we need to ask ourselves which aspects of
doctor–patient communication are universal and which
aspects are culture-specific, as culture adds just one more
dimension to an already difficult communication situation.
4.4. Practice implications
In line with our conclusions, health care providers should
keep an open mind regarding consultations with ethnic
minority patients and need to reflect on the way differences
in cultural values may play a role of importance in
intercultural medical communication. Providers’ knowledge
about patients level of acculturation and a good exchange of
explanatory models are essential in achieving an adequate
doctor–patient relationship. Furthermore, effective commu-
nication skills that expand language capabilities need to be
enhanced. In this respect, more use could be made of
migrant health educators employed as mediators to support
the consultations of ethnic minority patients. Previous
research has indicated that experiences in The Netherlands
of GPs, patients and these link workers have been positive
[73]. In sum, using a cultural sensitive approach by paying
attention to the cultural variables as outlined in our
theoretical model is recommended. Only by employing
such a combined approach we will make every effort to
decrease the extent of problematic communication in
intercultural medical encounters.
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