Cultural Diversity Calls for Culture-Sensitive Health Communication

“On average, 24 people worldwide were displaced from their homes every minute of every day during 2015.” ¹ This makes 65.3 million people in total who were forcibly displaced. Among these are refugees, internally displaced people, and asylum seekers. ¹ Furthermore, economic globalization requires employees to work abroad, creating international offices and intercultural exchange around the globe. In the United States, the immigrant population is estimated to be 13% of the whole population, including refugees as well as permanent residents who were not born in the United States.^2,a In addition, there is a large and increasing group of second-generation immigrants who were born in the United States but have at least 1 immigrant parent. These examples show that most societies deal with great variety in terms of cultural backgrounds of their citizens, cultural beliefs, and traditions.

Such a cultural diversity is a challenge for health care that aspires and requires trustful relationships between health care workers and the patient, as well as well-informed and committed patients. This special section of Medical Decision Making (MDM) highlights effects of cultural diversity on medical decision making and health promotion. Approaches in medical decision making strive to support informed and unbiased shared decision processes (e.g., when deciding between different cancer treatments), while health promotion practices strive to change people’s behavior toward a desired end state (e.g., taking up a healthy lifestyle ³ ). Three contributions in this special section will show that health communication has to be sensitive to the cultural background of the message receiver to maximize its effectiveness.

The challenge of cultural diversity among health care recipients can lie within a country or state, lie within large administrative regions such as World Health Organization (WHO) regions, or be temporally and locally enhanced during refugee crises. As an example for cultural diversity within a state, think of California. ⁴ The California Tobacco Control Program offers a range of different versions of its campaign against smoking ⁵ for Caucasians, Native Americans, African Americans, Asian Americans, and Hispanics. The Californian advertisements take into account the cultural differences by addressing the varying prevalence of smoking among men and women in Asian population groups ⁶ or previous ritual use of tobacco plants in spiritual Native American ceremonies. ⁷

Cultural diversity between countries is even more pronounced so that adapting poster campaigns will not suffice. International health organizations, such as the WHO, face the challenge to provide member states with technical support to improve health communication and medical decision making across the whole region. In a concerted effort to eliminate diseases, improve health, and reduce health inequalities, technical support has to be adapted to differences in health status and income levels but also to differences in cultural background. The WHO European Region, for example, comprises 53 member states from Portugal to Kyrgyzstan, bringing along a wealth of cultural diversity. Therefore, it is increasingly recognized that a “one-size-fits-all” approach will not be sufficient. For instance, the WHO/Euro offers its member states the guidance “Tailoring Immunization Programs” to overcome vaccine hesitancy and therefore to improve vaccine uptake and reduce the burden of diseases in these countries. ⁸ Thus, due to the necessity of taking culture and specific local needs into account, adaptive tools are being developed. Knowledge about cultural differences regarding the effectiveness of health information will support such processes.

Finally, in times of crisis, cultural differences may become especially apparent when language barriers hinder the social interactions and exchange of information and when suddenly large groups of people from a different cultural background enter a country. In response to the recent Syrian refugee crisis, for example, psychologists developed a brief guide of best practices to work with Syrian refugees, accounting for differences in religious and traditional practices that affect social interaction and the building of trust (such as cross-gender hand shaking ⁹ ).

These examples underline the importance of behavioral health research that includes culture as a major determinant and/or moderator of health behavior and the effectiveness of health information. Yet, most theories that inform interventions or health research are not designed to address cultural differences. Moreover, the determinants of health behavior themselves may vary in their structure and predictive power in different cultures (e.g., attitudes or the propensity for risky behavior or cooperation; for an overview, see Betsch and others ³ ). Even the concept of health and illness may vary, leading to different motivations to maintain health and to avoid illness.

Recognizing the need for increased attention to and awareness of the topic, a small group meeting was convened in 2014, bringing together experts from various scientific fields and from practice. The goal was to map the field of culture-sensitive health communication, identify research gaps in the field, and discuss the practical challenges. The first article in this special section, authored by the participants of the meeting, presents the outcomes of the meeting by proposing an agenda both for researchers as well as for practitioners that aims to increase the acknowledgment of culture in health research as well as health practice. ³ It defines culture-sensitive health communication as the deliberate and evidence-informed adaptation of health communication to the recipients’ cultural background to increase knowledge and improve preparation for medical decision making and to enhance the persuasiveness of messages in health promotion. This overview gives detailed insight into how culture affects determinants and processes of medical decision making and health promotion.

Two additional articles in this section highlight specific aspects of how culture affects health behavior and the effectiveness of health information. The study by Taylor and colleagues ¹⁰ shows that advice given regarding seasonal influenza vaccination within one household increases vaccination uptake. In most countries, vaccination against influenza is especially recommended for the elderly. In countries, however, where cultural traditions prohibit advising the elderly (e.g., in Japan), this advice was given mainly to the younger household members, leaving the risk group without advice. ¹⁰ Thus, culture can affect socially mediated health behavior.

Beyond these specific differences in cultural traditions and practices, there are also much broader underlying differences that are specific to members of one culture, beyond borders of countries, and that influence every aspect of human psychology, including cognition, emotion, and motivation.^11,12 In a broad sense, contemporary Western cultures tend to be more independent, whereas contemporary Asian cultures tend to be more interdependent. This influences the way in which the members of the culture see themselves in relation to others. Previous studies have shown that people from more individualistic cultures are more sensitive and responsive to the positive outcomes emphasized in gain-framed messages. On the other hand, people from more collectivistic cultures are more sensitive and responsive to the negative outcomes emphasized in loss-framed messages (for a comprehensive discussion, see Betsch and others ³ ). The study by Brick and colleagues ¹³ in this special section shows that cultural differences can also be acquired over time and that the amount of exposure to specific cultural settings can affect the effectiveness of messages using gain or loss framing. In their study, higher exposure to US culture reduced the effectiveness of a loss-framed message. ¹³

Both studies show that culture affects the way in which people react upon and interact with health information. These findings are especially valuable for health promotion where health communication strives to change people’s behavior toward a desired end state. However, such results are also important in relation to medical decision making that aims at supporting unbiased, informed choices. The studies showed that cultural differences can moderate the effects of information. Decision support systems will usually have to choose one way or another of framing and presenting information. They might also advise the readers to talk to their doctors or relatives. Being aware that the cultural background of the reader influences the way the information is processed, understood, remembered, or transferred into action poses additional challenges to the development of such tools, but it also offers the opportunity to make decision aids even more effective (e.g., by implementing a cultural tailoring approach). ³

Overall, the articles in this special section call for a better partnership between science and practice. Science needs to be more aware that research and theorizing is usually too Western focused and excludes other cultural perspectives. Practice needs more and better training of health communicators and health care personnel, informed by interdisciplinary, culture-sensitive research. A joint venture between research and practice can help to improve culture-sensitive health communication and promotion to improve health and reduce health inequalities.^3,14