Ethnicity Online

Cultural Awareness in Healthcare

Information And Resources: Communication Between Cultures

This section provides detailed information and advice about communicating with people from different cultures; information appears under the following headings:

  • language barriers
  • paralinguistic features
  • non-verbal signals
  • politeness
  • lessons to be learned when trying to communicate across cultures.

language barriers

Communication in any language involves far more than just words. Much of what is conveyed in a spoken message is done so instinctively and unconsciously, using a whole host of features including intonation, emphasis, volume, pace, contact and non-verbal gestures.

Second-language speakers have great difficulty unlearning these aspects of language, and may even be unaware of such differences. This can result in communication problems even if they use the correct grammar and vocabulary, particularly when they feel under stress, as they may well do in the healthcare environment. This also applies to forms of English spoken by, for example, Caribbean or Indian communities, which are likely to employ different cultural features: in such cases, the language barrier may be more significant because it is not perceived as such.

paralinguistic features

The tone of a conversation in British English may be conveyed using paralinguistic features including:

  • Conversation structure – which for most European languages, tends to follow the convention of stating the main point first. Speakers of other languages may build up to what is important, and may lose the interest of British English speakers who are unaware of this difference.
  • Emphasis – which is placed on a word to give it more importance within a sentence; for example, 'I told her that the diet was important' has subtly different inferences depending upon where the emphasis is applied. If 'told' is emphasised, the speaker may be conveying their own feelings of frustration at their ignored advice, but emphasis placed on 'I' points to ownership of the action. Other languages may employ the use of repetition, extra words or a change in the pace or pitch of their speaking, to convey their feelings or the relevance of something.
  • Intonation – which can turn a phrase into a question without the need to restructure the sentence. This can be very confusing to someone who has been taught English as a second language in a more formal manner. A second-language speaker may also have a much greater range of tones, or linguistic tunes, with which they convey friendliness, respect or interest, and may be confused or offended by our limited tonal range, which they feel conveys lack of respect or boredom. Some languages, for example Chinese, place great importance on intonation, which is used to give a single word numerous different meanings. Speakers of such tonal languages may be perceived as angry or arrogant by British English speakers.
  • Listening – which is shown by eye contact, nodding or encouraging noises, can very easily be misunderstood by second-language speakers, who may employ silence, stillness and even looking away to demonstrate their attentiveness.
  • Silence – which usually conveys unease, but may equally indicate that a second-language speaker is taking the topic of conversation very seriously.
  • Turn-taking – where only one person at a time speaks, and interruptions are viewed as rude. A speaker may indicate that it is someone else's turn to speak by lowering their voice, slowing down, becoming repetitive or pausing. Even the length of pauses varies, with British English speakers employing relatively long pauses. In other languages, people may speak over each other to show that they are actively involved in the conversation. If someone is unaware of the turn-taking conventions, they may feel frustrated or offended that it never seems to be their turn to speak.
  • Volume – which is normally fairly low, with a noticeable increase used to gain attention and emphasise what is being said. It can also convey strong feelings, and so speakers of languages that are generally louder can come across as upset, threatening or rude.

non-verbal signals

Non-verbal behaviour is instilled in us and therefore difficult to manipulate. Cultural differences between the use of non-verbal signals can easily lead to confusion over intentions and reactions. If someone displays what we feel to be inappropriate non-verbal behaviour, we tend to simply label them as rude and not pursue the matter with them. Non-verbal signals include the following:

  • Eye contact – which British English speakers tend to use to indicate attentiveness or honesty, but when used too much can make the recipient feel quite uncomfortable. However, in South Asia, eyes are lowered as a sign of respect, and too much eye contact indicates insolence or aggression. A British English speaker talking to someone from South Asia may feel that they do not know the answer to their question, do not understand or are being dishonest, when they are simply being humble towards them, particularly if they are a member of the medical profession.
  • Facial expressions – which can also be misleading. For example, the Japanese tend to be straight-faced when happy, and smile to mask unpleasant feelings such as anger or sadness.
  • Gestures – which may have totally opposite meanings, most notably the nodding/shaking of the head. In Islamic cultures, the left hand is considered unclean and it is offensive to use it to offer something to someone. A left-handed non-Islamic person may quite unwittingly cause offence by simply passing someone a pen or offering them a biscuit.
  • Personal space – which is an important aspect of feeling comfortable in the presence of others. Acceptable physical distance varies not only between cultures, but also within them according to relationships. If someone stands too close to another, that person may then step back to a distance with which they are comfortable, and this may well happen repeatedly.
  • Posture – which can have quite unexpected cultural differences. For example, folded arms, which are felt to indicate defensive or even hostile behaviour in the West, indicate that someone is relaxed and friendly in the East. With no equivalent in the West, in the East it is offensive to sit with your feet pointing towards someone.
  • Touch – which is used relatively rarely in the British culture, increasing only with more-intimate relationships. The level of use varies between the sexes, and even within families. Those from cultures that tend to employ more physical contact may cause great offence by simply acting naturally.


Politeness is a very important part of both written and verbal communication and includes the following features:

  • Greetings – which are used at varying levels in different cultures. In British English, their use is relatively limited and this may cause offence to those from cultures where they are used as often as at the beginning and end of every encounter with someone. They include shaking hands, joining the palms of hands, smiling and bowing.
  • Please and thank you – which are widely used in British English, such that their absence tends to be taken as a sign of arrogance or ignorance, especially if the speakers do not have equal social status. In other cultures, their lack of use is not important because they are implied by the tone of voice or specific choice of verb or pronoun (for example, 'tu' or 'vous' in French). Also, they may be regarded as superfluous in the context of someone's job, by both the provider and user of the service. In some cultures, gratitude may be shown by a kind look or gesture, or the giving of gifts, possibly money. If someone is unable to accept a gift of thanks, the giver is likely to be offended.
  • Saying no – which in many cultures is considered to be rude, particularly to someone of a higher status. Alternative ways of refusing a request or showing disagreement include changing the subject, procrastinating, being non-committal or using particular language that may cause great confusion when translated. British English speakers tend to avoid conflict and may try to make a joke or apologise rather than say 'no' directly. This behaviour could be interpreted as somewhat dishonest to those from cultures that use a more-direct approach.
  • Anger – which is something that British English speakers tend to avoid showing as far as possible; its effect therefore has a greater impact when it is expressed. In other cultures, anger is less of an issue, and is often expressed, received and forgotten as a matter of course. Again, British English speakers may come across as dishonest to those who are more open about their feelings. At the far extreme, in Japanese and Chinese cultures, it is totally unacceptable to express anger because it is felt to have a destructive effect.
  • Taboo words – which are often based on bodily functions and body parts, and are therefore likely to be an issue in a healthcare environment. There is usually a preferred medical alternative, for example, 'stool' rather than 'poo', which patients may prefer to use, but even British English speakers have to think twice before using them. Second-language speakers may not know or recognise them at all, and could accidentally cause offence by using the taboo form.

lessons to be learned when trying to communicate across cultures

When trying to communicate with those from other cultures, it may be useful to:

  • be aware of the reasons (many of which are listed above) why communication may fail, or not entirely succeed;
  • try to become more aware of your own automatic responses so that you can learn to keep them in check;
  • give the other person the benefit of the doubt and assume that their intentions are not unkind;
  • try to gauge other people's reactions to you and be prepared to adapt your approach.

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