Language, culture and emotions: Exploring ethnic minority patients’ emotional expressions in primary healthcare consultations

doi:10.1016/j.pec.2011.04.021

Patient Education and Counseling

Volume 84, Issue 3, September 2011, Pages 406-412

https://doi.org/10.1016/j.pec.2011.04.021 Get rights and content

Abstract

Objective

This study explores ethnic minority patients’ expression of emotional cues and concerns in primary healthcare, and examines relationships with patient, provider and consultation attributes.

Methods

191 video-recorded consultations were analyzed using the VR-CoDES. Patients were interviewed before the consultation. Generalized Estimating Equations models (GEE) were used to test for associations.

Results

Psychosocial versus bio-medically oriented encounters contained significantly more cues (p ≤ 0.05). Patients with poor versus good language proficiency expressed significantly less cues (p ≤ 0.001). No significant correlations were found with patients’ cultural values, patients’ or physicians’ gender or the presence of an interpreter. Female patients express more concerns (p ≤ 0.05), female physicians have a higher number of concerns expressed by patients (p ≤ 0.02).

Conclusion

This study shows that independent of physician and diagnosis, patients’ language proficiency has a more important impact on the number of cues expressed by the patient than cultural difference.

Practice implications

Medical schools and Continuing Medical Education should focus on training programs for recognizing and handling linguistic barriers between physicians and patients. Patient education programs should encourage patients who experience language barriers to open up to physicians. In situations where language is a barrier, physicians and patients should be encouraged to use interpreters to enhance the expression of emotions.

Introduction

Patients’ decisions to see a physician are not only driven by their medical complaints. Ideas and expectations about the disease, the physician and the outcome, as well as emotions (positive and negative) are brought into the consultation. Communication theories emphasize the importance of physicians’ awareness of these ideas, expectations and emotions as they are relate to so-called ‘good communication’. As Engel stated ‘the patient has to know and understand, and to feel known and understood’ [1].

Negative emotions may be caused by the illness itself: illness can increase anxiety, worry, uncertainty and, in severe cases, anger, depression and grief. Complaint-related worries may act as the motivation to consult a physician [3]. Life issues such as work- or family related stress, financial burden or bereavement may also negatively influence patients’ emotional wellbeing and health. Serious worry may have negative consequences such as dissatisfaction with care, or excessive use of healthcare services [4]. Unmet complaint-related worry may cause patients to become less trustful of their physicians, and can cause long-term worrying and somatization problems. However, when physicians do address worries, patient satisfaction with care is likely to increase [5], [6].

Usually, patients will not explicitly express the emotions related to the complaint or to life circumstances [7]. More often they convey emotions in a subtle, hidden manner, in the literature, these are called hints, cues, empathic opportunities or concerns.

Dealing with emotions while taking into account cultural and linguistic differences is a complex challenge for physicians, particularly with the knowledge that today's society is facing an increasing worldwide migration and a growing diversity in its population. In Belgium, the population of ethnic minorities is diverse, consisting of working migrants who arrived between the 1950s and 1970s as well as economical or political refugees and illegal immigrants. Dutch is the official language in the Flemish part of the country, languages used by ethnic minority groups are as diverse as the group itself.

Previous research has pointed out that across socio-economic classes and cultures, patients expect physicians to pay attention to their emotions by behaving in an empathic way [8].

Even though patients value a caring and understanding physician, it has been shown that, especially in ethnic minority patients, disparities in physician–patient communication still exist.

Several communication researchers have revealed a less affective relationship between physicians and ethnic minority patients: physicians show less affective utterances and behave less empathically. Minority patients on the other hand behave less assertively, show less affect and participate less actively [9], [10], [11], [12], [13], [14].

Research has been done on the influence of ethnicity and language within the physician–patient interaction. Patients with poor language proficiency receive poorer quality care, less information and demonstrate poor recall of information. Ethnic minority patients express less confidence in being treated equally by physicians [15], [9]. The presence of an interpreter can help patients to talk about their emotions with physicians [16].

The gender of the physician and patient may play a role in ethnic minority patients revealing their emotions. Female physicians generally show more partnership-oriented, non-verbal and effective verbal behaviors. Physicians, independent of their gender, give less signs of empathy towards male patients. Female patients express their concerns more easily [17].

In this study we used the Verona coding system for emotional sequences (VR-CoDES [24]) to explore patients’ expressions of negative emotions.

We hypothesized that there would be more cues in consultations that were (1) psychosocial, or (2) led by female physicians’ or (3) with female patients, (4) in consultations with an interpreter or (5) in which patients had a good language proficiency (of the language spoken during the consultation). We also hypothesized that there would be less expressions of negative emotions in encounters where patients’ cultural background was more conservative.

Section snippets

Study design

In this observational study physician–patient consultations with ethnic minority patients were video-recorded and analyzed for patients’ expression of negative emotions.

Data collection

All 77 primary care physicians working in areas of Ghent with more than 25% ethnic minority inhabitants were asked to participate in the study. All patients from ethnic minority background who consulted the participating physicians were invited to participate, until we reached 15 consultations per physician. Patients were

Descriptive results

60.8% (n = 110) of the coded consultations contain at least one cue or concern.

A mean of 3.45 cues (median = 2) per consultation was found in the group of consultations that contained a minimum of one cue or concern (n = 110), with a maximum of 18 cues per consultation. Concerns were present in 30.9% (n = 34) of these consultations, with a maximum of 4 and a mean of 1.82 per consultation.

Distribution of the subcodes for cues (see Table 4) showed that the most prevalent cues were “cue b” (verbal hints

Discussion

When minority patients consult a physician, many possible barriers to the communication process may arise. The perception is often that these difficulties, or challenges, are linked to cultural differences between physician and patients. Language and acculturation might also be possible barriers to effective communication. The ways in which patients express negative emotions or not in an encounter, can be the result of many factors: whether they are used to talking to physicians about their

Acknowledgements

The authors would like to express their gratitude to all participating physicians and patients, as well as students, volunteers and colleagues, for the time spent on this study.

References (23)

M.R. Floyd et al.
Patients with worry: presentation of concerns and expectations for response
Patient Educ Couns
(2005)
B.C. Schouten et al.
Cultural differences in medical communication: a review of the literature
Patient Educ Couns
(2006)
H. Harmsen et al.
When cultures meet in general practice: intercultural differences between GPs and parents of child patients
Patient Educ Couns
(2003)
B.C. Schouten et al.
Cultural diversity in patient participation: the influence of patients’ characteristics and doctors’ communicative behaviour
Patient Educ Couns
(2007)
C. Zimmermann et al.
Coding patient emotional cues and concerns in medical consultations: the Verona coding definitions of emotional sequences (VR-CoDES)
Patient Educ Couns
(2011)
T.M. Vatne et al.
Application of the Verona coding definitions of emotional sequences (VR-CoDES) on a pediatric data set
Patient Educ Couns
(2010)
K.A. Paez et al.
Provider and clinic cultural competence in a primary care setting
Soc Sci Med
(2008)
G. Engel
How much longer must medicine's science be bound by a seventeenth century world view?
V. Laakso et al.
Relieved after GP's consultation? Change in the complaint-related worry of young adult patients
Psychol Health Med
(2008)
R.L. Marple et al.
Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome
Arch Intern Med
(1997)

J.K. Rao et al.

Visit-specific expectations and patient-centered outcomes: a literature review

Arch Fam Med

(2000)

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View full text

Language, culture and emotions: Exploring ethnic minority patients’ emotional expressions in primary healthcare consultations

Abstract

Objective

Methods

Results

Conclusion

Practice implications

Introduction

Section snippets

Study design

Data collection

Descriptive results

Discussion

Acknowledgements

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Soc Sci Med

How much longer must medicine's science be bound by a seventeenth century world view?

Relieved after GP's consultation? Change in the complaint-related worry of young adult patients

Psychol Health Med

Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome

Arch Intern Med

Visit-specific expectations and patient-centered outcomes: a literature review

Arch Fam Med