Culturally competent patient–provider communication in the management of cancer: An integrative literature review

Figures & data

Fig. 1 PRISMA flowchart detailing flow of studies through the review.

Table 1 Rating system for the hierarchy of evidence for intervention/treatment questions (32)

Level I (strongest evidence)	Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs)
	Evidence from evidence-based clinical practice guidelines based on systematic reviews of RCTs
Level II	Evidence obtained from at least one well-designed RCT
Level III	Evidence obtained from well-designed controlled trials without randomization (quasi-experimental study)
Level IV	Evidence from well-designed non-experimental studies (case–control, correlational, cohort studies)
Level V	Evidence from systematic reviews of descriptive or qualitative studies
Level VI	Evidence from a single descriptive or qualitative study
Level VII	Evidence from the opinion of authorities and/or reports of expert committees

Table 2 Themes and subthemes

Themes	Subthemes	Delineation of the subthemes
Healthcare provider skills (N=32)	Communication skills (11, 18) (36) (N=18)	Engage in: • culturally sensitive communication (1, 5) (43, 49) • culturally congruent communication (5, 11) • clear (11, 44), accurate (11, 44), open (39, 42) (51, 53), flexible (42), and transparent (51) communication • congruent verbal and non-verbal communication (5, 11) Deliver care that patients understand (43, 57) Deliver culturally and linguistically sensitive services (55) Provide information in the patient's language (44) Learn the language (44) Develop a vocabulary of terms familiar to the patient (44) Provide clear information (48) Use simple language (38–42) Encourage the patient to ask questions (48) Repeat explanations (41) Check patients’ understanding of information (36, 39–41, 43) (44) Observe culturally appropriate non-verbal communication etiquette (5)
	Managing difference in the patient–provider encounter (N=13)	Avoid stereotyping and generalisations (5, 11) (37, 18) (36, 44) (45) Treat patients equally (38, 42) Avoid making assumptions about patient race, nationality, and language (1) Encourage patients to raise concerns about discrimination (39) Create a culturally safe and caring environment (41, 53) Individualise patient care (45, 53)
	Skills required for building the patient–provider relationship (N=12)	Invest time in the beginning (36, 46) (47) Engage the patient (11) Build rapport (41, 48) Gain patient trust (11, 17) (42, 48) (49) Actively engage patient in decision-making (36, 43) (48) Encourage and empower patients to raise trust issues (39) Address patients according to cultural preference (11) Recognise inherent power differentials (11) Be open about own cultural frame of reference (59) Acknowledge own cultural background to patients (1) Respond skilfully to cultural discordance (11)
	Ability to conduct a patient assessment (18, 26) beyond the biomedical (N=11)	Assess patients’ specific communication needs (46) Conduct a cultural assessment (40, 46) (51) • Active exploration of cultural issues (54) • Invite patients to describe their cultural backgrounds (57) • Explore views on family and community in the healthcare context (57) • Explore cultural (11) and health beliefs (54) • Explore family expectations, feelings, and concerns (51) • Explore level of family involvement required (54) • Determine who the main decision-makers are (patient or family?) (45, 47) • Explore preferences for truth disclosure (1, 36) (54) Conduct a spiritual assessment (51) Explore religious beliefs (1)
	Accommodating the patient's family (N=5)	Invest in and gain family trust (11, 38) Communicate with extended family as per patient's directive (11) Balance autonomy and dependency when meeting patient and family needs (52) Afford the family maximum control possible if this is a patient need (51)
	Accommodating religion and spirituality (N=4)	Recognise patients’ spiritual needs (53) Acknowledge the role of religion in the patient's belief system (11, 42) Demonstrate respect for religious beliefs (38)
Healthcare provider awareness (N=24)	Contextual awareness (N=11)	Awareness of: • country's socio-political history (41) • socio-cultural factors that affect the patient–provider relationship (45) • patients’ different phases of acculturation to the dominant culture (47, 56) • patient demographics in the service area (54) • the role of gender and religion in culture (48, 52) • patients’ level of education (38, 42) • patients’ experiences of discrimination in clinical settings (39) • dominant cultural narratives regarding health and illness (59) • culturally constructed myths about cancer (49) • patients possible combining allopathic and traditional medicine (59)
	Self-awareness (1, 18) (26) (N=9)	Awareness of own: • culture (55) • cultural beliefs (19) • belief systems (54) • spirituality (51) • own cultural assumptions, biases, and stereotypes (5, 18) (45, 54) (55)
	Interpersonal awareness (N=5)	Interpersonal awareness of: • inherent power differentials between patient and provider (41) • interaction between patient and provider's culture (40, 55) • communication differences between cultures (36, 48)
	Awareness of cultural expectations in the healthcare setting (N=5)	Awareness of: • the level of family involvement required (44, 54) • the role of family in cross-cultural clinical settings (1, 44) (52, 56) • patients’ possibly expecting a directive approach from providers (54)
Healthcare provider knowledge (N=22)	Context specific knowledge (N=9)	Knowledge of: • cultural groups attending services in the provider's clinical setting (11, 18) (36, 47) (52, 57) • serviced population's disease profiles, health disparities, and treatment outcomes (36, 37) • cultural health-related needs and health-seeking behaviours (18) • cultural approaches to illness and treatment (45) • cultural meanings of cancer (5) • patients’ perception of their illness (36) • influence of culture on how patient interacts with healthcare system (54)
	Self-knowledge (N=6)	Knowledge of own: • culture (11, 18) (36, 59) • belief system (18) • own biases and stereotypes (5, 11) (18, 54)
	Knowledge of patient's culture (N=5)	Knowledge of patients’: • health belief systems (11, 39) (44) • traditional health system (44) Knowledge of: • the role of gender and family in the decision-making (44, 47) • preferences regarding language used to discuss cancer (1) • non-verbal communication standards (1)
	Knowledge of broader contextual factors (N=5)	Knowledge of: • racism, sexism, and ageism (19, 62) • socio-political barriers to accessing healthcare (5, 11) (18) • the impact of past and present racism (18) • the role of gender, age and role expectations in the communication process (5) • socio-historical cultural context (5) • socio-cultural differences between self and patient (18)
Culturally competent healthcare systems (N=22)	Characteristics of culturally competent healthcare systems (N=6)	• are responsive to individual needs and to how cultures are perceived (18, 49) • promote and facilitate effective patient-centred communication (18) • respect cultural differences, and support effective care for diverse populations (18) • provide ethnic-specific services (5) • convert an awareness of disease prevalence into practices and policies (37) • develop and implement policies to support effective cross-cultural communication (18, 53) • link with culturally competent agencies and community organisations that provide bilingual and bicultural navigation, promotions, and community health outreach services (5) • have adequate support services (53)
	Strategies employed by culturally competent healthcare systems (N=17)	• use patient navigators (11, 24) (47, 48) (60, 61) • use professional translators (1, 5) (17, 39) (44, 45) (48, 54) (57, 59) • use of culturally sensitive print, visual, and audio-visual media and electronic communication (39, 43) (48) • use images to assist providers when discussing cancer with patients (41) • monitor patient characteristics (39) • translate written communications (45) • provide language-concordant encounters (39) • provide patient-centred care (60) • consult communities on cultural needs (41) • integrate community resources into cancer care (5) • display images of people from cultural groups attending the service (41) • have ethnically similar staff visible (41)
Healthcare providers’ personal characteristics and attitudes (N=13)	Healthcare providers’ personal characteristics (N=11)	• individual sensitivity (1, 18) (46, 61) • humility (1, 62) • empathy (18, 41) (57, 62) • curiosity (62) • compassion (18) • sincerity (19, 60) • tolerance (19) • acceptance (53) • authentic and respectful at all times (11, 19) (53, 57) (60) • value others (53)
	Healthcare providers’ attitudes (N=13)	• take responsibility for cultural aspects of health and illness (45) • take responsibility for combating discrimination in healthcare settings (45) • willingness to learn from patients (11) • openness to change and growth (53) • cultural sensitivity (1, 45) (53) • willingness to listen (53) • respect for cultural diversity, for the patient's culture and their cultural values (5, 11) (39, 42) (45, 52) (54, 62) • appreciation of different health belief systems (62) • willingness to explore culture with individual patients (36) • validate different cultures (57) • continual self-examination and self-reflection to examine one's own values and assumptions (18, 19) (53) • willingness to adjust behaviour and attitudes (36) • reflection on own interaction with cultural groups in the clinical setting (36)
Models of effective cross-cultural communication (N=3)	Kleinman's questions (17, 57) (N=2)	What do you think has caused your problem? Why do you think it started when it did? What do you think your sickness does to you? How severe is your sickness? Will it have a short or long course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear most about your sickness?
	The LEARN Model (36, 57) (N=2)	Listen with sympathy and understanding to the patient's perception of the problem Explain your perceptions of the problem Acknowledge and discuss the differences and similarities Recommend treatment Negotiate treatment
	The BELIEF Model (57) (N=1)	Beliefs about health (What caused your illness/problem?) Explanation (Why did it happen at this time?) Learn (Help me to understand your belief/opinion.) Impact (How is this illness/problem impacting your life?) Empathy (This must be very difficult for you) Feelings (How are you feeling about it?)
	The Four Habits Model of Highly Effective Clinicians (36) (N=1)	Invest in the beginning Elicit the patient's perspective Demonstrate empathy Invest in the end

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