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South African Dental Journal

versão On-line ISSN 0375-1562
versão impressa ISSN 0011-8516

S. Afr. dent. j. vol.69 no.9 Johannesburg Out. 2014




Transcultural and language barriers to patient care



S Naidoo

BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dipl Int Research Ethics (UCT), DSc (UWC); Senior Professor and Principal Specialist, Faculty of Dentistry, University of the Western Cape




Communities are become increasingly multicultural and ethnically disparate and dentists need to be alert to the diverse challenges this may bring to their practices. This is particularly true for South Africa where transcultural and language barriers continue to compromise a large proportion of the population in their access to health services and quality dental care. These challenges may lead to misunderstandings, communication problems and on occasions, breakdowns in the professional relationships which have little or nothing to do with the dentistry itself.1 Transcultural issues need to be managed with fairness, sensitivity and respect. The Patients' Rights Charter provides that patients should have access to health care and the right to health information that includes guidelines on the availability of health services and how best to use those services. Further, such information shall be in a language understood by the patient.2 The National Health Act (Act 61 of 2003) emphasises this latter requirement and states that "The healthcare provider must, where possible, inform the user, as contemplated in subsection (1), in a language that the user understands and in a manner which takes into account the user's level of literacy".3

Language barriers have been found to decrease work efficiency and the provision of holistic treatment.4 In addition, it makes communication time-consuming which increases frustration levels and decreases empathy and approach-ability.4 A first step in addressing these challenges is to develop a proactive understanding of all those with whom we come into contact in our professional capacity, and whose background is different to our own. Clinicians, patients and staff often do not use their first language to communicate at work. The nature or location of a practice may be such that a diverse mix of patients presents for treatment. However, it the onus is on the health professional to bridge cultural, ethnic and potential social divides. The ability to communicate effectively and to make an effort to do so - whatever the difficulties - is a demonstration of respect for the patient.1

Good communication has long been acknowledged as the cornerstone of the health professional-patient relationship and plays an important role in the quality of health care delivery.5 Despite this being the era of "patient-centred" care, many continue to have a reduced ability to participate in decision-making about their care and in doing so their autonomy is disrespected. These impediments also result in a power shift that favours the health professional.6 The inability to communicate can be a traumatic and fearful experience and studies have shown that language barriers result in increased avoidance behaviour which may result in late presentation by the patient and adds to their uncertainty and emotional stress. In addition, miscommunication can result in increased errors both in diagnosis and in management -resulting in decreased patient satisfaction and less compliance with education and treatment.7

Language cannot be isolated from culture and some cultural competency by dental practitioners is important, engendering greater patient respect.4 In some cultures it is a sign of respect not to question a doctor or dentist even if the patient has not understood what has been said!6 In many instances, there are wide cultural differences in body language, with different emphases being placed upon certain postures, signs and gestures in various cultures. What may be acceptable and normal in one culture can be grossly offensive in another! An understanding of and a sympathetic response to these differences can dramatically reduce the potential risk of miscommunication.1

The quality of a patient consultation relies on the different cultural lenses and world views of the patient and the dentist. A study on doctor-patient interactions on the outcomes of chronic diseases found that three aspects of communication had a critical link to patient outcomes: the amount of information exchanged between the patient and physician, the rapport between the patient and physician and the patient's control of the dialogue.8 Speaking and understanding the language of the patient allows for this. Cultural competence is necessary for providing appropriate care in the language of the patient and developing rapport, understanding and respect. Language translation is complex and training is necessary as bilingualism does not always result in effective translation. The use of family members, cleaners, administrative staff or other patients is not ideal. It affects patient confidentiality.6 The expense of hiring interpreters is an important consideration but the cost of not using interpreters may be even greater.9

Professional ethical standards do not tolerate acts of discrimination directed towards the patient. The Health Professions Council states that all "Health-care practitioners should be aware of the rights and laws concerning unfair discrimination in the management of patients or their families on the basis of race, culture, ethnicity, social status, lifestyle, perceived economic worth, age, gender, disability, communicable disease status, sexual orientation, religious or spiritual beliefs, or any condition of vulnerability such as contained in health rights legislation",10 Allegations of a lack of respect or discrimination should be avoided by taking care to deal fairly and equitably with all patients, regardless of ethnic origin, religion or other issues so that no individual is treated differently or less favourably, To do this, practitioners would need to invest time and effort to develop a better understanding of the ethnic and cultural background of both patients and staff, They need to be cognisant of situations where words and actions may be misinterpreted as being discriminatory or offensive to someone from a different ethnic background, Interactions where misunderstandings could lead to disagreement or conflict should be anticipated and avoided, Extra care and time needs to be taken when communicating with patients whose first language is not customarily used in the practice, or when dealing with those who may be unfamiliar or uncomfortable with treatment procedures for a variety of different cultural or religious reasons, Where practices are located within a multicultural, multi-ethnic community, it may be appropriate to select staff who are culturally and linguistically capable to understand specific transcultural issues, thereby enabling the practice to provide a much better overall quality of service and care to its patients.



1. Dental Protection Limited, Ethics, Values and the Law, Module 7: Honesty, 2009        [ Links ]

2. National Department of Health, The Patients' Rights Charter, Pretoria: National Department of Health, 2007.         [ Links ]

3. South African Parliament, National Health Act of No 61 of 2003, Chapter 2 Section 6, Pretoria.         [ Links ]

4. Hussey N. The language barrier: the overlooked challenge to equitable health care, SAHR 2012/13.         [ Links ]

5. Anita B, Bertin F. Multilingualism and healthcare in Nigeria: A management perspective, Commun Med 2004; 1: 107-17.         [ Links ]

6. Schlemmer A, Marsh B. The effects of a language barrier in a South African district hospital, S Afr Med J 2006; 96: 1084-7.         [ Links ]

7. Saha S, Fernandez A. Language barriers in healthcare, J Gen Intern Med 2007; 22 (Suppl 2): 281-2.         [ Links ]

8. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease, Med Care 1989; 27 (3 Suppl): S110-27.         [ Links ]

9. Jacobs E, Shepard S, Suaya J, Stone E. Overcoming language barriers in health care: Costs and benefits of interpreter services, Am J Public Health 2004; 94: 866-9.         [ Links ]

10. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Professions. Booklet 1: General Ethical Guidelines for the Health Care Professions, May 2008.         [ Links ]



S Naidoo
Department of Community Dentistry
Private Bag X1
Tygerberg 7505