Ethnographic Interviewing as a Technique to Increase Cultural Competence in Health Care

Kevin Browne, PhD

(This article was first published in Nursingmatters 16 (7)
July 2005, p.4, 14, and is reprinted here with permission)

With increasing emphasis on Culturally and Linguistically Appropriate Services (CLAS) in health care, many nurses may feel unprepared to meet these standards and provide quality care. No one can be expected to know all the meaningful cultural categories that have an impact on health decisions among the diverse patient population in today's world.

Culture is the shared set of concepts, symbols, values, and assumptions about life that form the basis for behaving in the world, and is transmitted generationally. Ethnography is a set of methods deriving from anthropology that seeks to understand the culture of other people. Ethnographic interviewing techniques have recently been applied in nursing and other health care disciplines. Ethnographic interviewing provides access to meaningful cultural values held by patients, and can be a bridge to understanding cultural differences. Ethnographic interviewing can increase patient and family acceptance of health care protocols, and thus positive outcomes. The main features of ethnographic interviewing include:

1. Adopting a learning stance. We are often unfamiliar with the culture of patients. With ethnographic interviewing the patient and their family are the experts. We can ask and learn about what the illness means to them, what are the categories (physical, spiritual) in which it is placed, the role of the family and community in help-seeking, adjunct treatments that the patient/family has tried or is contemplating, and so forth. This style of interaction helps to build trust and relationship with patients and families.
2. Asking open ended questions. Taking the time to listen attentively is critical. A list of open-ended questions can be prepared in advance. Here are some examples of broadly applicable questions:
   1. Can you tell me a little bit about yourself and your background?
   2. What does this illness mean to you, your family/community (is there agreement or contradiction among the parties?)?
   3. What is important to you and your family regarding the treatment of this illness?
   4. Can you tell me about any other treatment (s) you have received for this illness? How was this for you?
3. Involving the patient's family and/or community, if feasible. In an individualist culture such as characterizes mainstream U.S. society, it is usually assumed that illness resides with the individual, and at most affects the immediate family. In more collectivist cultures (including Native American, many Asian cultures, often Hispanic, African-American and southern European), such distinctions are different. An illness of one person can reverberate within the community, to varying degrees according to cultural norms, that person's status, social connections, and so on. It may be appropriate to hold discussions with members of the extended family and community, in order to show respect for the social aspects of the illness and to enlist family support.

Use of Interpreters:
In situations of language difference, the use of qualified interpreters is very important. Interpreters need to not only be fluent in the two languages, but also able to translate cultural meanings. The use of family members, and especially children, as translators is almost never a good idea. It introduces too many variables of emotion and power. Time and resources need to be set aside to have outside translators available.

Dimensions of Diversity:
Meaningful dimensions of diversity extend beyond the usual categories of race, gender, and ethnicity. A few that are frequently encountered include sexual orientation, rural-urban distinctions, and physical abilities, among others.

Communication styles:
In mainstream U.S. culture, it is assumed that it is healthy and therapeutic to express emotions, to state opinions openly, and to make eye contact. Communication styles and associated meanings (verbal and non-verbal) vary greatly across cultures, however. Silence, for instance, has a far different meaning in many Asian cultures than it does in the U.S. Here we assume that words carry the full meaning of the communication (low context communication). Many cultures rely far more on other aspects, such as the nature of the relationship, non-verbal communication, and the relative status of the parties (high-context).

With ethnographic interviewing, we become attuned to our own communication style and that of our patients', helping to build trust and facilitate therapeutic dialog.

Sample exercises:

1. Practice interviewing someone from a different cultural group. Here are some questions that can reveal important cultural values:
   1. How do children typically relate to parents, teachers, and other adults in that culture? This reveals power distance norms-the U.S. is a low power-distance society.
   2. Is it typical for people in their culture to emphasize individual or group achievement?
   3. What is different about U.S. culture from their own?
   Then, see if you can construct a partial description about that culture's values based on what you have learned. Tell that description back to the person. How much did you understand? What was difficult for you? What would have helped you understand more fully?

2. Interview a patient who is from a different cultural group. Ask open-ended questions. Pay attention to communication aspects like body language (interpersonal distance), eye contact, voice volume, speed of speaking, use of silence, and so on. How do these factors affect your conversation? What did you learn about your natural style and the other person's? How might modifying your style in some way facilitate rapport?

Integrating Ethnographic Interviewing into practice
Ethnographic interviewing can take more time than many standard practices. Ethnographic interviewing can be adapted, however, to fit many circumstances. Full integration of CLAS and ethnographic interviewing obviously takes commitment at all levels of an organization. Good strategic planning is essential at this level. Recognizing that health care organizations are at all stages of implementing such standards and practices, individual health care providers can make their own commitments toward greater cultural competence.

Research shows that successful illness outcomes often have as much to do with rapport between caregiver and patient as they do with specific treatments. Illnesses are social and emotional phenomena in addition to physical ones. Validating the patient's worldview and meaning-attribution, and enlisting the support of family and community, can also increase the likelihood that patients will follow the prescribed treatment protocol. Ethnographic interviewing is one broadly applicable, culture-general technique to aid in this.