In the United States, legal documents such as advance directives and durable powers of attorney are strategies to prolong autonomy in situations in which patients can no longer represent themselves (Searight & Gafford, 2005). Other cultures de-emphasize autonomy, perceiving it as isolating rather than empowering. Their belief is that communities and families, not individuals alone, are affected by life-threatening illnesses and that they should be involved in making medical decisions (Searight & Gafford, 2005).

Fate Versus Free Will “ Fate and free will” refer to the degree to which people believe they are the masters of their own lives (free will) or believe they are subject to events outside their control (fate). Basically, fate and free will refer to the beliefs people hold about their ability to change and maneuver the course of their lives and relationships. This concept also is called locus of control. People who believe that they have control over their health have an internal locus of control (free will belief), and people who believe that it is outside of their control (fate belief) have an external locus of control. In some ethnic groups, factors outside medical intervention, such as a divine plan and personal coping skills, may be more important for health and survival than medical intervention and health behaviors.

Health care professionals need to consider this aspect of social organization. For example, when health outreach workers in India attempted to provide children with free polio vaccinations, they found that many parents refused the immunization because they believed Allah would take care of their children’s health. Providing preventive care and treatment can be challenging when people believe that fate will determine their health and that their health behaviors will not change what the master plan is for them.

Communication Communication is an interactive process that involves sending and receiving information, emotions, thoughts, and ideas through verbal and nonverbal means. It is the basis of human interaction. Effective communication enables health care professionals to accurately exchange information, establish relationships, and understand the person’s needs and concerns. Effective communication is

important in all facets of life, but in health care it can be the deciding factor between life and death. Intercultural communication is sensitive to exchanging information across cultural boundaries in

a way that preserves mutual respect and minimizes miscommunication and conflict. If communication is hindered, patients who utilize traditional remedies may be reluctant to inform their biomedical providers about them, leading to potentially dangerous interactions between medications prescribed by the two types of providers.

In addition to better health outcomes, effective communication can lead to higher patient satisfaction, continued care, and better adherence to treatment recommendations while reducing conflict and errors, lost opportunities for encouraging health behavior changes, misinterpretations of treatment plans, damaged relationships (including a loss of trust) between provider and patient or community member, and legal actions. All of these reasons illustrate why culturally competent communication is a vital component of health care.

Verbal Communication As indicated in the quotation of Hoban at the beginning of this chapter, even people who speak the same language do not necessarily communicate even when using the same words. For example, in some age groups the word “ fox” means attractive, but someone from a different generation may think of the animal. People in the United States whose first language is English have a difficult time communicating, so imagine how difficult it must be to communicate with people when English is not their first language.