Hearing more by saying less. Karabo weaves the importance of culture and community into shaping health outcomes, and outlines strategies to better understand and address barriers faced by minoritised groups.

Health and behaviour are intricately linked. From physical exercise and diet, to smoking and drinking alcohol, to taking medication (and at the prescribed time and dosage), our behaviours are often important for our health. Behavioural change, then, is sometimes necessary to improve health. Key to changing our behaviour is knowing what changes to make and the outcomes of doing so on our health; information and encouragement that can impactfully be shared by healthcare professionals such as doctors. 

During a consultation, communication can affect interactional alignment, or the extent to which the health professional and patient are “on the same page” and can build rapport with each other. This is the basis for a positive doctor-patient relationship, which is important for patient satisfaction. The doctor-patient relationship is also strengthened when the patient feels heard and listened to, which in turn can influence whether patients follow, or adhere to, medical advice. This means the way doctors and patients communicate has implications for not only what happens during a consultation, but for patients’ behaviour long after the consultation has ended.

One model to predict health behaviours is known as the health belief model. According to this model, how likely a person is to carry out a particular behaviour is influenced by their beliefs about health, including their perception of risk and the costs and benefits associated with the behaviour. These beliefs are in turn moderated by demographic variables such as culture and ethnicity. In other words, patients’ backgrounds influence their perceptions and beliefs about health, which then affect the likelihood of engaging in a particular behaviour or action. Health communication therefore needs to be culturally sensitive in order to be effective in producing the desired behaviour change.

For patients from minoritised ethnic backgrounds, the lack of culturally sensitive health communication can have serious consequences. In the United Kingdom (UK), patients from minoritised ethnicities have poorer health outcomes compared to white patients, including conditions such as type 2 diabetes, which disproportionately affects Black and Asian communities. People from African and Caribbean backgrounds are three times more likely to be diabetic compared to the general population, a disparity which is linked to culturally inappropriate medical advice on self-managing diabetes. For example, advice to lose weight may be at odds with positive associations of weight or fatness in some cultures in Ghana, Kenya, South Africa, and Botswana. Similarly, advice to eat less of traditional, calorie-dense foods may clash with the values of young Sikh Punjabis living in the UK, for whom maintaining traditional dietary habits may be a key priority. As might be expected, and as the health belief model points out: patients are generally less likely to adopt advice which doesn’t reflect their cultural worldview.

Beyond interpersonal communication at the individual level, public health communication at a community-level or country-wide scale may also be important in understanding health inequities from the perspective of behaviour change. At the height of the COVID-19 pandemic, people from minoritised backgrounds suffered worse morbidity and mortality than their white counterparts. There are multiple complex factors contributing to this disparity, such as the observation that South Asian families are more likely to live in inter-generational homes, and that Black and Asian people are overrepresented in ‘frontline employment’. However, public health messaging about the pandemic has been identified as inappropriate, and therefore ineffective, for minoritised communities. By failing to take into account the historical, social, and cultural context of different communities, public health communication falls short in eliciting behaviour change such as getting vaccinated. Among Black communities living in the UK, for example, there is a history of mistrust of medical professionals and institutions, at whose hands Black people have suffered mistreatment and unethical experimentation. During the pandemic, this medical mistrust grew into scepticism and vaccine hesitancy.

Strategies by researchers, educators, and health advocates to ensure that healthcare communications are informed by diverse healthcare needs are increasingly common. One of these strategies comes from recognising that people from minoritised communities are less likely to be recruited to participate in research studies, which means their perspectives are “seldom heard”. Researchers are increasing efforts to design and deliver their research projects alongside patient and public involvement (PPI) groups that comprise of people from marginalised communities. This creates opportunities for researchers to develop studies that are acceptable and relevant to, and in turn produce findings that are informed by, the experiences of people from these underserved communities. Another method to ensure health communication speaks to diverse and representative populations is to study communications between doctors and patients and identify features that make interactions positive, and therefore more likely effective. This can be done through interviewing patients to find out about their experiences of communicating with doctors and what kinds of communication they prefer. Tools for doing this include more naturalistic methods, such as observation and conversation analysis, which seek to evaluate interactions between patients and doctors as they unfold in real time.

While there is more work still to be done to dismantle health inequities along ethnic lines, understanding the role of communication is an important step on the road to health equity. As communicating is not one-directional, the solution is likewise twofold: addressing how health professionals talk, and listening to the affected communities.

Useful organisations and resources

If you are worried about the contents of this article or found it distressing, please consider contacting the following organisations:

• African and Caribbean Health Network: https://www.cahn.org.uk/

• The Black, African and Asian Therapy Network (BAAT) - https://www.baatn.org.uk/

The author would like to thank her supervisors Dr Anna Hood, Dr Brian McMillan, and Dr Susan Speer for their help with this article.