Navigating the world of cultural differences in healthcare

To summarise, Rodenburg recommends a three-stage process to widen perspectives for those working across different continents:

• Self-awareness – getting to know your own culture

• Empathy – for other cultures and your own

• Knowledge – about the other culture you are working with.

Europe: rich diversity extends to healthcare systems

Though the second smallest continent in the world, Europe offers a wealth of diversity, including in its healthcare systems. Elena Donina Glukhman of medical assistance company AP Companies Spain explained: “The differences can be substantial, underscoring the significance of cultural awareness. For instance, the contrast between healthcare systems in Spain and Germany, both within the European Union (EU), highlights the significant variations in procedures, treatment approaches and medical protocols.”

By employing multiple perspectives, and refraining from cultural stereotyping, you create a more realistic expectation

She further explained the German system: “[It] operates on a complex system of coefficients known as the Diagnosis-Related Group (DRG) [system]. The final price of a medical procedure may vary widely based on factors such as the day of the week or the qualifications of the treating physician. Negotiating with German facilities requires a nuanced understanding of this system to avoid misunderstandings and ensure fair pricing for patients and insurers.”

Another issue that could cause friction inadvertently is language barriers. Communication can be limited significantly if patients, medical staff and assistance companies cannot talk to one another. Turkey-based air ambulance provider Redstar Aviation recognised this issue, particularly in conjunction with cultural differences: “Communication can already become an issue from the outset due to language barriers. When cultural differences are then added on top of this as an additional challenge, miscommunication or misunderstandings can easily happen.”

Carlos Lopes Da Costa, Providers Manager Iberia at MAWDY (previously MAPFRE Assistance), explained the consequences that these misunderstandings can have: “Misinterpretations of medical information can lead to medical errors, including incorrect dosages, treatments and procedures, with potentially serious consequences,” he said. But it is not just medical treatments that can be impacted; personal experiences can be greatly affected too. “When patients feel that their cultural values and beliefs are not respected, they may lose trust in healthcare providers and the healthcare system,” said Lopes Da Costa. “This can lead to decreased patient satisfaction, reluctance to follow treatment plans, and even avoidance of seeking medical care altogether.”

Therefore, all three companies have taken and applied preventative measures. Redstar’s ‘crews are trained in appropriate communication and cultural awareness from the start’ and it has ‘developed specific staffing protocols to be considerate of cultural expectations – for example having at least one female crew member onboard if the patient is female’. AP Companies Spain has employed ‘a diverse workforce from various countries, proficient in multiple languages’. Donina Glukhman explained the benefit: “When negotiating with healthcare providers in specific regions, we leverage the expertise of doctors and network specialists from that particular country or region.”

By fostering an environment of cultural sensitivity and understanding, we have witnessed positive outcomes

MAWDY also has multilingual staff throughout its operations. Lopes Da Costa affirmed: “[We] connect our customers with doctors or nurses speaking the same languages through our more than 20 contact centres, multilingual agents by teleconsultation or our global network of more than 35,000 active medical institutions across the world.”

Donina Glukhman summarised how appreciating cultural diversity and working with it can benefit everyone: “By fostering an environment of cultural sensitivity and understanding, we have witnessed positive outcomes where patients feel valued and respected, leading to smoother assistance processes and stronger partnerships between the assistance company, hospitals and insurers.”

Asia: different approaches to healthcare, family and communication

On to the largest continent in the world, by both land area and population: Asia. The continent is home to over four billion people, with the total population predicted to reach over five billion by 2050. With such a vast number of people living here, it is no surprise that so many cultures co-exist within Asia, making the navigation of healthcare systems complicated.

Dr Valensia Hanafi, Chief Operational Officer at Savana Assistance in Indonesia, explained that some common practices that exist around the world are not shared in all countries. “The concept of next of kin or legal guardian may not completely work in Indonesia,” she said. “We have big families here. When a family member falls ill, everyone needs to know. As a doctor, I can explain the same thing more than three times to different family members.”

Sumit Gaurav, Chief Executive Officer of Roy Medical Assistance, explained that the situation in the Maldives is similar. “Family plays a crucial role in healthcare decisions in the Maldives. Healthcare providers should be prepared to engage and communicate with the patient’s family when discussing treatment plans and medical procedures,” he said.

The approach taken in Japan is very different, explained Tomomi Takahata Steincamp, Chief Operating Officer at Emergency Assistance Japan. “In Japan, along with some other countries, doctors disclose very little medical information to patients,” she said. “The doctors decide how much information they will share and release to the patients, and this is very true especially if the condition is terminal – for example, late-stage cancer. If the doctors believe that disclosing the condition would severely affect the patient’s overall health, they can withhold this information. It is not uncommon that a spouse will learn about the condition from the doctor first, along with the doctor’s advice as to when to inform the patient.”

Assistance companies looking to Japan as a new market are aware of its diversity. For example, Hong Kong-based ATMS recently expanded its service region to include the country, and its Network Manager Rahul Gupta said that ‘Japan is a very distinct place from other countries in terms of both culture and language’. He explained: “We had to get ready for both the culture and the language before adding Japan on our bucket list.”

When patients feel that their cultural values and beliefs are not respected, they may lose trust in healthcare providers and the healthcare system

Religion also has an impact on healthcare in Asia. Indonesia is a majority Muslim country, therefore the concepts of halal – what is permissible – and haram – what is forbidden – are widely observed. Hanafi described how this can affect hospital care: “For certain patients with certain beliefs, it is strictly forbidden to use medicine that contains or is derived from swine, even if there’s no alternative to the offered treatment.” In Islam, pork products are explicitly haram, including those used in medicines. The Maldives is also an Islamic country.

Gaurav explained that religious practices need to be considered in healthcare settings. He said: “Healthcare providers may need to accommodate prayer times or dietary restrictions during treatment and hospital stays.”

Africa: diverse tapestry of communities and health behaviours

After Asia, Africa is the second largest and second most populous continent, comprising 54 countries. It hosts a ‘diverse tapestry of communities’ whose beliefs, value and practices ‘directly influence health behaviours and perceptions’, according to Dr Joseph Lelo, Medical Director of AMREF Flying Doctors.

The African air ambulance service once transferred a patient who believed strongly in traditional healing and was resistant to medical intervention. Dr Lelo explained the situation: “The patient was suffering severe respiratory distress due to Covid-19 infection and required immediate intubation and ventilator. As the leader of a large family, his word was final, and the wives would not dare go against his wishes. This caused a delay due to a standoff at the airside between the medevac team and the patient’s family.

Neglecting to consider cultural nuances can inadvertently lead to missed diagnoses, non-adherence to treatments, or even harm

“Fortunately, a renowned local traditional healer was nearby at the airport and was invited to talk to the patient and their family. He was able to convince them that intubation was not against their beliefs, and it was not going to kill the patient, but the disease was, and the intubation and medication would ease his distress. The patient and family finally accepted the procedure, and the patient was transferred safely to Nairobi.”

This unique collaboration between community healers and healthcare providers, alongside the culturally sensitive approach taken, led to successful patient care and a newly found respect between the parties.

Because of Africa’s ‘rich cultural milieu’, healthcare providers and assistance companies must be aware of the cultural differences and the more holistic approach towards medical treatment. Dr Lelo warned: “Neglecting to consider cultural nuances can inadvertently lead to missed diagnoses, non-adherence to treatments, or even inadvertent harm.”

Americas: understanding the patient’s mindset

The Americas cover a vast area of the world – North America, the Caribbean, Central and South America, which are all culturally very different.

Health City Cayman Islands works in the Caribbean, as well as in Latin America – where it feels the differences more. “Most of these [Caribbean] regions have a similar geographic make-up to the Cayman Islands so there is some familiarity when patients arrive here for medical care,” said Sales Manager for Latin America Dr Majorie Culbert. “However, where Latin America is concerned, there are differences, primarily in language and culture.”

She added: “We have found that it’s important to understand the culture of the Latin American countries we serve, such as Honduras, as this helps us to understand the patients’ mindset and expectations; improve the relationships and collaboration we can have with the patient, to ensure the highest level of care; develop strategies on how to subsidise the patients’ needs; and problem-solve if any issues should arise during our engagement with patients.”

It is key to have this knowledge so that you are able to set the right expectations to customers when they request assistance

Federico Tarling, Chief Service Officer at Argentina-based Assist Card, echoed this sentiment regarding patient expectations. “It is key to have this knowledge so that you are able to set the right expectations to customers when they request assistance, as well as saving valuable time when dealing with suppliers whose ‘ways’ are particular of that country,” he said.

One case from Donina Glukhman exemplified how Latin America can differ from the rest of the world. “In Mexico, surgeries commonly involve three surgeon assistants, a practice that might seem excessive in European countries where one assistant is usually sufficient,” she said. “However, this cultural difference is ingrained in the local medical tradition and must be respected.”

Another feature of Mexican healthcare, noted by Rodenburg, is the tendency ‘to try to please’, which can cause confusion when interacting with people from cultures that tend to be more direct. “Not saying ‘no’ directly, or any other negative for that matter, creates false expectations in cultures where people have the tendency to be more direct,” she said. “If you don’t understand where it comes from and how to interpret the way of communication, you might feel people are avoiding the topic, beating around the bush, when, in reality, people often are just trying to be polite and not inconvenience you and themselves.”

Caring for health and culture

Whether it’s the culture of the patient, the healthcare staff, or the country in which medical treatment is given, fostering an attitude of mutual understanding and respect is fundamental for assistance companies. The effects that could be faced if an attitude of ignorance was adopted could be extremely serious in multiple ways:

• For the patient – a breakdown in communication with the patient or their family, causing misunderstandings, or even misdiagnosis and incorrect treatment

• For the healthcare staff – feeling alienated or disrespected

• For the assistance companies – rifts in relationships with providers or insurers, leading to the loss of business or contracts.

Cultural differences run deep and, if not recognised and appreciated, all parties are worse off – with some potentially fatal consequences.

Assistance companies are already undertaking measures to be culturally aware, through training courses, multilingual staff or databases filled with local information. With so many cultures throughout the world, it is vital that these practices are kept up-to-date and are consistent across the industry. The most important, yet simple, step, though, is attitudinal: be respectful.