Patient Education and Counseling 100 (2017) 411–424
Contents lists available at ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
Review article
Culture and nonverbal expressions of empathy in clinical settings: A
systematic review
Áine Loriéa,1, Diego A. Reineroa,b,1, Margot Phillipsa , Linda Zhanga , Helen Riess, M.D.a,*
a
b
Massachusetts General Hospital/Harvard Medical School, Empathy and Relational Science Program, Department of Psychiatry, Boston, MA, USA
New York University, Department of Psychology, New York, NY, USA
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 10 December 2015
Received in revised form 22 July 2016
Accepted 23 September 2016
Objective: To conduct a systematic review of studies examining how culture mediates nonverbal
expressions of empathy with the aim to improve clinician cross-cultural competency.
Methods: We searched three databases for studies of nonverbal expressions of empathy and
communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed,
experimental or observational articles. Sixteen studies met inclusion criteria.
Results: Nonverbal expressions of empathy varied across cultural groups and impacted the quality of
communication and care. Some nonverbal behaviors appeared universally desired and others, culturally
specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone,
information exchange, visit length, and expression decoding during cross-cultural clinical encounters.
Racial discordance, patients’ perception of physician racism, and physician implicit bias are among
factors that appear to influence information exchange in clinical encounters.
Conclusion: Culture-based norms impact expectations for specific nonverbal expressions within patientclinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient
relationships, and is critical to high quality care.
Practice implications: Medical education should include training in interpretation of nonverbal behavior
to optimize empathic cross-cultural communication and training efforts should accommodate norms of
local patient populations. These efforts should reduce implicit biases in providers and perceived
prejudice in patients.
ã 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Culture
Empathy
Nonverbal
Systematic review
Patient-physician relationship
Contents
1.
2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Main findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
3.2.
Patient satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Affective tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.
3.4.
Information exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Visit length . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.5.
Expression decoding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.6.
Cultural preferences for NVBs: qualitative studies . . . . . . . . . . . . . . . . . .
3.7.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Emotion expression: cultural equivalence or cultural advantage model?
Cross-cultural considerations of nonverbal empathy . . . . . . . . . . . . . . . .
4.2.
* Corresponding author at: Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School. Wang
Ambulatory Care Center, Suite 812, 15 Parkman Street, Boston, MA, USA.
E-mail address: hriess@mgh.harvard.edu (H. Riess).
1
Equal author contribution.
http://dx.doi.org/10.1016/j.pec.2016.09.018
0738-3991/ã 2016 Elsevier Ireland Ltd. All rights reserved.
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5.
6.
7.
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
4.2.1.
Race . . . . . . . . . . . . . . .
Nationality . . . . . . . . .
4.2.2.
Gender and occupation
4.2.3.
Intergroup and implicit
4.2.4.
Limitations . . . . . . . . . . . . . . . . . . . . . .
Practice implications . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . .
Conflict of interest disclosures . . . . . .
Author contributions . . . . . . . . . . . . . .
Ethical approval . . . . . . . . . . . . . . . . . .
Acknowledgments . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
There is a critical need for health care providers to offer
culturally competent empathic care [1–3]. Increasing diversity in
patient populations and the healthcare workforce can generate
cross-cultural misunderstandings, contributing to medical errors,
lack of trust and adherence to treatment [4–7], and decreased
patient satisfaction [8–10]. The U.S. confirms this multicultural
trend, reporting that by 2043, no individual racial group within the
U.S. will make up a majority [11]. In spite of increasing global
diversification [12,13], medical trainees are not adequately
prepared to provide cross-culturally competent care [14]. In-group
biases (the effect wherein people give preferential treatment to
others who are perceived to be in the same group) arise in
cross-cultural contexts [15–18] and often disproportionally affect
minorities, leading to disparities in treatment, healthcare access,
and health outcomes [19–23]. Indeed, a previous literature review
of cultural differences in medical communication found that
clinicians are more verbally dominant and behave less affectively
(e.g., less rapport-building, friendly, or concerned) when
interacting with ethnic minority patients compared to White
patients [24]. Therefore, competence in cross-cultural communication is becoming increasingly critical in practices and policies of
health services, with a corresponding need to train medical
personnel in these skills to improve the quality of care and patient
outcomes [25].
Empathy, a capacity that includes cognitive and affective
components enabling individuals to perceive and respond to verbal
and nonverbal emotional cues of others [26] is a key component of
effective cross-cultural care [9,20,26–38]. Empathy is expressed
both through verbal and nonverbal behavior [39], and nonverbal
behavior (NVB) is estimated to account for 60%–90% of communication [40]. The importance of nonverbal empathy in clinical
encounters has been highlighted in previous work [41–47],
suggesting that clinician warmth and listening results in greater
patient satisfaction [48], and that specific NVBs, including head
nodding, forward lean, direct body orientation, uncrossed legs and
arms, arm symmetry, and mutual gaze, are associated with positive
health outcomes [49]. Providers who are more sensitive to
nonverbal cues reinforce the perception of physician sincerity,
dedication, and competence, which in turn improves utilization of
health services, functional status, and the overall provider-patient
relationship [50].
Although existing medical, psychological, and sociological
literature abounds with research that examines gaps in crosscultural communication, in-group bias, and the need for cultural
awareness and training [51–55], there is little research integrating
cross-cultural differences and patient-clinician NVB [56–61]. One
study that focused on the verbal exchange between patients and
clinicians reported difficulty in reliably detecting NVB, as such
expressions can be communicated vaguely, downplayed or
masked, and veiled by language barriers [62].
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420
420
420
421
421
421
421
422
422
422
422
423
Levine and Ambady’s [61] review examined the influence of
nonverbal behavior on racial disparities in healthcare. The findings
suggest that through both historical minority group derogation
and clinician disengagement, patient distrust can arise. Moreover,
negative
stereotyping,
and
culturally-bound
nonverbal
expectations obstruct nonverbal communication and engagement
in cross-racial patient-clinician encounters [61]. However, this
previous review was not systematic and focused primarily on
White doctors and African American patients, thus limiting the
scope and generalizability of its findings. Our systematic review
expands on Levine and Ambady’s work [61] by broadening the
cross-cultural context, and systematically examining a wider range
of groups that report culturally specific practices of NVB in
healthcare.
Culture has been defined as a learned system of knowledge,
attitudes, beliefs, behaviors, values, and norms that is shared by a
group of people, community, kin, or nation [63]. Our systematic
review is guided by the following research questions: (1) Are
nonverbal expressions in the clinical setting culturally specific or
universal? (2) If culturally specific, how does empathic NVB in the
clinical setting differ cross-culturally? (3) What are the effects of
empathic cross-cultural NVB on patient outcomes? An examination of these questions will reveal some of the complexities of
cross-cultural nonverbal communication and empathy, and may
subsequently offer solutions to improve provider training, clinician
cross-cultural competency, and the reduction of disparities. Our
systematic review will conclude with practice implications and
recommendations for future research.
2. Methods
We searched MEDLINE, PsycINFO, and CINAHL from 1990
through September 18, 2014. An example of our electronic search
strategy (MEDLINE) is outlined in Appendix A (PsycINFO and
CINAHL search strategies available upon request). The electronic
search strategy required that articles: (1) be written in English and
published in a peer-reviewed journal; (2) include in the title or
abstract at least one word related to culture (e.g., race, ethnicity,
immigrant, cross-cultural), clinician-patient communication (e.g.,
empathy, nonverbal, patient centered) and a clinical setting (e.g.,
hospital, clinic, primary care). For the review by hand, the inclusion
criteria were: (1) experimental or observational studies with
adults (age 18) and 10 subjects, written in English and
published in a peer-reviewed journal; (2) clinician-patient
interactions addressing health problems; (3) an analysis or
discussion of cultural components; (4) an analysis or discussion
of clinician-patient nonverbal communication. Studies were
excluded if: (1) not all four of the inclusion criteria were met;
(2) the patients had severe psychiatric, neurologic, or facial
impairments obstructing communication; (3) the health problems
discussed were addressed through non-traditional medical
practice, (4) translators were the main focus of the study. For
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
413
Fig. 1. Flow Chart of Study Selection Process.
full criteria, see Appendix B. Limitations are presented after the
Discussion.
Our electronic search yielded 16,143 articles (MEDLINE: 8709;
PsycINFO: 3079; CINAHL: 4355). Removing duplicates yielded
16,025 articles. For the initial review, two pairs of authors each
independently reviewed half of the titles. A fifth author resolved
disagreements between reviewer-pairs (99% reviewer-pair
agreement). Articles were included for the next round of review
if the title incorporated at least two of the three main content
criteria (“culture”, “communication”, “clinical”) and appeared
relevant to the study’s goal. This process yielded 1040 articles.1
The second round of review examined the abstracts of these
remaining articles, again with two pairs of authors each reviewing
one half of the results. Articles were included if the abstract
included all three content criteria. A fifth author resolved
disagreements between reviewer-pairs (95% reviewer-pair
agreement). This yielded 116 articles. This new total included
two additional articles that were hand selected from the reference
list of informative reviews. The final round examined the full text of
each article. Authors made independent judgments as to whether
1
Although this article selection process is common for systematic reviews, we
nevertheless performed a sensitivity check on 100 randomly selected results that
had previously been excluded (on the basis of the initial title review by two authors)
and systematically reviewed the abstracts of each of these articles. This sensitivity
check confirmed that none of the 100 articles met our inclusion criteria and
provides evidence that our study selection process is indeed robust.
the article met inclusion/exclusion criteria with particular focus on
quality of nonverbal communication measured. Disagreements
were resolved by face-to-face discussion of four authors, leading to
consensus judgment. Sixteen articles met our inclusion criteria.
This selection process adhered to PRISMA guidelines and is
illustrated in Fig. 1.
3. Results
The systematic review yielded 16 studies (Table 1). Eleven
studies were conducted in the United States; other locations
included Canada, Slovenia, Sweden, Australia, and Trinidad and
Tobago.
Six studies examined White Americans and African Americans
[64–69]; other cultural groups studied were Australian Aboriginals, Brazilians, Filipinos, South Asians, and Hispanics. Six studies
assessed scenarios in which the patients belonged to a minority
culture and clinicians belonged to the dominant culture [67,68,
70–73], and five studies examined combinations of patients and
providers in both majority and minority cultures [64–66,69,74]. By
contrast, four studies examined scenarios in which the providers
belonged to a minority culture [75–78], for example internationally educated nurses or physicians (from countries such as the
Philippines (39 total), India (11 total), China (5 total), Korea (3
total), Jordan (1 total), Lebanon (1 total), Nigeria (1 total), and
Kenya (1 total)). One study examined providers’ NVBs within the
majority culture [79].
414
Table 1
Overview of studies: sample, setting, methods, and nonverbal behaviors studied (studies are organized in reverse chronological order within study design).
Patient
sample size
(n of each
culture)
Observation
Strategy
Instruments
Interrater
reliability
Nonverbal behavior studied
Outcomes
7
(7 non-AA
physicians)
Audiotaped
clinic visits
RIAS, patient
questionnaire
0.98
Emotional tone of patient and physician Patient satisfaction and
provider satisfaction,
physician verbal
dominance, patient
centeredness, visit duration,
information exchange
Computerized
tests of
physicians'
ability to
decode facial
expressions and
vocal tones
1) Facial expression
coding system, 2) Vocal
tone assessment, 3)
Patient satisfaction
survey, 4) authordeveloped Patient
Adherence survey
NR
Facial expression decoding accuracy
and vocal tones decoding accuracy
Patient satisfaction, selfreported patient adherence
Audiotaped
clinic visits;
Implicit
Association
Tests (IAT) for
clinicians
Two IATs for measuring
racial attitudes and
stereotypes, and patient
questionnaire
0.86 1
Patient and physician positive affect
Implicit race bias and
compliance bias of
physicians, patient
satisfaction, visit length,
speech speed, clinician
verbal dominance, patient
centeredness
Study Design Country
Practice
Havranek
et al. [68]
Randomized
control trial
USA
Primary care 99
(99 AA)
Coelho and
Galan [74]
Crosssectional
USA
Hospitals
and clinics
30
60
(16 South Asian, 14
(30 South
Asian, 30 WA) WA physicians)
Cooper et al.
[66]
Cross
sectional
USA
2 Primary
care clinics
269
(213 AA, 56
WA)
40
(9 AA, 12 Asian, 19
WA physicians)
Stepanikova
et al. [64]
Crosssectional
USA
3 Primary
care clinics
209
(29 nonWhite, 190
WA)
Videotaped
30
(3 non-white, 27 WA clinic visits
physicians)
Xu et al. [75]
Crosssectional
USA
2 Hospitals
1
(1
standardized
patient)
52
(IENs: 38
Philippines, 5 India,
3 Korea, 3 China, 1
Kenya, 2 NR)
Videotaped
encounter of
nursing intake
of a
standardized
patient
Author-developed scales
0.82
Hausmann
et al. [67]
Crosssectional
USA
Veterans
Affairs
Hospitals
353
(100 AA, 253
WA)
63
(63 Orthopedic
surgeons)
Audiotaped
clinic visits
RIAS, patient
questionnaire
0.68 0.92 Provider warmth/respectfulness
Patient-rated visit
informativeness, and ease of
communicating with the
provider
Zaletel et al.
[79]
Crosssectional
Slovenia
27 Nursing
homes
267
(267
Slovenians)
267
(267 Slovenian care
givers)
Direct clinical
observation by
pairs of trained
observers
Kovacev Non-Verbal
Expression Checklist
NR
Distribution of nonverbal
behaviors by gender and
professional type
Johnson et al.
[69]
Crosssectional
USA
General
clinics
458
(256 AA, 202
WA)
61
(21 AA, 9 Asian, 30
WA, 1 Other
physicians)
Audiotaped
clinic visits
RIAS, patient
questionnaires
0.88 0.79 Patient and physician positive affect
score: dominance/assertiveness
(patient only), interest/attentiveness
(both), friendliness/warmth (both),
responsiveness/engagement (both),
and sympathy/empathy (both)
Adaption of the Nonverbal 0.83 0.96 Open body position, eye contact, smile, Patient ease, physician’s
Communication in
touch
mixed signals
Doctor–Elderly Patient
Transactions (NDEPT)
Eye contact, smile, body position,
nodding, gesture, hugging,
interpersonal space, and therapeutic
touch
Provider facial expressions, head
movements, gestures, body position,
silence
Global assessment of
communication
Patient positive affect,
physician positive affect,
verbal dominance, patientcentered orientation, visit
duration and speech speed
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
Clinician sample
size (n of each
culture)
Author
Patient-rated satisfaction,
trust, self-disclosure,
recommendation, recall,
compliance
Student
health clinic
116
(97 AA, 19
WA)
2
(1 AA, 1 WA
physician in a
simulated video)
Participants
watched 1 of 4
videos
Patient questionnaires
NR
Physician facial expression, distance
from patient, concern for patient,
understanding of patient
Bergman and Qualitative
Connaughton [70]
USA
Prenatal
clinic
48
(48 Hispanic)
NR
(American
providers)
Semistructured
interviews
Qualitative
NR
Physician warmth, friendliness, smile, Patient centered care
eye contact, patience, formal greetings approaches, patient trust,
provider credibility
Williams et al. Qualitative
[77]
Trinidad
and
Tobago
Medical
School
N/A
36
(36 medical
students)
Videotaped
focus groups
Qualitative
NR
Eye contact, personal space, body
movements, touch, vocal tone
Provider perceptions of
patient expectations
Jain and
Qualitative
Krieger [76]
USA
Hospital
N/A
12
(Internationally
educated resident
physicians: 6 India,
2 China, 1 Jordan, 1
Lebanon, 1 Nigeria, 1
Philippines)
Semistructured
audio-recorded
interviews
Qualitative
NR
Eye contact, touch, gestures, warmth
Internationally educated
resident physicians’ crosscultural strategies
Jirwe et al.
[78]
Qualitative
Sweden
Nursing
school
N/A
10
(5 Swedish student
nurses, 5 immigrant
student nurses)
Semistructured
audio-recorded
interviews
Qualitative
NR
Eye contact, smile, gestures, warmth
Swedish and non-Swedish
student nurse strategies and
difficulties in cross-cultural
encounters
Shahid et al.
[71]
Qualitative
Australia
Varied:
recruited
from
oncology
centers
30
(30
Australian
Aborigines)
NR
SemiAustralian providers structured
audio-recorded
interviews
Qualitative
NR
Patient nodding and silence, physician
friendliness
Trust, patient perception of
physician knowledge and
competence
Roberts [72]
Qualitative
USA
Community
centers
42
(42
Brazilians)
NR
American providers
Semistructured
interviews
Qualitative
NR
Perception of physician warmth, touch Patient satisfaction, patient
trust
Pasco et al.
[73]
Qualitative
Canada
Hospital
24
(24 Filipinos)
NR
Canadian nurses
Semistructured
interviews
Qualitative
NR
Touch, eye contact and gaze
Crosssectional
Patient trust
Notes: AA = African American, WA = White Americans, IEN = Internationally educated nurse, MD = physician, RN = Registered nurse, N/A = Not applicable, NR = not reported, NVB = Nonverbal behavior, RIAS = Roter Interaction Analysis
System, USA = United States of America.
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
USA
Aruguete and
Roberts
[65]
415
416
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
The methods of data analysis varied across the included studies.
There were nine quantitative studies and seven qualitative studies.
One study was a randomized controlled trial [68]; eight were
cross-sectional. Three studies used the Roter Interaction Analysis
System (RIAS) to code physician and patient behaviors during
clinical encounters [67–69]. Seven studies reported acceptable
inter-rater reliability. Sample sizes of quantitative studies ranged
from 52 to 458. The seven qualitative studies were based on semistructured interviews or focus groups, and their sample sizes
ranged from 10 to 48.
Patient and physician age and gender were reported in all of the
quantitative studies. Factors inconsistently reported were number
of years in host country, level of education, language proficiency,
and use of interpreters. Mood or mental state was assessed in two
studies [66,68].
Clinical specialties included primary care clinics (5 studies),
hospitals (5 studies), specialty clinics (2 studies), nursing home (1
study), medical school (1 study), nursing school (1 study), and
community center (1 study). Care providers of different specialties
and level of training were studied, including: general providers (3
studies), physicians (8 studies), nurses (2 studies), medical
students (1 study), nursing students (1 study), and nursing home
caregivers (1 study).
3.1. Main findings
Findings of nonverbal behaviors influencing empathic crosscultural care can be grouped into two main categories (Table 2). We
focus on quantitative studies demonstrating changes in patient or
clinician NVBs in cross-cultural clinical encounters and their
outcomes. These include patient satisfaction, affective tone,
information exchange, visit length, and expression decoding. Main
findings and recommendations from qualitative studies that
demonstrate cultural preferences for specific NVBs as part of
empathic care are presented in Table 2.
clinical encounters were found in several studies. Johnson et al.
found that both the patient and physician showed significantly less
positive affect during visits with AA patients as compared with
White patients (patient positive affect: p < 0.001; physician
positive affect: p < 0.02) [69]. Stepanikova et al. found that
nonverbal communication in concordant AA–AA dyads was more
positive, as indicated by more smile, touch, and open body
position, compared to communication in any other racial
combination [64].
Cooper et al. found a significant association between physician
implicit bias as measured on an Implicit Association Test (IAT) and
patient positive affect, where AA patients were less likely to
demonstrate positive affect (as observed by coders) as compared to
encounters with physicians without implicit race bias (p = 0.04).
Higher levels of physician implicit race bias were significantly
associated with greater clinician verbal dominance, lower patient
positive affect, and poorer ratings of interpersonal care among AA
patients [66]. Implicit bias also correlated with significantly higher
ratings of physician positive affect during visits with White
patients, but there was no significant change in positive affect
among White patients. Similarly, Hausmann et al. found that
encounters in which patients reported high levels of perceived
racism had a significant negative association with coder ratings of
nonverbal provider positive affect (B = 0.34, 95% CI = 0.66,
0.01) and with patient positive affect (B = 0.41, 95% CI = 0.073,
0.09) [67].
Havranek et al. [68] further explored how race influences
communication in race-discordant clinical encounters. In a
randomized controlled trial of the effects of a values affirmation
exercise (validation of patient self-worth and concerns) given prior
to clinic visits, coder ratings of warmth/friendliness and interactivity were significantly higher in the intervention group, whereas
ratings of depression/sadness and distress were significantly
higher in the control groups.
3.4. Information exchange
3.2. Patient satisfaction
Physician concern, communicated nonverbally, correlated with
patient satisfaction in several studies [65,66,68,72,74]. Aruguete
et al. showed that physician nonverbal concern, irrespective of
patient or physician race, was the best predictor of patient
satisfaction (p < 0.001) and positive physician recommendation
from the participant (p < 0.001) [65]. When the physician displayed
positive emotion, made eye contact, and appeared attentive,
physician race was not correlated to participants' evaluations [65].
In another study, poorer decoding of South Asian patients’ facial
expressions (regardless of physician race) was correlated with lower
visit satisfaction and lower likelihood of adhering to a physician’s
recommendations [74]. Similarly, high levels of perceived racism
among AA patients interacting with White physicians were
associated with low patient ratings of warmth and respectfulness
(OR = 0.19, 95% CI = 0.05, 0.72) [67]. Cooper et al. showed that higher
rates of physician implicit race bias in racially discordant dyads were
correlated with AA patients’ poorer ratings of patient care (e.g., AA
patients were less likely to feel that the doctor respects the patient
(50.2% vs 34.9%, p = 0.001), were less likely to report liking the
physician (46.6% vs 32.7%, p < 0.001), and less likely to recommend
the physician (47.3% vs 34.4%, p = 0.001)). Values for trust, feeling the
physician likes him or her, and having confidence in the physician
were not significant [66].
3.3. Affective tone
Changes in the affective tone (tone of voice, warmth, or
responsiveness) of patients and clinicians during cross-cultural
Racial discordance, patients’ perception of physician racism,
and physician implicit bias are among factors that appear to
influence information exchange in clinical encounters. In Havranek
et al., AA patients randomized to receive values-affirmation
training prior to their clinic visit gave and asked for significantly
more information about their medical condition than the control
group (p = 0.03) [68].
In racially discordant dyads, physicians were more verbally
dominant (p < 0.001) and less patient-centered (p < 0.05) with AA
patients than with White patients [69]. Physicians with higher
rates of implicit bias predicted significantly more cliniciandominated exchanges irrespective of patient race: (p < 0.05, and
p < 0.01) [66,69]. High levels of perceived racism among AA
patients were negatively associated with patient ratings of ease of
communication (OR = 0.22, 95% CI = 0.07, 0.67) [67]. Perceived
racism among White patients was negatively associated with
patient ratings of visit informativeness (OR = 0.4, 95% CI = 0.23,
0.71), but not among AAs [67].
3.5. Visit length
Findings for visit length varied. Visit length remained the same
despite significant improvements of information exchange after
patients received values affirmation training in Havranek et al.
Ratings of physicians’ rate of speech, verbal dominance, and
patient centeredness did not differ significantly between the
intervention and control groups [68]. In another study, higher
levels of physician compliance stereotyping (a measure of the
implicit association between race and the concept of the
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
417
Table 2
Studies' Main Nonverbal Findings (Studies are organized in reverse chronological order within study design).
Study
Refs.
#
Havranek
[68]
et al. (2012)
Study Design Research aims
Main nonverbal findings
Randomized
control trial
To test the effect of a values affirmation
intervention given to AA patients prior to
their clinic visit with a non-AA primary
care physician
Affective tone: overall communication in Values affirmation exercise can
the intervention group was significantly
improve the experience of AA patients
more friendly, interactive, and respectful
in primary care visits with non- AA
(p = 0.02). Patients were rated as less
physicians
Greater exchange of medical informadistressed and less depressed (p=0.03)
Information exchange: patients in the
tion is achieved without increasing visit
intervention group requested and
length, and overall positive affective
provided more information about their
tone of patients and physicians is
medical condition (p =0.03).
significantly greater
Visit length: no significant difference
Physicians should be aware that their
Patient satisfaction: no significant
affective tone may be influenced by the
difference
patient's level of comfort and moniPatient trust: no significant difference
toring cues such as instructiveness and
friendliness may influence patients'
affective tone and exchange of medical
information
Implications
Coelho and
Galan
(2012)
[74]
Crosssectional
To examine physicians’ abilities to decode
nonverbal emotions of Caucasian and
South Asian patients, and to test the
hypothesis that this ability correlates
with patient satisfaction and patient
adherence
Physicians can have difficulty interFacial and vocal tone decoding
accuracy: South Asian physicians were no
preting South Asian nonverbal cues
better at decoding the facial expressions
which is correlated with poorer patient
or vocal tones of South Asian patients, and
satisfaction and poorer patient adherboth South Asian and Caucasian
ence
Physicians should be trained to
physicians were better at decoding
Caucasian nonverbal stimuli (p < 0.001)
improve awareness of differences in
Patient satisfaction: South Asian
South Asian facial and vocal tone
patients were more likely to be
expression
dissatisfied with the quality of care
provided by their physician (p = 0.032)
Patient adherence: South Asian patients
reported they were less likely to adhere to
recommendations (p < 0.001)
Cooper et al.
(2012)
[66]
Crosssectional
To examine associations of clinician’s
implicit attitudes about race with visit
communication and patient ratings of
care
Training to improve clinician awarePositive Affect: clinician race bias was
associated with lower patient positive
ness of implicit race bias.
affect among Black patients and higher
Physician self-awareness can reduce
physician positive affect among White
implicit race and compliance bias, with
patients
improvements in overall communicaPhysician verbal dominance: clinician
tion and patient ratings of care, parrace bias was associated with greater
ticularly among Black patients
physician verbal dominance among Black
patients and White patients
Visit length and speech speed: clinician
race compliance bias was associated with
longer visits and slower speech among
Black patients and faster visits and faster
speech among White patients
Patient Satisfaction: greater clinician
race bias was associated with lower Black
patient ratings of clinician respect, liking,
(p < 0.001) or recommending physician
(p = 0.001)
[64]
Stepanikova
et al. (2012)
Crosssectional
To examine the influence of race of
physicians with patients who are over 65
years old, on nonverbal communication
during medical interviews
Open body posture, smile and touch:
Concordant race resulted in high use of
smile, touch, and open body position for
both AA and White physicians, and was
highest in AA–AA dyads compared to the
average across other dyads (open body
posture: p < 0.001; smile: p = 0.048;
touch: p < 0.001). Discordant race in AA
physicians with White patients resulted
in highest use of smile and gaze with
lowest use of open body position.
Eye contact: White physicians made
more eye contact with White patients as
compared to their AA patients but it was
only marginally significant (p = 0.08)
Training in nonverbal behavior across all
races with specific focus on open body
posture and awareness to avoid sending
mixed nonverbal messages, especially in
race discordant visits
Xu et al.
(2012)
Crosssectional
To evaluate nonverbal communication
behaviors of internationally educated
nurses (IENs) in the United States
Therapeutic touch (p < 0.01),
interpersonal space (p < 0.01), and eye
contact (p < 0.05) were positively
correlated to overall global impression
score
Provide targeted communication
training to newly arrived/hired IENs
with focus on therapeutic touch, interpersonal space, and eye contact to
improve patient rating of overall
clinical care
[75]
418
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
Table 2 (Continued)
Study
Refs.
#
Study Design Research aims
Main nonverbal findings
Implications
Hausmann
[67]
et al. (2011)
Crosssectional
To examine the relationship between AA Listening: Feeling that a physician did not Increase physician awareness of uninand White patients’ perceptions of
listen was the most common form of
tentional biases
discrimination from past healthcare
perceived racism expressed by both races Training to improve positive affective
encounters and patient-provider
Affective tone: less positive nonverbal
tone, listening, and how to counter
communication during a subsequent
affect among patients (Beta = 0.41, 95%
negative emotion states through rolemedical visit
CI = 0.73, 0.09) and providers
playing or mindfulness
(Beta = 0.34, 95% CI = 0.66, 0.01) was
associated with high levels of perceived
racism among AA patients
Warmth/respectfulness: high levels of
perceived racism was associated with low
patient ratings of provider warmth/
respectfulness (OR = 0.19, 95% CI = 0.05,
0.72) and ease of communication
(OR = 0.22, 95% CI = 0.07, 0.67). Perceived
classism yielded similar results
Zaletel et al.
(2012)
[79]
Crosssectional
To quantify nonverbal communication of Smile: No significant difference in rates of
caregivers in Slovenian nursing homes
smiling between gender or type of
caregiver
Eye contact: No significant difference in
rates of eye contact between gender or
type of caregiver
Gestures: associated with gender and
type of caregiver, with nurses and females
manifesting fewer negative expressions
(p = 0.034)
Johnson et al.
(2004)
[69]
Crosssectional
To examine the association between
patient race/ethnicity and patientphysician communication
Affective tone: overall physician affective
tone was less positive with AA compared
with White patients, and AA patient
affective tone was less positive compared
with White patients (p = 0.02)
Verbal dominance: physicians were 23%
more verbally dominant with AA patients
than with White patients (p < 0.001)
Patient-centeredness: content was 33%
less patient-centered with AA patients
(p < 0.5)
Training to improve clinician communication skills including affective
communication (e.g., rapport-building, minimizing verbal dominance),
and empowering minorities for active
participation in health care
Aruguete and
Roberts
(2002)
[65]
Crosssectional
Smile, facial expression, eye contact,
To examine the impact of race (AA vs.
White) and nonverbal communication on attentiveness, personal space
patient evaluations
(sitting < 2 feet from patient), and
posture (forward lean): physician display
of nonverbal concern via these behaviors
was the best predictor of patient
satisfaction (p < 0.001) and positive
physician recommendation (p < 0.001),
regardless of physician race
Increase nonverbal skills training for
students and practitioners in same and
discordant race encounters, with focus
on behaviors that communicate nonverbal concern
Friendliness: Patients expressed
preference for friendly (“amable”)
providers
Smile: a smile may convey warmth,
professionalism, and confidence that the
provider was competent
Eye contact: patients sought sustained
eye contact together with a smile as signs
of provider professionalism and warmth
Training to improve awareness of local
cultures' expectations for patientcentered communication: e.g., Hispanic women in prenatal clinic visits
expressed preferences for physician
friendliness, attentiveness, and patience/not rushing
Qualitative
Bergman and [70]
Connaughton (2013)
To understand the experience and
expectations of Hispanic women in
prenatal clinics
Williams et al. [77]
(2013)
Qualitative
To understand the challenges of teaching Eye Contact: in Tobago, it is considered
nonverbal communication skills in a
disrespectful to look into the eyes of an
Caribbean medical school
elder
Personal Space: in the Bahamas and
Jamaica, closer proximities are
considered invasive rather than
reassuring
[76]
Qualitative
To understand the communication
strategies international medical
graduates use in medical interactions to
overcome language and cultural barriers
Jain and
Krieger
(2011)
Internationally educated physicians
expressed difficulty knowing how to
respond to patients' emotions after giving
bad news because in their culture
physicians disclose medical information
to family members rather than to the
Training to improve rates of positive
nonverbal communication
Traditional (Western) teaching of physician nonverbal behavior did not reflect the diversity of patient preferences
in Caribbean cultures
Medical education should address culturally specific norms for nonverbal
communication
Training to improve communication
strategies of internationally educated
physicians early in their career, with
focus on disclosure of medical information and addressing patients' negative emotions when giving bad news
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
419
Table 2 (Continued)
Study
Refs.
#
Study Design Research aims
Main nonverbal findings
Implications
patient directly. They may compensate for
intercultural differences and language
barriers with several strategies, including
repeating information using non-verbal
communication such as eye contact,
friendliness, smile, vocally conveying
warmth and care, respectful silence,
and supportive touch
Jirwe et al.
(2010)
[78]
Qualitative
To understand the experiences of student Lack of skills and language barriers can
nurses' cross-cultural communication
result in patient and nurse dissatisfaction.
with patients
Communication strategies included
mirroring the patient’s emotions, using
pictures and using body language (smile,
eye contact, touch). Nurses who had
immigrated to Sweden expressed more
confidence communicating in crosscultural encounters than Swedish nurses
Training to improve nursing skills,
confidence, and satisfaction, including
use of smile, touch, eye contact, and
mirroring patient expressions
Shahid et al.
(2009)
[71]
Qualitative
To report Aboriginal patients' views about
effective communication between
Aboriginal people and cancer providers in
Australia
Warmth: Aboriginal patients tended to
act reserved and viewed many physicians
as lacking compassion and warmth
Silence: Aboriginal patients expressed
reluctance to admit to difficulty
understanding their physicians and
lacked the confidence to ask questions
Head Nod: Aboriginal patients may nod
rather than admit lack of understanding
Improve awareness of meaning of
Aboriginal patients' silence and nodding, and further integrate Aboriginal
clinical support and interpreters in
cancer care
Roberts
(2007)
[72]
Qualitative
To understand what health practices and Warmth: Brazilian immigrants
beliefs are common among Brazilian
experienced U.S. clinicians as lacking
immigrant patients
warmth and desired more personal
warmth from their providers (“carinho”)
Personal space: preference for more
physical closeness from providers
Touch: preference for a hug or a kiss over
a handshake
Smile and eye contact: can convey
warmth. Clinician “coldness” can be
interpreted by absence of a smile or eye
contact
Lengthen clinical encounters and
consider if the patient expects or
desires more warmth in nonverbal and
verbal behavior from clinicians
Pasco et al.
(2004)
[73]
Qualitative
To identify Filipino-Canadian values that
impact patient-nurse interactions
Improve nurse awareness of use of
gaze and touch to build relationships
with hospitalized Filipino patients
Touch by nurses helps develop trust in
hospitalized Filipino patients. Patients
experience a nurses' touch as conveying
respect for the patient
Eye contact: direct eye contact is valued;
lowered eyes may mean respect or shame
and is context-dependent. A head-to-toe
gaze by a nurse can be perceived as
demeaning
Notes: AA = African American, IEN = Internationally educated nurse, vs = versus.
“compliant patient”) were associated with longer visits, slower
speech, less patient centeredness, poorer ratings of interpersonal
care and lower ratings of patient positive affect among AA patients
[66]. In contrast, Johnson et al. showed no difference in speech
speed or visit duration when medical visits between AA or White
patients were compared [69].
3.6. Expression decoding
One study of physicians’ ability to identify nonverbal emotional
cues across races was included in our review [74]. South Asian
physicians were no better at decoding facial expressions or vocal
tones of South Asian or Caucasian patients than Caucasian
physicians. Physicians, regardless of their ethnicity, were more
accurate at rating Caucasian patients’ facial expressions and vocal
tones than South Asian faces and voice tones. Therefore,
assumptions cannot be made regarding greater attunement to
NVB between similar groups, as the accuracy in NVB decoding
appears to be related more to the influence of the dominant
culture.
3.7. Cultural preferences for NVBs: qualitative studies
The qualitative studies included in our review revealed explicit
patient preferences and expectations for certain NVBs as part of
empathic care [70–73,76–78]. They are summarized in Table 2.
4. Discussion
Our systematic review results indicate that nonverbal expressions of empathy are essential components of cross-cultural
clinical competency and quality care. However, optimal expression
of empathic NVB can vary across cultural groups, especially in
culturally diverse clinical settings. It appears that culture mediates
nonverbal empathic expression on several levels, including race,
nationality, gender, and occupation [64,66,67,69,71,74,79]. Greater
420
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
attention to and skill with interpreting and expressing NVB across
such cultural groups can improve the provider-patient relationship
and help to diminish disparities in quality of care. Several theories
inform the interpretation of our findings, discussed below.
4.1. Emotion expression: cultural equivalence or cultural advantage
model?
Extensive research suggests that the expressions of six basic
emotions (happiness, sadness, anger, fear, disgust, and surprise)
are universal [80],2 though members of the same national or ethnic
group may be more able to identify these facially-expressed
emotions [82]. There has also been debate as to whether empathy,
which encompasses the detection and expression of a broad range
of emotions, is a capacity that can be expressed and understood
universally (cultural equivalence model) or is subject to cultural
norms (cultural advantage model) [58]. This raises the concern of
whether specific nonverbal expressions of empathy may be
universally interpreted or culturally dependent. For example,
culturally determined power and status dynamics may drive
certain expectations of nonverbal deference to authority figures,
such as reduced or avoidance of direct eye contact with physicians.
Such culturally dependent expectations of behavior, as revealed
through NVB, may become more pronounced in cross-cultural
patient-clinician encounters, risking further miscommunication
within and between different cultural groups. These communication missteps may discourage patient participation, reduce shared
decision-making and diminish patient-centered care, which could
negatively impact the quality of care and ultimately, healthcare
outcomes.
for specific nonverbal expressions (e.g., gaze and proximity) that
are context dependent [70,72,73,77]. Western physicians must
take caution in cross-cultural contexts not to misinterpret acts of
nodding or silence as signs of mutual understanding as these
patient expressions could instead be masking confusion or
suppressing emotions [71]. Missing or inaccurately decoding such
NVB in a cross-cultural context may overlook patients’ physiological and psychological distress and could also decrease clinicians’
diagnostic acumen.
Specific NVBs, such as eye contact, may also have various
meanings. For example, a Filipino Canadian community voiced
preference for more direct eye contact from providers, especially if
the provider is giving instructions [73]. This same group also
cautioned against the use of lowered eye contact, which can
symbolize respect or shame depending on the context, as well as
head-to-foot gaze, which could be interpreted as demeaning [73].
However, in direct contrast, a study with Caribbean medical
students cautioned against the use of direct eye contact with some
Caribbean elderly as this could be interpreted as a sign of
disrespect [77].
In multiple studies, open body posture was assessed
[64,65,75,77,79] and associated with patient ratings of clinician
warmth and overall care. Proximity to the patient was generally
viewed as empathic (e.g., Brazilians preferred closer proximity and
warmth), although Williams et al. noted certain constraints by
gender and age in Caribbean cultures (Table 2). These nuanced
results further highlight that although training is often shaped by
the dominant culture, it should be tailored to the norms of the local
population. Therefore, a provider’s use and awareness of specific
NVBs should be aligned with the specific cultural norms of patients
to enhance both information exchange and patient satisfaction.
4.2. Cross-cultural considerations of nonverbal empathy
4.2.1. Race
Whereas our review’s search terms aimed to capture a broad
representation of cultural groups, our search ultimately yielded a
predominance of American reports that focused on race as the
cultural variable of interest in the patient-clinician encounter. This
emphasis on race may reflect perceived racial bias in the U.S.,
belying a lengthy historical context of minority group oppression.
Nonetheless, cross-racial communication issues may also extend
to other cross-cultural communication contexts, particularly those
examining group prejudices.
Race plays a role in physicians’ NVB and its influence is best
understood when physician race and patient race are considered
jointly [64]. One study showed that AA physicians exhibited more
positive NVB with AA patients than White physicians, in contrast to
mixed positive and negative signals found between AA physicians
interacting with White patients [64]. These findings suggest that
NVB exists at both conscious and unconscious levels of awareness.
In another study, high levels of perceived past discrimination by AA
patients were correlated with a perceived lack of White physician’s
positive affective tone and overall worse care [67]. This implies
that clinicians working with discordant groups should be
especially aware that past experiences of discrimination could
influence how patients perceive the clinician’s nonverbal displays.
4.2.2. Nationality
Differences in empathic nonverbal expressions were shown
across cultural groups [64–68,73,74,79,83]; however, each cultural
group valued and/or employed positive nonverbal signals. Some
studies indicated that particular cultural groups have preferences
2
Also see Ref. [81]. L.F. Barrett, Are emotions natural kinds, Perspect. Psychol. Sci. 1,
2006, 28–58.
4.2.3. Gender and occupation
NVB can vary according to gender and profession of the
provider, however differences in NVB by gender and occupation are
largely unexamined variables in the cross-cultural clinical context,
and here we report preliminary findings. Zaletel et al. examined
the frequency of NVBs in Slovenian nursing homes and found that
male caregivers3 exhibited more negative NVBs (e.g., dropping the
eyes, refusing by head shaking, frowning, staring, making
grimaces) than female caregivers. Non-physician professional staff
exhibited positive NVBs (e.g., making eye contact, smiling, raising
the eyebrows, nodding) significantly more frequently than nonprofessional “helpers” [79]. Additionally, gender differences were
noted in which female caregivers demonstrated mixed nonverbal
patterns with their male patients [79]. Stepanikova et al. found that
female physicians delivered highly positive nonverbal messages
using smile and gaze but at the same time, their body position was
more closed, suggesting a lack of social ease [64].
Studies of internationally educated nurses and physicians found
that NVBs served both as barriers and compensatory strategies for
empathic clinical care. Xu et al. [75] found that internationally
educated nurses in the U.S. used therapeutic touch less frequently
and were perceived as less warm by U.S. raters. The cultural norms
regarding touch are particularly important to understand, as touch
could be perceived as dominating or controlling, or as an
expression of warmth and caring depending on the cultural group
or cross-cultural context. In contrast, studies of internationally
3
The group of 267 caregivers (27 men, 240 women) consisted of three groups:
nursing staff (graduate nurses and nurse assistants), social helpers (auxiliary
personnel), and other non-physician professionals (physiotherapists, occupational
therapists, social workers).
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
421
educated clinicians [76,78] reported that clinicians attempted to
compensate for language gaps by using more touch and
emphasizing gestures, eye contact, smile, and friendliness to
convey care.
clinician samples that follow rigorous research methodologies,
both in qualitative and quantitative investigations.
4.2.4. Intergroup and implicit bias
In addition to racial and ethnic differences, the patientclinician relationship may be regarded as an intergroup interaction as there is an inherent power differential in the patientclinician relationship due to the clinician’s medical knowledge
and experience, and the patient’s subordinate role of seeking
medical advice. The power differential within the patientclinician relationship or the concept of “professional dominance”
[84] can also be affected by various cultural factors, including
nationality, socio-economic status, race, gender, and age. Current
intergroup research indicates that prejudice toward different
cultural groups often stems from implicit in-group biases, which
results in favoring or being selective towards members that share
the same group identity [85–88]. Our findings indicate that
implicit bias can “leak out” through inadvertent negative
nonverbal expressions and can be detected in the form of verbal
dominance and lower patient positive affective tone [66]. Implicit
biases could likewise be revealed in other inadvertent nonverbal
expressions, such as closed body position or reduced eye contact
[64]. Such culturally determined dynamics can seriously compromise successful clinical care and therefore require greater
awareness of these NVBs to advance and strengthen crosscultural competency [24].
Nonverbal communication is a critical component of crosscultural competency, which includes demonstrating respect for
patients and fostering empathy and trust. While these competencies appear to be universally valued, there are cultural differences
in how they are expressed and reciprocated. Clinicians’ cultural
competence can improve by learning the nonverbal norms of the
various cultural backgrounds that they serve. There are crosscultural nonverbal practices that appear to be widely desired, such
as open body posture, smile, and demonstrations of warmth by
facial expression. There are also reports of NVBs that convey
culturally different meanings, such as length and directness of eye
gaze, meaning of hand gestures, and touch, and these must be used
judiciously. This review summarized specific and generally desired
NVB’s in the cultural studies that met our inclusion criteria
(Appendix B). Specific techniques for training in cultural competency are described below.
Empathy is a process that involves both receptive and
expressive capacities [26], and clinicians in cross-cultural encounters require skills to perceive patient cues and express culturally
sensitive nonverbal behaviors. This can be achieved by promoting
clinician awareness of implicit race bias [66,67] and teaching
appropriate responses. Specific techniques may include roleplaying, imagery, mindfulness training [67] and nonverbal skills
training [26]. Values affirmation exercises prior to race-discordant
clinical encounters can also enhance information exchange and
perception of providers’ NVBs displays of warmth and respect [68].
Providers more skilled at cross-cultural NVB will also strengthen
their perceived dedication and competency amongst patients, as
well as help improve their diagnostic abilities by eliciting affective
cues and establishing rapport with the patient [89]. These
techniques are similar to the empathy training for medical
trainees, previously reported, [26], which can be applied to
cross-cultural interactions. Finally, how we train medical students
and clinicians should reflect the diversity of the populations they
serve, rather than the norms of the dominant culture in order to
promote diagnostic accuracy, mutual respect, and trust.
5. Limitations
This systematic review has several limitations. First, examining the provider-patient relationship, cultural dynamics, and NVB
is a complex undertaking and definitions and naming conventions
are heterogeneous. Second, we were limited to reviewing full-text
articles in English after 1990, thereby potentially excluding
relevant studies published pre-1990 or those published in other
languages. Pragmatically, we were limited to English-only papers
as we did not have ready access to translators or multilingual
authors. Although this presents a serious limitation in crosscultural research, one key area of interest is how other cultures
convey and perceive empathy via NVB as it relates to interactions
with U.S.-based clinicians. As noted in our introduction, the U.S. is
becoming more racially diverse and cross-cultural clinical
encounters are on the rise. This is of particular interest as our
systematic review allows us to make more concrete recommendations for our U.S.-based clinicians. The recent publication dates
of many of the cited studies confirm intensified research and
clinical interest in this topic due to rapidly changing demographics.
Additionally, there were methodological limitations of several
studies we examined. Two studies [65,75] included simulated
patients, and although this design increases internal validity, it
limits external validity. One study used a facial expression
computer program to test provider facial expression decoding in
lieu of direct clinical observation [74]. The sample sizes of our
studies were generally small and insufficiently powered to assess
confounding variables such as age, gender, socioeconomic status,
clinical setting, language fluency or degree of acculturation. Most
studies used convenience samples rather than randomized
samples, and most were Western and Eurocentric-based. Furthermore, because members of the dominant culture typically code
studies, additional coder bias may have been introduced. Together,
these methodological limitations suggest cultural NVB is an
important area for further research with larger patient and
6. Practice implications
7. Conclusion
Nonverbal communication and culture permeate virtually
every aspect of health care delivery, and this review demonstrates
that additional research is needed. Some cultural groups have
context-dependent preferences for certain NVBs [70,73,77]. This
complicates detection and delivery of nonverbal signals among
culturally discordant groups. Though culturally specific NVBs of
empathy exist, we recognize that culture is dynamic and
constantly changing, particularly in cross-cultural environments
[90]. Our review of the literature highlights that culture not only
shapes norms for NVB in medical encounters, but it also appears to
mediate communication itself [64,66,67,71,74,79]. Therefore,
greater training efforts are needed to improve perception and
interpretation of patients’ NVB, and to enhance clinicians’
awareness of their own displays of empathic NVB. Both undergraduate and graduate medical education initiatives could
encourage focus groups and specific training in this emerging
area. Medical trainees increasingly represent multinational and
multiracial backgrounds, or have worked in medical settings all
over the world. Such trainees could be invited to share cultural
norms from diverse backgrounds in experiential learning settings
to inform traditional patient-doctor courses. Training programs in
empathic behavior with patients from all backgrounds are needed.
422
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
Further research in empathic NVB is critical to the global
health conversation. Currents in today’s world political landscape
are creating additional urgency for training in cross-cultural
competence. With massive shifts of minority groups into racially
and ethnically dominant cultures, the misinterpretation of
cultural norms and NVB can have dire consequences if cultural
competence is not made a top priority – consequences not only
for individuals and patients, but for populations as a whole. This
review serves as a springboard to develop training programs that
focus on empathic NVB with special attention to cross-cultural
communication. Such training is urgently needed at the
undergraduate and graduate level to improve cultural competency nationally and internationally in our increasingly diverse
world.
Conflict of interest disclosures
Dr. Riess reports a financial interest in Empathetics, Inc. No
other disclosures were reported.
Author contributions
Helen Riess had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy of
the review.
Study concept and design: Lorié, Phillips, Zhang, Riess
Acquisition of data: Lorié, Reinero, Phillips, Zhang, Riess
Analysis and interpretation of data: Lorié, Reinero, Phillips,
Riess
Drafting of the manuscript: Lorié, Reinero, Phillips, Riess
Critical revision of the manuscript for intellectual content:
Lorié, Reinero, Phillips, Riess
Obtained funding: Riess
Administrative, technical, or material support: Reinero
Study supervision: Riess
All authors gave final approval to the submitted paper.
Ethical approval
No ethical approval was required for the systematic review.
Acknowledgments
All authors gratefully acknowledge that this project was made
possible with a grant from The Arnold P. Gold Foundation and the
David Judah Fund. The Arnold P. Gold Foundation and the David
Judah Fund had no role in study design, collection, analysis,
interpretation of data, writing the report, nor in the decision to
submit the report for publication. The authors would also like to
thank Carole Foxman, Martha Stone, Lidia Schapira, M.D., and
Arielle Gordon-Rowe for their invaluable assistance.
10 Touch/or touch*.ti,ab. (28443)
11 smiling/or (smile* or smiling).ti,ab. (3742)
12 (handshake* or shake hand* or hand shake*).ti,ab. (183)
13 lean*.ti,ab. (25884)
14 Posture/or postur*.ti,ab. (75225)
15 or/1-14 (311111)
16 Physician-Patient Relations/(59545)
17 Interpersonal Relations/(54776)
18 “Attitude of Health Personnel”/(90992)
19 Attitude/or additude*.ti,ab. (38762)
20 Trust/or trust.ti,ab. (20571)
21 stereotyping/or stereotyp*.ti,ab. (22961)
22 Personal Satisfaction/or satisf*.ti,ab. (198602)
23 communication barriers/or barrier*.ti,ab. (143193)
24 (doctor patient or patient doctor).ti,ab. (4900)
25 communication/or communicat*.ti,ab. (191659)
26 clinician*.ti,ab. (114903)
27 (patient adj1 physician).ti. (1816)
28 relations*.ti. (181398)
29 Primary Health Care/(53504)
30 medicine/or general practice/or family practice/(88263)
31 or/16-30 (1113105)
32 15 and 31 (37998)
33 exp Ethnic Groups/or ethnic*.ti,ab. (159069)
34 “Minority Groups”/or minorit*.ti,ab. (43777)
35 refugees/or “transients and migrants”/(14289)
36 Racism/or (race* or racial or racism or biracial).ti,ab. (94970)
37 Prejudice/or prejudic*.ti,ab. (24724)
38 Healthcare Disparities/or disparit*.ti,ab. (34508)
39 attitude to health/(72138)
40 health knowledge, attitudes, practice/(71692)
41 (culture* or cultural).ti,ab. (784151)
42 cross-cultural comparison/or cultural characteristics/or
cultural competency/or cultural diversity/(44690)
43 exp geographic locations/(3206192)
44 exp Continental Population Groups/(152589)
45 or/33-44 (4116502)
46 32 and 45 (10064)
47 limit 46 to english language (9382)
48 limit 47 to yr = “1990–2014” (8719)
49 animal/(5256927)
50 48 not 49 (8586)
51 humans/and 48 (8330)
52 50 or 51 (8653)
NOTE: A second search was run using these same search terms
but adding the search statement: “cues/or (cue*1 or clue*1).ti,ab.”
to the top of list, and identifying any new results as a consequence
of this addition.
Appendix B. . Inclusion and Exclusion Criteria
Appendix A. . MEDLINE Electronic Search Strategy
1. ) Inclusion Criteria
Database: Ovid MEDLINE(R) 1946 to Present
1 Empathy/or empath*.ti,ab. (16415)
2 compassion*.ti,ab. (4567)
3 affect/(24011)
4 eye contact.ti,ab. or Eye Movements/(23679)
5 (gaze* or gazing).ti,ab. (9762)
6 kinesics/or gestures/or (gesture* or body language).ti,ab.
(4209)
7 nonverbal communication/or (non-verbal or nonverbal).ti,ab.
(9773)
8 facial expression/or facial.ti,ab. (83410)
9 Voice Quality/or voice.ti,ab. (19708)
Experimental or observational studies examining each of the
following:
1) Communication, for example, “empathy”, “compassion”, “affective” “relationship”, “nonverbal”, “gaze”, “patient satisfaction”
2) Cultural groups, for example, “cross-cultural”, “socio-cultural”,
various ethnic, racial, and country groups, “cultural competence”;
3) Clinician-patient interactions addressing health problems.
4) Studies reported in English, peer-reviewed papers, subjects >
18 years old, N 10.
A. Lorié et al. / Patient Education and Counseling 100 (2017) 411–424
Exclusion Criteria
Commentaries, reviews, dissertations, replies, and book chapters
Studies on theoretical, hermeneutics, and concept analysis
Studies on patients with severe neurologic impairment and
disorders of face and neck that interfere communication
Studies on patients with active psychosis or developmental
disorders
Studies on nonverbal healing through massage or dance
therapy
Studies on sex therapy/relationship counseling
Studies on mother-infant bonding
Studies on infants
Studies on children
Studies on auditory disorders
Studies on pharmacy
Studies on translator communication
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