Cultural Competence

The cultural differences between groups is vast. What might be the norm in one culture is taboo in another.

Consider eating. In the west, we eat most meals with a fork, knife or spoon. To eat pasta or a curry with our hands would be considered unhygienic, unsavoury and child-like.

But in places like Nepal and India, eating with our hands is the standard. To eat otherwise is simply not right.

“Would you like a handful?”

Hands off

The same applies in healthcare.

Massage, mobilisations and manual therapy are an expectation of physiotherapy in countries like Canada, North America and Australia. A patient would be surprised, disgruntled or unsettled if a physio (in one of the above countries) didn’t do some ‘hands-on’ work.

But what about cultures outside of the ones we think we know? What are their expectations of us?

For some, it could come as a shock when we ask them to disrobe. But this is vital in your assessment and treatment, we might say.

What do we do now? Do we concede that this patient won’t do well under our care? Or do we do the work to find out ways around this obstacle?

What if a family member did the palpation and physical assessment under our instruction with the patient behind a veil?

Implicit biases

Cultural incompetence is more than what we don’t know about other cultures. It’s also about our hidden biases and perceptions of others too.

You see, every one of us holds implicit biases. These are unconscious things that affect the way we think, behave and interact with those around us.

For example, we might think we’re unbiased towards Group X. We think they deserve every right that we have. The right to marry and adopt, for example.

But we don’t have many Group X friends, for whatever reason. A lack of time spent with Group X people results in a lack of familiarity (and therefore understanding). So, we’re not as comfortable around them. As a consequence, we’ll hold a slight (and hidden) preference for our people over Group X people.

This preference affects the way we behave. We could inadvertently come across as insensitive, for instance.

How does it apply to physiotherapy?

Physiotherapy is about relationship and trust building at it’s core. Understanding our patients is inherent in constructing a productive partnership.

That’s why, it’s easy to get along with a person that’s like us (the same race, the same gender and with similar interests). We form a bond quickly. It’s like we’re on the same page.

But what happens when we don’t understand a person or their background? WE find it difficult to relate because we don’t get their beliefs, their expectations or their way of thinking.

And, to make matters worse, they don’t get us.


Cultural informed

With ever-expanding diversity throughout the world, it’s vital that we develop the necessary skills to make us effective with all people.

Consider that 52.2% of the Australian population was born overseas or has a parent who was born overseas.

Culturally informed practice and physiotherapy

Starting point

First, we must better understand our own beliefs, values and ideas. What biases are we bringing to the consultation?

It can be uncomfortable to unearth unsavoury beliefs about other people. But, undoubtedly, we all have them.

So, what do you think about Iranians, Italians and Israelites?

Uncover hidden biases

Even when you think you’ve analysed and appraised your beliefs about other groups, hidden ones remain.

That’s why tools like Project Implicit exist. This resource from Harvard includes tests assessing different areas, such as gender and culture to uncover our implicit beliefs.


Then, we must make sure we work with the patient and not their injury. We must uncover then understand their narrative. This means unlocking where they’re from and what they believe in.

For example:

  • What are their beliefs about physiotherapy?
  • How do physiotherapists operate in their country?
  • What sort of care do they expect?
  • How do they view injuries?

Overcome communication barriers

We speak in a way that we understand.

Consider the phrase, ‘no pain, no gain’. It’s a common one in the west. But what does it mean?

Different things to different people.

And this difference is amplified in populations that are dissimilar to our own. To most, ‘no pain, no gain’ means to accept some pain with exercise (recreational or during injury rehabilitation).

Other cultures might perceive this phrase to mean to exercise in spite of extreme pain. Of course, this could be to their detriment.

Therefore, we must think carefully before we speak. We must articulate with thought and clarity. And we must make sure that the patient understands.

“You mentioned that your pain was 3/10 when you did this exercise. That’s OK. Your pain can go up to 3 or 4 out of 10 when you do this exercise at home.”

Other way to better understand cultural communication variations include:

  • Watching and learning from simulated cross-cultural scenarios (here’s a neat Ted Talk about the subject)
  • Involve a health intepreter. Health care interpreters facilitate communication between patients with limited English (and other communication barriers) and their health professionals


Finally, we must tailor our intervention based on what we have learnt about a culutre. What barriers do we need to work around? What expectations must we meet?

Is treatment in a group environment expected, for example? How should we engage the famiy?

Culturally competent physios

Being culturally informed has never been more relevant.

As physios, we must learn the relevant skills through courses, like those offered by the SBS.

There’s no point knowing how to rehabilitate a person from lower back pain with the latest evidence if we don’t know who they are and what they believe.

What are your thoughts on cultural competence? Is it a skill we need? What ways do you work on becoming more culturally informed? Leave a comment below.

Author: Andrew Cammarano

Andy writes about anything that comes to mind. Oftentimes, he repeats himself. So, if you read a post and ask yourself, "I feel like I've read this before." Chances are you have. Apart from writing, he eats a diet high in peanut butter, he exercises (and suffers from a chafed butt from performing too many sit-ups in pursuit of a six-pack) and comes up with many fantastical ideas, like his peanut butter-based chafe cream. Reach out to him to share your opinions (or if you'd like to become his chafe cream business partner).

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