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158 Cultural Competence in Health Education and Health Promotion

techniques have strategic elements, which are often described as the four Ps: product,
price, place, and promotion. In order to address cultural differences it is necessary to
adjust at least one of the four Ps. The most commonly changed P is promotion, which is
basically the language of the advertisement.
Symbols are also often used when marketing a product. However, using symbols
is not recommended when marketing to multiple cultures. A symbol may be very
meaningful in one culture and arbitrary in another. For example, in the Western world,
it is gratifying to exchange gifts with visitors, and such gifts have specifi c meanings.
In the Chinese culture, although exchanges of gifts with visitors are tolerated, visitors
need to be beware of offering certain kinds of gifts. It is, for example, taboo to present
a Chinese person with a clock or a green cap. In Chinese culture, a gift of a clock
means that you want the recipient to die; a green cap means one is flirting with the

host ’ s wife. If one does not understand a community ’ s culture, one can easily create a
communication barrier when planning a health education program. So just as mes-
sages in translation may take on unintended and unfortunate meanings, symbols may
also lead to offending the community ’ s culture.
It is important to remember that market techniques and strategies must frequently
be revised when marketing to multiple cultures (Siegel & Lotenberg, 2007). Translat-
ing a message should be entrusted only to a professional translator or advertiser. Also,

as suggested earlier, symbols and icons may not have specific meanings in one culture
but may have very strong meanings in another. When marketing to various cultures,
keep in mind that each culture holds different values, and some strategies will not be
as effective as others.

COMMUNICATION PATTERNS AND LANGUAGE BARRIERS
According to Flores (2006), 47 million people (18 percent of the population) in the United
States speak a language other than English at home, and 22 million have limited English

proficiency. This typically makes it difficult for these individuals to access health care,

and health educators face major problems when planning, implementing, and evaluating
health education services or programs for these individuals. Because of these problems
these individuals ’ quality of care can deteriorate. The language barrier makes it diffi cult
for the patients and health care providers to communicate effectively, and Flores (2005)
found that patients who face a language barrier end up not receiving good health care. It
is the responsibility of the health educator in the health care setting to ensure that proper
translators are sought for such patients and optimal health care is provided.
Some studies (Peinkofer, 1994; Ponterotto, 1995; Murty, 1998; Flores, 2005, 2006;
Luquis & Pérez, 2005; Velde, Wittman, & Bamberg, 2003; Wang, 2005) on the issues
of communication patterns, cultural competence, and the language barriers faced by
minorities in the delivery of health care in general and health education services in
particular were reviewed for this chapter. Based on these reviews and the personal life
experiences of the author in growing up in a developing country (Nigeria), it is deduced
that language issues play a major role in the quality of all health care delivery services,
including health education services. Effective communication is a cornerstone in the

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