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Master of Advanced Studies in INTERCULTURAL COMMUNICATION

Case Studies in Intercultural Communication

Welcome to the MIC Case Studies page.

Here you will find more than fifty different case studies, developed by our former participants from the Master of Advanced Studies in Intercultural Communication. The richness of this material is that it contains real-life experiences in intercultural communication problems in various settings, such as war, family, negotiations, inter-religious conflicts, business, workplace, and others. 

Cases also include renowned organizations and global institutions, such as the United Nations, Multinationals companies, Non-Governmental Organisations, Worldwide Events, European, African, Asian and North and South America Governments and others.

Intercultural situations are characterized by encounters, mutual respect and the valorization of diversity by individuals or groups of individuals identifying with different cultures. By making the most of the cultural differences, we can improve intercultural communication in civil society, in public institutions and the business world.

How can these Case Studies help you?

These case studies were made during the classes at the Master of Advanced Studies in Intercultural Communication. Therefore, they used the most updated skills, tools, theories and best practices available.   They were created by participants working in the field of public administration; international organizations; non-governmental organizations; development and cooperation organizations; the business world (production, trade, tourism, etc.); the media; educational institutions; and religious institutions. Through these case studies, you will be able to learn through real-life stories, how practitioners apply intercultural communication skills in multicultural situations.

Why are we opening our "Treasure Chest" for you?

We believe that Intercultural Communication has a growing role in the lives of organizations, companies and governments relationship with the public, between and within organizations. There are many advanced tools available to access, analyze and practice intercultural communication at a professional level.  Moreover, professionals are demanded to have an advanced cross-cultural background or experience to deal efficiently with their environment. International organizations are requiring workers who are competent, flexible, and able to adjust and apply their skills with the tact and sensitivity that will enhance business success internationally. Intercultural communication means the sharing of information across diverse cultures and social groups, comprising individuals with distinct religious, social, ethnic, and educational backgrounds. It attempts to understand the differences in how people from a diversity of cultures act, communicate and perceive the world around them. For this reason, we are sharing our knowledge chest with you, to improve and enlarge intercultural communication practice, awareness, and education.

We promise you that our case studies, which are now also yours, will delight, entertain, teach, and amaze you. It will reinforce or change the way you see intercultural communication practice, and how it can be part of your life today. Take your time to read them; you don't need to read all at once, they are rather small and very easy to read. The cases will always be here waiting for you. Therefore, we wish you an insightful and pleasant reading.

These cases represent the raw material developed by the students as part of their certification project. MIC master students are coming from all over the world and often had to write the case in a non-native language. No material can be reproduced without permission. ©   Master of Advanced Studies in Intercultural Communication , Università della Svizzera italiana, Switzerland.

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22 Cases and Articles to Help Bring Diversity Issues into Class Discussions

Explore more.

• Course Materials
• Diversity, Equity, and Inclusion

T he recent civic unrest in the United States following the death of George Floyd has elevated the urgency to recognize and study issues of diversity and the needs of underrepresented groups in all aspects of public life.

Business schools—and educational institutions across the spectrum—are no exception. It’s vital that educators facilitate safe and productive dialogue with students about issues of inclusion and diversity. To help, we’ve gathered a collection of case studies (all with teaching notes) and articles that can encourage and support these critical discussions.

These materials are listed across three broad topic areas: leadership and inclusion, cases featuring protagonists from historically underrepresented groups, and women and leadership around the world. This list is hardly exhaustive, but we hope it provides ways to think creatively and constructively about how educators can integrate these important topics in their classes. HBP will continue to curate and share content that addresses these equity issues and that features diverse protagonists.

Editors’ note: To access the full text of these articles, cases, and accompanying teaching notes, you must be registered with HBP Education. We invite you to sign up for a free educator account here . Verification may take a day; in the meantime, you can read all of our Inspiring Minds content .

Leadership and Inclusion

John Rogers, Jr.—Ariel Investments Co.

—by Steven S. Rogers and Greg White

Gender and Free Speech at Google (A)

—by Nien-hê Hsieh, Martha J. Crawford, and Sarah Mehta

The Massport Model: Integrating Diversity and Inclusion into Public-Private Partnerships

—by Laura Winig and Robert Livingston

“Numbers Take Us Only So Far”

—by Maxine Williams

For Women and Minorities to Get Ahead, Managers Must Assign Work Fairly

—by Joan C. Williams and Marina Multhaup

How Organizations Are Failing Black Workers—and How to Do Better

—by Adia Harvey Wingfield

To Retain Employees, Focus on Inclusion—Not Just Diversity

—by Karen Brown

From HBR 's The Big Idea:

Toward a Racially Just Workplace: Diversity efforts are failing black employees. Here’s a better approach.

—by Laura Morgan Roberts and Anthony J. Mayo

Cases with Protagonists from Historically Underrepresented Groups

Arlan Hamilton and Backstage Capital

—by Laura Huang and Sarah Mehta

United Housing—Otis Gates

—by Steven Rogers and Mercer Cook

Eve Hall: The African American Investment Fund in Milwaukee

—by Steven Rogers and Alterrell Mills

Dylan Pierce at Peninsula Industries

—by Karthik Ramanna

Maggie Lena Walker and the Independent Order of St. Luke

—by Anthony J. Mayo and Shandi O. Smith

Multimedia Cases:

Enterprise Risk Management at Hydro One, Multimedia Case

—by Anette Mikes

Women and Leadership Around the World

Monique Leroux: Leading Change at Desjardins

—by Rosabeth Moss Kanter and Ai-Ling Jamila Malone

Kaweyan: Female Entrepreneurship and the Past and Future of Afghanistan

—by Geoffrey G. Jones and Gayle Tzemach Lemmon

Womenomics in Japan

—by Boris Groysberg, Mayuka Yamazaki, Nobuo Sato, and David Lane

Women MBAs at Harvard Business School: 1962-2012

—by Boris Groysberg, Kerry Herman, and Annelena Lobb

Beating the Odds

—by Laura Morgan Roberts, Anthony J. Mayo, Robin J. Ely, and David A. Thomas

Rethink What You “Know” About High-Achieving Women

—by Robin J. Ely, Pamela Stone, and Colleen Ammerman

“I Try to Spark New Ideas”

—by Christine Lagarde and Adi Ignatius

How Women Manage the Gendered Norms of Leadership

—by Wei Zheng, Ronit Kark, and Alyson Meister

Is this list helpful to you? What other topics or materials would you like to see featured in our next curated list? Let us know .

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Understanding Cultural Diversity in Healthcare

Case Studies

See culture in action.  Case studies bring you up close and personal accounts from the front lines of American hospitals and other countries on the issues of cultural diversity in healthcare.

The following case studies are presented by topic and contain quick recaps of some common cultural misunderstandings. More detailed information can be found in Caring for Patients from Different Cultures.

SHARE YOUR STORY HERE

Do you have a case study or field report about cultural diversity in healthcare that you would like to share? We want to hear about it!

• Stereotyping
• Communication
• Time Orientation
• Religious Beliefs and Customs
• End of Life
• Mental Health
• Traditional Medicine
• Additional Case Studies

Lamar Johnson, a thirty-three-year-old African American patient had been deemed a “frequent flyer” (a term used to describe those who keep coming to the hospital for the same reason, often assumed to be drug seekers) by the nurses and doctors in the emergency department. Each time he came in complaining of extreme headaches he was given pain medication and sent home. On this last admission, he was admitted to the ICU, where Courtney, a nurse, had just begun working. When she heard him described as a frequent flyer, she asked another nurse why he was thought to be a drug seeker. She was told, “He has nothing else better to do; I’m not sure why he thinks we can supply his drug habits.” Although Courtney says her instincts told her that something else was going on, she saw his tattoos, observed his rough demeanor, and went along with what everyone else was saying. While she was wheeling him to get a CT scan, Mr. Johnson herniated and died. It turned out that he had a rare form of meningitis and truly was suffering from severe headaches. If some of the staff had not stereotyped him as a drug seeker on one of his earlier visits, perhaps his life could have been saved. This incident left a lasting impression on Courtney, who vowed not ever to judge a patient on his looks, and to trust her instincts, rather than let others influence her nursing care.

While taking a course on cultural diversity, Anike Oghogho, a nurse from Nigeria, recognized his tendency to stereotype. He related an example of an African American male patient who presented with a swollen left foot. The patient, Jefferson Bell, kept ringing the call light and asking for more pain medication. Anike said that in the past, he would have assumed Mr. Bell was merely seeking pain meds. This time, however, he reassessed the patient. He discovered that Mr. Bell’s fourth and fifth toes were more red and swollen and had pus. Anike summoned the physician and Mr. Bell was eventually taken to the operating room for incision and drainage of his left foot. Stereotyping could have severely harmed the patient; fortunately, Anike had learned the lesson of not stereotyping in his class.

Hilda Gomez, a monolingual Spanish-speaking patient, came in to the clinic three days in a row to complain of abdominal pain. The first two times, the staff used her young, bilingual daughter to translate. They then treated Mrs. Gomez for the “stomach ache” she described. The staff didn’t understand why she kept returning with the same problem. Finally, on her third visit, the nurse located a Spanish-speaking interpreter. It turned out that Mrs. Gomez needed treatment for a sexually transmitted disease, but was too embarrassed to talk about her sexual activity with her daughter as interpreter. It taught the staff an important lesson.

Helena became very frustrated while caring for Gwon Chin, a seventy-nine-year-old Korean man who had recently suffered a stroke. Her frustration and impatience were aimed at Mr. Gwon’s wife and daughter. Since Mr. Gwon spoke only Korean, she had asked his bilingual daughter to tell her father not to get out of bed because his gait was unsteady. Helena was afraid he would fall and hurt himself. Throughout the day, however, Mr. Gwon continued to attempt to get out of bed. He became very agitated and his wife and daughter seemed almost afraid of him. When Helena questioned the daughter about it, she would only say that her father was “confused.” Eventually Helena called on a Korean nurse to help her. When the nurse told Mr. Gwon not to get out of bed because he might fall, he asked in a surprised tone, “Why would I fall?” When the nurse explained that he was unsteady from the stroke, the patient was shocked. “I had a stroke?!” Helena was in disbelief. He had been on the unit for two days; how could he not know he had had a stroke? When she questioned Mr. Gwon’s daughter about this, she explained that her brother has been out of town. He would be back today and tell him. When Helena, stunned by this, asked the daughter why she didn’t tell her father, she replied, “I could never tell my father what is wrong with him and what he can or can’t do. It would be disrespectful for me to do that when he has always told me what to do and what was wrong.”

Although Helena was angry that Mr. Gwon’s daughter preferred having her father possibly fall and hurt himself than tell him why he was in the hospital and that he must stay in bed, Helena remained silent. She asked the Korean nurse to explain to the patient how the numbness on his left side would make walking difficult so he should remain in bed. She also added that his son would be in later that day and would explain everything to him. After that, the patient remained calm and stayed in bed.  [For more discussion, see Chapter 2 of Caring for Patients From Different Cultures .]

Juanita Avelar was a forty-nine-year-old Mexican woman with kidney failure and diabetes. She relied on her niece and nephew to drive her to the clinic and was often late. In Mexican culture, the needs of the family typically take precedence over those of an individual. The nurses learned to take this into account when scheduling her appointments, and they allowed plenty of time for the family to discuss Mrs. Avelar’s condition as a family. When certain tests and medications required specific timing for accuracy and effectiveness, they stressed the importance of clock time.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “ Aye! Aye! Aye ! Mucho dolor ! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

After another hour, Robert called the physician. The surgical team came on rounds and opened Mrs. Mendez’s dressing. Despite a slight swelling in her leg, there was minimal bleeding. However, when the physician inserted a large needle into the incision site, he removed a large amount of blood. The blood had put pressure on the nerves and tissues in the area and caused her excruciating pain.

She was taken back to the operating room. This time, when she returned and awoke in recovery, she was calm and cooperative. She complained only of minimal pain. Had the physician not examined her again and discovered the blood in the incision site, Mrs. Mendez would have probably suffered severe complications.

Bobbie, a nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony.

Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her. [For more discussion, see Chapter 5 of Caring for Patients From Different Cultures .]

Pepe Acab, a Filipino patient, was being discharged on Coumadin, a blood thinner, to prevent clotting. Vitamin K reverses the effect of the drug and must be avoided. Normally, Libby, his nurse, would tell such patients to avoid foods like liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and any green, leafy vegetables. She suddenly realized, however, that there might be other foods he should avoid. She spoke with Mr. Acab and his wife, and got a list of foods he commonly ate. She then did some research and discovered that two foods on the list—soybeans and fish liver oils—are very high in Vitamin K. She was then able to educate him properly on what to avoid.

Susi Givens, a thirty-seven-year-old woman with two children, was horseback riding one day when a snake startled her horse. She was thrown off and landed on a stump, resulting in massive internal injuries. She was rushed to the hospital, where the surgical team discovered that there was a large amount of blood in her abdomen and that she needed to have a kidney removed.

Mrs. Givens had a medical alert card identifying her as a Jehovah’s Witness and stating that under no circumstances was she to receive blood. Her physician knew this but felt impelled by his oath to save lives to give her a blood transfusion. The hospital was unable to locate her husband, so the physician decided to transfuse her.

His actions saved her life; however, she was not grateful. She sued her doctor for assault and battery and won a $20,000 settlement. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures .]

Sol and Deborah Meyers, an Orthodox Jewish couple, came to the hospital late Friday night when Deborah was in active labor. When she gave birth at midnight, the nurses suggested that Sol accompany her to the postpartum unit and then return home to rest. He thanked them, then explained that he could not drive home because it was the Sabbath. The nurses suggested that he call a friend or relative to pick him up. Sol replied that he could not use the phone on the Sabbath, and even if he made a call, no one would answer because all his friends and relatives were also Sabbath-observant. The nurses understood and arranged for him to stay in his wife’s room, but were left wondering why Sol could drive to the hospital but not drive back home.

In the morning, a nurse noticed that Deborah had not received breakfast and was instead eating snacks from the bag she had brought from home. The nurse asked if she needed help ordering food, and Deborah explained that the hospital-provided meals did not adhere to kosher dietary laws. The nurse, trying to be helpful, suggested that Sol purchase kosher food from the gift shop on the first floor, but was told that due to the laws of the Sabbath, Sol was forbidden to ride in an elevator or handle money. The nurse left the room, confused but glad the couple had brought some food of their own.  

Later that afternoon, the nurse returned to check on Deborah, and made friendly conversation by asking how the baby’s nursery was decorated at home. She was surprised to learn that in Orthodox tradition, minimal preparations are made before a baby’s birth, and the baby’s room was not set up at all. Intrigued, she asked Sol to explain some of the laws of Sabbath observance. She learned that the couple had been able to drive to the hospital because, according to halacha (Jewish law), childbirth is considered an emergency requiring the breaking of the Sabbath, but that once the birth was over, they were not allowed to drive home due to the absence of an emergency.

Raj Singh, a seventy-two-year-old Sikh from India, had been admitted to the hospital after a heart attack. He was scheduled for a heart catheterization to determine the extent of the blockage in his coronary arteries. The procedure involved running a catheter up the femoral artery, located in the groin, and then passing it into his heart, where special x-rays could be taken. His son was a cardiologist on staff and had explained the procedure to him in detail.

Susan, his nurse, entered Mr. Singh’s room and explained that she had to shave his groin to prevent infection from the catheterization. As she pulled the razor from her pocket, she was suddenly confronted with the sight of shining metal flashing in front of her. Mr. Singh had a short sword in his hand and was waving it at her as he spoke excitedly in his native tongue. Susan got the message. She would not shave his groin.

She put away her “weapon,” and he did the same. Susan, thinking the problem was that she was a woman, said she would get a male orderly to shave him. Mr. Singh’s eyes lit up again as he angrily yelled, “No shaving of hair by anyone!”

Susan managed to calm him down by agreeing. She then called her supervisor and the attending physician to report the incident. The physician said he would do the procedure on an unshaved groin. At that moment, Mr. Singh’s son stopped by. When he heard what had happened, he apologized profusely for not explaining his father’s Orthodox Sikh customs. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures .]

Ricky, a five-year-old African American male with asthma, was supposed to take a controller medication (asthma inhaler #1, Steroid) twice a day as a preventative measure. When he was wheezing and/or having breathing problems, he was supposed to take asthma inhaler #2 (Albuterol) as an emergency medication. Dr. Arabel felt that she had given very clear instructions on how to use the two inhalers, but Ricky’s mother kept bring him back to the clinic with a lot of wheezing; his asthma was obviously not being well controlled. As it turned out, Ricky had not been using the inhalers as directed. His mother, who was enrolled in school, was overwhelmed and did not understand the significance of his asthma and the need to use the two inhalers properly. On one of the visits, Dr. Arabel learned that Ricky’s grandmother had accompanied them to the clinic. She brought the grandmother into the exam room, and explained everything to her. Once the grandmother became involved, everything changed. There were no more emergency room/urgent clinic visits and Ricky’s asthma was much better controlled. He only rarely needed the “emergency” Albuterol compared to earlier. Involving the grandmother had made a tremendous difference.  [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Julia was treating Mrs. Torres, an elderly Hispanic patient who was intubated. When she needed information, she would direct her questions to the eldest son. She assumed he would be the family spokesperson. However, he rarely had an answer for her. While in many cases the eldest son would be the decision-maker, in this case he was not. The youngest daughter held the durable power of attorney for medical decisions. It was several days before anyone even thought to ask the family who held power of attorney. The staff had made the mistake of stereotyping. Once Julia learned that the youngest daughter was responsible for making medical decisions for her mother, such decisions were reached more quickly and without unnecessary strain on the rest of the family. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Juan Martinez, a thirty-six-year-old Mexican man with second-degree burns on his hands and arms, posed a problem. The skin grafts had healed, and there was now danger that the area would stiffen and the tissue shorten. The only way to maintain maximum mobility was through regular stretching and exercise. The nurses explained to Mr. Martinez’s wife that feeding himself was an essential therapeutic exercise. The act of grasping the utensils and lifting the food to the mouth stretches the necessary areas. Mrs. Martinez seemed to understand the nurses’ explanation, yet she continued to cut her husband’s food and put it in his mouth.

When Linda, one of his nurses, observed this, she took the fork out of Mrs. Martinez’s hand and told Mr. Martinez to feed himself because he needed to exercise his arms and hands. Linda again explained to Mr. Martinez’s wife how important it was for him to do it himself. Mrs. Martinez appeared skeptical but did not argue. Mr. Martinez looked at Linda peevishly and made a feeble attempt at eating. His wife watched with pity. Linda knew from seeing Mr. Martinez when his wife was not around that he was perfectly capable of feeding himself. Linda left the room. When she looked in five minutes later, she saw Mrs. Martinez once again cutting her husband’s food and putting it in his mouth. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures .]

Before taking my course in cultural diversity, Jennifer, like all the nurses on her unit, tried to avoid taking care of Naser Assharj, a middle-aged Iranian Muslim patient, because the entire staff found his family to be very “uptight and demanding.” The nurses rotated care for this patient, because no one was willing to care for him more than one day at a time. When Jennifer learned a bit about Muslim culture, however, she understood why his family kept demanding a private room and made such a fuss over his meals. It was their way of showing love and care for their family member. He needed a private room so that, as devout Muslims, the family could pray together five times a day as commanded by Allah. It was also important that his food be halal , or follow the Muslim laws of what is permissible (see Chapter 5). Once Jennifer realized this, she contacted her supervisor and arranged to have the patient moved to a private room and spoke to the dietician regarding his food. The family members were very grateful for her efforts, and became much easier to deal with.

Amira Faroud was a three-year-old Middle Eastern patient, newly diagnosed with type 1 diabetes. Understanding the importance of involving the entire family in the patient’s care, Lisa tried to get the patient’s father, Mr. Faroud, to participate. She had seen other fathers reluctant to learn in the past, but eventually, they all were persuaded. But not Mr. Faroud. He would not even consider it. Eventually, Lisa changed the teaching plan to include Amira’s grandmother rather than her father, and all went well. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures .]

A female resident could not get a Hispanic mother to sign consent for a procedure for her child; she, too, insisted on waiting for her husband. In this case, however, it was urgent that the procedure be done as soon as possible. The resident asked an older male physician to speak to the mother. Apparently, the combination of his age and gender were enough to convince her to sign consent without speaking first to her husband.

Amiya Nidhi was a young woman in her twenties who had recently immigrated to the United States from India. She was in the hospital to give birth. Her support person was her sister, Marala. Marala kept telling her to get an epidural, but Amiya said that even though she would like one, she could not get one; her husband would not allow it. Cindy, her nurse, overheard the conversation. Having learned that husbands are the authority figure in the traditional Indian household, she went to speak with Mr. Nidhi. She explained why an epidural would be advisable. She said that he seemed pleased that she came to him about it. He said he would think about it, and let her know. About thirty minutes later, he came to Cindy and told her that he would like his wife to have an epidural. Everyone was pleased. By using cultural competence, Cindy helped her patient get the care she wanted, while still respecting the authority structure within the family. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures .]

An Iranian mother and father admitted their thirteen-month-old child, Ali, to the pediatrics unit. After three days of rigorous testing and examination, it was discovered that Ali had Wilms’ tumor, a type of childhood cancer. Fortunately, the survival rate is 70 to 80 percent with proper treatment.

Before meeting with the pediatric oncologist to discuss Ali’s treatment, Mr. and Mrs. Mohar were concerned and frightened, yet cooperative. Afterward, however, they became completely uncooperative. They refused permission for even the most routine procedures. Mr. Mohar would not even talk with the physician or the nurses. Instead, he called other specialists to discuss Ali’s case.

After several frustrating days, the oncologist decided to turn the case over to a colleague. He met with the Mohars and found them extremely cooperative. What caused their sudden reversal in behavior? The fact that the original oncologist was a woman.

Several weeks later, it became necessary to insert a permanent line into Ali to administer his medication. The nurse attempted to show Mrs. Mohar how to care for the intravenous line, but Mr. Mohar stopped her. “It is my responsibility only. You should never expect my wife to care for it.” Throughout each encounter with the hospital staff, Mrs. Mohar remained silent and deferred to her husband. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures .]

A twenty-eight-year-old Arab man named Abdul Nazih refused to let a male lab technician enter his wife’s room to draw blood. She had just given birth. When the nurse finally convinced Abdul of the need, he reluctantly allowed the technician in the room. He took the precaution, however, of making sure Sheida was completely covered. Only her arm stuck out from beneath the blankets. Abdul watched the technician intently throughout the procedure. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures .]

Fatima, an eighteen-year-old Bedouin girl from a remote, conservative village, was brought into an American air force hospital in Saudi Arabia after she received a gunshot wound to her pelvis. Her cousin Hamid had shot her. Her family had arranged for her to marry him, as was local custom, but she wanted nothing to do with him. She was in love with someone else. An argument ensued, and Hamid left. He returned several hours later, drunk, and shot Fatima, leaving her paralyzed from the waist down.

Fatima’s parents cared for her for several weeks after the incident but finally brought her to the hospital, looking for a “magic” cure. The physician took a series of x-rays to determine the extent of Fatima’s injuries. To his surprise, they revealed that she was pregnant. Sarah, the American nurse on duty, was asked to give her a pelvic exam. She confirmed the report on the x-rays. Fatima, however, had no idea that she was carrying a child. Bedouin girls are not given any sex education.

Three physicians were involved in the case: an American neurosurgeon who had worked in the region for two years; a European obstetrics and gynecology specialist who had lived in the Middle East for ten years; and a young American internist who had recently arrived. No Muslims were involved. The x-ray technician was sworn to secrecy. They all realized they had a potentially explosive situation on their hands. Tribal law punished out-of-wedlock pregnancies with death.

The obstetrician arranged to have Fatima flown to London for a secret abortion. He told the family that the bullet wound was complicated and required the technical skill available in a British hospital.

The only opposition came from the American internist. He felt the family should be told about the girl’s condition. The other two physicians explained the seriousness of the situation to him. Girls in Fatima’s condition were commonly stoned to death. An out-of-wedlock pregnancy is seen as a direct slur upon the males of the family, particularly the father and brothers, who are charged with protecting her honor. Her misconduct implies that the males did not do their duty. The only way for the family to regain honor was to punish the girl by death.

Finally, the internist acquiesced and agreed to say nothing. At the last minute, however, he decided he could not live with his conscience. As Fatima was being wheeled to the waiting airplane, he told her father about her pregnancy.

The father did not say a word. He simply grabbed his daughter off the gurney, threw her into the car, and drove away. Two weeks later, the obstetrician saw one of Fatima’s brothers. He asked him how Fatima was. The boy looked down at the ground and mumbled, “She died.” Family honor had been restored. The ethnocentric internist had a nervous breakdown and had to be sent back to the United States.

Sofia Toledo, a sixty-five-year-old upper-class Mexican woman, refused to be dialyzed when she learned that her usual dialysis station was unavailable. She said she would wait until her next treatment, when she could have her customary place. Unfortunately, this was not a viable alternative. Missing a treatment could result in serious complications or even death. When Julia, the nurse, asked her why the new station was unacceptable, Mrs. Toledo was very vague.

Julia finally called Mrs. Toledo’s daughter, and together they solved the problem. Mrs. Toledo’s usual station was unusual in that neither the nurses nor the patients at the other dialysis stations could see it very well. The rest of the stations were very open, designed for high visibility by the nurses. To be dialyzed, the patient had to remove her pants and don a patient gown. Her underwear was exposed during the process. Mrs. Toledo’s sense of modesty, a quality very strong in Hispanic women, made the more open station intolerable.

Julia said that at the time she found Mrs. Toledo’s behavior annoying. She and the other nurses saw it as a delay that would prevent them from leaving on time. They did not want to have the extra work of moving machinery or remixing the dialysate. She did not understand the importance of modesty in Hispanic culture, but she did realize that it was important to Mrs. Toledo, a normally “compliant” patient. In this case, a screen or curtain might have alleviated the problem.

Kayla was a staff nurse on a medical-surgical floor when she first met Dr. Ling, an Asian physician. They got along well until Kayla transferred to the diabetes clinic. Clinic protocols allow nurses to order new medications, adjust medications, and order lab work as needed, as long as they get a physician to sign the order. When Kayla asked Dr. Ling for his signature, he would rudely question why she felt the medication was necessary, and on a few occasions refused to sign, stating that he disagreed with the medication she had ordered. After learning more about Asian culture in a cultural competence course, she realized he probably perceived her approach as showing a lack of respect, despite the fact that she was following clinic protocols. She then changed her approach. Rather than just asking him to sign the medication order, she would go to him, explain the situation with the patient, tell him what she was considering, and ask him what he would like done. Kayla reported that Dr. Ling was much more receptive to this approach, probably because it allowed him to feel respected and in control. Taking the extra time to do this repaired the lines of communication between them. Although it could be argued that Dr. Ling is the one who should have changed his behavior, that is probably less realistic than having Kayla apply her cultural knowledge to achieve the results that she wanted.

Josepha, a Filipina nurse, did not get along well with her coworkers. The nursing staff on her unit was composed of two Anglo Americans, two Nigerians, and Josepha. She felt her coworkers were taking advantage of her, because they would ask for assistance whenever they saw her. Josepha was angry over what she perceived as obvious discrimination. She cheered herself by reminding herself that she was a better nurse than the others; she could do her work without their help. In addition, she was not lazy like they were. She took care of her patients; the other nurses insisted that their patients take care of themselves.

One day, Rena, one of the Anglo nurses, was unusually friendly, so Josepha opened up to her. As they got to know each other better, Josepha shared her feelings of being taken advantage of. Rena explained that it was common procedure for the nurses to help each other with their work. Rena confided that the others thought Josepha was being snobbish and proud because she never asked for help. They saw what Josepha had interpreted as laziness on the part of the others as being team players. Rena also explained that American health care providers believe that independence is important and encourage self-care among their patients.

Josepha was stunned by Rena’s revelations. Rena offered to help bridge the communication gap between Josepha and her coworkers. She explained to the others that Josepha was trying to save face by never asking for help; she didn’t want them to think she couldn’t do her job. Josepha began to teach her patients self-care and to ask her coworkers for assistance. Over time, the cross-cultural misunderstandings were resolved, and Josepha’s coworkers became her best friends.

Leslie reported that her hospital had recently hired five new Korean nurses. Unfortunately, they did not get along well with the rest of the nursing staff. They rarely said “please” or “thank you” and were generally perceived as rude. Leslie was reading an earlier edition of this book and suddenly realized that the Korean nurses were older than the other nurses on the unit and probably felt that “please” and “thank you” were implicit. Leslie then showed the other staff nurses the section on “Please” and “Thank You.” She reported that morale on the unit is much improved. Sometimes, all it takes is a little understanding.

An American physician and professor, consulting in Japan, was about to address a group of university physicians; it was fully understood by all that he would give his talk in English. He nevertheless prepared a brief introduction in Japanese, concluding with the statement, “My Japanese is limited, so with your permission, I will continue in English.” When he asked his Japanese secretary if his statement was grammatically correct, she seemed uncomfortable. On further questioning she reluctantly admitted that, grammar aside, it was not appropriate for someone of his stature to ask the audience for permission, and that this would diminish the audience’s ability to respect anything else he said. Instead, she suggested, he should merely announce that he would continue in English. In this context “asking permission” was entirely pro forma in American culture; it would be seen as a polite gesture. In Japan, however, it was considered inappropriate from someone in a position of authority, and would likely result in a loss of respect for the person doing the asking. [For further discussion, see Chapter 8 of Caring for Patients From Different Cultures .]

A labor and delivery nurse reported that the most difficult patient she ever attended was Robabeh Farag, an Iranian woman, who yelled and screamed for the entire duration of her labor. After she delivered their child, her husband presented her with a three-karat diamond ring. When her nurse commented on the expensive gift, she responded dramatically, “Of course. He made me suffer so much!” Iranian custom is to compensate a woman for her suffering during childbirth by giving her gifts. The greater the suffering, the more expensive the gifts she will receive, especially if she delivers a boy. Her cries indicate how much she is suffering. A young Iranian doctor recently told me that when his wife has a baby, he will present her with a diamond ring or a watch. [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Naomi Freedman, an Orthodox Jewish woman, was in labor with her third child. She had severe pains, which were alleviated only by back rubs between contractions. Her husband asked Marge, a nurse, to remain in the room to rub his wife’s back. Because she had two other patients to care for, Marge began to instruct him on how to massage his wife. To Marge’s surprise, he interrupted her, explaining that he could not touch his wife because she was unclean. Marge, assuming he meant she was sweaty from labor, suggested that he massage her through the sheets. In an annoyed tone, he explained that he could not touch his wife because she was bleeding. Marge was further surprised when, while Naomi began pushing, her husband left the room and did not return until after their baby was born.

Marge later learned from Mrs. Freedman that in halacha (Jewish law), the blood of both menstruation and birth render a woman spiritually unclean and therefore physical contact between husband and wife was prohibited. Mrs. Freedman also explained that in some Orthodox communities, husbands are prohibited from being present at birth in non-emergency situations.

[For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Maria Salazar was a thirty-two-year-old recent immigrant from Mexico with an infected incision from a caesarean section. She asked Tonya, her nurse, for some water. When Tonya grabbed the bedside pitcher to refill it, she discovered it was full. When Tonya pointed this out to her, she answered in Spanish, “Yes, but I have a fever and a cough. If I drink that cold water I will get even more sick.” Tonya, who spoke some Spanish, was taking a course in cultural diversity at the time and was elated to see hot/cold beliefs in action. She then emptied the ice water and refilled it with warm water. Curious, Tonya asked her if there were any changes she would like to see in her treatment. Mrs. Salazar nodded her head. She said she didn’t understand why the nurses kept insisting she do things that would make her ill—things like taking a shower. Didn’t they understand she had a fever and had just delivered a baby? And why did they want her to spend so much time walking, when she knew she should stay in bed and rest as much as possible? [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures .]

Raul Santiago was a Hispanic male in his seventies who had been in the hospital for seven months. He had been admitted for abdominal pain, but it soon became apparent that he had advanced stage pancreatic cancer. Mr. Santiago had 12 children, who all conspired to avoid using the word “cancer” in front of their father or to even acknowledge his fatal prognosis. Instead, they referred to his condition as “abdominal pain.” During the time he was in the hospital, Mr. Santiago became close to the nursing staff. One day while Tiffany was administering his pain medication, he looked directly at her and said with resignation, “I’m going to die, aren’t I?” Without waiting for her to respond, he continued. He explained to Tiffany that he didn’t want his children to suffer because of his illness, and he knew that if they knew that he knew he had cancer, it would cause them great distress. He told her that he was ready to be with his wife who had died two years earlier. He was content to pretend to be ignorant of his disease if it eased his family’s suffering. Whether or not it would have caused his children to suffer if they knew he knew, or if it would have been a relief is unknown. But the nurses honored his decision.

A fifty-two-year-old African American man named William Jefferson was admitted to the critical care unit with a diagnosis of pneumonia. On admission, he was offered an Advance Directive, which he refused, saying that God would help him with his illness. His lung cancer had gone into remission after radiation treatment; he believed that God had helped him through that illness, and would help him through the current one. He thought that signing a Do Not Resuscitate form or Advance Directive would be a sign of giving up or losing faith in God. Unfortunately, he died ten days later, after enduring a great deal of suffering. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures .]

Ngoc Ly, a twenty-five-year-old Vietnamese man, was hit by a car while riding his bicycle to work. Paramedics were able to resuscitate him, but the physician at the local trauma center determined that Mr. Ly was clinically brain dead. He placed him on life support until the family could be notified.

An interpreter explained Mr. Ly’s condition to his wife and parents. They nodded in understanding and quietly left the hospital. Normally, the staff neurosurgeon would then have pronounced Mr. Ly dead and removed him from the ventilator, but he was suddenly called to surgery.

Later that afternoon, Mr. Ly’s family met with Dr. Isaacs, the physician they had spoken to earlier. Dr. Isaacs intended to tell them of the plan to pronounce Mr. Ly dead and discontinue the ventilator, but the Lys had other plans. They informed him that they had consulted a specialist who said this was not the right time for him to die. Dr. Isaacs was confused. What kind of specialist would make such a recommendation? An astrologer who had read Ngoc Ly’s lunar chart advised that his death be postponed until a more auspicious date.

The physician had never encountered a situation like the one now facing him. Fearing legal repercussions if he did not abide by the family’s request, he agreed to keep Mr. Ly on life support until further notice. A little less than a week later, the Lys called to tell him that Ngoc could now die. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures .]

Canh Cao was a thirty-four-year-old Vietnamese woman who was treated by a medical student at a public health clinic. She had made several visits for various physical complaints—abdominal pain, backache, headaches. She was diagnosed with somatoform pain disorder—preoccupation with pain in absence of physical findings.

Several months later, Cao attempted suicide. She was sent for evaluation to a psychiatrist, who at that point diagnosed her with depression. She had been depressed all along, but the medical student was both inexperienced and unaware of cultural issues, so he missed it. [For further discussion, see Chapter 11 of Caring for Patients From Different Cultures .]

Amelia avoided a potential child abuse report with a Cambodian family, the Chhets. The child had suspicious burn marks on her body. Instead of assuming child abuse, she first interviewed both parents separately. Both explained that they had treated their child using cupping and coining to make her feel better and help her recover more quickly. Amelia then explained to her supervisor what she had learned from the parents, and they decided it was not a child abuse situation. The Chhets practiced the traditional form of cupping. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Mexican American mother refused to use cooling measures in caring for her febrile infant, despite medical instructions to do so. Mrs. Lopez had called the hospital because her infant’s temperature was very high. She was told to give the baby a mild analgesic and a cool bath and then to bring her in. Mrs. Lopez ignored both cooling instructions and, to the consternation of the medical staff, brought the child wrapped in several layers of blankets, outer garments, undershirt, and several pairs of socks. When asked why she did not follow the instructions given her, she replied, “He must sweat the fever out. Besides, he could get pneumonia from the night air and die.” [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Fariba was asked to interpret for Fereydoon Jalili, an Iranian man who had come to the hospital with gastrointestinal bleeding. Mr. Jalili spoke some English, and when the physician had asked him what medications he was taking, he told him he didn’t take any. When Fariba was brought in to interpret, she began talking to him about his health. During their conversation, he admitted that he took vitamins to stay healthy and he was very proud of the fact that he had never been sick. He also mentioned that he took two aspirins a day for his heart after seeing a commercial on television which said it prevented heart attacks. When Fariba asked him why he didn’t tell the doctor about the vitamins and aspirin, he said that he didn’t consider anything he bought over-the-counter to be a “real” medication. Once the physician learned what he had been taking, he educated Mr. Jalili on appropriate aspirin consumption, since that was the likely cause of his GI bleed. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Jen, a second-year medical student, was on a pediatrics visit learning how to perform a newborn exam. As she followed the attending into the patient’s room, she noticed that the baby’s mother was sitting on the side of the crib talking in Spanish to her husband. The attending started to explain to Jen what is important to notice about a baby and what to look for on the physical exam, and proceeded to ask her questions about the causes of pneumonia and meningitis in the newborn period. As they were talking, the infant’s mother came over to the crib. In an attempt to welcome her into their conversation, Jen said “hello,” and proceeded to compliment her on her beautiful child. As soon as she finished the sentence, the mother said “thank you,” but frowned, and her demeanor changed slightly—she stopped smiling, and looked nervous.

Jen wondered what she had done wrong, and suddenly realized that the family was Mexican, and her complimentary words, intended as a tool to gain the mother’s trust, resulted in causing her distress. Remembering what she had learned about Mexican culture and mal de ojo (evil eye), she touched the baby’s hand, and looked back at the mother. The change was remarkable—the mother smiled back at her, and nodded her head. She did not say anything, but her smile and nod tacitly communicated her gratitude for preventing mal de ojo. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

An eighty-three-year-old Cherokee woman named Mary Cloud was brought into the hospital emergency room by her grandson, Joe, after she had passed out at home. Lab tests and x-rays indicated that she had a bowel obstruction. After consulting with Joe, the attending physician called in a surgeon to remove it. Joe was willing to sign consent for the surgery, but it would not be legal; the patient had to sign for herself. Mrs. Cloud, however, refused; she wanted to see the medicine man on the reservation. Unfortunately, the drive took an hour and a half each way, and she was too ill to be moved. Finally, the social worker suggested that the medicine man be brought to the hospital.

Joe left and drove to the reservation. He returned three hours later, accompanied by a man in full traditional dress complete with feather headdress, rattles, and bells. The medicine man entered Mrs. Cloud’s room and for forty-five minutes conducted a healing ceremony. Outside the closed door, the stunned and amused staff could hear bells, rattles, chanting, and singing. At the conclusion of the ceremony, the medicine man informed the doctor that Mrs. Cloud would now sign the consent form. She did so and was immediately taken to surgery. Her recovery was uneventful and without complications. . [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

Emma Chapman was a sixty-two-year-old African American woman admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.”

When Judy, her nurse, asked her what she thought had caused the problem, she said she had sinned and her illness was a punishment. According to her beliefs, illnesses from “natural causes” can be treated through nature (e.g., herbal remedies), but diseases caused by “sin” can be cured only through God’s intervention. Remember, treatment must be appropriate to the cause. In addition, Mrs. Chapman may have felt that to accept medical treatment would be perceived by God as a lack of faith.

Mrs. Chapman finally agreed to the surgery after speaking with her minister, whom Judy called to the hospital. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures .]

A fifty-year-old Mexican woman named Sandra Ramirez came to the ER with epigastric pain. She told the nurse that she had been experiencing the pain constantly for the past week, but denied any nausea, vomiting, diarrhea, or constipation. There had been no changes in her diet or bladder or bowel function. She revealed that when she had experienced similar pain in the past, she was treated with an unknown medication that helped her greatly. The nurse who was interviewing her had just been introduced in class to the concept of the 4 C’s, so she also asked the patient what she thought the problem was. The patient called her condition “stressful pain,” and elaborated that it wasn’t the pain that caused stress, but that stress caused the pain. It turned out that the medication that had helped her in the past was Xanax. She had stopped taking it eight days earlier; the pain began seven days ago. Had the nurse not gotten the patient’s perspective on her condition—that it was related to stress—they would have done just a standard abdominal workup and perhaps not discovered that it was due to anxiety.

Emma Chapman, a sixty-two-year-old African American woman, was admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.” When her nurse asked what she thought caused her heart problems, Mrs. Chapman said she had sinned and her illness was a punishment. Her nurse finally got her to agree to the surgery by suggesting she speak with her minister. If she hadn’t learned about Mrs. Chapman’s religious beliefs while asking what she that was the cause of her heart problems, she might not have thought to contact her clergyman.

Olga Salcedo was a seventy-three-year-old Mexican woman who had just had a femoral-popliteal bypass. Anabel, her nurse, observed that Mrs. Salcedo’s leg was extremely red and swollen. She often moaned in pain and was too uncomfortable to begin physical therapy. Yet during her shift report, her previous nurse told Anabel that Mrs. Salcedo denied needing pain medication. Later that day, Anabel spoke with the patient through an interpreter and asked what she had done for the pain in her leg prior to surgery. Mrs. Salcedo said that she had sipped herbal teas given to her by a curandero (a traditional healer; see Chapter 12); she didn’t want to take the medications prescribed by her physician. Anabel, using cultural competence, asked Mrs. Salcedo’s daughter to bring in the tea. Anabel paged the physician about the remedy and brought it to the pharmacist, who researched the ingredients. Because there was nothing contraindicated, the pharmacist contacted Mrs. Salcedo’s physician, who told her she could take the tea for her pain. The next day, Mrs. Salcedo was able to go to physical therapy and was much more motivated and positive in demeanor. Although it took some time to coordinate the effort, in the end, it resulted in a better patient outcome. Had Anabel not asked what she had been using to cope with her pain, it is likely Mrs. Salcedo would have delayed physical therapy and thus her recovery.

Jorge Valdez, a middle-aged Latino patient, presented with poorly managed diabetes. When Dr. Alegra, his physician, told him that he might have to start taking insulin, he became upset and kept repeating, “No insulin, no insulin.” Not until Dr. Alegra asked Mr. Valdez what concerns he had about insulin did he tell her that both his mother and uncle had gone blind after they started taking insulin. He made the logical—though incorrect—assumption that insulin caused blindness. In this case, the patient expressed his fears, and because the physician was competent enough to pick up on them and explore them, she was able to allay them. In many cases, however, unless the physician specifically asks about concerns, patients will say nothing and simply not adhere to treatment. By asking, the health care provider can correct any misconceptions that can interfere with treatment.

A 35-year-old Jewish woman went in for a baseline mammogram.  A lump was discovered.  When discussing it with the radiologist, the woman questioned him about all the possible treatments if it turned out to be cancerous, as well as all the side effects of the treatment.  The radiologist had little patience for her questions; he repeatedly told her they should wait until after they get the results of the biopsy before they start discussing the side effects of chemotherapy and radiation.  The woman, however, felt that she had to know everything possible about the potential negative outcome; only through knowledge could she feel a degree of control.  The lump turned out to be benign, but she went into the biopsy procedure much more relaxed than she would have had she not known every possible eventuality.

A 27-year-old pregnant Mexican woman who had been living in the US for two years went to see a genetic counselor at the urging of a friend.  XFAP tests indicated the possibility of Down syndrome in her unborn child.  She declined the offer of amniocentisis, however, based upon the manner of the genetic counselor, who told her not to be afraid and to do whatever she wanted.  The patient later said she interpreted the lack of directiveness as an indication that the positive screening was “no big deal” and that if there were any real danger, the counselor would have insisted on the test.

A middle-aged Mexican female patient suffering from acute liver cirrhosis with abdominal ascites, began to experience extreme shortness of breath. The physician, a liver specialist, asked her to sign consent for an abdominal tap.  The patient refused, saying, “I am going to wait until my husband arrives.”  The physician was not happy with her response as he felt it was necessary to do the procedure as soon as possible.  Fortunately, the patient’s husband arrived within an hour, the paracentesis was done, and her shortness of breath was minimized.

An African American man in his 40s, suffering from diabetes and hypertension presented to his physician, complaining of “feeling poorly”.  When questioned, he admitted that he was not taking his insulin regularly; only when he felt that his sugar was high.

A Chinese woman in her 60s was diagnosed with cancer and scheduled to receive chemotherapy.  She was unaware of her diagnosis, due to her son’s insistence.  The staff was uncomfortable with having to withhold this information from her, so they asked her whether she wanted to know her diagnosis and why she was receiving chemotherapy medication.  Her answer was no.  She said, “Tell my son; he will make all of the decisions.”  They resolved the matter by having hersign a Durable Power of Attorney, appointing her son as legal decision-maker.  They were thus able to remove the legal and ethical obstacles to her care.

Bobbie, the nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony. Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her.

Nurses usually report that “expressive” patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while “stoic” patients often come from Northern European and Asian backgrounds. As a young Chinese man told me, “Even since I was little boy, my family watched dubbed Chinese movies, and by watching many of the male protagonists state ‘I’d rather shed blood than my tears,’ it is imbedded in my mind that crying or showing pain shows my weakness.” However, simply knowing a person’s ethnicity will not allow you to predict accurately how a patient will respond to pain; in fact, there are great dangers in stereotyping, as the next case demonstrates.

Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “Aye! Aye! Aye! Mucho dolor! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”

Reports from the Field

Field reports are submitted by students, peers and colleagues in the healthcare profession. Do you have field report to share?   Submit it here. Thank you!

A Filipino Case Study

Patient safety and satisfaction have always been a priority in nursing, but they can be compromised by nursing priority and time constraint. With higher patient to nurse ratios, increase patient acuity, managed health care system, and higher demands for quality patient care, nurses today are working harder.   Read More

Conditions in Kenya, Africa

HE DIDN’T ANSWER

Rounds have started. I move from bed to bed with the doctors, three patients at a time. Bed 3 contains Matu, Mugambi and Karanja. Matu’s spine is beginning to curve from six weeks of clutching his knees so he doesn’t touch the cold, contaminated floor. His spot at the foot of the bed is tinged yellow. He’s 4. He was treated for malaria and discharged two weeks ago, but with no family to claim him he’s still hereŠand getting sick again.   Read More

A Case of Polygamy

This is a case of a 49-year-old Hispanic male who was involved in a motor vehicular accident while not wearing a seat belt. He suffered multiple chest injuries, fractured ribs and humerus and sustained severe subdural bleeding. He was unconscious when brought to the Emergency Department, where a trauma work-up was done. His CT scan of the head revealed severe bleeding and was inoperable. His pupils were fixed and dilated.    Read More

I was on a pediatrics visit at Harbor-UCLA hospital learning how to perform a newborn exam. As I followed the Peds attending into the patient’s room, I noticed that the baby’s mom was sitting on the side of the crib talking in Spanish to her husband. The attending, I’ll call her Dr. Gabe, started to explain what is important to notice about a baby, what to look for on the physical exam, and proceeded to ask     Read More

Homelessness in our Hometown: The Hidden Community

In today’s society a person’s worth is determined by their material possessions, the size of their home, what kind of car they drive and how well they dress. How are you viewed by society if you have nothing and live on the streets? What kind of treatment do you receive if you chose to live this way?  Read More

Cultural Incompetence

Maria was a 4-month-old Hispanic infant with a history of Down’s syndrome and an ASD/VSD congenital anomaly. After her cardiac surgery, she had several complications that resulted in a lengthy ICU stay. During that time she had two cardio-pulmonary arrests, which resulted in the need to try to contact her parents. Her parents visited infrequently due to work obligations and the need to care for their other children.   Read More

A Vietnamese Death

I was invited to do a presentation on cultural competence to the hospice staff and a large, successful, and very white hospital. As part of my preparation, I visited the in patient hospice one afternoon. At the end of my visit I sat with the nurses as they debriefed the shift. One, a leader of some sort, said that she was pleased I would talk to them since she felt that she needed to know more.   Read More

Dangerous Dominican Powder

An article in the Nov. 6, 2003 issue of the New York Times, written by Richard Pérez-Peña, reported on a highly poisonous powder sold.   Read More

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How to Resolve Cultural Conflict: Overcoming Cultural Barriers at the Negotiation Table

Avoid cultural conflict by avoiding stereotypes when negotiating across cultures.

By Katie Shonk — on August 3rd, 2023 / Conflict Resolution

After losing an important deal in India, a business negotiator learned that her counterpart felt as if she had been rushing through the talks. The business negotiator thought she was being efficient with their time. Their cultures have different views on how to conduct negotiations, and in this case, the barrier prevented a successful outcome. In this useful cross cultural conflict negotiation example, we explore what this negotiator could have done differently to improve her negotiation skills.

Research shows that dealmaking across cultures tends to lead to worse outcomes as compared with negotiations conducted within the same culture. The reason is primarily that cultures are characterized by different behaviors, communication styles, and norms. As a result, when negotiating across cultures, we bring different perspectives to the bargaining table , which in turn may result in potential misunderstandings. Misunderstandings can lead to a lower likelihood of exploring and discovering integrative, or value-creating, solutions. Let’s talk about the main causes of cross cultural negotiation failure.

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Cultural conflict in negotiations tends to occur for two main reasons. First, it’s fairly common when confronting cultural differences, for people to rely on stereotypes. Stereotypes are often pejorative (for example Italians always run late), and they can lead to distorted expectations about your counterpart’s behavior as well as potentially costly misinterpretations. You should never assume cultural stereotypes going into a negotiation.

Instead of relying on stereotypes, you should try to focus on prototypes —cultural averages on dimensions of behavior or values. There is a big difference between stereotypes and prototypes.

For example, it is commonly understood that Japanese negotiators tend to have more silent periods during their talks than, say, Brazilians. That said, there is still a great deal of variability within each culture—meaning that some Brazilians speak less than some Japanese do.

Thus, it would be a mistake to expect a Japanese negotiator you have never met to be reserved. But if it turns out that a negotiator is especially quiet, you might better understand her behavior and change your negotiating approach in light of the prototype. In addition, awareness of your own cultural prototypes can help you anticipate how your counterpart might interpret your bargaining behavior. It’s not just about being aware of their culture, but also how yours might be viewed.

A second common reason for cross-cultural misunderstandings is that we tend to interpret others’ behaviors, values, and beliefs through the lens of our own culture. To overcome this tendency, it is important to learn as much as you can about the other party’s culture. This means not only researching the customs and behaviors of different cultures but also by understanding why people follow these customs and exhibit these behaviors in the first place.

Just as important, not only do countries have unique cultures, but teams and organizations do, too. Before partaking in any negotiation, you should take the time to study the context and the person on the other side of the bargaining table, including the various cultures to which he belongs—whether the culture of France, the culture of engineering, or his particular company’s corporate culture. The more you know about the client, the better off you will do in any negotiation.

In this cross cultural conflict negotiation example, we see that the negotiator has learned after the fact that her Indian counterpart would have appreciated a slower pace with more opportunities for relationship building. She seems to have run into the second issue: Using time efficiently in the course of negotiations is generally valued in the United States, but in India, there is often a greater focus on building relationships early in the process. By doing research on the clients cultural prototypes, they can adjust their negotiation strategy and give themselves a better chance at creating a valuable negotiation experience for both themselves and their counterpart.

As this business negotiator has observed, cultural differences can represent barriers to reaching an agreement in negotiation. But remember that differences also can be opportunities to create valuable agreements. This suggests that cross-cultural conflict negotiations may be particularly rife with opportunities for counterparts to capitalize on different preferences, priorities, beliefs, and values.

Related Article: Dealing with Difficult People – The Right Way to Regulate Emotion  – Knowing how to correctly project emotion at the bargaining table is a negotiation skill that the best negotiators have mastered. How do emotions change negotiation strategy and what negotiating skills and negotiation tactics can bargainers use involving emotions at the negotiation table? This article offers some negotiation skills advice and bargaining tips based on negotiation research.

Do you have any advice on how to solve cultural conflict? What experiences have you had that might help our other readers? We would love to hear from you.

Adapted from “Dear Negotiation Coach: Crossing Cultures in Negotiation,” by Francesca Gino (Associate Professor, Harvard Business School), first published in the Negotiation newsletter, September 2013.

Originally published 2014.

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No Responses to “How to Resolve Cultural Conflict: Overcoming Cultural Barriers at the Negotiation Table”

13 responses to “how to resolve cultural conflict: overcoming cultural barriers at the negotiation table”.

One should first understand cultural dynamics of the disputants. Local people should be the one to be included in the council as they are the custodians of 5he society.

One major problem most Americans have is the assumption that their way is the right way resulting in failed negotiations and cooperation. We also live and die by the clock compared to other cultures. I have been part of multiple key leader engagements (KLE) where military and civilian personnel were dismissive of cultural norms during meetings and when an impasse arose, along with running out of the allotted time for the KLE, an opportunity was lost.. I also see similar issues within the US as it pertains to gender, culture, race, etc. As individuals and groups, we need to do our homework on the environment and people were are to engage, make assessments upon arrival and be open to other view points and accept solutions that are conducive to the other person. A noticeable trait, Americans are great in the “sprint” but not so good with “marathons” in the international relations game.

Like so much in Interculturel Communications, these small anecdotal scenarios are logically analyzed, but in living color impossible to predict. Our problem is not how to introduce students to such case studies, but how to prepare young professionals for true encounters and disaster avoidance. In truth, let’s be honest…it is impossible without living it.

Perhaps one might consider diversifying negotiation teams to include more voices and perspectives from a wider range of cultural backgrounds.

Cross-cultural communication requires intercultural competence to be able to identify the underlying values behind the visible behavior observed on the negotiating table. Barriers often occur when one is trapped in own’s perspectives- as the saying goes, “we see according to what we know”.

Thanks. This is a valuable piece of discourse and very relevant to the peacebuilding initiatives/peace process in Mindanao, Philippines. I would like to think that civil society (local homegrown NGOs especially) has always been advocating this track in resolving the decades-long conflict in Mindanao (Southern Philippines) but the central government in Manila has always been calling the shots. The basic principle on Cultural Relativism in not just in the vocabulary of a unitary government. Hope to read more on this.

Like so much in Interculturel Communications, these small anecdotal scenarios are logically analyzed, but in living color impossible to predict. Our problem is not how to introduce students to such case studies, but how to prepare young professionals for true encounters and disaster avoidance. In truth, let’s be honest…it is impossible without living it.

in my opinion, as negotiator we must know that we meet all types of people from many difference cultures, it is a common sense that we must learn or adapt from others’ culture and not judge the book by its cover.

This article is very interesting, and we should admit that cross cultural negotiations are very difficult. For example, in the case where an American negotiator is conscious of the difference of culture between him and his Chinese counterpart, and thinks that he should adopt the Chinese method of negotiation, while his Chinese partner also thinks that to avoid misunderstandings he should adopt the American culture of negotiation. That could tangle up the negotiators, and could be perceived by each negotiator as a refusal to negotiate from the other part, don’t understanding that his counterpart wants to behave like him to facilitate the negotiations. To avoid this scenario, the solution could be simple. One party could at the beginning of the negotiation tell to the other that he/she will wishes that the negotiation to be made in his counterpart’s culture, to avoid misunderstandings. I really think it could greatly avoid misunderstandings, and where it appears, the counterpart will not first interpret the other’s gesture as hostile, but will first try to understand, knowing that his counterpart has expressed a real will to negotiate, and the misunderstanding is probably due to the cultural difference.By so doing, cross cultural negotiations could be eased.

This case is a filtering issue. If we see perceptions filtered through layers of personal traits, family and cultural traits everything we communicate is affect by each one of these layers. Same thing happens in the receiver side. Stereotypes are like biased filters. They tend to allow more of some “colors” than others. Still though its up to the “color” each individual emits and this can be much different from what we believe it should emit. This image probably best describes the above: http://e-negotiations.org/chapters/4-perception

Many thanks for describing and comparing all the points. They are crutial, valuable and worth to study and use in the field. Having experience I have got working for the International Criminal Court in the Hague the Netherlands with colleagues from all over the world I absolutely agree with all the information presented.

I am in agreement that it is critical to take time to study the context and the person. However, in an inter-cultural communication, it is difficult to assess the value or meaning of a specific behaviour or thoughts of the other party from your own point of view, which has been formed in a specific cultural background. That is, you see it but you do not recognized it.

I agree, please send mor articles in this feild, best

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• v.18(1); Winter 2020

Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients

Diversity is the one true thing we all have in common. Celebrate it every day. — Author Unknown

The 2002 Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare , brought into stark focus the issues of inequities based on minority status in health care services. The IOM report concluded that, “Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare” ( 1 ). Persons in racial and ethnic minority groups were found to receive lower-quality health care than whites received, even when they were insured to the same degree and when other health care access-related factors, such as the ability to pay for care, were the same ( 1 ). Clients in minority groups were also not getting their needs met in mental health treatment ( 2 , 3 ). The IOM report was a primary impetus for the cultural competence movement in health care.

Cultural competency emphasizes the need for health care systems and providers to be aware of, and responsive to, patients’ cultural perspectives and backgrounds ( 4 ). Patient and family preferences, values, cultural traditions, language, and socioeconomic conditions are respected. The concepts of cultural competence and patient-centered care intersect in meaningful ways. The IOM’s Crossing the Quality Chasm ( 5 ) document defines patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” (p. 3). Both patient centeredness and cultural competence are needed in striving to improve health care quality ( 6 , 7 ). To deliver individualized, patient-centered care, a provider must consider patients’ diversity of lifestyles, experience, and perspectives to collaborate in joint decision making. Patient-centered care has the potential to enhance equity in health care delivery; cultural sensitivity may likewise enhance patient-centered care ( 6 ). Indicators of culturally sensitive health care identified in focus groups of low-income African-American, Latino American, and European American primary care patients included interpersonal skills, individualized treatment, effective communication, and technical competence ( 8 ). The U.S. Office of Minority Health has set national standards for culturally and linguistically appropriate health care services ( 9 ). The Principal Standard is that health care must “provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs” (p. 1).

Five key predictors of culture-related communication problems have been identified in the literature: cultural differences in explanatory models of health and illness, differences in cultural values, cultural differences in patients’ preferences for doctor–patient relationships, racism and perceptual biases, and linguistic barriers ( 10 ). Physicians are often poorly cognizant of how their communication patterns may vary with respect to the characteristics of the individual they are treating ( 11 ). This unconscious preconceptualization is termed implicit bias , which refers to the attitudes or stereotypes that affect understanding, actions, and decisions in an unconscious manner ( 12 ). All people experience these—even those who strive to maintain a multicultural orientation and openness to diversity. Health care providers must openly reflect on and discuss issues of the patient’s culture, including ethnicity and race, gender, age, class, education, religion, sexual orientation and identification, and physical ability, along with the unequal distribution of power and the existence of social inequities, to effectively coconstruct a treatment plan that is patient centered and culturally sensitive.

Merging Cultural Competence With Cultural Humility

Cultural humility ( 13 ) involves entering a relationship with another person with the intention of honoring their beliefs, customs, and values. It entails an ongoing process of self-exploration and self-critique combined with a willingness to learn from others. Authors have contrasted cultural humility with the concept of cultural competence. Cultural competence is characterized as a skill that can be taught, trained, and achieved and is often described as a necessary and sufficient condition for working effectively with diverse patients. The underlying assumption of this approach is that the greater the knowledge one has about another culture, the greater the competence in practice. The concept of cultural humility, by contrast, de-emphasizes cultural knowledge and competency and places greater emphasis on lifelong nurturing of self-evaluation and critique, promotion of interpersonal sensitivity and openness, addressing power imbalances, and advancement of an appreciation of intracultural variation and individuality to avoid stereotyping. Cultural humility encourages an interpersonal stance that is curious and other-oriented ( 14 , 15 ).

The infusion of cultural humility into cultural knowledge has been coined competemility : the merging of competence and humility ( 16 ). Cultural competemility is defined as “the synergistic process between cultural humility and cultural competence in which cultural humility permeates each of the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters” ( 16 ). The competemility position allows a meaningful connection with each patient as a unique individual, with diverse perspectives, culture, and lifestyles. Cultural competemility necessitates a consciousness of the limits of one’s knowledge and the awareness of the ever-present potential for unconscious biases to limit one’s viewpoint ( 15 , 16 ).

Practicing Cultural Competence and Cultural Humility

Cultural competence, cultural humility, and patient-centered care are all concepts that endeavor to detail essential components of a health care system that is sensitive to patient diversity, individual choice, and doctor–patient connection. A culturally competent health care workforce highlights five components: cultural awareness, knowledge, skill, desire, and encounters. Cultural humility focuses on identifying one’s own implicit biases, self-understanding, and interpersonal sensitivity and cultivating an appreciation for the multifaceted components of each individual (culture, gender, sexual identity, race and ethnicity, religion, lifestyle, etc.), which promotes patient-centered approaches to treatment. The new concept of competemility is the synergistic combination of cultural competence with cultural humility. Health care professionals need both process (cultural humility) and product (cultural competence) to interact effectively with culturally diverse patients ( 17 ).

Establishing a collaborative mutual partnership with diverse patients requires an open, self-reflective, other-centered approach to understanding and formulating the patients’ strengths and difficulties and coconstructing the treatment plan. Below are tips for practicing cultural competence and cultural humility.

Get to know your community. Who lives there, and what are the resource disparities in the community? Is there a large immigrant or refugee population? What are the most common ethnicities and languages spoken? What is the climate in the community regarding cultural diversity?

• Consider whether politics or laws, such as immigration laws or a recent federal government move to eliminate protections in health care for transgender Americans ( 18 ), are adding to the stress of diverse communities.
• If you, as the physician, are a person of color, consider how that affects your practice and work with diverse patients. If you are European American, reflect on the implicit biases that may affect your practice with diverse patients and theirs with you.
• Pay attention to office practices: do they enhance an atmosphere of welcoming everyone? Are interpreter services available, if needed?
• Ask patients by which pronoun they would prefer to be addressed.
• Use a journal to jot down potential implicit biases and observations about rapport building, for ongoing self-reflection.
• Don’t assume. Ask the patient about background, practices, religion, and culture to avoid stereotyping.
• Reassure by words and actions that you are interested in understanding the patient and helping to coconstruct a plan to fit his or her needs. State upfront that this is a collaborative process and that you welcome input on the process (communicating openly with each other) and the product (treatment plan).
• Ask directly what the patient wants to achieve with the psychiatric consultation/treatment. This can help identify patient goals and treatment methods.
• A family genogram may help clarify family dynamics, cultural background, and possible generational trauma.
• Ask directly about experiences of discrimination, bullying, traumas, or harassment. Are there fears associated with minority status?
• Identify strengths, interests, and resilience factors.
• Discuss patient-centered care to determine whether this is understood or if this is an unfamiliar practice. Get patient input about collaborating in health care decisions. For patients who are accustomed to the doctor being the one making all the decisions, consider initiating a request for decisions, even small ones, to reinforce with them that you want to know their preferences and help them become comfortable with making health care decisions and communicating wants and needs.
• Inquire about what the patient feels would be helpful. Are there cultural practices or herbal remedies that they have already tried—and what was the result? Are there religious, cultural, or individual convictions that affect choice of treatment?
• Ask during the session whether the patient has any clarification of information that he or she didn’t feel the physician appropriately understood. If using an interpreter, make sure that he or she is interpreting the full discussion (and not summarizing, which loses the nuance and some meaning).
• After the session, ask the patient if he or she felt understood, if he or she understands the process, and if there is anything else he or she would like to add to be better understood.
• Model coconstruction of the treatment plan by asking about goals and helping the patient consider possible methods of meeting those goals.
• Clarify the patient’s preference for family involvement and, depending on the age and competence of the patient, what information will be communicated to the family.

Dr. Stubbe reports no financial relationships with commercial interests.

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A case study illustrates the problems in providing culturally competent mental health care.

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• Research article
• Open access
• Published: 22 August 2019

Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training

• Anu-Marja Kaihlanen   ORCID: orcid.org/0000-0002-4033-3673 1 ,
• Laura Hietapakka 1 &
• Tarja Heponiemi 1  

BMC Nursing volume  18 , Article number:  38 ( 2019 ) Cite this article

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Nowadays, healthcare professionals worldwide deliver care for increasing numbers of culturally and linguistically diverse patients. The importance of cultural competence is evident in terms of the quality of healthcare, and more knowledge is needed about different educational models and approaches that aim to increase cultural competence. This study examines the perceptions of nurses about the content and utility of cultural competence training that focuses on increasing awareness of one’s own cultural features.

The training was conducted at one primary care hospital in southern Finland. Participants were registered nurses ( n  = 14) and practical nurses ( n  = 6) from different hospital units. Four 4-h training sessions—including lectures, discussions and short web-based learning tasks—were arranged during a four-week period. Semi-structured, small group interviews were conducted with 10 participants to examine their perceptions about the content and utility of the training. Qualitative content analysis with a conventional approach was used to analyse the data.

Perceptions about the training were divided into three main categories: general utility of the training, personal utility of the training, and utility of the training for patients. General utility pertains to the general approach that the training provided on cross-cultural care, the possibility to initiate an open discussion, and the opportunity to improve current practices. Personal utility pertains to the opportunity to become aware of one’s own cultural features, to change one’s way of thinking, to obtain a new perspective on one’s own communication practices and to receive justification for carrying out particular workable practices. Utility for patients pertains to fostering better awareness and acknowledgement of patients’ differing cultural features and an increased respect in healthcare delivery. Additionally, the quality of the training was highlighted, and suggestions for improvement were offered.

Training that increases healthcare professionals’ awareness of their own cultural features was perceived as useful and thought-provoking. Increased awareness might facilitate the communication between healthcare professionals and patients, which is a crucial component of quality healthcare. It seems that in the future, training opportunities that allow larger groups to participate are needed, regardless of the time and place, and utilising the potential of e-learning should be considered.

Peer Review reports

Healthcare professionals worldwide are required to deliver care for an increasing number of culturally and linguistically diverse patients. Problems related to language and cultural issues are recognised as a threat to patients’ safety in hospitals [ 1 ] and the concept of cultural competence has gained attention as a strategy to provide equal and quality healthcare services for culturally diverse patient groups [ 2 ]. Cultural competence is known as a multi-dimensional construct, but it typically refers to a person’s cultural sensitivity or attitudes, cultural awareness and cultural knowledge and skills [ 3 , 4 , 5 ]. In the healthcare setting, cultural competence is defined as an understanding of how social and cultural factors influence the health beliefs and behaviours of patients and how these factors are considered at different levels of a healthcare delivery system to assure quality healthcare [ 6 ].

Effective communication between healthcare providers and patients is known to be necessary for quality healthcare [ 7 ]. A large number of culturally diverse patients often present communication challenges for healthcare delivery, especially if sociocultural differences are not completely accepted, appreciated, explored or understood [ 6 ]. A lack of cultural understanding increases negative attitudes towards cross-cultural care and also affects healthcare professionals’ perceived preparedness to take care of culturally diverse patients [ 8 ]. Moreover, anxiety about interacting with people from different cultures has an influence on a person’s level of engagement in intercultural communication [ 9 ]. And when combined with uncertainty, it further decreases effective communication and can lead to the increased use of stereotypes [ 10 ]. In contrast, an increased awareness about the sociocultural components of illness as well as reflecting on a healthcare professional’s own strengths and weaknesses when communicating with different populations are seen as key to overcoming different communication difficulties [ 11 ].

During the past decade, the need to increase the cultural competence of healthcare staff has been clearly recognised. This can be seen in the number of educational interventions and training programs that have been developed to improve the knowledge and skills essential to understanding and managing sociocultural issues in a healthcare setting [ 6 , 12 ]. To be able to improve and sustain the cultural competency of healthcare professionals, training should be offered throughout a professional’s career [ 2 , 12 ], tailored to take into account individual and organisational contexts [ 13 ] and involving key stakeholders in the design, implementation and evaluation of the programs [ 14 , 15 ]. It is further recommended that both standard cultural competence training as well as more situation-specific training should be provided [ 2 ].

Even though there is currently little evidence about the effectiveness of cultural competence training on patient-related outcomes [ 14 , 16 ], there is clear evidence about the positive effects of these interventions on healthcare professionals’ attitudes, knowledge and behaviour with respect to cross-cultural care [ 5 , 13 ]. However, more knowledge is still needed to determine which educational models are most effective and feasible in what specific contexts and groups and how many resources (e.g. time) should be allotted for reaching the desired outcomes [ 13 ]. This qualitative study was conducted to examine the perceptions of nurses regarding the content, utility and implementation of cultural competence training that aimed to ease cross-cultural encounters by increasing awareness of one’s own cultural features. The goal was to gain knowledge that can be used in the development of national cultural competence training to healthcare professionals.

Setting and participants

The study was conducted in one large primary care hospital in southern Finland in autumn 2017. This hospital was chosen because it is located in an area that has a large number of immigrants (1/4 of all immigrants living in Finland). In 2017, 16% of the population in this area were foreign-language speakers (compared with 7% in the total population of Finland). The largest groups were Russian, Estonian and Arabic speakers [ 17 ]. An invitation to participate in the training was delivered to healthcare professionals in the hospital by the ward managers. Participants were expected to be physicians, registered nurses or licensed practical nurses with prior experience in taking care of culturally diverse patients. A group of 20 registered nurses ( n  = 14) and practical nurses ( n  = 6) from seven different units were enrolled in the training. At the end of the training, an email was sent to all participants with an invitation to participate in small group interviews. Ten ( n  = 10) participants responded and were willing to participate.

Cultural competence training

Cultural awareness was chosen as the main construct for the training because self-reflection on one’s own culture can be seen as an important component of cultural competence, and understanding one’s own cultural features and values helps in understanding the beliefs, values and behaviour of others [ 18 ]. Cultural awareness is one component of Campinha-Bacote’s (2002) model of cultural competence in healthcare delivery, which explains cultural competence as a process that requires healthcare workers to engage in an active and ongoing effort to achieve the ability to provide culturally responsive healthcare services [ 18 ]. Instead of providing culturally specific facts about other cultures—which can increase the use of stereotypes [ 5 ]—the training was designed to take a more general approach to cultures, with the main goal being to increase awareness of different cultures by scrutinizing one’s own cultural features. In order to develop training that takes into account the context and involvement of key stakeholders, we utilised a wide range of sources in the development. The content of the training was based on (a) the theoretical literature about the different cultural dimensions (e.g. differences in cultural values, such as individualism vs. collectivism, power distance or orientation in time) [ 19 , 20 ]; (b) several research articles regarding cultural pain, differences in personal space, and the importance of considering the spiritual needs of foreign patients [ 21 , 22 , 23 ]; (c) knowledge obtained from different cultural experts such as a priest and personnel from the Centre for Torture Survivors in Finland; and (d) knowledge obtained from our previous interview study. Interviews with 25 Finnish healthcare professionals were conducted in order to examine the main challenges that such healthcare professionals (nurses, doctors and dentists) face when taking care of culturally diverse patients [ 24 ]. Additionally, these interviews assessed perceived educational needs. The interviews revealed that the challenges are mainly related to communication between the patients and healthcare professionals, including language barriers, problems with visitors, gender issues and differences in pain interpretation. Perceived educational needs related to gaining an understanding of patients experiences with the Finnish healthcare system, the need to share experiences with colleagues about cross-cultural care, and learning some culture-specific facts or guidelines that could help in everyday nursing practice.

Constructivism learning theory was chosen as the pedagogical approach because it highlights the activity and engagement of the learner in using one’s own prior experiences in constructing new knowledge, developing an understanding, and making meanings [ 25 ]. The participants were encouraged to reflect about their prior experiences and encounters with culturally diverse patients and discuss in groups in order to inspire further thinking. The training included 16 h of face-to-face teaching, which was divided into four 4-h sessions and arranged for 4 weeks. The sessions were arranged once a week to give participants an opportunity to ponder and assimilate the learned content in their daily work before the next session. Participants attended the sessions during their working hours, so afternoon times were chosen. It was believed that afternoon times would improve participants’ opportunities to attend the sessions because more staff was present in the wards then.

The sessions were designed to move from the theoretical level to the practical level, and each session built upon the previous one. The main teaching method was adapted from ‘storytelling’, wherein the educator—an experienced teacher from a multicultural centre—used real-life examples, stories and pictures to demonstrate different cultural aspects. Storytelling was used because of its strength in promoting the adoption of multiple viewpoints and making sense of unknown theoretical situations, norms and values by using real-life experiences [ 26 ]. For example, the teacher described situations where differences in the way of communication (regardless of the language) have created unexpected misunderstandings. Furthermore, the teacher showed pictures that demonstrated how differently people with different cultural backgrounds can perceive the same images. Each session also included group discussions and learning tasks such as construing personal factors behind one’s own cultural features in order to become aware of the cultural diversity and to understand why culture-specific ‘facts’ cannot be used in patient care. Web-based learning platforms such as Padlet (an on-line post-it board) were also utilised, as they allowed the participants to share their thoughts anonymously with others. A description of the contents of the sessions is presented in Table  1 .

Data collection

After the final training session, three semi-structured small group interviews ( n  = 4 + 2 + 3) and one single interview ( n  = 1) were conducted in the hospital to explore the perceptions of the participants about training. Five ( n  = 5) of the interviewees had attended all of the training sessions, three ( n  = 3) had attended three sessions, and two ( n  = 2) had attended two sessions.

Two researchers with a background in nursing and prior experience with interview studies conducted the interviews. The interviewers were familiar with the content of the training, as they had been present at each training session. The participants were asked questions such as how they perceived the content of the training, what they found useful or not useful in the training and why, whether something was missing from the training, and how they perceived the overall implementation of the training including the learning methods and the timing and length of the sessions. The interviews lasted 30–40 min and were audio-recorded and transcribed verbatim for the analysis. Field notes, such as demographics of the participants and the main points from each interview, were also taken during the interviews and used afterwards in the reflective discussion between the two interviewers [ 27 ].

Data analysis

Qualitative content analysis with a conventional approach was used to analyse the data. The method is suitable for interview data collected from open-ended questions, and it allows the researcher(s) to explore personal perceptions without resorting to preconceived categories [ 28 ]. First, the interview transcripts were read through several times to obtain a picture of the data in its entirety. After familiarising ourselves with the data, the transcripts were read again to code all the expressions from the text that described participants’ perceptions of the training. The length of the codes (the units of analysis) varied between a few words and a few sentences. While coding, notes were also made about first thoughts and impressions. Next, codes with similar content were grouped as subcategories, which were given a descriptive name. Finally, subcategories that had the same perspective were then grouped into five main categories (Table  2 ). One researcher made the initial categorisation, which was then discussed and verified by another researcher (who was also present during the data collection phase, had the field notes from interviews, and was familiar with the data).

The participants were registered nurses ( n  = 8) and licensed practical nurses ( n  = 2) from five different hospital wards. Most of the participants were female ( n  = 9), 23 to 55 years old (average age of 37). Their work experience in the healthcare field varied between 2 and 33 years (average 14 years). None of the participants had previously attended a cultural competence training designed to address cross-cultural care or multicultural issues. The participants reported whether they encounter patients from different cultural and linguistic backgrounds on a daily ( n  = 3), weekly ( n  = 4) or monthly ( n  = 3) basis.

We divided the participants’ perceptions of the training into three main categories: general utility, personal utility, and utility of the training for patients. The participants’ perceptions of how the training had been implemented were divided into two categories: quality of the training and suggestions for improvement. Each main category had two to four subcategories (Table 2 ).

General utility

Participants expressed that they were pleased that the cultural competence training had provided them with a more general, rather than entirely a healthcare-orientated, perspective on cultural issues. The fact that the educator in charge was not a healthcare professional was seen as an advantage because she was able to bring new ideas and viewpoints into the hospital environment. Participants also stated that they were pleased that many of the real-life examples presented in the lectures were not from the healthcare environment but dealt with more general incidences from everyday life.

‘Usually we are educated by nurses or some other healthcare professionals. They are so close to us, and the hospital environment, that they can be as blind as we might be in these matters.’ (i1, n4)

The participants saw the training as an important opportunity to start a general and open discussion about cultural issues and, for example, about conviction, which workers typically avoid discussing and which is not part of the general work culture. Having the possibility to share their thoughts with colleagues was highly appreciated, and the small group and engaging lecturing style of the educator seemed to facilitate participants’ involvement in the discussions.

‘The atmosphere was open and, because we were a small group, it was easy to interact. I realised that people rarely dare to speak up and discuss [things] as freely as we did. Usually people just sit quietly in these training [situations].’ (i2, n2)

Participants described the training as an opportunity to develop their current healthcare practices. In order to achieve any general improvements, they thought that the whole healthcare organisation should have the opportunity to attend such trainings. Participants also noted their own responsibility in making improvements, and they stated they were enthusiastic to share the learned knowledge with their co-workers. However, such sharing was noted to be challenging because increasing cultural awareness was primarily seen as an individual process.

‘It was difficult to tell others what was discussed in the lectures. The knowledge didn’t just come from the sentences that we heard. It was also behind the sentences and cannot be explained with words. When I tried to describe these things to others, the message [got] changed along the way.’ (i1, n1)

Personal utility

The training was described as an important opportunity to become aware of one’s own cultural features. The participants realized the extent to which their own cultural ‘cage’ guided their behaviour, and how it also affects the way they interpret the behaviour of others. Subsequently, the participants noted changes in their way of thinking. They felt more open-minded; and they reported that after the training, they had started paying more attention to the way they acted when taking care of culturally diverse patients. Participants felt that the training provided them many new, even surprising, perspectives about their own daily communication patterns. Realising the common features of their communication patterns, and how they might complicate their interactions with patients, allowed them to develop their communication skills.

‘Training really helped me to understand that that’s exactly how we act, and maybe we should try to act a bit differently … pay more attention to how we talk and interact with others.’ (i2, n1)

‘I really wasn’t aware that we often communicate with silence, [our] eyes, etc. … and how much we tend to communicate between the lines. These things had never crossed my mind because they’re so automatic.’ (i1, n2)

Despite the fact that several participants expressed a need to develop current practices and their own way of acting, many participants also perceived the training as a justification for carrying out certain practices that they feel are important with respect to established customs, regardless of the culture of the patient. The participants also reported that their courage to encounter culturally diverse patients increased as a result of the training.

‘Sometimes I feel that female patients’ husbands or relatives speak for the patients. I think that every patient must have a right to speak up, and the training gave me courage to stick with this principle and say, “In here, we would like to hear [from] the patient alone, therefore, could you please give us a minute … ”’ (i3, n1)

Utility of the training for patients

The participants reported that the training had utility value for the patients as a result of nurses having a better awareness of and ability to acknowledge the differing cultural backgrounds of particular patients. For example, participants stated that they had started paying more attention to supporting the communality of certain patient groups after the training.

‘Many cultures are so much more communal than we are. People also want to take care of their relatives when they are in the hospital, and I want to support that. We should try to learn from that.’ (i1, n4)

Additionally, participants reported that the training had increased the respect that culturally diverse patients receive when seeking healthcare. The participants emphasised the importance of providing equal treatment and being respectful and non-judgmental of others, especially when the customs of certain cultures differ from one’s own ideology.

‘Even if the patient and his or her relatives, family situations or way of living goes against my cultural beliefs, it doesn’t mean that I have a right to discriminate against them. For example, in some cultures, girls get married young and men have power in decision making. Despite (the fact that) that’s not happening in my life, in my country or in my culture, it doesn’t make it wrong, and I have to respect that. The training gave me the tools to think about these things.’ (i3, n1)

Quality of the training

The participants felt that the training was of a high quality, and many stated that the training had exceeded their expectations. They also noted the importance of providing training that serves the needs of the learners and that it is highly important to consider the starting level of the learner when designing the training. Participants were mostly satisfied with the contents of the sessions, but many felt the discussion model in the conviction session was unnecessary or too straightforward. Instead of using any pre-specified phrases, nurses felt that it is better to be sensitive to the situation and use their professional skills as nurses when discovering patient’s spiritual needs.

‘I feel that as a nurse, and after the nursing education [that] I have completed, I must be able to discuss several things with patients, including [their] convictions. If you can’t do it, you’re in the wrong place. The suggestions about how I can start a discussion with patients about [their] convictions didn’t serve me in any way.’ (i1, n1)

Participants stated that they greatly appreciated the expertise of the training provider and that the educator had done the proper background work and knew what she was talking about. They also noted that excellent teaching skills and the educator’s knowledge of complex cultural issues were meaningful. The ‘storytelling’ type of lecturing, and the high number of real-life examples that were presented in the sessions, were perceived as inspiring among the participants.

‘It was so immersive, lively and multidimensional. Even though it was lecturing, it was somehow creative.’ (i3,n1)

Suggestions for training improvement

Participants brought up a few notable ideas that could make the training better in the future. Some noted that hearing about the lived experiences of persons from different immigrant groups could be added to the content. Some participants also suggested that the training could be slightly condensed. They felt pressure to finish their work on time to make it to the sessions, and many felt that four full afternoon sessions was too long to be outside the ward.

‘It could have been a bit shorter, for instance by putting some material on the Web beforehand that could be used to orientate oneself and then having the face-to-face session where things would be summarised and discussed.’ (i2, n1)

Participants also shared their opinions about the one-week break after each training session. Some participants felt that it allowed them to think about the contents of the sessions; but others felt that it was difficult to remember what had been previously discussed, which complicated the presentation of the big picture. Many participants stated that a shorter time span would have helped them to remember more clearly the content of a previous session and also helped them to assimilate the learned knowledge. They suggested that a summary from each session could have been provided.

The participants mostly felt that after the training, they no longer needed to use checklists or guidelines about how to act with certain patient groups. However, they still felt insecure about different religions and how the rules of different religions should be taken into account in their daily actions.

‘We discussed how we encounter individuals, but not about how we respect different religious customs. For example, sometimes a male or female nurse is not allowed to help the patient with bathing, etc., or there are certain customs when it comes to end-of-life care.’ (i4, n1)

In this study, we examined the healthcare professionals’ perceptions of the content, utility and implementation of cultural competence training that focused on easing cross-cultural encounters by increasing nurses’ awareness of their own culture and cultural biases. The prior expectations of participants regarding cultural competence training had to mainly do with acquiring certain ‘quick-fix’ solutions or guidelines on how to act with patients from different cultures. These thoughts matched with traditional cultural competence education, which focuses on providing knowledge about common ‘facts’ or the generalised behaviours of certain cultural groups [ 29 ]. However, this approach could have increased the risk of stereotyping and ignoring about the individual differences that patients with similar cultural backgrounds may have [ 30 ]. In the end, participants said they were extremely satisfied with the training, which provided them with a totally different perspective on the subject. Increasing awareness and gaining a better understanding of their own (Finnish) cultural and communicational features seemed to help them to recognise the common pitfalls of cross-cultural communication, and thus allowed them to develop their communication skills. This finding is in line with previous evidence suggesting that the first step towards improving cross-cultural communication is to raise awareness of one’s own verbal and nonverbal communication styles [ 11 ]. It is essential to realise that communicational differences can occur in how silences, pauses, eye contact, and touching are used and interpreted, or in how clear and direct messages are emphasised in different cultures (high- vs. low-context cultures) [ 31 ].

Interestingly, the participants in this study perceived it as an advantage that the training was not provided by their own healthcare organisation or by a healthcare professional. They stated that it was useful to have a different perspective on cultural issues, and they indicated that bringing new perspectives and ideas to the hospital environment from outside the healthcare field could facilitate the development of cross-cultural care. Continuing education is commonly provided by the hospital/organisation that employs healthcare professionals [ 32 ], and therefore utilising multiple perspectives by using professionals from different fields or organisations should be considered. Furthermore, the participants suggested that members of different immigrant groups could be invited to share their views in the training sessions. Participants believed they would thus achieve a better understanding of different cultures and how these patients experience the Finnish healthcare services. This so-called ‘educational partnership’ method, whereby different ethnic community members share their lived experiences, has previously been shown to provide an efficient way to increase healthcare professionals’ understanding of cultural differences and encourage further discussion [ 29 ]. Understanding the difficulties experienced by migrants could help professionals in increasing their cultural sensitivity and providing culturally competent care [ 33 ].

The importance of encouraging discussion about different cultural issues was highlighted in this study, and the participants commonly expressed a willingness to share their experiences and learned knowledge with their co-workers. The challenge was on how to pass on the valuable lessons learned to others in the organisation in such a way that the messages lying ‘behind the sentences’ could also be understood. Passing on information can be especially difficult in training settings that require one’s own critical thinking and a certain level of self-awareness of the theme in question. Participants noted that in order to develop current practices regarding cross-cultural care, the training should be provided to all healthcare professionals working at different organisational levels. The findings of this study are similar to previous findings, which state that organisational-level cultural competency initiatives, strategies and commitments are needed to provide culturally competent healthcare [ 5 , 14 ].

Providing cost-effective training to a broader group of healthcare professionals would require utilising different educational methods, such as e-learning and technology-enhanced learning [ 34 ]. Despite the fact that the participants expressed appreciation for the face-to-face sessions with a storytelling-type of lecturing and discussions, they also had difficulties in detaching themselves from the busy wards and were stressed about being present and on time for all four training sessions. These difficulties, combined with irregular shift work, led to a decreasing number of participants in the sessions (approximately 12/20 participants were present per session). In addition, physicians were also invited to participate but none attended. This indicates that it can be difficult to arrange enough time in healthcare for this type of training and, therefore learning possibilities that are not bound to an exact time or place need to be further developed.

Limitations

Certain issues place limitations on the credibility and transferability of the results. A single organisation and a small sample size (consisting mainly of nurses working in somatic wards) restrict the generalisation of the results. It is possible that other healthcare professionals (such as physicians, physiotherapists and mental health specialists) can have different perspectives on cultural awareness. Perceptions about the training could also have differed or be more multifaceted if all the nurses could have attended all four training sessions. Additionally, participants who enrolled in the training possibly were highly motivated to learn and had a more positive attitude towards cross-cultural care before attending the training, which might have affected their responses. It must also be considered that all the participants highlighted the teaching skills and experience of the educator; therefore their perceptions of the training could have been different if less competent educators would have been used. We did not ask for feedback from the participants about the data categorisation or interpretation of the results, which would have increased the trustworthiness of the results. However, two researchers were involved in the data collection and analysis, and frequent discussions were held with the research group during different phases of the study.

There is clearly an international need to pay attention to the cultural competence of healthcare professionals. The results of this study indicate that increasing awareness of one’s own cultural features can be useful for easing cross-cultural encounters in a healthcare setting and improving the cultural competence of nurses. Participants expressed that the training was useful on many different levels, and they saw the small group size and inspiring lectures as important in facilitating discussion about cross-cultural care. In the future, it will be essential to provide cultural competence training to professionals at different levels of the healthcare system to increase their awareness of cultural differences and how culturally diverse patients are treated. Educational methods that would allow large groups to participate without restrictions on time and place are also needed. Future studies should compare traditional long-term training, such as the one used in the present study, to shorter training and Web-based learning platforms to find the most feasible way to increase cultural awareness and improve the cultural competence of healthcare professionals.

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Johnstone M, Kanitsaki O. Culture, language, and patient safety: making the link. Int J Qual Health Care. 2006;18(5):383–8.

Article   PubMed   Google Scholar  

Betancourt JR, Green AR. Commentary: linking cultural competence training to improved health outcomes: perspectives from the field. Acad Med. 2010 Apr;85(4):583–5.

Shen Z. Cultural competence models and cultural competence assessment instruments in nursing: a literature review. J Transcult Nurs. 2015;26(3):308–21.

Alizadeh S, Chavan M. Cultural competence dimensions and outcomes: a systematic review of the literature. Health & social care in the community. 2016;24(6):117–30.

Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio AM, et al. Cultural competence: A systematic review of health care provider educational interventions. J Gen Intern Med. 2004;19:134.

Google Scholar  

Betancourt JR, Green AR, Carrillo JE, Owusu A-FI. Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Rep. 2003;118(4):293–302.

Article   PubMed   PubMed Central   Google Scholar  

Negi S, Kaur H, Singh GM, Pugazhendi S. Quality of nurse patient therapeutic communication and overall patient satisfaction during their hospitalization stay. International Journal of Medical Science and Public Health. 2017;6(4):675–80.

Article   Google Scholar  

Marshall JK, Cooper LA, Green AR, Bertram A, Wright L, Matusko N, et al. Residents' attitude, knowledge, and perceived preparedness toward caring for patients from diverse sociocultural backgrounds. Health Equity. 2017;1(1):43–9.

Logan S, Steel Z, Hunt C. Investigating the effect of anxiety, uncertainty and ethnocentrism on willingness to interact in an intercultural communication. J Cross-Cult Psychol. 2015;46(1):39–52.

Gudykunst WB, Nishida T. Anxiety, uncertainty, and perceived effectiveness of communication across relationships and cultures. Int J Intercult Relat. 2001;25(1):55–71.

Li C, Son N, BA Abdulkerim M, Jordan CA, Christine Ga Eun Son, BA. Overcoming Communication Barriers to Healthcare for Culturally and Linguistically Diverse Patients. N Am J Med Sci. 2017;10(3):103–10.

Pearson A, Srivastava R, Craig D, Tucker D, Grinspun D, Bajnok I, et al. Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. Int J Evid Based Healthc. 2007;5(1):54–91.

PubMed   Google Scholar  

Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Serv Res. 2014;14(1):99.

McCalman J, Jongen C, Bainbridge R. Organisational systems’ approaches to improving cultural competence in healthcare: a systematic scoping review of the literature. Int J Equity Health. 2017;16(1):78.

Teunissen E, Gravenhorst K, Dowrick C, van Weel-Baumgarten E, Van den Driessen Mareeuw F, de Brà n T, et al. Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study. Int J Equity Health. 2017;16(1):32.

Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for health professionals. Cochrane Database Syst Rev. 2014;5:CD009405.

Statistics Finland [Internet].; 2016 []. Available from: http://www.tilastokeskus.fi/tup/maahanmuutto/maahanmuuttajat-vaestossa_en.html .

Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13(3):181–4.

Hofstede G. National Cultures in four dimensions: a research-based theory of cultural differences among nations. Int Stud Manag Organ. 1983;13(1–2):46–74.

Trompenaars F, Hampden-Turner C. Riding the waves of culture: understanding diversity in global business: Nicholas Brealey Publishing. Third edition. Oxfordshire: Hachette UK; 2011.

Beaulieu C. Intercultural study of personal space: a case study. J Appl Soc Psychol. 2004;34(4):794–805.

Campbell CM, Edwards RR. Ethnic differences in pain and pain management. Pain management. 2012;2(3):219–30.

Karvinen I. How to assess spiritual history? - northern perspective on spiritual history taking by opening-model. Danubius. 2014;32:181–8.

Balasubramaniam N, Kujala S, Ayzit D, Kauppinen M, Heponiemi T, Hietapakka L, Kaihlanen A. Designing an E-Learning Application to Facilitate Health Care Professionals' Cross-Cultural Communication. Stud Health Technol Inform. 2018;247:196–200.

Jones MG, Brader-Araje L. The impact of constructivism on education: Language, discourse, and meaning. Am Commun J. 2002;5(3):1–10.

Haigh C, Hardy P. Tell me a story †a conceptual exploration of storytelling in healthcare education. Nurse Educ Today. 2011;31(4):408–11.

Phillippi J, Lauderdale J. A guide to field notes for qualitative research: context and conversation. Qual Health Res. 2018;28(3):381–8.

Hsieh H, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Long TB. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012;19(3):102–8.

Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual framework for teaching and learning. Med Educ. 2009;43(3):229–37.

Eubanks RL, McFarland MR, Mixer SJ, Muñoz C, Pacquiao DF, Wenger AFZ. Chapter 4: Cross-Cultural Communication. J Transcult Nurs. 2010 10/01; 2019/05;21(4):137S–50S.

Griscti O, Jacono J. Effectiveness of continuing education programmes in nursing: literature review. J Adv Nurs. 2006;55(4):449–56.

Chae D. Experience of migrant care and needs for cultural competence training among public health workers in Korea. Public Health Nurs. 2018;35(3):211–9.

Scott KM, Baur L, Barrett J. Evidence-based principles for using technology-enhanced learning in the continuing professional development of health professionals. J Contin Educ Heal Prof. 2017;37(1):61–6.

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Acknowledgements

We would like to thank the healthcare professionals who participated in the training and interviews for their substantial contribution to this study. We would also like to thank the managers of the hospital for their cooperation regarding the practical arrangements of the intervention.

This study was funded by the Strategic Research Council (SRC) of the Academy of Finland (project 303607).

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Substantial contribution to study conception and design and drafting of the manuscript: A-M.K, L. H, T.H. Data collection, data analysis and interpretation of data: A-M.K, LH. All authors read and approved the final manuscript .

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Kaihlanen, AM., Hietapakka, L. & Heponiemi, T. Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training. BMC Nurs 18 , 38 (2019). https://doi.org/10.1186/s12912-019-0363-x

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The cosmetics giant manages to be very global—yet very French.

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As the cosmetics company L’Oréal has transformed itself from a very French business into a global leader, it has grappled with the tension that’s at the heart of every global enterprise: Achieving economies of scale and scope requires some uniformity and integration of activities across markets. However, serving regional and national markets requires the adaptation of products, services, and business models to local conditions.

Since the late 1990s, the L’Oréal Paris brand—which accounts for half the sales of the consumer products division—has dealt with that tension by nurturing a pool of managers with mixed cultural backgrounds, placing them at the center of knowledge-based interactions in the company’s most critical activity: new-product development.

L’Oréal Paris builds product development teams around these managers, who, by virtue of their upbringing and experiences, have gained familiarity with the norms and behaviors of multiple cultures and can switch easily among them. They are uniquely qualified to play several crucial roles: spotting new-product opportunities, facilitating communication across cultural boundaries, assimilating newcomers, and serving as a cultural buffer between executives and their direct reports and between subsidiaries and headquarters.

At the heart of every global business lies a tension that is never fully resolved: Achieving economies of scale and scope demands some uniformity and integration of activities across markets. However, serving regional and national markets requires the adaptation of products, services, and business models to local conditions. As U.S. and European companies increasingly look for customers in emerging economies, both the advantages of global scale and the need for local differentiation will only increase.

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Cross-Cultural Issues and Diverse Beliefs

Cross-cultural issues and diverse belief.

Douglas S. Diekema, MD, MPH, Professor, UW Dept. of Pediatrics, Adjunct Professor, UW Dept. of Bioethics & Humanities

Core Clerkships:   Pediatrics  I  Rehabilitation Medicine

Related topics:   Physician-Patient Relationship  I  Parental Decision Making  I  Termination of Life Sustaining Treatment  

Topics addressed:

Why is it important to respect what appear to me to be idiosyncratic beliefs?

What are some ways to discover well known sets of beliefs?

What is my responsibility when a patient endangers her health by refusing a treatment?

Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs?

What kinds of treatment can parents choose not to provide to their children?

Can a patient demand that I provide them with a form of treatment that I am uncomfortable providing?

Patients may bring cultural, religious and ideological beliefs with them as they enter into a relationship with the physician. Occasionally, these beliefs may challenge or conflict with what the physician believes to be good medical care. Understanding and respecting the beliefs of the patient represents an important part of establishing and maintaining a therapeutic relationship. While the principle of respect for autonomy requires that a physician respect the medical decisions of a competent adult patient, in cases of surrogate decision-making, the physician has an independent duty to guard the interests of the patient.

Respecting the beliefs and values of your patient is an important part of establishing an effective therapeutic relationship. Failure to take those beliefs seriously can undermine the patient's ability to trust you as her physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care when they need it.

There are many groups that share common sets of beliefs. These belief systems may be based on shared religion, ethnicity, or ideology. Knowledge of these beliefs and the reasonable range of interpretation of doctrine can be very helpful in deciding if unusual beliefs should be respected. Good resources for guidance in this area include patients and family members themselves, staff members with personal knowledge or experience, hospital chaplains, social workers, and interpreters. Unusual beliefs that fall outside known belief systems should prompt more in-depth discussions to insure they are reasonable.

It is important to explore each individual's beliefs, as shared membership in a particular religious or cultural group does not necessarily entail identical belief systems.

Adults have a moral and legal right to make decisions about their own health care, including the right to refuse treatments that may be life-saving. The physician has a responsibility to make sure that the patient understands the possible and probable outcomes of refusing the proposed treatment. The physician should attempt to understand the basis for the patient's refusal and address those concerns and any misperceptions the patient may have. In some cases, enlisting the aid of a leader in the patient's cultural or religious community may be helpful.

Parents have legal and moral authority to make health care decisions for their children, as long as those decisions do not pose a significant risk of serious harm to the child's health. Parents should not be permitted to deny their children medical care when that medical care is likely to prevent substantial harm or suffering. If necessary, the physician may need to pursue a court order or seek the involvement of child protective services in order to provide treatment against the wishes of the parents. Nevertheless, the physician must always take care to show respect for the family's beliefs and a willingness to discuss reasonable alternatives with the family.

Parents have the right to refuse medical treatments when doing so does not place the child at significant risk of substantial harm or suffering. For example, parents have the right to refuse routine immunizations for their children on religious or cultural grounds.

A physician is not morally obligated to provide treatment modalities that they do not believe offer a benefit to the patient or which may harm the patient. Physicians should also not offer treatments that they do not feel competent to provide or prescribe. However, it is important to take the patient's request seriously, consider accommodating requests that will not harm the patient or others, and attempt to formulate a plan that would be acceptable to both the physician and patient.

Additional Readings: Cross-Cultural Issues and Diverse Beliefs

• Bowman K. What are the Limits of Bioethics in a Culturally Pluralistic Society.  Journal of Law and Medical Ethics  2004; 32(4): 664-669.
• Carrese JA, Rhodes LA. Western bioethics on the Navajo Reservation: benefit or harm?  JAMA  1995; 274: 826-9.
• Diekema DS. Revisiting the Best Interest Standard: Uses and Misuses.  Journal of Clinical Ethics  2011; 22(2): 128-133.
• Gupta VB, Willert J, Pian M, Stein MT. When Disclosing a Serious Diagnosis to a Minor Conflicts with Family Values.  Journal of Developmental and Behavioral Pediatrics  2008; 29(3): S100-S102.
• Jecker NS, Carrese JA, Pearlman RA. Caring for patients in cross-cultural settings.  Hastings Center Report  1995; 25: 6-14.
• Gyamfi C, Gyamfi MM, Berkowitz RL. Ethical and medicolegal considerations in the obstetric care of a Jehovah's Witness.  Obstetrics and Gynecology  2003 Jul; 102(1): 173-80.
• Learman LA, Kuppermann M, Gates E, Nease RF Jr, Gildengorin V, Washington AE. Social and familial context of prenatal genetic testing decisions: are there racial/ethnic differences?  American Journal of Medical Genetics  2003 May 15; 119C(1): 19-26.
• Lapine A, Wang-Cheng R, Goldstein M, Nooney A, Lamb G, Derse AR. When cultures clash: physician, patient, and family wishes in truth disclosure for dying patients.  Journal of Palliative Medicine 2001Winter; 4(4): 475-80.
• Paasche-Orlow M. The ethics of cultural competence.  Academic Medicine  2004 Apr; 79(4): 347-50.
• Sayeed S, Padela A, Naim MY, Lantos JD. A Saudi family making end-of-life decisions in the PICU.  Pediatrics  2012 Apr; 129(4): 764-768.
• Quest TE, Franks NM. Vulnerable populations: cultural and spiritual direction.  Emergency Medicine Clinics of North America  2006 Aug; 24(3): 687-702.

Related Bioethics Websites by Topic: Cross-Cultural Issues and Diverse Beliefs

Case studies, cross-cultural issues and diverse beliefs: case 1.

Cross-cultural Issues and Diverse Beliefs

A mother brings her 18-month-old daughter to your office for a routine physical examination. The child has had no immunizations. Her mother says that they believe that vaccines weaken the immune system and have heard that vaccination can cause autism.

What is your role in this situation? Can parents refuse to immunize their children?

Case 1 Discussion

The risk faced by unimmunized individuals is relatively low, and the mother's refusal to immunize does not pose a significant likelihood of serious harm to her child. The physician should be sure that the child's mother understands the risks of remaining unimmunized and attempt to correct any misconceptions about the degree of risk associated with getting immunized. If the mother persists in her request, the physician should respect her wishes.

Cross-cultural Issues and Diverse Beliefs: Case 2

A 23-year-old Navajo man has injured his leg after a fall. He presents to the emergency room of the reservation hospital where he is complaining of pain. His leg appears to be broken. The man requests that you call a medicine man before doing anything further.

Should you find a medicine man? Should you proceed with treatment?

As a competent adult, this patient has the right to make decisions about his medical care. You must respect his wish not to be treated until he gives you permission to do so. Calling the local medicine man will show your respect for the patient and strengthen the patient's trust in you and your abilities.

Cross-cultural Issues and Diverse Beliefs: Case 3

A 3-year-old child is brought to your clinic with a fever and stiff neck. You are quite certain the child has meningitis. When you discuss the need for a spinal tap and antibiotic treatment, the parents refuse permission, saying, "We'd prefer to take him home and have our minister pray over him."

Can the parents refuse treatment in this case? How should you handle this?

The physician has a duty to challenge the decision of parents when their refusal of treatment would pose a significant risk of substantial harm. Failure to diagnose and treat bacterial meningitis would seriously threaten the health and even life of this child. The physician should share his or her view with the family and seek to elicit their cooperation through respectful discussion. The physicians should be open to alternatives that satisfy the parents’ concerns and achieve the goal of keeping the child safe. Inviting the family’s religious leader to the hospital while also providing standard medical therapy may prove to be an acceptable compromise. Should these efforts not result in parental permission, the physician is justified in seeking legal authority (in the form of a court order of authorization from a state child protection agency) to proceed with the procedure and treatment of the child. In most states a physician is legally authorized to provide emergency treatment to a child without a court order when delay would likely result in harm.  

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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• SPECIAL ISSUES

Many blame social media for poor mental health among teenagers, but the science is murky

If Jordy had a switch to instantly shut down social media, she would flip it.

"I'd switch it off, 100 per cent, even if it was for a week, just so people could have that taste of what it would be like," she said.

Now in her first year out of school, the 18-year-old studies nursing at university and works at a local cafe in Charleville, a small town 745 kilometres west of Brisbane, where she has lived most of her life.

Like Australian teenagers everywhere, she has another life online.

"It's like a second world, really," she said.

"You have reality and then you have social media — two extremely different things."

At the moment, she spends an average of five-and-a-half hours a day on her phone, but it's lower than her peak during high school.

"When I first got a phone I was on it constantly, probably like seven hours, eight hours a day," she said.

She has cut back since then because that second world was not always kind, especially when it came to body image — and despite the fact her parents were always strict about phone usage.

"Growing up, I've always been a big girl … and a sporty person — I'm pretty healthy," she said.

"But when we see images, it tends to be just very thin, skinny people.

"It can just take you down, with the click of your fingers."

Jordy was also being bullied at school, but social media meant it could happen around the clock, no matter where she was.

"A group of boys at my school had tagged me on TikTok telling me to go kill myself," she said.

"It was just so heartbreaking. I was just like, 'I go to school with you every day, we've never had an issue in the past.' That's probably the worst thing that's happened."

Jordy's mental health was tanking, and she began to withdraw from activities she used to love, like footy training or seeing friends.

"I just felt so scared to talk to my mum … I was just like, 'I don't want my mum to think I'm using social media the wrong way'," she said.

No matter how bad things got, logging off still felt impossible.

"It was like that fear of missing out, I guess. I think that's the addiction thing, right?" she said.

"You sort of just have to be on your phone to socialise."

Does more screen time cause worse mental health in teenagers?

Teen mental health has deteriorated at an accelerating rate in the last two decades — more or less exactly since social media and smartphones started to become widespread in 2007.

For obvious reasons, many people, especially concerned parents, have leapt to the conclusion that tech is the culprit.

But the science is surprisingly murky, even though there is a link — research shows more screen time is associated with higher rates of depression in adolescents.

"What we know about the link is there's a link, and that's pretty much what we know," said Aliza Werner-Seidler, a senior researcher at the Black Dog Institute.

"We have really good correlational data, there is a strong linear relationship, particularly in young girls.

"What we don't know is about causation — so is young people's mental health leading them to spend more time on social media and screens, or is it actually the other way around?

"We don't know the direction of the effect."

Dr Werner-Seidler is one of thousands of researchers around the world trying to solve that mystery.

Even if many people are convinced they already know the answer because of their own experience online.

"Personally I would say that it's both," Jordy said.

After a session doomscrolling perfect bodies on TikTok, she "would feel horrible" about herself.

"But then I'd continue to use it and then it made me feel even worse."

After 17 years, why don't we have the answers yet?

Despite 17 years of widespread smartphones and social media, researchers still don't have enough data to definitively say whether they're to blame for deteriorating teen mental health.

Getting those long-term studies done is particularly difficult because trends, algorithms and habits change so quickly.

"When I started this work, TikTok wasn't even a thing … Snapchat, really has only taken off in the last decade or so," Dr Werner-Seidler said.

"It's a very fast-moving field. And so it's very, very difficult to get a handle on it before the next thing comes out."

Part of the problem is that studies have focused on overall screen time, instead of looking at what people were doing online.

"Are they FaceTiming with Grandma? Are they viewing distressing content? Are they being groomed online?" Dr Werner-Seidler said.

"This idea of nuance and it matters what people do and how they do it and how long for and with whom.

"We can't tell any of this information just by looking at how long young people spend on screens."

What social media companies know but don't say

The National Mental Health Commission has been investigating the relationship between digital tech and teen mental health.

On Friday it released its findings after months of consultation, noting the lack of longitudinal evidence and calling for further research to be made a "top priority".

Frustratingly for Dr Werner-Seidler, and other researchers in this area, the data that might solve the mystery does exist — but they can't access it.

"Big tech companies have all of this information," she said.

"If they were to share it with academics and scientists, we would be able to learn so much more, so much more quickly."

The data that has so far emerged in other ways, courtesy of lawsuits and whistleblowers such as Frances Haugen in 2021, has been disturbing.

Ms Haugen, a former Facebook employee, revealed detailed internal research showing Instagram was harmful for teenage girls.

One slide from an in-house presentation reportedly said: "We make body image issues worse for one in three teen girls."

The peak body for Australia's technology industry — whose members include social media companies Meta, Snapchat and TikTok — has defended the sector's contribution to public research.

"DIGI's relevant members have long-standing research and community partnerships in mental health and online safety, and specific policies … informed by that work," a spokesperson said.

Depending on the platform, those policies might include parental controls, avenues to report inappropriate content and seek help, customisable settings, and age limits.

Adherence to those age limits has been mostly voluntary, and the federal government is spending $6.5 million on an age verification trial in the hopes of introducing a higher standard of proof.

Some social media companies are trying to get ahead of any future legislation.

Facebook's parent company Meta announced this week it would no longer allow Facebook users to edit their birthdate to say they're over 18 without verification — a feature that's been in place on Instagram in Australia since last year.

A window for change

The public and political mood when it comes to big tech has rarely been darker.

"I've never seen the appetite [for change] as strong as it is right now," said Alice Dawkins, executive director of Reset Tech Australia.

She says there's a window for change with the federal government currently reviewing its key legislation, the Online Safety Act.

"Our online safety laws are geared at protecting people from [one] another online … [but] there's virtually nothing that can be done about protecting people from the tech itself."

As it stands, companies are rarely obliged to share information on how their products, and not just the people using them, may cause harm.

"It's highly exceptional — think about other sectors, like food, like medicine, like toys — it's incredibly routine in those sectors to have risk assessment and risk mitigation of products," Ms Dawkins said.

"There's compounding public awareness of the problem … it's never been a more appropriate time for the government to legislate."

Dr Werner-Seidler said that for now, internal data was being used by big tech to keep users scrolling for as long as possible.

"These are commercial big companies [and] they use a whole bunch of engagement strategies to keep people coming back, and that is their goal," she said.

The conversation you need to have with your kids

Jordy eventually found the courage to tell her mum what was happening to her online.

"When it got really bad I was just like, 'Mum, I need to show you … this is what's happening.'"

After that, her parents insisted she cut back her screen time but, despite everything that had already happened, she still fought it.

"I was so mean to her … I would get so angry, I'd be like, 'Mum, it's not your life,'" she said.

But that was before Jordy noticed a big improvement in her mood and her grades.

"I'm thankful every day that my mum did what she did.

"You can't ever change the fact that your kids are going to use social media," said Jordy, although boundaries were useful in her case.

"Saying to your kids, 'What are you using social media for? Why do you have to be on social media?'

"For parents out there that are struggling, I think it's that conversation you need to have with your kids.

"As a kid, you're going to get frustrated, but it's really just parents trying to protect their kids from what's out there."

Mental health disorders among young people have soared by nearly 50 per cent in 15 years. The ABC is talking to youth, parents, and researchers about what's driving this pattern, and what can be done to turn things around.

• X (formerly Twitter)

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• Published: 03 June 2024

Minimizing IP issues associated with gene constructs encoding the Bt toxin - a case study

• Md Mahmudul Hassan 1 , 2 ,
• Francis Tenazas 1 ,
• Adam Williams 1 ,
• Jing-wen Chiu 3 ,
• Charles Robin 1 ,
• Derek A. Russell 4 &
• John F. Golz 1  

BMC Biotechnology volume  24 , Article number:  37 ( 2024 ) Cite this article

Metrics details

As part of a publicly funded initiative to develop genetically engineered Brassicas (cabbage, cauliflower, and canola) expressing Bacillus thuringiensis Crystal ( Cry )-encoded insecticidal (Bt) toxin for Indian and Australian farmers, we designed several constructs that drive high-level expression of modified Cry1B and Cry1C genes (referred to as Cry1B M and Cry1C M ; with M indicating modified). The two main motivations for modifying the DNA sequences of these genes were to minimise any licensing cost associated with the commercial cultivation of transgenic crop plants expressing Cry M genes, and to remove or alter sequences that might adversely affect their activity in plants.

To assess the insecticidal efficacy of the Cry1B M / Cry1C M genes, constructs were introduced into the model Brassica Arabidopsis thaliana in which Cry1B M / Cry1C M expression was directed from either single ( S4 / S7 ) or double ( S4S4 / S7S7 ) subterranean clover stunt virus (SCSV) promoters. The resulting transgenic plants displayed a high-level of Cry1B M / Cry1C M expression. Protein accumulation for Cry1C M ranged from 5.18 to 176.88 µg Cry1C M /g dry weight of leaves. Contrary to previous work on stunt promoters, we found no correlation between the use of either single or double stunt promoters and the expression levels of Cry1B M / Cry1C M genes, with a similar range of Cry1C M transcript abundance and protein content observed from both constructs. First instar Diamondback moth ( Plutella xylostella ) larvae fed on transgenic Arabidopsis leaves expressing the Cry1B M / Cry1C M genes showed 100% mortality, with a mean leaf damage score on a scale of zero to five of 0.125 for transgenic leaves and 4.2 for wild-type leaves.

Conclusions

Our work indicates that the modified Cry1 genes are suitable for the development of insect resistant GM crops. Except for the PAT gene in the USA, our assessment of the intellectual property landscape of components presents within the constructs described here suggest that they can be used without the need for further licensing. This has the capacity to significantly reduce the cost of developing and using these Cry1 M genes in GM crop plants in the future.

Peer Review reports

Introducing Crystal ( Cry ) genes from the soil bacteria Bacillus thuringiensis into commercially grown crop plants is a highly effective strategy to control insect pests, as insects across broad taxonomic groupings are susceptible to the encoded Bt toxins [ 1 ]. However, a common problem associated with this control strategy is the development of insect resistance to the Bt toxin present in the transgenic plants [ 2 , 3 ]. Several approaches have been used to reduce or prevent the development of insect resistance including the use of refuge crops (providing sufficiently high populations of susceptible insects to prevent resistance genes from becoming homozygous), high expression of Cry genes in plants, deploying different Cry genes in individual plants in a crop (seed mixtures), and combining multiple Cry genes (i.e., stacking) in the same plant [ 4 , 5 , 6 , 7 , 8 ]. Of these, high expression and stacking of Cry genes in the same plant are considered the most practical effective strategies [ 1 , 5 , 9 , 10 ]. For example, plants expressing both Cry1Ac and Cry1C genes greatly delayed the emergence of resistance to the encoded toxins by Diamondback moth (DBM) ( Plutella xylostella ) [ 11 ]. Plants with stacked Cry genes are also protected from insects that are less susceptible to Bt toxins such as Helicoverpa armigera [ 12 ]. For this reason, plants harbouring stacked Cry genes are favoured by companies developing Bt crops as exemplified by the replacement of GM cotton containing a single Cry ( Cry1Ac ) gene with a gene stack ( Cry1Ac / Cry2Ab ) [ 7 ]. Although plants with stacked Cry genes have been successful in controlling insect pests in the field, there is still the potential for resistance to develop. The most common form of insect resistance to a Bt toxin is associated with a mutation in the receptor that binds to the toxin in the insect mid-gut [ 13 , 14 , 15 ]. Therefore, selection of Cry genes used for stacking is an important factor determining durability of the Bt toxin in the field, as different Bt toxins may bind to different receptors with different strengths. As these binding patterns are becoming increasingly well understood, it is now possible to optimize stacking by selecting Bt genes that are not susceptible to known resistance mechanisms in particular insect targets.

High-level accumulation of Bt toxin within plant tissues is generally lethal to insects that are either fully susceptible or have a single copy of a recessive gene for resistance [ 2 , 9 , 16 , 17 ]. Cry gene expression in plants depends on many factors including their nucleotide structure, the promoter used to drive their expression, and the location and copy number of the Cry gene within a plant genome [ 18 ]. A suboptimal nucleotide structure is among the main factors contributing to low Cry gene expression in plants as, due to their bacterial origin, Cry genes contain many sequences that negatively impact on protein production in eukaryotic cells. The presence of signal sequences required for polyadenylation, mRNA decay and splicing, also affects mRNA structure and accumulation in plants [ 19 , 20 , 21 ]. For example, the presence of three AATAAA repeats within the coding region of Cry3A is associated with premature polyadenylation of the gene when expressed in plants, as these sequences match the polyadenylation signal usually found in the 3’-untranslated region of many eukaryotic genes [ 22 , 23 , 24 ]. In addition, Cry gene expression in plants is impacted by differences in nucleotide content between bacterial and eukaryotic genomes. For instance, Cry genes have a higher AT content (65%) compared to typical dicot (55%) or monocot (45%) plant genes [ 18 ]. These differences mean that the Cry genes utilize codons that are less common in plants, which reduces the rate of protein production due to the limited size of tRNA pools for these codons [ 25 ]. Furthermore, if a ribosome fails to incorporate the corresponding tRNA for a rare codon, translation may be aborted, resulting in the ribosome becoming disassociated from the mRNA. Poorly translated mRNAs are prone to degradation in the host cell by nonsense mediated RNA decay [ 20 ]. Rectifying these issues, together with the removal of spurious polyadenylation signal sequences and sequences that might be responsible for mRNA instability, such as the ATTTA motif, from plant-expressed Cry genes can significantly improve production of the encoded Bt toxin in plants [ 21 , 26 , 27 , 28 , 29 ]. By changing the composition of codons so that they better reflect the distribution of those seen in typical plant genes, significant increases in Bt protein have been observed in transgenic tobacco, tomato and potato plants [ 21 ].

Commercialization of GM crops requires the developer to manage multiple patent right hurdles, due to the complex patent landscape associated with the technologies used in the creation of GM crops. Almost all the significant components of the constructs used in plant transformation are patented. These include the ‘effect gene’ and associated regulatory sequences, as well as the selectable marker [ 30 ]. For example, use of an antibiotic resistance gene as selectable marker in plant transformation is restricted by a patent owned by Monsanto, however, this IP right only applies in the USA. Another example of a patent that has a considerable impact on construct design is the use of the cauliflower mosaic virus (CaMV) 35 S promoter to drive selectable marker gene activity in plants [ 30 ]. Patent holders frequently do not allow access to a patented technology if they are themselves using it commercially or have sole licensing agreements with other entities, and where they do allow it, licensing costs can be considerable. Therefore, at early stages of GM crop development, Freedom to Operate (FTO) needs to be established for technologies used in introducing new traits to crops of interest. Without securing all the necessary legal rights, GM crop developers may be exposed to legal liabilities, which ultimately prevent the use of the developed crop. A notable example of the complexity associated with IP issue was the development of golden rice, a transgenic rice line rich in ß-carotene (a precursor of vitamin A). Delivery of the golden rice for public use has been delayed, in part due to extensive patenting issues, associated with 72 patents owned by 40 organization [ 30 , 31 ].

As a part of Australian-Indian government strategic initiative, our aim was to develop Bt-expressing Brassica crops for commercial use in both countries where the licensing costs associated with the use of this technology was minimized. Here, we describe the generation of a Cry1B M / Cry1C M gene stack that may be used as an effective insecticide when introduced into plants. Nucleotide modification of the Cry1B / Cry1C genes, together with careful selection of components used in the design of the constructs, ensured both high-level expression in plants and minimal licensing costs associated with the use of these constructs. We demonstrate under laboratory conditions that Arabidopsis plants expressing the modified Cry genes display high-level resistance to diamondback moth (DBM) larvae, consistent with our modifications not adversely affecting the lethality of the Cry genes. The results of this study provide an example of how new Bt-expressing constructs that are relatively free of third-party IP may be generated, particularly for deployment in developing nations where farmers may have limited capacity to pay costs associated with Bt crops developed by multinational seed companies.

Plant materials and growth condition

The Columbia-0 ecotype of Arabidopsis thaliana was used as wildtype in this study. Seeds were either grown on a soil/perlite mix or plated on half-strength Murashige and Skoog (½ MS) media containing Phytagel. Seeds were stratified at 4°C for 2–3 days prior to placement in a growth room under continuous light at 18–20°C or a growth cabinet under continuous light at 20–22 °C.

Modification of Cry1B/Cry1C sequences

The DNA sequences of the original Cry1B / Cry1C genes were modified using the DNA strider software [ 32 ]. Initially, codon use frequency of the Cry gene was determined using the Sequence Manipulation Suite ( www.bioinformatics.org/sms2/codon_usage.html ) and then systematically replaced with synonymous codons to better reflect the codon usage of endogenous Brassica genes [ 33 ] (Supplementary Figs.  1 and 2 , Supplementary Tables 1 and 2 ). ORFfinder ( https://www.ncbi.nlm.nih.gov/orffinder/ ) was then used to determine the position of ORFs in the six reading frames of the Cry1B M /Cry1C M genes. ORFs that were 75 amino acids or longer were disrupted through the introduction of a stop codon (Supplementary Table 3 ). In addition, sequences that may function as splice sites (AGGT) [ 34 ] and the ATTTA instability motif [ 18 ] were altered by changing nucleotides within these motifs (Supplementary Figs.  1 and 2 ).

Selection of components for Cry1B M /Cry1C M constructs

The Cry1B M construct was designed to have either one or two S4 subterranean clover stunt virus (SCSV) promoters [ 35 ] upstream and the pea RUBISCO E9 terminator [ 36 ] downstream of the Cry coding sequence. In contrast, either one or two SCSV S7 promoters [ 35 ] were placed upstream and the Flaveria bidentis MALIC ENZYME ( ME ) terminator [ 35 ] downstream of the Cry1C M gene (Fig.  1 ). Our previous work with Cry1B/Cry1C genes identified leaky expression of Cry1C in E. coli . To prevent this, an intron from potato ST-LS1 gene [ 37 ] was placed within the Cry1C M coding sequence. A DNA fragment containing these elements ( ME ter : Cry1C M -intron::S7S7-S4S4::Cry1B M :: E9 ter ) was then synthesized to our specifications by Biomatik ( www.biomatik.com ) and cloned in the Eco RI/ Hin dIII sites of the pUC19 vector. This vector was subsequently digested with Bgl II enzyme to remove one copy of the S4 and S7 promoters resulting in single stunt promoter constructs ( ME ter Cry1C M -intron::S7-S4::Cry1B M :: E9 ter ) . Cry1 M genes under single or double stunt promoters were then isolated as Pac I fragments from their respective vectors, and cloned into binary vector PIPRA560 [ 36 ].

A NPTII expression cassette comprising a figwort mosaic virus 34 S promoter [ 38 ], the coding sequence of the NEOMYCIN PHOSPHOTRANSFERASE II ( NPTII ) gene [ 39 ] and the terminator of Agrobacterium MANNOPINE SYNTHASE ( MAS ) gene ( MAS ter ) [ 36 ] was synthesized and cloned into the Eco RI/ Hin dIII sites of the pUC19 vector. Included in this synthetic cassette were flanking tandemly arranged Lox sites to enable removal of the selectable marker cassette from the T-DNA as part of a strategy to generate marker-free plant transgenic plants (e.g [ 40 ]). . A glufosinate-ammonium resistant selectable marker was generated by replacing NPTII with the PHOSPHINOTHRICIN ACETYLTRANSFERASE ( PAT ) gene [ 41 ]. The PAT selection cassette was then isolated from this plasmid and cloned into the Sac II site of the binary vectors containing the modified Cry genes under the control of either S7-S4 or S7S7-S4S4 stunt promoters. These constructs, pJG1024 (single stunt (SS) construct) and pJG1027 (double stunt (DS) construct) (Fig.  1 ) were then introduced into Agrobacterium (C58) via electroporation.

Schematic diagram of T-DNA region of constructs used to test the insecticidal activity of Cry1B M and Cry1C M genes in plants; 34S pro : Promoter of Figwort mosaic virus (FMV) 34S RNA gene [ 38 ]; MAS ter : Agrobacterium tumefaciens MANNOPINE SYNTHASE ( MAS ) gene terminator [ 36 ]; Cry1B M / Cry1C M : Modified Cry1B / Cry1C genes; S4 / S7 : Subterranean clover stunt virus S4 and S7 promoters [ 35 ]; E9 ter : Terminator region of the pea Rubisco E9 gene [ 36 ]; ME ter : Terminator region of Flaveria bidentis MALIC ENZYME ( ME ) gene [ 35 ]; Intron: second intron ( IV2 ) of the potato gene ST-LS1 [ 37 ], E1 leader: 5’ leader sequence of the tapetum specific E1 gene of Oryza sativa, Lox sites: tandemly arranged Lox P sites; LB: Left border of the PIPRA560 plant binary vector; RB: Right border of the PIPRA560 plant binary vector

Plant transformation

pJG1024 and pJG1027 were inserted into wild-type Arabidopsis thaliana using floral dipping [ 42 ]. Transgenic plants were identified using glufosinate-ammonium (100 µg/ml) selection on soil and further confirmed by amplifying the herbicide resistance gene PAT using primers BaR-F (5’-GTTGGTTGCTGAGGTTGAG-3’) and BaR-3′R (5’-TGGGTAACTGGCCTAACTGG-3’). For each construct, ten independently transformed T 1 lines were randomly selected, and their progeny exposed to glufosinate-ammonium selection. Based on segregation ratios, lines judged to have a single T-DNA insertion (1:3, Glufosinate ammonium sensitive: Glufosinate ammonium resistant) were selected for further analysis. Homozygous T 2 plants derived from T 1 lines identified as having a single segregating T-DNA insertion were used in all subsequent assays.

Insect bioassay

A colony of diamondback moth (DBM) susceptible to the Bt toxins encoded by Cry1 M genes were maintained in an insect growth chamber at 25 °C. Arabidopsis plants homozygous for the T-DNA insertion were grown for ~ four weeks and their mature leaves collected for insect bioassay, RNA extractions, and protein quantification. For insect bioassay, two leaves were placed on a moist filter paper in a plastic cup (size 40 × 50 mm). On each leaf, ten DBM larvae (1st instar) were deposited. Larval mortality and leaf damage were scored after 48 h and again at 72 h if the larvae had survived after 48 h. Insect bioassays were performed at 25 °C. Leaf damage was scored on scale from 0 (no visible damage) to 5 (leaf skeletonised).

Quantification of Cry1C M protein

The abundance of Cry1C M protein in leaves of transgenic plants was quantified using a Cry1C-specific enzyme-linked immunosorbent assay (ELISA) assay (Cry1C-specific Quantiplate Kit; Envirologix, USA). Briefly, leaves collected from transgenic lines were weighed and put into a 1.5 ml tube. The tubes were then placed in Ziplock plastic bags containing silica beads and dried over a period of two weeks. Protein was extracted from 1 mg dried tissue using the extraction buffer supplied with the kit. The ELISA was performed according to the manufacture’s instruction. The amount of expressed Cry1C M protein in the leaf sample was calculated from a standard curve generated using the pure Cry1C protein supplied with the Quantiplate ELISA kit. The amount of Cry1C M protein content in the samples was determined using the standard curve and given as µg per gram dry weight (DW) of leaves.

RNA extraction and reverse transcription quantitative PCR (RT-qPCR)

RNA was extracted from leaf tissue using a Spectrum Plant Total RNA kit (Sigma, USA) according to the manufacturer’s protocol. Extracted RNA was treated using Turbo DNA-free kit (Ambion, USA) to remove contaminating genomic DNA before first strand cDNA was generated using Oligo (dT) primers and Superscript III reverse transcriptase (Thermo Fisher). RT-qPCR was performed using a SensiMix SYBR No-ROX Kit (Meridian, Australia). Briefly, 10 µl qPCR reactions containing 1 µl diluted (1:10) cDNA, 2.5 µM forward and reverse primer, with 1x SYBR Green Master Mix were set up in triplicate and run on a Bio-Rad CFX96 real time PCR machine. Cycle threshold (Ct) values were calculated using the Bio-Rad CFX manager version 3.1. The relative Cry1B M /Cry1C M mRNA expression level were determined using the comparative Ct method and normalized to ACTIN2 ( AT3G18780 ). The sequences of RT-qPCR primer used in this study were, Actin2-F (5’-TCTTCCGCTCTTTCTTTCCA-3’), Actin2-R (5’-TCTTCCGCTCTTTCTTTCCA-3’), Cry1B-F (5’-TAGAGGGACCGCTAACTATT C-3’)/Cry1B-R (5’-CGACAACCGATGTGAGTAAG-3’), and Cry1C-F (5’-GAAAGAATGCCGCAA TGTC-3’)/ Cry1C-R (5’-CTTACAACCGTGGGCTTAAC-3’).

IP landscape analysis

IP searches were performed using keywords and sequence-based approaches to identify relevant patent filings in national databases in the US ( https://ppubs.uspto.gov/pubwebapp/static/pages/ppu bsbasic.html), Australia ( https://www.ipaustralia.gov.au/ ), EPO ( https://www.epo.org/en/searching-for-patents/technical/espacenet ), WIPO ( https://patentscope.wipo.int/search/en/search.jsf ), and India ( https://iprsearch.ipindia.gov.in/publicsearch ). This provided information about the legal status of patents as well as their file histories. Results from these searches are provided in Table  2 and Supplementary Table 4 .

Modification of Cry 1B and Cry1C genes used in this study

To maximize activity of Cry1B / Cry1C genes in plants, we synthesized modified Cry1 sequences ( Cry1 M ) to eliminated features that are known to reduce the expression of these genes in eukaryotic cells. This included extensive codon-optimization, which involved the selection of codons used at high frequently in Brassica genes and are GC-rich (Supplementary Tables 1  and 2 ) [ 33 ]. Following this, the GC-content of the modified Cry genes Cry1B M and Cry1C M was 47.7% and 45%, respectively, which is higher than in their unmodified versions (Table  1 ).

Alternative open reading frames greater than 75 amino acids in the modified Cry genes were disrupt through the placement of a stop codon within the ORF (Supplementary Table 3 ), a key requirement for GM plants needing regulatory approval before commercialisation. Sequences known to affect transcript stability, such as ATTTA [ 18 ] and potential splice site AGGT [ 34 ], were removed from the modified Cry gene sequences along with any internal polyadenylation signal sequences that might cause premature termination of transcription (Supplementary Figs.  1 and 2 ). Following these modifications, the degree of identify between known Cry1B genes (e.g., Cry1B1 and Cry1B2) and Cry1B M was 79% at DNA level (Table  1 ) and the identity between Cry1C M and four other Cry1C genes ranged from 75 to 81% (Table  1 ). To the best of our knowledge this reduced DNA sequence identity means that Cry1B M and Cry1C M do not infringe IP associated with the original Cry1B and Cry1C sequences (Supplementary Table 4 ).

Design of Cry1B M / Cry1C M constructs

Where possible components and methodologies that are free of third-party IP were used in the development of the Cry1 M constructs to minimize IP obstacles, including any licensing costs associated with eventual commercial cultivation of plants expressing the Cry1 M genes. We performed a detailed online database search of the patents surrounding the binary vector, promoters, terminators, selectable markers, Cry genes and methodologies used in the generation of the Bt constructs and list their current IP status in Australia, USA, and India in Table  2 and Supplementary Table 4 .

The Cry1B M / Cry1C M gene construct was designed so that physical linkage between the genes ensured that they integrate into the same chromosomal site following transformation (Fig.  1 ). This design eliminated the need for crossing to combine transgenes following their separate introduction into plants. Binary vector PIPRA560 was selected for use in these experiments as the tangible property right was available under licence-free terms for commercial cultivation in developing countries and under modest fee-based terms for developed countries [ 36 ]. The herbicide resistance gene PAT was chosen as a plant selectable marker for transgenic plant selection as it had FTO in both Australia and India. The FMV 34 S promoter [ 38 ] and the terminator region of the MAS [ 36 ] gene were placed upstream and downstream of the PAT gene, respectively. These components are present within the PIPRA560 plasmid and were obtained under a UC Davis licensing agreement. Subterranean clover stunt virus (SCSV) promoters S4 and S7 were selected because previous work had shown that their use with other Cry genes led to high-level expression and subsequent insecticidal activity [ 35 ]. These are now available free of third-party IP (see Table  2 ). Two different configurations of these promoters were tested; the first being single S4 / S7 promoters (Fig.  1 A; hereafter referred to as SS) and the second being a double promoter configuration (Fig.  1 B; hereafter referred to as DS). By analysing expression of the Cry1 M genes arising from SS and DS constructs, we addressed whether these promoters arranged in tandem conferred a significantly higher level of expression than a single promoter configuration, as suggested in previous studies of these promoters [ 35 ].

Generation of transgenic lines and insect bioassay

More than 40 independent T 1 plants transformed with a T-DNA containing either the SS cassette or a DS cassette were generated. Of these, ten SS and DS primary transformants were randomly selected for initial insect bioassays and Cry1C protein content analysis (data not shown). First instar DBM larvae were placed on leaves collected from these primary transgenic Arabidopsis lines hemizygous for the T-DNA, along with those from wild-type plants. Larvae fed on the wild-type leaves developed normally, resulting in severe leaf damage associated with unconstrained feeding (Fig.  2 A). In contrast, transgenic leaves remained undamaged from larval feeding (Fig.  2 A). The number of live and dead larvae were assessed (Table  3 ).

Insect bioassay on Arabidopsis leaves derived from transgenic plants homozygous for Cry1B M / Cry1C M transgene. ( A ) Transgenic leaves expressing Cry1B M / Cry1C M genes under a single stunt (SS) and double stunt (DS) S4 and S7 promoters. ( B ) Image showing insect larval guts (indicated with blue arrowhead) after feeding on wild-type leaves. ( C ) Insect mortality found in individual transgenic lines having Cry1B M / Cry1C M expression under a single stunt ( S4 / S7 ) promoter. ( D ) Insect mortality associated with in individual transgenic lines with Cry1B M / Cry1C M expression under the control of double stunt ( S4S4 / S7S7 ) promoters

After 24 h, approx. 99% larvae placed on the T 1 leaves were dead, whereas all larvae placed on the wild-type leaves were alive and actively feeding (Table  3 ). After 48 h, all remaining larvae feeding on the transgenic leaves were dead, while almost all the larvae feeding on the wildtype leaves were alive (Table  3 ). Significant larval death (31.5%) was seen on the wildtype leaves, but only after day 6. Moreover, ~ 40% larvae placed on the wild-type leaves were found to have moulted beyond 1st instar, which was not observed for larvae placed on transgenic leaves. During the insect bioassay, the health of the larvae was examined. Healthy larvae were present on the wild-type leaves, whereas those feeding on the transgenic leaves appeared shrivelled and small, including some displaying gut bursting (Fig.  2 B). Segregation analysis performed on each of these ten primary transformants identified six SS transformants and six DS transformants with a single segregating T-DNA insertion. Homozygous T 3 progeny derived from these lines were subsequently used for insect feeding assays, which revealed close to 100% mortality within 48 h of feeding on transgenic leaves (Fig.  2 C, D). Interestingly, there was no discernible difference in insect mortality between transgenic leaves expressing Cry1 M genes under a single stunt promoter from those under a double stunt promoter (Fig.  2 C, D).

Cry1B M and Cry1C M expression level in the plants

Expression of Cry1B M and Cry1C M in vegetative tissue of seedlings homozygous for the SS and DS constructs was measured by RT-qPCR. While this revealed expression of both transgenes in all plants (Fig.  3 A, B), considerable variation was observed. For instance, lines SS-08 and DS-08, displayed high levels of both Cry1B M and Cry1C M expression, whereas low expression of both genes was detected in lines DS-13 and DS-14 (Fig.  3 A, B). Except for SS-08, SS-09, DS-08 and DS-17, most transgenic lines ( n  = 12) displayed significant differences between the Cry1B M and Cry1C M expression with the majority having higher Cry1B M expression compared to Cry1C M (Fig.  3 A, B).

Expression of Cry1B M and Cry1C M transgenes in the transgenic Arabidopsis plants. ( A ) Cry1B M / Cry1C M expression seen in transgenic lines with a single stunt ( S4 / S7 ) promoter (six independent transgenic events with single copy T-DNA with 5 plants per event). ( B ) Cry1B M / Cry1C M expression in transgenic lines with double stunt ( S4S4 / S7S7 ) promoters (six independent transgenic events examined with 5 plants per event). ( C ) Comparison of Cry1B M and Cry1C M expression (average of six independent single copy T-DNA transgenic events with 5 plants per event) under S4 / S7 single and double stunt promoters. An unpaired t -test found no statistical differences in the range of Cry gene expression values seen in plants with single or double stunt promoters. ( D ) Comparison of Cry1C M protein content in plants with single or double stunt promoters as assessed by enzyme-linked immunoabsorbent assay (ELISA) ( n  = 3 progeny plants derived from each of the six lines). SS: Lines with single stunt promoters, DS: Lines with double stunt promoters. Lines denoted by “*” indicates expression of Cry1B M and Cry1C M is significantly different. Statistical significance was assessed by Mann-Whitney test [ 44 ]

Levels of Cry protein were quantified by ELISA (Table  4 ). This analysis was restricted to Cry1C M due to the unavailability of a Cry1B M -specific ELISA kit. For SS lines, the quantity of Cry1C M protein ranged from 8.18 to 176.88 µg/g leaf dry weight (DW) with significant differences in protein content between transgenic lines (F = 87.20, p  < 0.0001).

Similarly, Cry1C M protein in DD lines ranged from 5.18 to 134.75 µg/g leaf DW with significant differences also detected between lines (F = 97.29, p  < 0.0001). It is worth noting that a previous study using a leaf-dip assay with pure Cry1Ca4 protein found that the lethal concentration (LC 50 ) to be < 1.18 ppm when fed to 26 global DBM populations and an average of only 0.18ppm in Indian DBM populations [ 45 ]. This suggests that most of transgenic lines generated in this study had Cry1C protein levels that would by themselves be effective against DBM (Table  4 ; Fig.  3 D).

Initial observations failed to detect a noticeable difference in the range of insecticidal activity displayed by transgenic lines expressing Cry1B M / Cry1C M under the control of single or double stunt promoters (Fig.  2 C, D). Consistent with this observation, no significant differences were found in the expression of lines transformed with SS as opposed to DS constructs as measured by RT-qPCR of the modified Cry genes ( Cry1B M , p-value = 0.161; Cry1C M , p-value = 0.112). Similarly, the range in Cry1C M protein content in leaves of SS and DS lines did not differ significantly (p-value 0.191).

Correlation between the Cry1C M expression and protein content

To determine the relationship between the amount of Cry1C M mRNA and corresponding protein content, RT-qPCR and ELISA results were compared. In most cases, levels of mRNA corresponded closely to protein content (SS-08, SS-09, DS-14, DS-17; Fig.  4 A). Furthermore, a Spearman rank correlation coefficient test identified a strong statistical correlation between the Cry1C M protein content and Cry1C M transgene expression (R s =0.846, P  = 0.0013). While there was a good correlation between gene expression and protein levels, there were some notable exceptions. For instance, the highest amount of Cry1C M transcript was detected in line DS-08 but this did not correlate with the highest amount of detectable Cry1C protein. Conversely, the high level of Cry1C protein content in line SS-08 arose from transcript levels of Cry1C M that were nearly half of that observed in DS-08 (Fig.  4 A).

Comparison of Cry1C M transgene expression and protein accumulation in transgenic Arabidopsis lines. ( A ) Histogram showing the amount of Cry1C M mRNA and protein content in twelve transgenic lines tested. ( B ) Graph showing the relative transgene expression and Cry1C M protein content in the lines listed in Fig.  2 C and D. Results from a Spearman rank correlation test are shown. SS: Lines with single stunt S4 / S7 promoters; DS: Lines with double stunt S4S4 / S7S7 promoters

The Cry1B / Cry1C combination, whose modification is described here, was previously shown to be effective against DBM [ 43 , 44 ] but has never been used in commercially available GM crops or as the basis for sprayable Bt insecticides [ 46 , 47 ]. For instance, purified Cry1Ba2 and Cry1Ca4 proteins displayed LC 50 values < 0.91 ppm and < 1.18 ppm, respectively, when tested against of DBM populations [ 45 ]. Furthermore, no cross-resistance was found between Cry1Ba2 and Cry1Ca4, or in experiments aimed at generating resistance to the two Bts in DBM laboratory [ 46 ]. The minor resistances that were observed in these studies were unstable and genetically recessive, as well as being associated with a high fitness costs [ 46 ]. Where resistance to Cry1C in DBM has been identified, it manifests as a polygenic trait [ 48 ]. Taking these observation together with the fact that Cry1B and Cry1C bind to different receptors in the insect gut [ 47 ]. This suggests that insect resistance to this combination of Cry genes is unlikely to arise.

While previous work [ 46 , 47 ] found that transgenic Brassica expressing the Cry1B / Cry1C stack displayed robust resistance to a range of lepidopteran pest species in small trials run in India, these lines (developed by a public/private-funded consortium), were not developed further due to the length of time likely to be required to gain regulatory approval for commercial planting. Despite this set-back, the Australian and Indian public partners in the public/private consortium wanted to continue the development of Brassica expressing Bt toxins for their respective markets. To facilitate this, it was necessary to alter the sequence of the Cry genes so that they were unequivocally not that of the private partner. We used this opportunity to both free the new Cry1 M gene constructs of proprietary IP as far as practicable and to optimise the nucleotide structure of the Cry genes for expression in plants. The PIPRA560 plant binary vector was used to deliver the Cry constructs to plants. The tangible property right holder, the University of California, Davis, allowed licence free research use and free commercialisation use for developing countries, including India. The MTA terms of use state that any construct developed using PIPRA560 must also be free to use by others.

As stated previously, one way to overcome the development of resistance to Bt toxin is to express the Cry gene at high level so that insects heterozygous for resistance mutation are eliminated from the population. Given this, we chose to test double stunt SCSV promoters for our Bt toxin gene construct design as plants expressing Cry gene under two stunt promoters would be more effective in killing insect than their single stunt counterpart. The results reported here showed no obvious difference in insect mortality between the plants expressing Cry1 M genes under single or double stunt SCSV promoters (Fig.  2 C, D; Table  3 ). Previous work characterising double stunt promoters had indicated that the S7S7 double promoter was better than S4S4 promoter [ 35 ], whereas our results indicate that S4S4 is slightly more effective than the S7S7 promoter (Fig.  3 C). Differences between our study and earlier work might reflect the assay system used to compare the promoter strength. For instance, the earlier studies of the S4S4 and S7S7 promoters relied upon Cry1Ab protein content assays to measure activity of the promoters, whereas in our study we used a combination of both protein and mRNA assays. As mentioned above protein production from mRNA is affected by multiple factors and hence protein content in GM plants may not be a reliable indicator of promoter strength. As performance of S4S4 and S7S7 double stunt promoters also varied according to the plant species used for transformation (cotton, tobacco and tomato; [ 35 ]), variation in SCSV promoter activity observed in our study might also reflect background differences between Arabidopsis and the plants used in earlier studies.

Despite variation in Cry1B M and Cry1C M expression between and within lines, there was no detectable variation in insecticidal activity, as close to 100% insect mortality was achieved within 48 h even in lines with low Cry1B M / Cry1C M expression (Fig.  1 B, C). Although transcript levels were measured both for Cry1B M and Cry1C M , quantification of Cry1B protein could not be performed due to lack of a Cry1B - specific ELISA commercial kit. Unfortunately, lack of access to the Cry gene constructs used in the preceding public/private partnership programme prevented us from directly testing whether the modified Cry gene sequences represent a significant improvement over the insecticidal activity of the unmodified Cry genes. Despite this, it seems reasonable to conclude that both proteins retained insecticidal activity under lab conditions. This is inferred from the observation that in some lines, one Cry gene was expressed at much higher levels than the other (e.g., SS-05, SS-16 DS-03; Fig.  3 B), yet still conferred 100% DBM larvae mortality. While there was a clear correlation between Cry1C M gene expression and protein abundance (Fig.  4 ), there were a few notable exceptions, e.g., line DS-03 and DS-08. This discrepancy presumably reflects inefficient conversion of mRNA to protein, an observation that has been reported in several other studies of Cry transgene activity [ 49 , 50 ]. However, due to the relatively modest sample size ( n  =–12 lines) in our study, as well as those reported by others [ 49 , 50 ], it is difficult to characterize a clear relationship between Cry gene expression and protein accumulation.

A potential problem arising from gene stacks is that when more than one gene is placed in the same T-DNA, their expression may be compromised due to gene silencing, particularly if they share similar sequences and regulatory elements such as promoters, 5′-UTRs and 3′-UTRs [ 51 ]. Therefore, expression analysis of each gene in plants is important, as silencing or sub-optimal expression of one gene may result in reduced efficacy of the insecticidal protection provided by the Cry gene stack. We found substantial differences in expression levels of Cry1B M and Cry1C M in most of the lines (Fig.  3 A, B). The variation in Cry1B M / Cry1C M expression seen in the same line (e.g., SS-09 & SS-10) might be a consequence of the stunt promoter arrangement. In both constructs these promoters are adjacent to one another in a reverse orientation, which may make their associated transgenes prone to gene silencing [ 52 , 53 ]. Alternatively, differences in Cry gene expression might be influenced by the Cry1B M / Cry1C M sequences, structural properties of promoters and position effects, in which genomic regions adjacent to the T-DNA insertion site influence transcription activity of the transgenes [ 51 , 54 , 55 , 56 ]. Similarly, variation in the extent of T-DNA insertion or its rearrangement prior to or after integration into the genome may influence Cry gene activity. Such variation between lines transformed with the same construct has been previously reported [ 57 ] and thus is not without precedent. Importantly, variations in Cry1B M and Cry1C M expression level observed in the transgenic Arabidopsis lines do not seemingly reflect an issue with their coding sequences. This can be inferred from the fact that in some cases Cry1B M is expressed at higher levels than Cry1C M (e.g., SS-18, DS-11), and vice versa (e.g., SS-09, DS-03).

The results provided here illustrate the types of sequence modification that can be successfully introduced into Cry genes as well as the suitability of components chosen for constructs that have FTO. The components used in the gene constructs reported here are to the best of our knowledge currently free of third-party IP in Australia and India. Confirmation that this applies in other countries would require detailed patent searches to be undertaken and legal advice sort. The use of components that have FTO in both the research and the commercialisation phases in public GM breeding programs is important as it can substantially reduce the complexities and costs faced in the commercialisation phase [ 36 ]. Proprietary elements used in the development phase, even no longer present in the sequence to be commercialised, can derail the success of the projects. While the work here only reports the activity of the Cry1B M / Cry1C M gene stack in the model plant Arabidopsis under laboratory conditions, work was undertaken to introduce these constructs into elite Brassica crop lines, and preliminary analysis suggests that they are as effective in crop plants as they are in Arabidopsis [ 58 ]. Unfortunately, funding constrains prevented these transgenic crop lines from being fully assessed for insect resistance in field trials.

Despite the obvious benefits of transgenic plants expressing Cry genes, which include preventing large scale crop losses from insect attack, this technology has been applied to only a few crops such as cotton, canola and maize which are grown on a large enough scale to make the costs of deregulation and the separation of the product in harvesting, storing and marketing economically attractive [ 59 ]. The timelines, costs, and political opposition to GM crops in a significant proportion of markets has delayed the introduction of Cry transgenes into other crops such as vegetables and major grain crops such as rice or wheat. Uptake of Bt technology in developing nations has been significantly curtailed by the difficulties of access to IP held by entities such as multinational seed companies [ 60 ]. Given this, publicly funded research organizations and academic institutions in developing nations have an incentive to develop their own Bt crops [ 36 ] in which licensing issues associated with the use of genetically modified material is minimised so that farmers can take advantage of the considerable benefits arising from the technology [ 59 ]. Our work here provides an example of an approach that might be taken to achieve this aim.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files. The sequences of gene constructs pJG1024 and pJG1027 has been deposited in NCBI gene bank and can be retrieved using their accession IDs which are PP194761 (pJG1024) and PP194762 (pJG1027).

Abbreviations

Crystal gene

• Bacillus thuringiensis

Arabidopsis thaliana

Subterranean Clover stunt virus

Freedom to operate

Intellectual property

Enzyme-linked immunosorbent assay

Untranslated region

Left/right border of T-DNA

Diamond back moth

Quantitative reverse transcription-polymerase chain reaction

Muralimohan N, Saini RP, Kesiraju K, Pattanayak D, Ananda Kumar P, Kasturi K, et al. Molecular stacking of two codon-modified genes encoding Bt insecticidal proteins, Cry1AcF and Cry2Aa for management of resistance development in Helicoverpa armigera . J Plant Biochem Biotechnol. 2020;29:518–27.

Article   CAS   Google Scholar  

Zafar MM, Razzaq A, Farooq MA, Rehman A, Firdous H, Shakeel A, et al. Insect resistance management in Bacillus thuringiensis cotton by MGPS (multiple genes pyramiding and silencing). J Cotton Res. 2020;3:33:1–13.

Article   Google Scholar  

Peralta C, Palma L. Is the insect world overcoming the efficacy of Bacillus thuringiensis ? Toxins (Basel). 2017;9:39.

Article   PubMed   Google Scholar  

Tabashnik BE, Carrière Y. Surge in insect resistance to transgenic crops and prospects for sustainability. Nat Biotechnol. 2017;35:926–35.

Article   CAS   PubMed   Google Scholar  

Jiang F, Zhang T, Bai S, Wang Z, He K. Evaluation of Bt corn with pyramided genes on efficacy and insect resistance management for the Asian corn borer in China. PLoS ONE. 2016;11:e0168442.

Article   PubMed   PubMed Central   Google Scholar  

Gayen S, Mandal CC, Samanta MK, Dey A, Sen SK. Expression of an engineered synthetic cry2Aa ( D42/K63F/K64P ) gene of Bacillus thuringiensis in marker free transgenic tobacco facilitated full-protection from cotton leaf worm ( S. Littoralis ) at very low concentration. World J Microbiol Biotechnol. 2016;32:62.

Carrière Y, Crickmore N, Tabashnik BE. Optimizing pyramided transgenic bt crops for sustainable pest management. Nat Biotechnol. 2015;33:161–8.

Gryspeirt A, Grégoire J-C. Effectiveness of the high dose/refuge strategy for managing pest resistance to Bacillus thuringiensis (bt) plants expressing one or two toxins. Toxins (Basel). 2012;4:810–35.

Zafar MM, Mustafa G, Shoukat F, Idrees A, Ali A, Sharif F, et al. Heterologous expression of cry3Bb1 and cry3 genes for enhanced resistance against insect pests in cotton. Sci Rep. 2022;12:10878.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Niu L, Mannakkara A, Qiu L, Wang X, Hua H, Lei C et al. Transgenic Bt rice lines producing Cry1Ac, Cry2Aa or Cry1Ca have no detrimental effects on Brown Planthopper and Pond Wolf Spider. Sci Rep. 2017;7:1940:1–7.

Zhao J-Z, Cao J, Li Y, Collins HL, Roush RT, Earle ED, et al. Transgenic plants expressing two Bacillus thuringiensis toxins delay insect resistance evolution. Nat Biotechnol. 2003;21:1493–7.

Mehrotra M, Singh AK, Sanyal I, Altosaar I, Amla DV. Pyramiding of modified cry1Ab and cry1Ac genes of Bacillus thuringiensis in transgenic chickpea ( Cicer arietinum L.) for improved resistance to pod borer insect Helicoverpa armigera . Euphytica. 2011;182:87–102.

Pardo-López L, Soberón M, Bravo A. Bacillus thuringiensis insecticidal three-domain Cry toxins: mode of action, insect resistance and consequences for crop protection. FEMS Microbiol Rev. 2013;37:3–22.

Caccia S, Hernández-Rodríguez CS, Mahon RJ, Downes S, James W, Bautsoens N, et al. Binding site alteration is responsible for field-isolated resistance to Bacillus thuringiensis Cry2A insecticidal proteins in two Helicoverpa species. PLoS ONE. 2010;5:e9975.

Ferré J, Van Rie J. Biochemistry and genetics of insect resistance to Bacillus thuringiensis . Annu Rev Entomol. 2002;47:501–33.

Wang Y, Zhang Y, Wang F, Liu C, Liu K. Development of transgenic Brassica napus with an optimized cry1C* gene for resistance to Diamondback moth ( Plutella Xylostella ). Can J Plant Sci. 2014;94:1501–6.

Bravo A, Soberón M. How to cope with insect resistance to Bt toxins? Trends Biotechnol. 2008;26:573–9.

Diehn SH, De Rocher EJ, Green PJ. Problems that can limit the expression of foreign genes in plants: lessons to be learned from B.t toxin genes. Genet Eng (NY). 1996;18:83–99.

Zhou X, Ren Y, Wang S, Chen X, Zhang C, Yang M, et al. T-DNA integration and its effect on gene expression in dual bt gene transgenic Populus ×euramericana cv. Neva Ind Crops Prod. 2022;178:114636.

Gingold H, Pilpel Y. Determinants of translation efficiency and accuracy. Mol Syst Biol. 2011;7:481.

Perlak FJ, Stone TB, Muskopf YM, Petersen LJ, Parker GB, McPherson SA, et al. Genetically improved potatoes: protection from damage by Colorado potato beetles. Plant Mol Biol. 1993;22:313–21.

Deng C, Peng Q, Song F, Lereclus D. Regulation of cry gene expression in Bacillus thuringiensis . Toxins (Basel). 2014;6:2194–209.

Liu D. Design of gene constructs for transgenic maize. Methods Mol Biol. 2009;526:3–20.

Zarkower D, Stephenson P, Sheets M, Wickens M. The AAUAAA sequence is required both for cleavage and for polyadenylation of simian virus 40 pre-mRNA in vitro. Mol Cell Biol. 1986;6:2317–23.

CAS   PubMed   PubMed Central   Google Scholar  

Murray EE, Lotzer J, Eberle M. Codon usage in plant genes. Nucleic Acids Res. 1989;17:477–98.

Iannacone R, Grieco PD, Cellini F. Specific sequence modifications of a cry3B endotoxin gene result in high levels of expression and insect resistance. Plant Mol Biol. 1997;34:485–96.

Adang MJ, Brody MS, Cardineau G, Eagan N, Roush RT, Shewmaker CK, et al. The reconstruction and expression of a Bacillus thuringiensis cryIIIA gene in protoplasts and potato plants. Plant Mol Biol. 1993;21:1131–45.

Sutton DW, Havstad PK, Kemp JD. Synthetic cryIIIA gene from Bacillus thuringiensis improved for high expression in plants. Transgenic Res. 1992;1:228–36.

Perlak FJ, Fuchs RL, Dean DA, McPherson SL, Fischhoff DA. Modification of the coding sequence enhances plant expression of insect control protein genes. Proc Natl Acad Sci USA. 1991;88:3324–8.

Dunwell JM. Review: intellectual property aspects of plant transformation. Plant Biotechnol J. 2005;3:371–84.

Potrykus I. Lessons from the Humanitarian Golden Rice project: regulation prevents development of public good genetically engineered crop products. N Biotechnol. 2010;27:466–72.

Marck C. DNA strider: a C program for the fast analysis of DNA and protein sequences on the Apple Macintosh family of computers. Nucleic Acids Res. 1988;16:1829–36.

Kumar PA, Sharma RP. Codon usage in Brassica genes. J Plant Biochem Biotechnol. 1995;4:113–5.

Nussinov R. Conserved signals around the 5’ splice sites in eukaryotic nuclear precursor mRNAs: G-runs are frequent in the introns and C in the exons near both 5’ and 3’ splice sites. J Biomol Struct Dyn. 1989;6:985–1000.

Schünmann PHD, Llewellyn DJ, Surin B, Boevink P, Feyter RCD, Waterhouse PM. A suite of novel promoters and terminators for plant biotechnology. Funct Plant Biol. 2003;30:443.

Chi-Ham CL, Boettiger S, Figueroa-Balderas R, Bird S, Geoola JN, Zamora P, et al. An intellectual property sharing initiative in agricultural biotechnology: development of broadly accessible technologies for plant transformation. Plant Biotechnol J. 2012;10:501–10.

Libiakova G, Jørgensen B, Palmgren G, Ulvskov P, Johansen E. Efficacy of an intron-containing kanamycin resistance gene as a selectable marker in plant transformation. Plant Cell Rep. 2001;20:610–5.

Sanger M, Daubert S, Goodman RM. Characteristics of a strong promoter from figwort mosaic virus: comparison with the analogous 35S promoter from cauliflower mosaic virus and the regulated mannopine synthase promoter. Plant Mol Biol. 1990;14:433–43.

Bevan MW, Flavell RB, Chilton M-D. A chimaeric antibiotic resistance gene as a selectable marker for plant cell transformation. Nature. 1983;304:184–7.

Verweire D, Verleyen K, De Buck S, Claeys M, Angenon G. Marker-free transgenic plants through genetically programmed auto-excision. Plant Physiol. 2007;145:1220–31.

Wohlleben W, Arnold W, Broer I, Hillemann D, Strauch E, Pühler A. Nucleotide sequence of the phosphinothricin N-acetyltransferase gene from Streptomyces viridochromogenes Tü494 and its expression in Nicotiana tabacum . Gene. 1988;70:25–37.

Clough SJ, Bent AF. Floral dip: a simplified method for Agrobacterium -mediated transformation of Arabidopsis thaliana . Plant J. 1998;16:735–43.

Van Rie J, Meulewaeter F. Van EldIk shen. Novel genes encoding insecticidal proteins. 2010; O6075679.8.

Mann–Whitney Test. In. The concise encyclopedia of statistics. New York, NY: Springer New York; 2008. pp. 327–9.

Google Scholar  

Shelton AM, Gujar GT, Chen M, Rauf A, Srinivasan R, Kalia V, et al. Assessing the susceptibility of cruciferous Lepidoptera to Cry1Ba2 and Cry1Ca4 for future transgenic cruciferous vegetables. J Econ Entomol. 2009;102:2217–23.

Kaliaperumal R, Russell DA, Kaliaperumal GT, Behere G, Dutt S, Krishna GK, et al. In: Srinivasan R, Shelton AM, Collins HL, editors. The efficacy and sustainability of the CIMBAA transgenic Cry1B/Cry1C bt cabbage and cauliflower plants for control of lepidopteran pests. Thailand: Kasetsart University, Nakhon Pathom, AVRDC; 2011. pp. 305–11.

Russell DA, Uijtewaal B, Dhawan V, Grzywacz D, Kaliaperumal R. Progress and challenges in the Bt Brassica CIMBAA public/private partnership. In: Srinivasan R, Shelton AM, Collins HL, editors. Proceedings of The Sixth International Workshop on Management of the Diamondback Moth and Other Crucifer Insect Pests. Kasetsart University, Nakhon Pathom, Thailand: AVRDC – The World Vegetable Center; 2011. pp. 19–27.

Zhao JZ, Collins HL, Tang JD, Cao J, Earle ED, Roush RT, et al. Development and characterization of Diamondback moth resistance to transgenic broccoli expressing high levels of Cry1C. Appl Environ Microbiol. 2000;66:3784–9.

Vogel C, Marcotte EM. Insights into the regulation of protein abundance from proteomic and transcriptomic analyses. Nat Rev Genet. 2012;13:227–32.

Finn TE, Wang L, Smolilo D, Smith NA, White R, Chaudhury A, et al. Transgene expression and transgene-induced silencing in diploid and autotetraploid Arabidopsis. Genetics. 2011;187:409–23.

Das S, Bansal M. Variation of gene expression in plants is influenced by gene architecture and structural properties of promoters. PLoS ONE. 2019;14:e0212678.

Van Houdt H, Bleys A, Depicker A. RNA target sequences promote spreading of RNA silencing. Plant Physiol. 2003;131:245–53.

Ingelbrecht I, Breyne P, Vancompernolle K, Jacobs A, Van Montagu M, Depicker A. Transcriptional interference in transgenic plants. Gene. 1991;109:239–42.

Einarsson H, Salvatore M, Vaagensø C, Alcaraz N, Bornholdt J, Rennie S et al. Promoter sequence and architecture determine expression variability and confer robustness to genetic variants. eLife. 2022;11.

Renganaath K, Chong R, Day L, Kosuri S, Kruglyak L, Albert FW. Systematic identification of cis-regulatory variants that cause gene expression differences in a yeast cross. eLife. 2020;9.

van der Hoeven C, Dietz A, Landsmann J. Variability of organ-specific gene expression in transgenic tobacco plants. Transgenic Res. 1994;3:159–66.

Stewart CN. Monitoring the presence and expression of transgenes in living plants. Trends Plant Sci. 2005;10:390–6.

Kalia P, Aminedi R, Golz J, Russell D, Choudhary P, Rawat S et al. Development of Diamondback moth resistant transgenic cabbage and cauliflower by stacking Cry1B and Cry1C bt genes. Acta Hortic. 2020;:237–46.

Rommens CM. Barriers and paths to market for genetically engineered crops. Plant Biotechnol J. 2010;8:101–11.

Chiu J. Obstacles to successful commercialisation of public investments in the development of GM crops. Doctoral dissertation. The University of Melbourne; 2017.

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Acknowledgements

The PIPRA560 vector was obtained from PIPRA, Department of Plant Sciences, University of California, Davis, CA95616.

This work at the University of Melbourne was supported by the Australia/India Strategic Research Fund – Grand Challenge Project GCF010009 – Crop Plants which remove their own major biotic constraints.

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Md Mahmudul Hassan, Francis Tenazas, Adam Williams, Charles Robin & John F. Golz

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Melbourne Veterinary School, University of Melbourne, Parkville, VIC, 3010, Australia

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MMH, DAR, CR and JG conceived the idea. MMH and AW undertook the molecular biology and plant work; FT and DAR conducted the insect experiments. JC and DAR conducted the IP analysis. MMH led the writing and revision of the manuscript. All authors accepted the final version of the manuscript.

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Hassan, M.M., Tenazas, F., Williams, A. et al. Minimizing IP issues associated with gene constructs encoding the Bt toxin - a case study. BMC Biotechnol 24 , 37 (2024). https://doi.org/10.1186/s12896-024-00864-3

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DOI : https://doi.org/10.1186/s12896-024-00864-3

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