You’re not confused by tag questions, are you?

Tag questions are used frequently in conversation and can be confusing for the English language learner.

Tag questions are common in spoken English. British use tag questions about 9 times as often as Americans, probably because British communication is more indirect. Tag questions can be used to seek agreement, show politeness, emphasis, expectation of a negative response, and a number of other intentions.

  1. What is a Tag Question
    A tag question is made of two parts: a statement and a modal tag: One is positive, one is negative.

For example:





The children can swim,

can’t they?

You didn’t add sugar,

did you?

Intonation is extremely important in tag questions and carries much of the message.

Rising or falling intonation changes the meaning for tag questions.

You don’t speak Spanish, do you?
Rising tone on tag: I’m not sure if you speak Spanish, but it’s possible.

Falling tone on tag: I believe you probably don’t speak Spanish

You speak Spanish, don’t you?
Rising tone on tag: I believe that you speak Spanish

How to Answer Tag Questions
Answer a tag question according to the truth of the situation. Your answer reflects the real facts, not (necessarily) the question. For example, if you speak Spanish, you will answer yes to both of these questions: If you don’t speak Spanish, your answer will always be no.

You speak Spanish, don’t you? (Yes, I speak Spanish)
You don’t speak Spanish, do you? (Yes, I speak Spanish)

In some languages, people answer a question like “You don’t speak Spanish, do you?” with “Yes” (meaning “Yes, I agree with you”). This is the wrong answer in English!

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Using the explanatory model to understand your patient’s culture

The Explanatory Model in healthcare is used as a way to understand how patients view their conditions and their expectations surrounding a cure. In the Explanatory Model, providers uses open questions to uncover the patient’s experience, ascribed meaning and behavior regarding an illness episode.

This model can provide insight into cultural, social, psychological and environmental factors affecting the patient. It can help the provider predict how receptive a patient will be to health information, diagnosis and treatment.

This model can help providers:

  • uncover cultural differences that may cause problems for clinical management
  • identify what sort of patient education is needed and most appropriate
  • clarify potential patient/provider conflicts related to different values and beliefs

When interviewing a patient, providers must hold a genuine attitude of interest in the patient’s point of view. The purpose is to gather information. The provider should be non-judgmental and not contradict the patient, which may lead the patient to shut down and stop speaking. Patients who feel ridiculed about their beliefs may withhold  information or not return for follow-up care.

The provider can use the information gained with this model to negotiate with the patient a treatment plan that is mutually satisfactory and most likely to be followed.

Sample questions include:

  1. How would you describe the problem?
  2. What do you think is causing your problem?
  3. Why do you think it started when it did?
  4. How does your sickness affect to you?
  5. What are the chief problems your sickness has caused for you?
  6. How severe is your sickness? Will it have a long or short course?
  7. What do you fear most about your sickness?
  8. How are you treating your sickness now?
  9. What type of treatment do you think you should receive?
  10. What are the most important results you hope to get from treatment?

(adapted from Klienman 1980)

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Pronunciation Errors for Chinese Speakers

When speaking in a second language, people will use the structures and style of their native language.  This is called first language transfer, or L1 transfer.  L1 transfer can affect one’s pronunciation, grammar, spelling, word choice, and communication style.

To reduce your accent, become aware of how your L1 transfer negatively impacts your English pronunciation.

Chinese Speakers

When speaking English, the biggest areas of difficulty for Chinese speakers are stress, intonation and linking. They are not used in Chinese, but are essential in English.

Below are a few common L1 transfer problems for Chinese speakers.

In Chinese, changes in tone are used to distinguish words, whereas in English, intonation affects the meaning of the whole sentence. Chinese speakers may have difficulty hearing and applying English intonation patterns.

Stress: The rhythm of English is created through a combination of stressed and unstressed syllables. However, Chinese does not have many reduced syllables. Therefore, Chinese speakers tend to stress all syllables equally and clearly when speaking English, and find stress patterns difficult to hear and adopt.

Linking: Unlike English, Chinese is basically a monosyllabic language, in which words predominantly consist of a single syllable.  Because of this, they may separate English words into syllables, rather than smoothly connecting them. This absence of linking makes speech sound choppy.

Vowels: Chinese has fewer vowel sounds than English, and so distinguishing the slight differences in sounds (eat, it) and the position of articulation (where your tongue, lips and jaw are) may be difficult.

Consonants: Final consonants, and final consonant clusters, common in English, do not exist in Chinese. They can be very difficult to pronounce correctly. Some consonants are harder to pronounce at the end of a word than at the beginning. For example the /l/ in the following words: like; people.

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Speak Clearly with Correct Stress

Stress is extremely important in English. Stressing the wrong syllable or pronouncing all syllables with equal stress are a common problem for non-native speakers, and can be very confusing for the listener.

A native speaker may not understand a word that has the wrong stress.
BA-NA-NA (all syllables with equal stress) and ba-na-NA (wrong syllable stressed) will not easily be understood by someone expecting to hear ba-NA-na.  Learning stress patterns takes time and effort, but using correct stress will significantly improve your clarity and fluency.

In English, the sentence rhythm comes from stressing important words, called content words, and reducing unimportant ones, called function words. Only 1 syllable in each word is stressed.

carry meaning and are stressed.
They are:

  • Noun
  • Verbs
  • Adjectives
  • Adverbs
  • Negatives

don’t carry much meaning and are reduced. They are:

  • Articles
  • modals
  • Prepositions
  • Pronouns
  • The verb “to be”

In the sentence: This is a faster system with a higher capacity, and it has the same footprint as prior models.

If we hear only the content words we can still get the general meaning
-  faster system higher capacity same footprint prior models.

If we hear only the function words, we have no idea of the meaning.
-  This is a with a and it has the as

It is the combination of stressed and unstressed syllables that creates the rhythm of English.

The correct stress for this sentence is:

This is a FASter SYStem with a HIGHer caPAcity, and it has the SAME FOOTprint as PRIor MOdels.

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The 3 components of cross-cultural healthcare communication

The interdependence of competency levels in each area defines the quality of the communication.

Cross-cultural communication in healthcare has 3 vital components: language fluency, culture, and health literacy. The culturally competent provider can assess a patient’s level in each of the 3 areas and adjust communication accordingly, to increase the chance of successful healthcare delivery and outcomes.

1. Health Literacy

Health literacy is how well one understands basic health information and services needed to make appropriate health decisions.  Examples include:

  • reading and filling out forms
  • understanding and following prescriptions and instruction
  • understanding tests and results
  • reading and understanding health brochures
  • navigating health care and insurance systems
  • ability to critically analyze health care options based on knowledge gathered

Providers can help develop patients’ health literacy by communicating in plain, simple English, avoiding technical language and jargon, and checking comprehension.

2. Culture

Both the patient and provider bring cultural filters to the healthcare setting.  The filter includes beliefs, norms, and practices surrounding wellness, illness and healthcare delivery. When possible, providers and organizations should work with and incorporate patients’ customs and beliefs to increase the likelihood of successful outcomes.

3. Language Fluency

How well does the patient speak English? LEP (limited English proficiency) patients may not fully understand information and instructions, and may lack the skills to ask for clarification. They also face the additional challenge of health-specific vocabulary and terminology, some of which may not exist in their native language. The culturally competent provider is able to quickly assess the language fluency level of LEP patients and apply communication strategies that ensure patient understanding.

Health care agencies and providers must actively work to enhance the patient and provider’s knowledge and abilities in these 3 areas in order to improve healthcare delivery and outcomes.

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Giving Performance Feedback Across Cultures

Task-oriented cultures and relationship-oriented cultures give and receive feedback differently. A culturally competent manager is aware of these differences and can adjust communication accordingly. When giving performance feedback across cultures, always keep in mind, “What type of feedback will this person be most receptive to hearing? What is the most effective way to get my message across?”

LAY IT ON THE LINE: Feedback for task-oriented cultures
Low context cultures, such as American, are task-oriented. The person and the task are viewed separately. The task, process, and result are critiqued, not you. Feedback is direct, specific, and quantifiable. It is expected that the person receiving the feedback will engage in discussion, rather than sit quietly. American managers giving feedback across cultures may need to encourage participation, questions, and discussion on the part of the recipient.

READ BETWEEN THE LINES: Feedback for relationship-oriented cultures
High context cultures, such as Asian and Hispanic, are relationship-oriented. The person is not seen as separate from the task. Feedback on work is taken personally, and saving face becomes important. Direct negative feedback leads to a loss of face, and therefore performance feedback is often indirect. In relationship-oriented cultures, my mistake is a loss of face, and my success belong to the team. Calling attention to individual contributions may be viewed negatively.

In relationship-oriented cultures, the recipient does not typically participate in or discuss the feedback, but only listens. Managers provide face-saving feedback by looking at options, alternate scenarios or “what ifs”, rather than discussing the employee directly.

Giving feedback to non-native speakers of English
If you are giving feedback to someone who is not fluent in English, adjust your feedback accordingly. Speak in shorter sentences. Check regularly for comprehension by asking questions, avoid idioms or jargon, and provide both spoken and written feedback. Sending a follow up email summarizing your feedback gives the person a chance to clarify any misunderstanding.

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3 Keys to Improving Presentation Skills for Non-Native Speakers

Giving presentations is already nerve wracking. Non-native speakers face the additional challenges of language and cultural barriers to communication.

Non-native speakers can dramatically improve their presentation skills and become significantly more understandable to the audience by focusing on three key areas of English communication: phrasing, intonation and stress.

English-speaking audiences  expect to hear certain patterns in these areas. If they do not hear these patterns, they will have a difficult time understanding you, and may lose interest in your presentation.

Phrasing and Thought Groups

Thought groups put information in understandable chunks to help lead the listener through the speaker’s message.  Clear boundaries showing where the phrases start and end, not only make it easier for your audience to follow your message, but make your speech sound less choppy and more fluent.

New research suggests / that average global temperatures / were higher in the past decade / than over most of the previous / 11,300 years


Intonation is the way your pitch rises and falls. It is extremely important in English and carries a great deal of information. English has many intonation patterns to show meaning and nuance. Using vocal variety and intonation patterns in your presentations makes your speech easier to understand and more engaging. Three common intonation patterns that are useful in presentations include:

rising, rising, falling – to show a list. Pitch rises for each list item and falls on the last.
rising, falling
- which can be used to show  if/then, either/or, and making comparisons
– to show the end of a statement


Stress is also key to English communication. Using the wrong stress can make you unintelligible. Using no stress, where each word gets equal emphasis, is monotone and confusing to follow.  In presentations, stress is often used to show emphasis and focus.  These “focus words”  are pronounced louder, longer and higher than the other words in a sentence. This brings the listeners’ attention to key words and let’s them know what’s important.

Using the wrong stress can make you unintelligible.

Hearing first, speaking second
Adopting these patterns is crucial to becoming a good presenter. However, you first have to get used to identifying them. Listen closely to native speakers as they talk or give presentations. Focus on listening for these 3 keys and practice mimicking them until they become natural for you. Using correct phrasing, intonation and stress will improve your communication dramatically.

Contact us to learn about Presentation Skills for Non-Native Speakers training programs.

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10 cultural factors that influence health care

In order to improve health care delivery and outcomes, providers must develop the cultural competence to serve patients from diverse cultures.

Western culture takes a biomedical approach to health care. However, many cultures take a more holistic approach that includes the body, mind, and spirit. Providers who work with the patient’s belief system, rather than against it or ignoring it, will have greater success in delivery and outcomes. Providers must also be aware of their own cultural filters in the health care delivery process.

To improve health care delivery and outcomes, providers should know the patient’s cultural views on:

  1. Role of family (roles of members, hierarchy, key decision-maker)
  2. Role of community
  3. Religion (impact on diet, beliefs about illness, treatment)
  4. Views on health and wellness
  5. Views on death and dying
  6. Eastern/western/alternative/traditional medicine.
  7. Beliefs about causes and treatments of illness, disease (physical and mental)
  8. Gender roles and relationships
  9. Sexuality,  fertility, childbirth
  10. Food beliefs and diet
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5 Best Practices for Serving Diverse Customers

Good customer service means different things to different people. Here are 5 ways to develop your cultural competency for customer service, and  have a greater opportunity to attract and retain diverse customers.

1. Know your clientele.
Spend time talking with clients to learn about where they are from. You should have a basic knowledge of relevant world views, values and beliefs. Expect difference, not similarities. The more you know about your clients, the better you can meet their needs through appropriate customer service.

2. Seek out culture-specific knowledge of your customers.
Is your client Japanese, Chinese or Korean? Don’t lump cultures under one umbrella.  Learn beyond “Asian” or “Hispanic” commonalities to discover the uniqueness each country. Mastering a few key phrases in their language is always a warm way to build relations.

3. Recognize patterns for communicating.
Does the client prefer  “speak your mind” or “read between the lines” when communicating?  Do they focus on relationships in customer service or value efficiency and speed? Pay attention to both verbal and nonverbal communication, and learn to mirror them in your customer service. By mirroring someone’s communication style you are affirming their values in that area.

4. Attract diverse customers by having a diverse workforce.
Create a welcoming environment for a variety of clients. When people see themselves and their cultures reflected in a business, they are more likely to become a customer than if they feel like an outsider.

5. Build relationships.
Your customers are not just a series of tasks to be completed or passed off to the next worker.  In  Hispanic, Asian, Arab and African cultures relationships are key to conducting business. Become an active listener and build relationships to grow a loyal customer base.

Below are 10 common areas for cross cultural conflict in customer service.
How do you feel about customers who do the following?

  1. Discounting or refusing to deal with women.
  2. Bringing whole family/children to appointments.
  3. Soft, “dead fish” handshake.
  4. Standing too close when talking.
  5. Having a heavy accent or limited English.
  6. Coming late to appointments.
  7. Withholding or not volunteering necessary information.
  8. Not taking initiative to ask questions.
  9. Being very informal and familiar.
  10. Not making a line or waiting one’s turn
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Through the Eyes of International Students

International students who come to study in America bring their own expectations and cultural filters to their learning experience.  The US recruiter or educator who understands these filters and expectations will be better able to attract and serve international students.

International students attending school in the US will have cultural biases and expectations around:

  1. The institution of education
    These are differing views on what education is and should be: who can attend and for what purpose.
  2. Roles of students and teachers in classroom dynamics
    In many cultures, teachers are all-knowing authorities, and there is a high power distance between teacher and student. Speaking up and challenging the teacher is not done.  Informal American teachers who act as friendly facilitators may not be respected.
  3. Concepts of cheating and plagiarism
    Students may have a different definitions for these terms and not realize the  severity of these academic offenses in the US.
  4. Rote learning vs. creative thinking
    Asian, African, and Hispanic cultures stress rote memorization, and not the individual creative problem solving stressed in the American classroom. Listening to classmates’ opinions or creative team projects may seem like a waste of time to an international student.
  5. Working/living in a multicultural environment (USA)
    This may be the first time the international student studies or lives  in a heterogeneous environment where discrimination by gender, race, religion, etc, is  not tolerated or legal.

Compared to the US, students in most academically top -ranked countries have:

  • earlier vocational or academic tracking
  • earlier selection of major
  • limited electives or extracurricular
  • national exams that limit university/program access
  • admission based on national test result, not holistic assessment (transcript, resume, interview, activities)
  • public universities better than private
  • free or low cost university
  • limited “campus life”
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