Cultural Issues in Pediatric Care

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Chapter 4 Cultural Issues in Pediatric Care

Linda Kaljee, Bonita F. Stanton

Pediatricians live and work in a multicultural world. Among the world’s 6 billion people residing in >200 countries, >6,000 languages are spoken. As the global population becomes more mobile and integrated, ethnic and economic diversity increases in all countries; from 1970 to 2000, the foreign-born population in the USA increased 3-fold. In the 2000 U.S. census, 25-30% of Americans self-identified as belonging to an ethnic or racial minority group. One or both parents of approximately 17 million children in the USA are foreign-born; 1 of every 5 children lives in an immigrant family. Whereas in 1920, 97% of immigrant families in the USA were from Europe or Canada; in 2000, 84% of U.S. immigrant children were from Latin America or Asia. Nonwhite children are projected to outnumber white children in the USA by the year 2030. Increased migration and diversity in the migrant pool is not limited to the USA; immigrants account for over 15% of the population in >50 nations.

The Importance of Culture to Medical Practice

The concept of culture includes the ways in which a group of people share and understand their history, beliefs, and values, and engage in behaviors reflective of these shared worldviews. Although culture is not synonymous with language, ethnicity, nationality, or socioeconomic status, groups with similar backgrounds with respect to these characteristics often share cultural norms and beliefs.

Within cultures, there are frameworks for classifying and organizing kin (family), assigning roles and responsibilities based on age, gender, and other social groupings, and defining concepts such as prosperity, success, knowledge, causes of disease, and health. Disease typology, prevention and intervention efforts, and health practitioners are culturally defined. Health-related cultural-beliefs and practices are integrated within health systems that include both biomedicine and traditional medicine.

Tables 4-1 to 4-3 display some cultural values associated with 4 minority populations in the USA: Latinos, Muslims, Native Americans, and African-Americans, illustrating both areas of significant overlap and great variation that are relevant to health perceptions and health seeking. Latinos may subscribe to the importance of “personalismo,” placing great importance on politeness in the face of stress and adversity and thus expect a display of warmth from their physician, including physical touching such as handshakes, hands on the shoulder, and occasionally hugging. By contrast, in the Muslim culture, for a person to touch the body of a member of the opposite gender, including on the arm or a pat on the shoulder, is considered highly inappropriate.

Table 4-1 CULTURAL VALUES* RELEVANT TO HEALTH AND HEALTH-SEEKING BEHAVIOR

CULTURAL GROUP RELEVANT CULTURAL NORMS
Description of Norm Consequences of Failure to Appreciate
Latino Fatalismo: Fate is predetermined, reducing belief in the importance of screening and prevention Less preventive screening
Simpatia: Politeness/kindness in the face of adversity—expectation that the physician should be polite and pleasant, not detached Nonadherence to therapy, failure to make follow-up visits
Personalismo: Expectation of developing a warm, personal relationship with the clinician, including introductory touching Refusal to divulge important parts of medical history, dissatisfaction with treatment
Respecto: Deferential behavior on the basis of age, social stature, and economic position, including reluctance to ask questions Mistaking a deferential nod of the head/not asking questions for understanding; anger at not receiving due signs of respect
Familismo: Needs of the extended family outrank those of the individual, and thus family may need to be consulted in medical decision-making Unnecessary conflict, inability to reach a decision
Muslim Fasting during the holy month of Ramadan: Fasting from sunrise to sundown, beginning during the teen years. Women are exempted during pregnancy, lactation, and menstruation and exemptions for illness, but may be associated with a sense of personal failure. Inappropriate therapy; will not take medicines during daytime misinterpreted as noncompliance; misdiagnosed
Modesty: Women’s body including hair, body, arms, and legs not to be seen by men other than in immediate family. Female chaperone and/or husband must be present during exam and only that part of the body being examined should be uncovered. Deep personal outrage, seeking alternative care
Touch: Forbidden to touch members of the opposite sex other than close family. Even a handshake may be inappropriate. Patient discomfort, seeking care elsewhere
After death, body belongs to God: Postmortem exam will not be permitted unless required by law, family may wish to perform after-death care Unnecessary intensification of grief and loss
Cleanliness essential before prayer: Individual must perform ritual ablutions before prayer, especially elimination of urine and stool. Nurse may need to assist in cleaning if patient is incapable. Affront to religious beliefs
God’s will: God causes all to happen for a reason, and only God can bring about healing Allopathic medicine will be rejected if it conflicts with religious beliefs, family may not seek health care
Patriarchal, extended family: Older male typically is head of household, and family may defer to him for decision-making Child’s mother or even both parents may not be able to make decisions about child’s care; emergency decisions may require additional time
Halal (permitted) vs harem (forbidden) foods and medications: Foods and medicine containing alcohol (some cough and cold syrups) or pork (some gelatin-coated pills) are not permitted Refusal of medication, religious effrontery
Native American Nature provides the spiritual, emotional, physical, social, and biologic means for human life; by caring for the earth, Native Americans will be provided for. Harmonious living is important. Spiritual living is required of Native Americans; if treatments do not reflect this view, they are likely not to be followed
Passive forbearance or right of the individual to choose his or her path: Another family member cannot intervene Mother’s failure to intervene in a child’s behavior and/or use of noncoercive disciplinary techniques may be mistaken for neglect
Natural unfolding of the individual: Parents further the development of their children by limiting direct interventions and viewing their natural unfolding Many pediatric preventive practices will run counter to this philosophy
Talking circle format to decision-making: Interactive learning format including diverse tribal members Lecturing, excluding the views of elders is likely to result in advice that will be disregarded
African-American Great heterogeneity in beliefs and culture among African-Americans Risk of stereotyping and/or making assumptions that do not apply to a specific patient or family
Extended family and variations in family size and child care arrangements are common; matriarchal decision-making regarding health care Advice/instructions given only to the parent and not to others involved in health decision-making may not be effective
Parenting style often involves stricter adherence to rules than seen in some other cultures Advice regarding discipline may be disregarded if it is inconsistent with perceived norms; other parenting styles may not be effective
History-based widespread mistrust of medical profession and strong orientation toward culturally specific alternative/complementary medicine In patient noncompliance, physicians will be consulted as a last resort
Greater orientation toward others; the role of an individual is emphasized as it relates to others within a social network Compliance may be difficult if the needs of 1 individual are stressed above the needs of the group
Spirituality/religiosity important; church attendance central in most African-American families Loss of opportunity to work with the church as an ally in health care
East and Southeast Asian Long history of eastern medicines (e.g., Chinese medicine) as well as more localized medical traditions May engage with multiple health systems (Western biomedical and traditional) for treatment of symptoms and diseases
Extended families and care networks. Grandparents may provide day-to-day care for children while parents work outside of the home. Parents may not be the only individuals a physician needs to communicate with in regard to symptoms, follow-through on treatments, and preventive behaviors
Sexually conservative. Strong taboos for premarital sexual relationships, especially for women. Adolescents may be reluctant to talk about issues of sexuality, pregnancy, birth control with physicians. Recent immigrants or native populations may have less knowledge regarding pregnancy prevention, STIs, and HIV.
Infant/child feeding practices may overemphasize infant’s or child’s need to eat a certain amount of food to stay “healthy” Guidelines for child nutrition and feeding practices may not be followed out of concern for child’s well-being
Saving face. This is a complex value whereby an individual may lose prestige or respect by a third party when a second individual says negative or contradictory statements. Avoid statements that are potentially value-laden or imply a criticism of an individual. Utilize statements such as “We have now found that it is better to…” rather than criticizing a practice.

* Adherence to these or other beliefs will vary among members of a cultural group based on nation of origin, specific religious sect, degree of acculturation, age of patient, etc.

Table 4-2 EXAMPLES OF DISEASE BELIEFS OR PRACTICES

CULTURAL GROUP EXAMPLES
Latino Use of traditional medicines (nopales or cooked prickly pear cactus as a hypoglycemic agent) along with allopathic medicine
Recognition of disorders not recognized in Western allopathic medicine (empacho, in which food adheres to the intestines or stomach), which are treated with folk remedies but also brought to the pediatrician
Cultural interpretation of disease (caida de mollera or fallen fontanel) as a cultural interpretation of severe dehydration in infants
Muslim Female genital mutilation: Practiced in some Muslim countries, the majority do not practice it and it is not a direct teaching of the Koran
Koranic faith healers: Utilize verses from the Koran, holy water, and specific foods to bring about recovery
Native American Traditional “interpreters” or “healers” interpret signs and answers to prayers. Their advice may be sought in addition or instead of allopathic medicine.
Dreams are believed to provide guidance; messages in the dream will be followed
East and Southeast Asian Concepts of “hot” and “cold,” whereby a combination of hot and cold foods and other substances (e.g., coffee, alcohol) combine to cause illness. One important aspect is that Western medicines are considered hot by Vietnamese, and therefore, nonadherence may occur if it is perceived that too much of a medicine will make their child’s body hot. Note: Hot and cold do not refer to temperatures, but are a typology of different foods; for example, fish is hot and ginger is cold.
Foods, teas, and herbs are also important forms of medicine because they provide balance between hot and cold.

Table 4-3 HOME REMEDIES FOR FEVER, COLIC, AND TEETHING AMONG AFRICAN-AMERICANS

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Despite the existence of shared values within a defined population group, there may be substantial variations within subgroups, such as the Latino national subgroups (e.g., Cuban, Puerto Rican, Dominican, Mexican), resulting in great variation in specific health-seeking behaviors. Likewise, within an overarching culture (“American”), persons who are economically and/or politically disenfranchised may utilize resistance, inverting the values of the dominant socioeconomic group. Such a reaction may include distrust of recommendations regarding health care from members of the perceived dominant or controlling group or class. Immunizations have been viewed with distrust among the poor in countries around the globe, as they were believed to be a form of birth control or sterilization and were often offered through institutions associated with “Western” and postcolonial rule. Within cultures, socially constructed categories of gender, sexuality, and age affect perceptions of an individual’s vulnerability to a particular disease or condition, as well as his or her access to health system resources. Adolescents girls living in cultures with strong taboos against premarital sexual relationships (e.g., Chinese, Muslim, Vietnamese) may not have social access to disease and birth control protection (e.g., condoms) resulting in increased risks for HIV, other sexually transmitted infections (STIs), and unwanted pregnancies.

There may also be significant generational differences between foreign-born parents and their American-raised children, particularly as these children go through adolescence. Such disparate experiences and cultural identities can result in a generational gap that decreases parent-child communication and subsequently lessens the important positive effects of communication on reducing substance use and engagement in sexual risk behaviors among youth.

Other values may be shared across disparate cultural groups. Multiple ethnic groups including Latinos and Muslims as well as Sudanese and Bengalis share a cultural belief of fatalism, with strong implications for health-seeking behavior.

The perceived role of the physician may also differ between cultures. Pediatricians are trained to offer advice on child rearing, and studies have shown that parents look to pediatricians for this advice. However, parents of differing cultural backgrounds may not desire or may be reluctant to accept such advice.

Newly Recognized Cultural Groups

Groups such as adolescents, gay, lesbian, or transgender youth, and deaf youth who may not traditionally be recognized as cultural groups may have shared values with implications for health and health seeking. Failure on the part of the pediatrician to recognize accepted language and frame of reference of these groups may result in the unintentional use of offensive terminology or assumptions, leading to loss of the physician’s credibility or noncompliance from the patient.

The Culture of the Medical Profession

The profession of medicine also has a distinct culture. Like other cultural groups, physicians share a common history, admiring the same role models, sharing the same preparatory courses that must be mastered for entrance into training for the profession, and subscribing to a common meaning of “competence” in medical practice. Physicians learn a new way to describe health and illness, requiring a new vocabulary and a prescribed pattern to the narrative history, which is not shared by those outside medicine. Physician reliance on “evidence-based practice” carries the implication that it is synonymous with truth or real knowledge. Of particular importance in the relationship with patients has been the lack of physician insight into the existence of a physician culture and the potential biases that may be inherent to that culture.

While physicians around the world recognize the great strides that have been made in child survival through the use of oral rehydration therapy in the treatment of dehydrating diarrheal diseases, parents are often anxious because the treatment does not stop the diarrhea. Physicians may be dependent on a particular style of communication and they may miss information from patients utilizing alternative narrative styles. Likewise, the physician-researcher forms questions through the prism of his or her own beliefs and literature, thereby reducing the likelihood of exploring alternative explanations or questions. While vast segments of the world’s population understand disease as an imbalance of “hot” and “cold,” this belief system has not been well represented in contemporary medical research.

Cultural Competence

Physicians and patients bring to their interaction personal and professional values from multiple cultural systems that have significant implications for the delivery of health care. Physician “cultural competence” is therefore critical to a successful patient-provider interaction (Fig. 4-1). Campinha-Bacote’s model for understanding and assessing culturally competency is frequently used in education and research: (1) learning to value and understand other cultures, in part through self-awareness of one’s own cultural values (“cultural awareness”); (2) learning basic fundamentals about other cultures, particularly those of the patients with whom the physician will interact (“cultural knowledge”); (3) developing the ability to apply cultural knowledge in patient encounters (“cultural skills”); (4) seeking exposure to cross-cultural interactions (“cultural encounters”); and (5) being motivated to achieve all of the previous (“cultural desire”). This framework provides an important guide to pediatric education and practice and, thus, will serve as the outline for the remainder of this chapter.

image

Figure 4-1 Components of cultural competency in pediatric practice.

(From Brotanek JM, Seeley CE, Flores G: The importance of cultural competency in general pediatrics, Curr Opin Pediatr 20:711–718, 2008, Fig 1, p 712.)

Cultural Awareness

Recognition of the importance of differing cultural expectations and explanations is critical to a pediatrician’s successful interactions with patients. Among many cultures (e.g., Muslim), kinship is of great importance and decision-making may involve the extended family. The erroneous belief on the part of a physician that a mother may execute independent decision-making in relation to her child’s health care (when in fact she may not be entitled to such a role in her family or culture) may result in an apparent noncompliance on the part of the mother.

Cultural Knowledge

Physicians and patients have differing definitions of health and illness and differing concepts of the origins of disease and therapeutic responses. Understanding the patient perspective will both increase the likelihood of correct diagnosis and patient adherence to therapy and decrease the possibility of misdiagnosis. The belief that becoming chilled causes dysentery is common among rural Chinese, and medical advice that directly challenges or runs contrary to this belief may be disregarded. Likewise, diarrhea among Bangladeshi children during teething may be regarded as normal and would not be identified as a health issue. Thus, asking the parent if the child has been ill might not reveal the presence of diarrhea. Rubbing a coin against a child’s skin is thought by some parents in Asia to reduce fever. Failure by the pediatrician to recognize the practice of coining could lead to the erroneous diagnosis of a rash or child abuse. In some instances, particularly in relation to developmental and emotional disorders, the manifestation of symptoms and/or recognition of symptoms by parents or other caregivers may be culturally defined. Autism is a condition characterized by communication and socializing disabilities. Yet expectations of children’s language and social skills development are culturally defined, resulting in potentially later identification by family members of a child’s disabilities and subsequently delayed treatment seeking.

Cultural Skill

Describing a diagnostic or therapeutic course of action that respects cultural beliefs but is consistent with good medical practice can be challenging. Common among many Latino groups is the belief of empacho, a condition wherein food is “stuck” to the stomach or intestinal wall, resulting in obstruction. The condition is believed to cause nausea, vomiting, diarrhea, and anorexia. Although many Latino parents would take a child with empacho to the physician for treatment, in Western settings, a pediatrician diagnosing the condition as viral gastroenteritis might only advise supportive management, leaving the parents perplexed and with no option but to seek independent treatment from an alternative or traditional healer. A culturally skilled pediatrician might suggest partnering with the traditional healer in such a situation. Likewise, in response to parents subscribing to a belief in fatalism and, consequently, a notion that preventive medicine or screening is not necessary, a skilled pediatrician might suggest that screening is the mechanism through which their destiny is intended to be reached. Referrals for services may also be affected by a patient’s culture and history. The need for psychologic services may be rejected because of cultural stigmas regarding psychological disorders. Likewise, referrals for HIV or STI testing may be more likely rejected by gay adolescent men from cultures in which homosexuality is highly stigmatized.

Central to “cultural skill” is the employment of language fully comprehended by the child’s parents. This goal is best realized if the pediatrician is at least conversant in the parent’s language, and thus a requirement for a second language is a reasonable goal for physicians. Familiarity with a language should not be confused with fluency or even competency. Professional interpreters should be available and accessed to overcome the language barriers. Ad hoc use of individuals at the workplace who are known to possess skill in the indicated language and/or use of telephone interpreter services may suffice if a professional interpreter is not available. A genuinely bilingual family member or friend may be helpful, but issues of confidentiality, disruption of social roles, and uncertain or inaccurate translation of medical terms may pose serious problems. Medical errors occur at a significantly higher rate among non-English speaking patients when nonprofessional (e.g., family members) translators are used to obtain a history or give medical advice.

Cultural Encounters

While cultural knowledge may be acquired through didactic training, the development of cultural skills requires experience that can only be gained through repeated “cultural encounters.” Nonminority clinicians provide lower quality of care to Latino and African-American patients, with these children being less likely to receive analgesia and/or nebulizers for asthma. Latino mothers have reported clinician attitudes as a major barrier to seeking care for their children. Another study among physicians revealed that participation in diverse medical educational settings and experience in community clinics predicted cultural knowledge. Cultural knowledge and participation in diverse educational settings, as well as Latino ethnicity and bilingual skills, predicted cultural awareness. Only cultural awareness predicted culturally competent actions. Consistent with observations that cultural competence may not be valued in the traditional medical culture is the observation that higher specialty training (e.g., subspecialty training among internists compared to general physicians, family medicine, or internal medicine generalists) predicted less cultural awareness. Children who receive care from practice sites with the highest cultural competence scores are less likely to underutilize preventive asthma medications.

Cultural Desire

Cultural competence is not something that can be achieved and retained in the absence of continued effort. The recognition that culture is integral to health and healing, and to disease and sickness, is central to the concept of “cultural competence.” Understanding of the role of culture in health outcomes is nascent; it is not yet known why less acculturated Latinos in the USA demonstrate significantly lower rates of low birthweight, depression, tobacco use, illicit drug use, and older age for sexual debut compared to those who are more acculturated. Likewise, less acculturation among Asian children is associated with lower prevalence of chronic illness. Perhaps environment more than gene type may represent a significant influence on the phenotype of acculturated individuals. Such findings expose the complexities between individuality, cultures, and biology.

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