Chapter 4 Cultural Issues in Pediatric Care
The Importance of Culture to Medical Practice
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 |
