Cultural Issues in Pediatric Care

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Chapter 4 Cultural Issues in Pediatric Care

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

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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