A word or two can make all the difference

Language can be the greatest single barrier to quality care, and speaking at least one other language with reasonable fluency is a major asset for any caregiver. However, no matter how linguistically challenged you may be, make it a point to acquire at least a handful of words and phrases of greeting in each of the languages spoken in your community. There is no faster way to bring a smile to the face of a parent or child or to ease the anxiety of a family already intimidated by a strange environment and a foreign culture than to greet them in their own language. Similarly, there is no better way to signify your respect for the family’s cultural individuality than by making this effort. A simple “Buon giorno” (Italian), “Buenos dias” or “Buenos tardes” (Spanish), “Salaam aleikum” (Arabic), “Ohayo gozaimasu” (Japanese), “Shalom” (Hebrew), “Bonjour” (French), “Gin Dobre” (Polish), or “Guten tag” (German) can be a good start. If, however, your community contains a significant number of families of a particular linguistic tradition, improving your communication skills in their language can do a world of good and relieve a great deal of anxiety.

Some people are under the mistaken impression that speaking (English) louder than normal helps people of other languages understand what they are saying. This is never true. Worse still, it is often upsetting to the family. Culturally insensitive care amounts to involuntary racism. The inverse, cultural competency, has been defined as “acting with grace across lines of difference.” You can learn much from discussing these cross-cultural issues with colleagues and friends from different cultural backgrounds and by keeping one or two reliable reference sources handy.

The variable meanings of looks and gestures

Some of the involuntary physical gestures that accompany or amplify our conversations can have very different meanings among various cultural groups. In North America and Western Europe, for example, we often shake hands upon meeting others or when saying goodbye. However, in certain cultures, shaking hands with people of the opposite gender is strictly taboo, and in Thailand, shaking hands is often avoided entirely. Among Finns, conversing with one’s hands in one’s pockets is considered impolite. Similarly, in the Western world we set a high value on eye contact with both adults and children, whereas North American Aboriginals and people from India and Asia may specifically avoid direct eye contact as a sign of respect. In Western cultures, we often nod our heads to signify understanding or agreement, but in some cultures, such a nod may simply mean, “I hear you speaking” or “If you say so.”

The people in some cultural groups, such as French, Italian, Russian, Jewish, and Greek, tend to be highly tactile, whereas persons in other cultures are not very tactile at all. Physical touch between people of different genders may be distinctly uncomfortable for conservative Arab Muslims. Furthermore, observant Muslims never use the left hand to eat in the presence of others. Doctors and physiotherapists may be puzzled upon finding that the parents of a child with a right hemiplegia are “uncooperative” when they try to encourage the child to use the left hand instead, but if the family observes the Muslim faith, this “solution” is unacceptable.

To reduce the risk of sudden infant death syndrome (SIDS), we currently discourage parents from sleeping with their infants. However, in some cultures, such as that of the Maoris of New Zealand or the Hmong of Laos, such sleeping situations are the norm and should be respected and accepted. Korean children may sleep with their parents until they are 4 years old. Similarly, although we discourage consanguinity for genetic reasons, it is the norm for some groups, and to them our traditional approach to genetic counseling may be both impractical and offensive.

Using interpreters effectively

Interpreters can be valuable, especially if they have professional training in medical assessment methods and are experienced cultural as well as linguistic interpreters. Such individuals should be sensitive to nonverbal as well as verbal messages, because effective interpretation goes far beyond mere translation of words. Many larger hospitals maintain lists of skilled, culturally competent health interpreters. Although telephone interpreters have been used (and may be helpful), it has been documented that Spanish-speaking patients, not surprisingly, are significantly more satisfied when an interpreter is physically present.

Using an interpreter is bound to prolong any clinical encounter, so be sure to allow the extra time required. Giving adequate care to a child from another culture often requires scheduling of additional visits. Before meeting with the family, discuss the goals of the interview with the interpreter. At the beginning of the interview, ask the family whether they feel comfortable speaking through an interpreter, and ask the interpreter to translate as literally as possible. Then introduce the interpreter and explain his or her role. Always look at the parent (not at the interpreter) and speak slowly, clearly (not loudly), and in short sentences. Use simple words and allow enough time for the interpreter to translate. Encourage the family to ask questions. Stay alert for any hint (often nonverbal) that a family member may not understand something. After the interview, ask the interpreter whether he or she has additional relevant observations to contribute.

False fluency

Using an interpreter does not eliminate the possibility of miscommunication, which occasionally may have serious consequences. Overestimating your own or your interpreter’s fluency in the patient’s language can lead you to overlook or misinterpret important information. This phenomenon has been called false fluency.

Interpreters may not be available on short notice in emergency situations. In such cases, health care providers can contact the AT&T Language Line Services in the United States or Canada at 1-800-752-6096. A fee for this translation service is charged to the health care provider.

Developmental assessment of the preschool-aged child

Before administering developmental screening tests to preschoolers from diverse backgrounds, you must know whether any test you propose to use has been validated in diverse populations or translated into the family’s language.

Family perceptions of the child with chronic illness

In many cultures, chronic illness or disability in a child may be viewed as a form of punishment, a sign of divine displeasure, a loss of spirit, or a curse. In societies that believe in reincarnation, a disability may be seen as evidence of transgression in a previous life. Although a family may listen to and accept your “rational” scientific explanation for an illness, doing so does not necessarily eradicate their traditional beliefs.

In some societies, a child’s gender can play a role in determining the extent to which parents seek medical help. In traditional East Indian and Chinese families, for example, less attention may be paid to illness in girls than in boys.

Another factor that may affect family attitudes and behavior is the parents’ expectation for the child’s survival. In some cultures, views about the inevitability of death may differ from our own, and these views may influence the amount of energy the family devotes to the child’s care and the extent to which they cooperate with caregivers.

A few open-ended questions, such as those listed here, can offer valuable insights into how a patient or family from another culture perceives an illness:

In her book The Spirit Catches You and You Fall Down, Anne Fadiman captures with extraordinary insight and eloquence the collision of cultures surrounding the health care of a young Hmong* child with epilepsy. Consider the following excerpt:

“All of [the American physicians] had spent hundreds of hours dissecting cadavers and could distinguish at a glance between the ligament of Hesselbach and the ligament of Treitz, but none of them had had a single hour of instruction in cross-cultural medicine. To most of them, the Hmong taboos against blood tests, spinal taps, surgery, anesthesia and autopsies—the basic tools of modern medicine—seemed like self-defeating ignorance. They had no way of knowing that a Hmong might regard these taboos as the sacred guardians of his identity, indeed, quite literally, of his very soul.”

This book should be required reading for anyone seeking a better understanding of cross-cultural health issues. It emphasizes the need for respect and compromise that are essential to the effective care of a child from another culture.

Alternative therapies and folk medicine

Every society, including our own, uses a wide variety of “folk medicines,” unproven remedies, and “alternative” therapies. In North America, physicians prescribe vast quantities of cough syrups, oral decongestants, teething remedies, and other over-the-counter products whose efficacy is unproved or, more often, disproved. Today, many families also use herbal and “natural” remedies or consult nontraditional therapists.

We therefore have no justification for any feelings of superiority or skepticism about folk remedies used in other cultures. It is important to identify all treatments a child has received. Gathering information about such treatments is best achieved through a stepwise approach to questioning, such as the following:

In areas with a large Puerto Rican population, it is common for people to patronize local botanicas to purchase traditional herbal remedies. For many parents, however, using traditional remedies does not exclude the use of other treatments. Generally speaking, it is best not to discourage the use of ethnomedicine unless there is evidence that it is harmful.

In caring for Hispanic or Latino families, caregivers should be familiar with the following common beliefs and customs:

You can elicit parents’ views of the cause and management of their child’s illness by asking the following open-ended, general questions:

Breaking bad news across cultures

The specific clinical skills for breaking bad news described in Chapter 1 become even more important when the family comes from a different ethnic or cultural background. The following additional issues must be considered:

Cross-cultural skills for physical examination

Conditions such as rashes, petechiae, and jaundice may differ markedly in people of different skin color. In dark-skinned persons, an alteration in skin consistency is more likely to indicate a rash than a change in color (see Chapter 19 for further details). Petechiae may be easier to detect in the nail beds, palms, soles, and oral mucosa than elsewhere. Cyanosis also may be more apparent in the nail beds, palms, soles, and conjunctivae than in other sites. In dark-skinned persons, the peripheral part of the sclerae may normally be yellowish, so jaundice may be best appreciated close to the iris or on the palate. Pallor is more likely to be detected through examination of the conjunctivae, nail beds, palms, and soles.

Children from some cultures may show physical evidence of having received certain folk medicine treatments. Among the most striking examples are patterned petechial eruptions, seen most often in children from Southeast Asia, which are caused by the treatment known as coin rubbing. In this common traditional treatment, the patient’s skin is rubbed with heated coins or spoons (which may have been dipped in oil) to treat a condition such as sore throat or bronchitis. Typically, this treatment leaves linear, dark, petechial eruptions on the skin. Clinicians unfamiliar with this practice and its characteristic physical signs have been known to mistake its skin manifestations for signs of child abuse. Similar false accusations of child abuse have been made by health professionals unfamiliar with the blue birthmarks known as mongolian spots, which occur in a high percentage of dark-skinned individuals of all racial backgrounds and can be mistaken for bruises by the uninitiated.

Culturally sensitive prescribing

Race and ethnic background can affect patient responses to prescribed medications. Significant ethnic differences in the distribution of genetic variants of enzymes involved in metabolizing many drugs can result in important variations in drug response and toxicity. For example, glucose-6-phosphate dehydrogenase (G6PD) deficiency is found in some African Americans, Southeast Asians, and people from the Mediterranean region, in whom it may cause hemolysis in response to medications, such as sulfonamides and antimalarial agents. Asians and African Americans may be more sensitive than whites to some psychotropic drugs. Variations in the way drugs are metabolized can alter their therapeutic effects. Hypertensive black patients tend to respond better to calcium channel blockers and diuretics than to β-blockers or angiotensin-converting enzyme inhibitors. Such examples underline the importance of “pharmaco-cultural” awareness in prescribing medications for patients of various racial and cultural backgrounds.

Gaining wisdom by hindsight

After you have had a clinical encounter with a family whose cultural background differs from your own, review the experience and ask yourself, “How could I have done better for this child and family?” Such reflection helps refine your cross-cultural sensitivity and makes your subsequent experiences with families from different cultures more satisfying for all concerned.