Skills for Culturally Sensitive Care

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chapter 2 Skills for Culturally Sensitive Care

Richard B. Goldbloom

As the traveller who has once been from home is wiser than he who has never left his own doorstep, so a knowledge of one other culture should sharpen our ability to scrutinize more steadily, to appreciate more lovingly, our own.

IN COMING OF AGE IN SAMOA (1928)

BY MARGARET MEAD

Many years ago, a resident was presenting the history of a sick Latino child to a distinguished American professor of pediatrics. The resident reported, “I wasn’t able to obtain a complete history because of the mother’s language difficulty.”

“Just a moment!” the professor interjected. “Whose language difficulty?”

This vignette says it all about an essential element of effective doctor-patient communication: We have a fundamental responsibility to provide sensitive care for all families whose ethnic or religious background, color, language, or culture differs from our own. You owe it to your patients to familiarize yourself with the customs and beliefs of the various ethnic and cultural groups that are represented in your own community. It is simply an issue of respect.

Each distinct group has its particular values and beliefs, traditions of acceptable and unacceptable behaviors, special patterns of speech and gesture, gender roles, health practices, customs, beliefs about the causes and cures of illness, birth and death rites, attitudes about transfusion, autopsy, organ donation, and organ transplants, food practices and intolerances, attitudes toward authority, and child-rearing practices. Each group also has its traditional style of displaying emotions such as fear, pain, grief, concern, pleasure, and disagreement. Skilled clinical assessment requires that you know and respect these differences. It also requires preparatory work. Faced with a family from a culture different from your own, you have no time to excuse yourself to brush up on their particular beliefs and customs, so come prepared.

Growing Scope Of Multiculturalism

The racial and cultural kaleidoscope of most developed countries is diversifying rapidly. In 1990, about 75% of the U.S. population was of white European descent. It is estimated that by 2020, this proportion will have decreased to 53%. Currently, 25% of all children younger than 5 years in the United States come from racial or ethnic minority backgrounds. This percentage is predicted to rise to 48% by 2025. In Canada’s 1996 census, more than 10% of the population consisted of visible minorities, with a high proportion of immigrants coming from a wide variety of ethnic and cultural backgrounds, and about 25% in the pediatric age group. These trends emphasize the growing importance of culturally sensitive health care. Concurrent with these striking demographic changes, marriages (and adoptions) between people of different races and cultural backgrounds are increasing steadily.

Key Point

Do not assume, on the basis of language, dress, or ethnicity, what the ideas and beliefs of a particular individual or family may be. Characteristics common within a group do not necessarily predict those of the individual or family.

Dangers of Stereotyping

We all run the risk of stereotyping linguistic, cultural, or religious groups, frequently on the basis of very limited exposure to them. The populations of most countries are heterogeneous with respect to language, traditions, and customs, and beliefs and practices vary as much within as between groups. Characteristics that may be common within a cultural group do not necessarily predict those of a particular individual or family from that group. Do not assume, based on language, dress, or culture, what an individual’s ideas or beliefs may be.

Cultural Disadvantage in Health Care

Many studies have consistently demonstrated that children whose racial or ethnic backgrounds differ from those of the mainstream population experience disadvantages regarding the frequency with which they receive health care and the quality of the care they receive. Many complex factors undoubtedly contribute to this discrepancy, including economic disadvantage, linguistic difficulties, an undersupply of culturally competent caregivers, transportation difficulties, and unmet needs for child care. Some families have difficulty following instructions for medications or other treatments. In the United States, even after adjustments are made for socioeconomic factors, health conditions, and number of physician visits, black and Hispanic children have been found to be less likely to receive prescription medications and to receive fewer services when hospitalized. Unfortunately, the diversity of ethnic and cultural backgrounds among health care providers has not kept up with the diversity of the people we serve.

Family Hierarchies—Who Are the Authorities and Decision-Makers?

Although many Western cultures have evolved over recent decades from a patriarchal to a more egalitarian model of family authority, other cultures have very different traditional hierarchies. These structures must be understood and respected by anyone caring for children. Among Vietnamese families, for example, the father is traditionally the decision-maker and the mother defers to him. The same is true in Saudi Arabian families, and, during family interviews, the father may answer questions directed to the mother. Physicians who address questions or comments to a parent who is not the traditional family leader may inadvertently upset both parents. Among traditional Chinese families, the loyalty and deference of younger persons to older family members is strictly observed by people of all ages. Preservation of family honor (“saving face”) is very important in Japanese families, and children’s unacceptable behavior may be regarded as reflecting unfavorably on their parents. In some Southeast Asian cultures, parents may be reluctant to make decisions about their children without consulting their traditional community leaders, whom they may regard as part of the extended family.

Get the Names Right

Many cultures do not follow the traditional Western naming system, in which everyone’s personal name is followed by a surname. Among traditional Chinese families, for example, the family name comes first, followed by a personal name that often is in two parts and sometimes is hyphenated. The Vietnamese use a similar system. South Asian Muslims have no tradition of a family name. Traditional Sikhs do not use a family name, only a first name plus a male or female title—Kaur for women and Singh for men. Make every effort to use, pronounce, and record names correctly. This courtesy is another important expression of respect.

Communication

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.

Key Point

When a parent nods his or her head in apparent assent while you are talking, do not assume that this means “I understand” or “I agree.” The best way to find out what parents have understood is to ask them to reiterate their understanding of the situation toward the end of the interview.

Disciplinary Practices

In some cultures, physical punishment has been a traditional form of parental discipline and should not be equated automatically with child abuse. What is considered a problem behavior in one culture may be seen in a very different light in another culture.

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