CHAPTER 8
Cultural Competency Issues in Pediatrics
W. Suzanne Eidson-Ton, MD, MS; Hendry Ton, MD, MS; Blanca Solis, MD; and Jesse Joad, MD, MS, FAAP
CASE STUDY
You are seeing AJ, a 12-year-old Mexican American boy, for a well-child visit. His mother speaks Spanish and “a little” English, is single, and works full time in motel custodial services. After school and during summers, AJ is cared for by his 17-year-old brother and his maternal grandmother, who lives a block away. AJ’s weight and body mass index are well above the 95th percentile for his age. When discussing his diet, you learn that his mother buys packaged foods that he can make for himself when she is away. She is concerned that he will not eat if she does not buy the processed, fatty foods he likes. Additionally, these types of foods are more plentiful than healthier options at the local market at which she shops. AJ sometimes eats at his grandmother’s home, but she is elderly and does not cook much anymore. When discussing physical activity, AJ states that he wants to play soccer. His mother is concerned about this, however, because he often complains of headaches and stomachaches when it is time for practice, and she does not want to buy the equipment if he will quit after a few weeks, as has happened in the past.
As is your practice with all adolescents, you ask to speak with AJ alone. During your assessment, you learn that he is attracted to boys but has not shared this information with anyone. He is certain that his brother will not approve and that his mother will be heartbroken. He is sometimes teased at school because he is “not tough enough,” and he fears some of the bigger bullies might try to jump him if he hangs around after school to participate in any after-school sports activities.
Questions
1. What is the definition of culture?
2. What is cultural competence? What is cultural destructiveness?
3. What is meant by unconscious bias?
4. Why is it important to use a certified interpreter when talking to the parent with limited English proficiency? When is it appropriate for the pediatric patient to interpret for their parent?
5. How does understanding the perspective of the patient and the parent affect medical decision making?
The provision of culturally competent care is no less important for pediatric patients than adult patients. Those who provide health care to children face many important issues concerning culturally competent care, including health disparities and health care disparities based on socioeconomic status, ethnicity and/or racial identity, sexual orientation, and gender identity. Many issues of cultural competency, health disparities, and approaches to cross-cultural care are similar across minority populations in the United States, including some rural white populations.
Definition of Culture
Culture is a set of meanings, norms, beliefs, and values shared by a group of people. It is dynamic and evolves over time and with each successive generation. Culture encompasses a body of learned behaviors and perspectives that serve as a template to shape and orient future behaviors and perspectives from generation to generation and as novel situations emerge. It shapes how and what symptoms are expressed and influences the meaning that individuals attribute to symptoms, including one’s beliefs about the causes, effects, and potential remedies for these symptoms. Culture is a broad category that includes not only race and ethnicity but also sexual orientation, gender roles, gender identity, socioeconomic status, nationality, and other group affiliations. The interaction between the culture of the patient and family and that of the physician is often significant and can result in bias in both assessment and treatment. These biases, in turn, can contribute to health and health care disparities.
Health Disparities
Health disparities are differences in health outcomes across different groups. Health care disparities, as defined by the Institute of Medicine (now the Health and Medicine division of the National Academies) in the document Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, are “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.” Health disparities and health care disparities exist within the United States and particularly affect minority populations. Although health disparities may be caused by many social determinants of health, such as socioeconomic status and access to safe neighborhoods, healthy food, and health care, health care disparities are directly related to what happens to certain patients in the health care system after they have accessed care. Addressing health disparities moves medicine and society closer to health equity, which is achieved, as defined by Braveman et al, “when everyone has a fair and just opportunity to be as healthy as possible.”
Latinx is a gender-neutral term that refers to individuals of Latin American heritage. Latinx children in the United States face significant health and health care disparities. (Throughout this chapter the term Hispanic is used for information reported from any study in which that term was used.) The Hispanic population has among the highest prevalence of overweight in children, but American Indian/ Alaska Native children having the highest rates of overweight, at nearly one-third of that population. Additionally, in the United States Hispanic children also have a lower fitness level and watch more television than white children. The reasons behind these disparities are complex and multifactorial. Many ethnic minorities and limited English proficiency (LEP) groups also face disparities in the health care they receive. For example, for minority groups the duration of their routine well-child visits is shorter and Latinx children are less likely than white children to receive counseling at these visits.
In addition to these examples of lack of access to quality health care, many social, political, and cultural elements contribute to health disparities observed in certain ethnic groups. Evidence exists to indicate that these social determinants have a more significant effect on health than medical care does (see Chapter 141). Although physicians can effectively address the social determinants of health through activism and advocacy, it may be difficult to do so on an individual patient care level. Nevertheless, it is important to understand these issues and how they may contribute to patients’ health outcomes. For example, lack of access to quality, low-cost foods in one’s neighborhood, lack of transportation, advertising practices that target low-income communities, and lack of access to safe playgrounds are examples of social determinants that contribute to obesity. It is also essential to understand the influence of culture on patients’ health beliefs, health behavior, and health status. Cultural issues are further discussed later in this chapter.
Finally, acculturation is also likely to affect health, health beliefs, and health behaviors. Second-generation Hispanic adolescents are twice as likely as first-generation Hispanic adolescents to have obesity or overweight. Similar findings have been observed in other populations (eg, Americans of Asian descent). Acculturation across generations in Hispanic communities has been associated with decreased fruit and vegetable consumption, increased soda consumption, and decreased physical activity. These effects of acculturation have been shown in other immigrant groups as well. Acculturation is a complex variable in relation to pediatric obesity, however. For example, in 1 study, Mexican American mothers who were less acculturated had children with higher body mass indices.
Cultural Competence
Physicians who strive for cultural competence attempt to minimize their bias and seek to incorporate cultural assets into their work with patients. Cultural competence is a continuum (Figure 8.1). Cultural destructiveness, the least developed state along that continuum, comprises attitudes and practices that are meant to be harmful to cultures and individuals within the particular culture. Physicians at this level may overtly discriminate against individuals based on their culture (eg, intentionally making homophobic, racist, or sexist remarks to colleagues). Physicians who have cultural incapacity do not overtly discriminate but lack the ability and willingness to recognize and intervene when discrimination happens. As a result, they ultimately reinforce culturally oppressive behaviors and policies. In the cultural blindness phase, an individual believes that culture makes no difference and that all people are the same. This viewpoint ignores cultural strengths, encourages assimilation, and often results in blaming the victims of racial injustices for their problems. Physicians at this stage may have difficulty believing in the validity of health disparities, despite the enormous body of evidence supporting the existence of such disparities. Although these physicians strive to give quality care to everyone, they do not recognize culture-specific experiences that affect patients’ health, such as poverty or violence based on race, sexual orientation, or gender, and they miss opportunities to incorporate culturally relevant strengths into treatment, such as collaboration with traditional healers, extended family, or faith-based organizations. Cultural precompetence is characterized by a willingness to deliver quality services and a commitment to civil rights but a lack of knowledge and experience to implement culturally relevant services. Culturally pre-competent physicians often struggle with knowledge that disparities exist and that perhaps they continue to contribute to them but are at a loss as to what to do about it. In contrast, physicians at the stage of cultural competence seek to expand their cultural knowledge and resources, often in consultation with culturally diverse communities. They also continuously self-assess and adapt traditional service models to enhance care for culturally diverse patients. Using native culture-based talking circles with American Indian youth to improve their understanding of obesity is an example of working at this stage of cultural competence. Finally, physicians who exhibit cultural proficiency hold cultural diversity in highest esteem and continuously advocate for increased cultural competence throughout the system of care. It is important to recognize that physicians move back and forth along this continuum dynamically, influenced by their own experiences. For example, physicians who identify with being in the culturally competent phase when working with Latinx patients may find themselves having cultural incapacity when working with gay or lesbian patients.
Figure 8.1. Steps in achieving cultural proficiency.
Another helpful model is the concept of cultural humility, which is a process of self-reflection and commitment to a lifelong learning process, thereby engaging the physician in an ongoing cou-rageous and honest process of self-critique and self-awareness. Both the cultural competence model and the cultural humility model reflect cultural competency as a process rather than an end result or a fixed state.
Communication
Initially, during every clinical visit, it is important to maximize communication with the patient and the parent (see Chapters 2, 3, and 4). Effective communication results in an improved physician-patient relationship, treatment adherence, and health outcomes. Poor communication may have negative consequences. Patients with LEP, in particular, have increased barriers to health care, decreased health quality, and decreased health status. In a Joint Commission study involving 6 hospitals, researchers found that patients with LEP were at increased risk for iatrogenic harm. In contrast, use of interpreters is associated with increased follow-up with preventive and primary care services. Ideally, a trained medical interpreter should be available to communicate with patients or parents who do not speak English. Although it happens often in clinical practice, it is inappropriate to rely on the patient to interpret for the parent. It is clearly a difficult position for a child or adolescent to interpret health information for a parent. It is not guaranteed that the patient understands what the physician is communicating or that the patient is interpreting correctly for the parent. It also disturbs the power balance between parent and child. Strategies for using interpreters are provided in Box 8.1.
Box 8.1. Strategies for Using an Interpreter in the Clinical Visit
•Talk with the interpreter briefly before the interview to discuss overall goals for the interview and ground rules (eg, use word-for-word interpretation). If using a certified medical interpreter via telephone, have a brief discussion about the goals for the interview.
•Give the interpreter and the patient permission to ask questions about terminology with which they may be unfamiliar.
•Use nonverbal behaviors, such as eye contact, nodding, and facial expressions, to signal to the patient that the physician understands what is being communicated.
•Speak directly to the patient and address the patient in the first person.
•Use short, simple statements and speak on 1 topic at a time.
•Avoid medical jargon and ambiguous statements.
•Meet briefly with the interpreter after the interview to confirm pertinent information, ask about cultural information, and discuss feedback. Do this with telephone interpreters as well.
•Remember that interpreters are not medical professionals. Therefore, consider information volunteered by interpreters as being reliable as collateral information provided by other individuals who are not health professionals.
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