Cultural Perspectives for Pediatric Primary Care

3 Cultural Perspectives for Pediatric Primary Care



Ardys M. Dunn


The ethnic and cultural face of America has changed rapidly in the past decade, and the population continues to become more diverse. From 2000 to 2009, more than half a million refugees or asylum seekers entered the U.S. Each year between 500,000 and 1 million immigrants were naturalized as U.S. citizens, and more than a million immigrants were granted legal permanent residence or “green card” status (Department of Homeland Security, 2010).


Many immigrants to the U.S. are unauthorized; that is, they entered the U.S. without documents or, having entered with proper documents (e.g., student visa), have overstayed their time limit. A recent review of U.S. census data by the Pew Research Center concluded that nearly 12 million unauthorized immigrants live in the U.S. This group is more likely than U.S. citizens or documented immigrants to live in families with children, and about 73% of children in these families are born in the U.S., making them U.S. citizens (Passel and Cohn, 2009). The stress of immigration, especially if exacerbated by an unauthorized entry or a history of having come from an area of war, famine, or dislocation puts families and children at risk for physical and psychological health problems. Health care providers must consider these circumstances when assessing and managing care for immigrant and refugee clients.


In addition, significant health disparities continue among minority cultural groups in the U.S. For example, the 2005 infant mortality rate for non-Hispanic blacks was 13.3 per 1000 live births, in contrast to an overall rate of 6.8 per 1000 live births and 5.7 for non-Hispanic whites (Centers for Disease Control and Prevention [CDC], 2011a). These disparities have not changed since 1995 and have been attributed in part to a lack of communication between providers and patients that may be related to cultural differences (Fadiman, 1997; Pavlish et al, 2010).


In response to demographic changes and in an effort to mitigate health disparities, many health education institutions have created curricula to develop more culturally competent providers (Calvillo et al, 2009; Kripalani et al, 2006). Evaluation of these curricula is just beginning and data vary on the difference they make in provider attitudes and health outcomes as well as how to best evaluate the programs (Bhui et al, 2007; Lie et al, 2008; Mostow et al, 2010; Sequist et al, 2010). Because of the complex circumstances of immigrant and ethnic communities, cultural competence needs to be expanded to incorporate a “critical awareness” of broad social, economic, and political dynamics. Educational programs must prepare clinicians to deal effectively with the complex interrelationship of variables that influence health behaviors, decisions, and outcomes, only one of which is culture per se (Airhihenbuwa and Liburd, 2006; Kumagai and Lypson, 2009; Underwood et al, 2005). Having this skill gives clinicians the ability to provide high-quality health care to all populations.


This chapter reviews some of the basic principles of cultural dynamics, emphasizing that environmental, economic, and social factors are integrally woven into the fabric of every client-provider encounter and that clinicians must consider the reality of individual history, experience, and meaning in every interaction. A new section has been added outlining care of recent immigrants and refugees. A more comprehensive discussion of the challenge of providing culturally competent care and eliminating health disparities for immigrants in the U.S. can be found in Walker and Barnett’s Immigrant Medicine (2007).



image Culture


Culture is defined as a set of “patterns, explicit and implicit, of and for behavior,” “acquired and transmitted by symbols” and based on “traditional [i.e., historically derived and selected] ideas and … their attached values. Culture systems may, on the one hand, be considered as products of action, on the other as conditioning elements of further action” (Kroeber, 1952). In an anthropologic and sociologic sense, culture is a social construction of the relationships within and among groups of human beings, specifically created through the ongoing interactions of individuals with others and with their environment (Berger and Luckmann, 1966). It is based on ethnicity, race, religion, class, and geography. The term ethnicity is used to identify groups of people within society, each of which shares distinctive traits and customs. Race, in contrast, classifies humans according to specific physical characteristics (e.g., pigmentation, facial features). Humans also differ by religion, social class, and the physical place or environment in which they experience life. All of these qualities contribute to shaping the culture of the social group.



Universal Characteristics of Culture


Although a cultural group may possess unique qualities, all cultures have certain common characteristics. These universal characteristics of culture represent the framework within which cultures exist. Understanding these characteristics gives health care providers a starting point from which to learn about the more specific culture of their client base. One must take care, however, not to assume that all members of a group share the same qualities; no one quality is definitive of a culture, and within cultural groups, individuals show great variation in behavior and beliefs.



Culture Is Dynamic and Shared


As both a product and function of human interaction, culture is constantly evolving; there is no absolute, reified quality that can be attributed to a group of humans. In most societies, a dominant group is clearly evident. The culture of this group largely shapes the lifestyle and collective consciousness of the community, functions as the guardian and sustainer of the controlling value system, and allocates rewards. Generally, individuals in a society learn to identify with the dominant cultural framework and incorporate its traditions and customs into their daily life and decision-making. The extent to which this adaptation of culture occurs is termed cultural embeddedness. Many factors influence the degree of cultural embeddedness, including level of education, socioeconomic status, social class, country of origin of individuals or their ancestors, exposure to other cultures, lifestyle, length of stay in the host country, and the exact region of the host country in which individuals grow up, reside, or both.


Individuals may also identify with a minority group (i.e., a group that shares racial or ethnic characteristics that differ from those of the majority group) or may have a number of subcultural affiliations based on gender, social class, religion, occupation, or socioeconomic status. In diverse societies, especially where minority groups are large or their members are vocal proponents of retaining their cultural integrity, assimilation into the dominant culture may not be easy or automatic, and cultural confusion or conflict may occur. Characteristics (e.g., skin color, religion) that set a minority group apart from the dominant group may result in collective discrimination within the society. Ethnocentrism and racism create and perpetuate the distinctions of dominant and minority groups. Ethnocentrism is the belief that one’s own ethnic culture or subculture is superior to all others. Racism is the assumption of inherent racial superiority or inferiority with consequent discrimination.


An individual or group that straddles two or more cultures and embraces more than one set of values is termed bicultural, but efforts to achieve this status can be a source of considerable stress. Tremendous intraethnic diversity may exist in life perspective, values, problem-solving strategies, and customs among individual members of dominant and minority groups. Thus one can expect to see variations within and between cultures. In diverse societies, all cultural groups will change as a result of their interactions.



Culture Is Learned


The elements of culture are transmitted from one generation to another through a complicated process of social interaction. This socialization process shapes a child’s reality; children learn how to perceive the world, the values, ideologies, and rules that motivate and define behavior. This learning is facilitated by the long period of dependency that humans have before reaching physical and social maturity and depends on the child’s temperament and biologic capabilities. Social institutions such as the family, school, peer groups, and media influence and support cultural socialization.



Family


The family is the first socializing force an individual encounters. A powerful primary group, the family provides material and psychological support and exposes the child to a set of values in the context of intensely personal relationships. Children first learn patterns of socially appropriate (or inappropriate) behavior in the family. Each culture possesses its own values, attitudes, and practices with regard to families and child rearing, and care and guidance are provided in culturally prescribed ways. Family dynamics can facilitate conformity to the prevailing standards and codes of behavior. As active family members, children develop their own personalities and a sense of self; the family provides the opportunity to identify feelings and emotions, express ideas and thoughts, and practice interactional skills that children will use throughout their lives.



School


The school functions to expand the child’s socialization beyond the boundaries of the family. Schools serve as models for much of the adult social world, teaching children strategies for negotiating one’s way within the institutions of adult society (e.g., workplace, politics, or organized recreation). For many children, schools may provide stability, opportunities for creative expression, and learning. A sense of collective identity and responsibility to the group may grow as children engage in school activities. For others, school experiences can have a negative effect on the child’s sense of self, leading to a feeling of rejection and isolation from the group.



Peer Group


Peer groups play a powerful role in socializing children to their culture, especially among older children. Peer groups can place children in a position of social equality unlike the socially inferior position that they may experience at home or in their school or community role. Through peer interactions, children explore their identities, give and receive validation of appropriate behavior, and further consolidate a sense of self.



Media


Television, radio, magazines, newspapers, films, and electronic media (e.g., phones, internet, texting, blogging) have an enormous influence on the cultural socialization of children, especially in the developed world. As an audience, contemporary Americans are conditioned to receive mass culture passively via these vehicles. Through the media, the child is exposed to a wide array of values, many of which conflict with those of the family and/or the school.



Culture Is Symbolic


Communication takes place between humans using cultural symbols such as language (verbal and nonverbal), dress, food, music, dance, sports, and other activities. The extent to which individuals understand and master these cultural symbols will shape their self-concept, how others perceive them, and their ability to function within and contribute to their culture.



Culture Is Integrated


Culture is reflected in and influences all aspects of an individual’s life. The cultural values, beliefs, and behaviors one learns are embedded in the fabric of one’s life and can be generalized from one social arena to another. Ideas about the appropriate behavior of children may extend from the family to the school to the community (e.g., “children should be respectful to adults”). On the other hand, a cultural group may have different expectations in different roles; for example, language used among peers in the street may be very different from that used in the school or at home.


Attitudes and behaviors regarding health, wellness, disease, and disability are an intricate part of this cultural framework.



Cultures in American Society


The population of the U.S. consists of numerous ethnic groups, races, and subcultures and is becoming increasingly diverse. It is often broken down into the dominant white middle class and a number of minority groups, including African Americans, Hispanic Americans, Asian Americans, Native Americans, Russian Americans, and Arab Americans. Within each of these categories, there are many subgroups. For example, most providers would include families from Iran, Syria, and Iraq in the category of “Arab Americans,” yet the cultural differences between each are immeasurable, and, though they may share some common characteristics, each is unique and constantly changing.


To present descriptions of each cultural group is beyond the scope of this text. Instead Table 3-1 lists some of the more common health issues found in some cultural groups. It must be remembered that these health issues are not exclusive to a particular culture; they may be, however, overrepresented in some groups (e.g., lead poisoning in African-American children) because of environmental, social, economic, and class factors, not intrinsic cultural characteristics. Thus, though cultural competence on the part of providers is essential, institutional, political, and social change will also have to occur before full equity in health care is realized. That, too, is a discussion beyond the scope of this text.


TABLE 3-1 Common Health Issues Found in Some Specific Cultural Groups






























































































Cultural Group Health Issue
African American High infant mortality rate
Sickle cell trait and disease
Hypertension
Obesity
Type 2 diabetes mellitus
Type 1 diabetes mellitus with beta-cell destruction
Slipped capital femoral epiphysis
Blount disease
Lead poisoning caused by environmental exposure in urban areas
Violence
Asian American Lactose intolerance
Tuberculosis
Dental caries
Cleft lip and palate
Caucasian Rett syndrome (girls)
Tay-Sachs disease (Ashkenazi Jew; French Canadian)
Tyrosinemia (French Canadian; Scandinavian)
Celiac disease
Cystic fibrosis
Phenylketonuria (Northern European)
Pyloric stenosis (Northern European)
Blount disease (Northern European)
Lactose intolerance
Type 1 diabetes mellitus
Glutaric aciduria type 1 (Amish and Hutterites; Canadian)
Lice
Latino Dental caries
Obesity
Type 2 diabetes mellitus
Blount disease
Asthma
Native American (American Indian) Otitis media
Poor prenatal care, low-birthweight babies, high infant mortality rate
Alcoholism
Unintentional injury
Samoan or Polynesian Dermatological conditions
Obesity
Slipped capital femoral epiphysis
Russian Obesity
American Alcoholism


image Providing Culturally Competent Care



Developing Cultural Competence


Today’s U.S. health care providers should be culturally competent in the care they provide. The effort to develop cultural competence is an excellent example of the dynamic nature of culture: U.S. health care providers are members of a particular personal and professional cultural group; their clients represent different cultures, and the intercultural exchange among clients and providers will change the nature of health care in America.


Cultural competence is the ability to communicate among cultures and demonstrate cultural skill outside one’s culture of origin. It is based on empathy, respect, and knowledge and requires a fundamental recognition and valuing of culture as a distinctive way of life. The culturally competent provider’s focus is not on how to interact with clients so that they will comply with a medical regimen. Instead, culturally competent providers work with clients to increase mutual understanding, share information and knowledge, strengthen clients’ control of their health, and construct more healthful decisions.


To achieve cultural competence, providers must work to:



• Understand and, if necessary, change their worldview


• Become familiar with core cultural issues


• Increase their knowledge about core cultural issues related to health and illness


• Become knowledgeable about the particular cultural groups to whom they deliver care and with whom they work, in general, and in terms of health and illness


• Develop skills that provide a basis for effective communication and negotiation between client and provider



Worldview


A worldview is a conceptual framework that allows members of a social group or culture to answer fundamental questions such as “How does the world function?” “Why does it operate that way?” “Where is it going?” “What does it mean? “What values, ethics, and moral standards is it working from?” “How should we act?” and “What is true or false?” “What is knowledge?” In the U.S., for example, the dominant worldview tends to reflect an activist, rational-mastery, future-oriented approach to life. It is based on a perception of independence and autonomy, and it values acquisition and power. Diversity of ideas, race, ethnicity, and lifestyle may be given little value unless they are useful to those in power. Incidents of discrimination based on race, gender, age, or sexual orientation can be outcomes of this perception.


Various aspects of worldviews have been identified and are often presented as dichotomies for purposes of comparison: for example, individualism versus collectivism; masculinity versus femininity; linear thinking versus global thinking. An example related to health care would be the U.S. culture of “individualism,” in which clients make their own decisions about treatment, as opposed to a Southeast Asian culture of “collectivism” (e.g., Hmong), in which the family is actively involved in deciding what treatment will be done. The dualistic thinking reflected in these taxonomies has come under criticism as being too simplistic, however, because it does not help explain the subtle nuances of cultures or the complexities of behaviors of members of social groups (Turiel, 2004). To understand human behavior, one must look at interaction within the larger socioecological context. Not all Hmong clients rely on family members to help them make decisions about health treatments, for example; nor do all Americans make their decisions independently. Though culture is a vital element in why people make the choices they do, those choices depend on many other factors as well.


For health care providers working with clients from a cultural group other than their own, this means two things: first, they need to examine their own worldview, look at what social and cultural dynamics affect their thinking and behavior, and determine how this influences their practice and interaction with clients. A relevant example might be clinicians who work with adolescents. Clinicians are part of an “adult culture.” To effectively work with adolescents, they need to reflect on what their “adult” perceptions are regarding teenagers and how those perceptions structure their approach to the client. There are additional dynamics to consider: Providers have experienced their own adolescence and have had their worldview shaped by that experience. They bring those perceptions to the interaction with their adolescent client (some providers have said, “Two people walk into the exam room when I see an adolescent—me as an adult caregiver, and me when I was 16 years old”). How do health care providers’ worldviews affect their thinking about this client? How, in turn, does this thinking influence the way they interact with adolescent clients? Additionally the current life situation of the provider may be important to consider; perhaps he or she is struggling with a rebellious teenager at home. This personal concern could change the provider’s ability to provide high-quality care to adolescents.


Second, health care providers must be open to understanding the worldview of their clients and be willing to adapt their own in order to find the most effective way of providing health care. For example, problem-solving approaches vary among cultures. Not everyone solves problems in the linear, cause-and-effect way often attributed to the dominant culture in the U.S. If clinicians present a health problem and its solution in a linear fashion and insist that their patients and families use the same perspective, they should not be surprised if the patient is sometimes “noncompliant.” An example might be a child who has a fever. Based on their worldview, clinicians begin a diagnostic process of examination and laboratory testing to rule out causes, with some idea of an infectious agent in the back of their mind that may need to be treated with an antibiotic. The family, however, may attribute the fever to a nonbiologic cause, and may have a more reflective, circuitous problem-solving style, part of which is a wait-and-see attitude. They may typically let the child’s body do what it will in response to the fever or may provide support in traditional cultural ways that involve preparation and time (e.g., sweats, prayer, chicken soup). Of added concern, conflicts in cultural worldviews may contribute to psychological problems created by stress that go beyond simple culture shock (Caldwell-Harris and Ayçiçegi, 2006) or to the labeling of clients as having problems, primarily psychological, when their behavior is actually consistent with their own deep-seated cultural expectations (Chen et al, 2009).

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Cultural Perspectives for Pediatric Primary Care

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