Many variables such as culture, socioeconomic factors, generational practices, and current trends affect patients' and families' health beliefs and practices. Routine and accepted US health care system processes, structures, and norms may be unfamiliar to patients and families from other countries or cultures. Following are some of the areas in which pediatricians are most likely to encounter differing (or a range of) perspectives.
Clinic and Emergency Department Use
Pediatricians understandably expect patients to comply with a predictable and scheduled appointment format. However, patients from other countries or cultures may be accustomed to different processes. In certain countries in Latin America, for example, patients are expected to walk in to a clinic or practice, take a number, and wait for the provider, instead of being scheduled for a specific time. Likewise, patients may favor using emergency services for non-emergent complaints rather than accessing a primary care provider. Some patients may use the emergency department as a medical home because of perceived advantages in accessibility, availability of ancillary laboratory and radiology services, and even availability of interpretive services. Pediatricians should clarify the scheduling process in their practices.
Pain and Analgesia
The expression of pain and the health-seeking behavior centered on the relief of pain varies from culture to culture. For example, in some cultures it is considered honorable and desirable to stoically tolerate pain, while these same behavior expectations are not shared by other cultures. While there are culturally associated variations in patients' expression of pain, physicians' analgesic prescribing responses to patients of different cultures also may vary. Although some research studies have demonstrated that physicians may prescribe less analgesia to ethnic and racial minority populations, there is evidence to suggest that the disparity has lessened over time.1
Traditional Practices, Alternative Medicine, and Indigenous Healers
It is increasingly recognized that some patients from the United States or other countries use alternative or traditional practices, medicines, or healers. Families may use these options prior to, in combination with, or after seeking medical care from the pediatrician. In some cultures, the concept of a "folk illness" is embraced and there is a strong belief in a definite constellation of symptoms and treatments associated with the folk illness. Pediatricians should respect patients' health beliefs that may not be consistent with a biomedical model of disease etiology. For example, some Latino/Hispanic families believe in folk illnesses such as empacho (gastrointestinal discomfort), susto (a form of panic attack), or mal de ojo (evil eye). Many traditional practices used to treat these and other folk illnesses may be entirely benign, while others have been associated with adverse health outcomes. Folk medicines such as greta and azarcon, often used by Mexican Americans, may contain elevated lead levels and have been associated with lead poisoning in children.
Bed Sharing and Sudden Infant Death Syndrome
Since the American Academy of Pediatrics (AAP) Back to Sleep campaign to decrease the incidence of sudden infant death syndrome (SIDS), there has been a substantial increase in the percentage of mothers that place their babies to sleep on their back or sides. However, in some minority populations, this public health campaign has not been as effective. African American mothers, for example, are more likely to share beds with their infants and place them in a prone position to sleep, both risk factors for SIDS. Co-sleeping is considered a culturally acceptable, if not desirable practice, in some communities. Additionally, in large families with few resources, co-sleeping can be viewed as a necessity rather than an option.
Birth and Early Infancy
At birth and immediately after birth, different cultural groups may have specific norms regarding the amount of postpartum time mothers are to remain indoors, the care of the umbilicus, early feedings, co-sleeping, circumcision, and others. In some cultures, for examples, mothers and newborns stay secluded indoors for a defined period. In other cultures, because of limited resources or cultural practices, newborns sleep in the same bed with their mother. Another example of a culturally bound practice involving newborns and babies centers on covering their heads, even if in tropical climates.
Death and Dying
Death rituals are often shaped by culture. In dying or severely ill patients, the amount of information that physicians and families share with the patient about his or her prognosis, the patient and family members' expression of grief, the use and acceptance of hospice care, the termination of life support systems, the integrity of the body and burial, and other end-of-life issues pose significant cross-cultural and bioethical challenges for pediatricians. Koenig and Gates-Williams2 offer the following helpful guidelines in dealing with these complex situations:
- Determine who controls access to the body and how the body should be approached after death.
- Consider the relevance of religious beliefs, particularly about the meaning of death, the existence of an afterlife, and belief in miracles.
- Assess how hope for a recovery is negotiated within the family and with health care professionals.
- Assess the degree of fatalism versus an active desire for the control of events into the future.
Role of Women
The culture-specific roles of women and men have the potential to affect the care of pediatric and adolescent patients. In some cultures, for example, women are expected to defer important decisions to and, in some instances, to communicate through the male figure. The concept of machismo in Hispanic cultures often portrays the masculine figure as a protector, provider, and decision-maker. Whereas the cultural connotation may be one of masculine honor and respect, it can be viewed as disempowering toward women. Men in some cultures, for example, may exert power and control over women. If men are viewed as final decision-makers on health matters, this may affect pediatricians' ability to empower female adolescent patients. This culturally bound and potentially disempowering role of women can adversely affect their ability to successfully negotiate condom use with a male sexual partner.
Role of Family
Given the cultural variability of the role of the patient's family in medical decision-making as well as healing processes, the pediatrician should respectfully ask questions with the goal of fully understanding these important issues. In some cultures, the family (nuclear and extended) is the main social unit and family members are actively engaged in all aspects of the care of the patient. In dealing with hospitalized patients, for example, pediatricians should anticipate the possibility of a large number of family members during visiting hours and the possibility of exceeding the hospital's allowable visitors' quota. Immigrant families may be divided between the United States and the country of origin, posing an added stressor in family-centered cultures.
1. Quazi S, Eberhart M, Jacoby J, Heller M. Are racial disparities in ED analgesia improving? Evidence from a national database. Am J Emerg Med. 2008;26:462–464
2. Koenig BA, Gates-Williams J. Understanding cultural difference in caring for dying patients. West J Med. 1995;163:244–249
Chapter 2 Tool and Resources
Tool 2A: AAP Healthy Child Care America: Back to Sleep Campaign
This Web site includes free, downloadable patient information materials in English and Spanish.
Resource 2A: Management Sciences for Health: The Provider's Guide to Quality & Culture: Relating to Patient's Families
This Web site provides additional tips and helpful resources to relate and interact with patients' families.
Resource 2B: Book chapter: "Analgesia" (Use "Skim This Chapter" to move to page 64.)
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Washington, DC: National Academies Press; 2003:64–66
This section of an Institute of Medicine publication provides summary of research studies on analgesia in minority populations.
Resource 2C: "Sleep Arrangements and Behavior of Bed-Sharing Families in the Home Setting"
Baddock SA, Galland BC, Taylor BJ, Bolton DP. Pediatrics. 2007;119:e200–e207