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AMERICAN

ACADEMY OF PEDIATRICS

Culturally Effective Pediatric Care: Education and Training Issues


1. Committee on Pediatric Workforce Next Section

Abstract
This policy statement defines culturally effective health care and describes its importance for pediatrics. The statement also defines cultural effectiveness, cultural sensitivity, and cultural competence and describes the importance of these concepts for training in medical school, residency, and continuing medical education. The statement is based on the premise that culturally effective health care is important and that the knowledge and skills necessary for providing culturally effective health care can be taught and acquired through 1) educational courses and other formats developed with the expressed purpose of addressing cultural competence and/or cultural sensitivity, and 2) educational components on cultural competence and/or cultural sensitivity that are incorporated into medical school, residency, and continuing medical education curricula. Previous SectionNext Section

CULTURALLY EFFECTIVE PEDIATRIC CARE: EDUCATION AND TRAINING ISSUES


The pediatric patient population in the United States is continuously becoming more culturally diverse. It is estimated that by the year 2020, approximately 40% of school-age Americans will be minority group children.* The American Academy of Pediatrics (AAP) recognizes that the cultural diversity of the population has implications for the provision of pediatric health services. The Academy recognizes the importance ofculturally effective pediatric health care, which is defined as: the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions. Such understanding should take into account the beliefs, values, actions, customs, and unique health care needs of distinct population groups. Providers will thus enhance interpersonal and communication skills, thereby strengthening the physician-patient relationship and maximizing the health status of patients.**

The American Medical Association considers cultural competence and culturally effective health care as synonymous terms but, has retained the use of the term cultural competence because of its widespread use and acceptance in the literature.1 Culturally effective health care is related to cultural competence and cultural sensitivity. However, whereas cultural competence and cultural sensitivity refer to the provider's attributes, the term culturally effective health care refers to the interaction between the provider and patient. Thus, culturally effective health care is based on cultural sensitivity and cultural competence, but also goes beyond these concepts in describing the dynamic relationship between provider and patient. To promote the provision of culturally effective health care to pediatric patients, the Academy recognizes the need to develop education and training materials and courses. The provision of culturally sensitive health care, according to Pachter,2 (chapter 4, page 16) involves three necessary steps: 1) the pediatrician needs to develop an awareness of the commonly held cultural beliefs and the culturally normative interactive styles in the patient's cultural group; 2) the pediatrician needs to assess how the beliefs and behaviors of this cultural group affect the patient or family; and 3) to optimize patient care, the pediatrician and the patient must negotiate between the ethnocultural beliefs and practices of the patient and those of the culture of biomedicine. Culturally effective health care can be promoted through education in cultural competence and cultural sensitivity training at all levels: medical school, residency training, and continuing medical education. These educational efforts should enhance the knowledge and understanding of pediatricians and nonpediatricians about the culture of their patients, and increase the ability of pediatricians and nonpediatricians to provide care in a manner that is responsive to the individual needs of each patient. To provide effective health care to pediatric patients, clinical expertise and strong interpersonal skills have always been important. At every level of education, child health providers must be able to interact effectively and comfortably with patients and their families. In addition, pediatricians and nonpediatricians need to be sensitive to the sociocultural background of their patients. The Academy believes that knowledge and skills for providing culturally effective health care can be taught and acquired through 1) educational courses and other formats developed with the sole purpose of addressing cultural competence and/or cultural sensitivity, and 2) specific educational components on cultural competence and/or cultural sensitivity within the curricula of the medical school, residency programs, and

continuing medical education programs. The Academy recognizes the importance of addressing race and ethnicity in clinical courses, when race or ethnicity are related to variations in treatment or outcomes. Previous SectionNext Section

BACKGROUND
Indicators of child health status, including low birth weight, infant mortality, and immunization rates, demonstrate ethnic differences in health status. In general, minority children have less favorable indicators of health status than white children. Health status may be influenced by many factors, including access to health services. There are numerous barriers to quality health care services for minority children such as poverty, geographic factors, lack of cultural sensitivity, racism, and other forms of prejudice. In its 1994 report, the AAP Task Force on Minority Children's Access to Pediatric Care expressed concern that the health services provided by many institutions in the United States reflect the values of the majority culture.3 Patients and families that have a different cultural orientation may experience difficulties in their interactions with health professionals, and these difficulties may have an adverse impact on the delivery of health care. Medical students, pediatric residents, and practicing pediatricians must enhance their ability to provide needed health care to minority group children through training in cultural competency and sensitivity. Because ethnic minorities are underrepresented among health professionals, patients and providers often have different cultural backgrounds. In these instances, language, socioeconomic status, and ethnicity may influence the provision of health services. All patients have culturally based concepts about health and illness. When patients' and families' cultural perceptions of health, illness, and treatments conflict with the pediatrician's diagnosis or management plan, cultural differences may become barriers to access to care or the provision of health care services. Cultural differences in verbal and nonverbal communication also have the potential to serve as barriers to effective pediatric care. However, the role of culturally linked behavior styles that may influence the provider-patient interaction, including eye contact and communication styles, has not been fully described. In addition, there may be communication anxiety during social interactions between individuals in underrepresented cultural groups and individuals holding expert roles such as physicians and social workers.4 There is an inherent imbalance of power in all physician-patient relationships, as the patient is in a position in which he or she is seeking advice or care from a physician in his or her role

as an expert or consultant. This imbalance may be even more pronounced when patients are from underrepresented cultural groups, and therefore may pose an even greater barrier to effective communication with these patients. The clinician's awareness of this imbalance may help to enhance his or her ability to overcome this potential barrier. Patients from some ethnic minority groups may also have unique health issues that the pediatrician must consider to provide optimal care, such as sickle cell anemia and certain hemoglobinopathies. To provide effective health services, providers must be able to communicate clearly with patients and their families. Just as there may be culturally based communication barriers between providers and patients, there may also be communication barriers between providers who have different cultural backgrounds. Health care providers at all levels and in all disciplines must be aware of the potential for miscommunication, particularly when there are socioeconomic, racial, or ethnic differences between providers. Previous SectionNext Section

CONSIDERATIONS FOR EDUCATION AND TRAINING


To provide culturally effective health care for pediatric patients, education and training are needed for child health providers at all levels. The Academy recognizes the value of these educational tools and programs, and calls for their development and incorporation at all levels of pediatric education: medical school, residency training, and continuing medical education. A variety of programs already exist, but the programs are quite variable. In addition, the availability of these programs varies according to geographic location.

Medical Student Education


A 1997 telephone survey of Deans of Students and/or course directors in the United States and Canada found that 85% of the 122 US medical schools incorporated multicultural issues with one to three lectures provided in larger courses or electives. However, only 9% of the 122 US medical schools taught cultural sensitivity as a separate course for medical students, and 7% had no multicultural program. Most of the courses used case-based instruction, with both didactic and group learning components, and virtually all courses (96%) were taught only in the first 2 years of medical school. The ethnic groups covered in these courses included Latinos (32%); African-Americans (31%); AsianPacific Islanders (21%); Native Americans (15%); and no specific focus

(36%).5 As a joint effort, the Council on Medical Student Education in Pediatrics and the Ambulatory Pediatric Association (APA) developed the General Pediatric Clerkship Curriculum and Resource Manual for clerkship directors to encourage the utilization of formal curricular goals and objectives. The manual cites cultural sensitivity and tolerance of difference among the important personal characteristics that are essential foundations for the medical student. This manual also outlines both learning objectives and competencies for medical students that relate to the provision of culturally effective health care.6

Residency Training
The program requirements for residency education in pediatrics developed by the Residency Review Committee call for structured educational experiences that prepare residents for the role of advocate for the health of children within the community and the inclusion of the multicultural dimensions of health care in the curriculum.7 The APA document, Educational Guidelines for Residency Training in General Pediatrics, includes goals, objectives, and references that relate to family, cultural, and ethnic issues. The goal that relates specifically to cultural, ethnic, and community sensitivity calls for the resident to recognize the importance of understanding, accepting, and appreciating cultural diversity in one's own patients and learn about the health-related implications of cultural beliefs and practices of groups represented in one's community. Ten specific objectives for addressing this goal are provided.8 An additional APA document, Training Residents to Serve the Underserved: A Resident Education Curriculum, provides guidance to medical educators in teaching residents about the provision of culturally effective health care. This curriculum outlines special considerations for treating ethnic minority groups within the pediatric population by identifying specific areas of knowledge and skills, necessary attitudes, and suggested advocacy activities that have the potential to enhance the provision of culturally effective health care. The curriculum also notes issues that might serve as potential barriers to providing culturally effective health care.9 Further study is needed to understand the usefulness of this curriculum.

Continuing Medical Education


The changing demographic characteristics of the pediatric population underscore the importance of culturally effective health care for pediatrics. Beyond residency training, pediatricians and other providers of child health care can benefit from continuing education to enhance the provision of culturally effective health care. As a lifelong learner,

the pediatrician should advocate for efforts that will enhance the provision of culturally effective health care. In addition, the use of patient satisfaction scoring systems and other measures of quality and outcomes will place greater emphasis on ascertaining and monitoring the cultural sensitivity and effectiveness of pediatricians and nonpediatricians. The medical literature on cultural competence and/or cultural sensitivity provides information for enhancing cultural effectiveness in pediatrics. In addition, other resources exist that may be helpful in identifying important components for educational activities to enhance the provision of culturally effective health care. For example,Culturally Competent Health Care for Adolescents: A Guide for Primary Health Care Providers discusses how the primary care physician can assess cultural factors within a health history, and how to modify patient management plans to accommodate cultural influences.10 Educational programs may include a component that allows the individual participant to engage in a personal analysis of beliefs and values. Programs may focus on the communication aspects of providing culturally effective health care by exploring how assumptions and stereotypes influence interactions between providers and patients, as well as between providers. Programs need not be all-inclusive or completely group-specific to discuss variations in the values and communication styles of various racial and ethnic groups. Because individuals are influenced by their own personal experiences and may or may not subscribe to group norms, individuals who share the same cultural background may think and act quite differently. For this reason, it is important that programs intended to address the cultural values and practices of specific groups not perpetuate stereotypes. Also, as Pachter notes, culture is not static, and changes occur over time. An appreciation of cultural change and the significance of intracultural diversity (variation among individuals within the same culture) prevents cultural stereotyping.11 Programs aimed at enhancing the provision of culturally effective health care should be tailored to the demographics of the pediatric population or community the pediatrician serves. Programs can emphasize the advantage of assessing cultural beliefs and practices directly from patients and families, rather than making assumptions about race, ethnicity, or culture. Pediatricians and nonpediatricians must use their knowledge of the cultural beliefs and practices or ethnic groups along with information learned from the individual patient or family. The pediatrician should encourage the patient and family to describe their cultural characteristics and health beliefs during patient encounters.

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CONCLUSION

Education and training to enhance the provision of culturally effective health care must be integrated into lifelong learning for pediatricians and nonpediatricians. This learning process involves both the curricular and clinical phases of medical school, residency training, and postresidency continuing medical education. Through these activities, current and future pediatricians and other child health providers will be prepared to meet the needs of all children, including children from racial and ethnic minority groups and children from other cultural minority groups. On the basis of the discussion and concepts within the statement, the Academy sets forth two general recommendations for the pediatric community: 1. To develop and evaluate curricular programs in medical schools and residency programs to enhance the provision of culturally effective health care. 2. To develop continuing medical education materials for pediatricians and nonpediatricians with the goal of increasing culturally effective health care.

Committee on Pediatric Workforce, 19971998


Elena

Fuentes-Afflick, MD, FAAP, Lead Committee Author J. Stoddard, MD, FAAP, Chairperson V. Britton, MD, FAAP

Jeffrey

Carmelita M.

Rosario Gonzalez-De-Rivas, MD, FAAP N. Keith, MD, FAAP G. Nelson, MD, FAAP

Stephen Kathleen Robert

Nordgren, MD, FAAP J. Pan, MD, FAAP

Richard Debra Jerold

Ralston Sowell, MD, FAAP C. Woodhead, MD, FAAP

Liaisons

Frances Ted

J. Dunston, MD, FAAP, National Medical Association

D. Sigrest, MD, FAAP, AAP Resident Section W. Tunnessen, Jr, MD, FAAP, American Board of Pediatrics

Walter

Former Committee Members (Retired 1997)


Rear Mary

Admiral Marion J. Balsam, MD, FAAP A. McIlroy, FAAP, MD

Principal Staff Author


Mary

Ruth Back, Health Policy Analyst

Considering the worldwide diversity of cultures, the diversity of cultures in the United States, and the diversity within any culture, no pediatrician can be expected to be an expert on all cultures that he or she might encounter. What can be expected of the pediatrician, however, is expertise in a set of issues related to understanding how culture impacts the quality of pediatric care and health outcomes. This chapter is directed at facilitating understanding of this complex interaction between culture and pediatric practice. Culture and ethnicity are relevant to culturally competent clinical care of children and to understanding children and the experience of childhood as relevant to health. The National Academy of Sciences' evaluation of the current science of early childhood development made culture the second of 10 core concepts: Culture influences every aspect of human development and is reflected in childrearing beliefs and practices designed to promote healthy adaptation. However, the complexity of culture and ethnicity in relation to health leaves many questions unanswered. Current demographic trends in the United States demand a high standard of culturally informed, or culturally competent, health care. As projected, European-Americans will not retain their majority status, and the minority-majority transition will occur at an earlier date for children. Pediatricians can expect to see greater percentages of diverse populations in their practice and research. Demographic trends take on even more importance in pediatric care when coupled with the growing body of evidence on cultural and ethnic disparities in health resulting from a combination of lifestyle issues influenced

by socioeconomic disadvantage, biologic and genetic factors, and access to and use of health care. Culture and ethnicity potentially affect all of these matters. Among the most compelling reasons for the tie of culture and ethnicity to pediatrics is that pediatrics, like no other branch of medicine, has the opportunity to shape an individual's lifelong perceptions of health care and use of health services. In addition to enhancing individual health, there is the potential for influence on the health of populations. Children are often at the forefront of societal and cultural change related to health and well-being, such as public health campaigns for smoking cessation and seatbelt use. 11 CULTURE AND ETHNICITY Many definitions of culture center on the ideas of culture as a learned, shared, and interpretive force that guides interactions among people. Culture is a broader term encompassing ethnicity. Children are not passive recipients of socialization into their culture, rather they shape and reinterpret it. Culture is experienced variably by different members of a group; it is not static, but dynamic and constantly changing. Ethnicity, which is generally used by lay people synonymously with culture, refers to group membership by virtue of common ancestry. This membership can be self- or otheridentified. The terms culture, ethnicity, and race should not be used interchangeably or synonymously, and care should be taken not to confound culture and ethnicity with religion or socioeconomic class. The relationship of culture and ethnicity to health care, including pediatrics, has been obscured by the use of major census categories to designate groupings of people, such as Latin-American/Hispanic, Asian/Pacific Islander, Native American, and AfricanAmerican. There are many distinct groups found within the census categories. The designation European-American similarly encompasses a wide range of cultures and ethnicities. These categories, which have found their way into common parlance, do not reflect cultural reality and may, in fact, mask rather than illuminate culture. At best, these categories can be used as shorthand or a starting point. Geographic considerations also are less frequently noted, such that Puerto Ricans, for example, living in New York may be quite different from Puerto Ricans living in Cleveland. Variability within any cultural or ethnic group often exceeds that between groups, and populations continually adapt to changing circumstances. Furthermore, when culture or ethnicity is identified on the basis of phenotypic characteristics, such as skin color, such groupings may not be meaningful

designations of culture or ethnicity, but instead serve as proxies for socioeconomic status. Both culture and medicine are dynamic and constantly changing. For example, in recent years the extensive use of nonconventional and alternative remedies by the American public, including children, has been recognized (see Chapter 713 ). The use of complementary and alternative medicine occurs in educated and affluent groups, challenging conventional wisdom that such practices are limited to those culturally different from the dominant society. Such complementary and alternative practices are included in many medical school curriculums. CULTURAL COMPETENCE AND PEDIATRIC PRACTICE Cultural competence refers to the acquisition of knowledge and skills needed to transcend cultural boundaries; it moves beyond sensitivity and awareness. The need for cultural competence is most obvious among patients who, for example, wear traditional dress or speak another language. In these circumstances, cultural diversity is relatively easy to spot, even if the possible health effects are not always straightforward. On the other hand, even if a patient appears to be culturally similar to the physician, congruence in health beliefs and behaviors cannot be assumed. What might be assumed to be similarities in orientation do not necessarily ensure optimal care, even among physicians. Whereas physicians' children have been found to have better access to pediatricians and increased pediatrician visits if hospitalized, they also experience delays in seeking pediatric care. Furthermore, pediatricians have been found to provide less detailed medical instructions and to be reluctant to discuss children's behavioral problems with fellow physicians than with other parents. One strategy for achieving cultural competence is to conceptualize illness as a series of unfolding stages. The pediatric visit may not be the first stage but usually comes later in the process after symptom recognition, formulation of etiologic explanations, and lay referral and consultation. Knowledge about each stage obtained during a pediatric visit can diminish the likelihood of cultural conflict or resolve it more quickly if it occurs. In eliciting a narrative account of illness while obtaining a medical history, information on culture can be obtained without adding a burdensome time commitment. Two points in the unfolding process are used here as illustrations: symptom definition and etiologic explanations. An initial point in an illness episode is the identification of symptoms of ill health. Children may identify these on their own, or they may be identified by a parent or

caregiver. Whether or not culturally diverse children, parents or caregivers, and physicians converge on the significance of symptoms is important to the course of subsequent treatment. Folk diagnoses and medical diagnoses may appear divergent, even when they converge in important ways. For example, a Mexican mother's diagnosis of entities such as susto (fright sickness), mal de ojo (evil eye), or caida de mollera (fallen fontanel) may be regarded as being at odds with the physician's diagnosis. Mothers may regard these entities as untreatable by Western physicians, and physicians might dismiss these folk classifications in their diagnosis. However, even though the labels for these conditions and their etiologic attributions differ, the presenting symptoms are likely to be recognized by both parent and physician as significant and potentially life-threatening, thereby establishing more common ground than at first is apparent. Common ground, then, can be found in the seriousness of symptoms, such as fever. Once symptoms are identified as signs of ill health, a process begins to try to explain their cause. Cultural conflict in medical care often emanates from disagreement as to etiology, because discerning the cause is important in formulating the cure. Although there is both intracultural and intercultural variability, there may be more congruence across cultures than was previously thought. Middle-class European-Americans and Latin-Americans, for example, recognize the common cold as a biomedical entity but also attribute its etiology, at least in part, to becoming chilled as part of a hot-cold system of beliefs. Nevertheless, the differences in culture may interfere with care if a pediatrician's planned course of treatment is not presented as related to the family's attribution of the cause of illness. Cultural knowledge is also empirical knowledge. For example, because remedies have worked in the past, it is assumed that they will work in the future. Middle-class parents in the United States routinely accept a pediatrician prescription for a second course of antibiotics for otitis media if a child's symptoms persist, assuming not that antibiotics are useless, but that a different drug or a longer course of treatment will resolve the problem. The same is true for indigenous treatments that have been proven through the force of custom over time. EMERGING AREAS IN CULTURE AND PEDIATRICS One area of interest, termed evolutionary medicine or ethnopediatrics, looks at crosscultural variability in child care practices and seeks to understand these practices in the context of human evolution. Sleep problems, a common issue in pediatric practice, serve

as an example. Co-sleeping with infants has likely occurred throughout human history, is exceedingly common cross-culturally, and is more common in the United States than was previously thought. While recent years have seen increasing flexibility in pediatric advice in this domain, common pediatric guidance is still that infants and young children should sleep separately from their parents, in a different room, and in their own beds for the night. Some sleep problems, then, may be viewed as rooted in behaviors of child care that may be inconsistent with the biologic needs and capacities of human infants rather than a failure on the part of the parent, child, or both. Another emerging area is viewing children as active shapers of their social and cultural environment rather than passive recipients of socialization. Even though pediatricians have 12 always relied on children for information, the social sciences are now more supportive of children's viewpoints being included in decisions regarding their lives. The United Nations Convention on the Rights of the Child also includes provisions affirming this position. A third area involves capitalizing on cultural and ethnic strengths and looking for common ground. Culture and ethnicity have more often been approached as being potential sources of conflict with the health care system rather than recognizing the point of congruence.

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