Social, Cultural, and Religious Influences on Child Health Promotion

Cultural Considerations

Providing Culturally Sensitive Care

The Child and Family in North America

Context provides perspective for nursing care. The health and well-being of the child in the North American family is influenced by two distinct contexts: the context of family and the context of culture. Therefore understanding these layers of influence on pediatric health is integral to developing a family-centered and culturally competent nursing practice (Thibodeaux and Deatrick, 2007). America’s orientation toward homogenization—“the great melting pot”—is changing to an orientation of complex cultural diversity. Increased awareness of the growing proportion of ethnic minorities that make up the U.S. population, coupled with a new appreciation for ethnic diversity, has resulted in a renewed interest in cultural variation.

The frontier background of the American culture has contributed to the overall orientation to life and childrearing. Americans have always had a basic optimistic view of the world, a belief that things can be better and that the children can and will be better off than their parents. With this hopeful outlook, a general future orientation, and the possibility of upward social mobility, American culture typically encourages development of self-confidence and autonomy in children. Children are generally permitted a greater degree of freedom than in more tradition-oriented cultures.

Family life in North America is characterized by increasing geographic and economic mobility. Families are less reliant on tradition, are fragmented, and have limited opportunity to transmit and acquire the traditional and accepted customs of a culture. Consequently, young adults rely to a greater extent on the professed experts, peers, and the mass media for acquisition of acceptable patterns of behavior, including childrearing practices. Conflicting information can be a source of confusion and frustration as parents attempt to determine the comparatively stable, essential components of the culture and transmit these to their children.

Children in North America grow up with a number of adults who differ from one another but who all provide input as role models, teachers, and standards for behavior. Most children live in some form of nuclear family located in sharply differentiated neighborhoods determined by income and ethnic status within a highly technical, largely urban society. Class differences in childrearing persist, but they are becoming less divergent.

Early in life children in minority cultures become aware of their cultural context and the discriminatory attitudes of the majority culture toward their racial or ethnic group. The direct effects of discrimination are anger and low self-esteem, which manifest in a variety of behaviors. Attitudes are slowly changing in some groups and in some places. With a relatively recent emergence of racial and ethnic pride along with a growing awareness, interest, and understanding of the majority, children in minority groups are becoming more secure and confident in their racial or ethnic identity. Individuals vary in their reactions to membership in a minority group, and much of this variation can be attributed to familial factors. The most important influences on development of a positive self-image are warm, understanding parents who actively foster their children’s growth. Parents who accept their children and react positively and constructively rather than in a negative manner will help their children develop feelings of self-worth, self-esteem, and self-acceptance. The more adequate children feel, the more positive their attitudes toward peers in both the majority and minority groups and the greater their ability to withstand prejudice and intolerance and build lasting relationships.

Social Roles

Much of children’s self-concept comes from their ideas about their social roles. Roles are cultural creations; therefore the culture prescribes patterns of behavior for persons in a variety of social positions. All persons who hold similar social positions have an obligation to behave in a particular manner. A role prohibits some behaviors and allows others. Because culture outlines and clarifies roles, it is a significant influence on the development of children’s self-concept (i.e., attitudes and beliefs they have about themselves).

A social group consists of a system of roles carried out in both primary and secondary groups. A primary group has intimate, continued, face-to-face contact; mutual support of members; and the ability to order or constrain a considerable proportion of individual members’ behavior. Two such groups are the family and the peer group, both of which have a great deal of influence on the child.

Secondary groups are groups that have limited, intermittent contact and generally less concern for members’ behavior. These groups offer little in terms of support or pressure toward conformity except in rigidly limited areas. Examples of secondary groups are professional associations and social organizations such as church groups.

A concept of social role also depends largely on whether a child is reared in a primary- or secondary-group community. Children are subjected to perceptibly different forms of parental training in these two types of environments.

Cultural Shock and Cultural Competence

Cultural shock is characterized by the inability to respond to or function within a new or strange situation. It can occur when the values and beliefs of a new cultural setting are radically different from those of the person’s native culture (Munoz and Luckmann, 2005). This state of shock or uneasiness can happen to a patient in a hospital or to a nurse caring for patients with different cultural backgrounds. Immigrants to a new country and persons from a subcultural group experience the same cultural shock when they must adjust to the ways of an unfamiliar subgroup or setting.

Numerous factors influence reactions to a new environment. Language barriers, including dialects and jargon specific to a subcultural group, inhibit effective communication. Habits and customs, such as different role behaviors or etiquette, and differences in attitudes and beliefs are puzzling to the newcomer in an unfamiliar environment. The child and family experiencing cultural shock can feel an intense sense of isolation, loneliness, and fear (Crom, 1995).

Nurses are challenged to overcome cultural shock and develop cultural sensitivity, an awareness of cultural similarities and differences. Doing so helps the nurse practice culturally competent care. This requires changing the way people think about, understand, and interact within the world around them (see Critical Thinking Exercise). The development of cultural competence is an ongoing, interactive process that involves six elements (Dunn, 2002):

When minority groups immigrate to another country, a certain degree of cultural and ethnic blending occurs through the involuntary process of acculturation, those gradual changes produced in a culture by the influence of another culture that cause one or both cultures to be more similar to each other. However, the changes occur to various degrees in different families and groups. Many groups continue to identify with their traditional heritage while adapting to the ill-defined concept of the “American way.” Acculturation may be referred to as assimilation, which is the process of developing a new cultural identity (Spector, 2009).

Ethnicity

Ethnicity is the classification of or affiliation with any of the basic groups or divisions of humankind or any heterogeneous population differentiated by customs, characteristics, language, or similar distinguishing factors. Ethnic differences extend to many areas and include such manifestations as family structure, language, food preferences, moral codes, and expression of emotion. Some standards of behavior (e.g., the traditional role of the father) result from the cultural heritage of the specific ethnic group. Others reflect the interaction between subcultures, most notably between members of the majority culture and a minority subculture. The term ethnic has aroused strong negative feelings, and the general population often rejects this term (Spector, 2009).

To establish their place in the group, children learn to follow a mode of behavior that is in accordance with standards distinctive to the group and learn how they can expect others to behave toward them. They take their cues by observing and imitating those to whom they are exposed. For example, children of a racial minority form a perception of their role as a group member by observing how role models within the subgroup respond to treatment by people outside the subgroup. When they see group members display an attitude of inferiority, they assume this to be the appropriate behavior and incorporate these perceptions into their own self-concept.

In the United States the cross-cultural lines are becoming blurred as subcultures are assimilated and blended into the larger culture (Fig. 2-1). Although ethnic differences in childrearing are probably diminishing, they remain important. It is particularly difficult for persons to attempt to maintain an identity within a subculture while living and conforming to the requirements of the larger culture.

Leavitt, Martinson, Liu, and colleagues (1999) found that immigrants from China who provided care for their children with cancer focused on dietary intake, whereas families that were of Caucasian descent focused on emotional support. The cultural framework directed the healing practices. Interestingly, the same study found that both groups shared the beliefs that mothers were the primary caregivers for the sick child. In this example one cultural behavior was unique to each cultural group while the other was similar. Consequently, children reared in this environment can become confused about roles and values of two or more cultures if they conflict. They usually adopt those of the more influential or higher-status culture. Youth, in particular, are influenced by the locally dominant group.

Ethnocentrism is the emotional attitude that one’s own ethnic group is superior to others; that one’s values, beliefs, and perceptions are the correct ones; and that the group’s ways of living and behaving are the best way (Spector, 2009). Ethnic stereotyping or labeling stems from ethnocentric views. Ethnocentrism implies that all other groups are inferior and that their ways are not in the best interests of the group. It is a common attitude among a dominant ethnic group and strongly influences a person’s ability to evaluate objectively the beliefs and behaviors of others. Nurses must overcome the natural tendency to have ethnocentric attitudes when caring for people from different cultures (Williams and Kruse, 1999). The culturally competent nurse has empathy for others, maintains an openness to feeling what the other feels, and remains curious and willing to ask questions to gain a better understanding. In addition, the nurse has a basic respect for self and others, and acknowledges the intrinsic value of all humans (Carrillo, Green, and Betancourt, 1999).

Minority-Group Membership

The United States has more racial, ethnic, and religious minority groups than any other country. Ethnic minority groups are becoming increasingly important because these groups are producing children at a faster rate than the majority Caucasian population. Consequently, the minority population is increasing. The rapidly emerging U.S. minority population will present special needs and require resources beyond what is currently available (Murdock, 2005).

The 2000 U.S. census revealed more than 280 million people in the United States, with 6.8 million reporting an ethnicity of more than two races. Blacks, or African-Americans, alone or in combination with another race, number more than 35 million, and Hispanics or Latinos of any race are more than 35 million. The Hispanic population increased 58%, or 13 million people, from 1990 to 2000 (US Census Bureau, 2001). Currently, Hispanics are the fastest growing minority in the United States and have many health needs that are not being met (Murdock, 2005; Warda, 2000). By the year 2010, Hispanics will surpass non-Hispanic blacks as the largest U.S. racial or ethnic group. In 2050 almost 30% of the U.S. population is expected to be Hispanic (Murdock, 2005) (see Cultural Competence box).

Socioeconomic Class

Family relationships may be stronger in some ethnic or cultural groups than others. However, the influence of socioeconomic class cannot be overlooked. This relates to the family’s economic and educational levels. Strong family relationships exist among those of lower socioeconomic class who have few resources and must rely on the support of a family network to meet physical and emotional needs. Middle- and upper-class people often have resources that reach beyond the extended family. They are able to access physical and emotional support in the community (Giger and Davidhizar, 1999). Do not confuse the term socioeconomic class with cultural or ethnic diversity. Children of a specific race are not necessarily of low socioeconomic status. Additionally, children of poverty do not automatically have developmental delays (Trawick-Smith, 2006).

Schools

When children enter school, their radius of relationships extends to include a wider variety of peers and a new focus of authority. Although parents continue to exert the major influence on children, in the school environment teachers have the most significant psychologic impact on their development and socialization. The teachers’ function is primarily limited to teaching, but, like parents, they are concerned about the children’s emotional welfare. Both parents and teachers must constrain behavior and enforce standards of conduct.

Communities

Surveys of more than 1 million youth in the United States in grades 6 to 12 have shown that persons who experience a higher number of specific assets in their lives are more likely to make healthy choices and avoid high-risk behaviors. These assets offer a framework for positive child and adolescent development. The child or adolescent’s community is made up of family, school, neighborhood, youth organization, and other members.

Four categories of external assets that youth receive from the community are (Search Institute, 2007):

Internal assets must also be nurtured in the community’s young members. These internal qualities guide choices and create a sense of centeredness, purpose, and focus. The four categories of internal assets are (Search Institute, 2007):

Peer Cultures

Peer groups also have an impact on the socialization of children (Fig. 2-2). Peer relationships become increasingly important and influential as children proceed through school. In school, children have what can be regarded as a culture of their own. This is even more apparent in an unsupervised playgroup, since in school the culture is partly produced by adults.

During their lives children are exposed to value systems such as those of the family, ethnic group, and social class. In peer-group interaction they confront a variety of these sets of values. The values imposed by the peer group are especially compelling because children must accept and conform to them to be accepted as members of the group. When the peer values are not too different from those of family and teachers, the mild conflict created by these small differences serves to separate children from the adults in their lives and to strengthen the feeling of belonging to the peer group.

The kind of socialization provided by the peer group depends on the subculture that develops from its members’ background, interests, and capabilities. Some groups support school achievement, others focus on athletic prowess, and still others are decidedly against educative goals. Scholastic achievement is strongly related to the peer group’s value system. Many conflicts between teachers and students and between parents and students can be attributed to fear of rejection by peers. What is expected from parents regarding academic achievement and what is expected from the peer culture often conflict, especially during high school. Chapter 19 discusses this in further detail.

Although the peer group has neither the traditional authority of the parents nor the legal authority of the schools for teaching information, it manages to convey a substantial amount of information to its members, especially on taboo subjects such as sex and drugs. Children’s need for the friendship of their peers brings them into an increasingly complex social system. Through peer relationships, children learn to deal with dominance and hostility and to relate with persons in positions of leadership and authority. Other functions of the peer subculture are to relieve boredom and to provide recognition that individual members do not receive from teachers and other authority figures.

The peer-group culture has secrets, mores, and codes of ethics that promote group solidarity and detachment from adults. They have traditions and folkways, including age-related games and other activities, that are transferred from “generation to generation” of schoolchildren and that have a great influence over the behavior of all group members. As children move from one level to the next, they discard folkways of the younger group as they adopt those of the new group. For example, a school-age child rides a bicycle to school; the high school student prefers a car. As they advance, children are forward oriented only—they look forward with anticipation but may look backward with contempt.

Biculture

Some children are exposed to the values, role relationships, and lifestyles of two or more cultures. The virtual “straddling” of two cultures is referred to as biculturation and involves the ability to efficiently bridge the gap between an individual’s culture of origin and the dominant culture (Rogers, 1995). This may occur because the child’s parents are from two or more different cultures. In Hawaii, for example, it is common for children to be from four or more cultures. Other children straddle cultures as members of a minority culture within the dominant culture. This biculture is sometimes observed in the playgroup but usually is not a significant factor until children enter school. Then they must unlearn some of the established practices of one culture to become socialized in the other, especially in role relationships. For example, children from Hispanic and Asian cultures are taught to look away when scolded; in U.S. schools the teacher expects direct eye contact—“Look at me when I speak to you.” Children learn new roles and social behavior more rapidly than their adult counterparts.

This biculture is particularly marked in language differences. The bilingual child is said to be at a disadvantage in school situations of the dominant culture, in which there is controversy over bilingual education. Those supporting bilingual education adhere to the principle that children will understand more readily and perform more realistically (especially in testing situations) if learning is directed in their own language; others contend that children living in a dominant culture should adopt the ways of that culture, including language. The child faces less conflict when the school supports his or her language and culture, even if the dominant language is used.

Mass Media

The media provide children with a means for extending their knowledge about the world in which they live and have helped narrow the differences between social classes. However, many people are concerned about the enormous influence the media can have on the developing child and on health promotion behaviors (see Research Focus box). Children and adolescents in the United States spend more than 6 hours per day utilizing entertainment media (Council on Communications and Media, 2009). Increased use of entertainment media has been associated with the epidemic of obesity in children and adolescents and increased aggression in children (Jordan, 2004; Council on Communications and Media, 2009).

Children may identify closely with people or characters portrayed in reading materials, movies, videos, and television programs and commercials. Pediatric nurses can educate and support parents on the effects of mass media on their children through the following recommendations (Jordan, 2004):

Poverty

A subcultural influence closely related to but different from social class is the condition known as poverty. It is a relative concept and is usually associated with the general standards of a population. The term poverty implies both visible and invisible impoverishment. It is a condition in which families live without adequate resources (Trawick-Smith, 2006). Visible poverty refers to lack of money or material resources, which includes poor nutrition, insufficient clothing, poor sanitation, and deteriorating housing. Invisible poverty refers to social and cultural deprivation such as limited employment opportunities, inferior educational opportunities, lack of or inferior medical services and health care facilities, and an absence of public services.

An absolute standard of poverty attempts to delimit a basic set of resources needed for adequate existence; a relative standard reflects the median standard of living in a society and is the term used in referring to childhood poverty in the United States; that is, what appears to be deprivation in one area may be a standard or norm in another.

An important development affecting the American family since the end of World War II is the widening disparity in income status among generations. Children from families with a single mother compose the largest group of children in poverty in the country (Wertheimer, 2005).

Growth in the number of poor children over the past decade has not been due to an increase in the number of welfare-dependent families, but to growth in the ranks of the working poor. Between 1994 and 2000, the poverty rate fell approximately 30%, but the trend has recently reversed, and the poverty rate rose 6% between 2000 and 2007. Approximately 18% of children in the United States live below the national poverty threshold, which is currently estimated at $21,027 for two adults and two children (Annie E Casey Foundation, 2009). In addition, approximately 20% of children live in neighborhoods where more than 20% of the population currently lives below the federal poverty threshold.

Such factors illustrate the growing inability of the American family to provide economic essentials for their children. Approximately 11.6% (about 8.5 million) of all children in the United States were uninsured in 2002 (Szilagyi, 2005). Uninsured children are more likely to miss school, jeopardizing their education as well as their health.

A high correlation between poverty and illness has long been observed. Impoverished families suffer from poor nutrition; without medical insurance, they have little if any preventive health care, inadequate health maintenance, and limited access to health services. One of the most significant health problems related to poverty is a high infant mortality rate. Although the rate of infant mortality has decreased in the United States, it still remains higher than that of most industrialized nations (Annie E Casey Foundation, 2009). Day-to-day needs of food, clothing, and lodging take precedence over health care as long as the ailing person feels able to perform activities of daily living.

Poor families may be denied access to some institutions for emergency or other hospital care. Frequently they must travel long distances to service centers that are willing to assume their care. In an emergency they must find money for taxi fare, borrow an automobile, or seek other means of transportation. They must find care for dependents, such as other infants and small children, or take them along when taking the ill child for care. Families tend to delay preventive care indefinitely unless health services are relatively accessible. They are more likely to consult folk practitioners or other persons within their community.

Poor nutrition accounts for many health problems in the lower classes. Lack of funds, education, and readily available healthy foods results in a diet that may be seriously lacking in essential food substances, especially protein, vitamins, and iron. This inadequate diet often leads to nutritional deficiency disorders and growth retardation in children. On the other hand, these issues may contribute to pediatric overweight and type 2 diabetes because nonnourishing foods are less expensive and are easier to access in some neighborhoods.

Dental problems are more prevalent because of deficient preventive care. Lack of standard immunizations together with reduced resistance from poor nutrition renders children in poor segments of the population vulnerable to communicable diseases. Poor sanitation and crowded living conditions also contribute to the higher incidence and perpetuation of illness. In general, poor people become ill more frequently and remain ill for longer periods than those in the general population.

Homelessness

One of the most pressing problems in the United States is the growing number of homeless families. Homeless individuals are those persons who lack resources and community ties necessary to provide for their own adequate shelter. In the past the homeless population traditionally included single adults, mostly men. Families with children make up 40% of the homeless population, compared with single men, who make up about 41% of the group (Redlener, 2005). Homeless children have increased in numbers as poverty has become feminized, minorities have become poorer, and low-income housing has become less accessible. Estimates of the number of homeless children in the United States may be as high as 1 million; about 10% of the children living in poverty were homeless (Redlener, 2005). Many homeless children are younger than 5 years and are from minority groups.

Most homelessness is a direct result of increasing number of people in poverty combined with a lack of decent, affordable housing. Other reasons include job layoffs, low incomes, parental mental illness, domestic conflict, and unexpected family or economic crises.

Another group of homeless children are the “runaway” and “throwaway” adolescents. Approximately 12% of the homeless population consists of adolescents (National Coalition to End Homelessness, 2009). Many runaways are victims of physical and sexual abuse and leave home because of long-term family or school problems. Poor parent-child relationships, extreme family conflict, feelings of alienation from parents, inconsistent supervision, and unpredictability in discipline are other factors often cited. These adolescents and young adults are at risk for violence, exploitation, substance abuse, and sexually transmitted infections (including HIV and AIDS).

Lack of a permanent housing deprives children of the most basic necessities for proper growth and development. Homelessness disrupts a child’s friendships and schooling (Strehlow and Amos-Jones, 1999). Homeless children suffer from physical and mental disorders more often than do poor children who have a permanent residence. Homeless children lack basic health care, including routine immunization and screening for routine problems, and they suffer high rates of acute and chronic illnesses (Redlener, 2005).

Migrant Families

Children in migrant farm worker families are medically underserved. Their numbers are staggering; of the 2 million migrant farm workers who labor in the United States, 63% are accompanied by minor children (Gentry, Quandt, Davis, et al, 2007). These children face both acute and chronic health care issues as a result of poverty, parental occupation, and assimilation into American culture. They are often exposed to risks similar to those facing their parents, since they may accompany them into the fields. These children frequently live in substandard housing conditions, which are subject to overcrowding and transmission of communicable diseases.

Migrant farm worker families face many obstacles when attempting to interface with the U.S. health care system. Three of every five families live below the federally designated poverty line and may lack insurance. The family’s use of health care may be affected by parental work schedules and access to transportation. Their own limited English proficiency is further exacerbated by a health care encounter that lacks cultural sensitivity, translation services, and language capability. Cultural expectations of the health care system may differ between the farm worker families and health care providers. This may ultimately have a negative effect on families’ utilization of the health care system. In fact, many families living on the U.S.-Mexico border seek the majority of care for their children in Mexico, regardless of their insurance status. In addition, less than 20% of migrant farm worker families use the primary care and health promotion centers that are federally funded through the 1962 Migrant Health Act (Gentry, Quandt, Davis, et al, 2007). These two statistics demonstrate the need for culturally sensitive care that is consistent with the perceived needs and expectations of the recipients of such care.

Skill—Providing Culturally Sensitive Care

Nurses and other health care providers should be mindful of the persistence of various forms of child labor in the United States (Hindman, 2006). Approximately 50% of 12- to 15-year-olds participate in some sort of paid activity each year, and half of this population have jobs in which they are considered employees. Children, adolescents, and young adults may work in a variety of areas, including agriculture, construction, retail, or even street trades or scams. Youth who work on family farms often face the greatest risk of injury and death from handling dangerous or heavy machinery. Youth who work in street trades and scams or traveling sales crews may be subject to physical or verbal abuse or victimization (Hindman, 2006).

Cultural Relativity

Although clinical characteristics of a disease or condition are essentially the same across cultures, how a child or family interprets or experiences the disease or condition varies. Culture as an influence is one obvious explanation for variance. Cultural relativity is the concept that any behavior must be judged first in the context of the culture in which it occurs. Cultural factors such as belief systems and view of the world influence the patient’s and family’s response to health care. These cultural beliefs and behaviors influence adherence to a treatment plan (Munoz and Luckmann, 2005). Some cultures, for example, may view a chronic illness or disability as affecting only particular aspects of a child’s life, and the child as a whole is viewed as normal. In contrast, other families may describe the illness as having global effects on many aspects of the child’s present and future life (Martinson, Armstrong, and Qiao, 1997). These contrasting views may result in parents having different goals and expectations for their children.

Culture influences the assignment of gender roles, perception of disease, and perception of the side effects of the disease and the treatment the child should receive. For example, the family may expect the mother to be the primary caregiver. This places her at risk for caregiver strain when she is caring for a sick child.

Nurses can often recognize a family’s health-related cultural perceptions and interpretations through discussion and observation. They should explore and consider implications of these perceptions when planning culturally appropriate interventions. Nurses must be comfortable having discussions with families about their cultural beliefs and practices. The conversations can begin easily as, “I want to take the best care of your child and family as possible. Is there anything in particular about your beliefs [cultural, religious, family] that you think I should know?”

Relationships with Health Care Providers

The manner of relating with health care providers differs considerably among cultural groups. For some nurses, one area of conflict is the attitude toward time and waiting that is part of some cultures. The time orientation of Hispanic and African-American ethnic groups is in the present. For example, African-Americans are flexible in their time orientation; an African-American family may be late for or miss appointments because other issues take precedence, and they may not communicate this to the health agency. Hispanics, too, have a relaxed view of time. Whereas the dominant culture in the United States says that “time flies,” the Hispanic says that “time walks.”

The Japanese, on the other hand, consider time to be valuable and to be used wisely. They tend to be punctual for medical appointments and persistent in following prescribed regimens. A Vietnamese family will subordinate time to values considered to be more significant, such as propriety. They may be late for an appointment because of an overextended visit by a friend in their home. In general, Asian-Americans view the American focus on time as offensive. They spend hours getting to know people and view predetermined, abrupt endings as rude. Introductory small talk is considered good manners.

Navajo Indians view time on a continuum with no beginning and no end. The present-time orientation may cause a Navajo to eat two meals a day today, four meals tomorrow, no meals the next day, and three meals the day after. This becomes an important nursing consideration if a Navajo is told to take medication with meals to ensure three doses per day.

In many cultural groups the mother assumes the responsibility for health care; in others both parents are involved equally in relationships with health workers. A somewhat different approach is apparent in some of the Asian cultures. For example, a Vietnamese or Filipino father, as unquestioned head of the family, is traditionally the one who interacts with persons, including health care providers, outside the family unit. In the Hispanic family the father, as head of the house, makes decisions regarding illness and treatment of adult family members, but the grandmother in the extended family is consulted regarding child care. Usually the family confers with other members before reaching a decision regarding treatment or hospitalization of a child. The Arab family also relies on others to give advice and guidance in a time of crisis. A Japanese father may appear to be passive and uninvolved but actually is involved according to his own cultural standards.

Nurses should learn about any specific attitudes regarding the manner of approach to a child in a given culture. Navajo Indians do not like a stranger near their infants. They fear that the stranger may “witch” the child and cause the child harm. On the other hand, if a stranger, particularly a woman, lavishes attention on a Hispanic infant but fails to touch the child, some Hispanics believe the infant will develop symptoms of the “evil eye” (see p. 33). Vietnamese and Korean families may become upset if a newborn is admired at length for fear the evil spirits will overhear and desire the infant.

Some groups, such as the Amish, consider a child’s admission to the hospital a family affair, with all members gathering to support and console the child and parents. In other groups the family is willing to relinquish the care of the child to the hospital authority without interference. Their visits with the child are short, although intense, but hospital staff may misinterpret this behavior as disinterest or abandonment.

All ethnic groups are entitled to be treated with dignity and respect. Family members should be addressed by their last names; many groups consider it an affront to be called by their first names. Stereotyping is to be condemned. People are individuals who are evaluated in relation to their cultural standards, needs, and preferences. For example, believing that fathers are never involved in the direct care of their child can result in wrong assumptions about a culture (Fig. 2-4).

Nurses who are members of a majority culture may encounter tension and distrust in a child from a minority culture as a result of the child’s learned conceptions or relationships with other persons in the majority group. Based on these perceptions, minority children may suspect that nurses have hostile feelings toward them and fear ill treatment. When such children are hospitalized, this suspicion increases the feelings of loneliness and helplessness that accompany fearful events and separation from families. The reverse situation may be encountered by a nurse from a minority culture attempting to meet the needs of a child who has been conditioned to view the nurse’s cultural or ethnic group as inferior. Either situation is more likely to occur if the nurse or the child has had little or no personal contact with the other’s culture. For example, a child from a minority culture from the inner city who lives in a neighborhood and attends school only with children from his or her minority culture may be more suspicious of a nurse from a different culture than would a child from the same minority group who lives in a culturally diverse neighborhood or attends an integrated school. Becoming familiar with cultures different from one’s own and making an effort to know each other as individuals can shatter myths and, with time, build the trust needed to establish rewarding relationships between children, their families, and the nurse.

Food Customs

Food customs and symbolism of various cultural, ethnic, and religious groups are an integral part of their lives. Although in a large country such as the United States most people have adopted the eclectic food habits that have evolved over generations, many still retain ethnic and geographic food traditions and preferences. Special holidays, ceremonies, and life experiences such as births, birthdays, weddings, and death are often marked by special food items or feasts. In many cultures specific food practices are followed during pregnancy in the belief that certain foods damage or benefit the developing fetus. The distinctive food customs of ethnic groups are a product of their native environment, determined by availability.

A number of restrictions are related to food items. Some have a physiologic origin, such as lack of dairy foods in the diets of some persons of African or Asian ancestry with lactose intolerance. Others are religious restrictions, such as kosher foods and food preparation of the Orthodox Jewish faith and the vegetarian diet of Seventh Day Adventists. (See Vegetarian Diets, Chapter 13.)

Children in a strange environment, such as the hospital, feel much more comfortable when they are served familiar foods. Hospital food often tastes strange and bland, especially to children who enjoy the highly seasoned foods of their culture. Also, the family may be concerned that the child is not receiving foods appropriate to their culture and beliefs. When possible, provide the children’s ethnic foods or allow families to bring favorite foods that are not on the hospital menu. Concern for differences in food habits and patterns projects an attitude of respect for the family’s ethnic or religious heritage (Ohio State University Extension, 2005).

It is also important for nurses and other health care providers to be mindful of the meaning of food and eating within a family or community. Feeding and food preparation are ways in which families nurture and care for one another. This is especially true in the parent-child relationship. Parents and other family members may struggle with this desire to feed and nurture their child in circumstances when the child does not want to eat or cannot tolerate oral intake (i.e., a child receiving chemotherapy). Nurses can encourage families to nurture the sick child in other ways, such as touch, reading, or other enjoyable activities.

1. What are the physical aspects of caring for the body (e.g., are there special clothes, foods, medicines)?

2. What are the mental parts of caring for health (e.g., feelings, attitudes, rituals, actions)?

3. What are the spiritual aspects of health (who I am, spiritual customs, prayers, healers)?

Health Beliefs

The beliefs related to the cause of illness and the maintenance of health are an integral part of a family’s cultural heritage. Often inseparable from religious beliefs, they influence the way families cope with health problems and respond to health care providers. Predominant among most cultures are beliefs related to natural forces, supernatural forces, and imbalance between forces.

Health Practices

Cultures have numerous similarities regarding prevention and treatment of illness. All cultures have some types of home remedies that they apply before seeking help from other persons. Within the ethnic community, folk healers who are endowed with the ability to “cure” maladies are sought for special situations and when home remedies are unsuccessful. The curandero (male) or curandera (female) of the Mexican-American community is believed to have healing powers that are a gift from God. The Asian consults an herbalist, knowledgeable in medicines, or perhaps an ethnic practitioner in Asian therapies, including acupuncture (insertion of needles), acupressure (application of pressure), and moxibustion (application of heat). Native Americans consult a variety of healers with specific skills and knowledge. Specialized medicine persons diagnose illness, provide nonsacred treatments (usually by way of massage and herbs), and care for souls. Other specialists perform services or effect cures through the use of spiritual means. Native Hawaiians consult kahunas and practice ho’oponopono to heal family imbalance or disputes.

The folk healers are powerful persons in their community and can acquire information about an illness without resorting to probing questions. They “speak the language” of the family who seeks help and often combine their rituals and potions with prayer and entreaties to God. They also are able to create an atmosphere conducive to successful management. Furthermore, they exhibit a sincere interest in the family and their problem.

Some folk remedies are compatible with the medical regimen and are useful to reinforce the treatment plan. For example, aspirin (a “hot” medication) is an appropriate therapy for “cold” diseases such as the common cold and arthritis. It is not uncommon to discover that a folk prescription has a scientific basis. In any case, respect practices that do no harm patients.

In cultures that believe in the concept, overcoming the effect of the evil eye usually requires specialized rituals conducted by the appropriate practitioner. For example, the Chicano curandero ascertains that the condition is truly the result of the evil eye by performing an assessment ritual and then performs a curative ritual. Sometimes faith in the folk practitioner delays obtaining needed medical treatment, although the practitioner usually suggests medical care if his or her ministrations are unsuccessful.

Health practices of different cultures may also present problems of assessment and interpretation. For example, certain cultural practices or remedies can be misdiagnosed as evidence of child abuse by uninformed professionals (Box 2-1). It is important to explain why some of these and other familiar remedies may now be considered harmful. Families need to understand how such practices can place them in jeopardy with child protective services, and they need to explore alternative measures that are more acceptable to the dominant culture (Hayes and Dreher, 1991).

Other cultural health remedies that are harmful include eating clay or excessive amounts of salt. A mercury compound, azogue (the Spanish name for quicksilver), is commonly used in Mexico and sometimes sold illegally to low-income Hispanic families in the United States as a remedy for diarrhea. Alert health care workers know that the drug can cause permanent central nervous system damage. A careful history can reveal these practices, but it may require the collaboration of a folk healer to convince a user to stop.

Faith healing and religious rituals are closely allied with many folk-healing practices. Wearing of amulets, medals, and other religious relics believed by the culture to protect the individual and facilitate healing is a common practice. It is important for health workers to recognize the value of this practice and keep the items where the family has placed them or nearby. It offers comfort and support and rarely impedes medical and nursing care. If an item must be removed during a procedure, it should be replaced, if possible, when the procedure is completed. The nurse should explain the reason for its temporary removal to the family to reassure them their wishes will be respected (see Family-Centered Care box).

Nurses can be most effective when operating from a multicultural perspective, which means using appropriate aspects of the culture in question to develop culturally acceptable health care interventions. When the folk practices do not interfere with the patient’s welfare, they need not be discouraged. Often a compromise can be reached that accomplishes the nurse’s goal while maintaining the patient’s dignity and self-esteem.

Importance of Cultural Competence to Nurses

A consensus exists among nurses that cultural competence of professional nursing practice should be raised (Lester, 1998). The challenge for nurses is to gain knowledge about cultural care values, beliefs, and practices and to use this knowledge in the care they provide (Leininger, 2001). To understand and deal effectively with families in a multicultural community, nurses must be aware of their own attitudes and values. Nurses, too, are a product of their own cultural background and education. They are part of the “nursing culture.” Nurses function within the framework of a professional culture with its own values and traditions and, as such, become socialized into that culture by educational programs and later by the work environment and professional associations.

Frequently nurses and other health care workers are not aware of their own cultural values and how those values influence their thoughts and actions. A model for self-examination on cultural competence is the ASKED model (Box 2-2). Recognizing that a behavior may be characteristic of a culture rather than being an “abnormal” behavior places nurses at an advantage in their relationships with families. Ethnocentric approaches to nursing care are ineffective in meeting health and nursing needs of diverse cultural groups of patients (American Nurses Association, 1991). When nurses respect the cultural differences of a family, they are better able to determine whether the behavior is distinctive to the individual or a characteristic of the culture. What appears to be puzzling behavior may simply be the customary response in the culture (e.g., expression of emotion).

Cultural standards and values, the family structure and function, and past experiences with health care influence a family’s feelings and attitudes toward health, their children, and health care delivery systems. It is often difficult for nurses to be nonjudgmental and objective in working with families whose behaviors and attitudes differ from or conflict with their own. The nurse needs to understand how his or her own cultural background influences the way care is delivered (American Nurses Association, 1991).

Relying only on one’s own values and experiences for guidance can result in frustration and disappointment. It is one thing to know what is needed to deal with a health problem; it is often more difficult to implement a fruitful course of action unless nurses work within the cultural and socioeconomic framework of the family (see Critical Thinking Exercise, p. 23).

It is essential to make an effort to adapt ethnic practices to the family’s health needs rather than attempt to change longstanding beliefs. To aid their efforts to understand and respect the cultural beliefs of families, nurses should have a readily available resource file containing pertinent information about the cultural and subcultural characteristics of the community in which they practice (e.g., traditional practices related to infant feeding practices and the time and manner of weaning and toilet training). Cultural competence is a process that is facilitated by recognizing cultural differences, integrating cultural knowledge, and acting in a culturally appropriate manner (Munoz and Luckmann, 2005) (see Cultural Competence box).

Physical Characteristics

Members of different racial groups have observable differences in physical appearance. The most obvious are skin and hair coloring and texture. Skin color is determined by the amount of melanin in the skin. People from countries located near the equator have darkly pigmented skin, which protects the skin from the year-round exposure to the sun’s rays; those from northern countries have light skin, which provides for maximum exposure to the sun’s rays (necessary for vitamin D metabolism) during the short daylight hours. Skin color can show wide variations between these two extremes because of geographic origin or intermixing of persons with dark and light skin color.

As a consequence of the dark pigmentation, the detection of skin color changes can be difficult and requires modification of assessment techniques. For example, vasomotor alterations, cyanosis, and jaundice are not easily recognized in very dark skin. Variations in skin color can alter the appearance of the skin in a given circumstance (see Table 6-8).

In the newborn, variations are often related to racial or ethnic origin. For example, newborn infants of Asian and African-American parents are smaller than infants of Caucasian parents, and bluish pigmented areas (mongolian spots) on the sacral region are a common observation in Asian, African-American, Native American, and Mexican infants. It is important that health care providers be familiar with these birthmarks. They should be documented at newborn examinations and subsequent visits so they are not suddenly interpreted as bruises (Garwick and Auger, 2000).

Evaluation of stature and body build reveals some racial tendencies. Children from Asian countries are commonly smaller, falling below the 10th percentile on weight and height charts used for children in the United States. This difference in stature can lead to misinterpretation of health status and capabilities. A small child may appear intelligent for body size but be of average mental ability for age.

Religious Influences

Probably the most influential factor shaping the U.S. culture is the Judeo-Christian faith. Many immigrants came to the United States for religious freedom and established a religious and moral atmosphere that persists today. However, individual differences are part of the general culture.

The family’s religious orientation dictates a code of morality and influences the family’s attitudes toward education, male and female role identity, and their ultimate destiny. It may also determine the school that the children attend, their companions, and often their mate selection. Religious beliefs are such an integral part of many cultures that it is difficult to distinguish the culture from the religion. In a few instances, such as in the Mennonite and Amish communities, religion is the basis for a common way of life that determines where the children are raised and their lifestyle.

Religious Beliefs

Religious and spiritual dimensions are among the most important influences in many people’s lives (Fig. 2-5). The terms religion and spirituality are often used interchangeably; however, spirituality includes religion. Both religion and spirituality lend meaning in life and provide a source of love and relatedness between individuals and their God (Lukoff, Lu, and Turner, 1995). Nurses promote holistic nursing care through an integration of spiritual and psychosocial care. The care focuses on activities that support a person’s system of beliefs and worship, such as praying, reading religious materials, and performing religious rituals. Meeting the spiritual needs of the child and family can provide strength, whereas unmet spiritual needs can result in spiritual distress and debilitation (Fulton and Moore, 1995). In practice, application of the nursing process for spiritual care (Box 2-5) can enhance the spiritual well-being of the child and family.

Religion influences the lifestyles of most cultures. Among many groups, illness, injury, or death is believed to be sent by God as a punishment for sin. Some may believe that health workers will be unable to help a person whom God is punishing and may express a fatalistic attitude toward treatment, stating that the illness is “the will of God.” Others view it as a test of strength, like the testing of Job in the Bible, and strive to remain faithful and overcome the conflicts.

The nurse clarifies dietary restrictions with the family, especially in denominations with many variations. Except when specific religious practices (such as fasting) interfere with the child’s health or therapy, the family’s wishes are respected. The nurse should ask family members whether they want a clergy member present and whether they prefer hospital staff to call or prefer to do this on their own.

It is important to determine the family’s wishes regarding baptism, rites or practices related to death, and other religious rituals (such as circumcision, communion, or use of amulets or icons). Many religions have special clothing requirements, such as a cap (kippah) for the head (Orthodox Jews) or underclothes (Mormons). Respecting these rituals is especially important during a physical examination or preparation for surgery. An important role of the nurse is to be aware of families’ spiritual needs and convey an attitude of concern for this important element of the child’s care. Religion, which offers families understanding and spiritual support, is a valuable asset to health care. Table 2-2 outlines characteristics of selected religions with beliefs that affect health care.

In some instances the rights of the family and the responsibility of the state may be in conflict. For example, Jehovah’s Witnesses refuse blood transfusions for themselves and for their children. Parents, by law, have the primary obligation to care for and make decisions about their minor children. However, the legal principle of parens patriae says that the state has an overriding interest in the health and welfare of its citizens. Parents’ refusal of medical treatment for their child that is deemed essential can be interpreted as neglect. In addition to advocating for the child and family, the nurse’s role may include assuming the role of consultant to the staff and family regarding new, alternative methods of transfusion and, if necessary, coordinating with officials to petition juvenile or family court for temporary guardianship of the child.

Key Points

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