Social, Cultural, and Religious Influences on Child Health Promotion
On completion of this chapter the reader will be able to:
Define culture, cultural competence, ethnocentrism, and cultural relativism.
Describe the subcultural influences on child development in the areas of socioeconomic class, poverty, religion, and schools.
Discuss the population shifts in number of minority children in the United States.
Identify four common diseases or disorders that affect certain ethnic or cultural groups.
Identify areas of potential conflict of values and customs for a nurse interacting with a family from a different cultural or ethnic group.
Describe three religious groups whose beliefs significantly affect their health practices.
RELATED TOPICS and ADDITIONAL RESOURCES
IN TEXTCommunicating with Families Through an Interpreter, Ch. 6
Family Assessment Interview, Ch. 6
Family Influences on Child Health Promotion, Ch. 3
Listening and Cultural Awareness, Ch. 6
Lactose Intolerance, Ch. 11
Nutritional Assessment, Ch. 6
Sickle Cell Anemia, Ch. 26
Skin, Ch. 6
Spiritual Development: General, Ch. 5; Toddler, Ch. 12; Preschooler, Ch. 13; School-Age Child, Ch. 15; Adolescent, Ch. 16
Vegetarian Diets, Ch. 11
CULTURE
The future of any society depends on its children; therefore society must provide for their care, nurturing, and socialization. Culture plays a critical role in the parenting behaviors that facilitate children’s development (Meléndez, 2005). The customs and values of the culture help to organize a society’s childrearing system and are transmitted from one generation to the next through the medium of the family. A holistic view of any child requires that nurses develop some understanding of the ways that culture contributes to the development of social and emotional relationships and influences childrearing practices and attitudes toward health.
As the ethnic, racial, and cultural diversity in the composition of the U.S. population increases, it is imperative that nurses become competent in transcultural nursing knowledge (Muñoz and Luckmann, 2005). This orientation to transcultural nursing includes an awareness of the nurse’s own culture. The nurse who is becoming culturally competent learns about other cultures, becomes able to assess the perspectives of others, and shares his or her own culture with others (Dunn, 2002).
Culture is a pattern of learned beliefs, values, and practices that are shared within a group; it includes practices; customs; views on roles and relationships, including parenting; and communication patterns and language (Betancourt, 2004). Culture differs from both race and ethnicity. Race is defined as a division of humans possessing traits that are transmissible by descent and that are sufficient to characterize it as a distinct human type. One classification of race, based on skin color, is Caucasian (white), Negroid (African American), and Mongoloid (yellow). Ethnicity is the affiliation of a set of persons who share a unique cultural, social, and linguistic heritage (Fig. 4-1). Socialization is the process by which society imparts its competencies, values, and expectations to children (Trawick-Smith, 2006).
FIG. 4-1 Ethnicity is an individual’s association with shared cultural, social, and linguistic heritage.
Culture is a complex whole in which each part is interrelated. It provides the lens through which all facets of human behavior can be interpreted (Spector, 2004). Culture is not a surface veneer that covers a basic outlook shared by all human beings; rather, it is an ingrained orientation to life that serves as a frame of reference for individual perception and judgment. People from one culture differ from those in other cultures in the ways they think, solve problems, and perceive and structure the world. Culture is, essentially, the way of life of a group of people that incorporates experiences of the past, influences thought and action in the present, and transmits these traditions to future group members. Adaptation is necessary, however, for the culture to survive in an ever-changing world. Consciously and unconsciously, the members abandon, modify, or assume new patterns to meet the needs of the group.
The cultural setting in which children are raised can influence many aspects of their life, from the food they eat to the way they behave in a social setting. To be acceptable members of the culture, children must learn how the culture expects them to behave toward others in the group. In turn, they learn how they can expect others to behave toward them.
Cultures and subcultures contribute to the uniqueness of child members in such a subtle way and at such an early age that children grow up to think that their beliefs, attitudes, values, and practices are the “correct” or “normal” ones. By age 5, children can identify persons who belong to their own race or cultural background. During later primary years, children are able to identify people from different cultures (Trawick-Smith, 2006). A set of values learned in childhood is likely to characterize children’s attitudes and behavior for life, guiding their long-range strivings and monitoring their short-range, impulsive inclinations. Thus every ongoing society socializes each succeeding generation to its cultural heritage.
The manner and sequence of the growth and development phenomenon are universal and fundamental features of all children; however, the variations in behavioral responses that children display to similar events are believed to be determined by their culture. Children acquire the skills, knowledge, beliefs, and values important to their own family and culture. The pace of acquisition of cognitive and motor skills can differ by cultural background as well as the child’s social and emotional development (Trawick-Smith, 2006).
Cultures may also differ in whether status in the group is based on age or on skill. Even children’s play and their types of games are culturally determined. In some cultures children play in groups composed of members of the same sex; in others, they play in mixed-sex groups. In some cultures team games predominate; in others, most play is limited to individual games.
Standards and norms vary from culture to culture and from location to location; a practice that is accepted in one area may meet with disapproval or create tension in another. The extent to which cultures tolerate divergence from the established norm varies among cultures and subcultural groups. Although conformity provides a degree of security, it is often a deterrent to change.
SOCIAL ROLES
Much of children’s self-concept is derived 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 it delineates and clarifies roles, the culture 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 is characterized by 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 exert a great deal of influence on the child.
Secondary groups are groups that have limited, intermittent contact and in which there is 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 church organizations (also considered in relation to subgroups). The childrearing orientation in a secondary-group environment, such as urban communities, differs considerably from that of a primary-group community. An urban community is dynamic and rapidly changing; therefore many of the traditional behaviors and values do not meet its needs. Consequently, parents are often uncertain about what to teach their children. They may wish to rear their children with values consistent with their own, but the differences in experience between the generations are too great. As a result, they often grant their children autonomy in some areas of decision making early in the developmental process, and other secondary groups assume a greater influence. The children are exposed to an assortment of social groups with diverse sets of values and expectations. None of the groups is highly dominant in its influence; therefore the children are exposed to an eclectic set of values, some in agreement and some in conflict with the others. From these they must ultimately select those that they determine to be best for them and adopt them to form a consistent set of roles and behaviors to be incorporated into the self-concept.
Self-Esteem and Culture
A child’s sense of self-esteem is influenced by his or her culture (Trawick-Smith, 2006). Some cultures are more collective in thought and action. A child from a collective culture will hold an inclusive view of self. Self-evaluation is related to the accomplishments or competencies of the entire family or community. School experiences that focus on personal achievement may promote positive self-esteem in some children but not in others, who are more dependent on the success of a whole family or peer group. A child’s sense of control may not come from individual self-reliance but rather from a feeling of worth in his or her family or community (Trawick-Smith, 2006).
Families and culture also influence the criteria children use to evaluate their own abilities. Additionally, cultures vary in whether they instill an internal locus of control (a belief in the ability to regulate one’s own life). Effects on self-esteem are minimal if these beliefs are directed by parents and are in accordance with cultural customs (Trawick-Smith, 2006). What is damaging to emotional health is helplessness that stems from prejudice. Ethnic pride is a factor that has helped maintain positive self-image and protect against the damage that prejudice can cause (Trawick-Smith, 2006).
SUBCULTURAL INFLUENCES
Except in rare situations, children grow and develop in a blend of cultures and subcultures. In a large, complex society such as that of the United States, different groups have their own set of standards, values, and expectations within the collective ways of the large culture. Although many cultural differences are related to geographic boundaries, subcultures are not always restricted by location.
Children’s membership in a cultural subgroup is, for the most part, involuntary. They are born into a family with a specific ethnic or racial heritage, socioeconomic level, and religious beliefs. Although in the complex North American society there are countless subcultures and considerable variation in the way of life, those subcultures that seem to exert the greatest influence on childrearing are ethnicity, social class, and occupational role. In addition, schools and peer-group subcultures are strong influences in the socialization of the child (Fig. 4-2).
Ethnicity
Ethnicity is the classification of or affiliation with any of the basic groups or divisions of humans 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 result from the cultural heritage of the specific ethnic group. The term ethnic has aroused strong negative feelings and is often rejected by the general population (Spector, 2004).
To establish their place in the group, children learn how to adhere to 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 the manner in which 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 blend into the larger culture. It is particularly difficult for persons to attempt to maintain an identity with a subculture while living and conforming to the requirements of the dominant culture. Universal customs and language used in commercial and educational systems are different from those of the minority culture. Consequently, children reared in this environment are confused about roles and values, and they usually adopt those of the more influential or higher status culture. Youths, in particular, are influenced by the locally dominant group.
Ethnocentrism is the concept that one’s own culture proves the right and natural way to do things while all other ways are unnatural and inferior (Galanti, 2004). Ethnic stereotyping or labeling stems from ethnocentric views of people. 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 the ability of one person to objectively evaluate the beliefs and behaviors of others. This inherent viewpoint of individuals tends to bias their interpretation and understanding of the behavior of others. The culturally competent nurse should be empathetic and aware of his or her own views and that they may differ from another’s based on culture or ethnicity. The nurse should be willing to ask questions that will provide a better understanding of patient or family views when appropriate.
Socioeconomic Class
It is important to recognize that family relationships may be stronger among some ethnic or cultural groups than others. However, the influence of socioeconomic class cannot be overlooked. Socioeconomic class relates to the family’s economic and education 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, 2004).
The term socioeconomic class should not be confused 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).
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 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 some basic set of resources needed for adequate existence. Relative poverty reflects the median income and median standard of living in a society or country and is the term used in referring to childhood poverty in the United States (Scruggs and Allan, 2006); that is, what appears to be substandard living conditions in one area may be a standard or norm in another.
The number of children living in poverty has continued to increase during the twenty-first century. The child poverty rate in the United States is among the highest in the developed world (American Academy of Pediatrics, 2005). In 2006, 18% of children were living in poverty, a 6% increase since the year 2000. In 2005, nearly 29 million U.S. children lived in low-income families. Low income is defined as having a family income (for a family of four) that is less than twice the federal poverty threshold with at least one parent working 50 or more weeks during the year. The majority of these children, or nearly 15 million, had at least one parent who worked regularly but were living on the economic edge and struggling to make ends meet (Annie E Casey Foundation, 2006). Poverty is a strong predictor of child health and is closely associated with poorer physical, developmental, and mental health outcomes (American Academy of Pediatrics, 2005).
Homelessness
One of the most pressing problems in the United States is the growing number of homeless families. Homeless individuals are those who lack resources and community ties necessary to provide for their own adequate shelter. Homeless children have increased in numbers as poverty has become feminized, minorities have become poorer, and low-income housing has become less accessible. Estimates on the number of homeless children in the United States are at 1.6 million children each year, with the number growing (American Academy of Pediatrics, 2005). The majority of children are younger than 5 years of age and predominantly from minority groups.
Most homelessness is a direct result of increasing numbers of people in poverty combined with a lack of decent, affordable housing. Government housing subsidies have decreased, whereas the number of working poor has increased (Tropello, 2000). Other reasons include job layoffs, low income, parental mental illness, domestic conflict, and unexpected family or economic crises. Many families move into homelessness gradually after family members and friends are no longer willing to provide housing. Another group of homeless children are the “runaway” and “throwaway” adolescents. Many runaways are victims of physical and sexual abuse and leave home because of long-term family or school problems.
Migrant Farmworker Families
One of the most disadvantaged groups is migrant farm workers and their children. Indications suggest that in the United States there are between 3 million and 5 million migrant and seasonal workers and their dependents, whose average yearly income is well below the poverty level. In addition, most of these families have no health insurance.
The low position of these families on the economic scale and their rootless, mobile existence subject them to inadequate sanitation, substandard housing, social isolation, and lack of educational and medical facilities (American Academy of Pediatrics, 2005). This lifestyle is especially deleterious to the children. Schooling and health care are inadequate. Children are likely to live in a number of localities and attend a variety of schools over the course of a year, with no continuity in either education or health care. Because both parents work in the fields, children receive little adult supervision; therefore injury rates are high, and meals are erratic.
Immigrant Children
The 2000 U.S. Census informed us that there are a growing number of immigrants who currently are living in the United States (US Census Bureau, 2001). In 2005 it is estimated that 21% of children (15.7 million) lived in immigrant families; the children were either born outside the United States or had at least one foreign-born parent (Annie E Casey Foundation, 2007). These children and families face unique stressors, including depression, grief, and anxiety related to migration and acculturation, separation from extended family and supports, language barriers, disparities in socioeconomic status compared with their country of origin, and possibly traumatic events that necessitated their immigration (American Academy of Pediatrics, 2005). Current laws restrict health benefits under government programs for immigrants who lawfully entered the United States after 1996; they must wait for 5 years to become eligible for comprehensive health benefits (American Academy of Pediatrics, 2005). Immigrant issues continue to require the attention of policymakers and child advocates.
Religion
An influential factor shaping the culture of the United States 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, there are individual differences that are part of the general culture.
The religious orientation of the family dictates a code of morality and influences the family’s attitudes toward education, male and female role identity, and beliefs regarding their ultimate destiny (Fig. 4-3). Religion may also be a factor in determining the school the children attend, the companions with whom they associate, and often their mate selection. 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 children are reared and their lifestyle. (See also Religious Beliefs, p. 64.)
Schools
Next to the family, schools exert the major force in providing continuity between generations by conveying a vast amount of culture from the older members to the young. In this way children are prepared to carry out the traditional social roles they are expected to assume as adults in society. School rules and regulations regarding attendance, authority relationships, and the system of sanctions and rewards based on achievement transmit to the child the behavioral expectations of the adult world of employment and relationships. School is often the only institution in which children systematically learn about the negative consequences of behaviors that deviate from social expectations. Teachers are expected to stimulate and guide the intellectual development of children and their sense of esthetics and to foster their capacity for creative problem solving. Through education, individuals in the lower classes are offered the opportunity and the capacity to move up in the social strata.
Traditionally, the socialization process of school began when the child entered kindergarten or first grade. Today, with more than 65% of mothers of preschool children working outside the home, this socialization process begins much earlier for a significant number of children in a variety of child care settings (Annie E Casey Foundation, 2006).
Children of some cultural groups fare less well in school. They come from under-represented groups, including African-American, Mexican-American, Puerto Rican, and Native American children (Trawick-Smith, 2006). These cultural variations can be attributed to high rates of poverty, different cognitive styles, ineffective schools, and parents’ views of schools as oppressive to cultural and traditional values (Trawick-Smith, 2006).
Communities
Surveys of more than 1 million young persons in the United States in grades 6 through 12 have shown that those 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’s or adolescent’s community is made up of the family, school, neighborhood, youth organization, and other members. They all contribute to the young person’s experience within any culture (Search-Institute, 2007).
Four categories of external assets that youth receive from the community include (Search-Institute, 2007):
1. Support—Young people need to feel support, care, and love from their families, neighbors, and others. They also need organizations and institutions that offer positive, supportive environments.
2. Empowerment—Young people need to feel valued by their community and be able to contribute to others. They need to feel safe and secure.
3. Boundaries and expectations—Young people need to know what is expected of them and what actions and behaviors are within the community boundaries and what are outside of them.
4. Constructive use of time—Young people need opportunities for growth through constructive, enriching opportunities and quality time at home.
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 include (Search-Institute, 2007):
1. Commitment to learning—Young people need to develop a commitment to education and life-long learning
2. Positive values—Youth need to have a strong sense of values that direct their choices.
3. Social competencies—Young people need competencies that help them make positive choices and build relationships.
4. Positive identity—Young people need a sense of their own power, purpose, worth, and promise.
Peer Cultures
Peer groups also have an impact on the socialization of children. 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. It is most apparent in the school and in the unsupervised play group. The play group presents this culture in a much purer form than does the school, in which 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 are confronted with 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 relationships in a peer group change over time, and leadership may shift (Trawick-Smith, 2006).
The kind of socialization provided by the peer group depends on the special subculture that develops from the background, interests, and capabilities of its members. Some groups support school achievement, others focus on athletic prowess, and still others are decidedly antithetic to educative goals. Scholastic achievement is strongly related to the value system of the peer groups. Many conflicts between teachers and students and between parents and students can be attributed to fear of rejection by peers. A conflict between what is expected from parents regarding academic achievement and what is expected from the peer culture is especially pronounced in high school.
Although it has neither the traditional authority of the parents nor the legal authority of the schools for teaching information, the peer group manages to convey a substantial amount of information to its members. Peer relationships also provide an important social context for the development of body image among both adolescent girls and boys. Although other subcultural forces such as the family and media influence the development of body image, adolescents’ perception of what is a desirable appearance is created by norms and expectations that are modeled and reinforced within the peer group (Jones and Crawford, 2006). It is through peer relationships that children learn ways to deal with dominance and hostility and to relate with persons in positions of leadership and authority. The peer subculture relieves boredom and provides recognition that individual members do not receive from teachers and other authority figures.
THE CHILD AND FAMILY IN NORTH AMERICA
The frontier background of the North American culture has contributed to the overall orientation to life and childrearing. There has always been 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 the parents. This hopeful outlook and a general future orientation, together with the possibility of upward social mobility, have created a pervasive overall attitude of optimism. Increasing development of self-confidence and autonomy in children is fostered and encouraged. Children in North America are generally permitted a greater degree of freedom than in more tradition-oriented cultures, where individuals remain in one class for life.
Family life in North America is characterized by increasing geographic and economic mobility. There is less reliance on tradition, families are fragmented, and there is limited opportunity to transmit and acquire the traditional and accepted customs of a culture. Consequently, young adults rely to a greater extent on professed experts, peers, and 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 as a result of the increased homogeneity of the culture.
Minority-Group Membership
The United States has more racial, ethnic, and religious minority groups than any other country as a result of high immigration rates and high birth rates among these groups. Ethnic minority groups are becoming increasingly important because it is anticipated that these groups will produce children at a faster rate than will the majority Caucasian population. Consequently, the minority population is increasing, whereas the majority Caucasian population is decreasing. When people from different cultures interact, this is termed cultural diversity (Purnell and Paulanka, 2003).
The 2000 U.S. Census found that there are more than 280 million people in the United States, with 6.8 million reporting more than two races. African Americans alone or in combination with another race comprise more than 35 million, and Hispanics or Latinos of any race comprise more than 35 million. The Hispanic population increased 58%, or 13 million people, from 1990 to 2000 (US Census Bureau, 2001). (See Cultural Awareness box.)
CULTURAL AWARENESSOverview of Race and Hispanic Origin in Census 2000
The federal government defines race and Hispanic origin as two separate and distinct concepts. In the 2000 U.S. Census, responders were first asked if they are of Spanish/Hispanic/Latino origin. The second question asked respondents to report the race or races they considered themselves to be. The definitions of racial groups included the following (US Census Bureau, 2001):
Caucasians are people having “origins in any of the original peoples of Europe, the Middle East, or North Africa.”
African Americans, sometimes referred to as blacks, are defined as “people having origins in any of the Black racial groups of Africa.”
An Asian is any person with “origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.”
Native Hawaiians and Other Pacific Islanders are “people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.”
Native Americans (referred to as American Indians) and Alaska Natives are defined as “people having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.”
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 the other. This process is involuntary; the minority group member is forced to learn the new culture to survive (Spector, 2004). 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, 2004).
Evidence indicates that changes in attitudes are slowly taking place in some groups and in some places. An attitude of cultural relativism provides for understanding behaviors in their cultural context and sees other ways of doing things as different but equally valid (Galanti, 2004). With growing awareness, interest, and understanding by increasing numbers of the majority group, which have accompanied the recent emergence of racial and ethnic pride, minority-group children 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. As with all children, the most important influences on development of a positive self-image are warm, understanding parents who take an active interest in fostering their children’s growth. Parents who accept their children and react positively and constructively rather than in a negative and demeaning manner will help their children develop feelings of self-worth, self-esteem, and self-acceptance. The more adequate children feel, the more positive will be their attitudes toward both majority and minority children, the greater their ability to withstand prejudice and intolerance, and the less their need for counteraggressive behavior.
A woman from the Middle East is visiting her child who is hospitalized for a serious illness. Her husband left for home a short time ago to wash and change clothes. She speaks little English. You need to obtain consent from her for an emergency procedure. She is hesitant and refuses to sign the consent form. What should you do?
1. Evidence—Is there sufficient information to draw any conclusions about this woman’s actions?
2. Assumptions—Describe some underlying assumptions about each of the following:
3. What priorities for nursing care should be established at this time?
CULTURAL SHOCK AND CULTURAL COMPETENCE
The term cultural shock describes the “feelings of helplessness and discomfort and a state of disorientation experienced by an outsider attempting to comprehend or effectively adapt to a different cultural group because of differences in cultural practices, values, and beliefs” (Leininger, 1978). This state occurs with both patients and health care providers who move from one cultural setting to another. It can happen to persons who immigrate to a new country (such as Asian refugees) or to those from a subcultural group who must adjust to the ways of an unfamiliar subgroup (such as children entering the school subculture or consumers entering the hospital subculture). Cultural shock is characterized by the inability to respond to or function in a new or strange situation (see Critical Thinking Exercise).
Numerous factors influence reactions to a new environment. Language barriers, including dialects and jargon (such as medical language) 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 stranger in the new environment. The outsider experiences intense feelings of isolation, loneliness, and nonrelatedness.
Nurses are challenged to overcome cultural shock and develop the dynamics of cultural sensitivity, an awareness of cultural similarities and differences. In doing so, the nurse is helped to practice culturally competent care. This requires changing the way people think about, understand, and interact within the world around them. Cultural competence is an ongoing process that is interactive and without end (Dunn, 2002). Six elements included in the process of developing cultural competence are (Dunn, 2002):
1. Working on changing one’s world view through examining one’s own values and behaviors and striving to reject racism and institutions that support it
2. Becoming familiar with core cultural issues by recognizing these issues and exploring them with patients
3. Becoming knowledgeable about the cultural groups we work with while learning about each individual patient’s unique history
4. Becoming familiar with core cultural issues related to health and illness and communicating in a way that encourages patients to explain what an illness means to them
5. Developing a relationship of trust with the patient and creating a welcoming atmosphere in the health care setting
6. Negotiating for mutually acceptable and understandable interventions of care
CULTURAL AND RELIGIOUS INFLUENCES ON HEALTH CARE
SUSCEPTIBILITY TO HEALTH PROBLEMS
Some groups of people are more susceptible than others to certain illnesses. An innate susceptibility is acquired through generations of evolutionary changes that take place within constrained or segregated populations. The proximity to disease, environmental factors, and general physical status are significant factors associated with health problems.
Hereditary Factors
Advances in science have found that many diseases have a genetic basis. The access to screening for these diseases will challenge genetic testing and counseling and can present complex moral dilemmas for the individual patient and family and for society.
A number of conditions show ethnic or racial differences based on genetics. For example, Tay-Sachs disease, characterized by early neurologic deterioration and mental retardation, affects primarily Ashkenazi Jewish families, particularly those of Northeastern European origin, whereas Sephardic Jewish families appear to be no more at risk for the disease than are other populations. The incidence of cystic fibrosis is highest in Caucasians and almost nonexistent in Asians, and the rare affected African Americans are usually in areas where there is apt to be mixed ancestry. A classic disorder of African Americans is sickle cell disease (see Chapter 26); however, the incidence of cardiovascular disease, pneumonia, and diabetes is also high among African Americans. Native Americans are at risk for type 2 diabetes and lactose intolerance. Racial and ethnic differences are further considered in relation to diseases and defects as they are discussed throughout the book.
Common food items and drugs may cause health problems in certain ethnic groups. For example, persons of Mediterranean, African, Near Eastern, and Asian origin frequently have glucose-6-phosphate dehydrogenase deficiency. They may develop acute hemolytic anemia after they ingest fava (horse or broad) beans or certain drugs such as aspirin preparations, sulfonamides, or primaquine. Other groups, especially Southern Europeans, Jews, Arabs, African Americans, Asians, and Native Americans, have a deficiency of lactase, the enzyme needed to metabolize lactose. Ingestion of lactose can cause abdominal distention, flatus, and diarrhea (Purnell and Paulanka, 2003). Unknowing but well-meaning health care workers may be responsible for these symptoms in their clients when they prescribe foods or food supplements containing lactose as sources of nutrients.
Physical Characteristics.: Among racial groups there are observable differences in physical appearance. The most obvious are skin and hair coloring and texture. Skin color is determined by the amount of melanin pigment present in the skin. Persons from countries located near the equator have darkly pigmented skin, which serves to protect the skin from the year-round exposure to the sun’s rays; persons from northern countries have very light skin, which provides for maximum exposure to the sun’s rays (necessary for vitamin D metabolism) during the short daylight hours. There can be wide variations in skin color between these two extremes as a result of geographic origin or intermixing of persons with dark and light skin color. In patients with dark pigmentation, the detection of skin color changes (e.g., vasomotor alterations, cyanosis, jaundice) can be difficult and requires modification of assessment techniques.
Variations in the newborn are often related to racial or ethnic origin. For example, newborn infants of Asian and African-American parents are smaller than infants of Caucasian parentage, and bluish pigmented areas (mongolian spots) on the sacral region are a common observation in Asian, African-American, Native American, and Mexican-American 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. “Typical” growth descriptions are often based on observations of middle-class Caucasian children from the United States. Children from Asian countries are commonly smaller, falling below the 10th percentile on weight and height charts used for children in the United States, whereas African and African-American children are more advanced in physical growth (Trawick-Smith, 2006). This difference in stature can lead to misinterpretation of health status and capabilities.
Socioeconomic Factors
The most overwhelming adverse influence on health is socioeconomic status. A higher percentage of lower-class individuals are suffering from some health problem at any one time than are those in any other group. The sum of all aspects of their situation contributes to and compounds health problems; this includes crowded living conditions and poor sanitation, which facilitate transfer of disease (e.g., tuberculosis). There is a higher incidence of lead poisoning in children from families from the lower socioeconomic classes because there is more ready access to lead in the environment, especially lead-based paint in old housing (Centers for Disease Control and Prevention, 2007).
In the lower classes, children are less likely to be immunized against preventable diseases than are children in the upper and middle classes. Lack of funds or inaccessibility of health services inhibits treatment for any but severe illness or injury. Sometimes health care is inadequate because of lack of information. In some areas a disorder is so commonplace that it is looked on as unavoidable; it is not recognized as something that requires (or is amenable to) treatment. The parents may not have information regarding causes, treatment, outcome of the illness, or preventive measures. The nurse can use the limited opportunities when the family does come into contact with the health care system to inquire about immunizations, screen for vision problems, provide nutritional information, and offer additional prevention and health promotion resources.
Poverty.: A high correlation between poverty and the prevalence of 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 medical treatment. One of the most significant health problems related to poverty is a high infant mortality rate. Although the infant mortality rate in the United States is at an all-time low, our nation’s infant survival rate remains lower than that of most industrialized nations (Annie E Casey Foundation, 2006).
Poor families are denied access to many health 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 have them accompany them 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. 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 nutrition accounts for many health problems in the lower classes. Lack of funds and knowledge results in a diet that may be seriously deficient in essential food substances, especially protein, vitamins, and iron. This inadequate diet often leads to nutritional deficiency disorders and growth retardation in children. In many the total intake is insufficient to support normal growth. Unstructured eating patterns and irregularly scheduled mealtimes can also contribute to erratic food intake and a proportionately larger consumption of nonnourishing snacks, which can result in excessive weight gain.
Because of deficient preventive care, dental problems are more prevalent. Lack of standard immunizations, together with reduced resistance from poor nutrition, renders the exposed 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 do persons in the general population.
Homelessness.: Research indicates that families are the fastest-growing subgroup of the homeless population (American Academy of Pediatrics, 2005). Homeless children experience all of the health problems associated with poverty, as well as other types of disorders. A majority of these children experience poor health. They not have a regular source of health care, and the focus of their care is not preventive. Their care is fragmented, crisis oriented, and often sought in emergency departments. Children who are homeless experience a higher incidence of trauma-related injuries, developmental delays, sinusitis, anemia, asthma, bowel dysfunction, eczema, and visual and neurologic deficits (American Academy of Pediatrics, 2005). Additionally, homeless adolescent youth are at risk for violence and victimization, substance abuse, pregnancy, and sexually transmitted diseases (American Academy of Pediatrics, 2005).
Migrant Farmworker Families.: Migrants generally suffer more illness, both acute and chronic, than the general population. They live in an environment of poverty, unstable and overcrowded housing, poor sanitation, unreliable transportation, and social isolation. Children of migrant farm–workers have a higher risk of respiratory and ear infections, gastroenteritis, intestinal parasites, skin infections, dental problems, lead and pesticide exposure, tuberculosis, short stature, undiagnosed congenital abnormalities, delayed development, and injuries (American Academy of Pediatrics, 2005).
When medical care is provided to migrant families, follow-up care is usually impossible because of their transient lifestyle. Compliance with medical therapies is primarily related to accessibility and availability. For example, medications provided by health workers are more likely to be taken than those that must be obtained at a pharmacy. In addition, medications are often discontinued after self-perceived recovery.
Immigrant Families.: Children who have immigrated may have diseases such as malaria or hepatitis A that are more common in their country but rarely diagnosed in the United States. Immigrants have a higher rate of tuberculosis infections than U.S.-born persons. Immigrant children may not have been screened at birth for congenital diseases such as hemoglobinopathies and inborn errors of metabolism. Immunizations may not have been adequate as well (American Academy of Pediatrics, 2005).
CULTURAL CUSTOMS
Nurses must be aware of the need to consider cultural differences in patients when providing health care. An understanding of the various beliefs regarding the causation of illness and disease, as well as traditional health practices, is essential to successful intervention. The more nurses know about the values, beliefs, and customs of other ethnic groups, the better able they are to meet the needs of these families and to gain their cooperation and compliance.
Cultural Relativism
Although clinical characteristics of a disease or condition are essentially the same across cultures, how a child or family interprets or experiences it varies. Culture as an influence is one obvious explanation for variance. Cultural relativism is the concept that any behavior must be judged first in the context of the culture in which it occurs (Purnell and Paulanka, 2003). Nurses must first relate to the family’s perceptions and interpretations of experiences from the family’s background and cultural belief system before they can effectively intervene.
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, Chinese families frequently 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 a difference in goals and expectations that parents have for their children.
In some cultures the child’s gender may influence a family’s perception of the implications of an illness or disability. For example, in the Arabic and Asian cultures the male child is held in higher esteem than the female child. This also holds true for some families of Jewish, Italian, Greek, and Indian origin. The male child may receive better health care and more food because this is the child who will take care of his parents in their old age (Galanti, 2004).
Perceptions of disease or signs and symptoms of illness are also influenced by culture. Some cultures, for example, see diarrhea as a cleansing of the body that is essential for health maintenance and illness prevention or cure. Furthermore, signs or symptoms resulting from diarrhea and ensuing dehydration, such as malaise, fever, anorexia, and irritability, may be viewed as separate illness entities.
Nurses can often recognize a family’s health-related cultural perceptions and interpretations through discussion and observation. Implications of these perceptions should be explored and considered when planning culturally appropriate interventions.
Relationships with Health Care Providers
Communication in the health care setting can be challenging when both parties speak the same language. It becomes even more complex when the patient and health care provider speak different languages. The same word can have different meaning in different cultures. Patients may say yes to a question they do not understand when they mean no. Communication styles can differ by style and demeanor, use of silence, use of eye contact, gestures, and body language (Galanti, 2004).
In relation to time, some cultures are oriented toward the clock, whereas others are more focused on activities. Conflicts can arise during an interaction involving these two orientations. For example, African Americans tend to be flexible in their time orientation; an African-American family may be late for or miss appointments because other issues take precedence, and the family may not communicate this to the health agency. The Japanese, on the other hand, consider time to be valuable and to be used wisely.
Family roles differ by culture as well. Decision making may involve the extended family. Authority figures in a family may be a mother or father or grandparent. Kinship structure is also determined by culture. Many cultures are unilateral in that they trace their descent from either a male or a female ancestor (Galanti, 2004) (Fig. 4-4).
FIG. 4-4 A father with his hospitalized child. (Courtesy E. Jacob, Texas Children’s Hospital, Houston.)
Nurses should inform themselves of any specific attitudes regarding the manner of approach to a child in a given culture. A primary social premise for Navajo Indians is that no person has the right to speak for another. They may allow a child to decide whether to take a medicine or not, whereas in other cultures this view might be viewed as irresponsible (Purnell and Paulanka, 2003). Some ethnic 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 others, such as the Samoan family, 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 this behavior may be misinterpreted by the hospital staff as indifference or abandonment.
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 perception or relationships with other persons in the majority group. Based on these biases, minority children may suspect that nurses have hostile feelings toward them and fear ill treatment. When such children are hospitalized, this feeling compounds the feelings of loneliness, helplessness, and retribution that accompany frightening experiences 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.
Communication.: Communication may be a source of distress and misunderstanding between persons from different ethnic groups, especially if the languages are different. Lack of interpreter services and linguistically appropriate health education materials are associated with patient dissatisfaction, poor understanding and adherence, and lower-quality health care (Betancourt, Green, Carrillo, and others, 2003). The Office of Minority Health of the U.S. Department of Health and Human Services has established national standards on culturally and linguistically appropriate services in health care. Health care organizations must ensure the competence of language assistance provided to persons with limited English proficiency (LEP) by interpreters and bilingual staff. Family and friends should not be used for interpretation services except on request by the patient (Shaw-Taylor, 2002).
Some persons with poor or limited language comprehension may simply smile and nod in agreement if they do not understand the questions or directives. It is vital that the family fully understand all implications of a child’s care and management before they sign permits for special procedures or assume responsibility for the child’s care. It is not uncommon for a Vietnamese or a Japanese family to indicate “yes” when in fact they mean “no” in order to avoid social disharmony. They tend to use indirectness rather than confrontation and may become evasive when direct questioning makes them uncomfortable.
Helpful communication tools include the following:
Have a series of audio and audiovisual recordings in several languages designed to greet and familiarize the family with the hospital.
If an interpreter is not available on site, the Language Line, a national telephonic interpreter service for all languages, can be accessed by institutions as a back-up system.
Have legal consent forms and explanations of common diagnostic tests available in several languages.
Keep cards with common greetings, phrases, and names of body parts in the family’s language with the patient’s chart (e.g., miseries [pain] and locked bowels [constipation] in African Americans; and caida de la mollera [fallen fontanel from dehydration], susto [fright], dolor, duele, or lele [pain], and la diarrhea [diarrhea] in Hispanics).
Nonverbal communication is a practiced art in many Native American tribes, and the members are highly sensitive to body language. They emphasize periods of silence to formulate thoughts in preparation for speech and often remain silent after listening to statements by others to properly assimilate what has been said. Interruption, interjection, or haste to arrive at abrupt conclusions is perceived as immature behavior.
The level of comfort with body space or distance from others varies among cultures. For example, Hispanics tend to get closer, and Asians prefer a greater distance.
Eye contact is viewed differently in cultures. Although Anglos are advised to look people straight in the eye, it is not uncommon for persons in some ethnic groups to avoid eye contact and become uncomfortable when conversing with health workers. A Vietnamese patient may not look directly into the nurse’s eyes as a sign of respect. Some Native Americans will make eye contact during the initial greeting, but continued, unwavering eye contact is considered insulting and disrespectful. Asians may consider eye contact a sign of hostility or impoliteness.
Gestures also may have different meanings. For example, some Asians consider finger or foot pointing disrespectful. Native Americans consider vigorous handshaking a sign of aggression, whereas to Anglos the gesture is a sign of good will.
Families may be reluctant to question or otherwise initiate contact with health professionals. In the Asian cultures, for example, it is considered a sign of disrespect to question those who are viewed as persons of authority. A Japanese family may wait silently rather than ask or question. They believe that the health professionals know best and will meet their needs without being asked. It is also important to avoid criticism. Criticism can cause Asians to “lose face,” to feel ashamed, which is highly undesirable.
Language and bureaucracy have been considered the biggest barriers to the use of health care services by many families (Betancourt, Green, Carrillo, and others, 2003). Long intake processes and wait times are also barriers for minority patients. Often families may have poor language comprehension, so it is necessary to speak slowly and carefully, not loudly, when conversing with them. Many persons are able to read and write English better than they can speak or understand it. Also, the dominant language usually takes over in anxiety-provoking situations, even in those who are able to communicate satisfactorily under ordinary circumstances.
Terms of address and use of first and last names vary among cultures and can create confusion. For example, in Asian cultures the family name is given first in respect for the family and the given name follows. Therefore all siblings in a family have the same first name. Ethiopians have a complex system whereby women retain their last names after marriage and the paternal grandfather’s name becomes the child’s last name.
The expression of emotion also varies ethnically. In some cultures (e.g., Hispanic or Jewish) emotions are expressed openly and members are accustomed to sharing their sorrows and joys with family and friends. Conversely, Nordic and Asian groups are more restrained.
Health care providers generally ask questions and use handouts, booklets, and—particularly with children—dolls and pictures as communication aids. This is uncommon in some cultures. For example, Native American healers ask few questions and do not use forms. Nurses need to consider both verbal and nonverbal communication techniques to interact effectively with children and their families from different cultures (see Nursing Care Guidelines box).
Food Customs
Food customs and symbolism are an integral part of various cultural, ethnic, and religious groups. Although in a large country such as the United States most persons have adopted the eclectic food habits that have evolved over countless generations, many ethnic and geographic food traditions and preferences are retained. 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 the developing fetus.
The distinctive food customs of ethnic groups are a product of their native environment, determined by availability. Fish is a staple food of persons living near the ocean, such as people from Japan, Polynesia, Southern Europe, and Scandinavia. Fruit and vegetable preferences are directly related to the climate in which they grow naturally or can be cultivated. The types of grain that are ethnically associated are also those that grow best in the native lands. Even in the continental United States there are regional favorites, such as rice, hominy grits, and okra in the Southern states. In some cultures food is highly spiced; in others, foods tend to be bland.
Children may have a number of restrictions 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 in whom a hereditary lactase deficiency prevents digestion of foods containing lactose. Others have religious restrictions, such as kosher foods and food preparation of the Orthodox Jewish faith, avoidance of pork in the diet of persons of Islamic faith, and the vegetarian diet of Seventh-Day Adventists (see Vegetarian Diets, Chapter 11).
Children in a strange environment, such as the hospital, feel much more comfortable when they are served familiar foods (Fig. 4-5). Hospital food often tastes strange and bland. The family may be concerned that their child is not receiving foods appropriate to their culture and beliefs. When possible, it is advisable to provide children ethnic foods or allow families to bring favorite foods. Concern for differences in food habits and patterns projects an attitude of respect for the family’s ethnic or religious heritage.
HEALTH BELIEFS AND PRACTICES
Beliefs related to the cause of illness and the maintenance of health are an integral part of the cultural heritage of families. Often inseparable from religious beliefs, they influence the way that families cope with health problems and the way that they respond to health care providers. Predominant among most cultures are beliefs related to natural forces, supernatural forces, and imbalance between forces.
Natural Forces.: The most common natural forces held responsible for ill health if the body is not adequately protected include cold air entering the body, impurities in the air, or other natural sources. For example, a Chinese mother may overdress her infant in an effort to keep cold wind from entering the child’s body. The Chinese believe that cold weather, rain, and wind are responsible for “cold” conditions. In the African-American culture, natural phenomena such as phases of the moon, seasons of the year, and planet positions are believed to affect the body and its processes; therefore health maintenance is strongly associated with the ability to read “the signs.” Most Native Americans consider health to be a state of harmony with nature and the universe.
Supernatural Forces.: High on the list of causes of illness are forces beyond comprehension and logical explanation. Evil influences such as voodoo, witchcraft, or evil spirits are viewed in some cultures as causes of adverse health, especially those illnesses that cannot be explained by other means.
A health belief that is common among people from Central America, the Middle East, the Mediterranean, some Asian, and some African societies is the concept of the evil eye (Galanti, 2004). The general belief is that one person inflicts evil on another and causes the victim to fall ill. The motive is usually envy. Each culture that believes compliment can cause the evil eye also has ways to neutralize them. This is part of the concept of health as a state of balance, and illness as a state of imbalance (see Imbalance of Forces). Infants and small children, because of immature development of their internal strength-weakness states, are especially vulnerable to the gaze of the evil eye. Consequently, the evil eye concept serves to rationalize an inexplicable onset of illness in children who display such symptoms as restlessness, crying, diarrhea, vomiting, and fever.
Although seldom expressed to health care providers, the belief that a witch can cast a spell over others at the request of someone who wishes them ill is found in Caribbean, African, and Australian aboriginal cultures. The victim is often tortured in effigy by pins driven into a doll at the location where the intended victim is to be hurt. “Voodoo deaths” have occurred from the victim’s belief in the curse and may result from dehydration as the victim gives up the will to live and refuses to drink (Chidester, 2001).
Imbalance of Forces.: The concept of balance or equilibrium is widespread throughout the world. One of the most common imbalances supported by the Hispanic, Filipino, Chinese, and Arab cultures is that which exists between “hot” and “cold.” This belief is reputedly derived from the Hippocratic theory of humoral pathology, which states that illness is caused by an imbalance of the four humors: phlegm, blood, black bile, and yellow bile. “Hot” and “cold” describe certain properties and conditions completely unrelated to temperature. Diseases, areas of the body, foods, and illnesses are classified as either “hot” or “cold.” In Chinese health belief, the forces are termed yin (cold) and yang (hot). To maintain health, these “hot” and “cold” forces must be kept in balance.
Illness is treated by restoring normal balance through the application of appropriate “hot” or “cold” remedies. A “cold” condition such as a respiratory disease is believed to be caused by exposure to cold weather, rain, or cold wind entering the body; it is treated by administering “hot” foods, herbs, or drugs. Menstruation is considered to be a “hot” condition; therefore women are cautioned against ingesting “hot” foods, which might increase menstrual flow or produce cramping. Ingesting too much of either “hot” or “cold” foods can also be interpreted as a cause of illness.
Health care workers who are aware of this belief are better able to understand why some persons refuse to eat certain foods. It is possible to help families devise a diet that contains the necessary balance of basic food groups prescribed by the medical subculture while conforming to the beliefs of the ethnic subculture.
The hot-cold food classification may have adverse effects. For example, newborn infants are often started on evaporated milk formulas. Evaporated milk is considered to be a “hot” food, whereas whole milk is viewed as a “cold” food. Infants tend to develop rashes, which are believed to be caused by “hot” foods; in such cases, parents may decide to switch to whole milk. However, parents fear that it is dangerous to change too rapidly, so they often feed the child some type of neutralizing substance, which may create additional health problems. Such a problem might be averted if the family’s preference is determined before discharge from the hospital, with a formula prescribed that is agreeable to both the family and the practitioner.
Health Practices
There are numerous similarities among cultures 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. There is the curandero (male) or curandera (female) of the Mexican-American community whose healing powers are believed to be a gift from God. The Asian consults an herbalist, knowledgeable in medicines, or an ethnic practitioner practiced 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 affect cures through 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. 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 can be used to reinforce the treatment plan. For example, most of the foods contraindicated for persons with peptic ulcers are “hot” foods and would be avoided because of their belief systems. Also, 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. However, numerous health remedies or preventive practices have no scientific basis, such as the use of garlic or asafetida (a bad-smelling gum resin obtained from various Asiatic plants that looks like a dried sponge), which is worn around the neck to prevent contagious diseases. Also, the wearing of copper or silver bracelets to protect the wearer as he or she grows has no scientific basis. Practices that do no harm should be respected. Overcoming the effect of the evil eye usually requires specialized rituals conducted by the appropriate practitioner. For example, the Chicano curandera ascertains that the condition is truly the result of the evil eye by performing an assessment ritual and then, with a confirmed diagnosis, performs a curative ritual. Sometimes the faith in the folk practitioner results in a delay in obtaining needed medical treatment, although the practitioner will usually suggest medical care if his or her ministrations are unsuccessful.
Health practices of different cultures may also present problems in assessment and interpretation. For example, certain cultural practices or remedies can be misdiagnosed as evidence of child abuse by uninformed professionals (Box 4-1). It is important to explain why these and other familiar remedies may now be considered harmful. Health care providers need to be aware of the practices so they do not misinterpret symptoms such as red welts from coining. Families need to understand how such practices can place them in jeopardy with child protective services (Galanti, 2004). Cultural health remedies that are detrimental to health include eating clay, excessive amounts of salt, or compounds that contain lead or mercury. A careful history can reveal these remedies, but it may require the collaboration of a folk healer to convince a user to stop the practice.
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 reason for its temporary removal is explained to the family, and they are reassured that their wishes will be respected.
Nurses can be most effective by operating from a multicultural perspective. Adopting a multicultural perspective means using appropriate aspects of each culture’s orientation to health to develop culturally acceptable health care interventions.
RELIGIOUS BELIEFS
Religious and spiritual dimensions are among the most important influences in many people’s lives. The term spirituality relates to an individual’s personal beliefs, transcendent experiences, and principles; religion refers to an organized system of beliefs or a place of worship. The pediatric nurse who learns how the patient and family view their traditions, values, and beliefs can understand how these dimensions may affect the patient’s health (McEvoy, 2003). Three areas to explore for information about the family’s culture, religion, or spirituality are beliefs and values, daily practices, and community involvement. An assessment tool can be easily used for integrating culture and spirituality into the nursing assessment (Box 4-2).
Religion affects the way people interpret and respond to illness (Spector, 2004). 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 it 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.
Religious affiliation has implications for many health-related functions and procedures. It is comforting for the family of an ill child to have this need recognized and respected. Nurses need to determine whether there are any special considerations, including dietary restrictions, related to spiritual practices that are important to the family. Family members are asked 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 also important to determine the wishes of the family regarding baptism, rites or practices related to death, and other religious rituals (such as circumcision, communion, or use of amulets or icons). Religion, which offers families understanding and spiritual support, is a valuable asset to health care. Characteristics of selected religions with beliefs that affect health care are outlined in Table 4-1.
TABLE 4-1
Religious Beliefs That May Affect Nursing Care
Data from Galanti G: Caring for patients from different cultures, ed 3, Philadelphia, 2004, University of Pennsylvania Press; Lipson JG, Dibble SL, Minarik PA: Culture and clinical care: a pocket guide, San Francisco, 2005, UCSF Nursing Press; Purnell LD, Paulanka BJ: Transcultural health care: a culturally competent approach, Philadelphia, 2003, Davis; Spector RE: Cultural diversity in health and illness, ed 6, Upper Saddle River, NJ, 2004, Pearson Prentice Hall.
IMPORTANCE OF CULTURE AND RELIGION TO NURSES
A general agreement exists among nurses to raise the cultural competence of professional nursing practice. To begin to understand and deal effectively with families in a multicultural community, nurses need to recognize barriers to transcultural communication and work to remove these barriers (Muñoz and Luckmann, 2005). Nurses, too, are a product of their own cultural background. They also need to recognize that 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 their professional culture in their educational program and later in their work environments 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 4-3). Recognizing that a behavior may be characteristic of a culture rather than an “abnormal” behavior places nurses at an advantage in their relationships with families. When nurses respect a family’s cultural differences, they are better able to determine whether the behavior is distinctive to the individual or a characteristic of the culture.
Cultural standards and values, family structure and function, and experience 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 non-judgmental and objective in working with families whose behaviors and attitudes differ from or conflict with their own. The nurse needs to understand how one’s own cultural background influences the way care is delivered (American Nurses Association, 1991). Relying 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 quite another to implement a fruitful course of action unless nurses work within the cultural and socioeconomic framework of the family.
It is beneficial to adapt ethnic practices to the family’s health needs rather than to attempt to change longstanding beliefs. To aid their efforts to understand and respect the cultural beliefs of families, nurses need to develop knowledge on how cultural groups understand life processes, define health and illness, and view the causes of illness. Nurses should combine their cross-cultural knowledge with excellent communication skills to learn from the individual patient and family about issues important to their care (Betancourt, Green, Carrillo, and others, 2003).
Some broad characteristics of selected cultures are outlined in Table 4-2. Tables 4-1 and 4-2 are presented as beginning frameworks for practicing transcultural nursing. Nurses must assess the cultural and religious practices of families to identify how these practices are similar to and different from those of their own cultural and religious backgrounds.
TABLE 4-2
Broad Cultural Characteristics Related to Health Care of Children and Families
Data from Galanti G: Caring for patients from different cultures, ed 3, Philadelphia, 2004, University of Pennsylvania Press; Lipson JG, Dibble SL, Minarik PA: Culture and clinical care: a pocket guide, San Francisco, 2005, UCSF Nursing Press; Purnell LD, Paulanka BJ: Transcultural health care: a culturally competent approach, Philadelphia, 2003, Davis; Spector RE: Cultural diversity in health and illness, ed 6, Upper Saddle River, NJ, 2004, Pearson Prentice Hall.
Culture is the sum total of mores, traditions, and beliefs about how people function and encompasses other products of human works and thoughts specific to members of an intergenerational group, community, or population.
Nurses have a responsibility to continually develop cultural competence. This includes understanding and respecting the influence of culture, race, and ethnicity on the development of social and emotional relationships, childrearing practices, and attitudes toward health.
A child’s self-concept evolves from ideas about his or her social roles.
Important subcultural influences on children include ethnicity, socioeconomic class, poverty, homelessness, immigration, religion, schools, community, and peers.
A trend that has significantly influenced the American family is increasing geographic and economic mobility.
Membership in a minority group presents special challenges for children, although changes in societal attitudes are slowly taking place.
A child’s physical characteristics and susceptibility to health problems can be related to ethnic and cultural variations of hereditary and socioeconomic forces.
Groups of children suffering from greater physical and mental health problems are those living in poverty, those who are homeless, those who live in migrant farm families, and those who are recent immigrants to the United States.
Because verbal and nonverbal communication is an important cultural consideration, nurses need to acknowledge and respect their patient’s practices for productive interaction to occur.
Cultural beliefs related to cause of illness and maintenance of health may focus on natural forces, supernatural forces, or imbalance of forces.
In planning and implementing patient care, nurses need to strive to adapt ethnic practices to the family’s health needs rather than attempt to change longstanding beliefs.
No cultural group is homogeneous; every racial and ethnic group contains great diversity.
answer to CRITICAL THINKING EXERCISE
1. Yes. An understanding of the Arab culture provides insight into the woman’s hesitancy to make decisions in her husband’s absence.
a. Typically in the Arab culture men make the decisions and women are expected to support these decisions.
b. The need for an interpreter is evident to make certain the mother understands the seriousness of the situation.
c. Knowledge of the procedures for obtaining approval for emergency procedures without informed consent will facilitate obtaining the best care for the child.
d. Appropriate documentation of how approval was obtained without parental consent is essential.
3. The first priority is to make certain the child is receiving the best care possible and that the necessary procedure is performed as soon as possible. The next priority is to use an interpreter to ensure the mother understands that the situation is an emergency.
4. Yes. The health status of the child is most important at this time.
5. Attempts to reach the father by phone should continue, and continued support of the mother during this stressful time is important.
REFERENCES
American Academy of Pediatrics. Committee on Community Health Services: providing care for immigrant, homeless, and migrant children. Pediatrics. 2005;115(4):1095–1100.
American Nurses Association. Position statement: cultural diversity in nursing practice. http://nursingworld.org/readroom/position/ethics/etcldv.htm, 1991. [retrieved April 15, 2007, from].
Annie E Casey Foundation, One out of five U.S. children is living in an immigrant family. Data Snapshot 2007;4. March retrieved April 15, 2007, from http://www.kidscount.org/sld/snapshot_immigrant.pdf
Annie E Casey Foundation. 2006 Kids count data book; state profiles of child well-being. http://www.aecf.org/upload/PublicationFiles/DA36221056.pdf, 2006. [retrieved April 20, 2007, from].
Betancourt, JR. Cultural competence—marginal or mainstream movement. N Engl J Med. 2004;351(10):953–954.
Betancourt, JR, Green, AR, Carrillo, JE, et al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and healthcare. Pub Health Rep. 2003;118:292–302.
Centers for Disease Control and Prevention. Childhood lead poisoning prevention program. http://www.cdc.gov/nceh/publications/factsheets/Child hoodLeadPoisoningPreventionProgram.pdf, 2007. [retrieved April 22, 2007, from].
Chidester, D. Patterns of transcendence: religion, death, and dying, ed 2. Belmont, Calif: Wadsworth, 2001.
Dreher, M, MacNaugton, N. Cultural competence in nursing: foundation or fallacy? Nurs Outlook. 2002;50:181–186.
Dunn, AM. Culture competence and the primary care provider. J Pediatr Health Care. 2002;16:105–111.
Galanti, G. Caring for patients from different cultures, ed 3. Philadelphia: University of Pennsylvania Press, 2004.
Garwick, A, Auger, S. What do providers need to know about American Indian culture? Recommendations from urban Indian family caregivers. Fam Systems Health. 2000;18:177–189.
Giger, JN, Davidhizar, RE. Transcultural nursing: assessment and intervention, ed 4. St Louis: Mosby, 2004.
Jones, DC, Crawford, JK. The peer appearance culture during adolescence: gender and body mass variations. J Youth Adolesc. 2006;2:257–269.
Leininger, M. Transcultural nursing. New York: John Wiley & Sons, 1978.
Martinson, IM, Armstrong, V, Qiao, J. The experience of the family of children with chronic illness at home in China. Pediatr Nurs. 1997;23(4):371–375.
McEvoy, M. Culture and spirituality as an integrated concept in pediatric care. MCN. 2003;28(1):39–43.
Meléndez, L. Parental beliefs and practices around early self-regulation: the impact of culture and immigration. Infants Young Child. 2005;18(2):136–146.
Muñoz, C, Luckmann, J. Transcultural communication in nursing, ed 2. Clifton Park, NY: Thomson Delmar Learning, 2005.
Purnell, LD, Paulanka, BJ. Transcultural health care: a culturally competent approach, ed 2. Philadelphia: Davis, 2003.
Scruggs, L, Allan, JP. The material consequences of welfare states: benefit generosity and absolute poverty in 16 OECD countries. Comp Pol Studies. 2006;39:880–904.
Search-Institute. Developmental asset categories 2007. http://www.search-institute/org/assets/assetcategories.html. [retrieved May 2, 2007, from].
Shaw-Taylor, Y. Culturally and linguistically appropriate health care for racial or ethnic minorities: analysis of the US Office of Minority Health’s recommended standards. Health Policy. 2002;62:211–221.
Spector, RE. Cultural diversity in health and illness, ed 6. Upper Saddle River, NJ: Prentice-Hall, 2004.
Trawick-Smith, J. Early childhood development: a multicultural perspective, ed 4. Upper Saddle River, NJ: Pearson Education, 2006.
Tropello, PD. The many faces of homelessness. In: Kelley ML, Fitzsimons VM, eds. Understanding cultural diversity. Sudbury, Mass: Jones & Bartlett, 2000.
US Census Bureau. Overview of race and Hispanic origin: Census 2000 brief. http://www.census.gov/prod/2001pubs/c2kbr01-1.pdf, 2001. [retrieved May 5, 2007, from].