Cultural Competence for Child and Youth Health Professionals

Terminology

Culture

Culture is defined as “the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups”. Culture is present in all patients and care providers, not just immigrant and refugee children, youth and families. Culture plays a role in the interactions among patients, their families, health care providers and systems.²

Cultural competence

Although the term “cultural competence” has appeared regularly in health care literature since the 1990s, there is no single, commonly accepted definition. The Office of Minority Health in the United States defines cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations”.²

Other terms used are:

• cultural effectiveness
• culturally effective health care
• cultural humility
• cultural safety

Cultural safety

Cultural safety is the ultimate goal in a learning process, according to Irihapeti Ramsden, the Maori nurse and educator who developed the concept. It starts with awareness of a patient’s ethnicity or community and, in culturally safe practice, growing concerns with “social justice ... and nurses’ power, prejudice and attitude”.³ Today, the term is used mostly in academic studies and government reports but it has also been adopted by some Aboriginal communities in Canada.

Cultural humility

Cultural humility expands on cultural competence by emphasizing a lifelong commitment to self-evaluation, self-critique, awareness of one’s own implicit or explicit biases, and managing inherent power imbalances related to culture. Here are some actions to help health care practitioners develop cultural humility:

• Focus on the patient during interviews, and listen for the way patients talk about themselves.
• Talk to patients using a less controlling and authoritarian style, using interactive communication. This approach tells patients that their own agenda and perspectives (biomedical and non-biomedical) are valued.
• Realize that you do not need to understand every group’s health beliefs. Encourage individual patients to communicate how much or how little their culture has to do with an issue.
• Be aware of the cultural differences between yourself and your patients. Being aware helps to avoid conflict during diagnosis or while developing a treatment plan.
• Critically examine, and bring awareness to, your own culturally influenced beliefs and biases as they arise in clinical encounters.
• Allow patients to take on the role of expert themselves and become true partners in determining the care they receive.
• As needed, guide patients about social and cultural norms or customs in Canada. To inform isn’t to blame or humiliate, it’s to respect the newcomer as a learner.  There are issues where stronger guidance may be needed (e.g. around a practice like female genital cutting).⁴ If a tradition conflicts with Canadian laws or human rights, be sure to let the patient know. 

Why cultural competence is important

Given Canada’s increasingly diverse population, it’s important for health care providers to be culturally competent. Culturally competent care helps to reduce disparities and improve health outcomes in a diverse population by improving communication and helping to effectively manage cultural differences, including beliefs about health and health practices, as part of patient care.^1,2,5

Culture, religion and ethnicity may influence people’s beliefs and values about health and health care, and both patients and providers bring cultural perspectives to each encounter. Areas where different perspectives can affect clinical care include:

• Birth and early infant care practices
• Nutrition and diet
• Bedsharing and Sudden Infant Death Syndrome
• Developmental disabilities
• Parenting and discipline
• Adolescent issues, including development, confidentiality, roles within the family and/or extended family, sexuality, substance use and other risky behaviours, identity development and acculturation
• Accessing health care systems, clinics and emergency departments
• Using traditional medicines and treatments

Read more about how culture influences health.  

What cultural competence is not

Cultural competence does not mean cultural ‘blindness’, being so-called “colour blind” (claiming not to see differences in race, culture, ethnicity) or “treating everyone the same way”. The ‘blind’ approach risks minimizing real differences and cultural aspects in patient–provider encounters that can affect health care. Also, this attitude does not acknowledge the health care provider’s own cultural bias.

Working with newcomer children and adolescents

When working with immigrant and refugee children, youth and families, health care providers need to be mindful of their own general approach to care, of including cultural issues in history-taking, and of involving cultural aspects with treatment planning and anticipatory guidance. The following steps can help with this process:^7,8

Health care providers need to be sensitive to differences between their own cultural background and a newcomer patient’s background. Differences in both verbal and nonverbal communication can influence care.

General approaches to care

• Assess your own biases and values. Self-awareness is as important as understanding a newcomer patient’s or family’s background. 
• Understand and consider the patient’s agenda.
• Show respect by acknowledging and validating  a patient’s or family’s personal and cultural strengths, their resilience in surviving adverse experiences and their ability to adapt to a new culture.
• Determine the patient’s understanding of and explanations for a health condition or illness.
• Project an attitude of curiosity—the patient becomes the teacher and the provider becomes the student. 
• Arrange for an interpreter to be present if needed and possible. 

By following these suggestions, you may spend considerable time and effort – and probably more than one visit – conducting a history. Consider this an investment in improved health outcomes. Read about medical assessments for newcomer children. 

Taking a history

To ensure that culture is included in a child’s or youth’s history, consider asking the following questions:^6,9-13

Assess immigration history and possible immigration stress or trauma. 

• What is your country of origin? What ethnic group(s) do you identify with? What language(s) do you speak? What is the main language spoken in your home? What language do you prefer speaking?
• Why and when did you come to Canada?  How did you arrive in this country? What were some of the challenges and difficulties? What helped you and your family adjust and cope with these challenges?

Acculturation relates to the change in the culture of a group or the change in the psychology of an individual in response to a new environment or other factors. Adaptation is the process of change in response to a new environment and is one component of acculturation. Learn more about acculturation and its importance to health. 

Assess identity development and acculturation, and potential acculturation gaps and conflicts within families.  

• What is causing you stress or difficulty? Do you have a support system? Have you made contact with local cultural associations?  
• Is your entire family in Canada? If you left family members behind, are they safe? How do you communicate with them? 
• Do you feel more comfortable being with people of your family’s background, or mainstream Canadian society, or both, or neither?
• Do the parents and children in the family speak the same primary language? Who speaks English or French? How well can you speak and read English or French? Do you ever interpret for your parents? 
• Do you know how to communicate by telephone? By electronic or social media?  
• Who makes meals? Who cares for younger siblings?
• Are you in school yet?  How do you like it?  How many days do you miss? What are your hopes for the future?
• Have you made friends?  Name your best friend. Where do you play with your friends? Do your friends visit you at home?

Explore sociocultural dimensions of health and health beliefs. This will help with negotiating a treatment plan.

• What do you think has caused this problem? What do you call it? How do you understand it?
• Have you had this problem before? How was it treated before? What do you believe will cure this problem?
• How does it affect your life (your child’s life)?
• What do you fear most about this problem? Are you afraid of being excluded from your own community because of this problem? (e.g., tuberculosis, a disability or a congenital abnormality) 
• Is there anything else you want to tell me, about this situation or your family or culture that will help me provide you with better care?

Recognize the role of traditional, complementary and alternative medicine.

• What kind of treatment do you think would work? Are there any healing practices or medicines that are traditional for your family that you think might help? Is there anything that may help you to feel better that doctors may not know about? 
• Who helps you to handle health issues?

Ask about bias, racism or discrimination.

Recognize that newcomer children and adolescents often experience bias, racism or discrimination in their school or neighbourhood. Such encounters can have a negative impact on development, mental health, family relationships and health behaviours. Ask about these experiences as part of the social history, validate them, and provide appropriate counselling or referrals to mental health and community agencies.

• Some other children (young people) with the same background have told me about being teased, bullied or harassed, just because of their background or the way they look. Has that ever happened to you?
• Do you play outside?  Walk to school?  Do you ever get scared going to school or playing?  Please explain it to me.

Screen all adolescents equally for risky behaviours, such as sexual activity or substance use.

Never assume that adolescents from a particular cultural group are more or less likely to adopt a behaviour than someone from another group.

Use available tools and resources for culturally competent care.

Treatment planning and anticipatory guidance 

To involve culture in a newcomer patient’s treatment, take the following steps:¹⁰

• Respect that a patient’s or family’s health beliefs may differ from a biomedical model of disease etiology and treatment. Demonstrate compassion by respecting cultural beliefs and practices (for example, traditional therapies).
• When differences arise, try to negotiate a treatment plan to create a shared understanding for treatment. This may include traditional treatments. Emphasize common goals (e.g., helping your child get better), while acknowledging differences. Use patient-centred, collaborative, respectful approaches, balancing compromise and flexibility with medical safety and ethical considerations. For more examples and discussion on negotiating a treatment plan, see J. Campinha-Bacote’s 2011 article on cultural competency. 
• Acknowledge and explain the limitations of Canadian health and education systems.
• Explain access to paramedical services, child care, and other educational or supportive services in your area. 
• Each newcomer will adapt to Canada in their own way and the nature of this relationship will change over time.  Acculturation and identity development are dynamic processes. 

Selected resources

• Campinha-Bacote J. Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. Online J Issues Nurse 2011;16(2):5.
• Canadian Nurses Association. Position statement: Promoting cultural competence in nursing. 2010.
• Fadiman, A. The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus and Giroux, 1997.
• Fleming M, Towey K. Delivering Culturally Effective Health Care to Adolescents. Chicago, IL: American Medical Association, 2001.
• Additional Cultural Competency Tools and Resources

References

1. Britton, CV; American Academy of Pediatrics, Committee on Pediatric Workforce. Ensuring culturally effective pediatric care: Implications for education and health policy. Pediatrics 2004;114(6):1677-85.
2. U.S. Department of Health and Human Services, Office of Minority Health. What is cultural competency? Washington, DC.
3. Ramsden IM. 2002. Cultural safety and nursing education in Aotearoa and Te Waipounamu. Thesis: Victoria University, Wellington, New Zealand.
4. Davis DS; American Academy of Pediatrics, Committee on Bioethics.  Ritual genital cutting of female minors.  Pediatrics 2010; 125(5): 1088-1093.
5. Betancourt JR, et al. Cultural competence and health care disparities: Key perspectives and trends. Health Aff 2005;24(2):499-505.
6. Fadiman, A. The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus and Giroux, 1997.
7. Kodjo, C. Cultural competence in clinician communication. Paediatri Rev 2009;30(2):57-64.
8. University of Washington Medical Centre. Communication guide: All cultures. Culture Clue for Clinicians, 2011.
9. Kleinman, A. Patients and Healers in the Context of Culture: An exploration of the borderland between anthropology, medicine and psychiatry. Berkeley and L.A.: University of California Press, 1980.
10. Campinha-Bacote J. Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. Online J Issues Nurse 2011;16(2):5.
11. Fleming M, Towey K. Delivering Culturally Effective Health Care to Adolescents. Chicago, IL: American Medical Association, 2001.
12. American Academy of Pediatrics. Culturally Effective Care Toolkit.
13. Vo DX, Park MJ. Racial/ethnic disparities and culturally competent health care among youth and young men. Am J Mens Health 2008;9(2):192-205.

Other works consulted

• American Academy of Pediatrics, Committee on Pediatric Workforce. Culturally effective pediatric care: Education and training issues. Pediatrics 1999;103(1):167-70.
• American Academy of Pediatrics, Committee on Pediatric Workforce. Enhancing the racial and ethnic diversity of the pediatric workforce. Pediatrics 2000;105(1 Pt 1):129-31.
• American Academy of Pediatrics, Committee on Pediatric Workforce. Policy statement: Enhancing the diversity of the pediatrician workforce. Pediatrics 2007;119(4):833-7.
• American Academy of Pediatrics, Committee on Pediatric Workforce. Pediatrician workforce statement. Pediatrics 2005;116(1):263-9.
• Ball J. Cultural safety in practice with children, families and communities [poster].
• Baugnet, L. L’identité sociale. Paris : Éditions Dunod,  1998.
• Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care: Application in family practice. West J Med 1983;139(6):934-8.
• Berry JW. Acculturation: Living successfully in two cultures. IJIR 2005;29(6):697-712.
• Brascoupé S, Waters C. Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness. J Aboriginal Health 2009;5(2)6-41.
• Bronheim S. Cultural competence: It all starts at the front desk. National Center for Cultural Competence, Georgetown University Center for Child and Human Development, Centers for Excellence in Developmental Disabilities.
• Brotanek JM, Seeley CE, Flores G. The importance of cultural competency in general pediatrics. Curr Opin Pediatr 2008;20(6):711-8.
• Canadian Nurses Association. Position statement: Promoting cultural competence in nursing. 2010.
• Cross TL, Bazron BJ, Dennis KW, et al. Towards a Culturally Competent System of Care: A monograph on effective services for minority children who are severely emotionally disturbed; Vol. I. Washington, DC: Georgetown University Center for Child and Human Development, 1989.
• Goode TD.  Self-assessment checklist for personnel providing primary health care services. Georgetown University Center for Child and Human Development, 2002.
• Hart-Wasekeesikaw F. Cultural competence and cultural safety in First Nations, Inuit and Métis nursing education: An integrated review of the literature. Ottawa, Ont.: Aboriginal Nurses Association of Canada, 2009.
• Karmali, K., et al. Enhancing cultural competence for improved access to quality care.  Healthc Q 2011;14(3): 52-7.
• Parish TG. The story catches you and you begin to understand. JPAE 2004;15(2):131-4.
• Phinney JS. Ethnic identity in adolescents and adults: Review of research. Psychol Bull 1990;108(3):499-514.
• Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc  2008;100(11):1275-85.
• Sutton M. Cultural competence: It's not just political correctness. It's good medicine. Fam Pract Manag 2000;7(9):58-60.
• Taylor JS. The story catches you and you fall down: Tragedy, ethnography, and “cultural competence”. Med Anthropol Q 2003;17(2):159-81.
• Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved 1988;9(2):117-25.
• Vo DX, et al. Voices of Asian American youth: Important characteristics of clinicians and clinical sites. Pediatrics 2007;120(6):e1481-93.