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PEDIATRICS Vol. 103 No. 1 January 1999, pp. 167-170
AMERICAN ACADEMY OF PEDIATRICS:
Culturally Effective Pediatric Care: Education and Training
Issues
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ABSTRACT |
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Top
Abstract
Background
Conclusion
References
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This policy statement defines culturally effective health care and describes its importance for pediatrics. The statement also defines cultural effectiveness, cultural sensitivity, and cultural competence and describes the importance of these concepts for training in medical school, residency, and continuing medical education. The statement is based on the premise that culturally effective health care is important and that the knowledge and skills necessary for providing culturally effective health care can be taught and acquired through 1) educational courses and other formats developed with the expressed purpose of addressing cultural competence and/or cultural sensitivity, and 2) educational components on cultural competence and/or cultural sensitivity that are incorporated into medical school, residency, and continuing medical education curricula.
The pediatric patient population in the
United States is continuously becoming more culturally diverse. It is
estimated that by the year 2020, approximately 40% of school-age
Americans will be minority group children.*
The American Academy of Pediatrics (AAP) recognizes that the cultural
diversity of the population has implications for the provision of
pediatric health services. The Academy recognizes the importance of
culturally effective pediatric health care, which is defined
as:
"the delivery of care within the context of appropriate physician
knowledge, understanding, and appreciation of cultural distinctions. Such understanding should take into account the beliefs, values, actions, customs, and unique health care needs of distinct population groups. Providers will thus enhance interpersonal and communication skills, thereby strengthening the physician-patient relationship and
maximizing the health status of patients."**
The American Medical Association considers "cultural
competence" and "culturally effective health
care" as synonymous terms but, has retained the use of the term
"cultural competence" because of its widespread use and
acceptance in the literature.1
Culturally effective health care is related to cultural
competence and cultural sensitivity. However, whereas cultural competence and cultural sensitivity refer to the provider's
attributes, the term culturally effective health care refers to the
interaction between the provider and patient. Thus, culturally
effective health care is based on cultural sensitivity and cultural
competence, but also goes beyond these concepts in describing the
dynamic relationship between provider and patient. To promote the
provision of culturally effective health care to pediatric patients,
the Academy recognizes the need to develop education and training materials and courses.
The provision of "culturally sensitive health care,"
according to Pachter,2 (chapter 4, page 16)
involves three necessary steps: 1) the pediatrician needs to develop an awareness of the commonly held cultural beliefs and the culturally normative interactive styles in the patient's cultural group; 2) the
pediatrician needs to assess how the beliefs and behaviors of this
cultural group affect the patient or family; and 3) to optimize patient
care, the pediatrician and the patient must negotiate between the
ethnocultural beliefs and practices of the patient and those of the
culture of biomedicine.
Culturally effective health care can be promoted through education in
cultural competence and cultural sensitivity training at all levels:
medical school, residency training, and continuing medical education.
These educational efforts should enhance the knowledge and
understanding of pediatricians and nonpediatricians about the culture
of their patients, and increase the ability of pediatricians and
nonpediatricians to provide care in a manner that is responsive to the
individual needs of each patient.
To provide effective health care to pediatric patients, clinical
expertise and strong interpersonal skills have always been important.
At every level of education, child health providers must be able to
interact effectively and comfortably with patients and their families.
In addition, pediatricians and nonpediatricians need to be sensitive to
the sociocultural background of their patients. The Academy believes
that knowledge and skills for providing culturally effective health
care can be taught and acquired through 1) educational courses and
other formats developed with the sole purpose of addressing cultural
competence and/or cultural sensitivity, and 2) specific educational
components on cultural competence and/or cultural sensitivity within
the curricula of the medical school, residency programs, and continuing
medical education programs. The Academy recognizes the importance of
addressing race and ethnicity in clinical courses, when race or
ethnicity are related to variations in treatment or outcomes.
Indicators of child health status, including low birth weight,
infant mortality, and immunization rates, demonstrate ethnic differences in health status. In general, minority children have less
favorable indicators of health status than white children. Health
status may be influenced by many factors, including access to health
services. There are numerous barriers to quality health care services
for minority children such as poverty, geographic factors, lack of
cultural sensitivity, racism, and other forms of prejudice. In its 1994 report, the AAP Task Force on Minority Children's Access to Pediatric
Care expressed concern that the health services provided by many
institutions in the United States reflect the values of the majority
culture.3 Patients and families that have a different
cultural orientation may experience difficulties in their interactions
with health professionals, and these difficulties may have an adverse
impact on the delivery of health care. Medical students, pediatric
residents, and practicing pediatricians must enhance their ability to
provide needed health care to minority group children through training
in cultural competency and sensitivity.
Because ethnic minorities are underrepresented among health
professionals, patients and providers often have different cultural backgrounds. In these instances, language, socioeconomic status, and
ethnicity may influence the provision of health services.
All patients have culturally based concepts about health and illness.
When patients' and families' cultural perceptions of health, illness,
and treatments conflict with the pediatrician's diagnosis or
management plan, cultural differences may become barriers to access to
care or the provision of health care services. Cultural differences in
verbal and nonverbal communication also have the potential to serve as
barriers to effective pediatric care. However, the role of culturally
linked behavior styles that may influence the provider-patient
interaction, including eye contact and communication styles, has not
been fully described. In addition, there may be communication anxiety
during social interactions between individuals in underrepresented
cultural groups and individuals holding "expert" roles such as
physicians and social workers.4 There is an inherent
imbalance of power in all physician-patient relationships, as the
patient is in a position in which he or she is seeking advice or care
from a physician in his or her role as an expert or consultant. This imbalance may be even more pronounced when patients are from
underrepresented cultural groups, and therefore may pose an even
greater barrier to effective communication with these patients. The
clinician's awareness of this imbalance may help to enhance his or her
ability to overcome this potential barrier. Patients from some ethnic minority groups may also have unique health issues that the
pediatrician must consider to provide optimal care, such as sickle cell
anemia and certain hemoglobinopathies.
To provide effective health services, providers must be able to
communicate clearly with patients and their families. Just as there may
be culturally based communication barriers between providers and
patients, there may also be communication barriers between providers
who have different cultural backgrounds. Health care providers at all
levels and in all disciplines must be aware of the potential for
miscommunication, particularly when there are socioeconomic, racial, or
ethnic differences between providers.
To provide culturally effective health care for pediatric
patients, education and training are needed for child health providers at all levels. The Academy recognizes the value of these educational tools and programs, and calls for their development and incorporation at all levels of pediatric education: medical school, residency training, and continuing medical education. A variety of programs already exist, but the programs are quite variable. In addition, the
availability of these programs varies according to geographic location.
Medical Student Education
A 1997 telephone survey of Deans of Students and/or course
directors in the United States and Canada found that 85% of the 122 US
medical schools incorporated multicultural issues with one to three
lectures provided in larger courses or electives. However, only 9% of
the 122 US medical schools taught cultural sensitivity as a separate
course for medical students, and 7% had no multicultural program. Most
of the courses used case-based instruction, with both didactic and
group learning components, and virtually all courses (96%) were taught
only in the first 2 years of medical school. The ethnic groups covered
in these courses included Latinos (32%); African-Americans (31%);
Asian-Pacific Islanders (21%); Native Americans (15%); and no
specific focus (36%).5 As a joint effort, the Council on
Medical Student Education in Pediatrics and the Ambulatory
Pediatric Association (APA) developed the General Pediatric
Clerkship Curriculum and Resource Manual for clerkship directors
to encourage the utilization of formal curricular goals and objectives.
The manual cites "cultural sensitivity" and "tolerance of
difference" among the important personal characteristics that are
essential foundations for the medical student. This manual also
outlines both learning objectives and competencies for medical students
that relate to the provision of culturally effective health
care.6
Residency Training
The program requirements for residency education in pediatrics
developed by the Residency Review Committee call for structured educational experiences that prepare residents for the role of advocate
for the health of children within the community and the inclusion of
the multicultural dimensions of health care in the curriculum.7
The APA document, Educational Guidelines for Residency Training
in General Pediatrics, includes goals, objectives, and references that
relate to family, cultural, and ethnic issues. The goal that relates
specifically to cultural, ethnic, and community sensitivity calls for
the resident to "recognize the importance of understanding, accepting, and appreciating cultural diversity in one's own patients and learn about the health-related implications of cultural beliefs and
practices of groups represented in one's community." Ten specific objectives for addressing this goal are provided.8 An additional APA document, Training Residents to Serve the Underserved: A
Resident Education Curriculum, provides guidance to medical educators
in teaching residents about the provision of culturally effective
health care. This curriculum outlines special considerations for
treating ethnic minority groups within the pediatric population by
identifying specific areas of knowledge and skills, necessary attitudes, and suggested advocacy activities that have the potential to
enhance the provision of culturally effective health care. The
curriculum also notes issues that might serve as potential barriers to
providing culturally effective health care.9 Further study
is needed to understand the usefulness of this curriculum.
Continuing Medical Education
The changing demographic characteristics of the pediatric
population underscore the importance of culturally effective health care for pediatrics. Beyond residency training, pediatricians and other
providers of child health care can benefit from continuing education to
enhance the provision of culturally effective health care. As a
lifelong learner, the pediatrician should advocate for efforts that
will enhance the provision of culturally effective health care. In
addition, the use of patient satisfaction scoring systems and other
measures of quality and outcomes will place greater emphasis on
ascertaining and monitoring the cultural sensitivity and effectiveness
of pediatricians and nonpediatricians.
The medical literature on cultural competence and/or cultural
sensitivity provides information for enhancing cultural effectiveness in pediatrics. In addition, other resources exist that may be helpful
in identifying important components for educational activities to
enhance the provision of culturally effective health care. For example,
Culturally Competent Health Care for Adolescents: A Guide for
Primary Health Care Providers discusses how the primary care
physician can assess cultural factors within a health history, and how
to modify patient management plans to accommodate cultural influences.10
Educational programs may include a component that allows the individual
participant to engage in a personal analysis of beliefs and values.
Programs may focus on the communication aspects of providing culturally
effective health care by exploring how assumptions and stereotypes
influence interactions between providers and patients, as well as
between providers. Programs need not be all-inclusive or completely
group-specific to discuss variations in the values and communication
styles of various racial and ethnic groups. Because individuals are
influenced by their own personal experiences and may or may not
subscribe to group norms, individuals who share the same cultural
background may think and act quite differently. For this reason, it is
important that programs intended to address the cultural values and
practices of specific groups not perpetuate stereotypes. Also, as
Pachter notes, culture is not static, and changes occur over time. An
appreciation of cultural change and the significance of intracultural
diversity (variation among individuals within the same culture)
prevents cultural stereotyping.11 Programs aimed at
enhancing the provision of culturally effective health care should be
tailored to the demographics of the pediatric population or community
the pediatrician serves.
Programs can emphasize the advantage of assessing cultural beliefs and
practices directly from patients and families, rather than making
assumptions about race, ethnicity, or culture. Pediatricians and
nonpediatricians must use their knowledge of the cultural beliefs and
practices or ethnic groups along with information learned from the
individual patient or family. The pediatrician should encourage the
patient and family to describe their cultural characteristics and
health beliefs during patient encounters.
Education and training to enhance the provision of culturally
effective health care must be integrated into lifelong learning for
pediatricians and nonpediatricians. This learning process involves both the curricular and clinical phases of medical school, residency training, and postresidency continuing medical education. Through these activities, current and future pediatricians and other child health providers will be prepared to meet the needs of all
children, including children from racial and ethnic minority groups and
children from other cultural minority groups.
On the basis of the discussion and concepts within the statement, the
Academy sets forth two general recommendations for the pediatric
community:
CULTURALLY EFFECTIVE PEDIATRIC CARE: EDUCATION AND TRAINING ISSUES
BACKGROUND
Top
Abstract
Background
Conclusion
References
CONSIDERATIONS FOR EDUCATION AND TRAINING
CONCLUSION
Top
Abstract
Background
Conclusion
References
COMMITTEE ON PEDIATRIC WORKFORCE, 1997-1998
Elena Fuentes-Afflick, MD, FAAP, Lead Committee Author
Jeffrey J. Stoddard, MD, FAAP, Chairperson
Carmelita V. Britton, MD, FAAP
M. Rosario Gonzalez-De-Rivas, MD, FAAP
Stephen N. Keith, MD, FAAP
Kathleen G. Nelson, MD, FAAP
Robert Nordgren, MD, FAAP
Richard J. Pan, MD, FAAP
Debra Ralston Sowell, MD, FAAP
Jerold C. Woodhead, MD, FAAP
LIAISONS
Frances J. Dunston, MD, FAAP, National Medical Association
Ted D. Sigrest, MD, FAAP, AAP Resident Section
Walter W. Tunnessen, Jr, MD, FAAP, American Board of Pediatrics
FORMER COMMITTEE MEMBERS (RETIRED 1997)
Rear Admiral Marion J. Balsam, MD, FAAP
Mary A. McIlroy, FAAP, MD
PRINCIPAL STAFF AUTHOR
Mary Ruth Back, Health Policy Analyst
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
* In this statement, the term "minority" is used to describe non-white ethnic groups. The term "minority" is based on national demographic figures for the US population, and "minority" is not intended as a pejorative term.
** Definition developed jointly by AAP Committee on Pediatric Workforce and the American Medical Association Advisory Committee on Minority Physicians, April 1995.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; APA, Ambulatory Pediatric Association.
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REFERENCES |
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Top
Abstract
Background
Conclusion
References
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- Continuing Medical Education Report 5-A-98, taken from American Medical Association Council on Medical Education General Session Agenda, March 6-7, 1998:32
- Pachter LM. Cultural issues in pediatric care. In: Nelson WE, senior ed; Behrman RE, Kinegman RM, Arvin AM, eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, PA: WB Saunders Co; 1996
- American Academy of Pediatrics. Report of the Task Force on Minority Children's Access to Pediatric Care. Elk Grove Village, IL: AAP; 1994:16
- Boyd CB. Cultures in Contrast: Developing Empowering Cross Cultural Partnerships. Workshop presented at University of Illinois at Chicago; March 9, 1996; Chicago, IL
- Gee DW, Flores G. Teaching Cultural Sensitivity in Medical Schools: Discounting Diversity, or Drowning in the Melting Pot? Washington, DC: Presented at the Pediatric Academic Societies Meeting, May 1997. Abstract
- Council on Medical Student Education in Pediatrics. Ambulatory Pediatric Association. General Pediatric Clerkship Curriculum and Resource Manual. Publication HRSA-240-BHPr-49(3). Washington, DC: Bureau of Health Professions, Division of Medicine;
- Accreditation Council on Graduate Medical Education. Graduate Medical Education Directory 1997-1998. Chicago, IL: Accreditation Council on Graduate Medical Education;
- Educational Guidelines for Residency Training in General Pediatrics, Ambulatory Pediatric Association, February 1996
- Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Care Health Providers. Chicago, IL: American Medical Association; 1994
- Pachter LM, Harwood RL Culture and child behavior and psychosocial development. J Dev Behav Pediatr. 1996; 17:191-198 [Medline]
Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
The following policy statement is a revision:
- Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy
- Committee on Pediatric Workforce
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