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.
- AAP =
- American Academy of Pediatrics •
- APA =
- Ambulatory Pediatric Association
CULTURALLY EFFECTIVE PEDIATRIC CARE: EDUCATION AND TRAINING ISSUES
The pediatric patient population in the United States is continuously becoming more culturally diverse. It is estimated that by the year 2020, approximately 40% of school-age Americans will be minority group children.*
The American Academy of Pediatrics (AAP) recognizes that the cultural diversity of the population has implications for the provision of pediatric health services. The Academy recognizes the importance ofculturally effective pediatric health care, which is defined as:
“the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions. Such understanding should take into account the beliefs, values, actions, customs, and unique health care needs of distinct population groups. Providers will thus enhance interpersonal and communication skills, thereby strengthening the physician-patient relationship and maximizing the health status of patients.”**
The American Medical Association considers “cultural competence” and “culturally effective health care” as synonymous terms but, has retained the use of the term “cultural competence” because of its widespread use and acceptance in the literature.1
Culturally effective health care is related to cultural competence and cultural sensitivity. However, whereas cultural competence and cultural sensitivity refer to the provider's attributes, the term culturally effective health care refers to the interaction between the provider and patient. Thus, culturally effective health care is based on cultural sensitivity and cultural competence, but also goes beyond these concepts in describing the dynamic relationship between provider and patient. To promote the provision of culturally effective health care to pediatric patients, the Academy recognizes the need to develop education and training materials and courses.
The provision of “culturally sensitive health care,” according to Pachter,2 (chapter 4, page 16) involves three necessary steps: 1) the pediatrician needs to develop an awareness of the commonly held cultural beliefs and the culturally normative interactive styles in the patient's cultural group; 2) the pediatrician needs to assess how the beliefs and behaviors of this cultural group affect the patient or family; and 3) to optimize patient care, the pediatrician and the patient must negotiate between the ethnocultural beliefs and practices of the patient and those of the culture of biomedicine.
Culturally effective health care can be promoted through education in cultural competence and cultural sensitivity training at all levels: medical school, residency training, and continuing medical education. These educational efforts should enhance the knowledge and understanding of pediatricians and nonpediatricians about the culture of their patients, and increase the ability of pediatricians and nonpediatricians to provide care in a manner that is responsive to the individual needs of each patient.
To provide effective health care to pediatric patients, clinical expertise and strong interpersonal skills have always been important. At every level of education, child health providers must be able to interact effectively and comfortably with patients and their families. In addition, pediatricians and nonpediatricians need to be sensitive to the sociocultural background of their patients. The Academy believes that knowledge and skills for providing culturally effective health care can be taught and acquired through 1) educational courses and other formats developed with the sole purpose of addressing cultural competence and/or cultural sensitivity, and 2) specific educational components on cultural competence and/or cultural sensitivity within the curricula of the medical school, residency programs, and continuing medical education programs. The Academy recognizes the importance of addressing race and ethnicity in clinical courses, when race or ethnicity are related to variations in treatment or outcomes.
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.
CONSIDERATIONS FOR EDUCATION AND TRAINING
To provide culturally effective health care for pediatric patients, education and training are needed for child health providers at all levels. The Academy recognizes the value of these educational tools and programs, and calls for their development and incorporation at all levels of pediatric education: medical school, residency training, and continuing medical education. A variety of programs already exist, but the programs are quite variable. In addition, the availability of these programs varies according to geographic location.
Medical Student Education
A 1997 telephone survey of Deans of Students and/or course directors in the United States and Canada found that 85% of the 122 US medical schools incorporated multicultural issues with one to three lectures provided in larger courses or electives. However, only 9% of the 122 US medical schools taught cultural sensitivity as a separate course for medical students, and 7% had no multicultural program. Most of the courses used case-based instruction, with both didactic and group learning components, and virtually all courses (96%) were taught only in the first 2 years of medical school. The ethnic groups covered in these courses included Latinos (32%); African-Americans (31%); 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
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:
To develop and evaluate curricular programs in medical schools and residency programs to enhance the provision of culturally effective health care.
To develop continuing medical education materials for pediatricians and nonpediatricians with the goal of increasing culturally effective health care.
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
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
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.
- ↵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
- Copyright © 1999 American Academy of Pediatrics