Chapter 2: Child health

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Authors: Diane Norton, Sigrid Watt

Introduction

In this chapter we shall consider the care that sick children, from diverse ethnic and cultural backgrounds, and their families, require from nurses and health care professionals. We shall refer to other modules in this series, books, key articles and texts, and we will provide activities and scenarios to help relate theory to the practice area.

There is a belief in nursing that the care provided should be equitable and 'fair' or democratic, the 'same for all' without prejudice or favouritism. This belief often assumes that the needs of all are identical and this clearly is not so. The child admitted for minor surgery, accompanied by their parents, pain-free and familiar with the ward routine and staff, will react differently to the child admitted as an emergency from A & E as the result of a car accident. The needs of each, and the care they require, will differ and, if they represent different cultural backgrounds, their perception of what is happening and their reactions to events may also vary.

The Nursing and Midwifery Council Professional Code of Conduct (2002) states that, as a nurse:

"You are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs"

(NMC 2002: 2.2)

The intention might be to avoid discrimination but it could be argued that, in order to recognise and respect the uniqueness and dignity of every patient in our care, we also need to take into account their ethnicity, religion, and culture; that is, delivering appropriate health care, of itself, requires that we are sensitive to cultural diversity.

According to Goold (2001:2) everyone has a right "to be treated differently because treating people the same can also be seen as being discriminating". Thus, we all have a preference for different clothes and food, and when shopping we want to purchase clothes or foods reflecting these preferences. Similarly, in accessing health care services, we want our individual needs to be recognised and met; this may be as simple as requesting to be admitted to a single-sex ward.

There is a danger, however, in treating certain groups of people 'differently' because of the assumptions made about their ethnic and cultural background; people and groups can be marginalised because they are perceived as different. There can be a general belief that the dominant culture is the norm, and its beliefs, values, habits and customs are 'normal' or 'right', while others, who express their ideas and beliefs about life differently, are viewed as 'not right' or 'unacceptable'. There can be cultural blindness in the assumption that "only other people are ethnic, whilst our own ethnic identity remains unstated. Ethnocentrism means unthinkingly taking your own culture as an absolute, an unquestioned source of truths whereby to judge the world and others" (Husband 2000:36).

Helman (2000) refers to the cultural 'lens' of society; a perception of the world or a lens through which we view life.

"…culture remains a central part of the lives of black communities, for it is the primary way in which black communities can give meaning and continuity to their own distinct identities, rites, traditions, values, beliefs and customs. For many black people, it is their culture which gives them the strength to survive in a hostile environment"

(DH 2000:39)

In Britain over 3 million people (5.5% of the population) are from black or minority ethnic groups; the vast majority live in urban areas such as London, Bradford and Birmingham. Children under 15 years of age form "33% of black and ethnic minority communities compared to 19% in white communities" (DOH 2000:38).

What do you currently know about ethnicity?

The Department of Health (2000) has explored definitions of 'ethnicity' and 'ethnic groups';

"Whilst race is defined by heritage, colour, physical appearance, and physical characteristics, ethnicity is defined by geographic, political, historical, religious and cultural factors. Cashmore (1984) describes an ethnic group as: a group possessing some degree of coherence and solidarity, composed of people who are, at least latently, aware of having common origins and interests."

(DH, 2000:47)

It is recommended that you refresh your knowledge about Ethnicity. As a useful reminder, the following extract is from pages 10 and 11 of The Transcultural Health Care Practice: Foundation Module by Elizabeth Anionwu, Dave Sookho and Jim Adams.

Ethnicity

Ethnicity is a common term used in health and related sciences and most definitions include references to place of origin, or ancestry, skin colour, cultural heritage, religion, and language. Ethnicity denotes a sense of kinship, group solidarity, and a common culture. Mackintosh et al., (1998, p.7) define ethnicity as 'the group a person belongs to as a result of certain shared characteristics including ancestral and geographical origins, social and cultural traditions, religion and languages'. We all belong to ethnic groups even though the term 'ethnic' is often incorrectly used in a shorthand way to only refer to individuals from black and minority backgrounds. Individuals may perceive themselves as belonging to particular ethnic groups, and identify themselves with people with whom they feel they share a common sense of identity. Thus, there are objective and subjective facets to ethnicity. The objective facet includes factual and observable characteristics such as ancestry, place of birth, cultural factors, religion, and language - these can be used as objective indicators to examine the concept of ethnicity. The subjective element is important to the individual's perception and identification of his/her ethnicity, and the group that he/she belongs to. In this instance, the individual may assign himself/herself an ethnic identity, an ethnic group affiliation. However, such assignment is a matter of choice and preference, and individuals may equally choose not to state their ethnicity. Ethnic identity is part of cultural identity, it is an interpretation by the individual, and is subjective. In addition, as Culley (2000, p. 133) has explained, 'ethnic identity is overlaid with gender, age, socio-economic and professional identities, each of which may be more or less significant in any specific situation, at any specific moment'. When the sense of ethnic identity is strong, individuals maintain solidarity, ethnic group values, beliefs, language, and culture.

An ethnic group is a social group, and has been defined as 'a community whose heritage offers important characteristics in common between its members and which makes them distinct from other communities' (Modood et al., 1997, p.13). Furthermore, it is necessary that there is a group consciousness among members of the ethnic group in order to express the ethnic identity of the group. As Modood and colleagues (1997, p.14) contend, 'group membership is a matter of opinion, which may change over a lifetime, and from generation to generation'. Ethnicity is not rigid and static; it is dynamic and interactive, shaped by the social, political and cultural relations between the ethnic groups, in part as responses to racism and prejudice.

Modood and colleagues (1997) have considered diversity in terms of three distinct ways - origin, socio-economic status, and lifestyles.

In summary, we all belong to an ethnic group. Ethnic groups may or may not be a minority within a larger community. 'Ethnicity' and 'ethnic group' are two concepts that are significant to how ethnic identities are perceived, and how people describe themselves.

It is essential, however, that you enhance your knowledge of Ethnicity further and we strongly recommend that you read part of Section Two (pages 55-70) of the module by Charles Husband, entitled The Politics of Diversity for a more detailed critique.

Exercise 2.1 Activity

How many children are members of minority ethnic groups in your neighbourhood? To find out this information we suggest you try the following sources:

Local library
Local government offices, census
Internet, including web sites such as Department of Health

In a multicultural society, with people being raised in a variety of cultural and ethnic communities, there can be a temptation to try to catalogue all the different customs and beliefs for various groups. In doing this we may falsely assume that we are now cultural 'experts' and know all there is to know about that person or group's belief system. Equally, it would be difficult to amass and remember such a bulk of information and, consequently, it may not be feasible to easily develop an appropriate sensitivity in the care delivered to the patient (McGee 1994).

"Ethnocentrism is entirely inconsistent with an ability to provide holistic nursing care. Recognising that someone is different is not a sufficient basis for cultural sensitive care"

(Husband 2000:58)

Husband continues that it is 'cultural relativism', the understanding of one's own culture and ethnicity and its place among many others in the world, that leads the nurse to consider other cultures not as weird or inferior but with "an openness to understanding the other ethnic community on their terms … and why their ethnicity makes sense to them" (page 59). This is important as culture and illness are intrinsically linked. As Leininger (1978:85) points out:

"Human beings are unique because they possess cultural characteristics which shape and guide their behaviour in different ways throughout the world. Likewise, culture as a learned and transmitted process greatly influences how people will tend to remain well or engage in sickness behaviour".

Thus, lay health beliefs and illness behaviours will vary across different cultures - across regions, ethnic groups and social classes.

Within nursing over the past thirty years there has been a move away from a reductionist approach towards a holistic approach, with the emphasis upon meeting the needs of the individual. In children's nursing this has been further developed to acknowledge the vital role that the family plays in the life of a child and the emergence of a philosophy of 'family-centred care' (Casey 1988). When children and their families require care in hospital or the community, they will act and react within the context of their particular family, community and societal culture. They will assume that we understand "where they are coming from" and why they react as they do. As nurses and health care professionals, we need to ensure that we are equipped with the insight and appropriate knowledge to reduce their stress and carry out culturally appropriate care.

Exercise 2.2 Reflective activity

If someone were to ask how you would define your culture, what markers or means of identification would you use? Write a short paragraph that describes your interpretation of your culture.

Group Activity

If several health colleagues in your group have undertaken this reflective activity, share your interpretations with each other. If you share similar cultural backgrounds, how do your perceptions differ? If you have different cultural backgrounds, what can you learn from your colleagues?

Dress, food, language, home location, work, religion or belief system are important aspects of who we are and how we define ourselves, and can contribute to the overall picture we have of our specific culture.

Between 1991 and 1993 'Action for Sick Children', together with BBC's 'Children in Need' and the Department of Health, conducted a study which explored the problems minority ethnic families encountered when a child was admitted to hospital. The results show that the 77 families interviewed felt their needs were not being met in the following areas:

Summary of Findings

Information giving
Food
Facilities for parents
Facilities for religious observance
Staff attitudes
Availability of interpreters
Awareness of the need for multicultural play
Ignorance of naming systems
Care and services for children with blood
disorders such as sickle cell disease and thalassaemia

Action For Sick Children (1993) 'Health for all our children'

The correlation between poverty and ill-health and the indication that minority ethnic groups experience poorer health (DOH 2000) means that health care providers, including nurses, need to address the areas highlighted above. Holistic, individualised, family centred care will be denied to large numbers of children and families in some areas of the country if the needs of such groups are not met.

Mark R D Johnson has provided a comprehensive introduction to the epidemiological issues affecting minority ethnic demography, disease patterns and pathways to care. For further information on health inequalities we recommend you refer to this module.

Many of these areas will be looked at specifically in this chapter and others will be referred to within the context of other topics. A linear approach has been taken; from birth to death, and from admission to discharge following the child and family throughout a hospital stay. It is not intended to be an exhaustive overview, but rather an attempt to stimulate thinking and discussion around the care currently being given and changes that may need to be implemented to ensure that all care is culturally appropriate.