The Importance of Cultural and Linguistic Issues in the Emergency Care of Children

0749-5161/02/1804-0271 Vol. 18, No. 4 PEDIATRIC EMERGENCY CARE Printed in U.S.A. Copyright © 2002 by Lippincott Williams & Wilkins, Inc. 10.1097/01.pec.0000026942.85374.8d The importance of cultural and linguistic issues in the emergency care of children GLENN FLORES, MD, JENNIFER RABKE-VERANI, BA, WHITNEY PINE, BA, ASHU SABHARWAL, BA Background: Rapid growth in the diversity of the US popu- medical conditions, the first clinical contact may be with folk lation makes it increasingly likely that emergency clinicians healers, and certain folk remedies are harmful or even fatal. will encounter greater numbers of patients from different cul- Certain parent beliefs and practices can result in serious mor- tures, but little is known about the importance of culture and bidity and fatalities (from lead poisoning, liver failure, and language in the emergency care of children. other causes), costly or unnecessary medical evaluations (eg, Objective: To conduct a critical review and synthesis of pub- Fenugreek teas), and clinical findings easily confused with lished studies on culture and language in the emergency care of child abuse (eg, coining). Biased provider attitudes and prac- children. tices can have profound clinical consequences, including eth- Methods: PubMed was used to perform a literature search nic disparities in prescriptions, analgesia, test ordering, sexual (using 17 search terms) of all articles on culture, language, and history taking, asthma care quality, and diagnostic evaluations. the emergency care of children published in English or Spanish Conclusions: Failure to appreciate the importance of culture from 1966 to 1999. and language in pediatric emergencies can result in multiple ad- Results: More than 2000 citations initially were identified; verse consequences, including difficulties with informed consent, consensus review yielded 400 papers that were photocopied. A miscommunication, inadequate understanding of diagnoses and final database of 117 articles revealed the following: certain treatment by families, dissatisfaction with care, preventable normative cultural values, such as the Navajo hozhooji (the im- morbidity and mortality, unnecessary child abuse evaluations, portance of thinking and speaking positively), can have pro- lower quality of care, clinician bias, and ethnic disparities in pre- found effects on informed consent and discussions of medical scriptions, analgesia, test ordering, and diagnostic evaluations. risk. For limited English proficient children and their families, studies document that medical interpreters frequently are not used, there is a lack of trained interpreters, there are more ac- INTRODUCTION cess barriers, and those who need but do not get interpreters Rapid growth in the diversity of the US population makes it in- have poor understanding of their diagnosis and treatment. Nu- creasingly likely that physicians will encounter greater numbers merous folk illnesses, such as empacho among Latinos, can af- of patients from different cultures. Over 78 million Americans, or fect care, because symptoms often overlap with important bio- about 29% of the nation’s population, are of nonwhite race or eth- nicity (1). One out of every three US children (Յ 18 years old) is nonwhite (2). Of the approximately 74 million children living in the US in 1999, 47.9 million (65%) were non-Latino white, 11.6 million From the Center for the Advancement of Urban Children, Department of (16%) were Latino, 10.8 million (15%) were non-Latino African- Pediatrics, Medical College of Wisconsin and Children’s Hospital of Wis- American, 3 million (4%) were Asian or Pacific Islander, and consin, Milwaukee, Wisconsin (G. Flores); Division of General Pediatrics, 714,000 (1%) were Native American (2). There already are more Boston University School of Medicine (W. Pine, A. Sabharwal), and Har- nonwhites than whites in the nation’s most populous state, with 52% vard Medical School (J. Rabke-Verani), Boston, Massachusetts. Address for reprints: Glenn Flores, MD, Center for the Advancement of of California’s population comprised of minorities (2). Nonwhites Urban Children, Department of Pediatrics, Medical College of Wisconsin, outnumber whites in eight of the 10 largest cities in the United 8701 Watertown Plank Road, Milwaukee, WI 53226. States (2). By 2025, almost 40% of Americans and about half of all Supported in part by the Generalist Physician Faculty Scholars Program US children will be nonwhite (2). From 1991 to 1997, almost 7 mil- and Minority Medical Faculty Development Program of the Robert Wood Johnson Foundation, grant K02 HS11305 from the Agency for Healthcare lion new immigrants came to the US, a pace that will allow 1991 to Research and Quality, and the project Maternal and Child Health contract 2000 to shatter the 20th century record for most immigrants in a 240-97-0026 from the Emergency Medical Services for Children Program decade (set in 1901 to 1910) (2). (Section 1910, US Public Health Services Act), administered by the Health The dramatic surge in the diversity of our nation has led to a Resources and Services Administration, Maternal and Child Health Bu- greater recognition of the importance of providing culturally com- reau, in collaboration with the US Department of Transportation, National Highway Safety Traffic Administration, and the Robert Wood Johnson petent and linguistically appropriate health care. A growing litera- Foundation. Honoraria were provided through the Robert Wood Johnson ture reveals that culture and language significantly impact clinical Foundation to the authors to support the creation of the paper. care, including health care processes, morbidity, mortality, quality Presented in part as an oral presentation at the 129th annual meeting of of care, and patient satisfaction, issues of intense interest in this age the American Public Health Association, October 22, 2001, in Atlanta, Georgia. of managed care. A recent review, for example, demonstrated that Key Words: Culture, folk illness, home remedy, language, parental be- failure to consider a patient’s cultural and linguistic issues can re- lief, provider behavior sult in a variety of adverse consequences, including miscommuni- 271 272 PEDIATRIC EMERGENCY CARE August 2002 cation, poor continuity of care, less preventive screening, difficul- All photocopied articles were reviewed by three of the authors ties with informed consent, inadequate analgesia, decreased access (G.F., J.R., A.S.). Additional articles were excluded if they failed to care, use of harmful remedies, delayed immunizations, and fewer to meet all inclusion and exclusion criteria. The final set of articles prescriptions (3). were then classified using the five-component cultural competency Although there has been a recent increase in the number of stud- model of Flores (3) and Flores et al. (5), which has been described ies on cultural issues in health care, not enough attention has been in detail elsewhere. In brief, these five components are 1) norma- devoted to culture and the emergency care of children. Indeed, in an tive cultural values, the beliefs, ideas, and behaviors that a particu- extensive literature search, we did not encounter any published re- lar cultural group generally values and expects in interpersonal in- views, conceptual frameworks, synthetic overviews, or models ad- teractions (but bearing in mind that individuals subscribe to group dressing culture and the emergency care of children. We therefore norms to varying degrees (3)); 2) language issues; 3) folk illnesses, conducted a literature review to 1) identify published studies on cul- culturally constructed diagnostic categories commonly recognized ture and language in the emergency care of children, 2) define the by an ethnic group; 4) parent and patient beliefs, including beliefs key issues for providers of emergency care of children, and 3) high- about disease causality, and use of home remedies, folk remedies light findings concerning managed care and health care policy. (except those used for specific folk illnesses), and over-the-counter medications; and 5) provider practices, the beliefs and practices of METHODS health care providers that are directly or indirectly associated with disparities or bias in health care. We used PubMed to perform a literature search of all articles on culture, language, and the emergency care of children published in RESULTS English or Spanish from 1966 through April 1999. The PubMed database includes MEDLINE, PreMEDLINE, HealthSTAR, and Literature Search. The PubMed search initially identified publisher-supplied citations (4). We used the following search terms, over 2000 citations. Consensus review of the initial citations both as medical subject headings and as key words: culture, lan- yielded 400 papers that were photocopied. The final database con- guage, interpreters, Aborigines, African-Americans, Asian-Ameri- sisted of 117 articles. cans, blacks, Eskimos, Gypsies, Hispanic-Americans, immigrants, Normative Cultural Values. An ethnographic study of Navajo Latinos, Pacific Islanders, Native Americans, North American Indi- traditional healers, biomedical health care providers, and laypersons ans, folk illnesses, home remedies, parental beliefs, and provider be- revealed normative cultural values that substantially differ from haviors. We then performed Boolean searches of each of these terms Western bioethical beliefs and can have profound effects on in- using the search terms “child,” “pediatric,” and “emergency care.” formed consent, advance directives,

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