Journal of Pediatric Nursing
Volume 23, Issue 6 , Pages 411-414, December 2008

The Challenge of Providing Culturally Competent Services

Journal of Pediatric Nursing, Los Angeles, CA

Article Outline

 

SCANT INFORMATION EXISTS to inform nursing professionals working with children, youth, and families about the unique cultural practices and customs of ethnic and racial subgroups that can have considerable influence on attitudes toward and understanding of the health care system, access to services, interactions and communication with health care professionals, health literacy, and adherence to the treatment regimen (Fiscella, 2003, Huang et al., 2005, Smedley et al., 2003, U.S. Department of Health and Human Services, 2001). Limited information exists that serves to apprise health care professionals about the distinct subgroups that constitute the larger aggregates of racial and ethnic groups, such as Latinos and Asian Americans.

For example, references to Asian Americans typically adopt a monolithic approach without referencing to the fact that within the Asian American population there are 28 distinct subgroups (Barnes and Bennett, 2002, Hsia and Spruijt-Metz, 2003, UCLA Asian American Studies Center, 2006). The population of 3 subgroups demonstrate the relatively small numbers: Filipinos, 1.8 million; Koreans, just over 1 million; and Vietnamese, 1.1 million (U.S. Census Bureau, 2000a, U.S. Census Bureau, 2000b, U.S. Census Bureau, 2000c). This same perspective applies to Latinos as well. Within the Latino aggregate, there are 20 unique subgroups (Martinez et al., 2004, Quinones-Mayo and Dempsey, 2005, Smedley et al., 2003). The population of 5 Latino subgroups demonstrate the range of these subgroup populations: Chileans, approximately 68,000; Cubans, 1.2 million; Mexicans, 20 million; Nicaraguans, 177,000; and Puerto Ricans, 3.4 million (U.S. Census Bureau, 2000d, U.S. Census Bureau, 2000e, U.S. Census Bureau, 2000f, U.S. Census Bureau, 2000g, U.S. Census Bureau, 2000h).

Obviously, it is more appropriate to consider the heterogeneity of racial and ethnic groups rather than the homogeneity perspective that has been typified by some experts as “ethnic gloss” referring to the lack of recognition of subgroup diversity (Mio, Trimble, Arredondo, Cheatham, & Sue, 1999). Individuals from each of these different countries represent unique histories as it relates to their reasons for migrating to this country, the family and community support that remains in their country of origin, period of migration, acculturation process, language proficiency, and history of persecution and political oppression (Hsia and Spruijt-Metz, 2003, Martinez et al., 2004, Smedley et al., 2003, Tsai et al., 2003, Ying et al., 2000, Villarruel et al., 2000).

To illustrate the growing importance of addressing the increasing diversity of the U.S. population pertaining to the provision of health care services, a recent report by the U.S. Census Bureau (2008a) portrayed a very different composition of U.S. residents by 2050. The U.S. population is projected to be 439 million by 2050. The projected growth of Latinos, Asians, American Indians and Alaska Natives, Native Hawaiians, and Pacific Islanders are estimated to significantly increase. By 2050, individuals of Latino descent are projected to triple amounting to nearly 200 million, meaning one of three U.S. residents would be of Latino descent. The Asian American population is expected to reach 40 million or 9.2% of the U.S. population. American Indians and Alaska Natives are expected to account for 2% of the population or 8.6 million. Native Hawaiians and Pacific Islanders are expected to number approximately 2.6 million (Louie, 2001; United States Census Bureau, 2008a, U.S. Census Bureau, 2008b).

The non-Hispanic White population is expected to increase to 203.3 million from 199.8 in 2008, which represents a decrease in the percent of the total U.S. population from 66% in 2008 to 46% in 2050. The black population is expected to increase slightly from 14% to 15% during this same time frame (United States Census Bureau, 2008a, U.S. Census Bureau, 2008b). The profiles of Asian Americans and Latinos illustrate the challenges of providing culturally competent care and the necessity for child health and pediatric nurses to seek out the necessary resources and supports to do so.

The challenge to fully understand the cultural nuances of beliefs and customs of smaller ethnic and racial subgroups is hampered by the lack of information and resources available to access. In some instances, exposure to ethnic and racial groups will be limited given the geographical regions wherein ethnic and racial groups settle. For example, the preponderance of Asian Americans live in fairly circumscribed regions of the country. Asian Americans live primarily in coastal and metropolitan regions. Forty-nine percent of Asian Americans reside in the western portion of the United States; 51% live in three states—California, Hawaii, and New York. In California, Asian Americans constitute 12.2% of its population, amounting to 4.5 million residents, the largest number of any state. Five of the 10 U.S. cities with the highest Asian American populations are located in California (Los Angeles, San Diego, San Jose, San Francisco, and Fremont). Nine of 10 cities with 100,000 or more residents with the highest proportion of Asian American are in California as well (Barnes & Bennett, 2002). A total of 1.4 million Asians live in Los Angeles County, the highest number of Asians of any county (National Coalition for Asian Pacific American Community Development, 2004, UCLA Asian American Studies Center, 2006, U.S. Census Bureau, 2008b).

Individuals of Mexican descent constitute about two-thirds of Latinos followed by Central and South Americans (13.1%), Puerto Ricans (9%), other Latinos (7.7%), and Cubans (3.4%). Latinos live primarily in the West (42.5%) and in the South (34.7%). In contrast, 13.8% of Latinos live in the Northeast and 8.9% in the Midwest. Sixty percent of Latinos live in the south western states of California, Arizona, New Mexico, Colorado, and Texas. Approximately fifty percent of Latinos live in California and Texas (US Census Bureau, 2006).

These regional differences affect national perspectives on the issues and needs of the subgroup differences within the all classifications of the U.S. population resulting in erroneous perceptions that there are few differences that distinguish these subgroups from one another in terms of their cultures. A brief example related to individuals of the Asian culture illustrates this viewpoint (Kim, Yang, Atkinson, Wolfe, & Hong, 2001).

Experts have identified values and norms characteristic of the Asian culture. A high value is placed on respect for and adherence to the family expectations for achievement and societal recognition (Rhee, Chang, & Rhee, 2003). Academic achievement is highly regarded as evidenced by the fact that 87% are high school graduates; 49% of Asians 25 years and older have a college degree, which is highest percentage of any other racial or ethnic group (UCLA AASC, 2006). There is a strong emphasis on family honor and respectful acknowledgement of elders. Given this familial framework, children are perceived differently in the Asian culture. Attitudes toward child rearing are characterized as overprotective, authoritarian, controlling, and judgmental based on the belief that children function in accordance with parental decisions (Rhee et al., 2003). Other values attributed to Asians are emotional restraint and modesty in self-presentation (Kim et al, 2001). Experts suggest that the basis of these values and norms are associated with the philosophies of Buddhism and Confucianism (Kim et al., 2001).

Stark differences exist between Asian American groups as evidenced by demographic profiles of languages spoken, educational level, socioeconomic status, and culture (Kim et al., 2001). For example, 68% of Indians have a college degree compared to 24% of Vietnamese (UCLA AASC, 2006). The native language of Filipinos is English compared to the languages of other Asian immigrants. Confucianism and Buddhism have strong influences in the cultures of Koreans, Chinese, and Japanese (Kim et al., 2001, Shrake and Rhee, 2004). In contrast, Vietnamese cultural influences include French, Buddhist, and Catholic beliefs (An, 2004).

As the experts have discussed, it is incorrect to make unwarranted homogeneity assumptions about the cultural practices and lifestyles of individuals who are members of subgroups of larger ethnic and racial groups. Conferring with the cultural competence experts within health care settings or in community settings is a strategy. Creating linkages with experts from community enclaves is another option. It is important for our colleagues to share their knowledge of lesser known ethnic and racial groups—knowledge that they have acquired through clinical practice or community outreach programs. We are and will continue to be well served by nurse researchers who investigate areas of inquiry pertaining to the health care needs of culturally diverse populations as a means to enhance and broaden our understanding of the role of cultural beliefs and practices. As I have stated previously in an editorial on immigrant children, ensuring that culturally competent care is provided promotes the health needs of all (Betz, 2008).

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PII: S0882-5963(08)00331-X

doi:10.1016/j.pedn.2008.08.004

Journal of Pediatric Nursing
Volume 23, Issue 6 , Pages 411-414, December 2008

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