Development is the unfolding of an individual’s full potential in a given cultural context. “Adolescence” may be understood differently across cultures1 and, even within cultures, continues to evolve overtime.* While some cultures emphasise the importance of the individual and the achievement of independence, others tend to place greater value on ethnic identity and allegiance to family.2 In a multicultural society like Australia, where about 16% of young people are born overseas and 24% are from a non-English-speaking background, adolescent health care is inevitably a multicultural challenge. Furthermore, health professionals themselves are a culturally diverse group, adding to the rich interplay of cultures in interactions with adolescent patients and their families.
In Australia, some young people are dealing not only with the developmental tasks of adolescence but also the experience of growing up between two cultures. While young people’s experience of belonging to or identifying with a particular culture can enhance their resilience and promote overall wellbeing,3 some adolescents not born in Australia may be at risk of poor mental health from stresses related to migration, resettlement and acculturation, as well as exposure to traumatic experiences.4
Young people are generally reluctant to seek professional help for their concerns,5 and additional barriers to care can arise from a lack of confidence and skills among service providers.6 Where cultural differences exist between young people and their health care providers, there is the potential for misunderstanding.7 Health professionals need to be particularly sensitive to the cultural influences operating in an adolescent’s life and have an appreciation of the wide range of cultural, ethnic, linguistic and social differences among adolescents.8
Culture may be defined as “the shared, learned meanings and behaviours that are transmitted from within a social activity context for purposes of promoting individual/societal adjustment, growth and development”.9 Thus, concepts of culture extend beyond language and ethnicity. Other factors such as age and generational issues, gender, sexuality, geographic location, religion and socioeconomic status may have as much or more cultural significance for any individual or community.
In dealing with young people from culturally diverse backgrounds, health care providers can function at a number of different levels. “Cultural awareness” is the recognition and acknowledgement that we are all “cultural beings” and that this may affect our interactions with adolescents, their families and our colleagues.10 “Cultural sensitivity” is the conscious attempt to understand the possible influences of culture and cultural differences on interactions between adolescents, their families and ourselves. “Cultural competency” is the ability to identify and challenge one’s own cultural assumptions, values and beliefs, the development of empathy for people viewing the world through a different cultural lens, and the application of specific communication and interaction skills that can be learned and integrated into clinical encounters.11 There is a growing body of evidence to support the need for cultural competence among health professionals to positively influence clinical consultations and health outcomes.12,13
The primary goal of the consultation with an adolescent, regardless of the presenting complaint or cultural background, is to foster a relationship of trust. The skills required to communicate in a culturally appropriate manner are the same generic skills that apply to consultation with any adolescent — namely an open, sensitive, empathic and non-judgmental approach; a positive regard and respect for differing values and practices; reassurance about confidentiality; an open-ended questioning style that avoids medical jargon; reassurance of normality; and the allaying of fears and anxieties.14
Preliminary measures include creating a “culturally friendly” practice environment by providing multilingual pamphlets on different health topics, displaying multilingual posters, artefacts or photographs that reflect specific cultural groups, scheduling longer appointments with adolescents from culturally and linguistically different backgrounds, asking how they would like to be addressed and learning to pronounce their names correctly.
The psychosocial history is crucial, and should include questions that enquire into acculturation and identity issues. Examples include asking about ways in which they do or don’t follow the norms of their culture; how they view themselves within the context of their culture; how they feel about their own culture, their parents’ culture, and host culture; what has changed, if anything, since they reached adolescence; and whether they are now treated differently by parents, siblings, and relatives.
Adopt a respectful, open and non-judgmental approach in dealing with differing cultural norms and practices. Be aware of your own cultural beliefs and values and the fact that these may not necessarily be aligned with those of a young person from a different cultural background. Assumptions about the role of verbal and non-verbal behaviour (such as eye contact) may not be transferable from one culture to another. Be mindful that it may be culturally unacceptable for a young person to discuss “private” family matters or to talk openly about his or her feelings.
Finally, avoid cultural stereotyping. People from a particular cultural or language background may not share the same set of cultural attributes, beliefs and practices, and it cannot be assumed that the young person necessarily relates to the cultural identity of the parents.
An illustrative case of a transcultural consultation is presented in Box 1.
While it is important to assess the degree to which cultural factors may play a role in diagnosis and treatment, do not assume that culture is always an issue.
Ask about the meaning of a young person’s symptoms, where relevant, within the context of their culture of origin (eg, mental health symptoms related to depression, anxiety or eating disorders).
Ask sensitively about experiences that may have adversely affected their development, health and attitudes to illness (eg, refugee experience, exposure to war and trauma, discrimination, racism). Be aware that the young person may be especially reticent about discussing these experiences.
Learn whether cultural difference (eg, attitudes to sexuality) might affect treatment.
Be sensitive to gender issues, particularly the needs of young women, when conducting physical examinations or investigating sexual health problems. Where possible, provide a female practitioner, or offer to conduct the examination in the presence of a female nurse or family member (if acceptable to the young person).
Develop a management plan that considers the influence of cultural issues and is culturally acceptable.
Engaging the family and gaining the trust of parents is critical in treating young people from other cultures. In many cultures, participation in health care is a family responsibility rather than an individual responsibility.15
Respect parents’ authority with regard to decision-making, while helping them to understand their child’s growing need for independence appropriate to his or her age and stage of development.
Where the young person is accompanied by a parent, try to spend some time alone with the adolescent. Explain to the parents your reasons for doing this and seek their permission.
Where appropriate, engage the support and involvement of parents and family in treatment, but never use a family member as interpreter (see next section).
Given the linguistically diverse nature of health professionals, language may not be an issue in consultations with culturally and linguistically diverse young people and their families. It may not be a problem even when dealing with people from a cultural background different to that of the health care provider. However, where there are language difficulties, use a professional health care interpreter. Do not rely on a member of the family, who may also have limited English and/or have an interest in presenting his or her own point of view. Even when a child or teenager is the most language-competent person in the family, many problems (ethical, cultural, informational, familial) can occur if the child is used in this way.
Also be aware of medicolegal issues — consent can only be given by a patient or parents if they are properly informed, which includes understanding the language used.
Irrespective of whether or not language is an issue, check out whether the young person and parents have clearly understood the questions asked and the information given to them. For example, check their understanding of the diagnosis and treatment instructions by asking them to repeat the instructions back to you in their own words. Do not assume that they have understood just because they say they have — in some cultures it may be considered impolite to disagree with or question an older person or someone in authority.
In framing questions for people who are functionally competent in English but not sophisticated speakers, consider the importance of volume, clarity and pace of speech (speak slowly); use of simple, non-technical language (of benefit to all patients); avoiding idioms or slang; non-verbal behaviour (eg, importance of non-verbal indicators of respect); questioning and clarifying; and the use of open-ended questions (Box 2).
Diversity among adolescent patients represents a significant challenge for the medical profession. The integral relationships between culture, development and health, and the expertise required by health practitioners to provide a culturally appropriate service, play out in adolescent practice. While cultural competence training has been shown to improve the knowledge, attitudes and skills of health professionals, we should continue to seek better ways of improving health outcomes and patient adherence to therapy.17
Meanwhile, an approach that incorporates respect for young people as individuals within their cultural framework, as well as sensitivity to the issues they and their families may face as migrants or refugees settling in a new country, will go a long way towards ensuring that they receive appropriate and effective health care.18
* The terms “adolescents” and “young people” are used interchangeably to refer to the age group 12–24 years.
1 Case study: Leah*
Leah is a 15-year-old girl, the third of five children, who lives at home with her parents (both unemployed), a paternal grandmother and siblings. She is brought to you by a local youth worker and tells you she is 6 months pregnant. She is in Year 10 at the local high school. The only person who knows about her pregnancy is the school principal.
Leah is 170 cm tall, of Melanesian appearance, and tells you that she was born in Fiji. She wears loose clothing and does not actually look pregnant. She wants to give the baby up for adoption without anyone at home or school knowing. Her plan is to “run away” for a couple of weeks around the time of the confinement. She strikes you as being somewhat “detached” and unemotional.
In asking about Leah’s cultural background, you learn that her family moved to Australia when she was 5 years old; they speak English at home; the father of the expected baby is a first cousin aged 17; her community is small and “everyone knows everyone”; and her family is Catholic. Leah believes her pregnancy would bring great shame on the family.
Management approach
In addition to rallying a comprehensive support team and booking her in for antenatal care, you discuss (with the youth worker and transcultural worker) possible cultural issues in relation to Leah’s affect and communication style, and work towards supporting her to tell her mother or other trusted adult about the pregnancy. You report the case to the child protection authorities.
Outcomes
The youth worker and social worker with the antenatal team inform Leah’s mother about the pregnancy. The sexual assault by her cousin is eventually disclosed, as well as a history of domestic violence. Leah stays at home with her mother’s support and delivers a healthy baby at term. Plans are made for relatives in a village in Fiji to adopt the baby.
Crosscultural issues
Leah’s nonverbal communication style is culturally related — little eye contact, emotions not readily expressed even when solicited.
Leah is part of a small, close-knit community, but one with significant social disadvantage and dysfunction.
The pregnancy per se did not necessarily contravene family expectations. The extended family proved to be supportive and protective rather than angry or judgemental.
While it is sometimes easy to “hide behind culture”, or use “culture” as an excuse not to act, legal and ethical issues (in this case, Leah’s and her baby’s safety) should override cultural considerations. There were reasons beyond her cultural background to account for her anxiety about secrecy.
* This case is fictitious.
2 Language mistakes commonly made by health (and other) professionals16
Speaking too loudly
Speaking too quickly
Patronising the interviewee
Using family members as interpreters
Not checking the meaning of what the interviewee says
Asking multiple questions and “double-barrelled” questions*
* A “double-barrelled” question is one that asks more than one question at once (eg, “When you feel down, who do you talk to, and how do your parents feel about this?”).
- David L Bennett1
- Peter Chown2
- Melissa S-L Kang3
- 1 The Children’s Hospital at Westmead, Sydney, NSW.
- 2 Department of General Practice, University of Sydney at Westmead Hospital, Sydney, NSW.
The authors wish to thank Ms Jan Kang, Coordinator of Planning and Operations, Diversity Health Institute, Sydney.
None identified.
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Abstract
In Australia, where about 16% of young people are born overseas and 24% are from a non-English-speaking background, adolescent health care is a multicultural challenge.
“Cultural competency” involves challenging one’s own cultural assumptions and beliefs, developing empathy for people from other cultures, and applying specific communication and interaction skills in clinical encounters.
For health professionals, sensitivity to the cultural, ethnic, linguistic and social diversity among young people helps to avert problems and misunderstandings, improves satisfaction for all concerned and leads to better outcomes.
Engaging the family and gaining the trust of parents is critical in treating young people from cultural backgrounds in which participation in health care is a family concern rather than an individual responsibility.