Some useful tips for developing cultural competence

• Be aware of your own cultural norms, attitudes, values, and beliefs, as well as your own prejudices and biases.
  
• Understand that cultural differences exist and realise that people’s experiences, beliefs, values, and language affect their ways of interacting with others and with the larger community, as well as their health and health-seeking behaviour.
  
• Treat all people as unique individuals. Be respectful and nonjudgmental of cultural differences (unless there are implications for safeguarding; see Chapter 5).
  
• Trusting relationships are essential and can only be developed through mutual respect and a desire for understanding.
  
• Just because some cultural practices may differ, do not allow them to be the basis for criticism and judgments. Do not enforce your own personal beliefs on others.
  
• Take time to listen: if you do not understand something, ask for an explanation.
  
• When dealing with specific cultures, having knowledge of some cultural norms and practices can help your sensitivity and understanding, and enables you to provide culturally sensitive information and advice that may be more acceptable to an individual or family. The public health walk in Chapter 3 is a great way to find out more about your local area and community.
  
• Developing cultural competence is an ongoing process and a lifelong journey – make it part of your continuing professional development (CPD) programme.

Women’s experiences of pregnancy, childbirth, and child rearing are influenced by cultural beliefs and practices. Many customs and rituals associated with these significant events shape future mothering behaviour. ‘May you bathe in milk and bloom among sons’ is a traditional blessing in India, where motherhood – preferably of a son – is highly regarded (Choudhry, 1997; Culley et al., 2007). Traditionally, in India, daughters are seen as a social and economic burden, whilst sons are seen as providers who can not only provide financial security for parents in old age but also perform rites for the souls of deceased family members. Antenatal sex selection, although illegal, is still widely practised on the subcontinent, and some hospitals in the UK have a policy of not telling parents the sex of their baby during routine scans. Information about local hospital policies can be found on the NHS Choices website (www.nhs.uk; see also ‘Can I Find Out the Sex of My Baby?’ on that site).

Whilst there are many similarities between the South Asian countries of origin of the British Asian population, religious variations affect the prevalence of some cultural beliefs and practices. Abortion, for example, is regarded as ‘haram’ (forbidden) by Muslims, and abortion of girls for sex selection is less commonly practised in Bangladesh and Pakistan than in India. The practice of ‘Daj’ (dowry), however, is widespread across cultures.

Diet in pregnancy is increasingly recognised as important, but there are very many cultural beliefs associated with food. In particular, in many Asian and South Asian cultures, the concept of ‘hot’ and ‘cold’ food is prevalent, much as the idea of the ‘four humours’ (earth, air, fire, and water, representing hot, cold, wet, and dry elements) is prevalent in Shakespeare’s plays. Here, ‘hot’ and ‘cold’ do not refer to the temperature at which foods are eaten, but to symbolic beliefs associated with them. Generally, hot (garam) foods are seen as being harmful during pregnancy. These include:

• meat, eggs, fish;
  
• beans, pulses, lentils;
  
• eggplant (aubergine), onion, garlic, ginger, chillies;
  
• ghee (clarified butter);
  
• some fruits, including papaya, banana, and dates;
  
• jaggery (unrefined cane sugar);
  
• alcohol, coffee, tea.

Research over many decades has provided evidence of the types of food that are considered hot (Quah, 2015). In a study of 1106 pregnant, lactating, and weaning women in India, Jesudason & Shirur (1980) asked about attitudes to certain foods: 20% of women believed that banana could cause fever and coughing in the mother and was bad for the foetus. Other studies have reported that fish, meat, egg, spices, and salt are often believed to induce abortion (Ferro-Luzzi, 1980; Jeffery et al., 1989; Nag, 1994). Papaya has been reported to have abortive powers, whilst aubergine is considered to be among the most harmful vegetables (Mathews & Benjamin, 1979; Rao, 1985; Pool, 1987; Nag, 1994).

In contrast, cold (thanda) foods are seen as beneficial during pregnancy. These include:

• milk and yoghurt;
  
• coconut and coconut water;
  
• wheat and rice;
  
• green, leafy vegetables.

Cold foods are especially recommended during early pregnancy, to avoid miscarriage (Nag 1994), and milk is considered to have particular benefits (Rao, 1985; Jeffery et al., 1989).

Perceptions surrounding ‘hot’ and ‘cold’ foods differ between regions and countries and are common in many cultures. Some mothers use Chinese herbal teas or ‘hot–cold’ food and drink to recover and balance their ‘yin/yang’ in the perinatal period.

When working with women from India, it is also important to be aware of the concept of ‘eating down’: eating less during pregnancy to avoid the risk of a large baby and a difficult delivery (Rao, 1985; Jeffery et al., 1989; Chatterjee, 1991). Many Indian women also fast and ingest herbal medicines during pregnancy in the hope of having a son (Raman, 1988).

These practices can have serious implications for a mother’s nutritional intake during pregnancy. In a qualitative study of pregnant British Bangladeshis, Yeasmin & Remi (2013) reiterate the need for an understanding of food practices and beliefs among practitioners and policy makers. D’Souza et al. (2015) undertook a review of dietary practices during pregnancy and concluded that migrant women may follow some of these practices but that there is a lack of research on their impact on birth outcomes. The Born in Bradford Cohort Study is one example of the way in which the impact of health in pregnancy in a community with a high migrant population is being assessed (www.borninbradford.nhs.uk). Health visitors need to ensure that all pregnant women are informed and educated about adequate nutritional intake, including adequate intake of iron and vitamin D, since nutritional rickets is a strong risk in dark-skinned population groups (Shenoy et al., 2005). The Asian Feeding Survey (ONS, 1997) found that up to one-third of Indian, Bangladeshi, and Pakistani children had low vitamin D status at age 2. People with darker skin are at increased risk of vitamin D deficiency, as their skin is less efficient at synthesising vitamin D, and therefore NICE Public Health Guidance 56 (NICE, 2014b) recommends that people of African, African Caribbean, and South Asian origins, as well as those who remain covered when outside, should be given vitamin D supplements.

As well as advising women about healthy eating in pregnancy, health visitors have a role in supporting them to access weight-loss programmes following birth if they have a BMI over 30 (NICE, 2015). It is recognised that women from some ethnic groups, including those of South Asian or East Asian origin, may have an increased risk of obesity at a lower BMI, which should also be taken into consideration by health care professionals (NICE, 2015).

Birth customs

There are many different rituals and customs related to childbirth. Whilst there may be variation in practices across people from different countries, they are generally based on religious beliefs; therefore, in this section, the birth customs of four major religions will be discussed. It is not possible for health visitors to know about all the different beliefs and practices that exist, nor is it important to do so – it is more important to be open and ready to have a discussion based on some understanding of the diverse range of beliefs and practices that exist (which are often also mirrored or found in the ‘majority’ culture). The routine antenatal contact carried out by health visitors as part of the Healthy Child Programme (DH, 2009) is an ideal opportunity to explore and discuss individual customs and practices. Having an understanding of these would enable health visitors to build better relationships with families, which is fundamental to providing effective support during their transition to parenthood and beyond.

Confinement following birth

Belief systems surrounding the necessity of confinement for a specific period of time after giving birth inform many cultures, and were prevalent in the UK until the 1950s. In the modern world, it is increasingly unusual that these traditions are observed fully. Sikh women traditionally observed a period of 40 days of seclusion after birth, when the mother is considered ritually unclean. During this time, women have a rich diet (a mixture of nuts, ghee, and sugar) and are not expected to cook or leave their home. On the 40th day, following a ritual bath, both mother and baby attend the Sikh temple and are reintegrated back into the community (Dobson, 1991; Rait, 2005). Similarly, Hindu women would be expected to stay at home following birth, usually in their mother’s house, in order to rest and refrain from any housework. Whilst there is no Islamic law that women should stay at home for 40 days following birth, many women will follow this tradition in order to rest and concentrate on the care of the newborn. Similar traditions of ‘sitting the month’ are also followed by some Chinese mothers, who may avoid exercise and hair washing (Tighe et al., 2014).

Mothers observing a period of confinement after birth may be unlikely to attend child health clinics. It is important to check with every family whether they have any cultural or religious beliefs or rituals that might prevent them from attending any necessary appointments. Health visitors could either see the mother and child at home for routine checks or arrange an appointment outside the confinement period.

Breastfeeding

Breastfeeding is a priority for improving children’s health and reducing health inequalities, and exclusive breastfeeding for the first 6 months of a baby’s life is advised (DH, 2009, 2013). The 2010 national infant feeding survey showed that the proportion of babies breastfed at birth had risen by 5% in the previous 5 years, from 76 to 81% (HSCIC, 2012), but many cultural practices can impact on breastfeeding.

In Muslim cultures where tahneek is practised (and other South Asian cultures), the baby’s first taste is likely to be softened date or a sweet substance, not breast milk. In many cultures, colostrum is not considered milk and is withheld from the baby; it is thought to be inferior, ‘dirty’, and not good for babies because it has been in the breast during pregnancy. A survey of 120 cultures showed that in 50, delay in implementing breastfeeding due to beliefs around colostrum was more than 2 days (Morse et al., 1990). There is evidence from different countries that these types of attitudes persist, but they are changing; for example, in Vietnam, Lundberg & Thu (2012) found some women continued to discard colostrum but others understood its health benefits. McFadden et al. (2013) suggest from their study of Bangladeshi women and health practitioners in West Yorkshire and the North East of England that health practitioners may apply outdated stereotypes (e.g. regarding migrant women’s attitudes to colostrum), which can mean that they fail to provide the support needed to initiate breastfeeding. Liampattong (2010) explores these issues further, taking a cross-cultural/public health approach to gaining understanding of the wide range of infant feeding practices throughout the world. Interestingly, whilst in the last national infant feeding survey (HSCIC, 2012), exclusive breastfeeding rates at birth were higher for all ethnic minority groups compared with white mothers, this difference was no longer evident at 1 week, where the rates for ethnic minority and white mothers were similar (46% white, 48% Asian, 49% black and Chinese or other ethnic groups). Mothers from ethnic minority groups were also less aware of the health benefits of exclusive breastfeeding compared to white mothers – 78% of white mothers were able to name a health benefit, compared to 64% of Chinese and other ethnic groups, 63% of black, and 59% of Asian mothers (HSCIC, 2012). This survey only categorised the ethnicity of mothers in five groups, however – white, mixed, black, Asian, and Chinese or other – which means that there are likely to be wide-ranging cultural practices within each of these categories. For example, Somalian women have strong beliefs in breastfeeding, but mixed feeding tends to be more common than exclusive breastfeeding (Graham et al., 2007). Many Somali families living in the UK have experienced refugee camps, malnutrition, or life-threatening diseases, such as tuberculosis. A fat baby is considered a healthy one – demonstrably free of malnutrition and disease – and as a result, children tend to be both breastfed and supplemented with formula.

It is important to be aware that a woman’s decision to breastfeed will be influenced by her own experiences, beliefs, and cultural norms and may be affected by a lack of information or education. Health visitors should educate all mothers about the value of colostrum and the benefits of exclusive breastfeeding in a sensitive and respectful manner, enabling them to make informed choices. Research on the benefits of breastfeeding can be found from the UNICEF Baby Friendly Initiative (UNICEF, n.d.).

Family members’ opinions, especially those of older female members, can have a great influence on breastfeeding initiation and continuation (MacDonald, 1991). Negative attitudes among partners and family members are significant influencing factors for women not starting or giving up breastfeeding (Arora et al., 2000). As well as working to inform and educate the mother, health visitors need to consider fathers and other family members. Where fathers are well informed and supportive of breastfeeding, overall breastfeeding rates are higher (Pisacane et al., 2005). Cultural sensitivity needs to be exercised, however, to ensure that the father is comfortable discussing breastfeeding with a health visitor.

Muslim mothers – indeed, many Asian mothers – may be embarrassed to breastfeed in public places due to the need to protect their modesty. Mothers may be reluctant to attend a breastfeeding group or seek assistance with breastfeeding if it involves having to breastfeed in front of a stranger. Health visitors should be mindful of this and consider having a breastfeeding room or a private screened-off area where mothers can breastfeed when attending group sessions or busy clinics in the community setting.

Diet, weaning, and feeding practices

Feeding practices and dietary intake are influenced by culture and religion. For Hindus, beef is forbidden, and many Hindus refrain from eating meat altogether and are vegetarian. When giving nutritional advice around parents’ or a child’s diet, it is important to know what types of food to suggest to ensure that the family is receiving a balanced diet. It is particularly important to ensure that vegetarian children are receiving iron-sufficient food. Whilst the Sikh family diet is varied, observant baptised Sikhs tend to be vegetarian and do not eat any fish, meat, or eggs, or any other meat products. Other Sikhs will eat meat, but most avoid eating beef. Milk is used, but ‘Indian’ cheese (paneer) is very different from the traditional European Cheddar or soft cheeses.

Muslims follow halal (permitted) dietary rules: they are forbidden to eat pork or drink alcohol, and meat must be slaughtered in a prescribed way. Jews also do not eat pork or any type of shellfish, and require their meat to be kosher; that is, slaughtered by a licensed Jewish slaughterer (shochet). Jews are also forbidden to eat milk and meat products together, and food is prepared with utensils and cooked in an oven that has only been used for kosher food. Both Muslim and Jewish parents may refuse medication containing gelatin, as it is derived from non-halal or non-kosher animal products. Some Muslims may also refuse medicines containing alcohol, even if the percentage is very low.

When advising on healthy eating and suitable foods for weaning, health visitors should always enquire whether the family has any special dietary requirements so that they can provide culturally sensitive information and food options, and avoid causing any offence. Being familiar with the types of food eaten in the family will also enable them to provide culture-specific weaning advice and recipes incorporating the family foods. Hogg et al. (2014) found that routine health visiting advice and information was often difficult to understand and use in traditional Pakistani or Chinese households. One mother stated, ‘They don’t have Chinese style recipes. So it’s difficult because we are not familiar with British ingredients, like custard? That’s why I just bought the readymade baby food’ (Hogg et al., 2014: 6). In such cases, providing families with recipes containing ingredients they are familiar with is likely to be more effective (see Box 6.1). It is, however, important not to make assumptions, as families from similar ethnic backgrounds may have very different food preferences and practices. Equally, it is important not to give the wrong advice just to be culturally sensitive. One health visitor commented on how she gave inappropriate advice to a Chinese family: ‘They don’t like to give children cold foods, I’d been stressing things like yoghurt that is completely inappropriate’ (Hogg et al., 2014: 6).

Each family situation should be assessed in its own right, as families are likely to adopt aspects of Western cultures to varying degrees. Having awareness of an individual family’s needs, preferences, and cooking methods, whilst checking the suitability of advice given, is a more effective way of providing culturally sensitive care than trying to learn every aspect of every culture.