Diversity in Pediatrics: Understanding Cultural and Socioeconomic Factors in Patient Care

In the field of medicine, diversity isn’t just a buzzword—it’s a critical factor in providing comprehensive and patient-centered care. This blog post aims to shed light on the intricacies of diversity in pediatrics specifically, and discuss strategies to improve representation and inclusivity in the pediatric field, ensuring every child receives the best care possible.

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The following post was contributed by a pediatric content author for Rosh Review.

Ask any primary care pediatrician what keeps them happy at work and you’ll likely get some variation of the same answer: building relationships with our patients and their families. It is, without a doubt, the most rewarding aspect for me.

By following patients over time, we as pediatricians have the privilege of becoming familiar with family dynamics and culture. A variety of cultural and socioeconomic factors affect how each family interacts with the healthcare system, and working to understand these has proven invaluable in optimizing care for my patients. 

As a primary care pediatrician working at a federally qualified health center (FQHC) in a large city, my practice is composed mainly of recent immigrants. I have the pleasure of treating patients and meeting families from all over the world, including Central and South America, East Asia, Africa, the Caribbean, and the Middle East. Prior to this position, I worked in private practice in an affluent suburb of the city, where there was little cultural or socioeconomic diversity. 

In transitioning to the FQHC, I became acutely aware of how important it is to consider cultural and socioeconomic factors in order to provide optimal and equitable health care. These factors, unique to each family, drive patients’ perspectives, values, and behaviors toward healthcare. 

Treating a more diverse population has been incredibly fulfilling and I couldn’t be happier in my role at the FQHC. However, no transition is easy and there have been some bumps in the road related to cultural and socioeconomic differences. As a result, a few salient concepts have become important in my day-to-day practice. 

Based on my experience, here’s some things I think pediatricians working with children from diverse backgrounds should know.

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4 Tips for Pediatricians Working With Diverse Patient Populations 

1. Much is lost in translation.

If using an interpreter, keep sentences short and ideas very simple. Once, I provided detailed counseling on reducing triglycerides by “increasing fruit and vegetable intake, increasing exercise, and switching to whole wheat bread and brown rice,” and the translation to the patient was, “Don’t eat white rice.”

I was lucky to understand enough of the Spanish translation to notice the abbreviated message so that I could ask the interpreter to elaborate. I’m sure there have been many other situations in which I didn’t catch a misinterpretation, but keeping the message short and simple can help minimize errors.

2. Consider educational attainment.

Just because you give a patient a document written in their native language doesn’t mean they’ll be able to read it.

We routinely give developmental questionnaires to parents of toddler patients, and when forms are returned incomplete I usually assume the form is needed in another language. However, there have been instances when the parent was not able to complete the form due to low literacy, not a language difference.

3. Poverty plays a role in everything.

If you have food or housing insecurity, this takes priority over other needs, including healthcare. I’ve had to reframe my perspective on patients who routinely miss appointments, as what may seem like noncompliance may actually be related to poverty.

It turns out that many missed appointments in my practice are not because the parent forgot, but because the parent cannot miss work, either because they’re concerned about job security or they can’t afford to lose any wages. The same goes for patients who don’t follow through with subspecialist referrals.

Likewise, patients who are not taking their medication may not have the funds to obtain the drug. Patients who are not changing their diet or lifestyle may not have access to healthy food or a safe neighborhood in which to exercise or play outside.

Although poverty may affect many aspects of healthcare, not all patients will readily offer this as an explanation. It’s up to us to identify barriers affecting care. 

4. Don’t make assumptions.

This is a big one that can be applied in almost every situation. Here are a few examples:

Parental Figures

I have learned over time not to assume the adult accompanying the patient in my exam room is a parent. A child may present for medical care with an aunt, cousin, or grandparent. Many cultures have extended family members living in the same home helping to care for the children. Additionally, some children immigrate to the US without their parents and are living with extended family or “sponsors.” 

Living Circumstances

In my previous private practice, sleep training was one of the main topics of discussion at well baby visits and we routinely recommended letting an infant cry overnight for short periods of time. This method assumes that only the parents will be disturbed by the baby crying, a living situation that requires a certain socioeconomic status.

The first time I recommended “crying it out” to a family in my free clinic, the parents were appalled as they were living in an apartment with neighbors on all sides. Many of my other patients live in homes with multiple family members sharing a bedroom, making this strategy less than ideal.

Gender Identity & Sexual Orientation

Caring for the LGBTQ+ community also requires putting preconceived notions aside, as you cannot assume gender identity or sexual orientation. Clarifying these attributes during a patient visit is essential for building a relationship and trust, particularly with a teen who may be struggling with acceptance. It also helps tailor anticipatory guidance regarding safe sexual practices. 

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Addressing the Need for More Diversity Among Pediatricians 

I have seen, over and over again, that addressing a medical problem in a vacuum will not offer the best outcome. You have to consider all circumstances affecting each patient. A relative lack of diversity among pediatricians when compared to the US population further complicates the task of bringing equitable medical care to all patient populations.

This highlights the importance of the AAP equity agenda, which (among other goals) aims to develop increased diversity among those selecting pediatrics as a career. In the meantime, those of us already in the workforce must do what we can to recognize and address barriers to health. 

Barriers to Healthcare for Children

Fortunately, awareness and research in the area of social determinants of health (SDOH) is on the rise. These determinants are often divided into five domains, all of which must be considered in order to help minimize health disparities:

• Economic stability.
• Education access and quality.
• Healthcare access and quality.
• Neighborhood and infrastructure. 
• Social and community context.

My FQHC is lucky to have several SDOH counselors who meet with families, identify barriers to healthcare, and recommend resources to navigate any needs they may have. 

If you’d like more information on the SDOH, they’re discussed in greater detail in this article. 

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Further Reading

Interacting with such a diverse patient population has been humbling. For me, it has been a source of personal growth. I am optimistic that, with continued work, the field of pediatrics will progress toward the goal of achieving equitable health care for all children. Follow these tips when it comes to working with diverse patient populations, and you’ll help us reach that goal. Every child deserves the best when it comes to healthcare. 

Looking for more ways to give back to your patients? Check out these other (free!) resources on the Rosh Review blog:

• Give Back to Your Patients (for Free!) with Quiz for a Cause
• Inclusive Language for Medical & Health Education: An Evolving Guide
• Tips for Communicating with Patients During Residency