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Safeguarding children: 3. Getting to grips with culture and ethnicity

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Janet Riddell-Heaney, MA, RN, RHV, DipChild Protection, Cert Ed; Mary Allot, BSc, RN, RSCN.

Janet-Designated Nurse for Child Protection, Harrow Primary Care Trust, Harrow; Mary-Independent Nurse Consultant

In our previous papers, we identified foundation child protection knowledge for health-care professionals and also examined how institutional racism may affect the delivery of effective child protection practice within the health-care field. (Riddell Heaney and Allott, 2003a, 2003b).
In our previous papers, we identified foundation child protection knowledge for health-care professionals and also examined how institutional racism may affect the delivery of effective child protection practice within the health-care field. (Riddell Heaney and Allott, 2003a, 2003b).

In this paper, we identify issues regarding culture and ethnicity. The terms 'culture' and 'ethnicity' are currently buzzwords in the NHS.

There is a tremendous drive to ensure that these issues are addressed. This is partly due to the 2000 Race Relations Amendment Act (Home Office, 2000), which gives the Commission for Race Equality (CRE) the powers to enforce the new amended legislation.

The Race Relations (Amendment) Act 2000 aims to strengthen the original remit of the 1976 Act by ensuring all public authorities consider and act on:

- Elimination of unlawful racial discrimination

- Promotion of equality of opportunity

- Promotion of good relations between people of different racial groups.

The Department of Health's (DoH) race equality guide for local authorities (2002) identifies the enforceable duties on all public authorities to promote race equality and make discrimination unlawful.

A turning point for many organisations in promoting and understanding culture and ethnicity was the Macpherson report (1999), the inquiry into the management of the police investigation of the murder of Stephen Lawrence in 1993. The King's Fund report into racism within the NHS (Coker, 2001) addresses these issues, as does the Race Relations (Amendment) Act 2000.

Terms and definitions
A step forward in clarifying what is exactly meant by culture and ethnicity is to use common definitions (Box 1).

Culture Culture is a broad umbrella term that encompasses lifestyle, belief systems, language, roots and origins. It also embraces aspects of behaviour and attitudes such as dress sense and gender identity roles within a family structure.

The DoH (1999) identifies that culture is:

- Universal: both black and white people have cultural identities

- Dynamic, not monolithic

- Acquired through life experiences

- Not static, but changes and develops over time

- Influenced by cultural and racial stereotyping.

Ethnicity This is more difficult to define. It is a complex concept that embodies aspects of country of origin, nationality, culture, language, religion, customs and reflects a sense of personal identity.

The DoH (1999) defines ethnicity as having 'geographic, political, historical, religious and cultural factors'. It is often used to provide a description of a person that is factual, for example, Irish, Albanian or Ugandan. It may also reflect skin colour, and at this point it becomes politicised.

In practice, ethnicity is often discussed in relation to the definitions used for National Census surveys. This time round, in 2001, the number of categories for people to fill in increased compared to 1991 (see Box 2) (ONS, 2001). Yet within broad ethnic groups, there are a vast array of differences and sub-ethnic groups, and this level of broad ethnic monitoring can exclude sub-ethnic-minority group populations.

As we stated previously (Riddell Heaney and Allott, 2003b), 'equality does not mean treating everyone in the same way' but is more about ensuring that the opportunity of service provision is equal for all service users. As health-care professionals working in child protection, we now have a legal obligation to work with other statutory, voluntary and private bodies that are in the process of safeguarding children from abuse.

Children and young people in Britain come from many backgrounds and represent many ethnic groups of various sizes. Within this are different faiths, skin colours, expectations of life and languages. One study (SOAS, 1997) reported that 275 languages are spoken by children in London alone. Almost one in three family homes speak a language other than English (Baker and Eversley, 2000). Most common are: Bengali, Punjabi, Gujerati, Hindi, Urdu, Cantonese, Turkish, Greek, Spanish, Italian and Portuguese.

See Box 3 for key issues highlighted by the Social Exclusion Unit (2000), which states that ethnic-minority groups suffer a 'double disadvantage'.

Factors influencing practice
Phillips (2002) suggests that a 'colour-blind approach' to child protection - common practice in the 1980s - was actually the process of judging families according to 'a white and middle-class view of normality'. This led to an immediate and automatic imbalance of power for many service users.

She says the DoH's paper Protecting Children (1988) was the first attempt to challenge this view. It recognised that cultural patterns within a family will influence parenting styles and the ways children are reared. Coupled with the Children Act 1989, practice was required to change as legislation laid definite responsibilities for local authorities to recognise 'religion, race, culture and language' (Section 22).

On the basis of all the information we have access to, and our professional obligations, all health-care professionals should be:

- Culturally sensitive

- Culturally competent

- Have a sound understanding and knowledge of how to serve ethnically diverse patient groups.

Some areas that may influence our practice in reporting and responding to a suspicion or evidence of abusive behaviour to a child are listed in Box 4.

It is reasonable to assume that we strive to work within an infrastructure committed to race equality for service users and for staff. Should we assume that having culturally matched staff to work with an ethnically diverse population will ensure relevant and more appropriate child protection services? The answers are not as straightforward as they might seem.

Farmer and Owen (1995) cite incidents of black health and social care workers being rejected by black families.

The Laming Inquiry (2003) said that there was no overt racism from staff before the death of Victoria Climbie. It stated that professionals who work in child protection require 'professional skills and personal qualities, not least of which are persistence and courage'.

Lord Laming advocates that training is made more available for practice nurses and GPs who often have contact with children in a non-urgent setting. All health professionals require further training and supervision to optimise their understanding and knowledge in the areas of cultural understanding and the importance of ethnicity.

Professionals working with child protection can be faced with difficult situations where child-rearing and parenting practices within various cultures might be mistaken for abuse or neglect. Stereotypical assumptions must not lead to omission of action or overzealous intervention.

Some parenting practices may be acceptable in one culture but not in another, for example female genital mutilation. Within each culture, there is a limit suggesting that the practice has exceeded acceptable limits and may constitute abuse. Regardless of cultural background, belief and value systems, female genital mutilation is illegal in this country.

As nurses, midwives and health visitors, we are in prime positions to be vigilant yet calm. Working Together to Safeguard Children (DoH, 1999) argues that the concept of significant harm must always be considered. The child's safety is paramount (Children Act 1989). If a child or young person will suffer harm, or is about to suffer harm as a result of any practice, action is required.

Culture does not explain abuse or explain the parent's action in response to values, beliefs or attitudes, although it may explain its context.

In Private Risks and Public Remedies, Farmer and Owen (1995) state:

'In spite of (or perhaps because of) considerable sensitivity in their perceptions, a few workers were somewhat overwhelmed by the number of factors which appeared to be relevant in minority-ethnic cases. They had difficulty in combining them, especially if culture, race and ethnicity were seen not as the total context for intervention but to be added at the end of a lengthening list.'

The Framework for the Assessment of Children in Need and their Families (DoH, 1999) provides practical guidelines for white staff who undertake assessments with black children, but all staff should be willing to reflect on their own practice.

Responding to independent DoH-commissioned research (Alexander, 1999) and the Macpherson report (1999), Alan Milburn, the health secretary said: '... it is clear that we will not achieve sustainable change if we simply tackle 'race' issues as a separate theme or initiative. Instead, we are working to mainstream these issues in everything we do as part of our programme of modernisation and specific priorities for action.'

Progress is being made, but the Laming report (2003) shows we have a long way to go before these issues become mainstream. Perhaps, as part of this process, it is time for child protection training to be made mandatory for all health-care professionals.

- The fourth paper in this series will be published in the May issue of Professional Nurse. It will examine the care of unaccompanied refugee and asylum-seeker children and young people in the UK and the role of health-care professionals in protecting them.

As a health professional who is working as an advocate for a child, consider how you should behave to ensure you are meeting the child's needs.

Identify the measures that you can take to ensure that communications with a child and family whose first language is not English are not inhibited.

As a nurse how could you redress any shortcomings in your own knowledge base and skills and where could you find the information?

The Laming Report (2003) is available on the website Visit the site and download parts of the inquiry that relate to your work setting, for example hospital or community, and discuss the recommendations.

The first part of the National Service Framework for Children, relating to children in hospital, will be introduced soon. It will set new national standards across the NHS and social services for children and young people, focusing on when they attend or are admitted to hospital. Discuss in your department how you will address cultural, race and ethnicity issues when considering the implementation of the standards.

Alexander, Z. (1999) Department of Health Study of Black, Asian and Ethnic Minority Issues. London: The Stationery Office (TSO).

Baker, P., Eversley, J. (eds). (2000) Multilingual Capital: The languages of London's school children and their relevance to economic, social and educational policies. London: Battlebridge.

Coker, N. (ed.). (2001) Racism in Medicine: An agenda for change. London: King's Fund.

Department of Health (DoH). (1988) Protecting Children: A guide for social workers undertaking a comprehensive assessment. London: TSO.

DoH. (1999) Working Together to Safeguard Children: A guide to interagency working to safeguard and promote the welfare of children. London: TSO.

DoH. (1999) Framework for the Assessment of Children in Need and their families. London: TSO.

DoH. (2000) The Race Equality Agenda of the Department of Health. London: TSO.

DoH. (2002) A Statutory Code of Practice on the Duty to Provide Race Equality: A guide for public authorities. London: Commission for Racial Equality.

Farmer, E., Owen, M. (1995) Child Protection Practice: Private risks and public remedies. London: TSO.

Home Office. (2000) Race Relations (Amendment) Act.

Laming, H. (2003) The Victoria Climbie Inquiry. Report of an Inquiry. London: The Stationery Office.

Macpherson, W. (1999) The Stephen Lawrence Inquiry. Report of an Inquiry by Sir William MacPherson of Cluny. London: The Stationery Office.

Madge, N. (2001) Understanding Difference: the meaning of ethnicity for young lives. London: National Children's Bureau.

National Commission of Inquiry into the Prevention of Child Abuse. (1996) Childhood Matters: Report of the National Commission of Inquiry into the Prevention of Child Abuse: Vol. 1: The report. London: The Stationery Office.

National Commission of Inquiry into the Prevention of Child Abuse. (1996) Childhood Matters: Report of the National Commission of Inquiry into the Prevention of Child Abuse Vol. 2: Background papers. London: The Stationery Office.

Office for National Statistics. (2001) Census 2001. London: ONS. Available at:

Phillips, M. (2002) Issues of ethnicity and culture. In: Wilson, K., James, A. (eds) The Child Protection Handbook (2nd edn.). Edinburgh/London: Ballière Tindall.

Riddell Heaney, J., Allott, M. (2003a) Safeguarding children: 1. The role of health and other professionals. Professional Nurse 18: 5, 280-284.

Riddell Heaney, J., Allott, M. (2003b) Safeguarding children: 2. Identifying and preventing institutional racism. Professional Nurse 18: 6, 350-354.

School of Oriental and African Studies. (1997) Language Survey. London: SOAS.

Social Exclusion Unit. (2000) Minority Issues with Social Exclusion and Neighbourhood Renewal: A guide to the work of the social exclusion unit and policy actions teams so far. London: SEU.

Terao, S., Borrego, Jr.J., Urquiza, A.J. (2001) A reporting and response model for culture and child maltreatment. Child Maltreatment 6: 2, 158-168.
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