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Children’s health retention in South Korea and the United States: a cross-cultural comparison
Children’s Health Retention in South Korea and the United States: A Cross-Cultural Comparison Betsy M. McDowell, PhD, RN, CCRN Nahn Joo Chang, MSN, RN, C Sang Soon Choi, PhD, RN
In recent decades, great strides have been made globally in decreasing child mortality. However, given that many countries still do not have basic healthcare, additional emphasis is being placed on health promotion activities among industrialized nations. As cultural differences of individual countries impact these health promotion practices, the cultural characteristics influencing children and families in two countries, South Korea and the United States, were compared. Major child health risk factors were examined, and health retention strategies tailored to the cultural characteristics and needs of the populations of each country are proposed, using the Neuman Systems Model as a guideline. © 2003 Elsevier Inc. All rights reserved.
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hild mortality has dropped dramatically throughout the world in recent decades. Deaths due to major health problems such as communicable diseases, circulatory problems, and cancers have decreased, resulting in increased life expectancy for children born at the beginning of the 21st century. With these changes in the world’s health status, healthcare practitioners are shifting their focus to one of health retention and promotion rather than one of cure. Cultural beliefs influence healthcare policies and decisions; culture exerts a significant force on children’s care and health promotion activities. Cultural differences of individual countries impact children’s health education and child health promotion practices. These educational and health promotion practices in turn affect the level of health of children in these countries. Additionally, the steady increase in the KoreanAmerican population in the United States brings with it an increased probability that healthcare workers will interact with these families. The purpose of this article is to compare selected child health risk factors and cultural characteristics that impact the health retention activities of children and families in two countries, South Korea and the United States of America (USA). Following this comparison, nursing interventions for improving child health that are tailored to the cultural characteristics of each country will be proposed.
Journal of Pediatric Nursing, Vol 18, No 6 (December), 2003
CONCEPTUAL FRAMEWORK According to the Neuman Systems Model (Neuman, 2002), the client is an open system in constant interaction with the environment. This client system can be an individual, a family, a group, or a community and is composed of five intertwined variables, including a sociocultural variable. Neuman notes that various stressors originate from the environment and attempt to penetrate the client’s defenses and thereby alter the client’s level of wellness. The client’s defenses include a flexible line of defense that serves as a buffer to these environmental stressors, the normal line of defense that is the composite of healthy behaviors over time, and the lines of resistance that are the resources that protect the integrity of the basic structure of the client. In a Neuman context, nursing consists of prevention activities directed at three different points in the stressor-client encounter— primary, secondary, and tertiary prevention as intervention. Primary prevention strategies focus on health retention and are aimed at reducing the possibility of stressor encounter and at strengthenFrom Lander University, Greenwood, South Carolina and Yonsei University, Wonju, South Korea. Address correspondence and reprint requests to Betsy M. McDowell, PhD, RN, CCRN, 320 Stanley Avenue, Lander University, Greenwood, SC 29649. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 0882-5963/03/1806-0000$30.00/0 doi:10.1016/S0882-5963(03)00159-3 409
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ing the client’s flexible and normal lines of defense (Neuman, 2002). For the purposes of this study, the children in South Korea and in the United States comprise the client systems. The basic core of each of these client systems includes the cultural characteristics of the specific populations. Each population has risk factors for stressor encounter that result from these cultural characteristics. Once these culturespecific risk factors are identified, prevention as intervention strategies can be tailored to accommodate these differences. DEMOGRAPHIC CHARACTERISTICS OF SOUTH KOREA AND THE UNITED STATES In comparing South Korea and the United States on geographic and population characteristics, several contrasts become obvious (Table 1). In 1999, South Korea had a population of almost 47 million (Lee, 1999), with 14.2 million (30.2% of the population) being infants and children up to 19 years of age, with slightly more boys than girls. The Table 1. Demographic Characteristics of South Korea and the United States South Korea
United States
● Total Population—almost 47 million people in 1999 ● Population ⱕ 18 years old— 14.2 million (30.2% of total population), with slightly more boys than girls ● Average Life Expectancy—73.5 years ● Land Area—about 1/100th the size of the United States or a little larger than the state of Indiana ● Population Density—475 persons per sq. km or 1230 persons per sq. mile ● Economy—Industrialized; free enterprise system ● Government—Republic with a president elected by the people; personal freedoms valued
● Total Population—over 270 million people in 1999 ● Population ⱕ 18 years old—70.2 million (26% of total population)
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● Average Life Expectancy— 74.9 years ● Land Area—3,615,276 sq. mile or 9,363,520 sq. km
● Population Density—29 persons per sq. km or 76 persons per sq. mile ● Economy—Industrialized; free enterprise system ● Government—Federal form with a president elected by the people; personal freedoms valued Education—Kindergarten ● Education—Kindergarten through post-secondary; through post-secondary; technical education available technical education available Literacy Rate—90% ● Literacy Rate—80% Location of Population—Majority ● Location of Population— urban; seven large cities with Urban or suburban areas over 1 million population each; rather than in rural areas; automobiles and mass estimated 75 cars per 100 transportation utilized population Religion—Confucianism, ● Religion—Christian 90% Buddhism, and Christianity
country covers an area about 1/100th the size of the USA or a little larger than the state of Indiana. Its population density in that same year was 475 persons per square kilometer or 1230 persons per square mile (Lee, 1999). The United States of America had a population of over 270 million in 1999 (Coffman and Sullivan, 1999), including 70.2 million infants and children under age 18 years, making up slightly more than a fourth (26%) of the total population (Forum on Child and Family Statistics, n.d.). The United States covers over 3.6 million square miles and had a population density of 29 people per square kilometer or 76 people per square mile in 1999 (Coffman and Sullivan, 1999). Although South Korea and the United States are not similar in geography and population, they do share several other characteristics in common. The average life expectancy at birth in both countries is relatively high, with South Koreans living for 73.5 years (Ministry of Health & Welfare, 2001) and with Americans living an average of 74.9 years. Both countries have democratic governments and value personal freedoms, such as freedom of religion and freedom of speech. Education is important in both countries and children have numerous opportunities for secondary and post-secondary education. The literacy rate in the United States is estimated to be at least 80%, and the literacy rate in South Korea is noted to be closer to 90%. Until the early 1900s, agriculture was the basis for the economy in both countries, but now they both are industrialized nations. South Korea and the United States are trading partners. The large majority of people in both countries live in urban or suburban areas rather than in rural areas so that automobiles and mass transportation are a fact of life. However, traffic jams and pollution also characterize life for most of the citizens of both countries who live in urban areas. COMPARISONS OF CHILD HEALTH RISK FACTORS Seven child health risk factors were compared for each country: (1) low birth weight babies; (2) infant mortality; (3) child mortality; (4) teen deaths due to accidental injuries, suicides, and homicides; (5) teen births; (6) childhood immunizations; and (7) children with no health insurance (Table 2). These parameters were chosen because they are nationally accepted indicators of child well-being (Annie E. Casey Foundation, 2000; Forum on Child and Family Statistics, n.d.) and reflect Neuman’s sociocultural variable. Data for this study
CHILDREN’S HEALTH IN SOUTH KOREA AND THE UNITED STATES Table 2. Child Health Risk Factors Low Birth Weight Babies Infant Mortality Child Mortality Teen Deaths Due to Injuries, Suicides, and Homicides Teen Births Childhood Immunizations Children With No Health Insurance
were taken from several governmental and nongovernmental sources and reflect the most current data available for each risk factor. Where possible, data from the same years were compared, although this was not possible in every instance. Many of the risk factors included here, however, were developed from samples, and like all sample data, a certain amount of random error may be included.
Low Birth Weight Babies The first child health risk factor to be compared was the percent of low birth weight babies. Babies weighing less than 2500 grams or 5.5 pounds at birth have a high probability of experiencing developmental problems, some of which can last a lifetime. Therefore, the percent of low birth weight babies reflects a group of children who are at risk for problems as they move through the growth stages (Lowdermilk and Perry, 2003, p. 483). The percentage of low birth weight babies in South Korea steadily decreased from 12.8% in 1980 to 9.8% of all live births in 1996 (Ministry of Health & Welfare, 1996b). (Accurate data for 1999 were not available due to lack of mandatory reporting of births in that country.) Most Korean women receive prenatal care provided by public health nurses, and a large number of the deliveries occur in the hospital, probably contributing to this decline in low birth weight babies. However, the percent of low birth weight babies in the United States increased from 6.8% in 1985 to 7.6% of all live births in 1998 (Forum on Child and Family Statistics, n.d.). This increase in the number of low birth weight infants in the USA is partly due to an increase in the number of multiple births and also may reflect an increased use of induction, Cesarean section, and other operative procedures with highrisk pregnancies. However, the increase in low birth weight infants in the USA also raises a number of troubling issues, including the possibility of declining health of American mothers, particularly teen mothers (teen birth rate 30 per 1000 females ages 15 to 17 years), the absence of health insurance, and the influence of inadequate prenatal care.
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Infant Mortality Because the first year of life is more precarious for infants than later years, negative social conditions such as low socioeconomic status, less than a high school education, poor nutrition, smoking, substance abuse, inadequate prenatal care, and excessive lifestyle stressors have a significant impact on this vulnerable group (Lowdermilk and Perry, 2003, pp. 650-651). Children born to families with fewer advantages are more likely to experience health problems at an early age. Therefore, the second child health risk factor to be examined was infant mortality. In 1999, the infant mortality rate of 7.7 per 1000 live births in South Korea (Ministry of Health & Welfare, 1996a) was slightly higher than in the United States, where the rate was 7.2 infant deaths per 1000 live births in 1998 (Annie E. Casey Foundation, 2000). Such rates in both countries may reflect large numbers of low-income families, infants born to parents with low educational attainment, and infants who would have died before or during birth but survived past the neonatal period due to aggressive neonatal intensive care programs. By the end of the 20th century, the leading causes of infant deaths were similar in South Korea (National Office of Statistics, 1996) and the United States (National Center for Injury Prevention and Control, 2000b). Perinatal disease accounted for the most infant deaths in South Korea, whereas congenital anomalies were first in the USA. The second leading cause of infant death was listed as congenital anomalies in Korea and problems resulting from short gestation in the USA. Sudden infant death syndrome (SIDS) was the third cause of infant deaths in both countries. Heart disease was the fourth leading cause of infant deaths in South Korea and maternal complications was fourth in the USA. Pneumonia rounded out the top five for South Korea, and respiratory distress syndrome was fifth in the USA. Surprisingly, car accidents were the sixth leading cause of infant death in South Korea but were not found among the top 10 causes of death of American infants. Minimal use of child safety systems in cars by Korean parents probably influenced this finding.
Child Mortality Once children survive the first year of life, their mortality rate drops sharply. The child death rates for both South Korea and the United States have decreased significantly in the last two decades.
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Nevertheless, the rate of child deaths between 0 and 14 years of age in South Korea (57 deaths per 100,000 children) (National Office of Statistics, 1999b) remains much higher than the rate of child death in the USA in the 1 to 14 year age group (25 deaths per 100,000 children) (National Center for Injury Prevention and Control, 2000b). These statistics must be viewed with caution, however, because the Korean data include infant deaths in the child death figures, but child deaths are reported separately from infant deaths in the United States. The causes of childhood deaths include some similarities as well as some differences by country. Motor vehicle accidents (MVAs) resulting from no child restraint systems accounted for more deaths of Korean children (National Office of Statistics, 1999a), and unintentional injuries accounted for more deaths of American children than the other four causes combined in each country (National Center for Injury Prevention and Control, 2000b). The remaining mechanisms of death differ by age group for each country. In the 1- to 9-year-old age group, drowning was the second leading cause of death and congenital anomalies were third in South Korea (National Office of Statistics, 1999a). In the USA, malignant neoplasms were second and congenital anomalies were third in this age group (National Center for Injury Prevention and Control, 2000b). Falls were the fourth leading cause of childhood deaths followed by leukemia at fifth place in South Korea (National Office of Statistics, 1999a). In the USA, homicides were the fourth and heart disease was the fifth leading cause of childhood death (National Center for Injury Prevention and Control, 2000b). For Korean teenagers, motor vehicle accidents lead the list followed by suicides, drowning, leukemia, and heart disease (National Office of Statistics, 1999a). Among adolescents in the United States, unintentional injuries were first, followed by homicides, suicides, malignant neoplasms, and heart disease (National Center for Injury Prevention and Control, 2000b).
Teen Deaths Due To Accidental Injuries, Suicides, and Homicides If the teen deaths due to accidental injuries, suicides, and homicides for each country are examined, several contrasts appear between the United States and South Korea. Traumatic deaths occurred at a rate of 11 deaths per 100,000 teens between 15 and 19 years of age in South Korea in 1996 but had jumped to 34 deaths by 1999 (Na-
MCDOWELL, CHANG, AND CHOI
tional Office of Statistics, 1999a). In contrast, in the USA, the rate was down from 62 deaths to 58 deaths per 100,000 teens/young adults between 15 and 19 years old due to these causes in the same time frame (National Center for Injury Prevention and Control, 2000a). Accidental teen deaths in South Korea are primarily from cars, drowning, and falls (National Office of Statistics, 1999a), whereas in the USA, motor vehicle occupant injury, drowning, poisoning, firearms, and other transportation accidents are the main causes of accidental teen deaths (National Center for Injury Prevention and Control, 2000a). In South Korea, teen suicides are generally by chemical insecticide, suffocation, or falls from high structures (National Office of Statistics, 1999a), whereas teen suicides in the USA are by firearms, suffocation, or drugs (National Center for Injury Prevention and Control, 2000a). Suffocation, stabbing, and striking are the primary means of teen homicides in South Korea (National Office of Statistics, 1999a), whereas firearms are responsible for over 82% of the teen homicides in the USA. Korean adolescents consider education as their first priority, so that very few social problems such as drugs, alcohol, or drunk driving are found in South Korea (Chang, Chang, & Freese, 2001). However, stress from the demand for high educational performance is a major contributing factor to the rate of teen suicides in South Korea. Because gun ownership by private citizens is not permitted in South Korea, gunshot injuries are not a cause of teen deaths in that country (Chang, Chang, & Freese, 2001).
Teen Births Both American and South Korean societies consider teenage childbearing problematic, although the rates of teen pregnancy are drastically different in the two countries (Annie E. Casey Foundation, 2000; Chang and Chang, 1994). Most teen mothers are unmarried and under the age of 18 years. Many of these mothers have not completed high school, have difficulty finding a stable job, and have relatively low financial resources. The children of single teenage mothers typically drop out of school, become unwed mothers themselves, and are on welfare (Annie E. Casey Foundation, 2000). According to 1998 data in South Korea, there were 2.7 unmarried teenage mothers per 1000 females between 15 and 19 years old (Park, 1998). The teenage birthrate in the United States for 15- to 17-year-old females was 30 per 1000 in 1998 (Forum on Child and Family Statistics, n.d.). These
CHILDREN’S HEALTH IN SOUTH KOREA AND THE UNITED STATES
statistics present even more of a divergence because the Korean figures cover a 5-year age span, whereas the USA figures address only a 3-year age range. This startling contrast may be explained by the fact that premarital sex is not accepted by the Korean culture; Confucianism is a dominant ethical/moral belief there and strongly discourages this behavior (Chang and Chang, 1994). Historically in Korea, a wife could be divorced for not being a virgin, but a husband could not (Ling, 1999).
Childhood Immunizations The percent of 2-year-old children who are fully immunized was chosen as a reflection of a country’s preventive health concern for its children. Immunizing the population against communicable diseases is a basic primary prevention strategy used by industrialized countries. By 2 years of age, American children are considered to be fully immunized if they had received vaccines against hepatitis, diphtheria, pertussis, tetanus, polio, measles, mumps, and rubella. The Korean immunization program is similar to that of the United States, but it includes the BCG vaccine against tuberculosis, a primary health problem in Korea for many years. In comparing the two countries, South Korea was noted to have a higher percentage (97% in 1999) of its 2-year-olds who were fully immunized (Public Health Office, 1999) than did the USA in the previous year (81% in 1998) (Annie E. Casey Foundation, 2000).
Children With No Health Insurance The final child health risk factor to be examined was the percent of children with no health insurance. Because access to healthcare is dependent on the financing of healthcare, the percentage of uninsured children reflects the value society places on preventive healthcare. Since insurance is the only accepted method of payment for healthcare in South Korea, all children (in fact the entire population) have been covered by health insurance since 1997, 3% by government insurance plans and the remaining 97% through personal insurance policies (Public Health Office, 1998). In contrast, 15% or 10.5 million American children under age 18 were not covered by some form of health insurance in 1998 (Annie E. Casey Foundation, 2000). Of the children who were covered by some form of health insurance, over 70% had personal insurance policies and over 20% were receiving public assistance through Medicaid or other governmental programs.
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NURSING INTERVENTIONS FOR IMPROVING CHILD HEALTH Both South Korea and the United States have areas of strength and areas for improvement for the child health risk factors that were examined previously. Both countries have a relatively low percentage of babies born who are underweight, although the American data reflect an increase in this percentage in recent years rather than a decrease as expected. Additionally, the decrease in infant mortality rates in both countries may reflect an emphasis on high-quality care for infants in the first year of life. Several nursing implications are evident as a result of these comparisons (Table 3). Because of the proven positive influence on fetal development, programs promoting early and coordinated prenatal care plus reduction in use of harmful substances such as tobacco, alcohol, and illegal drugs during pregnancy should be encouraged in the United States as primary prevention strategies. This is consistent with Neuman’s view of prevention as intervention (Neuman, 2002). Such programs have the potential to significantly decrease the rate of low birth weight as well as the rate of infant mortality in these countries. Educational programs about parenting and risk reduction that target teen mothers also may positively influence these statistics. Continued research aimed at the prevention of SIDS would also decrease the infant mortality rate in both countries. The relatively high rate of childhood deaths in South Korea from preventable accidents and the number of child deaths that could be prevented if child restraint systems were emphasized should be priority concerns for the Korean people. Educational and primary prevention programs aimed at decreasing child deaths due to preventable accidents could further decrease these numbers in both countries. Each community could analyze local mortality and morbidity statistics and then coordinate system-wide changes specific to its problem areas and resources. Nurses are in key positions to develop and implement such programs. Decreasing teen access to firearms, alcohol, and drugs would be a primary prevention action to lower the number of teen deaths from unintentional as well as intentional injuries in the United States. Alcohol is a contributing factor in many teen deaths from motor vehicle accidents; states are encouraged to take measures to reduce drinking and driving in an attempt to decrease the numbers of vehicular-related deaths and injuries (National Center for Injury Prevention and Control, 2000a).
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MCDOWELL, CHANG, AND CHOI Table 3. Suggested Primary Prevention Strategies Low Birth Weight Babies ● Continue current activities that have been effective in both countries ● Increase the use of strategies to decrease teen pregnancies in the USA ● Promote increased utilization of early and adequate prenatal care for American mothers ● Implement peer programs to reduce substance abuse (smoking, drinking, and illicit drugs) ● Increase health insurance coverage for all American children Infant Mortality ● Continue current activities that have been effective in both countries ● Facilitate access to health care for low-income families in both countries ● Increase the educational level of families in both countries ● Continue research in ways to improve outcomes of care for high-risk neonates in both countries ● Educate teen mothers on childrearing practices and risk reduction strategies ● Foster research to prevent SIDS in both countries ● Increase use of child safety systems, particularly in South Korea Child Mortality ● Continue current activities that have been effective in both countries ● Increase the use of child safety systems, particularly in South Korea ● Educate families on ways to decrease preventable accidents in both countries Teen Deaths Due to Injuries, Suicides, and Homicides ● Continue current activities that have been effective in both countries ● Decrease access to firearms, alcohol, and drugs in the USA ● Provide stress reduction programs for Korean teens Teen Births ● Continue current activities that have been effective in both countries ● Implement educational programs to empower American teens to make smart choices related to sex and pregnancy ● Encourage early and adequate prenatal care in the USA Childhood Immunizations ● Continue current activities that have been effective in both countries ● Promote health insurance coverage for immunizations in the USA ● Emphasize the benefits of childhood immunization in the USA Children With No Health Insurance ● Continue current activities that have been effective in both countries ● Promote health insurance coverage for all American children
Koreans hold education in high esteem, because whether or not a high school graduate is admitted to a prestigious college is an overriding priority for most Korean families (Chang, Chang, & Freese, 2001). As a result, teenagers in South Korea develop high levels of stress related to school and college acceptance and performance. As extreme stress is a major determinant of the rate of teen suicide, strategies to decrease the high amount of stress adolescents experience are critical to reducing the incidence of teen suicide in that country. Nurses could conduct community assessments of teen needs in individual communities, teach stress management techniques to high-risk groups, and advocate for increased suicide prevention programs. Traditional Korean cultural beliefs are probably the biggest factor in the low rate of teen pregnancies in that country; the rate of teen pregnancies in South Korea may begin to increase as more Western views are adopted by Korean teens. Because premarital sex and teen pregnancy are widely accepted in the USA, effective educational programs
aimed at empowering teens to make smart choices about these issues are desperately needed. Additionally, encouragement for early prenatal care may be effective in decreasing the rate of teen pregnancy and ultimately in decreasing the rates of low birth weight babies and infant mortality in the USA. Nurses are pivotal in planning and implementing such programs. As for the financing of children’s healthcare, Americans could follow the Korean example with respect to health insurance coverage for all children. Provision of health insurance and more educational programs that emphasize the benefits of childhood immunization may increase the child immunization rate in the United States to a rate comparable to that of South Korea (Annie E. Casey Foundation, 2000). Again, nurses would be valuable partners in such endeavors. An additional application of this study involves the influx of Koreans into the United States. According to the latest census statistics, there were over 1.2 million Koreans living in the USA in 2000. Korean-Americans currently rank as the
CHILDREN’S HEALTH IN SOUTH KOREA AND THE UNITED STATES
fourth largest Asian group in the USA, behind Chinese, Filipinos, and Indians. The population of Asian-Americans had increased by 72% in the preceding decade, although the overall population increase in the USA was just 13% for the same time period (Korean Southeast News, 2002). As a result, healthcare professionals working with this population in the USA must consider the unique blending of cultural backgrounds presented by Korean-Americans. In conclusion, healthcare systems in South Korea and the United States that emphasize prevention as intervention rather than illness care would
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further improve child health outcomes as the world’s citizens move through the 21st century. Educational programs for parents and communities aimed at strengthening the client system’s flexible and normal lines of defense would be crucial to such efforts. According to Neuman (2002), the teaching approaches that are selected must be tailored to the cultural characteristics of each group and cultural values weighed carefully when planning such educational programs. It is hoped that this assessment provides the starting point for nurses to initiate these activities in South Korea and the United States.
REFERENCES Annie, E. Casey Foundation. (2000). 2000 KIDS COUNT Data Online. Available at: http://www.aecf.org/kidscount/ kc2000/summary/htm, Accessed March 9, 2001. Asian-Americans increased by 72% last 10 years. (2002, March 14). The Korean Southeast News, p. 15. Chang, C.S., & Chang, N.J. (1994). Korean management system. Westport, CT: Quorum Books. Chang, C.S., Chang, N.J., & Freese, B.T. (2001). Offering gifts or offering bribes? Code of ethics in South Korea. Journal of Third World Studies, 18, 125-139. Coffman, J.E., & Sullivan, T.A. (1999). United States. In World book millennium 2000 (Version 4.0) [Computer Software]. New York: World Book, Inc. & IBM, Inc. Forum on Child and Family Statistics. (n.d.). America’s Children: Key Indicators of Well-being, 2000. Available at: http://childstats.gov/ac2000/highlight.asp, Accessed March 9, 2001. Lee, C.S. (1999). Korea. In World book millennium 2000 (Version 4.0) [Computer Software]. New York: World Book, Inc. & IBM, Inc. Ling, C.S. (1999). Divorce rate in Korea. Korean Times, August 29, p. 3. Lowdermilk, D.L., & Perry, S.E. (2003). Maternity Nursing, 6th ed. St. Louis: Mosby. Ministry of Health & Welfare. (1996a). Infant mortality survey report. Seoul, Korea: Ministry of Health & Welfare.
Ministry of Health & Welfare. (1996b). Infant studies: Data from 64 hospitals. Seoul, Korea: Ministry of Health & Welfare. Ministry of Health & Welfare. (2001). Government support for the elderly welfare in 2001. Seoul, Korea: Ministry of Health & Welfare, p. 3. National Center for Injury Prevention and Control. (2000a). Injury mortality reports, 1998. Available at: http://www. cdc.gov/ncipc, Accessed March 9, 2001. National Center for Injury Prevention and Control. (2000b). Leading causes of death in the United States, 1998. Available at: http://www.cdc.gov/ncipc, Accessed March 9, 2001. National Office of Statistics. (1996). Annual report on the causes of death. Seoul, Korea: National Office of Statistics. National Office of Statistics. (1999a). Annual report on the causes of death. Seoul, Korea: National Office of Statistics. National Office of Statistics. (1999b). Annual report on the vital statistics. Seoul, Korea: National Office of Statistics. Neuman, B. (2002). The Neuman systems model. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (pp. 3-33, 4th ed. Upper Saddle River, NJ: Prentice Hall. Park, Y.J. (1998). A study of teen’s pregnancy, abortion, and delivery. Journal of Korean Nursing, 28, 573-582. Public Health Office. (1998). Health insurance status report. Seoul, Korea: Public Health Office. Public Health Office. (1999). Immunization status of Korean children. Seoul, Korea: Public Health Office.
In recent decades, great strides have been made globally in decreasing child mortality. However, given that many countries still do not have basic healthcare, additional emphasis is being placed on health promotion activities among industrialized nations. As cultural differences of individual countries impact these health promotion practices, the cultural characteristics influencing children and families in two countries, South Korea and the United States, were compared. Major child health risk factors were examined, and health retention strategies tailored to the cultural characteristics and needs of the populations of each country are proposed, using the Neuman Systems Model as a guideline. © 2003 Elsevier Inc. All rights reserved.
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hild mortality has dropped dramatically throughout the world in recent decades. Deaths due to major health problems such as communicable diseases, circulatory problems, and cancers have decreased, resulting in increased life expectancy for children born at the beginning of the 21st century. With these changes in the world’s health status, healthcare practitioners are shifting their focus to one of health retention and promotion rather than one of cure. Cultural beliefs influence healthcare policies and decisions; culture exerts a significant force on children’s care and health promotion activities. Cultural differences of individual countries impact children’s health education and child health promotion practices. These educational and health promotion practices in turn affect the level of health of children in these countries. Additionally, the steady increase in the KoreanAmerican population in the United States brings with it an increased probability that healthcare workers will interact with these families. The purpose of this article is to compare selected child health risk factors and cultural characteristics that impact the health retention activities of children and families in two countries, South Korea and the United States of America (USA). Following this comparison, nursing interventions for improving child health that are tailored to the cultural characteristics of each country will be proposed.
Journal of Pediatric Nursing, Vol 18, No 6 (December), 2003
CONCEPTUAL FRAMEWORK According to the Neuman Systems Model (Neuman, 2002), the client is an open system in constant interaction with the environment. This client system can be an individual, a family, a group, or a community and is composed of five intertwined variables, including a sociocultural variable. Neuman notes that various stressors originate from the environment and attempt to penetrate the client’s defenses and thereby alter the client’s level of wellness. The client’s defenses include a flexible line of defense that serves as a buffer to these environmental stressors, the normal line of defense that is the composite of healthy behaviors over time, and the lines of resistance that are the resources that protect the integrity of the basic structure of the client. In a Neuman context, nursing consists of prevention activities directed at three different points in the stressor-client encounter— primary, secondary, and tertiary prevention as intervention. Primary prevention strategies focus on health retention and are aimed at reducing the possibility of stressor encounter and at strengthenFrom Lander University, Greenwood, South Carolina and Yonsei University, Wonju, South Korea. Address correspondence and reprint requests to Betsy M. McDowell, PhD, RN, CCRN, 320 Stanley Avenue, Lander University, Greenwood, SC 29649. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 0882-5963/03/1806-0000$30.00/0 doi:10.1016/S0882-5963(03)00159-3 409
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ing the client’s flexible and normal lines of defense (Neuman, 2002). For the purposes of this study, the children in South Korea and in the United States comprise the client systems. The basic core of each of these client systems includes the cultural characteristics of the specific populations. Each population has risk factors for stressor encounter that result from these cultural characteristics. Once these culturespecific risk factors are identified, prevention as intervention strategies can be tailored to accommodate these differences. DEMOGRAPHIC CHARACTERISTICS OF SOUTH KOREA AND THE UNITED STATES In comparing South Korea and the United States on geographic and population characteristics, several contrasts become obvious (Table 1). In 1999, South Korea had a population of almost 47 million (Lee, 1999), with 14.2 million (30.2% of the population) being infants and children up to 19 years of age, with slightly more boys than girls. The Table 1. Demographic Characteristics of South Korea and the United States South Korea
United States
● Total Population—almost 47 million people in 1999 ● Population ⱕ 18 years old— 14.2 million (30.2% of total population), with slightly more boys than girls ● Average Life Expectancy—73.5 years ● Land Area—about 1/100th the size of the United States or a little larger than the state of Indiana ● Population Density—475 persons per sq. km or 1230 persons per sq. mile ● Economy—Industrialized; free enterprise system ● Government—Republic with a president elected by the people; personal freedoms valued
● Total Population—over 270 million people in 1999 ● Population ⱕ 18 years old—70.2 million (26% of total population)
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● Average Life Expectancy— 74.9 years ● Land Area—3,615,276 sq. mile or 9,363,520 sq. km
● Population Density—29 persons per sq. km or 76 persons per sq. mile ● Economy—Industrialized; free enterprise system ● Government—Federal form with a president elected by the people; personal freedoms valued Education—Kindergarten ● Education—Kindergarten through post-secondary; through post-secondary; technical education available technical education available Literacy Rate—90% ● Literacy Rate—80% Location of Population—Majority ● Location of Population— urban; seven large cities with Urban or suburban areas over 1 million population each; rather than in rural areas; automobiles and mass estimated 75 cars per 100 transportation utilized population Religion—Confucianism, ● Religion—Christian 90% Buddhism, and Christianity
country covers an area about 1/100th the size of the USA or a little larger than the state of Indiana. Its population density in that same year was 475 persons per square kilometer or 1230 persons per square mile (Lee, 1999). The United States of America had a population of over 270 million in 1999 (Coffman and Sullivan, 1999), including 70.2 million infants and children under age 18 years, making up slightly more than a fourth (26%) of the total population (Forum on Child and Family Statistics, n.d.). The United States covers over 3.6 million square miles and had a population density of 29 people per square kilometer or 76 people per square mile in 1999 (Coffman and Sullivan, 1999). Although South Korea and the United States are not similar in geography and population, they do share several other characteristics in common. The average life expectancy at birth in both countries is relatively high, with South Koreans living for 73.5 years (Ministry of Health & Welfare, 2001) and with Americans living an average of 74.9 years. Both countries have democratic governments and value personal freedoms, such as freedom of religion and freedom of speech. Education is important in both countries and children have numerous opportunities for secondary and post-secondary education. The literacy rate in the United States is estimated to be at least 80%, and the literacy rate in South Korea is noted to be closer to 90%. Until the early 1900s, agriculture was the basis for the economy in both countries, but now they both are industrialized nations. South Korea and the United States are trading partners. The large majority of people in both countries live in urban or suburban areas rather than in rural areas so that automobiles and mass transportation are a fact of life. However, traffic jams and pollution also characterize life for most of the citizens of both countries who live in urban areas. COMPARISONS OF CHILD HEALTH RISK FACTORS Seven child health risk factors were compared for each country: (1) low birth weight babies; (2) infant mortality; (3) child mortality; (4) teen deaths due to accidental injuries, suicides, and homicides; (5) teen births; (6) childhood immunizations; and (7) children with no health insurance (Table 2). These parameters were chosen because they are nationally accepted indicators of child well-being (Annie E. Casey Foundation, 2000; Forum on Child and Family Statistics, n.d.) and reflect Neuman’s sociocultural variable. Data for this study
CHILDREN’S HEALTH IN SOUTH KOREA AND THE UNITED STATES Table 2. Child Health Risk Factors Low Birth Weight Babies Infant Mortality Child Mortality Teen Deaths Due to Injuries, Suicides, and Homicides Teen Births Childhood Immunizations Children With No Health Insurance
were taken from several governmental and nongovernmental sources and reflect the most current data available for each risk factor. Where possible, data from the same years were compared, although this was not possible in every instance. Many of the risk factors included here, however, were developed from samples, and like all sample data, a certain amount of random error may be included.
Low Birth Weight Babies The first child health risk factor to be compared was the percent of low birth weight babies. Babies weighing less than 2500 grams or 5.5 pounds at birth have a high probability of experiencing developmental problems, some of which can last a lifetime. Therefore, the percent of low birth weight babies reflects a group of children who are at risk for problems as they move through the growth stages (Lowdermilk and Perry, 2003, p. 483). The percentage of low birth weight babies in South Korea steadily decreased from 12.8% in 1980 to 9.8% of all live births in 1996 (Ministry of Health & Welfare, 1996b). (Accurate data for 1999 were not available due to lack of mandatory reporting of births in that country.) Most Korean women receive prenatal care provided by public health nurses, and a large number of the deliveries occur in the hospital, probably contributing to this decline in low birth weight babies. However, the percent of low birth weight babies in the United States increased from 6.8% in 1985 to 7.6% of all live births in 1998 (Forum on Child and Family Statistics, n.d.). This increase in the number of low birth weight infants in the USA is partly due to an increase in the number of multiple births and also may reflect an increased use of induction, Cesarean section, and other operative procedures with highrisk pregnancies. However, the increase in low birth weight infants in the USA also raises a number of troubling issues, including the possibility of declining health of American mothers, particularly teen mothers (teen birth rate 30 per 1000 females ages 15 to 17 years), the absence of health insurance, and the influence of inadequate prenatal care.
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Infant Mortality Because the first year of life is more precarious for infants than later years, negative social conditions such as low socioeconomic status, less than a high school education, poor nutrition, smoking, substance abuse, inadequate prenatal care, and excessive lifestyle stressors have a significant impact on this vulnerable group (Lowdermilk and Perry, 2003, pp. 650-651). Children born to families with fewer advantages are more likely to experience health problems at an early age. Therefore, the second child health risk factor to be examined was infant mortality. In 1999, the infant mortality rate of 7.7 per 1000 live births in South Korea (Ministry of Health & Welfare, 1996a) was slightly higher than in the United States, where the rate was 7.2 infant deaths per 1000 live births in 1998 (Annie E. Casey Foundation, 2000). Such rates in both countries may reflect large numbers of low-income families, infants born to parents with low educational attainment, and infants who would have died before or during birth but survived past the neonatal period due to aggressive neonatal intensive care programs. By the end of the 20th century, the leading causes of infant deaths were similar in South Korea (National Office of Statistics, 1996) and the United States (National Center for Injury Prevention and Control, 2000b). Perinatal disease accounted for the most infant deaths in South Korea, whereas congenital anomalies were first in the USA. The second leading cause of infant death was listed as congenital anomalies in Korea and problems resulting from short gestation in the USA. Sudden infant death syndrome (SIDS) was the third cause of infant deaths in both countries. Heart disease was the fourth leading cause of infant deaths in South Korea and maternal complications was fourth in the USA. Pneumonia rounded out the top five for South Korea, and respiratory distress syndrome was fifth in the USA. Surprisingly, car accidents were the sixth leading cause of infant death in South Korea but were not found among the top 10 causes of death of American infants. Minimal use of child safety systems in cars by Korean parents probably influenced this finding.
Child Mortality Once children survive the first year of life, their mortality rate drops sharply. The child death rates for both South Korea and the United States have decreased significantly in the last two decades.
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Nevertheless, the rate of child deaths between 0 and 14 years of age in South Korea (57 deaths per 100,000 children) (National Office of Statistics, 1999b) remains much higher than the rate of child death in the USA in the 1 to 14 year age group (25 deaths per 100,000 children) (National Center for Injury Prevention and Control, 2000b). These statistics must be viewed with caution, however, because the Korean data include infant deaths in the child death figures, but child deaths are reported separately from infant deaths in the United States. The causes of childhood deaths include some similarities as well as some differences by country. Motor vehicle accidents (MVAs) resulting from no child restraint systems accounted for more deaths of Korean children (National Office of Statistics, 1999a), and unintentional injuries accounted for more deaths of American children than the other four causes combined in each country (National Center for Injury Prevention and Control, 2000b). The remaining mechanisms of death differ by age group for each country. In the 1- to 9-year-old age group, drowning was the second leading cause of death and congenital anomalies were third in South Korea (National Office of Statistics, 1999a). In the USA, malignant neoplasms were second and congenital anomalies were third in this age group (National Center for Injury Prevention and Control, 2000b). Falls were the fourth leading cause of childhood deaths followed by leukemia at fifth place in South Korea (National Office of Statistics, 1999a). In the USA, homicides were the fourth and heart disease was the fifth leading cause of childhood death (National Center for Injury Prevention and Control, 2000b). For Korean teenagers, motor vehicle accidents lead the list followed by suicides, drowning, leukemia, and heart disease (National Office of Statistics, 1999a). Among adolescents in the United States, unintentional injuries were first, followed by homicides, suicides, malignant neoplasms, and heart disease (National Center for Injury Prevention and Control, 2000b).
Teen Deaths Due To Accidental Injuries, Suicides, and Homicides If the teen deaths due to accidental injuries, suicides, and homicides for each country are examined, several contrasts appear between the United States and South Korea. Traumatic deaths occurred at a rate of 11 deaths per 100,000 teens between 15 and 19 years of age in South Korea in 1996 but had jumped to 34 deaths by 1999 (Na-
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tional Office of Statistics, 1999a). In contrast, in the USA, the rate was down from 62 deaths to 58 deaths per 100,000 teens/young adults between 15 and 19 years old due to these causes in the same time frame (National Center for Injury Prevention and Control, 2000a). Accidental teen deaths in South Korea are primarily from cars, drowning, and falls (National Office of Statistics, 1999a), whereas in the USA, motor vehicle occupant injury, drowning, poisoning, firearms, and other transportation accidents are the main causes of accidental teen deaths (National Center for Injury Prevention and Control, 2000a). In South Korea, teen suicides are generally by chemical insecticide, suffocation, or falls from high structures (National Office of Statistics, 1999a), whereas teen suicides in the USA are by firearms, suffocation, or drugs (National Center for Injury Prevention and Control, 2000a). Suffocation, stabbing, and striking are the primary means of teen homicides in South Korea (National Office of Statistics, 1999a), whereas firearms are responsible for over 82% of the teen homicides in the USA. Korean adolescents consider education as their first priority, so that very few social problems such as drugs, alcohol, or drunk driving are found in South Korea (Chang, Chang, & Freese, 2001). However, stress from the demand for high educational performance is a major contributing factor to the rate of teen suicides in South Korea. Because gun ownership by private citizens is not permitted in South Korea, gunshot injuries are not a cause of teen deaths in that country (Chang, Chang, & Freese, 2001).
Teen Births Both American and South Korean societies consider teenage childbearing problematic, although the rates of teen pregnancy are drastically different in the two countries (Annie E. Casey Foundation, 2000; Chang and Chang, 1994). Most teen mothers are unmarried and under the age of 18 years. Many of these mothers have not completed high school, have difficulty finding a stable job, and have relatively low financial resources. The children of single teenage mothers typically drop out of school, become unwed mothers themselves, and are on welfare (Annie E. Casey Foundation, 2000). According to 1998 data in South Korea, there were 2.7 unmarried teenage mothers per 1000 females between 15 and 19 years old (Park, 1998). The teenage birthrate in the United States for 15- to 17-year-old females was 30 per 1000 in 1998 (Forum on Child and Family Statistics, n.d.). These
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statistics present even more of a divergence because the Korean figures cover a 5-year age span, whereas the USA figures address only a 3-year age range. This startling contrast may be explained by the fact that premarital sex is not accepted by the Korean culture; Confucianism is a dominant ethical/moral belief there and strongly discourages this behavior (Chang and Chang, 1994). Historically in Korea, a wife could be divorced for not being a virgin, but a husband could not (Ling, 1999).
Childhood Immunizations The percent of 2-year-old children who are fully immunized was chosen as a reflection of a country’s preventive health concern for its children. Immunizing the population against communicable diseases is a basic primary prevention strategy used by industrialized countries. By 2 years of age, American children are considered to be fully immunized if they had received vaccines against hepatitis, diphtheria, pertussis, tetanus, polio, measles, mumps, and rubella. The Korean immunization program is similar to that of the United States, but it includes the BCG vaccine against tuberculosis, a primary health problem in Korea for many years. In comparing the two countries, South Korea was noted to have a higher percentage (97% in 1999) of its 2-year-olds who were fully immunized (Public Health Office, 1999) than did the USA in the previous year (81% in 1998) (Annie E. Casey Foundation, 2000).
Children With No Health Insurance The final child health risk factor to be examined was the percent of children with no health insurance. Because access to healthcare is dependent on the financing of healthcare, the percentage of uninsured children reflects the value society places on preventive healthcare. Since insurance is the only accepted method of payment for healthcare in South Korea, all children (in fact the entire population) have been covered by health insurance since 1997, 3% by government insurance plans and the remaining 97% through personal insurance policies (Public Health Office, 1998). In contrast, 15% or 10.5 million American children under age 18 were not covered by some form of health insurance in 1998 (Annie E. Casey Foundation, 2000). Of the children who were covered by some form of health insurance, over 70% had personal insurance policies and over 20% were receiving public assistance through Medicaid or other governmental programs.
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NURSING INTERVENTIONS FOR IMPROVING CHILD HEALTH Both South Korea and the United States have areas of strength and areas for improvement for the child health risk factors that were examined previously. Both countries have a relatively low percentage of babies born who are underweight, although the American data reflect an increase in this percentage in recent years rather than a decrease as expected. Additionally, the decrease in infant mortality rates in both countries may reflect an emphasis on high-quality care for infants in the first year of life. Several nursing implications are evident as a result of these comparisons (Table 3). Because of the proven positive influence on fetal development, programs promoting early and coordinated prenatal care plus reduction in use of harmful substances such as tobacco, alcohol, and illegal drugs during pregnancy should be encouraged in the United States as primary prevention strategies. This is consistent with Neuman’s view of prevention as intervention (Neuman, 2002). Such programs have the potential to significantly decrease the rate of low birth weight as well as the rate of infant mortality in these countries. Educational programs about parenting and risk reduction that target teen mothers also may positively influence these statistics. Continued research aimed at the prevention of SIDS would also decrease the infant mortality rate in both countries. The relatively high rate of childhood deaths in South Korea from preventable accidents and the number of child deaths that could be prevented if child restraint systems were emphasized should be priority concerns for the Korean people. Educational and primary prevention programs aimed at decreasing child deaths due to preventable accidents could further decrease these numbers in both countries. Each community could analyze local mortality and morbidity statistics and then coordinate system-wide changes specific to its problem areas and resources. Nurses are in key positions to develop and implement such programs. Decreasing teen access to firearms, alcohol, and drugs would be a primary prevention action to lower the number of teen deaths from unintentional as well as intentional injuries in the United States. Alcohol is a contributing factor in many teen deaths from motor vehicle accidents; states are encouraged to take measures to reduce drinking and driving in an attempt to decrease the numbers of vehicular-related deaths and injuries (National Center for Injury Prevention and Control, 2000a).
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MCDOWELL, CHANG, AND CHOI Table 3. Suggested Primary Prevention Strategies Low Birth Weight Babies ● Continue current activities that have been effective in both countries ● Increase the use of strategies to decrease teen pregnancies in the USA ● Promote increased utilization of early and adequate prenatal care for American mothers ● Implement peer programs to reduce substance abuse (smoking, drinking, and illicit drugs) ● Increase health insurance coverage for all American children Infant Mortality ● Continue current activities that have been effective in both countries ● Facilitate access to health care for low-income families in both countries ● Increase the educational level of families in both countries ● Continue research in ways to improve outcomes of care for high-risk neonates in both countries ● Educate teen mothers on childrearing practices and risk reduction strategies ● Foster research to prevent SIDS in both countries ● Increase use of child safety systems, particularly in South Korea Child Mortality ● Continue current activities that have been effective in both countries ● Increase the use of child safety systems, particularly in South Korea ● Educate families on ways to decrease preventable accidents in both countries Teen Deaths Due to Injuries, Suicides, and Homicides ● Continue current activities that have been effective in both countries ● Decrease access to firearms, alcohol, and drugs in the USA ● Provide stress reduction programs for Korean teens Teen Births ● Continue current activities that have been effective in both countries ● Implement educational programs to empower American teens to make smart choices related to sex and pregnancy ● Encourage early and adequate prenatal care in the USA Childhood Immunizations ● Continue current activities that have been effective in both countries ● Promote health insurance coverage for immunizations in the USA ● Emphasize the benefits of childhood immunization in the USA Children With No Health Insurance ● Continue current activities that have been effective in both countries ● Promote health insurance coverage for all American children
Koreans hold education in high esteem, because whether or not a high school graduate is admitted to a prestigious college is an overriding priority for most Korean families (Chang, Chang, & Freese, 2001). As a result, teenagers in South Korea develop high levels of stress related to school and college acceptance and performance. As extreme stress is a major determinant of the rate of teen suicide, strategies to decrease the high amount of stress adolescents experience are critical to reducing the incidence of teen suicide in that country. Nurses could conduct community assessments of teen needs in individual communities, teach stress management techniques to high-risk groups, and advocate for increased suicide prevention programs. Traditional Korean cultural beliefs are probably the biggest factor in the low rate of teen pregnancies in that country; the rate of teen pregnancies in South Korea may begin to increase as more Western views are adopted by Korean teens. Because premarital sex and teen pregnancy are widely accepted in the USA, effective educational programs
aimed at empowering teens to make smart choices about these issues are desperately needed. Additionally, encouragement for early prenatal care may be effective in decreasing the rate of teen pregnancy and ultimately in decreasing the rates of low birth weight babies and infant mortality in the USA. Nurses are pivotal in planning and implementing such programs. As for the financing of children’s healthcare, Americans could follow the Korean example with respect to health insurance coverage for all children. Provision of health insurance and more educational programs that emphasize the benefits of childhood immunization may increase the child immunization rate in the United States to a rate comparable to that of South Korea (Annie E. Casey Foundation, 2000). Again, nurses would be valuable partners in such endeavors. An additional application of this study involves the influx of Koreans into the United States. According to the latest census statistics, there were over 1.2 million Koreans living in the USA in 2000. Korean-Americans currently rank as the
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fourth largest Asian group in the USA, behind Chinese, Filipinos, and Indians. The population of Asian-Americans had increased by 72% in the preceding decade, although the overall population increase in the USA was just 13% for the same time period (Korean Southeast News, 2002). As a result, healthcare professionals working with this population in the USA must consider the unique blending of cultural backgrounds presented by Korean-Americans. In conclusion, healthcare systems in South Korea and the United States that emphasize prevention as intervention rather than illness care would
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further improve child health outcomes as the world’s citizens move through the 21st century. Educational programs for parents and communities aimed at strengthening the client system’s flexible and normal lines of defense would be crucial to such efforts. According to Neuman (2002), the teaching approaches that are selected must be tailored to the cultural characteristics of each group and cultural values weighed carefully when planning such educational programs. It is hoped that this assessment provides the starting point for nurses to initiate these activities in South Korea and the United States.
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