Introduction and background

Globally, people have specific cultural practices related to nutrition, education, and health, including childrearing. Culture plays a significant role in all spheres of healthcare. Cultural practices, as an integral part of childrearing, remain a significant aspect that healthcare professionals should consider to ensure culturally sensitive care to infants and parents, particularly in the neonatal intensive care unit (NICU) [1]. The search for a universally accepted definition of culture has lasted for decades [2]. Culture is a multifaceted concept that encompasses more than just people’s daily routines and refers to the country’s associated or defined collection of commonly held features, such as traditional beliefs, values, and social practices, which influence the lives of the community [3,4,5]. Furthermore, culture is a complex social matrix characterised by “cultural determinants,” which refer to the features or factors that primarily distinguish one culture from another and shape ways of perceiving and accessing the world [3].

Cultural beliefs and practices influence how parents use healthcare services and interact with healthcare professionals. A study conducted in Ghana has shown the significant relationship between the cultural practices, norms, beliefs, and behaviours that influence maternal and child healthcare [6]. Furthermore, covert cultural practices are more likely to have detrimental health consequences when taken for granted [7]. Consequently, there is a need to understand the cultural practices, and beliefs, influencing maternal and child healthcare in hospital settings to enhance culturally sensitive healthcare services.

Childrearing in a cultural context is a unique practice, according to specific cultural customs and norms guiding parents and families’ behaviours [8]. Parental transformation and parent-infant interactions are dynamic, and the processes become complicated when there are preterm infants involved. Furthermore, parent-infant interaction is primarily shaped by specific cultural practices, beliefs, and caregiving contexts [8].

Preterm infants are babies born alive before the completion of the 37 weeks of pregnancy [9]. Health conditions of preterm infants often require hospital admission in neonatal intensive care units and later neonatal wards [10]. Furthermore, care of preterm infants during hospitalisation requires parental involvement [11].

Although studies have demonstrated the importance of integrating cultural practices into healthcare services, there has been no formal process of integrating cultural practices or beliefs into neonatal care. Furthermore, no study has explored and comprehensively synthesised the literature on the possible integration of cultural determinants into preterm infant care in the NICU. Thus, this paper aims to conduct an integrative literature review to synthesise whether there could be cultural determinants to be integrated into the care of preterm infants in the NICU as an intervention to ensure and promote culturally sensitive care.

Materials and methods

The conducting of the current integrative literature review was in accordance with a registered and published protocol on PROSPERO, Reg. No: CRD42021283895 [12]. In addition, the review adhered to a rigorous set of five steps for integrative review by Lubbe et al. [13], as deduced from authors such as Whittemore and Knafl [14], Toracco [15], Rusells [16], de Souza et al. [17]

Composition of review question

The PIOS model composed the review question [18]. PIOS is the mnemonic for the population (P), phenomena of interest (I), outcome (O) and setting (S) [19, 20]. In the context of the current review, P stands for the parent of preterm infants, I-cultural determinants, O-culturally sensitive care, and S-neonatal intensive care unit. The review question was, therefore, what is the best available published evidence on cultural determinants that could be integrated into preterm infant care in the NICU to ensure culturally sensitive care?

Sampling literature

Sampling of the literature was conducted in two steps, searching and screening, as described below.

Searching (scoping search and search strategy development)

The preliminary databases and PROSPERO searches revealed no previous or current reviews on the same topic. The search in EBSCOhost, PubMed, ScienceDirect, and Scopus databases was for published articles in September 2021 and again in October 2021 for updates. A comprehensive search was conducted in conjunction with the North-West University (NWU) librarian [21] using the Boolean operators [22]. Searching string included combinations of Medical Subject Heading terms and keywords: (preterm infant OR preterm baby OR premature infant OR premature baby) AND (cultural determinants OR cultural practice OR cultural factors) AND (parents OR mothers OR fathers OR caregivers) AND (neonatal intensive care unit OR NICU OR newborn intensive care unit). The search for unpublished studies (grey literature) used Google Scholar and Google. The integrative review focused on articles that discussed culturally sensitive care when caring for preterm infants. Articles published in English, between 2011 and 2021, met the inclusion criteria for screening. Articles published in the last 10 years or less are recommended for academic reference purposes [23]. There was a consideration of articles published in languages other than English if the abstract was in English. Excluded were studies published before 2011, and all articles addressing the generic care of preterm infants; the comprehensive search yielded 141 articles.

Screening

Three reviewers [MN, KDS, SSM] screened the articles to be included in the current review using EPPI Reviewer software, and the promotor [WL] served as the fourth reviewer, assisting in screening articles for which the three reviewers were unable to reach a consensus [23]. All retrieved articles (N = 141) were imported into EPPI Reviewer software for storage and screening. Before the screening process, the EPPI Reviewer software automatically identified 17 duplicated studies, which were eliminated. In total, there were 124 articles screened at the title level, and 44 articles excluded based on titles that were not relevant. If the title was unclear or provided an indication that it may address the review question, it was included for abstract screening. The abstracts of 80 included articles were screened to ensure they contained exact information pertinent to the discussion topic [24], and 20 excluded. No articles in non-English languages that matched the inclusion criteria based on the abstract screening were found, therefore, there was no translation required. Finally, the full text of 60 articles underwent screening for compliance with the eligibility criteria [25], and 40 excluded. All reviewers screened the reference lists of the included articles, but no new articles were added to the review. Armed with the content of 20 articles selected, based on full-text level, the reviewers justified the excluded studies. The reviewers documented the screening process using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (See Fig. 1) [26].

Fig. 1
figure 1

PRISMA 2020 flow diagram (Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. 2021)

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Critical appraisal

Critical appraisal is a systematic process for evaluating and determining the methodological quality of published studies [27]. Three reviewers evaluated the methodological quality of 20 (n = 20) identified and included studies at the full-text screening level using a John Hopkins Evidence-based Practice Appraisal tool to ensure transparency [28] and reduce the likelihood of bias [29]. The methodological quality appraisal step used EPPI Reviewer software. The choice of John Hopkins Evidence-based Practice Appraisal tool was because of its capability to assess the methodological quality of diverse study designs. All the disparities were resolved through discussion by the reviewers. Twenty (n = 20) articles were critically appraised; 14 (n = 14) were of high quality, five (n = 5) were of good quality, and one (n = 1) was of low quality. Based on the inclusion of articles rated as good or high quality, 19 (n = 19) articles were included as the final sample; one article was excluded based on the low methodological quality rating (see Table 1).

Table 1 Critical Appraisal
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Data extraction, synthesis, and analysis

Data extraction

Three reviewers [MN, KDS, SSM] manually extracted data using a standardised and pre-designed extraction tool [30]. The information on the extraction tool included author and year, aim/purpose, the population (sample size and characteristics), study context, methodology, and findings. There was no missing data, hence there were no authors contacted. The presentation of the extracted data was in a tabular format to enable data synthesis and analysis (see Table 2).

Table 2 Data extraction
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Data synthesis and analysis

Data synthesis is a process that entails the aggregation of specific data from various previous studies to develop new concepts or themes [31]. Braun and Clarke’s framework analysed the extracted data and translated the concepts from the identified studies into the current review, thereby evolving new theoretical perspectives that addressed the review question [32]. The data analysis was repetitive and used a step-by-step strategy. The initial step involved reading the extracted data multiple times to obtain an overall understanding of the data. As demonstrated in the data extraction table (see table 2), statements pertinent to the review questions were identified and underlined. The table matrix was used to document and synthesise the identified statements by facilitating the display of patterns and correlations of extracted data across sources (categorisation) [33,34,35]. Through a series of comparisons, reviewers established borders between the categories, and named and refined them. The iteration process focused on the extracted data as a whole and pertinent statement until reviewers found and agreed on the mutual final themes.

Results

Data synthesis and analysis from 19 articles (ten qualitative, three quantitative, five review and one mixed method articles) demonstrated the integration of cultural determinants into the care for parents of a preterm infant in the NICU. The 19 articles included represented 12 countries, each with their own distinct culturally based infant care approach. The 12 countries include Canada, China, Ghana, India, Iran, Jordan, Lebanon, Nigeria, Taiwan, Thailand, the United States of America, and Uganda. Although these countries were represented, the included studies only provided cultural information about a subset of the populations. The main themes identified are spiritual care practices, intragenerational infant-rearing practices, infant physical care practices, and combining treatment practices (see Table 3).

Table 3 Themes identified from data synthesis
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Spiritual care practices

Spiritual care has developed into a fundamental and significant component of comprehensive healthcare. The guide for spiritual care practices is an individual’s convictions, actions, emotions, and experiences to relate to the divine as a source of hope [36, 37]. For this review, spiritual care practices include religiously influenced feeding practices, religious observances, infant naming, and symbols of fortune.

Religiously influenced feeding practices

Two articles included in this review focused on religious considerations as part of the culture when discussing infant feeding practices. The term “feeding practice” refers to milk feeding methods, such as direct breastfeeding, donor milk, and formula feeding. One study stated that Jewish cultural considerations for milk kinship include that only a Jewish mother can be a milk donor to a Jewish preterm infant [34]. According to Islamic culture, a milk donor can be a mother from any culture but known to the parents of the recipient’s preterm infant [38]. Additionally, both studies [38, 39] stated that Jewish and Islamic cultures prohibit marriage between infants who share breast milk due to them considered as “milk kinship siblings”.

Religious observances

Parents primarily used prayer to request healing for their preterm infants and drew hope from the spiritual anchor. Five studies conducted in Jordan [40], Thailand [41], Taiwan [42], the United States [43] and Canada [44] found that parents prayed for spiritual protection and healing for their infants and were joined in their prayers by family members and healthcare professionals. Conversely, other studies [42, 43] demonstrated that some parents individually prayed for their infants but lacked the necessary privacy. With regard to dreadful news, such as the death of an infant, family members were the ones who communicated the bad news to parents through an introduction speech with spiritual content, which is regarded as the least painful way to receive difficult news [40].

Infant naming

Infant naming can be viewed positively or negatively depending on cultural practices and spiritual beliefs. A study by Candelaria et al. [39] pointed out that Jewish society values infant naming, with a male infant being named on the eighth day after birth and a female infant being given a Hebrew name in the temple on the first Sabbath following birth. In addition, a study by Cleveland et al. [43] revealed that addressing the infant by their first name establishes a meaningful connection between the parents and the infant and healthcare professionals. Conversely, from a different perspective, critically ill infants are not named in Jewish culture because their death would be negatively perceived if they did not survive [39].

Symbols of fortune

For centuries, fortune symbols have been integral to various cultural expressions associated with the spiritual belief that they bring good fortune. Studies indicate that fortune symbols were utilised with the belief that they conferred protection and brought luck to the retainer [42, 43, 45]. Although these studies relate to the function of fortune symbols, they all used different lucky items. For instance, in Ghana [45], wrist and neck bracelets are used to keep evil eyes away from the infant, and in Taiwan [42], parents hang a good-luck charm such as a Buddhist Dharma wheel in the incubator for protection against the devil. Additionally, Mexican Americans kept personal items such as blankets, bibles, family photographs, and clothing with the preterm infant, believing that the personal items would comfort the preterm infant and create a connection between the preterm infant and the family [43].

Intragenerational infant rearing practices

In this review, intragenerational infant rearing practice is a term that may refer to the process of caring for an infant within a family by the family to assist with daily care and influence parental behaviour and attitudes toward the next new parents. The main concepts that constitute intragenerational infant rearing practices are senior family members’ influences and family involvement.

Senior family members’ influences

In certain countries, the senior family members maintain a position of prominence within the family structure, retaining power and influence over the family, including infant rearing practices. The authors of the included articles revealed that in countries such as Ghana [45], Uganda [46], and Canada [44], senior family members, particularly elderly females, were involved in caring for preterm infants. For instance, grandmothers were reported to lead the daily care activities for preterm infants, such as bathing after hospital discharge [45, 46].

Furthermore, grandmothers culturally have power and influence over the care of preterm infants, even if in conflict with medical practice [45, 47]. For example, one of the Ghanaian parents reported that “When one day, I challenged my mother-in-law that she was not supposed to give my baby an enema, she got upset with me and called me ungrateful and disrespectful. I had to allow her to do her job because she has cared for eleven children” [45].

Family involvement

Family involvement offers comprehensive care for parents of preterm infants in relation to cultural practices. Seven studies conducted in Jordan [40], Taiwan [42], Canada [44], the United States [48, 49], Lebanon [50], and Iran [51] indicated that extended family members supplement the preterm infant’s care provided by parents. An example of this is family members assisting the parents with daily preterm infant care [40, 42, 44, 49] and decision-making contributions related to preterm infant care, preserving family values and cultural customs [50]; conversely, Iranian culture promotes family involvement, family members make negative and offensive remarks regarding preterm infants because Iranians do not perceive preterm infants as normal human beings [51].

Infant physical care practices

Physical care practices reflect the daily values and belief systems of families and their cultures within communities [48]. Infant physical care practices entail preterm infant bathing, infant massage, and infant cultural handling and position.

Infant bathing

Infant bathing is one of the cultural infant-rearing techniques practiced in different ways and for various reasons. Studies conducted in Ghana [45] and Uganda [46] reported that infants are bathed with water and traditional herbal concoctions to stimulate weight gain and protection from evil spirits. Additionally, bathing times vary, and it is common for infants to be bathed shortly after delivery in Ghanaian culture [47]. One study conducted in South India revealed that although most mothers bathed their infants on the delivery day, some infants were bathed two to seven days after birth; the authors did not provide specific reasons why the bathing of infants was on different days [52]. Another study found in Taiwan that infants who died in the NICU received a bath shortly after death [42].

Infant massage

Infant massage is a cultural practice that can be used to reduce pain and provide physiotherapy benefits. A study conducted in Lebanon [50] and India [52] reported that massage was with various oil-based products and that parents considered it a physiotherapy session for the infant. In the same vein, in China, another method of massaging is with the traditional touch called Yakson, in which parents caress their sick infant with their bare hands in the hope that their hands will alleviate the infant’s pain [53]. Furthermore, massage was reportedly a therapy to relax infants, boost their vagal activity and stomach motility, and eventually improve weight gain [54].

Infant cultural handling and positioning

Infant handling and positioning are meaningful on a cultural level. In the Nigerian culture, infant handling techniques, such as stretching infants’ limbs, aid neuro-motor development [55]; for example, the purpose of stretching limbs of infants aged 0–3 months was to ensure joint flexibility, bone strengthening, and alignment [55]. In Columbia, carrying infants on the chest facilitates kangaroo mother care; however, in certain cultures (authors did not specify), carrying infants on the chest rather than the back implies that the infant is ill or abnormal [47].

Combining treatment practices

Combined treatment practices may refer to the utilisation of traditional medical practices and western medical practices. Combining treatment practices in this review are the concurrent use of traditional and western medications to treat preterm infants.

Concurrent use of traditional and western medication

Evidence supports integrating cultural practices into modern treatments when caring for preterm infants. Two studies done in Uganda [46] and the United State [49] indicated that parents were incorporating cultural treatment practices into western medicine depending on the type and nature of the condition of the infant, as an example, some Lumbee parents in the United States would offer over-the-counter drugs for conditions such as fever, but the same parents would take their infant to their aunt to wash off the oral thrush with pieces of fatback and salt, which were effective [49]. Similarly, the Ugandan parents used chlorhexidine, which was better at dealing with foul umbilical cord smell than alternatives; however, the belief was that the use of kyogero, an herbal mixture, hastened umbilical cord separation [46]. Finally, in studies conducted in Canada [44] and India [56], parents indicated they would seek and implement medical treatment for their infant regardless of their beliefs in and use of home remedies.

Discussion and recommendations

The current review explored and synthesised evidence on integration of cultural determinants into caring for parents of preterm infants in the NICU. The review findings suggest it is possible to integrate cultural determinants, such as spiritual care practices, intragenerational infant-rearing practices, infant physical care practices, and intertwining treatment practices, into care of a preterm infant in the NICU as an intervention to ensure and promote culturally sensitive care.

The findings of this review demonstrate that utilisation of pooled human milk is culturally conditioned. Using human milk in Islamic societies necessitates the identification of the donor by the parents of the recipient to prevent future incest marriage between milk siblings; previous research noted similar findings [57, 58]. The findings contradicted those of the studies conducted in Malaysia [59], South Africa [60], France [61], China [61], and Spain [62]. Another cultural consideration is the prohibition of non-Jewish mothers from wet nursing Jewish infants. In the same vein, previous studies have indicated that Orthodox Jews may request breast milk from kosher-keeping mothers [63, 64]; the rationale could be that kosher-keeping donors follow the same religious dietary beliefs as the mother of the recipient. These conditions need consideration when using pooled human milk in the NICU to feed Islamic and Orthodox Jews preterm infants in a culturally appropriate way.

This review indicates that senior family members have the power to influence infant-rearing practices. The finding is in accordance with the previous evidence in which senior family members, such as grandmothers, were perceived as knowledgeable, experienced, and significant sources of support in infant-rearing practices [65,66,67,68,69,70]. An explanation for this result could be the cultural norm that the senior family member is typically the primary decision-maker in the family. Despite their influential positions, senior family members preferred cultural care practices rather than approved contemporary healthcare practices [71]. These findings could be an indication that senior family members should be engage in health programmes, such as education and counselling sessions regarding contemporary care practices, to ensure safe, culturally sensitive infant-rearing practices.

Integrating family into caring for a preterm infant in this review demonstrated the value of sustaining family and cultural practices as well as support. Literature suggests that this is a common occurrence [69, 72,73,74]. Conversely, previous studies established poor paternal support which led to the abdication of overall responsibility for infant care to mothers [75, 76]; this could be because in most cultural settings, fathers do not actively participate in the care of infants. Another explanation could be that certain families and cultures denigrate preterm infants, leading fathers to blame mothers for delivering preterm infants; for instance, a study conducted in Ethiopia described preterm infants using idioms and memes such as “little rat size and sick child” [75]. There is a need to discourage this unsupportive practice as it can lead to detrimental health outcomes such as stress, postpartum depression, and loneliness for mothers, consequently affecting the infant.

The practice of infant ritual bathing beliefs was an inheritance from the older generations. The current review found that Ghanaian and Ugandan parents perform the initial infant ritual bath at various times and with herbal medicine in the water. The findings corroborate previous research, which indicated that bathing should begin within six hours of delivery [77,78,79], within one week [80], and on day 9 or 11 with turmeric [81]. The performing of ritual bathing was for various reasons, including removing sperm and blood, alleviating odour, strengthening the infant, and preventing sickness in the infant [81, 82]. While acknowledging the various cultural bathing times, the recommendation is to delay the first infant bath for a full day [83]; however, if this is not possible for cultural reasons, the bath needs delaying for at least six hours to improve infant-maternal bonding and prevent hypothermia, hypoglycaemia, and dry skin [83]. To address infant bathing beliefs and values, the NICU healthcare professional should enquire with the parents regarding their preference in terms of infant bathing.

The practice of massaging an infant is an old phenomenon. In this review, the massaging of the infant in Lebanon and India was with oil-based products. There were similar findings observed in studies conducted in Pakistan [84], India [85, 86] sand Nepal [87]. Like in China, Yakson therapy as reported in the current review, gentle physical contact plays a significant role in healthy development [88]; additionally, the review indicated that infant massage therapy had beneficial health effects. Consistent with this finding, infant massage has shown to promote motor development [79] and weight gain in preterm infants [89], therefore, healthcare professionals should consider integrating infant massage sessions for preterm infants into the NICUs, guided by the cultural backgrounds of the parents.

In most cultures, it is culturally accepted to use traditional medicine [90, 91]. The review indicates that parents exhibited dualistic responsibility to care for the infant, both culturally and medically. Similar findings emphasise that parents initially used traditional home remedies before seeking medical treatment [69]. On the same note, literature further reported the use of traditional drying agents, such as ashes, soot, and cow dung [92], charcoal, powder, and dust [93] were to facilitate umbilical cord dryness, while chlorhexidine was seen to prolong the separation. In this review, United State Lumbee, Ghanaian, India, and Ugandan parents demonstrated the belief that both medical and traditional medicine contribute equally to the care of infants. While acknowledging cultural practices, harmful practices, such as applying ashes, cow dung, and dust needs to be discouraged as they pose a risk of infection.

Infant naming is rooted in specific rituals and practices and regarded as a significant affair with varying cultural connotations [94]. The review noted that Jewish infants receive names on specific days following birth to commemorate religious observances. Previous research has indicated a strong association between infant naming practice and spirituality [95]. The association could be that the infant names are more indicative of their family ties, the tribe of origin, and religious affiliations. Infant naming can occur a few days after birth [96]; this delay in naming could be due to the consultation of senior family members for advice and approval. Furthermore, the review revealed that Jewish culture prohibits naming of a critically sick infant due to its negative perceptions, particularly if the infant dies. Two studies [97, 98] made similar findings, emphasising that infant naming, even of an alive infant, can result in negative consequences, such as discrimination, bullying, and teasing by friends and peers. Therefore, to integrate culturally based infant naming practice, the care team should ask parents how and when will they like to name their infants.

Religious beliefs are an integral and significant part of a culture. The review found that parents from Jordan, Thailand, Taiwan, the United States and Canada relied on prayer and entrusted God for spiritual comfort and infant healing. The current review findings are consistent with previous research [99,100,101,102,103]. A study conducted in India reported that prayer was the daily religious and spiritual routine geared towards the admitted infant for healing [99]; this suggests parents use religious beliefs or beliefs in God as one of the coping mechanisms during an infant’s stay in the NICU. Therefore, parental religious and spiritual needs should be integrated into preterm infant care to construct a culturally sensitive and informed support structure for parents of preterm infants in the NICU. The NICU healthcare professionals could implement this by informing the religious parents of areas that are designated for prayer within the hospital premises, e.g. hospitals chapel building.

The use of lucky items is practiced in certain cultures. The current review found that in Ghana, religious objects were kept with the infant to prevent misfortune against the infant while Mexican Americans parents used personal belongings as a source of comfort to the infant. Similar findings were reported by two studies which documented that the parents employed traditional applicants for the infants to prevent illness and cast evil spirits; examples of lucky items used include neck, ankle, and wrist bands [102, 104]. Healthcare professionals in NICU settings need to be culturally sensitive when attending to newborns with these lucky items.

The review a study done in Nigeria indicates that infant positioning and handling had health benefits for the infant. Previous studies reported similar findings [105, 106]. Examples include stretching limbs, holding the infant tight on the mother’s chest or back, shushing, swaddling, and lying in a prone position [107, 108]; however, while other culturally accepted positions were beneficial, they also pose a health risk to the infant. Swaddling, for example, has been shown to reduce cold exposure and improve sleep patterns [108, 109], but it is also a significant risk factor for hip dysplasia [110]. Furthermore, carrying infants on the chest is known as the “kangaroo mother care position,” however, the review found that in other cultures not specified by the author, it denotes the condition of the infant, such as being ill or abnormal. There were no previous similar findings identified, which may imply that less is known about chest carrying positions or handling practices in other cultures, which warrants further research.

Conclusion

The current review provides significant insights regarding the integration of cultural determinants of parents into the care of preterm infants to improve culturally sensitive healthcare services. The findings highlight that most infant-rearing practices are influenced by or based on spiritual care, intergenerational infant-rearing practices, physical care, and combining traditional and western treatment. All cultural practices must be safe for use when providing healthcare services, however, the review revealed that certain cultural practices are not always safe, even though they may be significant to the parents’ cultural beliefs. Such unsafe practices should therefore be discouraged. Consequently, there is a need for parents and families to be educated on safe cultural practices, for healthcare professionals to be educated on the safe integration of cultural determinants of parents into preterm infant care in the NICU, and for healthcare policies to serve as guidelines for culturally sensitive healthcare services that are well-balanced with infant safety. However, a gap exists on how integration of cultural determinants in NICU setting can be implemented. Therefore, further research is recommended to develop a conceptual framework or model on how best can cultural practices be integrated in NICU care approach to ensure comprehensive culturally sensitive care.