Cultural Diversity among Elders in the US: Meeting the Challenge of the Ethnogeriatric Imperative

America's Ethnogeriatric Imperative

Demographers, teachers, and reporters have made the vision of the bulge in the population pyramid that is approaching the age of Social Security and Medicare benefits familiar to the American public and the public health community. Its predicted influence on health care is frequently referred to as “the geriatric imperative.” Not so familiar, however, is the recognition that this bulge of older Americans represents an increasingly diverse population—diverse in many ways, but especially in their ethnic background, so that, in reality, the imperative is an ethnogeriatric one.

The ethnic population categories for which data are available are those used by the census and other federal agencies, designated as the “ethnic minority” populations. The projected growth of the number of elders from those categories from 2000 to 2050 is included in Table 1 . The categories considered “races” by the US Census are American Indian and Alaska Native, Asian, Pacific Islander, black or African American, and white; Hispanics or Latinos can be of any “race,” as defined by the census, so that the separation by Hispanic and non‐Hispanic is necessary for each racial group. Projections are that more than one in three of the projected 80 million elders will be from one of the “ethnic minority” categories by mid‐century and that all are growing more rapidly than non‐Hispanic whites (Federal Interagency Forum on Aging Related Statistics 2000).

Table 1 Relative size of older ethnic minority populations in the US 2000 & 2005

Although the projections for the growth of elders in these populations are impressive, it drastically underrepresents the diversity the US will increasingly experience. Within each of these populations designated as ethnic minority is a vast heterogeneity. Among the rapidly growing set of elders in the Hispanic/Latino designation, for instance, the most numerous are those who describe themselves as Mexican, and smaller proportions from Puerto Rico and Cuba. But in addition, Hispanic/Latino elders are from seven different countries in Central America, ten in South America, and from Spain.

Soon to be the second largest minority population are elders who describe themselves as black or African American. While US‐born African American elders make up the vast majority, immigrants from the Caribbean and from Somalia, Nigeria, and other African nations are also part of this category and will make up a growing proportion as they age. As is true in all of the population categories, large and important differences exist among African American elders in education, rural/urban background, income, occupation, religion, family support, living arrangements, health and functional status, and almost all other variables that affect public health concerns.

It is particularly important to recognize the heterogeneity among older Asian and Pacific Islander Americans as their cultural traditions originate in countries that span more than half the globe, and frequently have very little in common with each other, in spite of the common usage of term “Asian” to designate individuals in this category. Table 2 illustrates some of the heterogeneity of these populations.

Table 2 Asian and Pacific Islander American elders 65 and over, 2000

The unique and frequently unrecognized differences also apply to elders from American Indian background. There are over 500 federally recognized tribes in the US, and many smaller groupings known as bands or rancherias, most of whom have their own specific histories and cultures. More American Indian elders than those from other racial categories described themselves as being from more than one race when they had that opportunity in the 2000 census, which emphasizes the diversity in acculturation among this group. Another important source of diversity is the difference in types of communities in which they live. In spite of the stereotype of Indians on remote reservations, more Indian elders are now in urban areas than on reservations, which means that they have less access to Indian Health System resources.

Elders in the “white” non-minority population are also very ethnically diverse. In addition to those from Northern and Western European backgrounds usually associated with the white designation, increasing numbers of elders in the US are from Arab and other countries in the Middle East. Older immigrants from Russia and other Eastern European countries also comprise populations with unique cultural backgrounds and needs.

Celebrate the Diversity and Appreciate the Complexity

This ethnogeriatric imperative presents providers who work with older adults an amazingly diverse population with which to be familiar, if they are to provide competent care, and that diversity provides interest, fascination, and richness, which is to be celebrated. It also presents amazing complexity that needs to be appreciated in itself. However, if one also considers the increasing ethnic diversity of the providers working with older Americans, that complexity multiplies many times over. This is especially evident in long‐term care settings where individuals from countries around the globe have taken positions on the nursing staff in nursing homes and in assisted living communities in the US. This is also true in geriatric medicine where the ethnic background of geriatric fellows reflects an international population, many of whom go on to take positions in geriatric medicine in hospitals and clinics. As a result of the growing diversity of both the elders and their providers, the probability that a clinical encounter will be an intercultural interaction becomes very high.

So what difference does all this complexity make? At a minimum, it means that the need for cultural competence in geriatric care is probably the most important need for organizations to develop in meeting the challenge of this ethnogeriatric imperative. With the increasing attention to the disparities in health status and health care between ethnic populations highlighted in the publication of the Institute of Medicine (2002) report, “ Unequal treatment: confronting racial and ethnic disparities in health care,” and among older Americans (Anderson et al. 2004; Schneider et al. 2002), cultural competence has become a suggested tool to decrease those disparities (Brach and Fraser 2000).

Organizational Cultural Competence

The term “cultural competence” is becoming increasingly common, and organizations are encouraged to use it as a guidepost for their missions and goals. There are numerous definitions in the literature, but most include some of the components proposed by Cross et al. ( 1989) in one of their earlier papers: “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals, and enables that system, agency, or those professionals to work effectively in cross‐cultural situations.”

The two parts of cultural competence commonly identified are organizational or institutional and provider competence. The organizational component is usually conceptualized as a continuum. Although there are other versions of this continuum, the one suggested by the pioneering work of Cross et al. ( 1989) indicates that organizations can be placed on a scale from “destructiveness” to “proficiency” depending on how culturally competent they are, as illustrated in Figure 1 . If the two poles of the continuum are thought of as being the extremes, very few organizations are likely to be at either end, especially those serving older adults. Providers in workshops conducted by the Stanford Geriatric Education Center (SGEC) have suggested that perhaps the Ku Klux Klan would be an example of a “destructive” organization, and the United Nations one that fits the requirements of “proficiency.” In reality, most health care organizations would probably lie somewhere between “incapacity” and “competence.” It is interesting to note that “blindness” is placed on the middle of the continuum when many organizations pride themselves as being “color blind,” treating everyone the same. So, the goal for organizations would be to find strategies to move themselves up this continuum toward cultural competence, or even the ideal of proficiency.

Figure 1

Continuum of cultural proficiency Source: From Cross et al. ( 1989).

One of the motivations that health care organizations have been given to move up the continuum, including outlining techniques that should be used, is the development and publication of the Standards for culturally and linguistically appropriate services (CLAS Standards) by the US Office of Minority Health ( 2000) included in Table 3 . These are increasingly being used as guidelines for accrediting agencies for clinical care. Standards 4–7 dealing with language access for patients are actually part of the mandates from the Civil Rights Acts. The remaining standards are highly recommended, except for the last one, which is optional.

Table 3 Standards for culturally and linguistically appropriate services, Office of Minority Health, US Department of Health and Human Services

The CLAS Standards provide major strategies for organizations to focus on to improve their ethnogeriatric care. Among the most important they call for are:

• a. Training staff to show culturally appropriate respect and to recognize and respect culturally based health beliefs.

• b. Providing trained and competent interpreter services for verbal interactions and translation services for written materials, including posting signs in languages appropriate for the patients in the populations they serve.

• c. Collaborating with diverse communities to assess needs and provide appropriate services for elders from those populations.

Having appropriate interpreter services for all their older non‐English‐speaking patients is a major challenge for many health care organizations, but is extremely important, especially for elders who may want to talk to their providers about issues not culturally appropriate for family members acting as interpreters to hear, such as gynecological issues or elder abuse. A practice that can be devastating emotionally for children is asking them to act as interpreters for older members of their families because they are not likely to know the terminology involved in English or their native language. If organizations cannot have trained interpreters available for all the major language groups they serve, they are encouraged to make telephone‐based services available to their providers.

In addition to the strategies for increasing cultural competence included in the CLAS standards, some other important ones are the following:

• a. Recruiting board members and administrators from the diverse populations they serve so that individuals in policymaking and decision making roles will more likely understand the needs of elders from diverse communities.

• b. Hiring staff at all levels that mirror the population they serve. Level of comfort of new patients is enhanced if they can see someone that “looks like them” or at least might seem to be from a familiar background.

• c. If hiring qualified staff from target populations is not possible, organizations can recruit “cultural guides” or “cultural brokers” from diverse communities to be consultants for appropriate services. They might be from ethnically based religious or civic groups, clan leaders, or interpreters. These resources are especially important to have available when there is a culturally based misunderstanding.

Provider Cultural Competence

The second necessary part of cultural competence is that of individual providers. This can be seen as having three components: attitudes, knowledge, and skills.

Attitudes

Providers’ attitudes toward individuals from other cultures or traditions are likely to be the most important but frequently the least accessible part of provider cultural competence. The images and assumptions people have about elders and families from other groups are frequently learned early and emotionally rather than rationally, so that they are more difficult to unlearn directly. The importance of attitudes in clinical care was illustrated by the study of physician referral patterns by Schulman et al. ( 1999) in which internists and family physicians were half as likely to refer older black women to cardiac catheterization as they were white women and men, and black men with the same symptoms, based on professionally acted video‐taped scenarios. The authors concluded that the results suggest bias among the physicians that could be overt prejudice, but was more likely to be based on subconscious perceptions.

To minimize the possibility of similar subconscious perceptions affecting clinical interactions, providers are encouraged to explore their own memories of learning about other groups at an early age, how and what they learned and from whom, so that they can be aware of, and perhaps avoid, potential unintended consequences.

Other strategies to help reduce the effects of unconscious stereotypical images would be for providers to expect within group differences, consciously making note of a wide variety of characteristics they observe in elders and family members from the same ethnic background. For example, if one is clearly aware of both well and poorly educated individuals, those practicing different religions, with different language abilities, and different health beliefs in the same ethnic group, it is more difficult to let specific preconceptions influence decisions and interactions.

Knowledge

There might be a long list of types of information one could make that would be helpful for providers, administrators, and policy makers to know to increase their cultural competence, but given the complexity of the diversity with which health care must deal, reality suggests that there are limits to what can be expected. One valuable guide, Doorway thoughts: cross‐cultural care for older adults, was developed by the Ethnogeriatrics Committee of the American Geriatrics Committee (Adler and Kamel 2004). Some crucial pieces of knowledge were recommended by Lavizzo‐Mourey and MacKenzie ( 1996) in an early paper on the topic, when they suggested that health care providers should know the specific health risks faced by different populations with which they deal, and their culturally related health beliefs and practices.

Health Risks of Elders from Diverse Backgrounds

Morbidity and mortality data for older Americans are much easier to access for some ethnic populations than others. The majority of the national data sets compare white and black or African American health status; recently, much more is available for elders in the Hispanic category, but little is specific to the Hispanic/Latino subpopulations. The smaller populations frequently have too few individuals in national samples to analyze, so that available data rely on community‐based studies. Much of the data for older American Indians come from the Indian Health Service, which includes only those on or near reservations. Given those reservations, examples of available information on differences in health risks are included in Table 4 . For a comprehensive review of disparities data on mortality and their limitations, see Hummer et al. ( 2004).

Table 4 Examples of differences in health risks among ethnically diverse elders in the US

One particular anomaly should be pointed out in the information available for Hispanic/Latino elders, which is known as the “Latino Paradox.” Although much of the morbidity and functional status data indicate greater impairment for Hispanic/Latinos than for non‐Hispanic/Latino whites, their death rates are lower. The reason for this paradox is not clear, but possible explanations include misclassification of ethnicity on death records and older immigrants returning to Mexico and other native countries to die.

Health Beliefs and Practices

There are major between‐group and within‐group variations in the kind and degree of beliefs about health that elders hold. Because these beliefs influence elders’ health‐seeking behavior, the degree to which they act on clinical recommendations, their satisfaction with care, and their concurrent use of non-biomedical alternative therapies and medications, it is important for providers to be familiar with the major culturally based belief systems they may encounter. Examples of these systems that are very different from the Western biomedical model are: the balance system of health and illness ( yin/yang) and the influence of the life force Qi from classical Chinese medicine, which has influenced many other Asian countries, such as Korea, Japan, and Vietnam; Ayurvedic medicine from India that also relies on balance of elements; religiously based beliefs concerning punishment for bad deeds in this life or past lives such as those in Latin America or belief in the karma associated with Buddhism; and the influence of spirits in the health beliefs of the Hmong. A more complete description of these and other beliefs are included in the various modules of the online Curriculum in Ethnogeriatrics developed by the inter‐Geriatric Education Center Collaborative on Ethnogeriatric Education, which can be accessed at www.stanford.edu/group/ethnoger (Yeo 2001).

As there is great variation by acculturation level and other variables in the degree to which elders in the US in specific ethnic populations believe in and practice these culturally based beliefs, providers should use the knowledge as general background but not assume that any one person adheres to the systems from their native culture or religion.

Cohort Experiences

Another set of information important for geriatric cultural competence is the knowledge of what elders are likely to have experienced in their lifetimes. In taking a health and social history, assessing the risk for certain health problems, or providing patient education, some knowledge of the experience of the patient's cohort in issues such as discrimination, trauma, and migration provides important background. This is especially true in long‐term care, where knowing, for example, that fear of showers may be related to dementia patients’ experience as holocaust survivors, or the importance older Russian residents place on tiny pieces of paper may be related to the fact that they are the only surviving possessions from a lifetime of forced migrations.

In the effort to make this information more accessible, core faculty members from SGEC have developed summaries of the cohort experiences of elders from eight ethnic populations in the US (Yeo et al. 1998).

Skills

Culturally Appropriate Respect

Especially because other cultures tend to value age and elders more than is found in mainstream America, the expectation for respectful courteous behavior toward older patients may be high. However, it may be difficult for providers to know what behavior is considered respectful in various cultures. Some of the indications of respect that vary by culture include: shaking hands, bowing, eye contact, personal conversation before business conversation, and where and how someone may be touched. In most cases (and especially with African American elders because of the indignities and disrespect their cohort has experienced), it is recommended that providers address elders by Mr. or Mrs. unless they are given permission to do otherwise, although in some Southeast Asian cultures, the most respectful greetings of elders use family terms such as “grandmother.” It is extremely important for reception staff also to be trained to show respect and call elders by “Mr.” and “Mrs./Ms.” because they are usually the first interactions older patients will have. To learn the appropriate respectful skills, cultural guides and bicultural interpreters can be extremely valuable.

Younger members of the family frequently bring elders in for health care appointments, and it is very easy for providers to talk directly to them rather than to the elders themselves, especially if only the younger ones speak English. This, however, is frequently seen as disrespectful by both the elders and their adult children.

Communication

Skills in a number of other communication issues are also important for providers.

Use of Interpreters

Because of the large proportion of foreign‐born elders among Asian and Latino populations, providers need to be prepared to offer and appropriately use trained interpreters. Appropriate use would include orienting the interpreters to the plan for the encounter, looking at and talking to patients rather than the interpreters, and asking the interpreters for help in understanding any cultural issues that come up.

If trained interpreters are not available and there is no other choice but to use family members (not children), they can be oriented briefly to make the interactions more effective. This would include: assuring the family member that his/her own opinion and information about the elder's condition is important to hear after the provider talks to the elder; asking the family member to translate everything the elder says without comment to the extent the family member is able; asking the family member to let the provider know if there are terms that are not familiar to him/her so that they can be said another way. Unless the elder is cognitively impaired, it is important that he/she understands the recommendations the provider makes, and not just the family member. Writing instructions down in English makes it possible for the elder to have them translated by other members of the family as well if there are any questions about it. It should be noted that in some cultures, modesty values make it unacceptable to talk about some private health issues (e.g., gastrointestinal and genitourinary) in the presence of family members of the opposite sex.

Nonverbal Communication

Gestures and other nonverbal forms of communication can be problematic, sometimes without the provider knowing it. For example, certain common American gestures (e.g., the upcurled index finger requesting someone to “come here”) are offensive because they are associated with communicating with animals in some cultures. Even worse, some are considered very insulting (e.g., showing the sole of a shoe to someone in some Arab cultures). It is highly recommended that providers working with elders who are less acculturated to the mainstream US culture ask cultural guides about particular nonverbal communication issues.

Explanatory Models of Illness

Eliciting an older patient's perception of her own condition can be extremely helpful in helping providers understand the cultural beliefs involved and what may be acceptable as management strategies. These perceptions, known as explanatory models, and their importance, were described in a pioneering article by Kleinman et al. ( 1978) that has become a classic in the literature. Being able to understand and incorporate elders’ explanatory models in recommendations is thought to increase patients’ “compliance.” Questions such as “What do you call your condition?” and “What do you think caused your condition?” can be used to help elicit these perceptions. For a more comprehensive discussion and recommended techniques, see Module 4 in the Core Curriculum of the web‐based Curriculum in Ethnogeriatrics (Yeo 2001).

Physical Examination and Assessment

In many cultures, it is inappropriate to have a provider of the opposite sex, especially when it involves physical examinations. This is especially true among Afghan American elders, and others from conservative Muslim cultures (Morioka‐Douglas et al. 2004). As there are portions of the body that are inappropriate for providers to touch in some cultures, it is safer to explain the procedures in physical exams and ask permission before beginning.

Another major issue in assessments is the use of standardized measures of cognitive status and depression that may not be appropriate because of language or literacy level. It is extremely important to have versions in the elders’ preferred language, preferably versions that have been validated for those populations. The commonly used cognitive screening measure, the Mini Mental Screening Exam, is available in more than 40 languages online at http://www.minimental.com. Likewise, translations of the Geriatric Depression Scale commonly used to screen for depression is available at http://www.stanford.edu/∼yesavage/GDS.html. However, a large proportion of older adults from a number of ethnic backgrounds (e.g., Mexican American) did not have the opportunity to go to school at all, and many others had an elementary education or less, so that translations are not adequate if elders are not able to read them even in their preferred language. In those cases, the screens need to be administered orally. Other resources on cross‐cultural assessments are found in Module 4 of the Curriculum in Ethnogeriatrics (Yeo 2001) and the book Ethnicity and the dementias (Yeo and Gallagher‐Thompson 1996).

End of Life Care

There are many culturally relevant issues involved in appropriate care of terminally ill elders. Provider skills are needed to ascertain preferences for life‐sustaining treatments among elders in cultures where families are expected to make those decisions. It is not uncommon for families to request that elders not be told they have a serious or life‐threatening illness in order to protect them from bad news or giving up hope. Hospice care and/or advance directives are seen as inappropriate by some families because death is based on God's timing. In others, such as among African Americans, preference for all possible aggressive treatments stems from lack of trust in the health care system due to centuries of discrimination in health care. Understanding and learning to respond appropriately to these varied needs requires the development of skills not frequently taught in health care training programs.

Conclusion

In order to meet the challenge of the impending ethnogeriatric imperative, it is imperative that the US public health community prepare itself quickly by educating health care organizations and providers. This should take the form of assisting them in understanding the need for, and complexities of, providing accessible and culturally appropriate care to the older Americans from widely diverse ethnic backgrounds.