Preparing Health Care Providers for the Challenges of Ethnogeriatric Care

Health care policy experts have emphasized that many health care professionals in a variety of care settings are not well-prepared to serve older adults. A recent paper by Dr. Gwen Yeo in the July issue of the Journal of the American Geriatrics Society titled “How Will the U.S. Healthcare System Meet the Challenge of the Ethnogeriatric Imperative? (JAGS 57:1278-1285) suggests that health care professionals are even less prepared to serve older adults from different cultural, racial and ethnic backgrounds—many of whom routinely experience language barriers, and share much different health beliefs, risk for disease, and health practices.

By mid-century, more than one in three older adults will be from one of the four “minority” populations: African American, Asian/Pacific Islander, Hispanic and American Indian. Moreover, within each of these four groups lies wide variation in public and private health insurance coverage, family systems, and dependency on adult children—which can each influence health, access to care, care quality, safety, and health care costs. These issues add to the existing challenges of providing care to older patients who frequently present with multiple chronic conditions and often require more of the health care professional’s time, and better care coordination and management.

Disparities in health care treatment and utilization have been well-documented in groups such as African-Americans, who are less likely to receive preventative health care screenings, evidence-based care for common chronic conditions, and post-hospital follow-up. While well-known, the causes of these disparities are often complex and multifaceted. Among American Indians, for example, access to elder care may be limited. Urban Indian Health Centers who provide the bulk of services are generally poorly funded and lack comprehensive geriatric care. In most cases, tribes are responsible for providing elder care services which are often not available on most reservations.

This article cites language barriers and poor health literacy as key drivers of poor health care among these populations. In the 2000 census, 38% of older Hispanic or Latino people and 41% of older Asians reported that they spoke little or no English. Consequently, these patients are at increased risk for adverse health care events resulting in harm, complications, limited access to appropriate care, and excess tests and procedures. Additionally, higher costs and poor satisfaction with care are common. And while the use of trained interpreters is recommended (as opposed to family translators, particularly minors), the Joint Commission on Accreditation of Health Care Organizations found that 79% of JCAHCO hospitals say they frequently use family and friends as interpreters.

Given that low health literacy is linked to higher rates of hospitalization and emergency care, avoidable health care costs, medication errors, and other medical errors, special steps are recommended to improve health literacy. More than half of people from Mexican backgrounds and more than 30% from Asian subpopulations have less than a ninth-grade education, demonstrating the challenges of low health literacy in these patients who are now routinely seen in health care settings in the US.

Another challenge is the diverse cultural backgrounds and health beliefs represented by these patients. For example, in many traditional Chinese and Asian medical systems, yin/yang balance and the free flow of chi is important; in India, the influence of humors in Aryurvedic medicine is key; individuals from Caribbean and Latin American countries often subscribe to beliefs about hexes and spiritual healing practices. Within Hmong cultures, concerns about spirits and soul are prevalent. Healing and cleansing ceremonies may be used by individuals from American Indian cultures, while coining and cupping are accepted treatments for wind illness and other conditions in Southeast Asia. These backgrounds and beliefs can result in much misunderstanding, distrust, and a reluctance to seek western care if health care professionals are unaware, uninformed, or dismissive.

Beliefs and cultural differences about long-term and end-of-life care can also be problematic. The extended family remains solely responsible for long-term care in many cultures. When placed in long-term care facilities, these older adults may grow isolated and despondent, losing touch with family and friends, and having to adjust to common American foods and customs. In Asian cultures, many adult children will often insist that their parent’s life be extended at all costs. In traditional Navajo and Chinese families, talk of death is not considered appropriate. In many cultures, the onus of health care decision-making falls on the family, not the patient. Moreover, discontinuation of nutrition and hydration may be unacceptable in some cultures who believe it is important to "die with a full stomach." Most long-term care settings may find prescribed rituals common to these cultural group difficult to accommodate.

The author recommends a number of steps to provide better, more culturally competent care for these older adults. As a start, all organizations who serve these populations should implement Culturally and Linguistically Appropriate Services (CLAS) as specified by the Office of Minority Health (OMH). These are available at the OMH website. Additionally, health care providers should be well-versed in key considerations and approaches for ethnogeriatric care. Two excellent resources have been developed. A free curriculum in Ethnogeriatrics is available online. Additionally, the American Geriatrics Society has developed a series titled: Doorway Thoughts: Cross-Cultural Health Care for Older Adults. These publications are available for purchase online. Regardless of whether providers serve younger or older adults from different cultures, ethnic backgrounds or races, these resources can help prepare providers for their increasingly frequent cross-cultural encounters.