CULTURALLY APPROPRIATE GERIATRIC CARE: FUND OF KNOWLEDGE
DESCRIPTION
This module focuses on background information geriatric providers should have to provide effective care to elders from diverse cultural backgrounds. The learner is introduced to the importance of knowledge of:

(1) major systems of health beliefs including the use of complementary/alternative medicine and issues in end-of-life care; and

(2) major historical events experienced by cohorts of elders in the US from diverse ethnic backgrounds.

Knowledge of the range of culturally based beliefs and values in health practice provides a broad background for assessing and understanding individual elders' explanatory models regarding an illness and adherence to recommended health treatment or management strategies. Knowledge of historical experiences of the various cohorts may also give providers insight into the response to the clinical situation and prescribed plan of care by elders and their families.

LEARNING OBJECTIVES
After completion of this module, the learner will be able to:

1. Define major systems of culturally based health beliefs, values, attitudes, and behaviors.

2. Recognize indicators of conflicting expectations and responses to conflicting values and beliefs.

3. List health beliefs that might affect adherence to recommended treatment or care plan.

4. Describe the model of cohort analysis as a way to understand the historical experiences of various cohorts of elders from diverse ethnic backgrounds.

5. Use a cohort analysis of a selected ethnic group to discuss possible implications in the clinical setting (e.g. trust of providers, acceptance of treatment, follow-up).

6. Identify resources for information on historical experiences of various ethnic cohorts helpful to clinicians.

CONTENT OUTLINE

I. Major systems of culturally based health beliefs, use of complementary/alternative medicine, and issues in end-of-life care

A. Medical researchers and practitioners now realize that complementary and alternative medicine (CAM) is used by a significant proportion of the American population. In surveys, 30-41% of older adults reported using CAM; 38-50% of ethnic minority elders in one California study had used CAM (Astin et al., 2000; Eisenberg et al., 1998).

B. Cultural groups are heterogeneous, and members vary in beliefs about death. Practitioners should consider social history, cultural values, and personal experiences, and discuss end-of-life issues in a culturally appropriate manner [See discussion in Module Five: Health Care Interventions, Access, and Utilization].

C. All health belief systems are culturally based.

Biomedical Model (Western, Allopathic)	Biomedical model of medicine and nursing, the primary healing system of the dominant culture/group in the United States. Based on scientific reductionism and characterized by mechanistic model of the human body; separation of mind and body, and discounting of spirit or soul.
Traditions from American Indian Nations	Health beliefs and views of death predate European immigration and vary by tribe. Many are characterized by mind-body-spirit integration, spiritual healing, and use of herbs from native plants. Harmony with natural environment (e.g., animals, plants, sky, and earth) was important for health. Illness is sometimes seen as a result of an individual's offenses, to be treated by a ritual purification ceremony or a ceremony by a medicine person. In many tribes, life and death are viewed in a circular pattern rather than linear as in European traditions.
Traditions from Africa and Early African American Heritage	Various African traditions frequently integrated with American Indian, Christian, and other European traditions. In the variety of systems, most illness could be seen as: a natural illness, which is a result of a physical cause, such as infection, weather, and other environmental factors; a occult illness, which is resulted from supernatural forces, such as evil sprits and their agents (e.g., conjurers); or a spiritual illness is a result of willful violation of sacred beliefs or of sin, such as adultery, theft, or murder Common characteristics of healing include: healing power of religion, Christian in some cases; and use of herbs, or " root working". In some Caribbean Islands, African traditions evolved into strong beliefs in power of spirits and use of healers to maintain health and treat illnesses. However, those beliefs probably have a weak influence on most urban African Americans today. Many current African American elders, particularly those from the rural South, grew up using alternative practices of self-treatment, partly in response to lack of access to mainstream care. Experiences of segregation and memories of the Tuskegee experiment may make the current cohort of older African Americans skeptical and distrustful of mainstream medicine, especially when making decisions about care at the end-of-life.
Traditions from Asia	Classical Chinese medicine influenced traditions in Japan (Kampo), Korea (Hanbang), and Southeast Asia. It is characterized by need for balance between yin and yang to preserve health, especially through the use of herbs and diet; unblocking the free flow of qi, (chi) or vital energy, through meridians in the body by acupuncture, tai chi, moxibustion, and cupping; and interaction of basic elements of the environment (e.g. water, fire, earth, metal, and wood). In parts of Asia, Taoism and Buddhism have influenced the healing traditions. Taoism emphasizes the need to adapt to the order of nature, and Buddhism emphasizes meditation for spiritual and physical health. Ayurvedic medicine practiced in India: is shaped by Hinduism and traditional Indian culture. includes basic elements of the environment (e.g., air, water, and wind) which have analogues in the body. is characterized by the use of yoga, meditation, herbs, and by integration of mind-body-spirit. Traditional Hmong health beliefs are characterized by: interventions of a wide variety of spirits that promote health or cause illness; and risk of loss of soul that brings illness. For many Asian American elders, traditional healers’ offices serve as meeting places to socialize with other elders. The socialization function of traditional healing parallels the traditional Chinese medical view that illness should be addressed not only through medicine, but also through social and psychological aspects of life. End-of-life decisions about care may be characterized by: family vs. individual decision making—even if the elder is competent to make decisions, family members might feel that it is their filial duty to take the decision-making role; non-disclosure of terminal illness to protect the elder; and placement of the dying person or the body—wanting to "go home to die" and the practice of not disturbing the body reflecting reluctance of organ donation or autopsy.
Traditions from Latin America	Most Latino Americans practice the biomedical model, but among some elders there may be reminiscences of other beliefs. Beliefs rooted in models developed from Native American, European, and African practices form an intricate cultural blend. Examples are Santeria, Espiritismo, and Curanderismo, in which religion is an important component of the system. CAM practices are seen as exogenous, and in opposition, to the biomedical model. There is an integration of elements from both practices forming a complex cultural product. Latino Americans are less likely than European Americans to: make individual decisions on end-of-life issues or complete advance directives, endorse the withholding or withdrawal of life prolonging treatment, use hospice services, support physician-assisted death, and organ donation. Cultural themes that can influence beliefs and practices concerning end-of-life decisions may include the emphasis on the well-being of the family over the individual; respect for hierarchy; and the emphasis on the present as opposed to past or future.
Other European American Systems	Folk healing systems from European countries predating biomedicine, many of which include religious healing and use of herbs, may still be practiced in some areas of the U.S. Variations on the belief systems of allopathic medicine, or competing health philosophies have emerged in the U.S. in the past century. Two of the major ones are: Osteopathy, similar to allopathic medicine, but deals with the "whole person" and emphasizes the interrelationship of the muscles and bones to all other body systems; Homeopathy emphasizes the healing power of the body, and relies on the "law of similars" to choose drug therapy.

D. Medical pluralism in the US

1. Elders from any one ethnic background may or may not know, or may not espouse, the health beliefs connected with their traditional heritage. It is important for providers to be familiar with the range of belief systems found in the U.S. but not to assume, based on ethnic backgrounds, that any individual maintains those beliefs. Practitioners should be aware of the distinct explanatory models of illness among elderly persons from all cultural backgrounds, and explore the meanings of illness, which may be unique to the individual. Causes of illness may be attributed to cultural constructions or idioms (For techniques to assess explanatory models of illness held by older patients, see Module Four).

2. Health care can be viewed as a local system composed of three overlapping sectors. It is necessary to understand the interactive nature of these sectors, particularly for subgroups of older Americans who have affiliations with other cultural traditions of medicine.

a. The professional sector including organized healing traditions, which are considered the dominant healing paradigm. In the U.S., it is Western biomedicine.

b. The popular sector includes self-treatment, family care, and socially based networks of care.

c. The folk sector includes practitioners and healers who use alternative therapies based on paradigms outside of the dominant (e.g. biomedical) model.

II. Historical Experiences of Cohorts of Older Ethnic Populations

A. Cohort analysis is a tool to understand the impact of historical experiences of various ethnic cohorts on the lives of elders. It includes major influences on the ethnic group during the lifetime of the current population of elders, such as periods of higher discrimination or immigration.

1. Influence of an event differs based on the age of elder at the time.

2. Not all individuals who identify themselves as members of the ethnic group will have been influenced by all events.

B. Use of cohort analysis in clinical care:

1. Taking relevant social histories.

2. Understanding influences on elders' trust of providers and attitudes toward the health care system.

C. Examples of outlines of cohort analysis from four major ethnic populations. See the following charts for older African American, American Indian, Chinese American, and Mexican American (Source: Yeo, Hikoyeda, McBride, Chin, Edmonds, & Hendrix, 1998).

COHORT EXPERIENCES - AFRICAN AMERICAN ELDERS

 

1900-1920	1920-1940	1940-1960	1960-1980	1980-Present
Urban Migration	Harlem Renaissance	WWII: Segregated Troops; factory work in North and West	Civil Rights Movement and Law	Jesse Jackson ran for President
NAACP and Urban League Founded	Marcus Garvey’s back to Africa Movement	Desegregation in plants, schools and military.	Dr. Martin L. King, Jr. led non-violence and then was assassinated	Black Muslims
Ku Klux Klan Active	Klan marched on Washington	Montgomery Bus Boycott	Affirmative Action	Rodney King trial
WWI and the "Red Summer"	Depression	Jackie Robinson	Political Activism	Million Man & Woman Marches
	Jesse Owens and Joe Lewis		Kennedys assassinated	Declining Affirmative Action
			The Black Panthers

AGE AT HISTORICAL EXPERIENCE
CURRENT AGE COHORTS
85+	Children & Adolescents	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old	Old
75-85	Children	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old
65-75		Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old
55-65		Children	Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged

1900-1920	1920-1940	1940-1960	1960-1980	1980-Present
Reservations	Citizenship	World War II Service	Vietnam War	Education of Professionals
"Vanishing American"	Adoption of Indian Children by Whites	Relocation by BIA to Urban Areas	Indian Activism	Litigation
Forced Boarding Schools	Loss of Land by Allotment System	Termination of 100 Tribes	Youths Return to Traditional Practices	Self-Determination of Tribes
Traditional Culture "Bad"	Forced Assimilation	Forced Assimilation	Urbanization for Education & Jobs	Urban Pan-Indianism
Law Banned Spiritual Practices	Boarding Schools			Reservation Gaming

AGE AT HISTORICAL EXPERIENCE
CURRENT AGE COHORTS
85+	Children & Adolescents	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old	Old
75-85	Children	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old
65-75		Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old
55-65		Children	Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged

 

 

1900-1920	1920-1940	1940-1960	1960-1980	1980-Present
Chinese exclusion act in effect	1924 Immigration Act Excludes all Asians	Repeal of Exclusion Act	New immigration act favors family members	Continued heavy immigration, from Taiwan, Hong Kong and Vietnam
Urbanization	Families emerge in Chinatowns	Chinese Americans in WWII	Increased educational opportunities	Seen as "Model Minority"
Immigration of "Paper Sons"	Family Associations	Immigration of wives	Continued discrimination in union employment	"Followers of Children"
Predominantly male	Pearl Buck novels	Fear of Chinese Communists		Anti-immigrant bias

AGE AT HISTORICAL EXPERIENCE
CURRENT AGE COHORTS
85+	Children & Adolescents	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old	Old
75-85	Children	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old
65-75		Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old
55-65		Children	Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged

1900-1920	1920-1940	1940-1960	1960-1980	1980-Present
Heritage of Loss of Land	Massive Immigration	WWII Participation	Chicano Movement	Increasing Political Power
Mexican Revolution	Depression	Immigration	Bilingual Education	Anti-Immigrant Bias
	Repatriation	Urbanization	Latino Arts and Media	Welfare Reform Movement
		GI Forum	Deportation and Amnesty	Anti-Bilingual Education Trend

AGE AT HISTORICAL EXPERIENCE
CURRENT AGE COHORTS
85+	Children & Adolescents	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old	Old
75-85	Children	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old	Young Old & Old
65-75		Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged	Middle Aged & Young Old
55-65		Children	Children & Adolescents	Adolescents & Young Adults	Young Adults & Middle Aged

INSTRUCTIONAL STRATEGIES

The following are possible methods of instruction for this module:

A. Lectures and reading assignments on variations in culturally based health beliefs.

B. Discussion sessions in which learners are asked to:

(1) share the health beliefs of their own families based on cultural and religious backgrounds;
(2) explore the similarities and differences; and
(3) respect the differing values and beliefs.

C. Inviting elders from diverse ethnic populations to discuss the important historical events in their lives and health beliefs that they and others of their ethnic group hold. (See appendix B for strategies for student assignments for interviewing members of older ethnic populations.)

D. Viewing profiles of elders from films of various ethnic groups and asking learners to place the elder in a specific cohort and discuss the possible influences on their clinical care.

E. Assigned reading of biographies of ethnic elders (e.g., "Having our Say" by Sarah and Elizabeth Delany).

F. Comparison of two generations of elders from the same ethnic population in terms of the responses to health care system based on their historical experiences.

EVALUATION

Evaluation of the learner's progress can be based on the following chart relating strategies to learning objectives. *Letters refer to the Instructional Strategies above

Define major systems of culturally based health beliefs, values, attitudes, and behaviors	Multiple choice or essay questions identifying characteristics of major health belief systems
Recognize indicators of conflicting expectations and responses to conflicting values and beliefs	Multiple choice or essay questions identifying characteristics of major health belief systems that are potential sources of conflict between patient and provider Project B*
List health beliefs that might affect adherence to recommended treatment or care plan	Assigned paper analyzing possible clinical implications of historical influences on different cohorts of elders from a locally relevant ethnic population Reports based on Projects B and C*
Describe the model of cohort analysis as a way to understand the historical experiences of various cohorts of elders from diverse ethnic backgrounds	Essay question Reports from Projects C, D, & E*
Use cohort analysis of a selected ethnic group to discuss possible implications in the clinical setting (e.g. trust of providers, acceptance of treatment, follow-up).	Assigned paper analyzing possible clinical implications of historical influences on different cohorts of elders from a locally relevant ethnic population Project F*
Identify resources for information on historical experiences of various ethnic cohorts helpful to clinicians.	Essay question asking learners to write a rationale to persuade a clinic administrator to invest in print resources or inservice training on historical experiences of cohorts of elders from various ethnic backgrounds

REFERENCES AND RESOURCES

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Astin, J. A., Pelletier, K. R., Marie, A., & Haskell, W. L. (2000). Complementary and alternative medicine use among elderly persons: One-year analysis of a Blue Shield Medicare Supplement. Journal of Gerontology, 55A: M4-M9.

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McBride, M., Morioka-Douglas, N., & Yeo, G. (1996). Aging and health: Asian Pacific Islander American Elders (2^nd ed.). Working Paper # 3, Stanford, CA: Stanford Geriatric Education Center.

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McNeilly, M., Musick, M., Efland, J. R., Baughman, J. T., Toth, P.S., Saulter, T. D., Sumner, L., Sherwood, A., Weitzman, P., Levkoff, S. E., Williams, R. B., & Anderson, N. B. (2000). Minority populations and psychophysiologic research: Challenges in trust building and recruitment. Journal of Mental Health and Aging, 6: 91-102.

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Yeo, G., Hikoyeda, N., McBride, M., Chin, S-Y., Edmonds, M., & Hendrix, L. (1998). Cohort analysis as a tool in ethnogeriatrics: Historical profiles of elders from eight ethnic populations in the United States. Working Paper#12, Stanford, CA: Stanford Geriatric Education Center.

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WEB SITES

http://www.diversityrx.org

http://www.hslib.washington.edu/clinical/ethnomed