MODULE THREE

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.
MAJOR SYSTEMS OF CULTURALLY BASED HEALTH BELIEFS

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

COHORT EXPERIENCES – AMERICAN INDIAN ELDERS

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

COHORT EXPERIENCES - CHINESE AMERICAN ELDERS 
 
 

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

COHORT EXPERIENCES – MEXICAN AMERICAN ELDERS

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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Like, R. C., Steiner. R. P., & Rubel, A. J. (1995). Recommended core curriculum guidelines in culturally sensitive and competent health care. Monograph developed by Society of Teachers of Family Medicine's Task Force on Cross Cultural Experiences. Washington, DC: Society of Teachers of Family Medicine.

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

McCabe, M., & Cuellar, J. (1994). Aging and health: American Indian/Alaska Native Elders, (2nd ed.), Working Paper # 6, Stanford CA: Stanford Geriatric Education Center.

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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Reynoso-Vallejo, H. (1999). Guidelines for working with Latino-American elders. Paper Presented at the Meeting of the Multicultural Coalition on Aging, Boston.

Richardson, J. (1996). Aging and health: African American Elders (2nd ed.), Working Paper # 4, Stanford, CA: Stanford Geriatric Education Center.

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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