Fall 2008

Cultural Sensitivity: A Wellness Program Necessity
By Cheryl Phillips, MD, AGSF
Aging Well
Vol. 1 No. 4

Healthy aging involves more than simply getting old without disease. Rather, it focuses on ways older adults can avoid decline in function and identify tools that support their ability to prevent illness. Additionally, healthy aging includes the highest possible level of self-management of chronic conditions.

But how does healthy aging fit into our understanding of cultural diversity? The United States is comprised of a rich mixture of cultures and heritages, and all its nonwhite ethnic groups are seeing increases in their over-65 populations. The U.S. Bureau of Statistics reports that in 2006, 81% of those aged 65 and older were identified as white non-Hispanic, and it estimates that by 2050, this number will decrease to 61%. Older adults from other ethnic groups will comprise 39%.

The shift in California will be even more dramatic. Based on California census data, 70% of older adults are described as being white. By 2030, it is estimated that 45% will be white, and 55% will be elders from all other groups, with Hispanics, African Americans, and Asians comprising the majority of that 55%.

Recognizing Disparities

Healthcare is beginning to recognize the critical role of understanding the unique cultural, language, and ethnic needs of the growing numbers of older adults, yet considerable gaps remain. Healthcare disparity is the term most commonly used, meaning that some cultural or ethnic groups experience less access to or availability of services than others.

Examples of such disparities include important findings by the Agency for Healthcare Research and Quality such as the following:

• Nonwhites are more likely to be diagnosed with late-stage breast cancer and colorectal cancer when compared with whites.

• African Americans and individuals in lower socioeconomic positions are more likely to be admitted to a hospital for reasons considered to be avoidable with optimal primary care and prevention.

• Hispanics are less likely to receive optimal care for acute myocardial infarctions.
Creating a Framework

Why is understanding cultural diversity important in a wellness program? Far too often, healthcare is based on the one-size-fits-all concept. In other words, a standard template or system is put into place with the expectation that individuals needing services will find a way to adapt the system to their own language or experience. However, the very basis of wellness revolves around a person-centered focus. This focus centers on the following:

• What information does an individual need to make the best health decisions?

• What tools or support does the individual need to change behaviors?

• What activities can improve health or decrease the risk of decline?

• How can the family or community support the individual in this endeavor?

It is clear that to provide health and wellness in a truly person-centered way, we need to understand the cultural context of the elder being served. This context includes language and literacy, dietary customs, family and community structure, and an individual’s cultural and personal views on health, wellness, and illness. A useful way to frame ethnic and cultural diversity into wellness and aging is to consider the following six domains:

What is the elder’s view of health, wellness, sickness, and aging? How is this view shaped by the individual’s culture and customs?

How does the individual typically seek care? Is an elder’s culture one that values stoicism? Are there gender norms that predict whether an individual will seek care?

Are there particular genetic predispositions to certain symptoms or conditions that differ from one ethnic group to another? (For example, Native Americans have a much greater risk of diabetes; non-Hispanic whites have a greater risk of osteoporosis.)

What is the older adult’s environment? Does the individual typically live in a large extended family, or is he or she more likely to live alone and be isolated? Does the elder have access to care services in the community?

What are the language and literacy barriers? Can the individual understand the information provided or the instructions to be followed?

Does the older adult trust those who are providing care? Do the providers know how to address individuals in a person-centered way? Have they had experience with healthcare disparities in the past?

Prevention and Cultural Diversity

Prevention can be described by the following three basic strategies, all of which apply to the older adult population:

• Primary prevention provides interventions conducted to stop or prevent a disease before it starts. Examples for elders include providing the influenza or pneumococcal vaccines to help prevent pneumonia. Even elders identified as at-risk or frail can benefit from primary prevention strategies such as home safety checks to identify issues that contribute to the risk of falls and prevent injuries due to falls.

• Secondary prevention refers to the early identification of diseases, potentially decreasing their severity or decreasing risks of serious consequences. Examples of secondary screening include cancer screenings, nutritional status assessments, screenings for osteoporosis, and skin checks for the early signs of skin cancer.

• Tertiary prevention involves management of existing problems or conditions to prevent further or worsening complications. For elders with chronic conditions such as high blood pressure or diabetes, tertiary prevention is a critical tool to help them self-manage their conditions through lifestyle and dietary changes, as well as taking prescribed medications.

Each of these three approaches is critical to maintaining optimal health and function as we age. Now imagine the older adult who holds a different view of screening for disease or who may not understand why vaccines or medications are recommended. What if the information provided about nutrition and lifestyle changes discusses foods and activities that have no relationship with that individual’s own experience?

Culturally Sensitive Blueprint

• Begin by understanding the culture of the elders you serve. Learn about customs and traditions, especially those that involve healing and wellness. Learn about foods, social structure, celebrations, and the impact of spirituality.

• Focus on each individual. Understand the context of his or her life. Who makes the decisions in the family? What is the individual’s role within the family and the community?

• Determine the elder’s health literacy. Can the individual express in his or her own words the health and wellness recommendations you offer? Can the elder read or would other techniques such as pictures be more helpful?

• Assess the desire for change. Does the individual want to quit smoking or increase physical activity? Does he or she recognize the value in the recommendations being offered?

• How do such recommended changes impact relationships with the family and community? For example, advising a 68-year-old grandmother that she should follow a low-fat diet may present a challenge if she cooks for a large extended family that traditionally eats fried breads and other high-fat foods.

Carefully think through each of these steps for each intervention and continue to reexamine and reevaluate. Each of us struggles with maintaining health changes in our own lives, but imagine attempting to effect changes in another culture, with another language, with medications that we don’t understand and food selections that we don’t prefer.

It’s Never Too Late

Regardless of age or frailty, there are benefits to be derived among older adults in delivering wellness and prevention interventions within a context of cultural awareness. The On Lok PACE (Program of All-inclusive Care of the Elderly) Program is a model of care serving nursing home-eligible older adults living in the community through an interdisciplinary team approach. While On Lok originally served the Chinese and Italian communities of Chinatown and North Beach in San Francisco more than 36 years ago, the organization now serves a broad and diverse spectrum of elders. In fact, the participants now represent more than 30 different languages and an equal number of cultures and ethnicities.

Yet, despite the challenges of language, custom, and culture, the On Lok team sees each older adult in the context of his or her own personal experience. The team, in partnership with the individual and his or her family, identifies primary, secondary, and tertiary prevention approaches to improve wellness and decreases the risk of the elder’s further decline. The goal is to maximize health and independence in the context of the individual’s environment and lifestyle.

Approaching health and wellness for a culturally and ethnically diverse group of seniors is a rich and rewarding process. It requires that from the very start, we look beyond our “wisdom” and focus on the world as it appears to the individual. It means adopting a truly person-centered focus. It allows us to broaden our perspectives of health, wellness, happiness, sickness, and healing. Most importantly, when created with the individual in mind, such programs have dramatic impacts on the lives of older adults through the prevention or delay of disease and the improvement of function in elders’ day-to-day lives.

— Cheryl Phillips, MD, AGSF, is the chief medical officer for On Lok Lifeways based in San Francisco.