ETHNOGERIATRICS AND SPECIAL POPULATIONS
Curricular Framework: Core Competencies in Multicultural Geriatric Care Recommendations of the University of California Academic Geriatric Resource Program and the Ethnogeriatrics Committee of the American Geriatrics Society Prepared by the Cultural Competencies Writing Group, a collaboration of leaders in geriatric education from the University of California and the American Geriatrics Society
George Xakellis, MD, Sharon A. Brangman, MD,w W. Ladson Hinton, MD, Vida Y. Jones, PhD, z Donna Masterman, MD,§ Cynthia X. Pan, MD,8 Jorge Rivero, MD,z Margaret Wallhagen, RN, PhD,# and Gwen Yeo, PhD
Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula. J Am Geriatr Soc 52:137–142, 2004. Key words: competency; geriatrics; culture; ethnogeriatrics; curriculum
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he demographic profile of America’s older population is projected to change dramatically in the coming century. By 2050, the older adult population in the United States is expected to increase 230%. Within the same time frame, the population of minority elders is expected to grow 510%.1 The increase in the cultural and racial diversity of the nation’s elders poses challenges to current standards for From the University of California, Davis, wSUNY Upstate University; z University of California Office of Health Affairs, §University of California, Los Angeles, 8Mt. Sinai School of Medicine, zUniversity of California, Irvine, # University of California, San Franscisco, and Stanford University School of Medicine Address correspondence to Gwen Yeo, PhD, Stanford Geriatric Education Center, VAPAHCS, Bldg 4 (182B-SGEC), 3801 Miranda Avenue, Palo Alto, CA 94304. E-mail:
[email protected]
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training the United States’ future healthcare providers. Cultural differences in health beliefs, and behavior and disparities in the health and health care of minority elders, are well documented.2 To ensure that a high quality of care is provided to all older adults, future curricula for healthcare professionals must be developed in which specific cross-cultural training is included.3,4 To address this need, the University of California’s (UC) Academic Geriatric Resource Program (AGRP) partnered with the Ethnogeriatrics Committee of the American Geriatrics Society (AGS) to create a curricular framework for multicultural geriatric care that is adaptable to a variety of academic programs. Faculty leaders in geriatrics education from the UC health sciences campuses and from the AGS formed a writing group to develop this framework and its companion resources. The Writing Group, the Ethnogeriatrics and Education Committees of the AGS, and faculty members of the AGRP Advisory Committee contributed review and comment during the development process. Demographers and educators recognize that the preferred terms for ethnic and racial populations may vary over time and among individuals, even within the population being described. For clarity, the writing group chose to refer to population categories used by the U.S. Census Bureau: Black/African American, Hispanic/Latino, American Indian and Alaska Native, Asian, and Pacific Islander. The AGRP and AGS faculty similarly recognizes the heterogeneity inherent within all of these minority categories, within the ethnic groups that constitute the categories, and within the nonminority non-Hispanic white population. In addition, a growing number of Americans identified themselves in the 2000 Census as a member of more than one group (e.g., African American and Asian American).
DISPARITIES IN HEALTH AND HEALTHCARE DELIVERY Researchers have found that members of many minority groups have rates of morbidity and mortality that are higher
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than those of nonminority control groups. Mexican Americans have a 200% greater incidence of diabetes mellitus, African Americans have a 50% greater rate of lung cancer and a 35% greater cancer death rate, and Vietnamese American women have a 500% higher rate of cervical cancer than the general population.2,5–8 Researchers also report that minority adults often receive fewer healthcare services. Studies funded by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) showed that, in addition to other disparities, African Americans are 13% less likely to undergo coronary angioplasty and 33% less likely to undergo bypass surgery than whites. Older Asian-American, Hispanic, and African-American residents of nursing homes are also less likely than whites to have sensory and communication aids, such as glasses and hearing aids.9
Causes and Contributing Factors There are multiple, complex causes of health disparities, but it is known that older minority adults are more likely to have lived in poverty or to have experienced financial hardship. This characteristic correlates with limited access to health services and poorer health outcomes, but even when factors such as socioeconomic status, medical condition, education level, and health insurance coverage are controlled for, older minority adults are less likely to receive a variety of health services than their nonminority counterparts.2,8 Several studies reveal that uninformed cultural attitudes, inconsistent referral patterns, intercultural communication difficulties, and ineffective provider-patient interactions are likely to contribute to observed disparities.10–12 These data emphasize the importance of making healthcare professionals aware of their own cultural attitudes and the potential to address ethnic and racial disparities in health care by achieving cultural competency. Reducing Disparities through Cultural Competence In 1978, a group of researchers defined culture as the ‘‘integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group.’’13 Later, others defined cultural competency as ‘‘a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.’’14–17 Becoming culturally competent in geriatric care requires the development of certain essential skills. These include the ability to: – work effectively with interpreter services – be familiar with culturally specific methods of showing respect to elders and nonverbal communication styles (e.g., avoid eye contact, limit physical contact in greetings) – understand, elicit, and work with culturally related health beliefs that may not be congruent with dominant American culture (e.g., believing that disease states are caused by an imbalance in ying/yang or by karma from past lives) – be sensitive to critical cohort experiences shaping a patient’s world view and psyche (e.g., place and country of
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birth, major life experiences, histories of migration, war, torture or refugee status) – understand the use of spiritual advisors and native healers
Acquiring and then applying these skills will equip healthcare providers to better meet the needs of patients of any race, religion, or social group. Consider the following case. Mrs. D is an 82-year-old Vietnamese woman who received care elsewhere and is being seen in this setting for the first time. She speaks no English, has a flat affect, and avoids eye contact. An African-American home attendant accompanies her and delivers a note from the elder’s family stating, ‘‘She is eating and sleeping poorly, and she feels cold in her legs even though they are warm to touch. Please also help her petition for her visa so she can stay in the U.S.’’ Her medical record includes a report of a computed tomography scan performed a year ago that states that Mrs. D has a brain tumor. A call to Mrs. D’s son to obtain more information and to request that he come to future appointments is met with the response that he has posttraumatic stress disorder from being in the Vietnam War and has his own problems. Questions or discussion points for the culturally competent clinician to consider are: Is an interpreter needed? If so, who is the best resource? What is the meaning of eye contact in the cultural context? Does lack of eye contact show respect and deference or depression and disengagement? How does cultural tradition affect concepts of hot and cold in the manifestation of illness? Does her cultural background affect Mrs. D’s preferences for truth telling and disclosure of serious or life-threatening illnesses? How important is knowledge of past experiences of the older cohort of patients and family members, and how might these affect Mrs. D’s healthcare access?
With appropriate instruction, healthcare professionals in training or in practice can gain or continue to develop the tools to provide culturally competent care to older patients.
Increasing Cultural Competency Through Medical Education The following section provides information that directors of health professional programs can use to develop curricula to improve care for older people from different cultures. The competencies in the framework are designed primarily for educating physicians at the residency level, but they can be adapted to serve as a useful resource for faculty, students, and practitioners from any healthcare discipline. Because the framework is extensive, faculty should consider incorporating segments of this information into the curriculum over time, expanding to other areas as experience is gained. The format was modeled on the Core Competencies for the Care of Older Patients developed by the Education Committee of the AGS.18
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ACHIEVING CULTURAL COMPETENCE IN GERIATRIC CARE This curricular framework is intended to address core competencies, recommend instructional strategies for faculty, and provide additional resources (see Appendix 1) that are important in preparing health professionals to provide competent, high-quality, compassionate care to America’s increasingly diverse older population.
a paucity of available services and goods in minority communities) – avoid stereotyping and overgeneralization; recognize medical myths related to ethnicity or cultural affiliation (e.g., African-American women do not develop osteoporosis)
Core Competencies Attitudes Cultural competence is not color blindness. Rather, it is the ability to respect and value ethnic and cultural differences. No culture is monolithic. Attitudes and beliefs vary widely from one individual to another within a single cultural group. Factors such as education, religion, economic status, acculturation level, sex, age cohort, rural/urban background, and immigration history are but a few of the elements shaping an individual’s cultural attitudes. Therapeutic doctor-patient relationships are based on effective communication, including the doctor’s ability to read cues from patients. Attitudes and cultural background affect communication styles (verbal and nonverbal). As a first step in cultural competency education, the student assesses his or her values and biases and those of the medical profession as a whole. Despite the importance of this exercise, it is not often a component of clinical training. Although self-assessment can be uncomfortable, providersin-training must appreciate their own beliefs before trying to understand and interact appropriately with the beliefs and values of others. Trainees should be able to:
Knowledge Knowledge and data are available to inform care providers about culturally appropriate practices and to educate trainees on matters of cultural diversity in geriatric care. Such efforts can influence attitudes and help to improve healthcare outcomes. To address cross-cultural issues at the patient level, trainees should be able to:
– describe their cultural values, perspectives, preconceptions, and health beliefs – consider their own personal views and beliefs (perhaps unconscious) about other groups of people – explain how the above may affect their care of patients – give examples of how generalities may help provide a context for understanding but also may be inaccurate for individual patients given the heterogeneity of older adults within the same ethnic population – value and appreciate the importance of culturally sensitive interactions in the provision of high-quality geriatric health care and the promotion of equal access – support health decisions based on a patient’s cultural values – explain when and how they would seek consultation, identify other appropriate resources, or refer the patient to another provider if they do not feel comfortable with the patient interaction because of a difference in values – appreciate the effect of historical and current experiences (e.g., racism, discrimination, forced migration, genocide) on lives, health, feelings, attitudes, and preferences of older adults – recognize and work to reduce the influence of historical and current practices and regulations in healthcare organizations that negatively affect access to health care and care of older minority adults (e.g., lack of diversity in some parts of the workforce, scarcity of materials translated into other languages, longer waiting times for Medicaid patients, and
Developing cultural competency is a complex and ongoing process. It is appropriate to take incremental steps toward achieving these objectives.
– discuss the importance of patients’ perception and explanations of their illnesses – describe the following for major ethnic minority categories and regionally specific ethnic groups: differences in the epidemiology of common diseases health disparities differences in response to medications validated measures for assessment (e.g., cognitive status, depression, osteoporosis, spirometry) – compare and contrast the extent of differences in the major ethnic minority categories and regionally specific ethnic groups with respect to: common complementary and alternative medical practices that are not congruent with Western practices (e.g., acupuncture, herbal supplements, spiritual healing, cupping and coining) major systems of culturally related health beliefs that may affect behaviors and practices, especially those that may not be congruent with the dominant health beliefs (e.g., flow of qi, evil eye, wind illness, yin/yang or balance theory, cold or hot concepts, and nondifferentiation of spirituality and health) major coping skills or strategies used by various ethnic groups (e.g., family support systems and spiritual strength through prayer and religiosity) traditional attitudes toward long-term care and available resources for culturally appropriate long-term care attitudes toward disclosure of life-threatening diagnoses, advance directives, talking about death, and end-of-life care traditional nonverbal communication behaviors, gestures, and styles traditional family decision-making practices and roles (e.g., family centered, matriarchal or patriarchal, participation of sons or daughters) To address cross-cultural issues at the institutional and provider level, trainees should be able to: – define major terms used in ethnogeriatrics: culture, ethnicity, minority, acculturation continuum – describe the categories of minority and nonminority populations in the United States used in the 2000 Census and
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other federal government documents and the ethnic groups they include and their major demographic characteristics – explain the continuum of cultural competence at the system or organization level (e.g., destructiveness, incompetence, blindness, sensitivity, competence) and factors used to evaluate an organization’s place on the continuum – describe and give examples of damaging, institutionalized cultural attitudes within healthcare organizations and possible solutions to these problems – describe the importance of culturally sensitive interactions in geriatric care, access, and quality of care – explain the lack of trust or fear of the healthcare system that many patients experience and the historical reasons for the distrust and fear – recognize the major cohort experiences of elders from different ethnic groups – critique current health policy decisions in terms of their effects on healthcare access and care practices (e.g., formulary, long-term care, availability of healthcare resources, eligibility) – compare and contrast the effects of differences in physician referral for similar conditions between elders from different cultural and ethnic groups – identify culturally appropriate resources in the community to support patient care – describe the advantages and disadvantages of using different types of interpreters in a clinical encounter in which an elder speaks a different language than the provider
Skills Trainees should be able to: – formally assess their individual cultural beliefs and values about health and aging – work with trained interpreters, use telephone-based interpreter services, teach members of a patient’s family who are acting as interpreters how to communicate effectively, and avoid, if possible, having underage children serve as interpreters – apply the concept of culturally appropriate respect in clinical care, including appropriate use of nonverbal communication and silence (e.g., ask how patients prefer to be addressed, avoid interrupting patients in midsentence, and thoughtfully determine whether and when eye and physical contact are appropriate) – elicit the patients’ perceptions of their illnesses as a component of the presentation of illness, being sensitive to their use of terminology or symptomatology – take a social history from patients with special reference to their cohort experiences (e.g., Where were you born? Have you emigrated from another country or region? If so, how old were you? Please describe the reason for that immigration and how it affected you. With what culture(s) do you identify? Give me some examples of friends or family who have had good or bad healthcare experiences and why.) – demonstrate culturally appropriate use of touch and respect for modesty during physical examination – recognize varied presentations of diseases in patients with different skin tones (e.g., anemia, jaundice, rash, pressure ulcers, frostbite)
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– elicit elders’ preferences for making their own healthcare decisions or identifying a family member to make decisions on their behalf – include spiritual advisors and providers of alternative medicine or native healers in the healthcare team as appropriate – implement effective patient education strategies that are based on an understanding of a variety of world views (e.g., holism, interdependence, rational, independent) – identify situations in which communication or interaction did or did not work and analyze ways to modify unsuccessful approaches and replicate those that are successful – find cultural guides or brokers within the patient’s community who can help providers solve difficult interactions and bridge gaps in communication – incorporate cultural healthcare practices into treatment when appropriate
Instructional Strategies The opportunities available to incorporate strategies for implementing parts or all of the core competencies into each curriculum will determine the strategies. For example, core competencies could be integrated into a preclinical class, clinical rotation in geriatrics, or community medicine course for medical students. Family medicine, internal medicine, or psychiatry residents could attend a series of didactic presentations during a geriatric rotation. Geriatric fellowship training programs could develop a series of seminars, combined with targeted clinical experiences, to incorporate important issues related to cultural competency. Overall, it is important that curricular activities allow trainees to interact with patients of diverse cultural backgrounds. Recommended instructional strategies include opportunities to: – develop cases to illustrate the complexity of ethnogeriatric issues – use standardized patients to teach and evaluate trainee performance because these are especially appropriate for developing effective communication skills – make referrals to courses on ethnogeriatrics available on the Internet – involve students in interactive case studies using branching logic or progressively complex questions – provide CD ROM instructional materials with cases – use a self-assessment tool, along with exercises, assignments, and an inventory of values/attitudes – develop cultural heritage/cultural competency workshops for new medical students – plan fun and unconventional ways to teach, such as mnemonics and game shows (e.g., ‘‘Geriatric Jeopardy’’) – arrange interviews or clinical experiences with elders from diverse ethnic backgrounds in community sites, such as ethnically oriented senior centers, community clinics, or in elders’ homes; ideally, follow these interactions with debriefing sessions (i.e., discussing the details of the visit in the classroom setting to expand the knowledge base)19,20 – invite senior consultants or peer teachers from diverse backgrounds to provide insights into the historical
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experiences and traditions of their cohort that can affect clinical interactions
CONCLUSION Good provider-patient relationships form the core of highquality medical practice. The foundation of this relationship is based on trust, which is developed over time and predicated on an appreciation of patients’ individual characteristics. The goal of developing cultural competency is neither to overemphasize nor underestimate the effects of culture in the healthcare encounter but to understand the influence of cultural factors on healthcare and health outcomes and to work with these factors in optimizing the services provided. Although it is important to be aware of various cultures and customs, cultural competence does not require familiarity with every culturally specific belief and behavior. Rather, it requires that clinicians respect the diversity of cultural perspectives that influence the health of individuals and communities.21 Achieving this goal is particularly compelling in view of the report by the Institute of Medicine recommending cultural competency education for all health professionals as a means of reducing healthcare disparities within the United States.2 Intercultural issues have profound ramifications for the health professions and should be increasingly integrated within education and training and clinical practice guidelines to ensure the delivery of high-quality care. ACKNOWLEDGMENTS The Writing Group would like to express sincere appreciation to the large number of colleagues who reviewed the manuscript, especially Dr. Reva Adler, Chair of the Ethnogeriatrics Committee of AGS, Dr. David Reuben, Chair, and other members of the University of California AGRP Advisory Committee, Dr. Jerry Johnson and Dr. Joseph Ouslander, past presidents of AGS, and members of the AGS Education and Ethnogeriatrics Committees.
REFERENCES 1. Federal Interagency Forum on Aging-related Statistics. Older Americans 2000. Key Indicators of Well-being, Population Section. Washington, DC: Federal Interagency Forum on Aging-related Statistics, 2000.
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2. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment. Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press, 2003. 3. Briggance B. Shaping America’s health care professions. The dramatic rise of multiculturalism. West J Med 2002;176:62–64. 4. Sondik E, Lucas J, Madans J et al. Race/ethnicity and the 2000 Census: Implications for public health. Am J Public Health 2000;90:1709– 1713. 5. U.S. Department of Health and Human Services. The President’s Initiative on Race, Health Care Access for All: Barriers to Health Care for Racial and Ethnic Minorities: Access, Workforce Diversity, and Cultural Competence. Washington, DC: U.S. Department of Health and Human Services, 1998. 6. Addressing Racial and Ethnic Disparities in Health Care. Fact Sheet, February 2000 (AHRQ Publication no. 0–P041). Rockville, MD: Agency for Healthcare Research and Quality, 2000. 7. Epstein AM, Ayanian JZ, Keogh JH et al. Racial disparities in access to renal transplantation: Clinically appropriate or due to underuse or overuse? N Engl J Med 2000;343:1537–1544. 8. Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA 2002;287:1288–1294. 9. Mayberry RM, Mili F, Vaid IGM et al. Racial and Ethnic Differences in Access to Medical Care: A Synthesis of the Literature. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 1999. 10. Mukamel A, Ananthram M, Weiner D. Racial differences in access to highquality cardiac surgeons. Am J Public Health 2000;11:1774–1777. 11. Weinick RM, Zuvekas SH. Racial and ethnic differences in access to and use of health care services, 1977–96. Med Care Res Rev 2000;57:36–54. 12. Andrews R, Elixhauser A. Use of major therapeutic procedures: Are Hispanics treated differently than non-Hispanic whites? Ethn Dis 2000;10:384–394. 13. Kleinman A, Eisenberg L, Good B. Culture, illness, and care. Ann Intern Med 1978;88:251–258. 14. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev 2000;57:181– 217. 15. Cross TL, Barzon BJ, Dennis KW et al. Towards a Culturally Competent System of Care. A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center, 1989. 16. Fadiman A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus & Giroux, 1997. 17. Administration on Aging. Achieving Cultural Competence. A Guidebook for Providers of Services to Older Americans and Their Families [on-line]. Available at: http://www.aoa.gov/prof/adddiv/cultural/addiv_cult.asp Accessed September 18, 2003. 18. Core competencies for the care of older patients: Recommendations of the American Geriatrics Society. The Education Committee Writing Group of the AGS. Acad Med 2000;75:252–255. 19. Klein S, ed. Ethnogeriatrics. A National Agenda for Geriatric Education, White Papers. Rockville, MD: Bureau of Health Professions, U.S. Department of Health and Human Services, 1996. 20. Ishler K, Appendix C. Instructional strategies for interviewing elders from diverse ethnic backgrounds. In: Yeo G, ed. Curriculum in Ethnogeriatrics: Core Curriculum, 2nd Ed. Stanford, CA: Collaborative on Ethnogeriatric Education. Available at: www.stanford.edu/group/ethnoger September 18, 2003. 21. Hunt L. Beyond cultural competence: Applying humility to clinical settings. Park Ridge Ctr Bull, 2001.
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Appendix 1. Cultural Competency Resources An Administration on Aging Web site that contains a guidebook designed for use by providers of services to racially and ethnically diverse older populations: http://www.Aoa.gov/minorityaccess/guidbook2001/default.htm Additional information on the development of culturally sensitive curricula is provided in ‘‘Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care’’ by Like RC, Steiner RP, and Rubel AJ. Family Medicine 1996;29:291–297. A Web site for a curriculum in ethnogeriatrics, developed by the members of the Collaborative on Ethnogeriatric Education, includes a five-module core curriculum and 11 ethnic-specific modules: www.stanford.edu/group/ethnoger ‘‘Diversity, Healing and Health Care’’ is a Web-based resource for clinicians who work with patients whose cultures and religions are different from their own and can be accessed at http://www.gasi.org/diversity.htm Information on the explanatory models of illness is provided in ‘‘Culture, Illness, and Care’’ by Kleinman A, Eisenberg L, Good B. The Annals of Internal Medicine 1978;88:251–258. To order information on cohort experiences of elders from eight ethnic populations, see the Stanford Geriatric Education Center (SGEC) Web site at www.stanford.edu/dept/medfm/gec/page1.html ‘‘Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies’’ by Mutha S, Allen C, Welch M. from the Center for the Health Professions, University of California San Francisco, 2001. U.S. Department of Health and Human Services Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care: Final Report. Federal Register (December 22, 2000) 65:80865–80879.
