Welcome toEthnogeriatricsin Primary Care Presented by Gwen Yeo, PhD

Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA)

with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative.

This webinar is being offered by the San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as

the California Primary Care Office (PCO).

Welcome toEthnogeriatricsin Primary Care Presented by Gwen Yeo, PhD

The presentation will begin shortly

Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA)

with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative.

Ethnogeriatricsin Primary Care

Gwen Yeo, PhD

Stanford Geriatric Education CenterFunded by the Bureau of Health Professions

Questions to be Discussed

Why is ethnogeriatrics important ?

What tools do clinicians need to care for culturally diverse elders effectively?

How can clinics and other health care organizations reduce barriers for ethnically diverse elders?

Ethnogeriatric Imperative

Increasing numbers of elders from diverse ethnic backgroundsForty percent of U.S. population 65+ are projected to be from one of the four minority categories by midcenturyIncreasing heterogeneity within older ethnic populations

Our Ethnogeriatric ImperativeProjections of Percent of

Ethnic Minority Elders in U.S.

Stanford Geriatric Education Center

Projections of Growth of U.S. Minority Elders

AoA, 2010

Bob Chamberlin / Los Angeles Times

LA Times Feb. 12, 2009

Least Acculturated: Followers of Children

Consequences Of Diversity for Geriatric Clinicians

CELEBRATE THE DIVERSITYAPPRECIATE THE COMPLEXITY!NEED FOR CULTURAL COMPETENCE

ETHNOGERIATRIC CULTURAL COMPETENCE FOR CLINICIANS

Effects of Race and Sex on Physician Referrals

00.10.20.30.40.50.60.70.80.9

1

White Male Black Male White Female Black Female

Odds ratio for referral for cardiac catheterization (n=720)

Source: Schulman et al., NEJM 340:8, 1999

Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.

Cultural Humility

Tervalon, & Murray-Garcia. J Health Care for Poor & Underserved, 1998

27

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Knowledge and Skills in Ethnogeriatric Care

Know Clinically RelatedDemographic Characteristics

Educational Background e.g. ~ half of Mexican American elders in CA have less than 9 years of education.English Proficiency e.g. ~ 60% CA Chinese Am. & Korean Am.,~ 80% from SE Asia, and 40% of Mexican Am. elders speak little or no English(See demographic chart in handouts)

Cohort AnalysisCohort analysis is a tool to understand the impact of historical experiences of various ethnic cohorts on the lives of elders.

Helps to understand influences on elders' trust and attitudes toward the health care system.

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

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

Use of cohort analysis in clinical care: Incorporate quickly into family health historyTaking relevant social histories.

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Available at :http://sgec.stanford.edu/resources/sgec_order_resources.html

Non-Western non-biomedical traditions e.g. balance theoriesTraditional treatments e.g., herbal medicines that might interact with prescriptions, coining and cupping

Health Related Cultural Values and

Practices

Stanford Geriatric Education Center 2008

CUPPING

Ethnogeriatric Skills/CompetenciesShow elders culturally appropriate respect

How would you know what might be culturally appropriate?

Shake hands? Bow? Eye contact?

Demonstrating Respect To Older Patients In Culturally Appropriate Ways

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Non-verbal Communication

A.A. Pace of conversation & tone of Pace of conversation & tone of voicevoice

B.B. Physical distancePhysical distance

C.C. Eye contactEye contact

D.D. Emotional expressivenessEmotional expressiveness

E.E. GesturesGestures

F.F. TouchTouch

ETHNOGERIATRIC CURRICULUM: MODULE FOUR

http://www.stanford.edu/group/ethnoger/module_four.htmlhttp://www.stanford.edu/group/ethnoger/module_four.html49

Body gestures can be easily misinterpreted based on what is considered culturally appropriate.

Individuals from some cultures may consider some types of finger pointing or other typical American hand gestures or body postures disrespectful or obscene. Others may consider vigorous hand shaking as a sign of aggression

Nodding may not mean agreement but rather just mean “I’m listening.”

When in doubt, ask an interpreter or other cultural guide. 50

GESTURES

TOUCH While physical touch is an important form of non-verbal communication, the etiquette of touch is highly variable across and within cultures. Practitioners should be thoroughly briefed about what kind of touch is appropriate for cultures with which they work.

Asking permission for physical exams is a sign of respect for many elders.

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Eliciting Explanatory Models of Illness

(Arthur Kleinman, MD, and colleagues)1. What do you call your problem?2. What do you think caused it?3. Why do you think it started when it did?4. What does it do to you?5. How severe is it?6. What do you fear most about it?7. What are the chief problems it has caused you?8. What kind of treatment do you think you should receive?

Explanatory Models: Chief Complaint (76 Cambodian Elders in San Jose)

Contributory: Multiple EMs Cited Pruiy chiit kiit chraen 68% Physical Stress 67% Aging 57% Imbalance of the elements 53% Karma 53% Excess “hot” element 45% “Wind illness” 41% Saasey (misalignment) 37%

Source: Handelman & Yeo, 1994

DISPARITIES IN HEALTH RISKAND

MANAGEMENT OF CHRONIC DISEASE

Diabetes in Older Women of Color

0

5

10

15

20

25

30

35

African Am. Am.Indian Mexican Am. NH White

Source: NIH, Women of Color Health Data Book, 1998

Percent

All Cancer Death Rates in U.S. Men, 2007

Rates are per 100,000 persons.

CDC's Division of Cancer Prevention and Control

12 Month Prevalence of Depressionin U.S. Elders 65+

IOM, 2012

DEPRESSION

Cultural Issues in Assessment of Depression Somatization common in some Asian populationsGeriatric Depression Scale is a screening tool available in 36 different languagesDownload from

http://www.stanford.edu/~yesavage/GDS.html

Barriers to Mental Health Treatment• STIGMA• Beliefs about mental illness• Lack of providers from same

background• Lack of information about services• Lack of age and

culturally/linguistically appropriate services

• Lack of transportation• Lack of funds IOM, 2012

Treatment Preferences of Older Mental Health Patients by Ethnicity

African Am. more likely to seek spiritual adviceLatinos more likely to prefer medications, less likely to prefer group counselingAsian Am. did not express a strong preference, but much less likely to prefer group counseling

Jimenez et al., 2012

Prevalence of DementiaNorth Manhattan Study (N=1449)

0

10

20

30

40

50

60

Hispanic African Am NH White

65-74 75-84 85+

Gurland et al., Nat. Research Council, 1997

SALSA StudySacramento Area Latino Study on Aging

N= 1778 aged 60+ 45% born in Mexico, 49% in USMean years of education: 4.7 for Spanish speakers, 10.7 for EnglishOverall dementia prevalence: 4.8%Risk 8x higher for those with diabetes and stroke

Haan et al., 2003

Cultural Influences on Late Presentation for Assessment~Normalization: Belief that dementia symptoms are a normal part of aging~Belief that dementia has spiritual, psychological, health or social cause~Shame or stigma~Belief that nothing could be done~Lack of trust in the health care system~

Mukadam et al., 2010

Cross-cultural Dementia Screening t

~ CASI (Cognitive Assessment Screening Instrument) Teng, Hasegawa, Homma et al. Int. Psychogeriatr 6 (1) 45-58. 1994.

~ RUDAS (Rowland Universal Dementia Assessment Scale. Storey, Rowland, Basic, et al. Int. Psychogeriatr 16 (1), 13-31, 2004.

Resource:Edited volume with chapters by

experts from diverse populationsEthnicity and the Dementias,

2nd Ed. (Yeo & Gallagher-Thompson, Eds.) Taylor & Francis/Routledge, 2006

4 chapters on assessment14 chapters on working with families

(Royalties go to Stanford GEC)

Relationship of Caregiver Percentage of Ethnic Patients

0

10

20

30

40

50

Spouse Son Daughter Other Rel. Friend

White Black Hispanic Asian/PI

Yeo et al, 1996 Ethnicity & Dementias

End of Life Issues

ADVANCE DIRECTIVES

Giving up HopeGod’s TimingFamily DecisionHospice Model

Talking about Death

Beliefs about Pain Relief

Autopsy & Organ Donation

Rituals

Institutional Cultural Competence

CONTINUUM OF CULTURAL PROFICIENCY

Destructiveness Blindness Proficiency

Incapacity Competence Cross et al, 1989

What Motivation Would Health Care Organizations Have to Move Up the

Continuum of Organizational Proficiency?

The Joint Commission

CLAS Standards

Reduction of Medical ErrorsEvidence Based Care

Standards for Culturally and Linguistic Appropriate Services

(CLAS)14 Standards for Health Care Organizations4 Mandated – Language Services9 Recommended as Mandates – Cultural Competence1 Voluntary-Public Information

http://www.omhrc.gov/CLAS

Stanford Geriatric Education Center

CLAS Standards #4,5,6,&7

LANGUAGE ACCESS

•Language assistance services to patients with limited English proficiency (LEP)

•Notice of right to language assistance

•Assure competence of language assistance

•Family and friends should not be used

•Easily understood written material

•Signage

Evidence Base on Interpreters“-- the findings of this review suggest that professional interpreters are associated with an overall improvement of care for LEP patients. .. decrease communication errors, increase patient comprehension, equalize health care utilization, improve clinical outcomes, and increase satisfaction with communication and clinical services for limited English proficient patients.” Karliner et al. 2007

“Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters”. Flores et al, 2012

Use of professional interpreters at admission and/or discharge result in shorter length of stay and lower readmission rates. Lindholm et al, 2012

More Strategies for Organizations to Reduce Cultural Barriers

Recruit ethnic guides and consultants from patient populations

Create a welcoming environment

Stanford Geriatric Education Center

Organizational Barriers to Ethnogeriatric Proficiency

The American health care culture itself is a barrier to elders who are

less acculturated to it

Resource from American Geriatric Society

Doorway Thoughts:  Cross-Cultural Health Care for Older Adults addresses the role of ethnicity in health decision-making in America. Three small volumes focus on how clinicians caring for older adults can develop an understanding of different ethnic groups in order to effectively care for their older patients

Please feel free to contact me for follow-up questions or information

gwenyeo@stanford.edu

For More Ethnogeriatric Resources, seeStanford Geriatric Education Center Website

http://sgec.stanford.edu