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Welcome to Ethnogeriatrics in Primary Care

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Title: Multicultural Aspects Of Aging Author: Gwen Yeo Last modified by: Strayhand, Tricia_at_OSHPD Created Date: 7/18/2000 3:00:42 AM Document presentation format – PowerPoint PPT presentation

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Title: Welcome to Ethnogeriatrics in Primary Care


1
Welcome to Ethnogeriatrics in 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).

2
Welcome to Ethnogeriatrics in 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.

3
Ethnogeriatrics in Primary Care
  • Gwen Yeo, PhD
  • Stanford Geriatric Education Center
  • Funded by the Bureau of Health Professions

4
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?

5
Ethnogeriatric Imperative
  • Increasing numbers of elders from diverse ethnic
    backgrounds
  • Forty percent of U.S. population 65 are
    projected to be from one of the four minority
    categories by midcentury
  • Increasing heterogeneity within older ethnic
    populations

6
Our Ethnogeriatric Imperative Projections of
Percent of Ethnic Minority Elders in U.S.
7
Projections of Growth of U.S. Minority Elders
AoA, 2010
Stanford Geriatric Education Center
8
Least Acculturated Followers of Children
Bob Chamberlin / Los Angeles Times
LA Times Feb. 12, 2009
9
Consequences Of Diversity for Geriatric Clinicians
  • CELEBRATE THE DIVERSITY
  • APPRECIATE THE COMPLEXITY!
  • NEED FOR CULTURAL COMPETENCE

10
  • ETHNOGERIATRIC CULTURAL COMPETENCE FOR CLINICIANS

11
Effects of Race and Sex on Physician Referrals
Source Schulman et al., NEJM 3408, 1999
12
Cultural Humility
  • 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.

Tervalon, Murray-Garcia. J Health Care for Poor
Underserved, 1998
27
13
Knowledge and Skills in Ethnogeriatric Care

42
14
Know Clinically Related Demographic
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)

15
Cohort Analysis
  • Cohort 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 history
  • Taking relevant social histories.

39
16
Available at http//sgec.stanford.edu/resources/
sgec_order_resources.html
17
Health Related Cultural Values and Practices
  • Non-Western non-biomedical traditions e.g.
    balance theories
  • Traditional treatments
    e.g., herbal medicines that might
    interact with prescriptions, coining
    and cupping

18
CUPPING
Stanford Geriatric Education Center 2008
19
Ethnogeriatric Skills/Competencies
  • Show elders culturally appropriate respect
  • How would you know what might be culturally
    appropriate?
  • Shake hands?
  • Bow?
  • Eye contact?

20
Demonstrating Respect To Older Patients In
Culturally Appropriate Ways
  • Acknowledge and greet older persons first.
  • Generally, use formal term of address (Mr.,
    Mrs.), at least initially.
  • Train office staff to do the same

48
21
Non-verbal Communication
  • A. Pace of conversation tone of voice
  • B. Physical distance
  • C. Eye contact
  • D. Emotional expressiveness
  • E. Gestures
  • F. Touch
  • ETHNOGERIATRIC CURRICULUM MODULE FOUR
  • http//www.stanford.edu/group/ethnoger/module_four
    .html

49
22

GESTURES
  • 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 Im listening.
  • When in doubt, ask an interpreter or other
    cultural guide.

50
23
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.

51
24
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?

25
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
26
Disparities in health Risk and Management of
Chronic disease

27
Diabetes in Older Women of Color
Percent
Source NIH, Women of Color Health Data Book,
1998
28
All Cancer Death Rates in U.S. Men, 2007 Rates
are per 100,000 persons.
CDC's Division of Cancer Prevention and Control
29
12 Month Prevalence of Depression in U.S. Elders
65
DEPRESSION
IOM, 2012
30
Cultural Issues in Assessment of Depression
  • Somatization common in some Asian populations
  • Geriatric Depression Scale is a screening tool
    available in 36 different languages
  • Download from
  • http//www.stanford.edu/yesavage/GDS.html

31
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
32
Treatment Preferences of Older Mental Health
Patients by Ethnicity
  • African Am. more likely to seek spiritual advice
  • Latinos more likely to prefer medications, less
    likely to prefer group counseling
  • Asian Am. did not express a strong preference,
    but much less likely to prefer group counseling

Jimenez et al., 2012
33
Prevalence of Dementia North Manhattan Study
(N1449)
Gurland et al., Nat. Research Council, 1997
34
SALSA Study Sacramento Area Latino Study on Aging
  • N 1778 aged 60
  • 45 born in Mexico, 49 in US
  • Mean years of education 4.7 for Spanish
    speakers, 10.7 for English
  • Overall dementia prevalence 4.8
  • Risk 8x higher for those with diabetes and stroke
  • Haan et al., 2003

35
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
36
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.

37
Resource Edited volume with chapters by experts
from diverse populations Ethnicity and the
Dementias, 2nd Ed. (Yeo Gallagher-Thompson,
Eds.) Taylor Francis/Routledge, 2006 4
chapters on assessment 14 chapters on working
with families (Royalties go to Stanford GEC)
38
Relationship of Caregiver Percentage of
Ethnic Patients
Yeo et al, 1996 Ethnicity Dementias
39
(No Transcript)
40
End of Life Issues
  • Talking about Death
  • Beliefs about Pain Relief
  • Autopsy Organ Donation
  • Rituals
  • ADVANCE DIRECTIVES
  • Giving up Hope
  • Gods Timing
  • Family Decision
  • Hospice Model

41
Institutional Cultural
Competence
CONTINUUM OF CULTURAL PROFICIENCY
Destructiveness Blindness
Proficiency
Incapacity
Competence
Cross et al, 1989
42
What Motivation Would Health Care Organizations
Have to Move Up the Continuum of Organizational
Proficiency?
The Joint Commission
Reduction of Medical Errors
Evidence Based Care
CLAS Standards
43
Standards for Culturally and Linguistic
Appropriate Services (CLAS)
  • 14 Standards for Health Care Organizations
  • 4 Mandated Language Services
  • 9 Recommended as Mandates Cultural Competence
  • 1 Voluntary-Public Information
  • http//www.omhrc.gov/CLAS

44
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

Stanford Geriatric Education Center
45
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

46
More Strategies for Organizations to Reduce
Cultural Barriers
  • Recruit ethnic guides and consultants from
    patient populations
  • Create a welcoming environment

47
Organizational Barriers to
Ethnogeriatric Proficiency
  • The American health care culture itself is a
    barrier to elders who are less acculturated to it

Stanford Geriatric Education Center
48
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

49
For More Ethnogeriatric Resources, see Stanford
Geriatric Education Center Website http//sgec.st
anford.edu
Please feel free to contact me for follow-up
questions or information gwenyeo_at_stanford.edu
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