Cross Cultural Care and Education in
Geriatrics
Jerry Johnson, M.D.
Professor of Medicine
University of Pennsylvania
Objectives
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Overall Goal: Preparation to Teach Cross Cultural
Aspects of Geriatrics
 Anticipate
predictable challenges
 Relate your teaching content to the domains of cross
cultural interactions
 Apply mnemonics for interactions with patients and
caregivers
 Use diverse approaches to teaching
 Identify resources for education and learning
Crossing the Quality Chasm
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“The system by which health care is delivered
and financed must be designed to ensure that care
is safe, effective, efficient, equitable, timely, and
tailored to each individual’s specific needs and
circumstances.”
- Institute of Medicine Report, 2001
Analytic Framework: Cultural Diversity
Training for Providers
Cultural diversity
training
programs for
providers
Increase provider
sensitivity to attitudes
and beliefs which
marginalize ethnic
groups
Increase provider
abilities and strategies
for cross-cultural
interactions
Increase provider
knowledge of
culturally-based
beliefs and behaviors
Decrease differential
treatment due to
unconscious
discrimination
Greater client
adherence to
care and treatment
recommendations
Increase use of
culturally appropriate
health care interventions
Improved
health status
outcomes
Decrease ethic
differentials
in utilization
and treatment
Greater
satisfaction
with care
Challenges of Cross-cultural Care
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Defining the concept of culture
Concern about stereotyping, relevance and legitimacy
Cross cultural care overlaps with other aspects of clinical
care: professionalism, humanism
Multiple levels of cultural competence
 the
health professional- patient relationship
 the health system
 the community
What is Culture?
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Acquired attitudes, values and beliefs or “unwritten rules
of behavior.”
Caveats
 Culture is not synonymous with race or ethnicity,
but...
 “Culture is not a fixed, knowable entity that guides
individuals’ behaviors in linear ways” (see Gregg J.
Losing Culture on the Way to Competence: the use and misuse
of culture in medical education. Acad Med 2006: 81: 542-547).
 Culture is mutable and multiple.
Cross cultural education is
relevant because health care is
delivered in a cultural context.
Relevant Cultural Constructs
• The culture of the patient
• The culture of the practitioner
• The culture of the practitioner’s profession:
e.g. medicine, nursing, and social work.
• The culture of the workplace: health
system, institution, or other entity
Relevance of Group Identities
Each individual’s identity is partly determined by
group affiliation: gender, ethnicity, religion....
 Preservation of these group identities for many is
a matter of self esteem
 Group identity partly determines how others view
us and interact with us

Cox, Taylor . Cultural Diversity in Organizations. 1993
Content Areas or Domains of
Cross- Cultural Care
Content Areas Relevant to Interactions
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Self awareness
World view
Causation or explanatory models
Spirituality
Complementary alternative medicine
Help-seeking behavior (community and family)
Language and health literacy
Historical, social and economic factors
CREATE SOME REPRESENTATIVE CASES
Case Example: Explanatory Model
and Alternative Healing

Depression in a 75 yo man, self explained by the
patient, and treated outside the formal health care
system.
Case Example: Spirituality
Woman with multiple admissions for CHF
accompanied by markedly elevated BP, who
believes her faith, not medications, will treat
HTN.
 Woman dying of metastatic breast cancer who
wants chemotherapy as an example of “being
strong” and maintaining faith.

Case Example: Language issues
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Russian speaking man admitted with pain and gait
dysfunction
Case Example: social and economic
factors
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Woman with large family, inadequate funds,
under significant stress
Negotiating with Patients and
Families
Conceptual Framework

Emphasis on the illness and its context:
 Kleinman’s
questions: Eisenberg et al. Culture, illness, and
care: clinical lessons from anthropologic and cross cultural
research. 1978

Carillo et al. Cross cultural primary care: a patient based approach. Annal Int
Med 130:829, 1999
 Explore the meaning of illness
 Conduct a social context “review of systems”
 Negotiate management
Kleinman’s Questions
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1 What caused it?
2 Why now?
3 How affects you?
4 How severe is it?
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5 What treatment?
6 What results expected?
7 What chief problem?
8 What do you fear most?
9 What duration?
Mnemonics
Mnemonics for Cultural Interactions
 LEARN
 BELIEF
 RESPECT
 ETHNIC
and ETHNICS
 BATHE
 ADHERE
 Others
LEARN
Listen with sympathy and understanding to the
patient’s perception of the problem
 Explain your perceptions of the problem
 Acknowledge and discuss the differences and
similarities
 Recommend treatment
 Negotiate treatment
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Berlin E. Western Journal of Med 1983; 139: 934-938
BELIEF
Health Beliefs (What caused your illness ?)
 Explanation (Why did it happen?)
 Learn (Help me understand your belief/opinion)
 Impact (How is this illness affecting your life?)
 Empathy (This must be very difficult for you)
 Feelings (How are you feeling?)
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RESPECT
Respect: a demonstrable attitude
 Explanatory model: patient explanation of cause
 Social cultural context: gender, migration status,
sexual orientation, economic group, history
 Power differential: acknowledge it
 Empathy: put into words
 Concerns and fears: eliciting them
 Therapeutic alliance and trust
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ETHNIC and ETHNIC(S)
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Explanation : What do you think is the reason for your
sx?
Treatment: What kinds of treatment have you tried, what
kinds of treatment do you want?
Healers: Advice from alternative healers?
Negotiate: discuss options and expected results
Intervention. Determine an intervention
Collaboration
Spirituality or Seniors
Levin, S. Ethnic. Patient Care 2000; 34 (9): 188-189
BATHE
Background (what is going on in your life?)
 Affect (How do you feel?)
 Trouble (What troubles you most?)
 Handling (coping)
 Empathy (That must be very difficult)
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ADHERE
Acknowledge (need for treatment and joint goals)
 Discuss (potential treatments and alternatives)
 Handle (questions)
 Evaluate (health literacy and barriers to
adherence)
 Recommend (treatment)
 Empower (the patient by listening)
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General Tips in Cross Cultural Care
Avoid idioms
 Use titles such as Mr. and Miss
 Yes does not always mean yes
 Be cautious of touching
 Use trained interpreters when available
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TRAINING TOOLS AND APPROACHES
Large Group Exercises
Aging Panel: Who are the elderly
 Working with interpreters-film
 Spirituality panel and case discussions
 CAM presentation with practitioners
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Small Group Activities
Discussion sessions following large groups, often
with guests (seniors, chaplains)
 Self awareness exercises
 Introduction to the Physical Community
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 part
of a home visitation course
 Narrated van tour of West Philadelphia
 Resident and fellow presentations in community sites
Faculty and Preceptor Education
One or two orientation sessions per year
 Materials prepared with key readings and
discussion questions for small groups
 Debriefings after small group sessions
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Evaluation
Students: one or two page description of an
experience with presentation to peers in a small
group
 Focus groups of trainees
 Critique of presentations and sessions: value,
lessons learned
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References and Materials
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Full Curricula
 UCSF:
Culture and communication in health care, a
curriculum
 TACCT: Tool for assessing cultural competence
training : a project initially privately funded, now
adopted by the AAMC
References and Materials
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Monographs and articles
 Doorway
Thoughts-American Geriatrics Society
 Ham and Sloan: Cased Based Primary Care Geriatrics,
chapters on Ethnic and Cultural Aspects of Geriatrics
(4th and 5th editions). Jerry Johnson
Other Resources for Teaching
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Stanford: stanford.edu/group/ethnoger
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HRSA website: cultural and linguistic competence
education:
www.hrsa.gov/culturalcompetence/curriculumguide
The California Endowment website
Kaiser Foundation website
Manager’s electronic resource center (ERC) a cultural
competence quiz produced by Management Sciences for
Health
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Summary
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Cultural differences are common and germane.
The process of inquiry, rather than knowing a set of facts
about a group, is fundamental.
Knowledge of critical domains can direct the interaction.
Several mnemonics are available.
Discussions and interactive exercises work.
Extensive resources on cross cultural care are available.
Culture matters