Aging and Diversity
• Within racial/ethnic minority groups there
is further diversity. For example, Asian
Americans comprise 26-census-defined
sub-ethnic groups. While some segments
of the Asian population have been in the
United States for many generations,
others have arrived only recently. They
have come from more than two dozen
countries. They do not share a common
language, a common religion, or a
common cultural background.
Aging and Diversity
• Approximately three million foreign-born
persons 65 years of age or older live in the
United States. Among them, more than
one third were born in Europe, one third in
Latin America, and one fourth in Asia.
• In the future, increasing numbers of
foreign-born older adults will likely be from
Latin America and Asia ( He, 2002 ).
• In 2050, 16 million of the projected 81
million elderly will be foreign born (Pew
Center, 2008).
Aging and Diversity
• Older women represent over 58 percent of
the population aged 65 years and over,
more than two-thirds (69 percent) of the
U.S. population aged 85 years and over,
and 80 percent of the population aged 100
years and over.
• The U.S. Census Bureau projects that by
2030, the number of women aged 65
years and over will double to 40 million
(U.S. Census Bureau Population Division,
2006).
Aging and Diversity
• The number of
lesbian/gay/bisexual/transgender
(LGBT) older adults is increasing. The
National Gay and Lesbian Task Force
estimated that one to three million
Americans over 65 have LGBT sexual
orientation. By 2030, roughly four million
older Americans will identify as lesbian,
gay, bisexual or transgender (National
Gay and Lesbian Task Force, 2005).
Aging and Diversity
• At later life this issue commingles with age
in many ways that expand the need for
cultural competencies beyond that of just
getting older and have an LGBT identity. If
the essence of cultural competence is to
affirm and value the dignity of the person
different from the mode, then issues of
age and LGBT require special attention
(National Gay and Lesbian Task Force, 2006 and the Task Force on Appropriate
Therapeutic Responses to Sexual Orientation, 2009).
Aging and Diversity
• As the baby boomer generation in the U.S.
ages, the rates of disability have dropped
considerably. According to data from the
National Long-Term Care Survey
(NLTCS), the chronic disability fell from
26.5% in 1982 to 19% in 2005, suggesting
that older adults are becoming healthier
and less disabled.
• In fact, the brunt of the disability process
appears to occur earlier in the life span
and not in old age (Martin, Freeman,
Schoeni, & Andreski, 2009).
Aging and Diversity
• Unfortunately, racial/ethnic older adults, and
those living in poverty do not share the same
advantages as older adults with greater lifetime
resources & access to health care (Bowen & González,
2008).
– Among African American elders, 25.7% report
mobility disability;
– Native American or Alaska Native elders (or
both), 20.6% percent report disability;
– Hispanic older adults, the rates of disability
appear to be similar to those of older Whites, at
18%; and
– Asian elders, 20%.
Aging and Diversity
• Although racial/ethnic minority groups
have also shown a decline in disability
over the decades, those who are living in
poverty have shown the smallest declines
in disability (Schoeni, Martin, Andreski,
Freedman, 2005).
– Thus, the intersection of race, ethnicity and
poverty can account for increased
disability.
Aging and Diversity
• Mental disabilities in late life are also on
the rise, as the number of people with
severe and persistent mental illnesses are
receiving better healthcare overall and are
living longer than in the past (e.g. Palmer,
Heaton & Jeste, 2004).
Aging and Diversity
• While most older adults are not poor, there
are a significant number of older
Americans living below the poverty line
– 3.4 million older persons - and an
additional 2.2 million “near poor.”
– The proportion of older adults living in
financially strained circumstances (living at
or below 50% of their area median income, the
definition HUD uses to determine eligibility for
social programs) is even higher and is
estimated to be approximately 10% of the
older population.
Aging and Diversity
• Racially/ethnically diverse older adults
experience poverty at a disproportionate
rate: 21.9% of elder African-Americans
and 21.8% of elder Hispanics were poor in
2001, compared to 8.9% of older Whites.
Aging and Diversity
• Almost half of older Hispanic women and
African-American women who live alone or with
non-relatives are poor (Proctor & Dalaker, 2002).
• The median income for Native American men
aged 65 or over is $9,967, as compared to
$14,775 for comparable white males.
• For women in this age group, the median income
is $6,004 for Native Americans compared with
$8,297 for whites. Overall, 20% of Native
Americans (versus 10% of whites) 65 years or
older live below the official poverty level.
Aging and Diversity
• While we celebrate the rich diversity
among older adults, we recognize that
culturally diverse older Americans often
are at greater risk of poor health, social
isolation, and poverty, than are their
younger counterparts.
• Evidence of racial and ethnic disparities
can be found across a broad spectrum of
health conditions and outcomes.
• Excessive deaths and excess morbidity
and disability are prevalent among racial
and ethnic minority elders.
Aging and Diversity
• A higher incidence of obesity, diabetes,
and hypertension, as well as an earlier
onset of chronic illness is evident in
minority older adults as compared to
majority older adults (AOA, 2008).
• Regarding older adults with an LGBT
identity, the challenges are many,
including poorer health care, and securing
reasonable housing, and caregiving
services.
Resilient but Not Impenetrable
 25% of the 65 year old and over
population live in rural areas.
Rural elders are becoming
isolated.
 The proportion of older adults in
rural communities is larger than the
proportion in urban areas primarily
as a result of younger populations
moving to larger urban areas.
Along with the out-migration of
younger people is an in-migration of
retired elderly.
Resilient but Not Impenetrable
Rural elders are one of the greatest at-risk
groups for experiencing physical & mental
health problems.
In many rural communities there are no
psychosocial services available to meet
the needs of the rural elderly.
"Take Care of Our Own" (Bushy, 2000)
 Traditional rural values stress:
 Self-reliance
 Conservatism
 Family network
 Work orientation
 Religion/ Fatalism
 Mistrust of health care professionals:
 Distrust of outsiders
 Fear associated with Tuskegee Syphilis Experiment
 "I don't know if that works for me."
Families: Family Structure
In the United states there are currently many
three, four, and five generation families as a
result of increased life expectancy.
There are fewer persons born into each
generation therefore, family trees are smaller.
The number of existing generations in families
along with the decreased numbers in each
generation has produced what Qualls (1996)
describes as “tall, skinny, family trees.”
Families: Changing Family Structures
Living Apart Together (LAT): is a more recent
phenomenon, which seems to have the potential of
becoming the third stage in the process of the social
transformation of intimacy. In contrast to couples in
‘commuting marriages’, who have one main household in
common, couples living in LAT relationships have one
household each. This article presents data on the
frequency of LAT relationships in Sweden and Norway,
and explores the variation which exists within LAT
relationships. The article argues that the establishment of
LAT relationships as a social institution requires the prior
establishment of cohabitation as a social institution.
(Levin, I. (2004). Living apart together: A new family form. Current Sociology, 52(2), 223-240)
Gay & Lesbian Aged

Older lesbians & gay men have concerns that
are related to their age & sexual orientation.



Nursing home or inpatient placement for themselves or
their mates.
 May lead to loss of contact.
Often no legal capacity to make medical, financial or
burial decisions for mate.
Different from cohort of other older adults.
Homosexuality was not “accepted” before 1969
Gay & Lesbian Aged
Older lesbians & gay men have concerns
that are related to their age & sexual
orientation.
 Nursing home or inpatient placement for themselves
or their mates.
 May lead to loss of contact.
 Often no legal capacity to make medical, financial or
burial decisions for mate.
 Different from cohort of other older adults.
Homosexuality was not “accepted” before 1969.
Culture: Religion/Spirituality
 National surveys indicate that older adults attach a high
value to their religious beliefs & behaviors.
 This is particularly true of ethnic & minority elders who
show a high degree of religious involvement.
 The vast majority of research finds that religious
involvement is associated with greater well-being & life
satisfaction, greater purpose & meaning in life, greater
hope & optimism, less anxiety & depression, coping with
stressful life events, more stable marriages & lower rates
of substance abuse.
McFadden, S.H. , 1996; Crowther, Parker, Larimore, Achenbaum, & Koenig,2002;
Koenig, 1990; Dull & Skokan, 1995
The SPIRITual History
S
P
I
R
I
T
Spiritual belief system
Personal spirituality
Integration with a spiritual community
Rituals or Restriction
Implications for medical care
Terminal events planning
Maugans T. (1996). Arch Fam Med, 5: 11-16
SPIRITual History Questions
What does spirituality mean to you?
What aspect of religion/spirituality would you
like me to keep in mind as I care for you?
Would you like to discuss the religious or
spiritual implications of your health care?
Maugans T. (1996). Arch Fam Med, 5: 11-16
1.
Which of the following would be good ways to promote cultural
competence in your workplace?
2.
Seek out information about the various customs, holidays and
religions of cultures different from your own that you will
encounter in your work.
3.
Try to bring your patients into mainstream American culture as
much as possible. It will be easier for them that way.
4.
Learn how to respectfully ask questions about cultural beliefs.
5.
Avoid talking to patients about anything other than medicine.
CULTURAL COMPETENCE IN
THE WORKPLACE
Integrated
Healthcare
Interdisciplinary Awareness
 Collaborative relations across disciplines
demonstrates a supportive, collaborative and
interdisciplinary team focused on improving
care for older adults.
 The structure of interdisciplinary teams has
evolved from a hierarchy, with the physician in a
"command" position, to a team interfacing many
different kinds of health care professionals,
each with separate and important knowledge,
technical skills, and perspectives.
(APA, 2007)
Interdisciplinary Teams: Balance Several Factors
(APA, 2007)
Older People & Health Care System
 Older people are disadvantaged by a health care
system not sensitive to their needs.
 Multiple morbidities
 Life span experiences
 Fragmented care
 Marginalization
 Ageism & Stigma
Everyone doesn’t need integrated model.
For example, someone with an earache.
However, because older adults often have
co-morbid conditions the integrated model
is very useful.
(APA, 2007)
1. What cultural factors could strongly influence a persons’
reactions to serious illness & decisions about healthcare?
GROUP QUESTION:
CULTURE & HEALTHCARE
Joe, an 85 year old African American male, was diagnosed with
hypertension 15 years ago. Joe exhibits dramatic fluctuations with his
blood pressure due to noncompliance with prescribed treatment regimens.
Joe’s physician discusses how Joe should manage his “hypertension”.
1.
What wording could the physician have used to help Joe understand
his condition?
2.
What other disciplines may have been involved in helping Joe
manage his hypertension better?
CASE VIGNETTE: JOE
“With so many factors to consider, how does
one move forward with developing cultural
competence without being overwhelmed with
the complexity and the dangers of
stereotyping, or reifying the culture of
others? Practicing “cultural humility” is the
key.”
California Health Advocates, 2009
CULTURAL HUMILITY
GROUP EXERCISE
1.
Identify your own cultural and family beliefs and values.
2.
Define your own personal culture/identity: ethnicity, age,
experience, education, socio-economic status, gender,
sexual orientation, religion…
3.
Are you aware of your personal biases and assumptions
about people with different values than yours?
4.
Challenge yourself in identifying your own values as the
“norm.”
5.
Describe a time when you became aware of being different
from other people.
California Health Advocates, 2009
Cultural Humility Defined
 A lifelong process of self-reflection and self-critique.
 “The starting point for such an approach is not an
examination of the client’s belief system, but rather having
health care/service providers give careful consideration to
their assumptions and beliefs that are embedded in their
own understandings and goals of their encounter with the
client.
 In practicing cultural humility, rather than learning to
identify and respond to sets of culturally specific traits, the
culturally competent provider develops and practices a
process of self-awareness and reflection.”
Dr. Melanie Tervalon and Jann Murray-Garcia , California Health Advocates,
2009
Cultural Humility: Values
Openness
Appreciation
Acceptance
Flexibility
Mia Luluquisen, Katherine Schaff & Sandi Galvez, Alameda County Public Health
Department (2009)
Cultural Skills Across Domains
Policy &
Advocacy
Organizational
Program
Planning:
Interpersonal
Personal
Cultural Skills Across Domains
Personal:
 Ability to regularly conduct self-evaluation about how
values and beliefs impact worldviews
Interpersonal:
 Ability to communicate with others who have different
language and worldview
 Capability to translate ways of seeing and behaving
from one culture into another
Cultural Skills Across Domains
 Program Planning:
 Ability to show respect for another culture’s values and
identity
 Capacity to include the cultural, social and environmental
influences on communities in program design
 Talent for building trust, developing relationships and
working with culturally diverse community members
 Organizational:
 Ability to establish organizational vision and leadership
that promotes a positive multicultural work environment
 Capability to create and implement policies and
procedures to foster diversity and inclusion
Cultural Skills Across Domains
Policy and Advocacy:
 Capability to assess and revise existing policies
and procedures in the planning, delivery and
evaluation of comprehensive programs and
services for diverse populations
 Capacity to review and revise policies that allocate
resources for culturally diverse populations, such
as translation and interpretation services
Cultural Competency & Cultural Humility
Cultural Competency can include:







mandates
laws
rules
policies
standards
practices
attitudes
Cultural Humility is a process and a lifelong
commitment to self-evaluation and critique to
improve relationships and outcomes.
On-line Resources
 Administration of Aging Achieving cultural competency: A guidebook
for providers of services to older Americans and their families.
http://www.aoa.gov/prof/adddiv/cultural/addiv_cult.asp
 Alzheimer’s Association Diversity Toolbox: Caring for Diverse
Populations.http://www.alz.org/professionals and
researchers_caring_for_diverse_populations.asp
 National Center for Cultural Competence
http://nccc.georgetown.edu/index.html
 Cultural Competence
http://www.alz.org/Resources/Diversity/downloads/GEN_EDU10steps.pdf
 Multicultural Outreach Manual
http://www.alz.org/national/documents/GEN_OUTMulticulturalManual.pdf
On-line Resources
 American Geriatrics Society Position Statement on Ethnogeriatrics.
http://www.americangeriatrics.org/products/positionpapers/ethno_comm
ittee.shtml
 Use of Interpreter During Clinical Encounters Position Statement
http://www.americangeriatrics.org/products/positionpapers/interpreter_0
22307PF.shtml
 American Psychiatric Association Ethnic Minority Elderly Curriculum
http://www.aagponline.org/prof/pdfs/08cultcompcur.pdf
 American Psychological Association Task Force on Diversity
Education Resources: Teaching and Learning about Aging (2008)
http://teachpsych.org/diversity/ptde/aging.php
On-line Resources
 Stanford University, Geriatric Education Center Curriculum in
Ethnogeriatrics http://sgec.stanford.edu/resources/ethno.html
 Ethnogeriatric Educational Resources including emergency
preparedness; mental health and diabetes; and, on line training
manuals on improving communication with elders of different cultures,
and diversity, healing and
healthcare;http://sgec.stanford.edu/resources/
 Our Ethnogeriatric Imperative Powerpoint by G. Yeo;
http://sgec.stanford.edu/pdf-word/Gwen_AAHPM.pdf
On-line Resources
 Initiative to Eliminate Racial and Ethnic Disparities in Health
(http://raceandhealth.hhs.gov/)
 Health Disparities Collaborative
(http://www.healthdisparities..net/hdc/html/home.aspx)
 American Public Health Association. “Eliminating Health
Disparities: Toolkit” (2004). http://www.apha.org/NPHW/toolkitPHW04-LR.pdf
Suggested Future Readings
 American Society on Aging. (2002). Recognizing diversity in aging,
moving toward cultural competence. Generations, 26(3).
 Jackson, J.S., Brown, E. and Antonucci, T.C., (2004). A cultural lens on
biopsychosocial models of aging. In P. Costa & I. Siegler (Eds.)
Advances in Cell Aging and Gerontology Vol. 15 (pp. 221-241). New
York: Elsevier.
 Xakellis, G., Brangman, S. A., Ladson Hinton, W., Jones, V. Y.,
Masterman, D., Pan, C. X., Rivero, J., Wallhagen, M., & Yeo, G. (2004).
Curricular framework: Core competencies in multicultural geriatric care.
Journal of the American Geriatric Society, 52, 137-142.
 Yeo, G. & Gallagher-Thompson, D. (Eds.), (2006). Ethnicity and the
dementias (2nd ed.), NY: Taylor & Francis.
Suggested Future Readings

LaVeist, T.A. (2005). Minority Populations and Health: An Introduction to Health
Disparities in the United States. San Francisco, CA: Jossey-Bass Publication.

Williams, D.R., Collins, C. (2001). Racial residential segregation: A fundamental
cause of racial disparities in health disparities. Public Health Reports, 116, 404416.

Baicker, K. Chandra, A. Skinner, JS, Wennberg, JE.(2004). Who are you and
where you live: How race and geography affect the treatment of Medicare
beneficiaries. Health Affairs. (www.healthaffairs.org)

Lu MC & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A
life course perspective. Journal of Maternal Child Health 7 (1) 13 130.

Satcher, D & Pamies, RJ (2006). Multicultural Medicine and Health Disparities.
New York, NY, McGraw-Hill Medical Publishing Division, 2006.