An older woman with dementia has home health care. At 5 a.m., her caregiver notices the woman trying to get out of bed and moving her hands. She thinks the woman is agitated and calls the doctor, who prescribes something to calm the patient. It doesn’t occur to either that this woman, a devout Muslim, is just trying to pray. It’s something she has done five times a day all her life.
An elderly patient who received a prosthesis after a leg amputation reported vague pain and discomfort on follow-up doctor visits. A home health physical therapist could not determine a specific cause. During an evaluation, the doctor did not see any reason for an improper fit. Finally, the patient said she believed that because God allowed her leg to be amputated, she didn’t believe it was right to replace it.
As the elderly population becomes more racially and ethnically diverse, officials say the health care industry lacks proper resources to address the growing cultural, religious and language divide.
The U.S. elderly immigrant population rose from 2.7 million in 1990 to 4.6 million in 2010, a 70 percent increase in 20 years. And it’s still on the rise.
It is estimated that the number of U.S. immigrants 65 and older will quadruple to more than 16 million by 2050. In 2014, about 15 percent of people age 65 and older live in a home where a language other than English was spoken. In 2010, more than 1 in 8 adults 65 and older were foreign born, a number that is also expected to continue to grow.
“A lot of immigrants from the Middle East moved here in the 1970s. Now they are older,” said Mehrdad Ayati, MD, founder of the Geriatric Concierge Center in Menlo Park, California. “The majority of people I see, they immigrated here because their children were here. They take care of their grandchildren. They’ve become isolated.”
When they need health care, particularly home health care, it becomes a challenge.
Cultural Value Systems
“They don’t speak English well. So they can’t communicate with their caregivers,” Ayati said. “They have a perception mentally that they will live with their family, and that’s not always possible. Or they don’t want the caregiver in their home.”
Just 20 percent of Hispanics age 40 and older are “extremely or very confident” that home health aides can take their cultural needs into account, according to a recent study from The Associated Press-NORC Center for Public Affairs Research, a Chicago-based research and journalism partnership.
The study showed that 16 percent of older Hispanic adults are confident that nursing homes can meet their cultural needs, and 18 percent feel the same about assisted living communities. Of those who experienced a cultural or language barrier in the health care system, 67 percent said it resulted in stress or delays in getting care, and 51 percent said it took more time and effort to overcome those barriers.
Many immigrants are from Asian, African or Middle Eastern cultures where older people are given a lot of respect “so they don’t like having a caregiver tell them what to do,” Ayati said. “It makes them more anxious. It seems small, but it’s going to be a huge issue.”
John T. Brinkmann, assistant professor and research prosthetist at Northwestern University in Chicago, said providing care in a patient’s home can give a practitioner important insight into an individual’s value system and culture and gives a more realistic picture of the individual’s life and routines.
But, “it can also challenge the power dynamics of a traditional medical encounter, since we’re now on their ‘turf,’” Brinkmann said. “Rather than directing patients to a particular room or chair, we need to show deference to their preferences regarding where we perform our duties.
“I’ve always tried to remain sensitive to the reality that I’m a guest in their home,” Brinkmann said. “It can be challenging to balance that sensitivity with the need to still carry out all of our responsibilities, but I believe that type of challenge makes us better practitioners.”
Education is Key
Ayati said education is key. “The main thing we are lacking is education for caregivers to understand cultures. We are so behind on that,” he said. “As a geriatric doctor, I’m very concerned about the future. How many caregivers are getting this information and education from qualified people?”
To address the issue, Ayati spoke to the U.S. Senate Special Committee on Aging in January 2018. “I was impressed by how interested they are in the issues facing the aging population,” he said. “I was very happy they are starting to get into this conversation.”
Ayati came to the United States from Iran, and his native tongue is Farsi. He has yet to see any materials that help caregivers understand the Farsi-speaking population. “There’s nothing. Not even a booklet.”
Support from large organizations at the national level is vital to get the word out. “We need to talk about it,” Ayati said.
Brinkmann said NCOPE, the accreditation body for prosthetics/orthotics education programs, requires that students receive instruction on cultural aspects of health care.
“There is a growing awareness of the importance of psychosocial aspects of care in general, and greater sensitivity to cultural differences,” Brinkmann said. “I’ve seen changes in the medical school curriculum, and anticipate that our future curriculum will include more specific elements to address this important area.”
Brinkmann said it is tough to know if the issue is being given enough exposure, “but the movement we’re making is encouraging.”
One way to educate about cultural differences is to recruit and support prospective students from diverse backgrounds. “When we modify our education strategies in consideration of students with different cultural backgrounds, we’re modeling how these differences can be handled appropriately,” Brinkmann said.
“I believe we will continue to see greater diversity in every aspect of life,” Brinkmann said. That’s important because “it’s easy to paint with too broad of a brush when considering norms and values.”
Cultural differences, Brinkmann pointed out, exist in even more ways than those related to language, religion or nation of origin. “For instance, there can be significant differences between two families who live in the same broader religious or ethnic culture, and even between individuals within that family.”
Brinkmann also believes we underestimate the cultural divide between individuals at different socioeconomic levels. “We’ve gotten used to particular ways of dealing with payment issues, for instance, and as our health care system changes we will experience different challenges related to those types of disparities,” he said.
A student recently asked Brinkmann whether it was important to know if an individual was biologically male or female. “The question and the discussion were eye-opening for me,” he said. “We concluded that in many cases that question is unnecessary, since the answer wouldn’t impact the person’s prosthetic/orthotic care. Knowing if, when, and how to ask questions like that could become a bigger issue in the next 10 to 20 years.”