welcome to ethnogeriatrics in primary care presented by gwen yeo, phd funds for this webinar were...
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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
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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
For More Ethnogeriatric Resources, seeStanford Geriatric Education Center Website
http://sgec.stanford.edu