Introduction

Dramatic shifts in population demographics due to migration have led to the requirement that health professionals acquire cultural sensitivity in addition to medical acumen in geriatric health care. A dramatic example of the effects of migration can be seen in the United Kingdom (UK). In the 1950s, Bethnal Green, an area in London, was a predominantly white, working-class neighbourhood, whereas in the 1990s it had changed to Tower Hamlets, the home of large numbers of Bangladeshi immigrants. Wolverhampton, in the West Midlands, UK, has a significant multicultural nature. It has an above-average level of non-Christian religions (13.6% of people, compared with 5.5% for England and Wales). Sikhs account for 7.6% of Wolverhampton’s population. The number of Hindus is also higher than the England and Wales average (Wolverhampton 3.9%, England and Wales 1.1%). Leicester is one of the oldest cities in the UK and is also one of the most ethnically diverse. It has small communities of Poles, Irish, Indians from the Indian sub-continent, Kenya and Uganda, Dutch citizens of Somali origin and a significant number of East European migrants. The Commission for Racial Equality (CRE) estimated that by 2011 Leicester will have approximately a 50% ethnic minority population, making it the first city in Britain not to have a white British majority. Changes such as these require training programmes for health professionals in how beliefs of different cultures may impact the interactions between older persons and their health care providers.

The ultimate goal of geriatric care providers is to provide good medical care to all older patients. This goal is made difficult when patients do not possess adequate health literacy, that is, the ability to understand and manage their own health care. Good communication is so critical to improving health literacy. When the cultural characteristics of both patients and providers are so different that communication is compromised, poor health literacy is likely to make it difficult for patients to receive good health care. This chapter presents ideas on how cultural context affects the provision of health care to an ageing, multiethnic population. Collaboration between providers and the patients and their caregivers becomes even more important in these circumstances. This chapter addresses some of the barriers to accomplishing the goal of providing good health care that arise from cultural differences. Suggestions on how to minimize cultural differences in the clinical encounter will be given. Because there is so much cultural diversity worldwide, this chapter will serve as a reminder that the problem must be addressed, rather than provide a laundry list of solutions. A list of resources at the end of the chapter will help guide practitioners in the development of their own strategies to develop and maintain cultural sensitivity with the goal of improving health care to their multicultural patient base.

The Importance of Health Literacy in Health Care

Multiple factors influence health literacy (Table 11.1). Factors such as increasing age, less education, lower income, ‘blue collar’ jobs and poor health status (both mental and physical) can all put people at risk for marginal or inadequate health literacy.5 This risk impacts health outcomes and therefore the cost for caring for older persons. Limited health literacy is associated with low socioeconomic status, comorbidities and poor access to health care, suggesting that it may be an independent risk factor for health disparities in older people.6 Lower literacy was more common among African Americans, older patients and patients who required medication assistance.7 Poor health literacy has dire consequences (Table 11.2). Among community-dwelling older adults who had recently enrolled in Medicare, inadequate health literacy was independently associated with poorer physical and mental health.8 Older patients are particularly affected by health literacy issues because their reading and comprehension abilities are influenced by their cognition and their vision and hearing status. Inadequate health literacy can result in difficulty in accessing health care, following instructions from a physician and taking medication properly. Patients with inadequate health literacy are more likely to be hospitalized than patients with adequate skills.9

Table 11.1 Common factors affecting health literacy.

Table 11.2 Consequences of low health literacy.

Functional literacy declines with age.10 Home interviews conducted with community-dwelling elderly persons (n = 2774) found that a significant decrease in health literacy was associated with every year increase in age, even following adjustments for gender, race, ethnicity, cognitive status and education. Differences in newspaper reading frequency, visual acuity, chronic medical conditions and health status did not explain the lower literacy of older participants. Both health literacy and cognitive abilities independently predict mortality. Interventions to improve patient knowledge and self-management skills should consider both the reading level and cognitive demands of the materials.11 Memory and verbal fluency are strongly associated with health literacy, independently of education and health status, even in those with subtle cognitive dysfunction. Reducing the cognitive burden of health information might mitigate the detrimental effects of limited health literacy in older adults.12 In addition, there are age differences in knowledge, as shown by Farrer et al.13 in a study on mental health literacy. In Australia, this study showed that a community’s knowledge and beliefs about mental health problems, their risk factors, treatments and sources of help varied as a function of age. Older adults (70+ years) were poorer than younger age groups at correctly recognizing depression and schizophrenia. Older respondents were more likely to believe that schizophrenia could be caused by character weakness.13

The Role of Education in Health Literacy

Education plays a key role to overcoming the effects of poor health literacy. If health information is shared via spoken instruction, it is best to remember that older patients understand medical information better when spoken to slowly, simple words are used and a restricted amount of information is presented. Often health literacy is addressed using written materials. However, in the United States, many older adults read at an eighth-grade level and 20% of the population reads at or below a fifth-grade level. A study of 177 low-income, community-dwelling, older adults (with no cognitive or visual impairments) was carried out to determine whether they had difficulty in understanding written information provided by clinicians. The subjects’ mean reading skills were at fifth-grade level, below those of the general American population. One-quarter of subjects reported difficulty in understanding written information from clinicians.14 However, most health care materials are written at a tenth-grade level.5 Health care providers must identify patients with marginal or inadequate health literacy and adjust their health care education strategies to meet these literacy needs. For optimal comprehension and compliance, patient education material should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations.9 It is also important to provide instruction in the language in which the patient is most fluent. For example, compared with those with adequate and marginal health literacy, women with inadequate functional health literacy in Spanish were significantly less likely to have ever had a Papanicolaou (Pap) test.15 Of course, having assessment tools translated into the original language does not solve problems with health literacy. In Turkey, in a clinic where 2.7% of patients had inadequate (less than or equal to sixth grade) health literacy, 38.6% had marginal (seventh to eighth grade) and 58.7% (greater than or equal to ninth grade) had adequate health literacy. Being female, primary school educated, in poor economic condition and older were all risk factors for the lowest level of health literacy.16 Cordasco et al.17 recruited 399 English- and Spanish-speaking inpatients being evaluated or treated for congestive heart failure or coronary artery disease at a large, urban safety-net teaching hospital in Southern California. They compared by age (aged 65 years or more, 51–64 years and less than 50 years), levels of health literacy, educational attainment, English comprehension and language use and found that the prevalence of inadequate health literacy increased significantly with increasing age. The correlation between older age and lower health literacy persisted when controlling for educational achievement, race, ethnicity, gender and immigration status. Additionally, older patients were more likely to have never learned to read, to have no formal education, to have limited English comprehension and to speak a non-English language at home. This study suggests that in order to meet the chronic disease needs of a growing older, multiethnic patient population and ameliorate the negative health effects of associated low literacy, safety-net hospital leaders and providers need to prioritize the development and implementation of low-literacy educational materials, programmes and services.17 Finally, differences in mental health literacy across the adult lifespan suggest that more specific, age-appropriate messages about mental health are required for younger and older age groups.13

Educational Strategies to Improve Health Literacy

Fortunately, proper educational techniques (Table 11.3) can make a difference in health care for persons with low health literacy.7 Of 111 patients with poorly controlled diabetes, 55% had literacy levels at the sixth grade level or below. Over the 6 month study period, patients with low and high literacy had similar improvements in A1C when they received one-to-one education and medication management for these patients using techniques that did not require high literacy from clinic-based pharmacists. Among community-dwelling Korean older adults, limited health literacy was associated independently with higher rates of chronic medical conditions and lower subjective health status. Nurses were found to be key to providing health education to these older adults18 to help them maintain their independence. The greatest potential barrier to addressing health literacy is the fact that most patients are often unwilling to admit that they have literacy problems.9 Indeed, Weiss et al found that 97% of their research subjects, regardless of literacy level, reported that television was their primary source of information.14

Table 11.3 Educational techniques to improve health literacy.

Cultural Sensitivity in Geriatrics

Developing strategies to increase awareness of cultural differences and to address them appropriately in the context of providing good health care is difficult because of the various influences on culture (Table 11.4). This goal is further complicated by the fact that culture is fluid and constantly changing. These changes compound misunderstandings between members of different cultural groups. A further complication is the fact that there are cultural differences between the different generations of people who share the same cultural background. Also, cultural differences often seem to be insurmountable between men and women of the same cultural background. Gender differences across cultures can be even more complicated. These differences highlight the complicated and constantly changing nature of culture. Geriatrics requires that the health care providers interact with multiple generations of the same family. Therefore, any general strategies employed to address cultural differences in the clinical setting need to be general and flexible in approach.

Table 11.4 Cultural factors that affect health care.

When Cultures Clash

Culture surrounds and defines everyone. Both providers and patients have their own national and ethnic cultures. These cultures include their culture of origin and also those cultural values, beliefs, language and skills of the local culture (acculturation) that they have adopted. The patients’ cultures will influence when they seek treatment, what their expectation of care will be and whether or not they will comply with the providers’ recommendations.19 Health care providers have the culture of biomedicine in general and that of their specific profession (e.g. medicine, nursing and pharmacy) and specialty (e.g. surgery, geriatrics and rheumatology) in particular. In addition, both providers and patients have cultural ideas and values that relate to their social culture,20–22 age,23, 24 gender25, 26 and gender identity.27, 28 Finally, health care providers for geriatric patients are almost always younger than their patients. This age difference also has ramifications in compliance based on trust and respect.29

Finding a way to communicate effectively is critical to good patient care. Patient satisfaction and the likelihood of compliance with medical instructions30, 31 are linked to patient–provider communication. If cultural differences are not addressed, then poor health outcomes and limited quality of medical decision-making may result.32 Patient satisfaction with health care is affected by age, race and literacy level. In low-income populations, communication satisfaction may be lower for groups that are traditionally active in doctor–patient interactions (e.g. younger patients, patients with higher literacy skills). Health care providers should be aware that older, non-white, optimistic and literacy deficient patients report greater communication satisfaction than their younger, white, pessimistic and functionally literate peers and are more likely to cope with their illnesses by withdrawing rather than by actively pushing for a higher standard of care.33 Therefore, health care providers should continuously seek ways to facilitate dialogue with patients who are older, non-white and have poor literacy skills. Thus, cultural sensitivity can help providers improve health care delivery in the clinical encounter. It can lead to better provider–patient communication, more accurate diagnosis, more effective treatment, higher patient satisfaction/compliance and efficient use of medical resources.

For most adults who are not health care providers themselves, navigating the culture of biomedicine is challenging. These challenges are exacerbated for older adults who are handicapped with physical, mental and/or social limitations. Most older adults suffer with chronic diseases in addition to acute diseases. The physical burdens that these chronic diseases put on older persons, especially if they have low health literacy, are often underappreciated by health care providers. For example, community-dwelling Korean older adults with low health literacy often have been reported to have significantly higher rates of arthritis and hypertension. After adjusting for age, education and income, older individuals with low health literacy had higher limitations in activity and lower subjective health. Older individuals with low health literacy were more likely to report lower levels of physical function and subjective health and higher levels of limitations in activity and pain.18 Nor are the patients themselves the only ones with challenges. The providers have their own challenges when applying their biomedical culture to an ageing population. They were taught ‘Primum non nocere’ (or ‘First, do no harm’, the origins of which are discussed elsewhere34), but many cures are harsh. This is because so many cures are designed for younger, robust patients who are experiencing an acute illness, and who have natural reserves that will allow them to overcome any debilitating effects of the ‘cure’. This is not true for the frail elderly. For them, multiple pharmaceuticals increase the possibility of lethal drug interactions and/or side effects. Surgery is dangerous and the subsequent recovery can be debilitating. Medical care is expensive and cannot be paid for by everyone. Sometimes the care is available but not always in a timely manner. This waiting period can be particularly problematic for an older person, especially is he/she lacks the cultural understanding of the need for haste or confrontation. Finally, the culture of medicine often emphasizes the quantity of life over the quality of life. However, older patients may insist upon more autonomy than the culture of biomedicine encourages.35 They do not always follow instructions, especially if they feel that quality of life is preferred over quantity of life. It is not uncommon for family members to decide that an older patient should not be treated of a serious disease such as depression26 or cancer.36, 37 This makes treatment difficult, if not impossible.

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